Catalog Number 13200100 |
Device Problem
Device Inoperable (1663)
|
Patient Problem
No Known Impact Or Consequence To Patient (2692)
|
Event Date 01/19/2017 |
Event Type
malfunction
|
Manufacturer Narrative
|
Once the investigation has been completed, any additional information will be reported in a supplemental report.
|
|
Event Description
|
Target device does not work accurately anymore.
Distal misdrilling occurred.
Procedure completed successfully by manual locking.
|
|
Manufacturer Narrative
|
Evaluation revealed the target device as primary product.
No associated products were 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.
A mis-targeting could not be reproduced during performance of the pre-operative check.
The alleged event ¿target device does not work accurately anymore and distal mistargeting¿ 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 engineering change.
Although a real root cause could not be determined the alleged event is most likely caused due to a suboptimal intra-operative procedure.
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
|
Target device does not work accurately anymore.
Distal misdrilling occurred.
Procedure completed successfully by manual locking.
|
|
Search Alerts/Recalls
|