dall miles surgical protocol

Dall-Miles® Trochanter Grip and Trochanter Grip Plate.

Trochanteric Reattachment and Cerclage.

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Dall-Miles® Cable SystemSurgical Protocol

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Introduction

Contraindications(Trochanter Grip & Grip Plate)

Absolute contraindications include:• Overt infection.• Distant foci of infections (which may

cause hematogenous spread to theimplant site).

• Skeletally immature patients.• Cases where there is a loss of abductor

musculature, poor bone stock or poorskin coverage around the hip joint.

• Compromised vascularity that wouldinhibit adequate blood supply to thefracture or operative site.

The Grip Plate is not to be used on it’sown as a primary fixation device in peri-prosthetic proximal femoralfractures. It should be used to augmentother fixation devices (for example afemoral stem, which is well fixed distally,augmented with cortical allograft struts,secured with cerclage cables, and /or theTrochanter Grip Plate).

This publication sets forth recommendedprocedures for using StrykerOrthopaedics devices and instruments.It offers guidance that you should heed,but, as with any such technical guide,each surgeon must consider theparticular needs of each patient andmake appropriate adjustments when and as required.

System Overview

The Dall-Miles Recon & Trauma Cable System provides the surgeonwith a means of achieving trochantericreattachment and a variety of methodsof cerclage fixation.

Indications

• The Trochanter Grip is used toreattach the greater trochanter, inprimary or revision Total HipArthroplasty when a trochantericosteotomy or trochanteric slide hasbeen used.

• The Trochanter Grip Plate is indicatedwhen an extended trochantericosteotomy is used, or to augmentfixation of peri-prosthetic proximalfemoral fractures.

This surgical technique is designed toprovide the experienced surgeon withguidance for performing TrochantericReattachment in Total Hip Arthroplastyusing either the Dall-Miles TrochanterGrip or Trochanter Grip Plate.It should be read in conjunction with the operative technique for the Dall-Miles Recon & Trauma Cable System.

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Trochanter Grip Surgical Protocol

Fig. 2a

Fig. 1

Fig. 2b

NOTE: The following techniqueassumes that the acetabularcomponent has been implantedand that the femur has beenprepared for the selectedfemoral prosthesis

Technique for Total HipArthroplasty

A trial reduction is carried out to checkstability of the hip. The trial reductionwill also allow determination of theoptimal position of the trochanter forreattachment.

Location of TrochantericCables

Using a Dall-Miles Femoral Cable Passer,two cables are sequentially passed distalto the lesser trochanter. The tip of thecable passer should stay in close contactto the bone to ensure that the softtissue surrounding the femur is notcompromised by the cables. The cablesshould be parallel to one another andshould not be overriding one another.

Alternatively, two 2.7mm drill holes are made in the area of the lessertrochanter. A cable is then passedthrough each hole.

NOTE: The Grips accept 2.0mm Dall-Miles Cables.It is recommended that Non-Beaded Cables are used to ensure even tensioning ofthe Grip with the Double-SidedTensioner device.

NOTE: 2.0mm Non-Beaded Cables areavailable in either StainlessSteel or Vitallium® and shouldbe used with either the StainlessSteel or Vitallium® Griprespectively.

Application of TrochanterHolding Forceps

The hip is now reduced. The forcepsshould be applied as distally as possibleon the detached trochanter (Figure 1)to allow room on the trochanter forplacement of the Trochanter Grip.

Passing Cables Under theAbductor Muscles

Utilizing a Dall-Miles Trochanter CablePasser, the anterior end of the proximal cable is passed near the tip of thetrochanter as close to the anteriorsurface of the trochanter as possible(Figure 2a).

The distal cable is then passed in asimilar fashion approximately halfwayalong the anterior surface of thetrochanter; again as close to theanterior surface of the trochanter aspossible. Proper placement of thecables is essential for minimizing softtissue inter–position between the cablesand bone (Figure 2b).

Positioning the Trochanter

The trochanter should be placed backon the bed of the trochantericosteotomy. The amount of trochantericadvancement should now bedetermined.

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Passing the Cables Throughthe Trochanter Grip

The Grip is secured to the GripIntroducer and the free cable endspassed through the holes in the bridgesof the Grip.

The proximal cable should be passedthrough the proximal bridge and thedistal cable should be passed throughthe distal bridge (Figure 3).

