AEQUALIS ASCEND MODULAR REVERSE SHOULDER SYSTEM

K110599 · Tornier, Inc. · PHX · Jun 14, 2011 · Orthopedic

Device Facts

• Record ID: K110599
• Device Name: AEQUALIS ASCEND MODULAR REVERSE SHOULDER SYSTEM
• Applicant: Tornier, Inc.
• Product Code: PHX · Orthopedic
• Decision Date: Jun 14, 2011
• Decision: SESE
• Submission Type: Traditional
• Regulation: 21 CFR 888.3660
• Device Class: Class 2
• Attributes: Therapeutic

Intended Use

The Aequalis Ascend Modular Reverse Shoulder System is indicated for use as a replacement of shoulder joints for patients with a functional deltoid muscle and with massive and non-repairable rotator cuff-tear with pain disabled by: Rheumatoid arthritis Non-inflammatory degenerative joint disease (i.e. osteoarthritis and avascular necrosis) Correction of functional deformity Fractures of the humeral head Traumatic arthritis Revision of the devices if sufficient bone stock remains The Reverse Metaphysis and Assembly Screw or the Reverse Metaphysis, Reverse Spacer, and Reverse Spacer Assembly Screw are indicated for use as components of the Aequalis Ascend Modular Reverse total shoulder replacement and for transformation of the Aequalis Ascend Anatomic shoulder into a reverse shoulder prosthesis without the removal of the Diaplyseal stem during revision surgery for patients with a functional deltoid muscle. The components are pennitted to be used in the transformation from anatomic to reverse if: The Diaphyseal stem is well fixed The patient has a functional deltoid muscle The arthropathy is associated with a massive and non-repairable rotator cuff-tear. Notes: All components are single use The humeral stem is intended for cemented or cementless use The glenoid implant is anchored to the bone with 4 screws and is for non- cemented fixation.

Device Story

Modular reverse shoulder prosthesis; replaces shoulder joint in patients with functional deltoid and massive, non-repairable rotator cuff tears. System components (reverse metaphysis, assembly screws, inserts, optional spacers) assemble in OR onto existing well-fixed Aequalis Ascend Anatomic humeral stems or as primary total shoulder replacement. Metal metaphysis impacts onto stem taper; secured by assembly screw. Polyethylene inserts provide articulation. Used by orthopedic surgeons in clinical settings. Enables conversion from anatomic to reverse configuration without removing well-fixed diaphyseal stems. Benefits include restoration of joint function and pain relief in complex shoulder pathologies.

Clinical Evidence

Bench testing only. Testing included fatigue testing, fretting corrosion, and static disassembly testing of the reverse insert.

Technological Characteristics

Modular shoulder prosthesis. Materials: Titanium (ASTM F136) for metaphysis/spacer; Cobalt-Chromium-Molybdenum (ASTM F1537) for assembly screws; UHMWPE (ASTM F648/ISO 5834-2) for screw plugs/inserts. Fixation: Cemented or cementless humeral stem; non-cemented glenoid fixation via 4 screws. Single-use.

Indications for Use

Indicated for patients with functional deltoid muscle and massive, non-repairable rotator cuff tears causing pain and disability due to rheumatoid arthritis, osteoarthritis, avascular necrosis, functional deformity, humeral head fractures, traumatic arthritis, or revision surgery with sufficient bone stock.

Regulatory Classification

Identification

A shoulder joint metal/polymer semi-constrained cemented prosthesis is a device intended to be implanted to replace a shoulder joint. The device limits translation and rotation in one or more planes via the geometry of its articulating surfaces. It has no linkage across-the-joint. This generic type of device includes prostheses that have a humeral resurfacing component made of alloys, such as cobalt-chromium-molybdenum, and a glenoid resurfacing component made of ultra-high molecular weight polyethylene, and is limited to those prostheses intended for use with bone cement (§ 888.3027).

