inforMED

HOEN

Received Oct 8, 2015 · Event occurred Aug 13, 2015

Report 3007208013-2015-00026 · MDR key 5147864

Device

Generic name

Dural Separator

Model number

65-1102

Catalog number

65-1102

Product problems

  • Insufficient Device Problem Information
  • Appropriate Device Problem Term/Code Not Available

Patient

43 YR

  • No Known Impact Or Consequence To Patient

Narrative

Additional Manufacturer Narrative

SYMMETRY DID NOT RECEIVE THE BROKEN DEVICE BACK FROM THE HOSPITAL. DEVICE FAILURE WAS DETERMINED TO BE MISUSE OF THE PRODUCT. INSTRUMENT SPECIALIST ON SITE INDICATED: DEVICE IS INTENDED TO SEPARATE THE DURA MATER THAT COATS THE BRAIN AND THE SPINAL CORD, DEVICE SHOULD NOT BE STRUCK.

Description of Event or Problem

DURING A POSTERIOR LUMBAR DISCECTOMY THE TIP OF THE HOEN DURAL SEPARATOR BROKE OFF INSIDE THE PATIENT WHEN STRUCK WITH A MALLET BY THE SURGEON. A C-ARM X-RAY WAS BROUGHT IN TO LOCATE THE BROKEN TIP THAT WAS IN THE PATIENT. THE BROKEN PIECE WAS RECOVERED WITHOUT HARM TO THE PATIENT. THE DEVICE WAS DISPOSED OF.

Remedial action

  • Other