MAUDE MDR 3411550

MDR report key
3411550
Report number
3008812173-2013-00002
Event key
0
Event type
3
Date received
2013-08-19
Adverse event
3
Product problem
3
Patients in event
0
Reporter occupation
0
Health professional
3
Initial report to FDA
3
Event location
0

Manufacturer Contact#

Contact
DAVID NICHOLS
Address
900 AIRPORT RD, STE 3B WEST CHESTER PA 19380 US
Phone
484-484-4848
Report source
M
Manufacturer link flag
Y

Devices#

Seq, Brand, Generic table
SeqBrandGenericManufacturerProduct codeModelCatalogLotPMA510(k)ImplantEvaluatedAvailability
1ACCUPORT SIDE TARGETED CANNULA (SELF-DRILLING)NONEKNEE CREATIONS, LLCFGY307.03276038-01M26894Y Y

Patients#

Sequence, Received, Treatment table
SequenceReceivedTreatmentOutcome
12013-08-190

Event Narratives#

D

Patient 1

ON (B)(6) 2013, THE SURGEON PERFORMED A KNEE SCOPE ON A (B)(6) YEAR OLD PT'S LEFT KNEE. THE SURGEON PROCEEDED TO X-RAY THE KNEE IN ORDER TO PLACE THE ACCUPORT CANNULA INTO THE MEDIAL FEMORAL CONDYLE. UPON PLACING THE CANNULA HE INITIALLY WENT IN TOO FAR AND HE TRIED TO BACK IT OUT USING THE PIN DRIVER. THE PIN DRIVER WAS UNABLE TO GRASP THE PIN TO REVERSE THE PIN TO BACK IT OUT. HE THEN TRIED TO SPIN THE PIN AND CANNULA MANUALLY. HE MOVED THE KNEE BACK INTO EXTENDED AND TRIED TO BACK IT OUT WITH THE PIN DRIVER AGAIN. THE CANNULA, SLIGHTLY PROXIMAL TO THE TIP, HAD BROKEN OFF AND WAS STILL IN THE FEMUR. THE SURGEON DECIDED THAT GOING AFTER THE BROKEN PIECE WOULD DO MORE HARM TO THE BONE THAN GOOD.

N

Patient 1

THE CANNULA IN QUESTION WAS RETRIEVED AND REVIEWED UNDER CLOSE EXAMINATION. THERE WERE NO CLEAR VISIBLE DEFECTS OF MANUFACTURING; NO CLEAR DEFECTS OR EVIDENCE THAT WOULD POINT TO THE EXACT NATURE OF THE FAILURE. THE PRODUCT FAILURE OCCURRED IN THE PROXIMAL AREA OF THE THREADS IN THE OUTER CANNULA. THERE WERE VISIBLE SCORES AND MARKS ON THE DRIVING STYLUS PIN OF THE DEVICE. IT WOULD APPEAR THE SURGICAL DRILL/DRIVER DID NOT ADEQUATELY GRIP INTO THE DEVICE BUT LEFT FOCAL SCORES OR MARKS IN SOME AREAS. UPON FURTHER INVESTIGATION, THE REP PRESENT DURING SURGERY PROVIDED SOME FURTHER DETAILS: THE PT DID WEIGHT LIFTING AND MOST LIKELY HAD COMPARABLY DENSER HARD BONE. THE SURGICAL DRILL/DRIVER USED IN THE CASE WAS AN OLD DRIVER WHERE THE CONNECTION LOOSELY FIT ONTO THE PIN AND THE DRILL RELIED ON AND PRESSURE TO HOLD ONTO THE PIN. THE SURGERY WAS DONE FREEHAND WITHOUT THE INSTRUMENT GUIDE.