BEUDAMED
    FDA Adverse Event Malfunction Summary report: N

    APPLICATION INSTRUMENT FOR STERNAL ZIPFIX

    MDR report key: 5813125 · Received July 21, 2016

    Report

    Report Number
    2520274-2016-13570
    Event Type
    Malfunction
    Date Received
    July 21, 2016
    Report Date
    July 7, 2016
    Manufacturer
    SYNTHES MONUMENT
    Product Code
    JDQ
    PMA / PMN Number
    K110789
    Product Problem
    Yes
    Report Source
    Manufacturer report
    Reporter Location
    US
    Reporter Occupation
    OTHER

    Narratives

    Additional Manufacturer Narrative · 1

    DEVICE WAS USED FOR TREATMENT, NOT DIAGNOSIS. ADDITIONAL NARRATIVE: DATE SUBJECT DEVICE WAS RECEIVED BY MANUFACTURER FOR EVALUATION. A SERVICE AND REPAIR EVALUATION WAS PERFORMED FOR THE SUBJECT DEVICE (APPLICATION INSTRUMENT FOR STERNAL ZIPFIX, PART NUMBER 03.501.080, LOT NUMBER 9812895). THE CUSTOMER REPORTED THE FINS WERE BENT AND THE TRIGGER WAS HAVING PROBLEMS. THE REPAIR TECHNICIAN REPORTED THE LEVER ARM WAS BENT. ¿BENT¿ IS THE REASON FOR REPAIR. THE SUBJECT DEVICE IS NOT REPAIRABLE PER THE INSPECTION SHEET. THE CAUSE OF THE ISSUE IS UNKNOWN. THE SERVICE AND REPAIR EVALUATION CONFIRMED THE COMPLAINT CONDITION. THE SUBJECT DEVICE WAS FORWARDED TO SYNTHES CUSTOMER QUALITY FOR ADDITIONAL INVESTIGATION. A REVIEW OF THE SERVICE AND DEVICE HISTORY RECORDS WAS COMPLETED FOR THE SUBJECT DEVICE LOT. MANUFACTURING LOCATION: SYNTHES (B)(4). DATE OF MANUFACTURE JUN 27, 2016. THE REVIEW SHOWED THAT THERE WERE NO ISSUES OR NONCONFORMANCES DURING THE MANUFACTURE OF THE PRODUCT THAT WOULD CONTRIBUTE TO THE COMPLAINT CONDITION. A PRODUCT DEVELOPMENT INVESTIGATION WAS PERFORMED FOR THE SUBJECT DEVICE. THE DEVICE WAS RECEIVED WITH BENT LEAF SPRINGS (BENT UPWARD). THE DEVICE WAS FUNCTIONALLY TESTED AND THE BENT SPRINGS ARE CAUSING A STICKING/JAMMING CONDITION AND NOT ALLOWING THE DEVICE TO FUNCTION AS INTENDED. THUS, THE COMPLAINT CONDITION IS CONFIRMED, CONSISTENT WITH THE REPORTED CONDITION, AND CAN BE REPLICATED. NO FURTHER FUNCTIONAL ISSUES WERE OBSERVED. WHILE A ROOT CAUSE OF THE ISSUE WITH THE TRIGGER COULD NOT BE DETERMINED, REVIEW OF THE FAILURE MODE AND DISCUSSION WITH THE PRODUCT DEVELOPMENT SUBJECT MATTER EXPERT DETERMINED THAT IT IS CONSISTENT WITH THE RESULT OF NOT PROPERLY MAINTAINING THE DEVICE AS INDICATED IN THE TECHNIQUE GUIDE. THIS DEVICE IS PART OF THE STERNAL ZIPFIX SYSTEM AND USED TO TENSION AND CUT THE STERNAL ZIPFIX IMPLANTS. PROPER USE AND MAINTENANCE IS ADDRESSED IN TECHNIQUE GUIDE. THE TECHNIQUE GUIDE PROVIDES INSTRUCTIONS FOR LUBRICATING THE DEVICE PRIOR TO STERILIZATION AND INCLUDES THIS LOCATION AS ONE OF THE THREE SPECIFIC LOCATIONS TO OIL DIRECTLY. AS THE DETAILS REGARDING THE USE AND MAINTENANCE OF THIS DEVICE ARE UNKNOWN A ROOT CAUSE CANNOT BE DEFINITIVELY DETERMINED FOR THIS PORTION OF THE COMPLAINT. A REVIEW OF THE CURRENT DRAWING AND HISTORY FOR THE TOP LEVEL ASSEMBLY WAS PERFORMED. THE FOLLOWING COMPONENT DRAWINGS WERE ALSO REVIEWED; SPRING ASSEMBLY AND PUSHER ASSEMBLY, END CAP COMPONENT AND PUSHER SLEEVE COMPONENT. NO PRODUCT DESIGN ISSUES OR DISCREPANCIES WERE OBSERVED. NO UNADDRESSED ISSUES OR DISCREPANCIES RELATING TO THE COMPLAINT CONDITION WERE OBSERVED AND THE CURRENT DESIGNS WERE DETERMINED TO BE SUITABLE FOR THEIR INTENDED USE WHEN EMPLOYED AND MAINTAINED AS RECOMMENDED. IF INFORMATION IS OBTAINED THAT WAS NOT AVAILABLE FOR THE INITIAL MEDWATCH, A FOLLOW-UP MEDWATCH WILL BE FILED AS APPROPRIATE.

