DVR Anatomic Surgical Technique
2016-04-01
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DVR® Anatomic Volar Plating System Surgical Technique BMET0011 DVRtech ST.indd 1 6/19/12 9:20 AM DVR ® Anatomic Volar Plating System BMET0011 DVRtech ST.indd 2 6/19/12 9:20 AM Introduction Ten years ago the DVR helped change the treatment of distal radius fractures. Through the past decade the DVR has been continually improved and adapted to provide a broad range of surgical options to help surgeons address the needs of their patients. With 10 years of positive clinical experience and over 300,0001 plates sold worldwide, Biomet, Inc. is proud and honored to have participated with Dr. Orbay and the surgeon community to advance the art and science of fracture fixation. Biomet, Inc. is committed to providing our surgeons with the best combination of technology and service possible in order to treat their patients. We look forward to another 10 years of innovation and clinical success for the DVR® Anatomic Distal Radius Plating System. • F.A.S.T. Guide ® Technology to simplify and speed up surgery • Cobalt chrome multi-directional pegs to provide the surgeon the flexibility to adjust peg trajectories while still creating a strong, stable construct Clinical Indications The DVR® Anatomic Plate is intended for the fixation of fractures and osteotomies involving the distal radius. Surgical Approaches The list of DVR innovations include: Simple and acute fractures can be treated through the standard Flexor Carpi Radialis (FCR) approach. • The first implant system with divergent pegs to capture dorsally displaced fractures from a volar approach Intra-articular fractures, nascent malunions and established malunions are best managed through the extended form of the FCR approach. • A low profile implant designed to mimic the volar aspect of the bone and be used as a reduction template • Fixed angle K-wires to confirm implant placement prior to final implantation 1 BMET0011 DVRtech ST.indd 1 6/19/12 9:20 AM DVR ® Anatomic Volar Plating System DVR ® Anatomic Volar Plating System Oblong screw hole allows for fine tuning of the plate position. Ulnar most proximal fixed angle k-wire is used to reference proper plate position as well as predict peg distribution when using the standard technique Distal fixed angle k-wire hole used to reference proper plate position when using the distal first technique F.A.S.T. Guide® technology allows for easy drilling of fixed angle locking screws as well as indicates side specific implants by color coding Locking pegs and screws provide a strong peg to plate interface Anatomic design of the plate matches the topography of the distal radius and thus follows the “watershed” line to provide maximum buttress for volar marginal fragments The distal end of the plate is contoured to match the watershed line and the topographic surface of the distal volar radius Proprietary divergent and converging rows of pegs provide 3 dimensional scaffold for maximum subchondral support Threaded pegs available to secure fragments in the coronal plane Multi-directional threaded pegs allow for angulation within a cone of 20 degrees for maximum interoperative flexibility of locking screw placement Available plate sizes and lengths listed on page 18. Screws and Pegs Screws/Pegs Available Lengths Smooth Pegs (Locking) 10, 12, 14, 16, 18, 20, 22, 24, 26, 28 and 30 mm Partially Threaded Pegs (Locking) 10, 12, 14, 16, 18, 20, 22, 24, 26, 28 and 30 mm Multi Directional Threaded Pegs (Locking) 10, 12, 14, 16, 18, 20, 22, 24, 26, 28 and 30 mm Cortical Bone Screws 10, 12, 13, 14, 15, 16, 18 and 20 mm Screws (Non-locking) 10, 12,14, 16, 18, 20, 22, 24, 26, 28 and 30 mm 2 BMET0011 DVRtech ST.indd 2 6/19/12 9:20 AM Flexor Carpi Radialis (FCR) Figure 2 Incision Figure 1 Figure 3 FCR Approach Release the Flexor Carpi Radialis (FCR) Tendon Sheath Incision Expose and open the sheath of the FCR tendon. (Figure 2) Make an incision over the course of the flexor carpi radialis (FCR) tendon. Dissect the FCR tendon distally to the level of the superficial radial artery. A zigzag incision is made across the wrist flexion creases to allow better access and visualization. (Figure 1) Crossing the Deep Fascia Retract the FCR tendon towards the ulna while protecting the median nerve. (Figure 3) Incise through the floor of the FCR sheath to gain access to the deeper levels. Split the sheath of the FCR tendon distally up to the tuberosity of the scaphoid. 