Seating the Trochanter Grip

The Dall-Miles Trochanter Grip hastwo longer proximal hooks and twosmaller distal hooks. The proximalhooks must be engaged just over thetop of the trochanter. Because theinsertion of the abductor musclesmakes it impossible to visualize the topof the trochanter, it must be carefullypalpated through the muscles. Thehooks are passed through the abductormuscle insertions and engaged as closeas possible to bone. Cable slack is takenup manually at the same time (Figure 4).

Once the proximal hooks of the Gripare properly positioned, the distalhooks can then be driven into the boneusing a mallet. The Grip Introducermay be removed now, or alternatively,can be left in situ to assist inpositioning the trochanter.

Positioning of the Trochanterand Application of Tensioners

Two Double-Sided Tensioners are nowapplied to the proximal and distalcables.

Utilizing the Trochanter HoldingForceps or Grip Introducer, positionthe trochanter into the desired positionon the trochanteric osteotomy bed.The position of the trochanter shouldbe maintained while the cables aretensioned. The cables may be tensionedsimultaneously or sequentially tocapture the trochanter in the desiredposition. Remove the TrochanterHolding Forceps or Grip Introducer.

Trochanter Grip Impaction and Final Cable Tensioning

The Trochanter Grip should beimpacted with the Impactor to drivethe distal hooks firmly into the bone(Figure 5). The Grip should sit flat onthe trochanter. The cables should againbe tightened. Impaction of the Gripand further tightening of the cables canbe carried out if necessary (Figure 6).

NOTE: Over-tensioning should beavoided. The Dall-MilesDouble-Sided Tensioner is apowerful instrument and candamage the cables or cutthrough the bone if extensiveforce is applied.

Check manually for secure fixation.If the position or fixation of thetrochanter is not satisfactory, releasethe tensioners and repeat the procedureas described above.

NOTE: When not in use, the Double-Sided Tensioners should bestored with the cams fullyreleased. A lubricant for surgicalinstrument care should be usedregularly on the threadedportion to keep the tensionermechanism from binding.

Fig. 3

Fig. 4

Fig. 5

Fig. 6

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Crimping

The bridges of the Dall-MilesTrochanter Grip are crimpedindividually using the Crimp Tool tosecure the cables (Figure 7). The orderof crimping is not important. It may benecessary to remove soft tissue adjacentto the bridges in order to ensure properlocation and seating of the CrimpTool's jaws.

Before placing Crimp Tool on bridge ofGrip, be sure the ratchet mechanism isdisengaged. If it is not, squeeze thehandles slightly and push the releaselever to disengage the ratchet and openthe handles fully.

The ratchet mechanism will engage ascrimping starts. The ratchet will holdthe tool in place if it is necessary toreposition the hands.

Squeeze the handles until the ratchetmechanism disengages. At that point,release the handles and the crimp iscomplete. Once both bridges have beenthoroughly crimped, the tensioners areremoved.

Cutting the Free Cable Ends

Use the Dall-Miles Cable Cutter to cutthe free ends of the cable.

The free end of each cable is passedthrough the Cutter tip, introducing iton the side with the laser mark thatreads: "CUT THIS SIDE" (Figure 8a).

While applying longitudinal tension onthe cable, advance the Cutter tip overthe cable and push it as flush againstthe Grip as possible (Figure 8b). This isimportant in order to leave as short atag as possible. Pull the Cutter handleto cut the cable.

An ordinary wire cutter should not beused as it will result in a poor cut andsplay the cable filament ends whichmay cause soft tissue irritation. Withthe cable cut, further trimming of thecable should be AVOIDED, to preventintroduction of cable filaments intothe wound and surrounding softtissue area.

Fig. 7

Fig.8a

Fig.8b

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Trochanter Grip Plate Surgical Protocol

The Surgical Technique for implantingthe Trochanter Grip Plate follows asimilar protocol to the Trochanter Grip,please refer to previous section. A trialreduction is carried out to checkstability of the hip and the optimalposition of the osteotomized portion of the trochanter – proximal femur.

Grip Plate sizing

The size (medium or large) and lengthof Grip Plate to use is dependent on theshape of the proximal femur and lengthof the extended trochanteric osteotomy.The trial template can be used to assessthe proximal femoral size and length of the shortest Grip Plate, prior toimplant selection (Figure 9).

