| Catalog Number |
49338030 |
| Medical Device Problem Codes |
Break (1069); Fracture (1260)
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| Health Effect - Clinical Codes |
Insufficient Information (4580); No Clinical Signs, Symptoms or Conditions (4582)
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| Date of Event |
08/12/2025
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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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Analysis results are not available at the time of this report.A follow-up report will be sent when the analysis is complete.
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Event or Problem Description
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It was reported that two broken 1.8mm olive wires in proximal ring of hlrf frame.Immediate full weight bearing on right side (frame side).Non weight bearing on left side one at hlrf wire bolt interface and one in the bone.Patient noticed first broken wire at home on (b)(6).Patient phoned surgeon and was advised nwb and to come straight to clinic.Patient attended clinic that afternoon and second broken wire was identified.Patient returned to theatre, the two broken wires were removed and replaced with three new wires.Wire lot numbers are not available as this section of the wire was cut off and discarded when cutting to length during initial build no bone quality concerns and patient has type 2 diabetes.
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Additional Manufacturer Narrative
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Correction to g4(pma/510(k), h3 (device evaluated by mfg), h6 (device code) to remove break code.The complaint could be confirmed, since the product was returned for evaluation and matches the alleged failure.The investigation revealed the following: visual examination of the received product shows that the wire is broken as reported.On one side there are marks visible from the wire bolt, on the other side the wire is broken.The part will be forwarded for further evaluation.Mechanical engineering reviewed the images and noted: wire with black marks: conclusion: fatigue failure mode is detected.During the surgery: the torque applied to wire bolt 2 during the wire tensioning step was too high (finger tightening is recommended).This overtightening increases friction and changes the real tension in the wire, as shown on the tensioner scale, which reduces its fatigue resistance.During treatment of patient: no wire slippage was observed (which can happen during the treatment) on both wire bolt.Remark: the absence of the second segment of wire doesn¿t influence the analysis.The missing information about which wire bolt was connected to the wire doesn¿t influence the analysis.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 investigation, the root cause was attributed to a use related issue.The failure was caused most likely by to much tightening before final tensioning, as fatigue resistance got reduced.If more information is provided, the case will be reassessed.
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Event or Problem Description
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It was reported that two broken 1.8mm olive wires in proximal ring of hlrf frame.Immediate full weight bearing on right side (frame side).Non-weight bearing on left side one at hlrf wire bolt interface and one in the bone.Patient noticed first broken wire at home on (b)(6).Patient phoned surgeon and was advised (b)(6) and to come straight to clinic.Patient attended clinic that afternoon and second broken wire was identified.Patient returned to theatre, the two broken wires were removed and replaced with three new wires.Wire lot numbers are not available as this section of the wire was cut off and discarded when cutting to length during initial build.No bone quality concerns and patient has type 2 diabetes.
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Search Alerts/Recalls
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