BEUDAMED
    FDA Adverse Event Injury Summary report: N

    4.2MM THREE-FLUTED DRILL BIT QC/330MM/100MM CALIBRATION

    MDR report key: 6349598 · Received February 22, 2017

    Report

    Report Number
    2520274-2017-10570
    Event Type
    Injury
    Date Received
    February 22, 2017
    Date of Event
    January 27, 2017
    Report Date
    January 27, 2017
    Manufacturer
    SYNTHES USA
    Product Code
    HTW
    PMA / PMN Number
    EXEMPT
    Adverse Event
    Yes
    Product Problem
    Yes
    Report Source
    Manufacturer report
    Reporter Location
    WV, US
    Reporter Occupation
    PHYSICIAN

    Narratives

    Additional Manufacturer Narrative · 1

    (B)(6). A PRODUCT INVESTIGATION WAS COMPLETED : THE 03.010.441 LOT NUMBER 14-1990 AIMING ARM AND 03.010.440 LOT NUMBER 15-7233 INSERTION HANDLE WERE RETURNED AND REPORTED TO HAVE CONTRIBUTED TO THE 03.010.061 DRILL BIT MISSING THE LOCKING HOLE. THIS COMPLAINT CONDITION WAS LIKELY CAUSED BY PRESSURE FROM SOFT TISSUE OR OTHER INTRAOPERATIVE CONDITIONS; HOWEVER, THIS COMPLAINT IS NOT LIKELY A RESULT OF ANY DESIGN OR MANUFACTURING RELATED DEFICIENCY. A VISUAL INSPECTION, DEVICE HISTORY RECORD REVIEW, COMPLAINT HISTORY REVIEW, DESIGN AND CLINICAL RISK MANAGEMENT REVIEW, AND DRAWING REVIEW WERE PERFORMED AS PART OF THIS INVESTIGATION. THIS COMPLAINT IS UNCONFIRMED. THE RETURNED 03.010.442 LOT NUMBER 7660447 12.0MM/8.0MM PROTECTION SLEEVE WITH FLATS WAS RECEIVED WITHOUT ALLEGATION OR IDENTIFIABLE COMPLAINT CONDITION. THE 03.010.061 4.2MM THREE-FLUTED DRILL BIT AND 03.010.064 8.0MM/3.2MM DRILL SLEEVE USED DURING THIS PROCEDURE WERE NOT RETURNED. PER THE TECHNIQUE GUIDE, THE 03.010.441 AIMING ARM, 03.010.440 INSERTION HANDLE, AND 03.010.061 4.2MM THREE-FLUTED DRILL BIT ARE INSTRUMENTS ROUTINELY USED IN THE SUPRAPATELLAR INSTRUMENTATION FOR TITANIUM CANNULATED TIBIAL NAILS SYSTEM. THE DRILL BIT WAS REPORTED TO HAVE MISSED THE NAIL DURING SURGERY AND THAT THE RETURNED INSERTION HANDLE AND AIMING ARM CONTRIBUTED TO THE MISALIGNMENT. THIS CONDITION IS UNCONFIRMED; THE RETURNED INSERTION HANDLE AND AIMING ARM ASSEMBLE PROPERLY, AND ALONG WITH THE RETURNED PROTECTION SLEEVE, ACCURATELY TARGET LOCKING HOLE LOCATIONS. THE IMPLANTED NAIL AND DRILL BIT USED DURING SURGERY WERE NOT RETURNED TO FULLY FUNCTIONALLY TEST THE CONSTRUCT. IT IS LIKELY THAT PRESSURE FROM SOFT TISSUE OR OTHER INTRAOPERATIVE CONDITIONS HAS LED TO THIS COMPLAINT CONDITION. THE AIMING ARM WAS MANUFACTURED IN SEPTEMBER 2014 AND IS OVER TWO YEARS OLD. THE INSERTION HANDLE WAS MANUFACTURED IN MARCH 2016 AND IS A YEAR OLD. THE BALANCE OF EACH OF THE RETURNED DEVICES IS IN OTHERWISE FAIRLY GOOD CONDITION WITH ONLY SOME SUPERFICIAL WEAR. THE RELEVANT DRAWINGS WERE REVIEWED AND DETERMINED TO BE SUITABLE FOR THE INTENDED DESIGN, APPLICATION AND DIMENSIONAL CONFORMITY WHEN USED AS RECOMMENDED. THE CONDITION OF THE RETURNED DEVICE DOES NOT AGREE WITH THE COMPLAINT DESCRIPTION. THE COMPLAINT CONDITION FOR THIS DEVICE CANNOT BE REPLICATED. UPON REVIEW OF THE DEVICE HISTORY RECORD, NO NON-CONFORMANCE REPORTS GERMANE TO THE COMPLAINT CONDITION WERE GENERATED DURING THE PRODUCTION OF THIS DEVICE. DEVICE WAS 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.

    Additional Manufacturer Narrative · 1

    ADDITIONAL DEVICE PRODUCT CODE USE: FSM. (B)(4). DEVICE IS AN INSTRUMENT AND IS NOT IMPLANTED / EXPLANTED. DEVICE IS NOT EXPECTED TO BE RETURNED FOR MANUFACTURER REVIEW/INVESTIGATION. (B)(4). DEVICE EVALUATION/INVESTIGATION COULD NOT BE COMPLETED; NO CONCLUSION COULD BE DRAWN AS PRODUCT WAS NOT RETURNED TO MANUFACTURER. DEVICE HISTORY RECORDS REVIEW COULD NOT BE COMPLETED WITHOUT LOT NUMBER. DEVICE WAS 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 ON (B)(6) 2017, DURING A SUPRAPATELLAR INSERTION OF A NAIL, THE DRILL BIT CONTACTED THE NAIL THROUGH THE AIMING ARM AND INSERTION HANDLE. HAVING MISSED THE LOCKING HOLE OF THE NAIL, THE DRILL BIT WAS BACKED OUT AND THE INNER SLEEVE WAS REMOVED. ADDITIONAL FLUOROSCOPY WAS USED TO LOCATE THE LOCKING HOLE OF THE NAIL. WITH THE INNER SLEEVE REMOVED, SURGEON WAS THEN ABLE TO ALIGN THE DRILL BIT WITH THE LOCKING HOLE OF THE NAIL. PROCEDURE WAS DELAYED APPROXIMATELY TWO MINUTES BUT WAS COMPLETED SUCCESSFULLY WITH NO HARM TO PATIENT. CONCOMITANT DEVICES REPORTED: 9 MM TITANIUM CANNULATED TIBIAL NAIL (PART# 04.034.349S, LOT# 9848027, QUANTITY 1), PROTECTION SLEEVE WITH FLATS FOR SUPRAPATELLAR (PART# 03.010.442, LOT# 7660447, QUANTITY 1). THIS REPORT IS FOR ONE (1) 4.2 MM THREE FLUTED DRILL BIT. THIS IS REPORT 1 OF 4 FOR (B)(4).

    Devices

    Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
    131398 4.2MM THREE-FLUTED DRILL BIT QC/330MM/100MM CALIBRATION BIT,DRILL HTW SYNTHES USA

    Patients

    Seq Age Sex Outcome Treatment
    1 22 YR Required Intervention PART# 03.010.442, LOT# 7660447, QUANTITY 1| PART# 04.034.349S, LOT# 9848027, QUANTITY 1