MAUDE MDR 6085144

MDR report key
6085144
Report number
1220246-2016-00484
Event key
0
Event type
3
Date of event
2016-10-18
Date received
2016-11-08
Adverse event
3
Product problem
3
Patients in event
0
Reporter occupation
0
Health professional
3
Initial report to FDA
3
Event location
3

Manufacturer Contact#

Contact
VIK BAJNATH, SR MDR ANALYST
Address
1370 CREEKSIDE BOULEVARD NAPLES FL 34108 US
Phone
800-800-8009
Report source
M
Manufacturer link flag
Y

Devices#

Seq, Brand, Generic table
SeqBrandGenericManufacturerProduct codeModelCatalogLotPMA510(k)ImplantEvaluatedAvailability
1ANGEL BMC KITPLATELET AND PLASMA SEPARATOR FOR BONE GRAFT HANDLINGARTHREX, INC.ORGABS-10062621566404R N

Patients#

Sequence, Received, Treatment table
SequenceReceivedTreatmentOutcome
12016-11-0801. O

Event Narratives#

N

Patient 1

PATIENT DEMOGRAPHICS (AGE AT TIME OF EVENT, DATE OF BIRTH) WERE REQUESTED BUT NOT PROVIDED. NO FURTHER PATIENT INFORMATION WAS PROVIDED AT THE TIME OF THIS REPORT OR MADE AVAILABLE IN RESPONSE TO FOLLOW-UP COMMUNICATION. NO ADDITIONAL ADVERSE CONSEQUENCES HAVE BEEN REPORTED FROM THIS EVENT. THIS DEVICE IS USED FOR TREATMENT. NO DEVICE MALFUNCTION IDENTIFIED. AT THIS TIME, IT CANNOT BE DETERMINED IF THE DEVICE MAY HAVE CAUSED OR CONTRIBUTED TO THE PATIENT'S EXPERIENCE. AN EVALUATION OF THE DEVICE CANNOT BE PERFORMED AS THE DEVICE WAS NOT RETURNED TO ARTHREX. DEVICE HISTORY RECORD REVIEW REVEALED NOTHING RELEVANT TO THIS EVENT. ADDITIONAL INFORMATION HAS BEEN REQUESTED BUT NOT MADE AVAILABLE. SHOULD ADDITIONAL INFORMATION BECOME AVAILABLE IT WILL BE REPORTED IN A SUPPLEMENTAL REPORT UPON COMPLETION OF THE INVESTIGATION. THIS IS THE FIRST COMPLAINT OF THIS TYPE FOR THIS PART/LOT COMBINATION. THE POTENTIAL CAUSE(S) OF THIS EVENT WILL BE COMMUNICATED TO THE EVENT REPORTER. IF ADDITIONAL RELEVANT INFORMATION IS RECEIVED, A FOLLOW-UP REPORT WILL BE SUBMITTED. DEVICE REQUESTED BUT NOT YET RECEIVED.

D

Patient 1

IT WAS REPORTED THAT DURING A BMC AND OA/HTO PROCEDURE, THE OPERATING SURGEON ATTEMPTED TO USE THE TROCAR FROM THE KIT IN THE OSTEOTOMY THAT WAS MADE FOR THE HTO BUT THE DRAW WAS UNSUCCESSFUL DUE TO THE OPEN SYSTEM CREATED FROM THE OSTEOTOMY. NEXT THE OPERATING SURGEON MALLETED THE TROCAR INTO THE TIBIAL CREST ABOUT 6 INCHES DISTAL TO THE OSTEOTOMY AND ATTEMPTED A BMC DRAW FROM THAT SITE, WHICH WAS UNSUCCESSFUL. THE SURGEON AND THE SALES REP DISCUSSED THE INCIDENT AND AFTER DISCUSSING WITH A FELLOW SURGEON THEY DETERMINED THAT THEY WOULD TRY TO DRAW VIA THE NOTCH IN THE DISTAL FEMUR. THE TROCAR WAS PLACED IN POSITION AND WAS HIT WITH THE MALLET AND IT ENTERED THE IM CANNULA. THE TROCAR WAS MET WITH SOME RESISTANCE AND THE SURGEON STOPPED IMMEDIATELY. FLUORO WAS UTILIZED TO CONFIRM POSITIONING. THE SURGEON ATTEMPTED ANOTHER DRAW USING THE VACUUM SYRINGES IN THE KITS. THIS ATTEMPT WAS UNSUCCESSFUL AND SURGEON PULLED THE TROCAR OUT OF THE FEMUR. WHEN TROCAR WAS REMOVED THE FELLOW SURGEON REALIZED THAT THE TROCAR TIP WAS BROKEN. THE TIP WAS LODGED IN THE DISTAL FEMUR OF THE PATIENT. FLOURO WAS USED TO TRY AND RECOVER THE TIP BUT WAS UNSUCCESSFUL. PER THE SALES REP, THE OPERATING SURGEON DETERMINED THE BROKEN TIP WAS NOT PROTRUDING INTO THE JOINT AND WOULD NOT BE A PROBLEM FOR THE PATIENT LEAVING IT IN THE DISTAL FEMUR. THE PATIENT WAS INFORMED AND THE PIECE OF THE TROCAR REMAINED IN HIS FEMUR.