IN SITU BENDER-RIGHT 388.112

MAUDE Adverse Event Report

MAUDE data represents reports of adverse events involving medical devices. This maude entry was filed from a 00,07 report with the FDA on 2014-08-15 for IN SITU BENDER-RIGHT 388.112 manufactured by Synthes Tuttlingen.

Event Text Entries

[4878567] It was reported that during surgery utilizing the in-situ benders, the bender tips splayed open. The surgery included 5. 5 mm rods in a deformity construct in levels t6-s2. The case resumed with the construct complete, and without delay or complications for the patient. There were no fragments and the patient outcome was good. The damaged tips were first noticed postoperatively, during cleaning of the instruments. This report is for the right side bender this is report 2 of 2 for (b)(4).
Patient Sequence No: 1, Text Type: D, B5


[11987381] Device was used for treatment, not diagnosis. Additional common device name: hxw. Device is an instrument and is not implanted/explanted. The investigation could not be completed; no conclusion could be drawn, as no product was received. If information is obtained that was not available for the initial medwatch, a follow-up medwatch will be filed as appropriate.
Patient Sequence No: 1, Text Type: N, H10


[31034863] A review of the device history records has been requested. The device was received, the investigation could not be completed, and no conclusion could be drawn, as product is entering the complaint system. 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.
Patient Sequence No: 1, Text Type: N, H10


[33237482] Device was used for treatment, not diagnosis. The device history record review could not be performed as the records could not be identified as device is over 9 years old. The visual inspection of the returned device performed as part of the product investigation reported the part was received with the slot opening at the curved end bent open. Material deformation is evident at both openings. One in situ rod bender right (part# 388. 112 lot# a7qa28) and one in situ rod bender left (part# 388. 113 lot# a7qa28) were returned for the tips reportedly bending open. The benders are included in uss, pangea, and click? X systems for in situ sagittal plane bending of rods. Alternatively, rod benders 388. 91, 388. 92, 388. 112, 388. 113, 388. 117, 388. 961, 03. 620. 020, 03. 622. 060, 03. 622. 061, and 03. 622. 062 may be used to achieve contouring of the rods (technique guides: j4437-b, j7243-b, j6418-c, j5462-b, j9009-b, j6718-a). Product drawings 388_112 rev c and 388_113 were reviewed during the investigation. Both instruments have the slot opening, where the instrument is placed around the rod, bent open. The openings have yielded material along the lateral half suggesting that the instrument may not have been fully seated around the rod when used. Multiple areas of material deformation at the opening also indicate that excessive force may have been used repeatedly. Both benders are made from h900 heat treated 17-4ph and is appropriate for the intended use of the instruments as h900 provides maximum hardness. Wear coupled with user technique may have caused the complaint condition however the user technique is unknown and so the root cause is indeterminate. Review of the product drawings found the material, dimensions, tolerances and finishing process of the instruments adequate for their intended use. The complaint may be a result of gradual wear, applying excessive bending force or user technique although it cannot be definitively determined which contributed to the complaint condition. If information is obtained that was not available for the initial medwatch, a follow-up medwatch will be filed as appropriate.
Patient Sequence No: 1, Text Type: N, H10


MAUDE Entry Details

Report Number2520274-2014-13168
MDR Report Key4013052
Report Source00,07
Date Received2014-08-15
Date of Report2014-07-23
Date of Event2014-07-23
Date Mfgr Received2014-09-02
Device Manufacturer Date2005-07-11
Date Added to Maude2014-08-15
Event Key0
Report Source CodeManufacturer report
Manufacturer LinkY
Number of Patients in Event0
Adverse Event Flag3
Product Problem Flag3
Reprocessed and Reused Flag3
Health Professional3
Initial Report to FDA3
Report to FDA0
Event Location0
Manufacturer ContactLINDA PLEWS
Manufacturer Street1302 WRIGHTS LANE EAST
Manufacturer CityWEST CHESTER PA 19380
Manufacturer CountryUS
Manufacturer Postal19380
Manufacturer Phone6107195000
Manufacturer G1SYNTHES TUTTLINGEN
Manufacturer StreetUNTER HASSLEN 5
Manufacturer CityTUTTLINGEN 78532
Manufacturer CountryGM
Manufacturer Postal Code78532
Single Use3
Previous Use Code3
Event Type3
Type of Report3

Device Details

Brand NameIN SITU BENDER-RIGHT
Generic NameINSTR., BENDING OR CONTOURING
Product CodeHXP
Date Received2014-08-15
Returned To Mfg2014-08-04
Catalog Number388.112
Lot NumberA7QA28
OperatorHEALTH PROFESSIONAL
Device AvailabilityR
Device AgeDA
Device Eval'ed by MfgrY
Device Sequence No1
Device Event Key0
ManufacturerSYNTHES TUTTLINGEN
Manufacturer AddressUNTER HASSLEN 5 TUTTLINGEN PA 19380785 GM 19380 7853


Patients

Patient NumberTreatmentOutcomeDate
10 2014-08-15

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