BEUDAMED
    FDA Adverse Event Malfunction Summary report: N

    EXACTECH

    MDR report key: 13953939 · Received March 30, 2022

    Report

    Report Number
    1038671-2022-00330
    Event Type
    Malfunction
    Date Received
    March 30, 2022
    Date of Event
    April 19, 2019
    Report Date
    April 25, 2022
    Manufacturer
    EXACTECH, INC.
    Product Code
    LXH
    Product Problem
    Yes
    Report Source
    Manufacturer report
    Reporter Location
    CA, US
    Reporter Occupation
    PHYSICIAN
    Health Professional
    Yes

    Narratives

    Additional Manufacturer Narrative · 0

    AS A RESULT OF AN FDA INSPECTION CONDUCTED IN JAN 2020, EXACTECH, (B)(4), HAS COMMITTED TO REMEDIATING 3 YEARS OF COMPLAINTS (2017-2020). THIS MDR IS BEING SUBMITTED AS PART OF THAT REMEDIATION. INFORMATION WAS NOT PROVIDED FOR: PT. INFO. FINDINGS: THE WELD ON 02-029-219-1202 REV A IN THE CASE OF MULTI-PIECE CONSTRUCTION WAS BREAKING. THIS ALLOWED THE COMPONENT PARTS TO DISASSEMBLE. THE PRINT DOES NOT SPECIFY A TYPE OF WELD TO BE USED IN THE CASE OF MULTI-PIECE CONSTRUCTION. MOST LIKELY UNDERLYING CAUSE/ROOT CAUSE: BASED ON THE CAPA AND CRC, THE BROKEN DEVICE REPORTED WAS LIKELY THE RESULT OF AN INSUFFICIENT WELD ON 02-029-219-1202, WHICH LED TO WELD FRACTURE AND COMPONENT DISASSEMBLY. CORRECTIVE ACTION TAKEN: PARTS WILL NOT BE ORDERED UNLESS THEY ARE SINGLE PIECE CONSTRUCTION. IFU 700-096-181: INSTRUMENT INSPECTION ¿ VISUALLY INSPECT THE INSTRUMENTS FOR DAMAGE SUCH AS FRACTURES; CRACKS; GOUGES; DEFORMATION; BURRS; DISCOLORATION, CORROSION, OR RUST; EXCESSIVE COMPONENT WEAR; NICKS ON CUTTING SURFACES, MISSING OR LOOSE COMPONENTS; BLOCKAGES IN CANNULAE, CLEANING HOLES OR OTHER CAVITIES THAT CANNOT BE REMOVED VIA STANDARD CLEANING; WORN OR DIFFICULT TO READ MARKINGS/ENGRAVINGS; OR OTHER APPARENT DAMAGE. ¿ CHECK THE FUNCTION OF MECHANISMS BY ACTUATING ANY LEVERS, KNOBS, SWITCHES, CONNECTORS, SLIDING FEATURES, HINGES, OR OTHER MECHANICAL INTERFACE FEATURES. ENSURE SMOOTH OPERATION OF THESE FEATURES OVER THEIR FUNCTIONAL RANGE OF MOTION. ¿ IF DAMAGE, WEAR, OR NON-FUNCTIONING/POORLY FUNCTIONING MECHANISMS ARE FOUND, DO NOT USE THE INSTRUMENT, AND CONTACT THE SALES REPRESENTATIVE OR CUSTOMER SERVICE FOR DISPOSITION. IFU STATES: THE SURGEON SHALL BECOME THOROUGHLY FAMILIAR WITH THE TECHNIQUE OF IMPLANTATION OF THE PROSTHESES BY: (1) APPROPRIATE READING OF THE LITERATURE, AND (2) TRAINING IN THE OPERATIVE SKILLS AND TECHNIQUES REQUIRED FOR SURGERY, AND (3) REVIEWING INFORMATION REGARDING USE OF INSTRUMENTATION. IT IS A CLINICAL STANDARD OF PRACTICE IN THE OPERATING ROOM THAT ALL INSTRUMENTS SHOULD BE VISUALLY AND FUNCTIONALLY INSPECTED BEFORE USE, THESE GUIDELINES ARE FROM STANDARD ASSOCIATION OF PERI-OPERATIVE REGISTERED NURSES (AORN) GUIDELINES. SURGEONS ARE TO BE FAMILIAR AND KNOWLEDGEABLE WITH ALL INSTRUMENTATION, DEVICES AND PROFICIENT WITH SURGICAL TECHNIQUES. DEVICE(S) USED FOR TREATMENT NOT DIAGNOSIS. BASED ON REVIEW OF ALL AVAILABLE INFORMATION, THERE IS NO EVIDENCE TO REASONABLY SUGGEST THE REPORTED EVENT IS RELATED TO MANUFACTURING ISSUES. THERE IS NO REPORTED PATIENT ADVERSE EVENT. BROKEN PIECES DID NOT FALL INTO THE SURGICAL SITE. BASED ON (B)(4) THE BROKEN DEVICE REPORTED WAS LIKELY THE RESULT OF AN INSUFFICIENT WELD ON 02-029-219-1202, WHICH LED TO WELD FRACTURE AND COMPONENT DISASSEMBLY.

    Additional Manufacturer Narrative · 0

    H11: AS A RESULT OF AN FDA INSPECTION CONDUCTED IN JAN 2020, EXACTECH, FEI 1038671, HAS COMMITTED TO REMEDIATING 3 YEARS OF COMPLAINTS (2017-2020). THIS MDR IS BEING SUBMITTED AS PART OF THAT REMEDIATION. THIS MEDWATCH IS BEING RESCINDED: UPON FURTHER REVIEW OF REPORTABILITY- IF THE MALFUNCTION WERE TO RECUR, IT IS NOT LIKELY TO CAUSE OR CONTRIBUTE TO SERIOUS INJURY OR DEATH. THE DISASSEMBLED PARTS ARE NOT LIKELY TO FALL INTO THE WOUND SITE OR INTERFERE WITH THE SURGICAL IMPLANT PROCEDURE.

    Description of Event or Problem · 0

    IT WAS REPORTED FROM THE US THAT DURING AN ORTHOPEDIC SURGERY THE SURGEON EXPERIENCED AN ISSUE WITH THE INSTRUMENTATION. THE SURGEON WAS BACKSLAPPING WITH THE SLAP HAMMER ¿REALLY HARD, MAYBE A LITTLE OFF AXIS, AND THE TWO PRONGS CAME OFF THE MOUNT OF THE FEMORAL EXTRACTOR¿. THE SURGEON WAS ABLE TO EXTRACT THE BASE TRIAL COMPONENT, ¿AND WE HAD A BACK-UP IF HE WANTED TO TRIAL AGAIN¿. THE DEVICE WAS RECEIVED FOR ANALYSIS. THE REP WAS PRESENT AT THE TIME OF SURGERY. PER THE REPRESENTATIVE NO PIECES WERE IN THE SURGICAL SITE. THE CASE WAS DELAYED BY 5 MINUTES AS THEY KEPT TRYING TO REMOVE THE PART. NO INJURY OR ADVERSE EVENT. THE OUTCOME WAS ¿GOOD¿. THERE IS NO ADDITIONAL INFORMATION FROM THE CONTACTS FOR THIS EVENT.

    Devices

    Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
    2190555 EXACTECH TRUL FEM TRIAL EXTRACTOR LXH EXACTECH, INC. 117574004

    Patients

    Seq Age Sex Outcome Treatment
    1 Male