UNIVERSAL CLAMP, 5.5MM TIILE N/A SN2027-0-20006S

MAUDE Adverse Event Report

MAUDE data represents reports of adverse events involving medical devices. This maude entry was filed from a foreign,health professional,u report with the FDA on 2016-10-12 for UNIVERSAL CLAMP, 5.5MM TIILE N/A SN2027-0-20006S manufactured by Zimmer Spine.

Event Text Entries

[57159243] Current information is insufficient to permit a valid conclusion about the cause of this event. If additional information is obtained that adds value to the relevant content of this report and/or a conclusion can be drawn, a follow-up report will be sent.
Patient Sequence No: 1, Text Type: N, H10


[57159244] It was reported that a patient lost neurological signals on the left side during a deformity correction procedure. The first loss of signals occurred after a cobalt chrome rod was installed and locked into place. The surgeon loosened the set screws and removed the rod. After a short duration of time, the patient's signals returned to normal. The surgeon reduced the amount of rotational correction to the patient's spine and reinstalled and tightened a cobalt chrome rod. After the construct was completed, the patient lost neurological signals a second time. This required the prompt removal of the rod from both sides resulting in both cross connectors, all set screws and all locking screws to be removed from the patient. The pedicle screws remained in place. The surgeon then decided to change to a titanium rod instead of cobalt chrome. After this construct was completed, the patient lost neurological signals a third time. This again required the prompt removal of all set screws, all universal clamp locking screws, both rods and both cross connectors from the patient. The surgeon then made the decision to fuse the patient in-situ instead of correcting the deformity. As he sequentially tensioned and final tightened the 6 universal clamps as per the surgical technique, 3 out of the 6 locking screws on the universal clamps stripped. This resulted in the need for 3 new locking screws to be used. The patient maintained neurological signals after this final construct was installed, and the procedure was completed. In a post-case discussion with the surgeon and the anaesthetist, the repeated loss of neurological signals was due to the flexibility of the patient's musculoskeletal structure combined with the positioning of his blood vessels and spinal cord in the spinal canal. This resulted in dr gray's need to adjust his planned amount of correction and also the material of the rod during the case. It was a clinical decision that led to the need for multiple re-tightening of the universal clamps resulting in 3 new locking screws needing to be used.
Patient Sequence No: 1, Text Type: D, B5


[62741047] No product was available for return. A review of the manufacturing records did not identify any issues which would have contributed to this event. The information received states that the closure tops were installed, loosened, and reinstalled several times during the procedure. The labeling states implants are single-use only. Therefore, they are not intended to be installed multiple times. Additional information in device manufacture date and evaluation codes. This is report one of two for this event. Reference report 3003853072-2016-00157.
Patient Sequence No: 1, Text Type: N, H10


MAUDE Entry Details

Report Number3003853072-2016-00123
MDR Report Key6020482
Report SourceFOREIGN,HEALTH PROFESSIONAL,U
Date Received2016-10-12
Date of Report2016-12-16
Date of Event2016-06-10
Date Mfgr Received2016-12-07
Device Manufacturer Date2015-06-09
Date Added to Maude2016-10-12
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 FDA3
Event Location3
Manufacturer ContactTERESA GEORGE
Manufacturer Street23 PARVIS DES CHARTRONS
Manufacturer CityBORDEAUX 33080
Manufacturer CountryFR
Manufacturer Postal33080
Manufacturer Phone0003034437
Manufacturer G1ZIMMER SPINE
Manufacturer Street23 PARVIS DES CHARTRONS
Manufacturer CityBORDEAUX 33080
Manufacturer CountryFR
Manufacturer Postal Code33080
Single Use3
Previous Use Code3
Removal Correction NumberN/A
Event Type3
Type of Report3

Device Details

Brand NameUNIVERSAL CLAMP, 5.5MM TIILE
Generic NameUNIVERSAL CLAMP SPINAL FIXATION SYSTEM
Product CodeOWI
Date Received2016-10-12
Model NumberN/A
Catalog NumberSN2027-0-20006S
Lot NumberW53195
ID NumberN/A
OperatorHEALTH PROFESSIONAL
Device AvailabilityN
Device AgeDA
Device Eval'ed by MfgrR
Device Sequence No1
Device Event Key0
ManufacturerZIMMER SPINE
Manufacturer Address23 PARVIS DES CHARTRONS BORDEAUX 33080 FR 33080


Patients

Patient NumberTreatmentOutcomeDate
101. Hospitalization; 2. Required No Informationntervention 2016-10-12

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