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U.S. Department of Health and Human Services

MAUDE Adverse Event Report: CONMED CORPORATION TUBE SET 24K TRUE INTRA-ARTICULAR PRESSURE SENSING ARTHROSCOPE

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CONMED CORPORATION TUBE SET 24K TRUE INTRA-ARTICULAR PRESSURE SENSING ARTHROSCOPE Back to Search Results
Catalog Number 24KTIPS
Device Problems Excess Flow or Over-Infusion (1311); Increase in Pressure (1491); Material Rupture (1546); Pressure Problem (3012)
Patient Problems No Consequences Or Impact To Patient (2199); Joint Swelling (2356)
Event Date 05/09/2017
Event Type  malfunction  
Manufacturer Narrative
As reported, the involved device was disposed of by the user facility and is therefore not available for further evaluation. However, the user facility provided a photograph of the involved device. Visual inspection of the photo found the "bladder" inside the tubing had ruptured and this confirmed the reported finding from the surgeon. In this instance, without the actual device, an evaluation could not be performed and the root cause of the reported "bladder ruptured" could not be determined. Evaluation of a previous complaint from the same user facility revealed that the balloon within the 24ktips can collapse if connected to the patient before connecting to the pump (such that pressure regulation will not work). The user facility has since been made aware of this requirement. An in-service was also conducted after the reported incident with the surgeon and his team, where the correct use of the 24ktips tubing was reviewed. This lot #201612084 was manufactured on 09-dec-2016. A review of the device history record for this lot found no noted of discrepancies during the manufacturing process that could have caused or contributed to reported issue. Of the lot containing 288 units, there have been no other similar complaints received for this item and lot number combination. In addition, a 2-year review of product history for this device shows other than this complaint there have been no other similar complaints received. During this same 2-year time frame, approximately (b)(4). To date, there have been no serious injuries or death related to the reported issue or the use of this device. This reported issue will continue to be monitored via the complaint system to ensure product safety. This failure mode is addressed in the dfmea, and the safety risk has been found to be acceptable. This tubing set is intended for use, in conjunction with the conmed linvatec 24k system, to improve pressure measurement accuracy during arthroscopic procedures. To reduce the risk of patient injury, the instructions for use (ifu) provides the user with the following precautions and warnings: - avoid abrupt changes in joint position, which may result in high intra-articular pressure spikes and/or extravasation. - do not crimp, kink, puncture or roll over the tips tubing set with carts or other equipment. Erroneous readings may result, possibly causing injury and/or extravasation to the patient. - connect the tips tubing set to the console first, then to the cannula. If connected in reverse order, the tips system may not measure joint pressure accurately and may result in compromised performance. - periodically examine the distal location of the inflow cannula or sheath to ensure that the cannula or sheath is within the joint capsule. Extravasation may occur as a result of improper cannula or sheath placement or excessive intra-articular joint pressure. - for tips to operate properly, pressure sensing should occur in the joint space closest to the working space. Failure to do so may result in increased risk of extravasation. - extravasation may occur if the pressure sensing system does not function properly. Always perform a patency test prior to each procedure. - do not squeeze the tips balloon while the pump is operating. Unexpected acceleration of the pump may occur. - frequently examine and palpate the patient's joint to check for extravasation and proper distention. Device was discarded at user facility.
 
Manufacturer Narrative
The used 24ktips tube set is not expected to be returned for evaluation, as it was discarded at the user facility after the surgery. As of this filing the investigation remains in process, a supplemental and final report will be filed upon the completion of the complaint investigation. Device was discarded at user facility.
 
Event Description
On (b)(6) 2017, conmed (b)(4) received an email from the surgeon, who alleged that at least 4 times over the last 3-4 week he has had a situation where during use of the 24ktips in a rotator cuff repair procedure, the 24k pump started to pump at "crazy pressure with the shoulder swelling up tremendously in a short period of time". The report further stated that upon inspection it was found that the "bladder inside the tubing" had ruptured, leading to the pump not being able to sense the actual pressure and a "dangerously high continuous inflow of fluid". As reported, the procedure performed on (b)(6) 2017 was completed as planned with the use of another 24ktips from the same lot. In addition, follow-up with the surgeon confirmed that "excess fluid was absorbed naturally" and there was no serious injury occurred or any long term adverse effect anticipated to the patient. However, attempts to verify if there were 3 other separate incidents and if so, the dates of the individual incident for the other 3 alleged cases with the surgeon and the theater manager have failed to confirm such incidents. To date, no additional patient/event information, no incident dates from the other mentioned cases could be obtained from the surgeon and/or facility. Should additional information become available, the complaints will be generated and processed accordingly. This report is filed on the basis of potential for patient injury with recurrence.
 
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Brand NameTUBE SET 24K TRUE INTRA-ARTICULAR PRESSURE SENSING
Type of DeviceARTHROSCOPE
Manufacturer (Section D)
CONMED CORPORATION
525 french road
utica NY 13502 5994
Manufacturer (Section G)
CONSOLIDATED MEDICAL EQUIPMENT COMPANY
ave. alejandro dumas no. 11321
complejo industrial chihuahua
chihuahua, cp, 1136
MX 1136
Manufacturer Contact
n. kim grady
525 french road
utica, NY 13502-5994
7273995479
MDR Report Key6615008
MDR Text Key195044322
Report Number3007305485-2017-00133
Device Sequence Number1
Product Code HRX
Combination Product (y/n)N
Reporter Country CodeAS
PMA/PMN Number
K063326
Number of Events Reported1
Summary Report (Y/N)N
Report Source Manufacturer
Source Type company representative,foreig
Reporter Occupation
Type of Report Initial,Followup
Report Date 07/07/2017
1 Device was Involved in the Event
0 Patients were Involved in the Event:
Date FDA Received06/06/2017
Is this an Adverse Event Report? No
Is this a Product Problem Report? Yes
Device Operator
Device Expiration Date12/07/2021
Device Catalogue Number24KTIPS
Device Lot Number201612084
Was Device Available for Evaluation? No
Is the Reporter a Health Professional? Yes
Was the Report Sent to FDA?
Event Location No Information
Date Manufacturer Received07/06/2017
Was Device Evaluated by Manufacturer? Device Not Returned to Manufacturer
Date Device Manufactured12/09/2016
Is the Device Single Use? Yes
Is This a Reprocessed and Reused Single-Use Device? No
Type of Device Usage Unkown

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