Special Controls

*Classification.* Class II. The special controls for this device are:(1) FDA's: (i) “Use of International Standard ISO 10993 ‘Biological Evaluation of Medical Devices—Part I: Evaluation and Testing,’ ” (ii) “510(k) Sterility Review Guidance of 2/12/90 (K90-1),” (iii) “Guidance Document for Testing Orthopedic Implants with Modified Metallic Surfaces Apposing Bone or Bone Cement,” (iv) “Guidance Document for the Preparation of Premarket Notification (510(k)) Application for Orthopedic Devices,” and (v) “Guidance Document for Testing Non-articulating, ‘Mechanically Locked’ Modular Implant Components,” (2) International Organization for Standardization's (ISO): (i) ISO 5832-3:1996 “Implants for Surgery—Metallic Materials—Part 3: Wrought Titanium 6-aluminum 4-vandium Alloy,” (ii) ISO 5832-4:1996 “Implants for Surgery—Metallic Materials—Part 4: Cobalt-chromium-molybdenum casting alloy,” (iii) ISO 5832-12:1996 “Implants for Surgery—Metallic Materials—Part 12: Wrought Cobalt-chromium-molybdenum alloy,” (iv) ISO 5833:1992 “Implants for Surgery—Acrylic Resin Cements,” (v) ISO 5834-2:1998 “Implants for Surgery—Ultra-high Molecular Weight Polyethylene—Part 2: Moulded Forms,” (vi) ISO 6018:1987 “Orthopaedic Implants—General Requirements for Marking, Packaging, and Labeling,” and (vii) ISO 9001:1994 “Quality Systems—Model for Quality Assurance in Design/Development, Production, Installation, and Servicing,” and (3) American Society for Testing and Materials': (i) F 75-92 “Specification for Cast Cobalt-28 Chromium-6 Molybdenum Alloy for Surgical Implant Material,” (ii) F 648-98 “Specification for Ultra-High-Molecular-Weight Polyethylene Powder and Fabricated Form for Surgical Implants,” (iii) F 799-96 “Specification for Cobalt-28 Chromium-6 Molybdenum Alloy Forgings for Surgical Implants,” (iv) F 1044-95 “Test Method for Shear Testing of Porous Metal Coatings,” (v) F 1108-97 “Specification for Titanium-6 Aluminum-4 Vanadium Alloy Castings for Surgical Implants,” (vi) F 1147-95 “Test Method for Tension Testing of Porous Metal,” (vii) F 1378-97 “Standard Specification for Shoulder Prosthesis,” and (viii) F 1537-94 “Specification for Wrought Cobalt-28 Chromium-6 Molybdenum Alloy for Surgical Implants.”

Predicate Devices

• Tornier Aequalis Ascend Modular Anatomic Shoulder Prosthesis (K102924)
• Tornier Aequalis Reversed Shoulder Prosthesis (K100142)
• Tornier Aequalis Reversed Fracture Shoulder Prosthesis (K082120)
• Encore Reverse Shoulder Prosthesis (K051075)
• Biomet Comprehensive Reverse Shoulder (K080642)
• Depuy Delta Xtend Reverse Shoulder System (K062250, K073676, K081620)

Reference Devices

• Aequalis Reversed or Aequalis Reversed II glenoid implants (K081059)

Submission Summary (Full Text)

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DEPARTMENT OF HEALTH & HUMAN SERVICES

Image /page/0/Picture/1 description: The image shows the logo for the U.S. Department of Health & Human Services. The logo consists of a stylized depiction of an eagle or bird-like figure with three parallel lines forming its body and head. The bird is positioned above a circular text that reads "DEPARTMENT OF HEALTH & HUMAN SERVICES-USA".

Food and Drug Administration 10903 New Hampshire Avenue Document Control Center - WO66-G609 Silver Spring, MD 20993-0002

November 2, 2016

Tornier, Incorporated Mr. Brahim Hadri Sr. Regulatory Affairs Specialist 100 Cummings Center, Suite 444C Beverly, Massachusetts 01915

Re: K110599

Trade/Device Name: Aequalis® Ascend™ Modular Reverse Shoulder System Regulation Number: 21 CFR 888.3660 Regulation Name: Shoulder joint metal/polymer semi-constrained cemented prosthesis Regulatory Class: Class II Product Code: PHX, KWS, HSD, KWT Dated: February 28, 2011 Received: March 17, 2011

Dear Mr. Hadri:

This letter corrects our substantially equivalent letter of June 14, 2011.

