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A facility reported that during "c2-7 posterior cervical laminectomy and fusion" procedure, the mayfield composite series skull clamp (a3059) unlocked while flipping the patient to prone position.The procedure was completed as per usual, but the team had to be cautious and vigilant on patient positioning throughout the procedure.There was no patient injury or surgical delay.
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The mayfield composite series skull clamp (a3059) was returned for evaluation: device history record (dhr) - the dhr was reviewed and shows no abnormalities related to the reported failure.Failure analysis - evaluation of the returned unit shows that the unit has up and down movement in the lock, and the index knob is cracked which allows for movement while in the locked position.To resolve the issue, the disk ratchet, index knob, retaining ring, screw, nut, washer and wave spring will be replaced and general maintenance and cleaning will be performed.Root cause - the complaint is confirmed via inspection of the unit, and the probable root cause is rough or improper handling of the unit.No further corrective action is required based on the acceptability of risk and no adverse trends identified.This will be monitored and trended going forward.At present, we consider this complaint to be closed.
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