| Catalog Number |
23605070S |
| Medical Device Problem Code |
Positioning Failure (1158)
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| Health Effect - Clinical Code |
Insufficient Information (4580)
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| Date of Event |
04/02/2025
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Type of Reportable Event
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Serious Injury
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Additional Manufacturer Narrative
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Additional information has been requested and if received, will be provided in the supplemental report.
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Event or Problem Description
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As reported: "ankle nail was introduced.Screws were locked.Most distal calcaneal screw trajectory was drilled with a 4.2mm drill, trough the targeting device.The drill didn't end up in the hole, but scratched the nail on the side.The nail was removed, tested and re-inserted.The incident happened again.This was tried 3 times.Surgery was delayed by 2 hours.A plate was used to fuse the ankle, which lead to extra incision and due to the plate no bone graft could be used, which was planned.".
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Event or Problem Description
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As reported: "ankle nail was introduced.Screws were locked.Most distal calcaneal screw trajectory was drilled with a 4.2mm drill, trough the targeting device.The drill didn't end up in the hole but scratched the nail on the side.The nail was removed, tested and re-inserted.The incident happened again.This was tried 3 times.Surgery was delayed by 2 hours.A plate was used to fuse the ankle, which lead to extra incision and due to the plate, no bone graft could be used, which was planned.".
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Additional Manufacturer Narrative
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Correction: please refer to sections d9 the device was returned and h6 (method, results and conclusion codes).The reported event could be confirmed since the misdrilling marks are visible on the nail.The device inspection revealed the following: only the ankle nail and one screw was received for evaluation.Other components such as drill, sleeves, target device were not received for analysis.Ankle nail is damaged near the distal holes.There is strong contact most probably with the drill during drilling operation as stated in the event description as well.Notably both the circular distal hole is having this kind of damage.The received screw is showing marks of usage both in the head and the tip region as indicated by the damaged coating.It looks like an attempt was made to tighten the screw but due to misdrilling the screw insertion did not took place.A functional inspection was done using sample drill, drill sleeve, tissue protection sleeve, target device and returned screw and nail, it was confirmed that the drill and screw is easily passing through the distal holes of the nail which contradicts the alleged failure.A review of the device history for the reported lot did not indicate any abnormalities.No corrective actions are required at this time.A review of the labeling did not indicate any abnormalities.No indications of material, manufacturing or design related problems were found during the investigation.Based on the investigation, the root cause was attributed to a usage related issue since the screw does not contribute towards alleged failure.If more information is provided, the case will be reassessed.
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