2.1 RIO ROBOTIC ARM INT. ORTH. SYSTEM
Report
- Report Number
- 3005985723-2015-00011
- Event Type
- Injury
- Date Received
- February 10, 2015
- Date of Event
- January 12, 2015
- Report Date
- January 12, 2015
- Manufacturer
- MAKO SURGICAL CORP.
- Product Code
- OLO
- PMA / PMN Number
- K112507
- Adverse Event
- Yes
- Report Source
- Manufacturer report
- Reporter Location
- FL, US
- Reporter Occupation
- OTHER
Narratives
AS PART OF NORMAL COMPLAINT FOLLOW-UP, AN EVALUATION OF THE EVENT IS BEING COMPLETED AT MAKO SURGICAL. A SUPPLEMENTAL REPORT WILL BE FILED WHEN ADDITIONAL INFORMATION IS OBTAINED.
REPORTED EVENT: DURING PARTIAL KNEE REPLACEMENT SURGERY, THE TIP OF A 3.2X140MM BONE PIN BROKE OFF AND EMBEDDED IN PATIENT AS SURGEON ATTEMPTED DRILL THE PIN INTO THE PATIENT. DEVICE EVALUATION AND RESULTS: VISUAL INSPECTION WAS NOT PERFORMED AS THE DEVICE WAS NOT RETURNED FOR EVALUATION. DIMENSION INSPECTION COMPLETED AT THE TIME OF MANUFACTURING SHOWS THE LOT WAS WITHIN SPECIFICATION. DEVICE HISTORY REVIEW: REVIEW OF THE DEVICE HISTORY RECORDS FOR THE ASSOCIATED LOT INDICATED (B)(4) DEVICES (111621 NON-STERILE BONE PIN, SINGLE) WERE MANUFACTURED AND SHIPPED TO (B)(4) ON 12/10/2014 AND ACCEPTED INTO FINAL STOCK ON 12/10/2014 PER ERP. COMPLAINT HISTORY REVIEW: A REVIEW OF COMPLAINTS IN TRACKWISE AND CATSWEB RELATED TO P/N 111620, LOT NUMBER W38525 SHOWS NO COMPLAINTS RELATED TO THE FAILURE IN THIS INVESTIGATION. TRACKING OF COMPLAINTS RELATED TO THE 111620 PART NUMBER WILL BE TRACKED THROUGH (B)(4). CONCLUSIONS: AS PART OF THE INVESTIGATION INTO THIS COMPLAINT, THE STRYKER REP THAT WAS PRESENT FOR THE CASE WAS CONTACTED. IT WAS DETERMINED THAT THE SURGEON DID NOT USE THE DRILL GUIDE DURING PLACEMENT OF BOTH BONE PINS. DUE TO THE NON-USE OF A DRILL GUIDE AS REQUIRED PER MAKOPLASTY PARTIAL KNEE APPLICATION USER GUIDE, 206388 REVISION 01 FOR PLACEMENT OF BONE PINS, THIS EVENT CONSTITUTES AN OFF-LABEL USE OF THE DEVICE. CORRECTIVE ACTION/PREVENTIVE ACTION: NO ACTION IS REQUIRED AT THIS TIME AS THERE IS NO INDICATION TO SUGGEST A PRODUCT NON-CONFORMITY OR UNANTICIPATED HAZARD.
THE SURGEON PERFORMED A PARTIAL KNEE ARTHROPLASTY PROCEDURE ON (B)(6) 2015 USING THE ROBOTIC ARM INTERACTIVE ORTHOPEDIC SYSTEM (RIO) AND RESTORIS MULTICOMPARTMENTAL KNEE (MCK) IMPLANTS. DURING THE CASE, THE TIP OF THE BONE PIN SHEARED OFF IN THE PATIENT'S TIBIA. THE SURGEON DECIDED TO LEAVE THE TIP OF THE BONE PIN IN THE PATIENT'S TIBIA. THE OUTCOME OF THE CASE WAS SUCCESSFUL.
THE SURGEON PERFORMED A PARTIAL KNEE ARTHROPLASTY PROCEDURE ON (B)(6) 2015 USING THE ROBOTIC ARM INTERACTIVE ORTHOPEDIC SYSTEM (RIO) AND RESTORIS MULTICOMPARTMENTAL KNEE (MCK) IMPLANTS. DURING THE CASE, THE TIP OF THE BONE PIN SHEARED OFF IN THE PATIENT'S TIBIA. THE SURGEON DECIDED TO LEAVE THE TIP OF THE BONE PIN IN THE PATIENT'S TIBIA. THE OUTCOME OF THE CASE WAS SUCCESSFUL.
Devices
| Seq | Brand | Generic | Product Code | Manufacturer | Model | Lot | UDI-DI |
|---|---|---|---|---|---|---|---|
| 95200 | 2.1 RIO ROBOTIC ARM INT. ORTH. SYSTEM | STEROTAXIC DEVICE | OLO | MAKO SURGICAL CORP. |
Patients
| Seq | Age | Sex | Outcome | Treatment |
|---|---|---|---|---|
| 1 | 73 YR | Required Intervention |