We have reviewed your Section 510(k) premarket notification of intent to market the device referenced above and have determined the device is substantially equivalent (for the indications for use stated in the enclosure) to legally marketed predicate devices marketed in interstate commerce prior to May 28, 1976, the enactment date of the Medical Device Amendments or to devices that have been reclassified in accordance with the provisions of the Federal Food, Drug, and Cosmetic Act (Act) that do not require approval of a premarket approval application (PMA). You may, therefore, market the device, subject to the general controls provisions of the Act. The general controls provisions of the Act include requirements for annual registration, listing of devices, good manufacturing practice, labeling, and prohibitions against misbranding and adulteration. Please note: CDRH does not evaluate information related to contract liability warranties. We remind you, however, that device labeling must be truthful and not misleading.

If your device is classified (see above) into either class II (Special Controls) or class III (PMA), it may be subject to additional controls. Existing major regulations affecting your device can be found in the Code of Federal Regulations, Title 21, Parts 800 to 898. In addition, FDA may publish further announcements concerning your device in the Federal Register.

Please be advised that FDA's issuance of a substantial equivalence determination does not mean r load be act not a determination that your device complies with other requirements of the Act or any Federal statutes and regulations administered by other Federal agencies. You must comply with all the Act's requirements, including, but not limited to: registration and listing (21 CFR Part 807); labeling (21 CFR Part 801); medical device reporting (reporting of medical device-related adverse events) (21 CFR 803); good manufacturing practice requirements as set

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forth in the quality systems (QS) regulation (21 CFR Part 820); and if applicable, the electronic product radiation control provisions (Sections 531-542 of the Act); 21 CFR 1000-1050.

If you desire specific advice for your device on our labeling regulation (21 CFR Part 801), please contact the Division of Industry and Consumer Education at its toll-free number [phone] or [phone] or at its Internet address

http://www.fda.gov/MedicalDevices/ResourcesforYou/Industry/default.htm. Also, please note the regulation entitled, "Misbranding by reference to premarket notification" (21CFR Part 807.97). For questions regarding the reporting of adverse events under the MDR regulation (21 CFR Part 803), please go to

http://www.fda.gov/MedicalDevices/Safety/ReportaProblem/default.htm for the CDRH's Office of Surveillance and Biometrics/Division of Postmarket Surveillance.

You may obtain other general information on your responsibilities under the Act from the Division of Industry and Consumer Education at its toll-free number [phone] or [phone] or at its Internet address

http://www.fda.gov/MedicalDevices/ResourcesforYou/Industry/default.htm.

Sincerely yours,

# Lori A. Wiggins -S

for

Mark N. Melkerson Director Division of Orthopedic Devices Office of Device Evaluation Center for Devices and Radiological Health

Enclosure

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### Indications for Use

#### K110599 510(k) Number (if known):

# Device Name: Aequalis® Ascend™ Modular Reverse Shoulder System

#### Indications for Use

- The Aequalis Ascend Modular Reverse Shoulder System is indicated for use ● as a replacement of shoulder joints for patients with a functional deltoid muscle and with massive and non-repairable rotator cuff-tear with pain disabled by:
- o Rheumatoid arthritis
- Non-inflammatory degenerative joint disease (i.e. osteoarthritis and O avascular necrosis)
- Correction of functional deformity o
- o Fractures of the humeral head
- Traumatic arthritis o
- Revision of the devices if sufficient bone stock remains o
- The Reverse Metaphysis and Assembly Screw or the Reverse Metaphysis, o Reverse Spacer, and Reverse Spacer Assembly Screw are indicated for use as components of the Aequalis Ascend Modular Reverse total shoulder replacement and for transformation of the Aequalis Ascend Anatomic shoulder into a reverse shoulder prosthesis without the removal of the Diaplyseal stem during revision surgery for patients with a functional deltoid muscle. The components are pennitted to be used in the transformation from anatomic to reverse if:
- The Diaphyseal stem is well fixed o
- The patient has a functional deltoid muscle o
- The arthropathy is associated with a massive and non-repairable rotator o cuff-tear.
- Notes: o
- o All components are single use
- The humeral stem is intended for cemented or cementless use O
- The glenoid implant is anchored to the bone with 4 screws and is for non- O cemented fixation.

