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Photographs of the device were provided, evaluated, and confirmed the reported event as the inserter tip appeared to be fractured at the bottom thread.Additionally, a review of the fractured device service on the photograph appears to indicate the device sustained a high-load flexural fracture.Operative notes were not provided for review of usage/technique.Based on the information obtained, the root cause of the reported fractured was excessive off-axis and/or twisting motion forces being applied during the attempted insertion into the disc space.Labeling review: "the implantation of spinal systems should be performed only by experienced spinal surgeons with specific training in the use of this spinal system because this is a technically demanding procedure presenting a risk of serious injury to the patient." "instrument malfunctions which potentially result in surgical delays (thereby causing additional exposure to anesthesia, blood loss, and infection), a change in surgical plan, failure to achieve optimal clinical result and/or, infrequently, cancellation of a procedure.Such malfunctions include instrument fracture, which could make necessary removal difficult or sometimes impossible, with possible consequences of late infection and migration; instrument fracture may also result in injury to the patient." "pre-operative warnings: the method of use for the instruments are to be determined by the user¿s experience and training in surgical procedures.The instruments should be treated as any precision instrument and should be carefully placed on trays, cleaned after each use, and stored, according to generally accepted hospital methods and practices.The instruments should be carefully examined prior to use for functionality, excessive wear, or damage.A damaged instrument should not be used as this may increase the risk of malfunction and potential patient injury." "intra-operative warnings: the physical characteristics required for many instruments do not permit them to be manufactured from implantable materials.If any broken fragments of instruments remain in the body of a patient, they could cause allergic reactions or infections.If an instrument breaks in surgery and fragments go into the patient, these pieces should be removed prior to closure and should not be implanted.".
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It was reported that during a procedure, the distal, threaded tip, of the device fractured off into the engaged implant and could not be retrieved.The fractured portion was retained in the implant so the surgeon opted to leave the portion in situ.No further patient impact was reported.
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