VAULT ALIF SYSTEM

{0}------------------------------------------------ K130445 Page 1 of 2 # 510(k) Summary for the Vault ALIF System APR 2 5 2013 In accordance with 21 CFR 807.92 of the Federal Code of Regulations the following 510(k) summary is submitted for the Vault ALIF System #### 1. GENERAL INFORMATION Date Prepared: February 18, 2013 Trade Name: Vault ALIF System Common Name: Intervertebral Body Fusion Device Classification Name: Intervertebral Fusion Device With Integrated Fixation, Lumbar Class: II Product Code: OVD CFR section: 21 CFR section 888.3080 Device panel: Orthopedic Legally Marketed Predicate Device: Spinal USA Vault ALIF System - K103369 Submitter: Spinal USA 2050 Executive Drive Pearl, MS 39208 601-420-424 Contact J.D. Webb 1001 Oakwood Blvd Round Rock, TX 78681 512-388-0199 Tele 512-692-3699 Fax e-mail: jdwebb@orthomedix.net ## 2. DEVICE DESCRIPTION The Vault ALIF System consists of implants with various widths, heights, lengths and bone screws to accommodate individual patient anatomy and autogenous bone graft size. All components are manufactured from medical grade polyetheretherketone (PEEK LT1). ### Change from Predicate: This Special 510(k) is submitted in order to gain clearance for the Redesigned Vault ALIF System. Materials: Optima LT1 PEEK (ASTM F2026) Ti-6AL-4V (ASTM F136) ### 3. INTENDED USE The Vault ALIF System is indicated for intervertebral body fusion of the spine in skeletally mature patients. The device system is designed for use with autograft to facilitate fusion. One device is used per intervertebral space. {1}------------------------------------------------ The Vault ALIF System is intended for use at either one level or two contiguous levels in the lumbar spine, from L2 to S1, for the treatment of degenerative disc disease (DDD) with up to Grade 1 spondylolisthesis. DDD is defined as back pain of discogenic origin with degeneration of the disc confirmed by history and radiographic studies. The lumbar device is to be used with autogenous bone graft. Patients should have at least six months of non-operative treatment with a lumbar intervertebral fusion device. The Vault ALIF System is a stand-alone system intended to be used with the bone screws provided and requires no additional supplementary fixations. ## 4. SUMMARY OF TECHNOLOGICAL CHARACTERISTICS / SUBSTANTIAL EQUIVALENCE The Spinal USA Vault ALIF System is substantially equivalent to the predicate device(s) in terms of intended use, design, mechanical safety and performances. The Spinal USA Vault ALIF System is manufactured from an equivalent material, is packaged and sterilized the using the same methods as the predicate device(s). #### 5. NON-CLINICAL TEST SUMMARY The following tests were conducted: - Dynamic axial compression per ASTM F2077 . - Dynamic shear compression per ASTM F2077 . The results of this testing indicate that the Redesigned Vault ALIF System is equivalent to predicate device. #### 6. CLINICAL TEST SUMMARY No clinical studies were performed ### 7. CONCLUSIONS NONCLINICAL AND CLINICAL Spinal USA considers the Redesigned Vault ALIF System to be equivalent to the predicate device listed above. This conclusion is based upon the device's similarities in principles of operation, technology, materials and indications for use. {2}------------------------------------------------ Image /page/2/Picture/0 description: The image shows the logo for the U.S. Department of Health and Human Services. The logo consists of a circular seal with the text "DEPARTMENT OF HEALTH & HUMAN SERVICES - USA" arranged around the perimeter. Inside the circle is an abstract symbol resembling an eagle or bird in flight, composed of three stylized human profiles. Food and Drug Administration 10903 New Hampshire Avenue Document Control Center - WO66-G609 Silver Spring, MD 20993-0002 # Letter dated: April 25, 2013 Spinal USA % The Orthomedix Group, Incorporated Mr. J.D. Webb -1001-Oakwood-Boulevard-Round Rock, Texas 78681 Re: K130445 Trade/Device Name: Vault ALIF System Regulation Number: 21 CFR 888.3080 Regulation Name: Intervertebral body fusion device Regulatory Class: Class II Product Code: OVD Dated: March 25, 2013 Received: March 27, 2013 Dear Mr. Webb 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 that FDA has made 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 {3}------------------------------------------------ # Page 2 - Mr. J.D. Webb forth in the quality systems (OS) 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 Small Manufacturers, International and Consumer Assistance at its tollfree number (800) 638-2041-or (301)-796-7100 or at-its-Internet-address- http://www.fda.gov/MedicalDevices/Resourcesfor You/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 Small Manufacturers; International and Consumer Assistance at its toll-free number (800) 638-2041 or (301) 796-7100 or at its Internet address http://www.fda.gov/MedicalDevices/Resourcesfor You/Industry/default.htm. Sincerely yours. Mark N. Melkerson - S Mark N. Melkerson Director Division of Orthopedic Devices Office of Device Evaluation Center for Devices and Radiological Health Enclosure {4}------------------------------------------------ ## INDICATIONS FOR USE 510(k) Number (if known): __K13 0445 Device Name: Vault ALIF System Indications for Use: The Vault. ALIE_System_is_indicated_for_intervertebral_body_fusion_of_the_spine_in_skeletally ... mature patients. The device system is designed for use with autograft to facilitate fusion. One device is used per intervertebral space. The Vault ALIF System is intended for use at either one level or two contiguous levels in the lumbar spine, from L2 to S1, for the treatment of degenerative disc disease (DDD) with up to Grade I spondylolisthesis. DDD is defined as back pain of discogenic origin with degeneration of the disc confirmed by history and radiographic studies. The lumbar device is to be used with autogenous bone graft. Patients should have at least six months of non-operative treatment prior to treatment with a lumbar intervertebral fusion device. The Vault ALIF System is a stand-alone system intended to be used with the bone screws provided and requires no additional supplementary fixations. 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 OF NEEDED) Concurrence of CDRH, Office of Device Evaluation (ODE) Anton E. Dmitriev, PhD Division of Orthopedic Devices