3 BMET0011 DVRtech ST.indd 3 6/19/12 9:20 AM DVR ® Anatomic Volar Plating System Watershed Line Pronator Quadratus (PQ) Figure 4 Incision Figure 5 Mid-Level Dissection Identifying the Watershed Line Develop the plane between the flexor pollicis longus (FPL) and the radial septum to reach the surface of the radius. Palpate the radius distally to identify the volar rim of the lunate fossa. This establishes the location of the watershed line. (Figure 5) Develop widely the subtendinous space of parona and expose the pronator quadratus muscle (PQ). (Figure 4) The transitional fibrous zone (TFZ) is a 1 cm wide band of fibrous tissue located between the watershed line and the PQ that must be elevated to properly visualise the fracture. Release the PQ by sharply incising over the watershed line and proximally on the lateral edge of the radius. (Figure 5) 4 BMET0011 DVRtech ST.indd 4 6/19/12 9:20 AM Brachioradialis Figure 6 Figure 7 Elevating the Pronator Quadratus (PQ) Release of the Distal Fragment Use a periosteal elevator to elevate the PQ to expose the volar surface of the radius. (Figure 6) Release the insertion of the brachioradialis which is found on the floor of the first compartment in a step cut fashion. (Figure 7) The fracture line on the volar cortex is usually simple, facilitating reduction. Note: The brachioradialis is the prime deforming force of the distal fragment. The origin of the FPL muscle can be partially released for added exposure. Identify and retract the APL and EPB tendons. Note: The pronator quadratus is frequently ruptured. Note: Care should be taken to protect the radial artery. Caution: Please refer to Warning and Precautions Section on Page 21. 5 BMET0011 DVRtech ST.indd 5 6/19/12 9:20 AM DVR ® Anatomic Volar Plating System Figure 8 Figure 9 The Extended FCR Approach Provisional Fracture Reduction Pronation of the proximal fragment out of the way provides exposure to the dorsal aspect of the fracture allowing fracture debridement and reduction. After fracture debridement, supinate the proximal radius back into place and restore radial length by reducing the volar cortex. (Figure 9) Intra-Focal Exposure Intra-focal exposure is obtained by pronating the proximal fragment out of the way. A bone clamp facilitates this maneuver. (Figure 8) Preserve the soft tissue attachments to the medial aspect of the proximal fragment. Note: This is where the anterior interosseous vessels that feed the radial shaft are located. 6 BMET0011 DVRtech ST.indd 6 6/19/12 9:20 AM Figure 11 Figure 10 Figure 12 Proximal Plate Positioning Determine the correct position for the plate by judging how the plate conforms to the watershed line and the volar surface of the radius. Measure the required screw depth using the flat side of the Depth Gauge. (Figure 11) Insert the appropriate length cortical screw. (Figure 12) Using the 2.5 mm bit, drill through the proximal oblong hole of the plate, which will allow for plate adjustments. (Figure 10) 7 BMET0011 DVRtech ST.indd 7 6/19/12 9:20 AM DVR ® Anatomic Volar Plating System Figure 13 Figure 14 Figure 15 Distal Plate Fixation Final Fracture Reduction Drilling the Proximal Rows Final reduction is obtained by indirect means using the DVR® Anatomic Plate as a template, then applying traction, ligamentotaxis and direct pressure over the dorsal aspect. (Figure 13) Using a 2.0 mm bit, drill through the proximal single-use F.A.S.T. Guide® starting on the ulnar side in order to stabilize the lunate