BEUDAMED
    FDA Adverse Event Malfunction Summary report: N

    NUVASIVE RELINE SYSTEM

    MDR report key: 12691667 · Received October 25, 2021

    Report

    Report Number
    2031966-2021-00144
    Event Type
    Malfunction
    Date Received
    October 25, 2021
    Date of Event
    September 16, 2021
    Report Date
    October 25, 2021
    Manufacturer
    NUVASIVE, INCORPORATED
    Product Code
    NKB
    UDI-DI
    00887517596185
    PMA / PMN Number
    K143684
    Removal / Correction Number
    NA
    Product Problem
    Yes
    Report Source
    Manufacturer report
    Reporter Location
    CA, US
    Reporter Occupation
    PHYSICIAN

    Narratives

    Additional Manufacturer Narrative · 1

    THE PRODUCT HAS BEEN RECEIVED ALONG WITH RADIOGRAPHS PROVIDED CONFIRMED THE COMPLAINT. THE PATIENTS POST OP PHYSICAL ACTIVITY LEVELS ARE UNKNOWN. IT IS ALSO UNKNOWN IF THE PATIENT EXPERIENCED A FALL OR OTHER ACCIDENT. EXAMINATION OF THE RETURNED CONNECTOR FOUND THE CLOSED LOCK SCREW TO BE CROSS THREADED AND NOT SECURING THE ROD AND IS CONSIDERED THE ROOT CAUSE OF THE POST-OPERATIVE ROD SEPARATION. NO ADDITIONAL INVESTIGATION REQUIRED. LABEL REVIEW "POTENTIAL ADVERSE EVENTS AND COMPLICATIONS - AS WITH ANY MAJOR SURGICAL PROCEDURES, THERE ARE RISKS INVOLVED IN ORTHOPEDIC SURGERY. INFREQUENT OPERATIVE AND POSTOPERATIVE COMPLICATIONS THAT MAY RESULT IN THE NEED FOR ADDITIONAL SURGERIES... POTENTIAL RISKS IDENTIFIED WITH THE USE OF THIS SYSTEM, WHICH MAY REQUIRE ADDITIONAL SURGERY, INCLUDE: BENDING, FRACTURE OR LOOSENING OF IMPLANT COMPONENT(S) LOSS OF FIXATION." "WARNINGS, CAUTIONS AND PRECAUTIONS: ALL LOCK SCREWS SHOULD BE FINAL-TIGHTENED WITH THE COUNTER-TORQUE AND TORQUE T-HANDLE. DO NOT FINAL-TIGHTEN THROUGH COMPRESSION INSTRUMENTS (E.G. C/D RACK AND FIGURE 8 COMPRESSOR) IN THE SET, AS THE ROD MAY NOT BE ABLE TO NORMALIZE TO THE TULIP. BE CAUTIOUS NOT TO OVER COMPRESS OR DISTRACT AS YOU CAN LOOSEN THE SCREWS IN THE SPINE AND POTENTIALLY PULL OUT THE SCREW. THE BULLETED PORTION OF THE NOSE OF THE ROD AND THE FACETED PORTION OF THE ROD (WHERE THE INSERTER LOCKS DOWN ON THE ROD) MUST EXTEND FULLY OUTSIDE OF THE MOST INFERIOR OR MOST SUPERIOR TULIP ON THE CONSTRUCT. THE SET SCREW CANNOT BE LOCKED DOWN ON THIS UNUSABLE PORTION OF THE ROD, AS THIS MAY COMPROMISE THE STABILITY OF THE CONSTRUCT." "PATIENT EDUCATION: PREOPERATIVE INSTRUCTIONS TO THE PATIENT ARE ESSENTIAL. THE PATIENT SHOULD BE MADE AWARE OF THE LIMITATIONS OF THE IMPLANT AND POTENTIAL RISKS OF THE SURGERY. THE PATIENT SHOULD BE INSTRUCTED TO LIMIT POSTOPERATIVE ACTIVITY, AS THIS WILL REDUCE THE RISK OF BENT, BROKEN OR LOOSE IMPLANT COMPONENTS. THE PATIENT MUST BE MADE AWARE THAT IMPLANT COMPONENTS MAY BEND, BREAK OR LOOSEN EVEN THOUGH RESTRICTIONS IN ACTIVITY ARE FOLLOWED." "COMPATIBILITY: ALL IMPLANTS SHOULD BE USED ONLY WITH THE APPROPRIATELY DESIGNATED INSTRUMENT REFERENCE SURGICAL TECHNIQUE." "PRE-OPERATIVE WARNINGS: 3. CARE SHOULD BE USED IN THE HANDLING AND STORAGE OF THE RELINE IMPLANTS. THE IMPLANTS SHOULD NOT BE SCRATCHED OR DAMAGED. IMPLANTS AND INSTRUMENTS SHOULD BE PROTECTED DURING STORAGE AND FROM CORROSIVE ENVIRONMENTS. 5. CARE SHOULD BE USED DURING SURGICAL PROCEDURES TO PREVENT DAMAGE TO THE DEVICE(S) AND INJURY TO THE PATIENT."

    Description of Event or Problem · 1

    ON (B)(6) 2021 A PATIENT UNDERWENT A POSTERIOR LUMBAR INTERBODY FUSION PROCEDURE FROM T12 TO L2. DURING A POST-OP FOLLOW UP ON AND UNKNOWN DATE IT WAS DISCOVERED VIA RADIOGRAPH THAT THE ROD SLIPPED AND DISPLACED FROM THE CONNECTOR. ON (B)(6) 2021 A REVISION OCCURRED WERE BOTH IMPLANTED CONNECTORS AND THE RODS WERE REPLACED. THE PATIENT IS RECOVERING WELL POST REVISION.

    Devices

    Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
    1590287 NUVASIVE RELINE SYSTEM THORACOLUMBOSACRAL PEDICLE SCREW SYSTEM NKB NUVASIVE, INCORPORATED 11102255 TU7914 00887517596185

    Patients

    Seq Age Sex Outcome Treatment
    1 73 YR