The Recall Desk
HighFDA (Devices)·Z-2395-2021·Announced 2021-09-08

Surgical instrument software error may cause limb misalignment

DePuy Orthopaedics' TruMatch CT Pin Guide Kit has a software coding error that may misalign bone landmarks during joint replacement surgery, potentially causing limb malalignment. No injuries have been reported.

What this means for you

Real risk of harm even if no illness or injury has been reported yet. Stop using the product and follow the agency's guidance.

Our severity reasoning: The software error could cause incorrect anatomic landmark positioning and result in limb malalignment during orthopedic surgery, a potentially serious complication. However, no injuries or illnesses have been reported, making this a theoretical hazard situation subject to the rubric's maximum score of 3.

Plain-English summary

The product being recalled is the TruMatch CT Pin Guide Kit R, manufactured by DePuy Orthopaedics, Inc. These patient-specific surgical instruments are designed to guide the positioning of joint replacement components during orthopedic surgery.

The FDA identified a coding error in the Fast3D Segmentation software associated with these kits. During the scanning process, the three images required to map the hip, knee, and ankle may not align properly. This misalignment could result in incorrect anatomic landmark locations, potentially causing limb malalignment during surgery.

Six cases of the affected kit have been distributed to surgical centers and hospitals in California, Colorado, Florida, Illinois, Indiana, Michigan, Minnesota, New York, Texas, Washington, Poland, and the United Kingdom. The affected lot numbers are 27929, 27855, 27667, 27591, 27521, and 27332 (GTIN 10603295430803).

No injuries or illnesses have been reported at this time. Healthcare facilities using this equipment should contact DePuy Orthopaedics, Inc. immediately to address the software issue and determine appropriate corrective actions.

The recalled product

Product
TRUMATCH CT PIN GUIDE KIT R- TruMatch Patient Specific Instruments are intended to be used as patient-specific surgical instrumentation to assist in the positioning of a joint replacement component intra-operatively and in guiding the marking of bone before cutting Part Number:
Manufacturer
DePuy Orthopaedics, Inc.
Hazard
  • software-error
  • patient-positioning-error
  • surgical-misalignment

Is your product affected?

Check your packaging against the codes below. If any of them match, the product is part of this recall.

Lot numbers (6)

  • Lot number/ GTIN: 27929
  • 27855
  • 27667
  • 27591
  • 27521
  • 27332 GTIN 10603295430803

Distribution

Distributed in 10 states:

  • CA
  • CO
  • FL
  • IL
  • IN
  • MI
  • MN
  • NY
  • TX
  • WA