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SMITH & NEPHEW ORTHOPAEDICS LTD BHR CURVED CUP INTRODUCER; PROSTHESIS, HIP, SEMI-CONSTRAINED, METAL/METAL, RESURFACING
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| Catalog Number |
90128257 |
| Medical Device Problem Codes |
Fracture (1260); Solder Joint Fracture (2324)
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| Health Effect - Clinical Code |
No Clinical Signs, Symptoms or Conditions (4582)
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| Date of Event |
03/25/2025
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Type of Reportable Event
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Malfunction
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Event or Problem Description
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It was reported that, during a thr surgery, one (1) bhr curved cup introducer broke during use.A weld broke loose.The procedure was resumed, without any delay, using the same device.No injury was reported as a consequence of this issue.
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Additional Manufacturer Narrative
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This complaint was opened by smith+nephew to document a product problem associated with a smith+nephew device.The reported problem relates to known inherent device and/or procedural risks that are appropriately documented in our risk files.Smith+nephew will continue to monitor trends in accordance with our post-market surveillance process and take necessary action as required if anticipated severity and/or occurrence rates are exceeded.Smith+nephew has no reason to suspect that the product failed to meet any specifications at the time of manufacture.Based on our review of all currently available information, we are unable to identify a definitive root cause.However, as the use of our product cannot be excluded as a potential cause or contributory factor to the reported issue, we are conservatively submitting this report in accordance with applicable regulations.If additional investigative findings or information becomes available that alters the conclusions of this report, a follow-up report will be submitted as required.
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Event or Problem Description
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It was reported that, during a thr surgery, one (1) bhr curved cup introducer broke upon his final mallet strike during cup impaction.A weld broke loose.Nothing fell into the wound.The procedure was resumed, without any delay, using the same device.No injury was reported as a consequence of this issue.
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Additional Manufacturer Narrative
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Internal complaint reference: (b)(4).B5 updated.
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Additional Manufacturer Narrative
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Additional information: h6 (medical device problem code, component code, type of investigation, investigation findings and investigation conclusions), h8, h11 (roi).H3, h6: the complaint device was not returned for investigation.A visual evaluation was performed on images provided by the complainant, and it showed that weld inside the device fractured.A review of the historical complaints data for the alleged device was performed using batch number, part number and the reported failure modes to evaluate patterns of repeated failures or defects.Similar complaints have been identified for the bhr curved cup introducer.This failure will continue to be monitored via routine trending.The subject instrument has been in distribution for more than ten years, likely experiencing multiple uses and worn or damaged from repeated normal use, misuse, and cleaning practices.Surgical instruments are subject to normal wear and tear throughout their life and over time may no longer perform as intended.Therefore, a device history records review for this incident is considered unnecessary as no other evidence to suggest a manufacturing deficiency in this case, thus this is unlikely to be identified as a cause or contributing factor.A risk management review was performed.The alleged failure modes and associated risks have been anticipated within the risk file and the anticipated risk level is still adequate.No further actions are required at this time.A review of historic escalation actions related to the products and similar complaint events was performed.Following the review, no prior applicable escalation actions were identified.No further escalation actions are required.The root cause can likely be ascribed to problems traced to the device reaching the end of its useful life.This device is a reusable instrument that can be exposed to numerous surgeries.Damage from prolonged use, misuse or rough handling are likely potential factors that could contribute to the reported event.Furthermore, the damage found in the visual inspection indicates that the device will not function as intended.Therefore, all reusable instruments must be routinely inspected for signs of wear and damage after reprocessing.Any instruments found to be damaged should be replaced as necessary to ensure their proper functioning and to maintain patient safety.This guidance is provided by the bhr surgical technique.Should the devices or additional information be received, the complaint will be reopened.Based on this investigation, the need for corrective and preventative actions is not indicated.
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