    Additional Manufacturer Narrative · 1

    NO REPORTED PATIENT OR SURGICAL INVOLVEMENT. DATE OF EVENT: UNKNOWN. (B)(4). DEVICE IS AN INSTRUMENT AND IS NOT IMPLANTED OR EXPLANTED. THE COMPLAINANT PART IS EXPECTED TO BE RETURNED FOR MANUFACTURER REVIEW/INVESTIGATION, BUT HAS YET TO BE RECEIVED. (B)(4). INVESTIGATION COULD NOT BE COMPLETED AND NO CONCLUSION COULD BE DRAWN AS NO DEVICE WAS RETURNED. SERVICE HISTORY RECORD REVIEW: NO SERVICE HISTORY REVIEW CAN BE PERFORMED BECAUSE THE LOT/SERIAL NUMBER IS UNKNOWN AND CANNOT BE TRACED. THE MANUFACTURE DATE IS UNKNOWN. THE SERVICE HISTORY REVIEW IS UNCONFIRMED WITHOUT A VALID LOT NUMBER, A REVIEW OF THE DEVICE HISTORY RECORDS CANNOT BE REQUESTED. DEVICE USED FOR TREATMENT, NOT DIAGNOSIS. IF INFORMATION IS OBTAINED THAT WAS NOT AVAILABLE FOR THE INITIAL MEDWATCH, A FOLLOW-UP MEDWATCH WILL BE FILED AS APPROPRIATE.

    Description of Event or Problem · 1

    IT WAS REPORTED THAT THREE (3) APPLICATION INSTRUMENTS FOR STERNAL ZIPFIX WERE FOUND WITH TRIGGER PROBLEMS AND BENT FINS DURING THE STERILIZATION PROCESS. AT THIS TIME, IT IS UNKNOWN IF THE TRIGGER ISSUES AND BENT FINS (WHICH LED TO LEAVER MOVEMENT AND SEATING ISSUES) AFFECTED ALL ITEMS OR IF IT WAS ONE (1) IDENTIFIED MALFUNCTION PER DEVICE. THERE WAS NO REPORTED PATIENT OR SURGICAL INVOLVEMENT. THIS REPORT IS 3 OF 3 FOR (B)(4).

    Devices

    Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
    466847 APPLICATION INSTRUMENT FOR STERNAL ZIPFIX CERCLAGE FIXATION JDQ SYNTHES MONUMENT 9812895

    Patients

    Seq Age Sex Outcome Treatment
    1