FDA Adverse Event Injury Summary report: N

ROSA ONE BRAIN

MDR report key: 20333627 · Received September 30, 2024

Report

Report Number
3009185973-2024-00013
Event Type
Injury
Date Received
September 30, 2024
Date of Event
August 14, 2024
Report Date
July 23, 2025
Manufacturer
MEDTECH SAS
Product Code
HAW
UDI-DI
03760244032492
PMA / PMN Number
K214065
Adverse Event
Yes
Product Problem
Yes
Report Source
Manufacturer report
Reporter Location
NY, US
Reporter Occupation
PHYSICIAN
Health Professional
Yes

Narratives

Additional Manufacturer Narrative · 0

(B)(4). H3: THE CUSTOMER HAS NOT INDICATED WHETHER THE PRODUCT WILL BE RETURNED TO ZIMMER BIOMET FOR INVESTIGATION OR NOT. ONCE THIS INFORMATION IS OBTAINED A FOLLOW-UP MDR WILL BE SUBMITTED.

Additional Manufacturer Narrative · 0

(B)(4). UPDATED: A3, B4, B5, D2, D9, G3, H1, H2, H4, H6, H11. A REVIEW OF THE LOG FILES CONFIRMED THE REPORTED EVENT FOR CALIBRATION FAILURE BUT THERE WERE NO ERRORS RELATING TO DRIFTING OBSERVED. THE SURGERY WAS NOT COMPLETED AND WAS ABORTED. THE BONE FIDUCIALS WERE PLACED BUT NO INCISIONS FOR THE IMPLANTS OCCURRED. A FIELD SERVICE ENGINEER WAS ONSITE TO EVALUATE THE SITUATION AFTER THE ABORTED CASE. THEY RESET THE SOFTWARE AND RECALIBRATED THE TOOLS AND FORCE SENSOR AND REPLACED THE CALIBRATION FILES. THE ROBOT WAS WORKING AS INTENDED AT THAT TIME. THE LOANER UNIT WAS INSTALLED TWO DAYS LATER, AND THE CASE WAS COMPLETED WITHOUT ADDITIONAL ISSUE. DEVICE HISTORY RECORD WAS REVIEWED AND NO DISCREPANCIES RELEVANT TO THE REPORTED EVENT WERE FOUND. A DEFINITIVE ROOT CAUSE COULD NOT BE DETERMINED. IF ANY FURTHER INFORMATION IS FOUND WHICH WOULD CHANGE OR ALTER ANY CONCLUSIONS OR INFORMATION, A SUPPLEMENTAL WILL BE FILED ACCORDINGLY. ZIMMER BIOMET WILL CONTINUE TO MONITOR FOR TRENDS.

Additional Manufacturer Narrative · 0

THIS FOLLOW-UP REPORT IS BEING SUBMITTED TO RELAY ADDITIONAL INFORMATION. THE FOLLOWING SECTIONS WERE (UPDATE/CORRECTED). CORRECTED: G4. UPDATED: G3; H2.

Description of Event or Problem · 0

IT WAS REPORTED THAT APPROXIMATELY A MONTH AGO A PATIENT WAS PUT UNDER ANESTHESIA AND HAD BONE FIDUCIALS PUT IN WHEN THE CASE HAD TO BE ABORTED DUE TO A DRIFTING ARM AND BEING UNABLE TO CALIBRATE THE TOOLS. THE SURGERY WAS COMPLETED TWO DAYS LATER.

Description of Event or Problem · 0

NO FURTHER EVENT INFORMATION AVAILABLE AT THE TIME OF THIS REPORT.

Description of Event or Problem · 0

NO FURTHER EVENT INFORMATION AVAILABLE AT THE TIME OF THIS REPORT.

Devices

Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
2602706 ROSA ONE BRAIN NEUROLOGICAL STEREOTAXIC INSTRUMENT HAW MEDTECH SAS N/A N/A 03760244032492

Patients

Seq Age Sex Outcome Treatment
1 NA Female Other