Proximal Cables

Two proximal Non-Beaded 2.0mmCables are positioned below or throughthe lesser trochanter, as described in theTrochanter Grip protocol (Figure 1).These cables are then passed under theabductor muscles and through the Gripportion as described in the previoussection. (Figures 2 & 3). Usually it iseasier to perform this part of theprocedure with the hip reduced, butoccasionally it is preferable to locate allcables prior to reduction.

Distal Cables

The distal part of the Grip Plate can befixed with up to 1, 3 or 5 additionalcables depending on the length ofimplant chosen.

Either Beaded or Non-Beaded 2.0mmCables may be used. Beaded arepreferable as, in conjunction withtension-retaining devices (Figure 10),they enable the surgeon to tension allthe cables fully with Single-SidedTensioners (and Tension RetainingDevices), prior to crimping.

The plate section should be pre-loadedwith Beaded Cables before passingthem around the femur. Some priorthought should be given to which side of the plate the beads should bepositioned. This will be dictated by thechosen surgical approach and the lie ofthe soft tissues.

Fig. 9

If the easiest access for the Tensioners isanterior to the plate, the beads shouldbe positioned posterior and vice-versa.

Using the Femoral Cable Passer thecables are passed at appropriate positionsaround the proximal femur.If Beaded Cables/Single-Sided Tensionersare not available, Non-Beaded Cables withDouble-Sided Tensioners may be used.

With the implant in position and cablesin place, tension and re-tension thecables until the Grip Plate is securelyfixed (Figure 10). The bridges are nowcrimped, tensioners removed and freecable ends cut off.

The timing of the final tensioning andcrimping of the cables passed throughthe proximal grip portion of theimplant is dependent on the surgicalcircumstances and the surgeon’spreference.

This can be done before or at the sametime as the distal cables are finallytensioned and crimped.

NOTE: For Beaded Cables, the Single-Sided Tensioner is required.Depending on the number ofTensioners that are available,these may be used with orwithout the Tension RetainingDevice. (Please refer to pages8,9 & 10).

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Trochanter Grip Plate Surgical Protocol

Screw Fixation

It is possible to augment the fixation ofthe Trochanter Grip Plate with Stryker®SPS cortical bone screws, to provideadditional rotational stability. A rangeof 4.5mm Ø screws commencing with14mm length are available in bothStainless Steel and also Titanium (for Vitallium® implants).

A 3.2mm Ø drill bit should be used.

Fig. 10

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Cerclage Protocol Using Beaded Cables

Dall-Miles Beaded Cables arerecommended for use with theSingle-Sided Tensioner for cerclage;while Dall-Miles Non-Beaded Cablesare recommended for use withthe Double-Sided Tensioner.

Step 1

Position the sleeve at the beaded endof the cable (Figure 1).

Step 2

Once the Cable Passer is positioned,insert the cable through the end of thepasser farthest from the passer handle(Figure 2). Remove the passer.

Pass the free end of the cable throughthe sleeve and always position the sleevewith the narrow side with the lasermarkings facing the bone (Figure 3).

Manually tighten sleeve against the bone(Figure 4 inset). If necessary, the SleeveHolding Forceps can be used to positionthe sleeve (Figure 4).

Step 3

With the Single-Sided Tensioner in thefully open position (tensioner knobturned fully counter-clockwise), insertthe cable end through the nozzle tip;position the tip flush against the side ofthe sleeve. Turn knob clockwise untildesired tension is achieved (do notexceed 150lb tension) (Figure 5).

Fig. 2 Fig. 3

Laser Markings

BONE

Fig. 4

Fig. 5

Fig. 1

Narrow side with laser markingsfacing the bone.

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Dall-Miles Cabling System Surgical Protocol

Optional Technique Using Tension Retaining Devices

An optional technique is to use theDall-Miles Tension Retaining Deviceto hold a tensioned cable in place whileadditional cables are placed using thesame Single-Sided Tensioner. Onceseveral cables are in place andsequentially tensioned, the TensionRetaining Devices enable the surgeonto go back and retension cablesas needed before final crimping.

Step 1

Turn winged screw on the TensionRetaining Device counter clockwiseuntil it is opened.

Step 2

Insert the free cable end through thelong nozzle tip of the Tension RetainingDevice. Advance the Tension RetainingDevice along the cable until the longnozzle tip is flush against the sleeve.