| Prescription Use | X (Part 21 CFR 801 Subpart D) | AND/OR | Over-The-Counter Use (21 CFR 807 Subpart C) |
|------------------|-------------------------------|--------|---------------------------------------------|
|------------------|-------------------------------|--------|---------------------------------------------|

(PLEASE DO NOT WRITE BELOW THIS LINE - CONTINUE ON ANOTHER PAGE IF NECESSARY)

Concurrence of CDRH, Office of Device Evaluation (ODE)

El Keith

| 510(k) Submission: | | |
|------------------------------|-----------------------------------------------------------|---------------|
| Tornier Inc. Aequalis Ascend | (Division Sign-Off) | Page 11 of 76 |
| | Division of Surgical, Orthopedic, and Restorative Devices | |
| 510(k) Number | K110599 | |

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K110599 (144)

JUN 1 4 2011

## SECTION 5

#### 510(k) SUMMARY

#### Summary of Safety and Effectiveness information

#### Tornier Inc. Aequalis Ascend Modular Reverse Shoulder System

Regulatory authority: Safe Medical Devices Act of 1990, 21 CRF 807.92

- 1) Device name
Trade name: Acqualis Ascend Modular Reverse Shoulder System Common name: Shoulder Prosthesis

Classification Number/ Classification name/Product code:

- Shoulder joint metal/polymer non-constrained cemented prosthesis are class II devices under 21 CFR 888.3650 (product code KWT) and are classified by the Orthopedic Devices Panel.
- . Shoulder joint metal/polymer semi-constrained cemented prosthesis are class II devices under 21 CFR 888.3660 (product code KWS) and are classified by the Orthopedic Devices Panel.
- Shoulder joint humeral (hemi-shoulder) metallic uncemented ● prosthesis are class II devices under CFR 888.3690 (product code HSD) and are classified by the Orthopedic Devices Panel.
- 2) Submitter

Tornier Inc.

7701 France Avenue South; Suite 600 Edina, MN 55435 Registration Number: 9100540

#### 3) Company contact

Brahim Hadri

Sr. Regulatory affairs Specialist 100 Cummings Center, Suite 444C. Beverly, MA 01915, U.S.A Phone: [phone] ext: 617 1 978-232-9998 Fax:

[e-mail]

S 10(k) Submission

Tornier Inc. Aequalis Ascend Modular Reverse Shoulder System

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K110599 (2 of 4)

- 4) Classification

| Device class: | Class II |
|-----------------------|---------------|
| Classification panel: | Orthopedic |
| Product code: | KWT; KWS; HSD |

- 5) Legally Marketed Device to which Equivalence is Claimed:
- · Tornier Aequalis Ascend Modular Anatomic Shoulder Prosthesis: K102924
- · Tornier Aequalis Reversed Shoulder Prosthesis: K100142
- · Tornier Aequalis Reversed Fracture Shoulder Prosthesis: K082120
- · Encore Reverse Shoulder Prosthesis: K051075
- · Biomet Comprehensive Reverse Shoulder: K080642
- · Depuy Delta Xtend Reverse Shoulder System: K062250, K073676, K081620
- 6) Device description

The Aequalis Ascend Modular Reverse Shoulder system is a modular Reverse version of the Aequalis Ascend Modular Anatomic Shoulder System (K102924) with Reverse adapters.

The Aequalis Ascend Modular Reverse Shoulder system is supplied in separate sterile packages which will be assembled in the operating room. The components provided will be:

- The Modular Reverse Metaphysis and Modular Reverse Assembly Screw .
- � The Modular Reverse Inserts
- . The Modular Reverse Angled Inserts
- An optional Modular Reverse Spacer and Modular Reverse Spacer Assembly o Screw can be used when maximum insert thickness does not achieve sufficient tension.
- When the Modular Reverse Spacer is implanted, the Modular Reverse O Spacer Assembly Screw will be used in place of the Modular Reverse Assembly Screw.

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#### Primary Reverse Shoulder:

The Aequalis Ascend Modular Reverse Metaphysis and Aequalis Ascend Modular Reverse Assembly Screw will mate with the existing; FDA cleared Tornier Aequalis Ascend Modular Anatomic Distal Stem (K102924) which when assembled together with the Aequalis Ascend Modular Reverse Insert form complete reverse prostheses. The reverse assembly must be used in association with the Aequalis Reversed or Aequalis Reversed II glenoid implants (K081059).

