MAUDE MDR 8432349

MDR report key
8432349
Report number
1818910-2019-87742
Event key
0
Event type
3
Date of event
2019-02-04
Date received
2019-03-19
Adverse event
3
Product problem
3
Patients in event
0
Reporter occupation
100
Health professional
3
Initial report to FDA
3
Event location
3

Manufacturer Contact#

Contact
MS. KARA DITTY-BOVARD
Address
1210 WARD AVENUE WEST CHESTER PA 19380 US
Phone
610-610-6103
Report source
M
Manufacturer link flag
Y

Devices#

Seq, Brand, Generic table
SeqBrandGenericManufacturerProduct codeModelCatalogLotPMA510(k)ImplantEvaluatedAvailability
1IN-CONDL CHISEL 8X10X7 3/4 INKNEE INSTRUMENT : CUTTING INSTRUMENTSDEPUY ORTHOPAEDICS INC USFZO242101000S02015050* R

Patients#

Sequence, Received, Treatment table
SequenceReceivedTreatmentOutcome
12019-03-190

Event Narratives#

N

Patient 1

IF INFORMATION IS OBTAINED THAT WAS NOT AVAILABLE FOR THE INITIAL MEDWATCH, A FOLLOW-UP MEDWATCH WILL BE FILED AS APPROPRIATE. DEVICE IS AN INSTRUMENT AND IS NOT IMPLANTED/EXPLANTED. INVESTIGATION SUMMARY: EXAMINATION OF THE RETURNED DEVICE CONFIRMED THE REPORTED EVENT. ADDITIONALLY, THE TIP OF THE DEVICE WAS IDENTIFIED AS CHIPPED. THE COMPLAINT CONSISTED OF (1) 242101000 IN-CONDL CHISEL 8X10X7 3/4 IN, LOT NUMBER S02015050 EXAMINATION OF THE SUBMITTED IN-CONDL CHISEL 8X10X7 3/4 IN CONFIRMED THE DEVICE WAS WORN. ADDITIONALLY, THE TIP OF THE DEVICE WAS IDENTIFIED AS CHIPPED. THE BROKEN OFF FRAGMENT WAS NOT RETURNED. THE INITIAL REPORTING STATED NO PIECES OF THE DEVICE WERE LEFT IN THE PATIENT. THE RADEL HANDLE HAS SCRATCHES AND DISCOLORATION EXPECTED WITH NORMAL USE OF THE INSTRUMENTS. WEAR MARKS WERE ALSO PRESENT. A COMPLAINT DATABASE SEARCH AGAINST PRODUCT CODE 242101000 FOUND SIMILAR REPORTED EVENTS. ADDITIONAL REPORTED EVENT WAS INVESTIGATED AND FOUND THE TIPS OF THE CHISELS WERE LOADED BEYOND THE MATERIAL LIMIT RESULTING IN MIXED MODE DUCTILE AND BRITTLE OVERLOAD OF THE MATERIAL AND FRACTURE. THE ROOT CAUSE IS ATTRIBUTED TO USER ERROR/TECHNIQUE. THE TIP OF THE CHISEL WAS LOADED BEYOND THE MATERIAL LIMIT RESULTING IN MIXED MODE DUCTILE AND BRITTLE OVERLOAD OF THE MATERIAL AND FRACTURE. NO EVIDENCE WAS FOUND INDICATING PRODUCT ERROR WAS A CONTRIBUTING FACTOR TO THE DEVICE BREAKAGE AND THE NEED FOR CORRECTIVE ACTION WAS NOT INDICATED. MONITOR COMPLAINTS. DEPUY CONSIDERS THE INVESTIGATION CLOSED. SHOULD ADDITIONAL INFORMATION BE RECEIVED, THE INFORMATION WILL BE REVIEWED AND THE INVESTIGATION WILL BE RE-OPENED AS NECESSARY.

D

Patient 1

IT WAS REPORTED THAT THE TIPS OF THE INSTRUMENTS WERE WORN AND NEED REPLACING. THERE WERE NO BROKEN PARTS, NO BROKEN PIECES AND NO INSTRUMENTS LEFT IN THE PATIENT. EXAMINATION OF THE RETURNED DEVICE CONFIRMED THE REPORTED EVENT. ADDITIONALLY, THE TIP OF THE DEVICE WAS IDENTIFIED AS CHIPPED.