Step 3

With the Single-Sided Tensioner knobin the fully opened position, insert thefree cable end through the curvedTensioner nozzle tip. While advancing,take up any cable slack and position theTensioner tip inside the recessed bodyof the Tension Retaining Device(Figure 6).

Step 4

Turn the Single-Sided Tensioner knobclockwise until desired tension isachieved (do not exceed 150lb oftension). Turn winged screw on TensionRetaining Device clockwise until it istightened (Figure 7). Remove theTensioner by turning knobcounterclockwise until it releases. Eachcable can then be incrementallytensioned before final crimping(Figure 8).

Fig. 7

Fig. 8

Fig. 6

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Retensioning with TensionRetaining Device AlreadyApplied

In order to achieve satisfactoryretensioning, the following steps mustbe taken:

Step 1

Follow instructions in Step 3, page 9.

Step 2

Release the tensioned cable in theTension Retaining Device by turning thewinged screw counterclockwise. Oncereleased, the cable is now ready to be re-tensioned.

Step 3

Follow instructions in Step 4, page 9.

Crimping

Step 4

Before placing the Crimp Tool on thesleeve, be sure the ratchet mechanism isdisengaged. If it is not, squeeze thehandles slightly and push the releaselever to disengage the ratchet and openthe handles fully.

Place the Crimp Tool on the sleeve andsqueeze the handles (Figure 9). Theratchet mechanism will engage ascrimping starts. The ratchet will holdthe tool in place if it is necessary to reposition the hands.

Squeeze the handles until the ratchetmechanism disengages.At that point, crimping is complete.

Remove the Single-Sided Tensioner orTension Retaining Device (whichever isapplicable) by turning the knob orwinged screw counterclockwise until itreleases.

Cutting the Free Cable Ends

Use the Dall-Miles Cable Cutter to cutthe free ends of the cable.

The free end of the cable is passedthrough the Cutter tip, introducing it onthe side with the laser mark that reads:“CUT THIS SIDE.”

While applying longitudinal tension onthe cable, advance the Cutter tip over thecable and push it as flush against theSleeve as possible (Figure 10). This isimportant in order to leave as short a tagas possible. Pull the Cutter handle to cutthe cable.

Do not use an ordinary wire cutterbecause a long tag may be left and may cause soft tissue irritation.

Fig. 10

Fig. 9

Dall-Miles Cabling System Surgical Protocol

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Instrument Use & Cleaning Instructions

Use

Turn knob counter clockwise until thecross-head seats fully on the lower bodyof the Tensioner. Some resistance will befelt as the head engages the studs on thebody. Continue turning the knob evenwhen this resistance is encountered.

Once fully seated, the cable can bethreaded around the pulleys through theholes in the lower body, up through thetensioner heads.

Pull the cable as tight as possible byhand and then turn the knob clockwiseto tension the cable. The Tensioner isequipped with self gripping heads.

After crimping the implant, turn theknob counterclockwise and fully seat thecross-head to release the cable. The cablecan then be drawn out of the tensionerand the tensioner removed.

Cleaning/Maintenance

Flush the wheels, threads and Tensionerheads thoroughly with plenty of waterand cleaning agent.

Turn knob counterclockwise to fully seatthe cross-head. Flush Tensioner headsfrom the top to clear any debris from thejaws mechanism.

Turn knob clockwise to release the jawsand do a final rinse over the instrument.

Prior to autoclaving, apply a lubricantor instrument milk to the threads andthe jaw mechanism within the heads.Be sure that the lubricant penetratesthe mechanism fully.

NOTE: The Tensioner heads arereplaceable but do not need to be removed when cleaning or as a routine procedure whenused. These heads need to remaintight for the instrument tofunction correctly.

Tensioner Head Replacement(6704-9-351)

Turn Tensioner head counterclockwiseuntil it is removed from device. TakeReplacement Head and turn it clockwiseuntil it is fully seated. A wrench may beused to provide a more snug fit.

NOTE: Improper cleaning and maintenance may impair the normal function of an instrument.

Cross-head

Lower Body

TensionerHead

Use

Turn knob counterclockwise until itstops. Some resistance will be felt as thehead engages the stud on the inside ofthe instrument. Continue turning theknob even when this resistance isencountered. The threaded shaft will berecessed inside of the knob when thejaws are fully open.

