LOCKING SCREW, FULLY THREADED T2 TIBIA Ø5X55 MM
Report
- Report Number
- 0009610622-2014-00139
- Event Type
- Injury
- Date Received
- March 27, 2014
- Date of Event
- March 7, 2014
- Report Date
- March 7, 2014
- Manufacturer
- STRYKER TRAUMA KIEL
- Product Code
- HSB
- PMA / PMN Number
- K032244
- Adverse Event
- Yes
- Product Problem
- Yes
- Report Source
- Manufacturer report
- Reporter Location
- OK, US
- Reporter Occupation
- PHYSICIAN
Narratives
DEVICE WILL NOT BE RETURNED. IF ADDITIONAL INFORMATION BECOMES AVAILABLE IT WILL BE PROVIDED ON A SUPPLEMENTAL REPORT.
EVALUATION THE REPORTED ISSUE WAS CONFIRMED VIA X-RAYS. THE NAIL AND BOTH BROKEN LOCKING SCREWS WERE CLASSIFIED AS PRIMARY PRODUCTS DURING INVESTIGATION. NO DEVIATIONS WERE FOUND DURING REVIEW OF THE MANUFACTURING AND INSPECTION DOCUMENTS (DHR) FOR THE NAIL. THE NAIL WAS DOCUMENTED AS FAULTLESS PRIOR TO DISTRIBUTION. THE DHR FOR THE SCREWS WAS NOT REVIEWED BECAUSE THE LOT CODES WERE NOT PROVIDED. THE IMPLANTS WERE NOT AVAILABLE FOR INVESTIGATION; THE ROOT CAUSE COULD NOT BE DETERMINED. THE POSTOPERATIVE X-RAYS SHOW THAT THE NAIL IS WRONG INSERTED APPROX. 70° TWISTED TO INTENDED POSITION: THE PROXIMAL SCREWS ARE INSERTED POSTERIOR TOWARDS ANTERIOR (SHALL BE INSERTED LATERAL TOWARDS MEDIAL); THE DISTAL SCREWS ARE INSERTED ANTERIOR TOWARDS POSTERIOR (SHALL BE INSERTED LATERAL TOWARDS MEDIAL). THE PROXIMAL LOCKING SCREW, INSERTED IN THE THREADED OBLIQUE HOLE, IS NOT COMPLETELY INSERTED INTO THE NAIL HOLE AND STICKS OUT TOWARDS POSTERIOR. ALSO THE CHOSEN SCREW PLACEMENTS ARE NOT RECOMMENDED IN THE OPERATIVE TECHNIQUE. ADDITIONALLY BOTH DISTAL SCREWS ARE BROKEN, MOST LIKELY DUE TO WRONG NAIL INSERTION IN COMBINATION WITH HEAVY LOADS AND OBESITY. THE IFU AND OPERATIVE TECHNIQUE DESCRIBES IN DETAIL THE CORRECT USAGE OF GTN NAILS AND SCREWS. NO DISCREPANCIES WERE DETECTED DURING RISK ANALYSIS REVIEW. NO NON-CONFORMITY IDENTIFIED; NO PREVIOUS OR ACTUAL ACTIONS ARE IN PLACE.
IT WAS REPORTED THAT THERE WAS A REVISION OF GTN NAIL, REVISED DUE TO NON-UNION AND HARDWARE FAILURE.
IT WAS REPORTED THAT THERE WAS A REVISION OF GTN NAIL, REVISED DUE TO NON-UNION AND HARDWARE FAILURE.
Devices
| Seq | Brand | Generic | Product Code | Manufacturer | Model | Lot | UDI-DI |
|---|---|---|---|---|---|---|---|
| 181626 | LOCKING SCREW, FULLY THREADED T2 TIBIA Ø5X55 MM | ROD, FIXATION, INTRAMEDULLARY AND ACCESSORIES | HSB | STRYKER TRAUMA KIEL | UNKNOWN |
Patients
| Seq | Age | Sex | Outcome | Treatment |
|---|---|---|---|---|
| 1 | 38 YR | Required Intervention |