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U.S. Department of Health and Human Services

MAUDE Adverse Event Report: SYNTHES SELZACH REAMER Ø11 F/PFNA BLADE

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SYNTHES SELZACH REAMER Ø11 F/PFNA BLADE Back to Search Results
Catalog Number 356.821
Device Problems Break; Material Fragmentation
Event Date 10/25/2016
Event Type  Injury  
Manufacturer Narrative

Device was used for treatment, not diagnosis. (b)(4). Device is an instrument and is not implanted/explanted. The subject device is expected to be returned to the synthes manufacturer for evaluation but has not yet been received. (b)(6). Device is not distributed in the united states, but is similar to device marketed in the usa. The investigation could not be completed; no conclusion could be drawn, as no product was received. Without a lot number the device history records review could not be completed. The date of manufacture is unknown. If information is obtained that was not available for the initial medwatch, a follow-up medwatch will be filed as appropriate.

 
Event Description

Device report from synthes (b)(4) reported an event (b)(6) as follows: it was reported that during the surgery on (b)(6) 2016 while using the proximal femoral nailing set, the reamer broke. The surgeon was able to retrieve a large reamer fragment but a small fragment still remains in the patient outside of the bone. Another set was opened and it was noticed that the tip of the reamer in the second set was broken too. It is unknown if the second reamer broke when it was last used or whether it broke during the cleaning process. Additional information is not available. This report is 1 of 2 for (b)(4).

 
Manufacturer Narrative

(b)(4). A review of the device history records has been requested. Device was used for treatment, not diagnosis. If information is obtained that was not available for the initial medwatch, a follow-up medwatch will be filed as appropriate.

 
Event Description

The patient outcome was not affected. The surgery was prolonged approximately fifteen to twenty (15-20) minutes. They used time for an additional x-ray to locate the missing pieces of the broken off reamer.

 
Manufacturer Narrative

Device history records review was completed for part# 356. 821, lot #416863. Manufacturing location: (b)(4), manufacturing date: dec 29, 2008. No non conformance reports were generated during production. Review of the device history records showed that there were no issues during the manufacture of the product that would contribute to this complaint condition. Manufacturing investigation was completed for part# 356. 821, lot #416863. The tip is partially broken off, one big fragment was sent back for evaluation, the other fragments are missing. The received drill bit is in a very used condition, there are stress marks at the shaft visible, the coupling piece has wear marks from often use, the cutting edges are completely blunt and have nicks all over. The manufacturing documents were reviewed and no complaint related issues were found. The drill bit with lot 416863 was manufactured in december 2008 according to the specification. The relevant dimensions were checked and no deviation was found. Based on these findings we exclude any manufacturing related issue. As stated above, the cutting edges are completely blunt and the evaluation of the also received fragment has shown that there is large dent at the surface. This finding does indicate that an excessive metallic contact did lead to a mechanical overload and finally the breakage of the drill bit. The use of a blunt instrument may also have played a certain role, due to the bad overall condition of the cutting edges. In general it is mentioned in important information leaflet regarding reprocessing: end of life of a device is normally determined by wear and damage due to use. Evidence of damage and wear on a device may include but is not limited to corrosion (i. E. Rust, pitting), discoloration, excessive scratches, flaking, wear and cracks. Improperly functioning devices, devices with unrecognizable markings, missing or removed (buffed off) part numbers, damaged and excessively worn devices should not be used. Device was used for treatment, not diagnosis. If information is obtained that was not available for the initial medwatch, a follow-up medwatch will be filed as appropriate.

 
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Brand NameREAMER Ø11 F/PFNA BLADE
Type of DeviceREAMER
Manufacturer (Section D)
SYNTHES SELZACH
bohnackerweg 5
selzach PA CH254 5
SZ  CH2545
Manufacturer (Section G)
SYNTHES SELZACH
bohnackerweg 5
selzach CH254 5
SZ  CH2545
Manufacturer Contact
michael cote
1302 wrights lane east
west chester , PA 19380
6107195000
MDR Report Key6071038
Report Number2520274-2016-15151
Device Sequence Number1
Product CodeHTO
Report Source Manufacturer
Source Type COMPANY REPRESENTATIVE,FOREIG
Reporter Occupation
Type of Report Initial,Followup,Followup
Report Date 10/25/2016
1 Device Was Involved in the Event
1 Patient Was Involved in the Event
Date FDA Received11/01/2016
Is This An Adverse Event Report? Yes
Is This A Product Problem Report? Yes
Device Operator HEALTH PROFESSIONAL
Device Catalogue Number356.821
Device LOT Number416863
OTHER Device ID Number(01)07611819291102(10)U112364
Was Device Available For Evaluation? Device Returned To Manufacturer
Date Returned to Manufacturer11/30/2016
Is The Reporter A Health Professional? No
Was the Report Sent to FDA?
Event Location No Information
Date Manufacturer Received11/30/2016
Was Device Evaluated By Manufacturer? Yes
Date Device Manufactured12/29/2008
Is The Device Single Use? No
Is this a Reprocessed and Reused Single-Use Device? No
Type of Device Usage Unkown

Patient TREATMENT DATA
Date Received: 11/01/2016 Patient Sequence Number: 1
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