Once the knob is turned as far as it cango, the cable can be threaded throughthe nose and up through the Tensioner.

Pull the cable as tight as possible byhand and the turn the knob clockwise totension the cable. The Tensioner isequipped with a self gripping head.

After crimping the implant, turn theknob counterclockwise to release thecable. The cable can then be drawn outof the Tensioner and the tensionerremoved.


Turn the knob counterclockwise, asdescribed by the arrow indicating“loosen”, until it stops.

Flush instrument from the knob end,through the cannulated nozzle until thepassage is cleared. A small brush may beused to dislodge any debris.

Turn the knob clockwise, as describedby the arrow indicating “tighten,” until itspins freely.

Flush instrument from the knob end.

Twist nose loose and remove. An openend wrench may be used to loosen thenose if it is too difficult to loosen byhand.

Flush area inside of the outer cylinderand flush again from the knob end.

Turn knob counterclockwise to advancethe jaws within the cylinder and add aninstrument lubricant or instrumentmilk to the mechanism prior toautoclave sterilization. Be sure that thelubricant fully penetrates the jawmechanism.

Turn knob clockwise to retract the jawmechanism and re-attach the nozzle.Apply lubricant to the threadedstud/knob interface prior to autoclavesterilization as well.

Double-Sided Tensioner(6704-9-350)


Single-Sided Tensioner (6704-9-320)

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Use

Turn knob counterclockwise to fullyretract the tip of the instrument.

Place the square-shaped tip throughthe central window in the Grip or Grip Plate.Turn knob clockwise until tight.

To disengage the instrument from theGrip, turn knob counterclockwise andremove the instrument.


Flush the tip thoroughly with plenty ofwater to remove all contaminates.Ensure that the entire tip is clean.Apply a lubricant or instrument milkto the underside of the knob prior toautoclave sterilization.

Use

To open jaws, turn nut counterclockwiseon threaded stud to allow jaws to fullyopen. Squeeze handles to close jaws todesired position. To hold jaws indesired position, turn nut clockwise onthreaded nut to tighten.


No special cleaning is required.However, apply a lubricant orinstrument milk to the pinned jointand threaded stud prior to autoclavesterilization.

Head Replacement (6704-9-721)

Turn Impactor Head counterclockwiseuntil it is removed from the device. TakeReplacement Head and turn it clockwiseuntil it is fully seated.

Use

To release the teeth, separate thehandles by pulling them apart.Grasp the sleeve and then squeezehandles together to lock sleeve inposition.


With the forceps handles in the fullyopen position, thoroughly flush thepivoting point with water prior toautoclave sterilization.


Cable Passers(6704-9-760/770/800/820)


Flush the cannulated body until thepassage is cleared. A small brush maybe used to dislodge any debris.


Grip Introducer (6704-9-715)

Trochanter Forceps (6704-9-550)

Grip Impactor(6704-9-720)

Sleeve Holding Forceps(6704-9-520)

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Use

Turn winged screw on the TensionRetaining Device counterclockwise untilit is opened.

Insert the free cable end of the BeadedCable through the long nozzle tip of theTension Retaining Device. Advance the

Tension Retaining Device along thecable until the long nozzle tip is flushagainst the sleeve.

With the Single-Sided Tensioner knob inthe fully opened position, insert the freecable end through the curved Tensionernozzle tip. While advancing, take up anycable slack and position the tip insidethe recessed body of the TensionRetaining Device.

Turn knob clockwise on the Single-Sided Tensioner until desired tension isachieved (do not exceed 150lbs. oftension). Turn winged screw clockwiseon Tension Retaining Device until it istightened. Remove the Tensioner byturning the knob counterclockwise untilit releases. Each cable can then beincrementally tensioned before finalcrimping.


Flush the tube and threads thoroughlywith plenty of water and cleaning agent.

Turn winged screw clockwise to engageinner clamp. Flush tube once again withplenty of water and cleaning agent toclear any debris from inner clamp.

Turn winged screw counterclockwise todisengage the inner clamp and do a finalrinse over the entire instrument.

Prior to autoclaving, apply a lubricantor instrument milk to the threads.Be sure the lubricant or milkpenetrates the threads fully.

