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U.S. Department of Health and Human Services

MAUDE Adverse Event Report: OBERDORF SYNTHES PRODUKTIONS GMBH 2.7MM TI VA LCKNG SCR SLF-TPNG WITH T8 STARDRIVE RECESS 26MM; SCREW, FIXATION, BONE

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OBERDORF SYNTHES PRODUKTIONS GMBH 2.7MM TI VA LCKNG SCR SLF-TPNG WITH T8 STARDRIVE RECESS 26MM; SCREW, FIXATION, BONE Back to Search Results
Catalog Number 04.211.026S
Device Problem Device Handling Problem (3265)
Patient Problem No Code Available (3191)
Event Date 08/20/2019
Event Type  Injury  
Manufacturer Narrative
Additional pro-code: hrs.Complainant part returned for manufacturer review / investigation.(b)(6).(b)(4).A review of the device history record has been requested.The investigation could not be completed; no conclusion could be drawn at the time of filing this report.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
Device report from synthes reports an event in (b)(6) as follows: it was reported that on (b)(6) 2019, the patient underwent the surgery with the va distal humerus plate and the 3 locking screws in question.After the surgeon drilled the va locking hole with a drill sleeve 2.7 at an angle, he inserted the locking screw, but the locking mechanism between the screw and the plate didn't work properly.When the surgeon removed the screw, he found that the screw head was shaved off and a thread fragment was generated.The surgeon tried to insert another locking screw, but the screw head was shaved off, too.The locking mechanism of the plate didn't work completely because the surgeon tried to insert a few times.The surgeon inserted the screw manually into the hole without locking it, and he finished the surgery.No further information is available.Concomitant device reported: unknown drill sleeve (part # unknown, lot # unknown, quantity# 1).This complaint involves four (4) devices.This report is 3 of 4 for (b)(4).
 
Event Description
Update: no fragments remained in the patient.
 
Manufacturer Narrative
Depuy synthes is submitting this report pursuant to the provisions of 21 cfr, part 803.This report may be based on information which depuy synthes has not been able to investigate or verify prior to the required reporting date.This report does not reflect a conclusion by fda, depuy synthes or its employees that the report constitutes an admission that the device, depuy synthes, or its employees caused or contributed to the potential event described in this report.Visual inspection: we received three (3) screws back for investigation.All screws were found deformed and damaged at the threaded head as well as at the threaded shaft.The anodized layer is partially disappeared at all damaged areas which does confirm a post manufacturing damage.Moreover, one (1) of three (3) screws was found deformed at the screw-recess.The relevant mating part (plate) was not returned.All features related to the reported complaint condition were reviewed and no other issues were identified.Dimensional inspection: a dimensional test is not appropriate to all received screws, since all complaint-relevant dimensions can no longer correspond to the valid technical drawings specifications due to the damage incurred.Drawing/specification review: the manufacturing review shows that the production procedures were according to the specifications and there were no issues that would contribute to this complaint condition.The correct material was used according to iso 5832-11.Conclusion: the complaint condition is confirmed due to the bad condition of the screws.This damage is clearly caused post manufacturing considering the evidence that anodized layer is partially disappeared.Based on the findings above a manufacturing related issue can be excluded.It was determined that the devices became deformed due to post manufacturing damage which was likely caused by handling error such as excessive force application and/ or alignment issues during insertion procedure.During the investigation, manufacturing issues were observed that may have contributed to the complaint condition.Additional monitoring for any potential safety signals will be conducted through complaint trending and other post market safety surveillance activities.Based on the investigation findings, it has been determined that no corrective and/or preventative action is proposed as no product related issue could be detected.Pictures are attached at pi-(b)(4).Device history part: 04.211.026s, lot: 5l20042, manufacturing site: selzach, supplier: (b)(4), release to warehouse date: 28 june 2019, expiry date: 01 june 2029.Lot 5l20042 was manufactured from non-sterile part 04.211.026 lot 3l32692, since there is no allegation against packing or sterility dhr review is done for non-sterile part: part number: 04.211.026, franchise lot number: 3l32692, release to warehouse date: 13 june 2019, manufacturing site: monument.Manufacturing location: monument, manufacturing date: 30-may-2019, part number: 04.211.026, 2.7mm ti va lckng scr slf-tpng with t8 stardrive recess 26mm, lot number: 3l32692 (non-sterile), lot quantity: 234.One piece was scrapped in cell at op#40, bead blast, after being dropped.Production order traveler met all inspection acceptance criteria apart from the one piece noted.Inspection sheet, in process / inspect dimensional / final inspection, met all inspection acceptance criteria.Packaging label log (pll) was reviewed and determined to be conforming.Packaging bom was reviewed and determined to be conforming with no deviations to normal packaging identified.This lot met all dimensional, visual and packaging criteria at the time of release with no issues documented during the manufacture that would contribute to this complaint condition.Component part(s) reviewed: component parts were not reviewed as the reported complaint condition of ¿locking mechanism didn¿t work properly¿ does not indicate breakage of the screw.Therefore, review of the raw materials would not be pertinent to the reported complaint condition.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 Name
2.7MM TI VA LCKNG SCR SLF-TPNG WITH T8 STARDRIVE RECESS 26MM
Type of Device
SCREW, FIXATION, BONE
Manufacturer (Section D)
OBERDORF SYNTHES PRODUKTIONS GMBH
eimattstrasse 3
oberdorf 4436
SZ  4436
MDR Report Key9101171
MDR Text Key159487031
Report Number8030965-2019-68540
Device Sequence Number1
Product Code HWC
Combination Product (y/n)N
PMA/PMN Number
K100776
Number of Events Reported1
Summary Report (Y/N)N
Report Source Manufacturer
Source Type company representative,foreig
Type of Report Initial,Followup
Report Date 08/26/2019
1 Device was Involved in the Event
1 Patient was Involved in the Event
Date FDA Received09/20/2019
Is this an Adverse Event Report? Yes
Is this a Product Problem Report? Yes
Device Operator Health Professional
Device Catalogue Number04.211.026S
Device Lot Number5L20042
Was Device Available for Evaluation? Device Returned to Manufacturer
Date Returned to Manufacturer09/16/2019
Date Manufacturer Received10/10/2019
Patient Sequence Number1
Treatment
UNK - GUIDES/SLEEVES/AIMING: SLEEVE; UNK - GUIDES/SLEEVES/AIMING: SLEEVE
Patient Outcome(s) Required Intervention;
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