MAUDE MDR 6181674

MDR report key
6181674
Report number
2183456-2016-00008
Event key
0
Event type
3
Date received
2016-12-16
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
MS KATHLEEN BARLOW
Address
1901 WILLIAM STREET RACINE WI 53404 US
Phone
262-262-2626
Report source
M
Manufacturer link flag
Y

Devices#

Seq, Brand, Generic table
SeqBrandGenericManufacturerProduct codeModelCatalogLotPMA510(k)ImplantEvaluatedAvailability
1ANCHOR BOLT-LSB STYLEANCHOR BOLT-LSB STYLEAD-TECH MEDICAL INSTRUMENT CORP.GCZUNKNOWNUNKNOWNR N

Patients#

Sequence, Received, Treatment table
SequenceReceivedTreatmentOutcome
12016-12-1601. O

Event Narratives#

N

Patient 1

ACCORDING TO AD-TECH CLINICAL SPECIALIST, THE ANCHOR BOLTS MOST LIKELY BROKE OR BENT AFTER IMPLANTATION. IN THIS SPECIFIC CASE (AS STATED IN THE EVENT DESCRIPTION), THE PATIENT EXPERIENCED A GRAND MAL SEIZURE WHICH RESULTED IN THE PATIENT PULLING THE ELECTRODES OUT. THE MAJORITY OF THE ANCHOR BOLT BREAKS OCCURRED AT THE THREADS ON THE BOLTS. BECAUSE OF THIS, THE SURGEON HAD TO MAKE A BIGGER INCISION DURING EXPLANT. IT WAS MENTIONED THAT PER PROTOCOL AT MT. SINAI, ALL SEEG PATIENTS ARE CONFINED TO THEIR BEDS IN THE ICU AFTER SURGERY AND FOR THE DURATION OF RECORDING. PADDING IS USED AROUND THE BED FOR SAFETY PROTOCOL. THIS INVESTIGATION IS CURRENTLY STILL ONGOING.

D

Patient 1

AD-TECH WAS MADE AWARE OF AN ISSUE ON (B)(6) 2016 IN REGARDS TO THE USE OF THEIR CRANIAL ANCHOR BOLTS. THE CUSTOMER REPORTED THAT THEY EXPERIENCED SEVERAL ANCHOR BOLTS THAT EITHER BROKE OR BENT DURING THE COURSE OF THE SURGERY PROCESS, RESULTING IN MORE INVASIVE EXPLANT INCISIONS. IT WAS STATED THAT THE CUSTOMER NOTICED THE BOLTS BROKE OR BENT AFTER IMPLANT, DURING POST-OPERATIVE MONITORING. FURTHER INFORMATION WAS RECEIVED ON (B)(6) 2016. IT WAS FOUND THAT THE PATIENT HAD 13 CRANIAL ANCHOR BOLTS IMPLANTED AND ALL 13 ANCHOR BOLTS BROKE. THE PATIENT EXPERIENCED A GRAND MAL SEIZURE DURING POST-OPERATIVE MONITORING WHICH RESULTED IN THE PATIENT PULLING THE ELECTRODES OUT. MAJORITY OF THE ANCHOR BOLT BREAKS OCCURRED AT THE THREADS ON THE BOLTS. BECAUSE OF THIS, THE SURGEON HAD TO MAKE A BIGGER INCISION DURING EXPLANT. TO DATE, THERE HAVE BEEN NO REPORTS IN REGARDS TO NEGATIVE IMPACT TO PATIENT SAFETY.