Use

Before placing instrument on theimplant to be crimped, be sure theratchet mechanism is disengaged. If it isnot, squeeze the handles slightly andpush the release lever to disengage theratchet and open the handles fully.

Crimp implant as usual. The ratchetmechanism will engage as crimpingstarts. The ratchet will hold the tool inplace if it is necessary to reposition thehands.

Squeeze the handles until the ratchetmechanism disengages.At that point, release the handles andcrimping is complete.

If a crimp less than the full throw of thehandles is needed, squeeze to theappropriate point. While holding thehandles, squeeze slightly and push therelease lever to disengage the ratchetmechanism and open the handles.


Standard cleaning procedures can beused. Ensure that the ratchet mechanismis cleaned thoroughly before sterilizing.

Prior to autoclaving, apply a lubricantor instrument milk to all of the pinnedjoints and to the ratchet mechanism.Be sure the lubricant penetrates thejoints fully.

After each use, the jaws of the CrimpTool should be tested using the CrimpTool Gauge (6704-9-130). To test thejaws, squeeze the Crimp Tool handlestogether to engage the ratchet on the lasttooth. Try to insert the edge of theGauge between the jaws:

• If Gauge fully seats in the jaws,Crimp Tool needs to be replaced.

• If Gauge does not fully seat,the Crimp Tool is good for next use.

Jaws


Tension Retaining Device (6704-9-250)

Crimp Tool(6704-9-150)

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Use

The free end of the cable is passedthrough the Cutter tip, introducing it onthe side with the laser mark that reads:“CUT THIS SIDE.”

While applying longitudinal tension onthe cable, advance the Cutter tip over thecable and push it as flush against theimplant as possible. Pull the Cutterhandle to cut the cable.


Flush the handles out through the slotsin the body of the Cutter. Be sure allcontaminates are removed and theinstrument flushes clean.

Flush the tip thoroughly and pull handlefrequently until the instrument isflushed out.

Prior to autoclaving, apply a lubricantor instrument milk to the handle jointand Cutter tip and work lubricant intothe mechanism.

NOTE: The tip of the Cutter isremovable for replacement only. Toreplace the tip, follow the instructionsprovided below.

Tip Replacement(for 6704-9-420) (6704-9-421)

Using a wrench, turn the retaining nutloose and remove.

Twist tip counterclockwise to unthreadthe plunger and outer sleeve from theCutter.

Use

The Cable Removal Cutter is ONLY tobe used for cable removal and NOT fortrimming cable ends.

Position cable between tips of Cutterand squeeze the Cutter handles togetherto cut the cable.


Standard cleaning procedures can beused.

Prior to autoclaving, apply a lubricantor instrument milk to the pinned joint.Be sure the lubricant penetrates thejoint fully.

To replace the tip, remove the retainingnut from the new Cutter tip and threadtip into Cutter. Thread the tip down farenough that the outer tube body can sitflush against the Cutter body.

To ensure Cutter tip is at the correctdepth, place Cutter tip in the right mostor 0 degree position when holding as ifaiming a gun. The hole should be clearwhen handles are in the releasedposition and fully blocked by the outertube when the handles are squeezedcompletely. If the hole is not fullyblocked when the handles are squeezed,turn the tip one complete revolutionclockwise and retest. If the hole is notcompletely clear when handles are in thereleased position, turn tip one fullrevolution counterclockwise and retest.

With the tip in any position, performthe same tests. In any position, the holeshould be clear when the handles arefully released and completely blockedwhen the handles are squeezedcompletely.

When adjustments are complete, threadthe retaining nut into the tip andwrench tighten.

Instrument Use & Cleaning InstructionsNOTE: Improper cleaning and maintenance may impair the normal function of an instrument.

Cutter(6704-9-420)

Cable Removal Cutter (6704-9-460)

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XXXXXX

The information presented in this brochure is intended to demonstrate a Stryker product. Always refer to the packageinsert, product label and/or user instructions before using any Stryker product. Surgeons must always rely on their ownclinical judgment when deciding which products and techniques to use with their patients. Products may not be availablein all markets. Product availability is subject to the regulatory or medical practices that govern individual markets. Pleasecontact your Stryker representative if you have questions about the availability of Stryker products in your area.

Stryker Corporation or its subsidiary owns the registered trademark: Stryker.

DRAFT - FOR INTERNAL USE ONLY

Copyright © 2007 Stryker

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