fossa. (Figure 15) Note: Bend the K-wire out of the way to facilitate drilling. Note: A properly applied bolster helps to maintain the reduction. Distal Plate Fixation First, secure the distal fragment to the plate by inserting a k-wire through the most ulnar k-wire hole on the proximal row. (Figure 14) Proper plate positioning can be confirmed by obtaining a 20-30 degree lateral. The k-wire should be 2–3 mm subchondral to the joint line on this view. 8 BMET0011 DVRtech ST.indd 8 6/19/12 9:20 AM Figure 17 Figure 16 Figure 18 Gauging Through the F.A.S.T. Guide® Proximal Peg Placement Assess carefully the length of the proximal row pegs with the appropriate side of the depth gauge. (Figure 16) Remove each F.A.S.T. Guide® with the peg driver after checking the drilled depth. (Figure 17) Caution: Avoid excessive peg length as this can potentially cause extensor tendon irritation. Using the same peg driver, fill the peg holes with the appropriate length peg. (Figure 18) Note: if the F.A.S.T. Guide® is removed before gauging the screw depth, use the scale on the flat side of the depth gauge. Note: The use of threaded pegs will help to capture dorsal comminuted fragments. 9 BMET0011 DVRtech ST.indd 9 6/19/12 9:20 AM DVR ® Anatomic Volar Plating System Figure 19 Figure 20 Final Proximal Plate Fixation Final Plate Fixation Final Radiographs Fill all the holes of the distal peg row. A 20° – 30° elevated lateral fluoroscopic view allows visualization of the articular surface, evaluation of volar tilt, and confirmation for proper peg placement 2 – 3 mm proximal to the subchondral plate. (Figure 20) As the distal row converges on the proximal row between 16 mm and 18 mm, an 18 mm length peg is all that is needed in the distal row. To confirm that the length of each individual peg is correct, pronate and supinate the wrist under fluoroscopy. Apply the remaining proximal cortical screws. (Figure 19) SP screws are not intended to provide subchondral support and use should be limited to capture of remote bone fragments where partially threaded pegs can not be used. Note: The proximal row of pegs provides support to the dorsal aspect of the articular surface. The distal row of pegs provides support to the central and volar aspects of the subchondral plate. Remove all F.A.S.T. Guide® even if the peg hole is not used. 10 BMET0011 DVRtech ST.indd 10 6/19/12 9:20 AM Figure 21 Final Appearance A properly applied plate should be just proximal to the watershed line and not project above or beyond it in order to avoid contact with the flexor tendons. (Figure 21) Wound Closure Repair the TFZ in order to cover the distal edge of the DVR® Anatomic Plate. Repair the brachioradialis. Suture the PQ to the TFZ and the repaired brachioradialis. 11 BMET0011 DVRtech ST.indd 11 6/19/12 9:20 AM DVR ® Anatomic Volar Plating System K-wire Osteotomy Plane Figure 23 Figure 22 Figure 24 Distal Fragment First Technique For Established Malunions Complete exposure and place a K-wire 2 – 3 mm proximal to the articulating surface and parallel to the joint line. Release the brachioradialis, then pronate the radius and release the dorsal periosteum. (Figure 24) Note: Use the K-wire hole on the distal row of the DVR® Anatomic Plate as a guide for proper K-wire placement. (Figure 22) Note: The location of the distal peg rows can be identified and drilled prior to the osteotomy. Create the osteotomy plane parallel to the K-wire. (Figure 23) 12 BMET0011 DVRtech ST.indd 12 6/19/12 9:20 AM Figure 27 Figure 25 Figure 26 Figure 28 Supinate the proximal fragment and slide the DVR® Anatomic Plate over the K‑wire. (Figure 25) The K‑Wire will assure proper restoration of volar tilt. Once distal fixation is complete, the tail of the implant is secured to the shaft of the radius to re-create the 12 degrees of normal volar tilt. Fix the DVR® Anatomic Plate to the distal fragment. (Figure 26) The watershed line provides guidance for proper radiolunate deviation. After fixation, autograft is applied and the wound closed. (Figure 28) Confirm postoperative results with radiographs. 