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Spine & Trauma 3D Navigation recallZ-1082-2019 · Brainlab AG · initiated Feb 27, 2019

Terminated

Is my device affected?

  1. Compare the model, catalog and lot or serial numbers on your device or its packaging with the code information below. A recall usually covers only specific models or lots.
  2. If yours is listed, follow the instructions from Brainlab AG or your healthcare provider. The company's action is summarized under what the company is doing.
  3. Do not stop using a prescribed or implanted device on your own — talk to your healthcare provider first.

Where to find your model and lot numbers · What recall classes and statuses mean

Why it was recalled

In certain occurrences, the affected navigation software application might unexpectedly display a navigated instrument in an axial, coronal/sagittal (ACS) view representation with fixed planes in the image reconstruction (the not-updated ACS view ), instead of displaying the desirable view representation Inline View , which is commonly used for navigating invasive instruments at the spine. This could lead the surgeon to be unable to determine the position of the navigated instrument. This might occur after a crash restore or after changing between different navigation workflows during the same patient treatment.

FDA root cause category: Software design

What the company is doing

The firm, BrainLab, notified their existing customer base by email on with a letter entitled "URGENT FIELD SAFETY NOTICE / PRODUCT NOTIFICATION" 02/25/2019. The notice explained the issue, product and actions to be taken. The customers were instructed to do the following: "User Corrective Action: 1. Avoid workflow changes with already registered datasets, if possible. If not absolutely necessary (e.g., for intraoperative screw planning), avoid switching between the workflow application selections 3D Navigation Intraoperative Imaging and 3D Navigation during one patient treatment. 2. After restarting the application with a previously registered dataset (crash restore or workflow change), always activate and deactivate the sub-menu Orientation once to ensure that the correct, expected view representations are displayed for the current session. Please continue to follow the instructions and warnings as described in the user guide. Especially relevant is the following warning in the Brainlab Spine & Trauma 3D Navigation 1.0 Software User Guide: Before beginning any surgical step, always ensure that navigation accuracy can be sufficiently maintained. If a surgical step could easily lead to reference displacement, remount the reference at an optimal position with a reduced possibility of displacement, and then register and verify again. The following methods can be used to ensure accuracy is sufficient: - Landmark verification - Fluoroscopy (compare the instrument location in the fluoro image with the display on the navigation system)" Brainlab will provide all affected customers with a software revision of Spine & Trauma Navigation Software with the described issue corrected. Brainlab will actively contact you, starting in June 2019 to schedule the update. If you have any questions, contact the Customer Hotline: +49 89 99 15 68 1044 or +1 800 597 5911 (for US customers)

Recall details

Recall number
Z-1082-2019
Status
Terminated
Initiated by the company
Feb 27, 2019
Posted by the FDA
Apr 15, 2019
Recalling firm
Brainlab AG
Quantity
148 units
Product code
HAW
FDA submissions
K070106
Distribution
Worldwide Distribution: US (Nationwide) and countries of: Australia, Austria, Belgium, Canada, Czech Republic, Denmark, Ecuador, France, Germany, Greece, Hong Kong, Ireland, Italy, Japan, Kazakhstan, Malaysia, New Zealand, Philippines, South Africa, Spain, Sweden, Switzerland, Taiwan, Thailand and United Kingdom.

Product description

Spine & Trauma 3D Navigation 1.0 (subpart of the system Navigation Software Spine & Trauma 3D, Version 3.0 ) Intended Use The Spine & Trauma Navigation System is intended as an intraoperative image-guided localization system to enable minimally invasive surgery.

Code information (models, lots, serial numbers)

Version 1.0.0.249, GTIN 04056481140328

Devices named in this recall

1 device in the FDA device registry whose identifier appears in the recall's code information.

Product lines

Other devices under the same FDA submission

1 device cleared under K070106 are not named by identifier in this recall. One submission often covers many models, so they may or may not be affected.

Sources and updates

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