CHISEL HANDLE 399.54

MAUDE Adverse Event Report

MAUDE data represents reports of adverse events involving medical devices. This maude entry was filed with the FDA on 2019-02-22 for CHISEL HANDLE 399.54 manufactured by Wrights Lane Synthes Usa Products Llc.

Event Text Entries

[137525071] Part: 399. 540; lot: 8891875; manufacturing site: (b)(4); release to warehouse date: june 12, 2014. The device history record shows this lot was processed through the normal manufacturing and inspection operations with no rework or nonconformities noted. This lot met all functional and visual criteria at the time of release with no issues documented during the manufacturing process. Review of the device history record showed that there were no issues during the manufacture of this product which would contribute to this complaint condition. Visual inspection: device was received at cq in two pieces (screw separate from chisel handle assembly). Visual inspection of the returned device performed at customer quality (cq) identified the condition of a broken screw. A portion of the distal tip of the screw component has broken off. This is causing difficulty inserting the screw into the chisel handle. It was also observed that the proximal hex drive recess in the screw is malformed / rounded. Functional test: the screw is difficult to insert into the chisel handle because a portion of the distal leading thread form has broken off. The received condition agrees with the complaint description. The complaint can be replicated with the returned device. Device history record (dhr) review: the returned device was manufactured in june 2014. The device history record shows this lot was processed through the normal manufacturing and inspection operations with no rework or nonconformities noted. This lot met all functional and visual criteria at the time of release with no issues documented during the manufacturing process. Review of the device history record showed that there were no issues during the manufacture of this product which would contribute to this complaint condition. Document/specification review: the following design drawings were reviewed during this investigation. Chisel handle assembly design drawing. Screw component design drawing. No product design issues or discrepancies were observed during this investigation. Dimensional inspection: a dimensional inspection relevant to this complaint condition could not be performed because of the post manufacturing damage. Material analysis: the design specified the screw component to be manufactured from 1. 4057 material and hardened & tempered to 43 +5 / -0 hrc. A material confirmation for the screw component from the time of manufacture could not be reviewed during this investigation because components were not lot tracked. Conclusion: a definitive root cause for the post manufacturing damage could not be determined based on the provided information. However, per the reported complaint description "it was also reported that it must have been somebody who was new who did not know how to take it apart". This complaint is confirmed, however, no product design issues or manufacturing discrepancies that would contribute to the reported complaint condition were identified during this investigation. No new, unique or different patient harms were identified as a result of this evaluation. Additional monitoring for any potential safety signals will be conducted through complaint trending and other post market safety surveillance activities. Based on the investigation findings, it has been determined that no corrective and/or preventative action is proposed. 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


[137525072] It was reported that during decontamination on an unknown date, the screw of the chisel handle that tightens down and keeps the blade intact had fallen off. It was still in the thread of the handle. Sales consultant thought the event most likely did not happen during a procedure, but afterward when the instrument was taken apart, potentially by somebody who was new who did not know how to take apart the device. There was no patient involvement. Concomitant device: chisel blade (part: unknown, lot: unknown, quantity: 1). This report is for a chisel handle. This is report 1 of 1 for (b)(4).
Patient Sequence No: 1, Text Type: D, B5


MAUDE Entry Details

Report Number2939274-2019-56596
MDR Report Key8361588
Date Received2019-02-22
Date of Report2018-11-30
Date Mfgr Received2019-02-21
Device Manufacturer Date2014-06-12
Date Added to Maude2019-02-22
Event Key0
Report Source CodeManufacturer report
Manufacturer LinkY
Number of Patients in Event0
Adverse Event Flag3
Product Problem Flag3
Reprocessed and Reused Flag3
Reporter OccupationOTHER HEALTH CARE PROFESSIONAL
Health Professional3
Initial Report to FDA3
Report to FDA3
Event Location3
Manufacturer ContactKARA DITTY-BOVARD
Manufacturer Street1302 WRIGHTS LANE EAST
Manufacturer CityWEST CHESTER PA 19380
Manufacturer CountryUS
Manufacturer Postal19380
Manufacturer Phone6103142063
Manufacturer G1WERK BETTLACH (CH)
Manufacturer StreetMURACHERSTRASSE 3
Manufacturer CityBETTLACH 2544
Manufacturer CountrySZ
Manufacturer Postal Code2544
Single Use3
Previous Use Code3
Event Type3
Type of Report0

Device Details

Brand NameCHISEL HANDLE
Generic NameCHISEL, BONE, SURGICAL
Product CodeEML
Date Received2019-02-22
Returned To Mfg2018-12-17
Catalog Number399.54
Lot Number8891875
OperatorHEALTH PROFESSIONAL
Device AvailabilityR
Device Eval'ed by MfgrY
Device Sequence No1
Device Event Key0
ManufacturerWRIGHTS LANE SYNTHES USA PRODUCTS LLC
Manufacturer Address1302 WRIGHTS LANE EAST WEST CHESTER PA 19380 US 19380


Patients

Patient NumberTreatmentOutcomeDate
10 2019-02-22

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