Y-KNOT ALL-SUTURE ANCHOR DRILL BIT
Report
- Report Number
- 1017294-2013-00012
- Event Type
- Malfunction
- Date Received
- April 2, 2013
- Date of Event
- February 28, 2013
- Report Date
- March 5, 2013
- Manufacturer
- CONMED LINVATEC
- Product Code
- GFG
- Product Problem
- Yes
- Report Source
- Manufacturer report
- Reporter Location
- PA, US
- Reporter Occupation
- NURSE
Narratives
CONMED LINVATEC RECEIVED A BROKEN DRILL BIT FOR EVALUATION. VISUAL INSPECTION OF THE RETURNED DRILL BIT CONFIRMED THE REPORTED BREAKAGE AND THE BROKEN PORTION WAS NOT RETURNED. A REVIEW OF THE DEVICE HISTORY RECORDS SHOWED LOT #397314 WAS MANUFACTURED ON SEPTEMBER 10, 2012 IN A LOT OF (B)(4) UNITS WITH NO NOTED DISCREPANCIES DURING THE MANUFACTURING PROCESS THAT COULD HAVE CAUSED OR CONTRIBUTED TO THE REPORTED BREAKAGE. THERE WERE NO OTHER SIMILAR COMPLAINTS RECEIVED FOR THIS ITEM AND LOT NUMBER COMBINATION. THIS IS A RELATIVELY NEW DEVICE WHICH IS VERY TECHNIQUE DEPENDENT. EVALUATION OF SIMILAR COMPLAINTS REVEALED THAT THE MOST LIKELY CAUSE OF THIS SUSPECTED FAILURE IS USER-RELATED. THIS FAILURE MODE IS ADDRESSED IN THE DFMEA, AND THE SAFETY RISK HAS BEEN FOUND TO BE ACCEPTABLE. TO REDUCE THE RISK OF DRILL BIT BREAKAGE AND INJURY TO THE PATIENT, THE INSTRUCTION FOR USE (IFU) PROVIDED THE FOLLOWING WARNINGS AND PRECAUTIONS: PRIOR TO USE, REMOVE ALL PROTECTIVE PACKAGING AND TIP PROTECTOR, IF APPLICABLE. INSPECT INSTRUMENTS PRIOR TO USE TO ENSURE THEY ARE IN GOOD PHYSICAL CONDITION. THERE SHOULD BE NO LOOSE, BROKEN OR MISALIGNED PARTS. INSPECT INSTRUMENTS AFTER USE TO ENSURE THEY HAVE NOT BEEN DAMAGED. DO NOT USE EXCESSIVE FORCE ON INSTRUMENTS TO AVOID DAMAGE OR BREAKAGE DURING USE. DO NOT USE INSTRUMENTS TO PRY, AS BENDING OR BREAKAGE MAY OCCUR. EXERCISE CARE WHEN USING THE DRILL BIT AND DRILL GUIDE. APPLYING SIDE OR BENDING LOADS MAY CAUSE DRILL BIT BREAKAGE, OVERSIZED TUNNEL OR GENERATION OF METAL PARTICULATES. DO NOT RE-SHARPEN, RE-STERILIZE, OR REUSE. SOME INSTRUMENTS MAY BE EXTREMELY SHARP. HANDLE WITH CARE TO AVOID INJURY. THE DRILL BIT IS SINGLE USE AND MUST BE DISPOSED ACCORDING TO HOSPITAL POLICY AND PROCEDURES.
TO DATE THE DEVICE HAS NOT BEEN RETURNED FOR EVALUATION. A FOLLOW UP REPORT WILL BE FILED UPON RECEIPT OF THE DEVICE AND COMPLETION OF THE EVALUATION.
IT WAS REPORTED THAT DURING USE OF THIS Y-KNOT ALL-SUTURE ANCHOR DRILL BIT IN A LEFT ANKLE ARTHROSCOPIC PROCEDURE, THE TIP BROKE OFF. THE TIP WAS REMOVED, THE SURGERY WENT ON AND COMPLETED AS INTENDED WITHOUT ANY FURTHER COMPLICATION. X-RAY WAS ALSO PERFORMED TO VERIFY THAT THE TIP WAS REMOVED. OTHER THAN A SHORT DELAY OF A FEW MINUTES TO REMOVE THE TIP, THERE WAS NO SERIOUS INJURY TO THE PATIENT.
Devices
| Seq | Brand | Generic | Product Code | Manufacturer | Model | Lot | UDI-DI |
|---|---|---|---|---|---|---|---|
| 134503 | Y-KNOT ALL-SUTURE ANCHOR DRILL BIT | BIT, SURGICAL | GFG | CONMED LINVATEC | 397314 |
Patients
| Seq | Age | Sex | Outcome | Treatment |
|---|---|---|---|---|
| 1 |