Catalog Number 13200100 |
Device Problem
Use of Device Problem (1670)
|
Patient Problem
No Known Impact Or Consequence To Patient (2692)
|
Event Date 10/13/2016 |
Event Type
malfunction
|
Manufacturer Narrative
|
Once the investigation has been completed any additional information will be reported in a supplemental report.
|
|
Event Description
|
Distal missdrilling during medical procedure.Procedure successfully completed by free hand locking.
|
|
Manufacturer Narrative
|
Evaluation revealed the target device as primary product.No associated products reported.Appearance of item and inspection records identified the target device returned being of new design version.Deviations in the inspection documents were not found.A check of the function on 100% of the devices (sub-supplier) and additional in-house spot check of the lot in question revealed function was given in full on the devices at the stage of delivery.Functional test revealed neither proximal ¿ nor distal contacts of the drill to the drill holes of the sample nail.The function of the target device returned was fully given.The reported event that the gamma3 target device was alleged of causing distal missdrilling during medical procedure could not be confirmed.Potentially reduced accuracy in guidance is usually found during functional check (required per ifu).In case of any deviation it is realized prior to use.Pre-supposing that targeting accuracy for drilling was confirmed by pre-operative check it was concluded that the event(s) were mainly based in the intra-operative procedure.Reasons for misaligned drilling and misaligned distal locking screws are various.Potential miss-targeting can also be caused but is not limited by e.G.Ensure that the nail holding bolt is still fully tightened.Avoid soft tissue pressure on the distal locking sleeve assembly- therefore the skin incision would be made (co-linear) in direction of the sleeve assembly check that the distal locking sleeve assembly with the trocar removed is in contact with the lateral cortex of the femur and is locked securely with the speedlock sleeve knob.Confirm final locking screw placement with a/p and lateral fluoroscopic x-ray.Neutralize the power tool weight during drilling procedure and do not apply force to the targeting arm.Start the power tool before having bone contact with the drill.Use sharp and center tipped drills only.Regarding misdrilling the operative technique has already been modified by ecn.Although a real root cause could not be determined the alleged event is most likely caused due to a suboptimal intra-operative procedure and thus user related.The event did not involve a product problem indicating a non-conformity, adverse trend or unanticipated hazard.Investigation revealed no non-conformity, therefore no ncr was initiated.A review of the labeling did not indicate any abnormalities.
|
|
Event Description
|
Distal missdrilling during medical procedure.Procedure successfully completed by free hand locking.
|
|
Search Alerts/Recalls
|