### Conversion Reverse Shoulder:

The Aequalis Ascend Reverse Metaphysis and Aequalis Ascend Modular Reverse Assembly Screw are designed to allow the transformation of the Aequalis Ascend Anatomic shoulder (K102924) into an Aequalis Ascend Modular Reverse Shoulder without removal of the Diaphyseal Stem if the stem is well fixed during revision surgery. The Aequalis Ascend Reverse Metaphysis is a metal component aimed to articulate as a reverse prosthesis with a specific polyethylene insert. The metal metaphysis is impacted onto the taper of the Diaphyseal Stem and then secured with the Ascend Modular Reverse Assembly Screw. The screw is tightened until it is firmly seated on the Reverse Metaphysis. A Reverse Spacer can be used when the maximum insert thickness does not achieve sufficient tension. During these situations, after impaction of the Reverse Metaphysis on the Diaphyseal stem, the metal spacer is impacted on the taper of the Reverse Metaplıysis and then secured with the Ascend Modular Reverse Spacer Assembly Screw. The screw is tightened until it is firmly seated on the Reverse Spacer.

#### 7) Materials

- · The Modular Reverse Metaphysis and Modular Reverse Spacer components are manufactured from Titanium according to ASTM F 136 Standard Specification for Wrought Titanium - 6Aluminum - 4Vanadium ELI (Extra Low Interstitial) Alloy for Surgical Implant Applications
- The Modular Reverse Assembly Screw and Modular Reverse Spacer Assembly Screw o are manufactured from Cobali Chromium Molybdenum alloy according to ASTM F-1537 Standard Specification for Wrought Cobalt-28-Chromium-6-Molybdenum Alloy for Surgical Implants
- . The Modular Reverse Assembly Screw and Modular Reverse Spacer Assembly Screw include an Ultra High Molecular Weight Polyethylene (UHMWPE) plug. The material of the screws is accordance to ASTM F648 Standard Specification for Ultra-High-Molecular-Weight Polyethylene Powder and Fabricated Form for Surgical Implants or ISO-5834-2. Implants for surgery -- Ultra-high-molecular-weight polyethylene -- Part 2: Moulded forms

510(k) Submission Tornier Inc. Aequalis Ascend Modular Reverse Shoulder System

Page 14 of 76

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#### 8) Indications for Use

- The Aequalis Ascend Modular Reverse Shoulder System is indicated for use . as a replacement of shoulder joints for patients with a functional deltoid muscle and with massive and non-repairable rotator cuff-tear with pain disabled by:
- Rheumatoid arthritis o
- Non-inflammatory degenerative joint disease (i.e. osteoarthritis and o avascular necrosis)
- Correction of functional deformity o
- Fractures of the humeral head o
- Traumatic arthritis o
- Revision of the devices if sufficient bone stock remains o
- The Reverse Metaphysis and Assembly Screw or the Reverse Metaphysis, . Reverse Spacer, and Reverse Spacer Assembly Screw are indicated for use as components of the Aequalis Ascend Modular Reverse total shoulder replacement and for transformation of the Aequalis Ascend Anatomic shoulder into a reverse shoulder prosthesis without the removal of the Diaphyseal stem during revision surgery for patients with a functional deltoid muscle. The components are permitted to be used in the transformation from anatomic to reverse if:
- The Diaphyseal stem is well fixed O
- The patient has a functional deltoid muscle 0
- The arthronathy is associated with a massive and non-repairable rotator O cuff-tear.
- . Notes:
- All components are single use o
- The humeral stem is intended for cemented or cementless use o
- The glenoid implant is anchored to the bone with 4 screws and is for nono cemented fixation.

#### 9) Summary of technologics

The Tornier Aequalis Ascend Modular Reverse Shoulder System was subjected to non-clinical testing such as Fatigue Testing, Fretting Corrosion, Static Disassembly Testing of Reverse Insert. The results of those non-clinical tests allow us to conclude that the Tornier Aequalis Ascend Modular Reverse Shoulder System described in this submission is substantially equivalent and as safe and effective as the cited predicate devices.

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