13 BMET0011 DVRtech ST.indd 13 6/19/12 9:20 AM DVR ® Anatomic Volar Plating System Figure 29 Figure 30 Installation of Multi Directional Threaded Peg Ensure that the fixed-angle pegs have been installed prior to installing the MDTP. Place the 2.0 mm drill bit through the STG until it comes in contact with the bone. Determine the trajectory of the drill bit by varying the angle of the STG and drill (Figure 29). The MDTP’s can be successfully installed within a cone of 20 degrees off of the fixed angle trajectory. Remove the F.A.S.T. Guide® using the peg driver. Place the 2.0 mm end of the Soft Tissue Guide (STG) into the radial styloid and/or the most ulnar hole in the proximal row of the DVR Anatomic plate. Assemble the Multi Direct 2.0 mm insert (231211002) into the modular handle (MQC), verifying that it is firmly attached. (Figure 30) Note: The MDTPs are not recommended for the distal row. 14 BMET0011 DVRtech ST.indd 14 6/19/12 9:20 AM Figure 31 Figure 32 Figure 33 Measure the depth of the hole using the flat side of the F.A.S.T. Bone Depth Gauge (FBDG). (Figure 31) Install the MDTP into the pre-drilled hole. Be careful to keep the driver fully engaged with the peg. Install the peg firmly until increased torque yields in no further rotation. (Figure 33) Load the appropriately sized MDTP into the driver. The peg should grip the driver. (Figure 32) Note: If necessary, after installation the MDTP can be removed and reinstalled to further improve positioning. 15 BMET0011 DVRtech ST.indd 15 6/19/12 9:20 AM DVR ® Anatomic Volar Plating System Ordering Information Pegs and Screws Smooth Peg, Locking Provides subchondral support Threaded Peg, Locking Distal threads to capture and lag fragments PXX000 Diameter: 2.0 mm 10 mm – 30 mm lengths (2 mm steps) TPXX000 Diameter 2.5 mm 10 mm – 30 mm lengths (2 mm steps) Screws, Non-Locking Fully threaded to anchor fragments for added fixation Cortical Screws Provide bicortical fixation for proximal fragments SPXX000 Diameter: 2.5 mm 10 mm – 30 mm lengths (2 mm steps) Multi Directional Threaded Peg Provides interoperative freedom to vary the trajectory of a fixed angle locking trajectory within a cone of 20 degrees. 1312111XX Diameter: 2.5 mm 10 mm – 30 mm lengths (2 mm steps) CSXX000 Diameter: 3.5 mm 10,12,13,14,15,16, 18 and 20 mm DVR® Anatomic Plates Narrow Short: 21.6 mm x 48.9 mm DVRANSL DVRANSR Narrow Standard: 21.6 mm x 57.2 mm DVRANL DVRANR Wide: 28.2 mm x 62.6 mm DVRAWL DVRAWR Standard Short: 24.4 mm x 51.3 mm DVRASL DVRASR Standard: 24.4 mm x 59.5 mm DVRAL DVRAR Standard Extended: 24.4 mm x 89.5 mm DVRAXL DVRAXR Standard Extra Extended: 24.4 mm x 175.3 mm DVRAXXL DVRAXXR 16 BMET0011 DVRtech ST.indd 16 6/19/12 9:20 AM DVR® Anatomic Plate Modular Tray Fully modular tray system addresses multiple applications with the use of a single tray • Reduced OR Instruments • Improved Workflow 17 BMET0011 DVRtech ST.indd 17 6/19/12 9:21 AM DVR ® Anatomic Volar Plating System DVRA Tray System Instrumentation DVRA Plate System Cortical Screws DG20 Drill Guide 2.0 CS10000 Screw Cortical 3.5mm, 10mm FPD20 Peg Driver F.A.S.T. CS12000 Screw Cortical 3.5mm, 12mm FBDG Bone Depth Gauge F.A.S.T. CS13000 Screw Cortical 3.5mm, 13mm SDG Depth Gauge Sleeveless CS14000 Screw Cortical 3.5mm, 14mm MQC Handle Peg Driver/Handle Mini Quick Connect CS15000 Screw Cortical 3.5mm, 15mm BC Bone Clamp DR CS16000 Screw Cortical 3.5mm, 16mm MHR Retractor Mini Hohmann CS18000 Screw Cortical 3.5mm, 18mm STG Soft Tissue Guide DR CS20000 Screw Cortical 3.5mm, 20mm 231211000 Modular QK Connect Handle 231211001 Captive Insert 231211002 MDTP Driver Mini Quick Connect DVRA Steel Tray DRT Sterilization Tray DVR Anatomic DRTSC Screw Caddy DRT Disposables: FDB20 Drill Bit F.A.S.T. 2.0mm DB25 Drill Bit 2.5mm KW062SS KWIRE 1.6MM SS DVRA Plate System DVRAR DVR Anatomic Standard Right DVRAL DVR Anatomic Standard Left DVRAXR DVR Anatomic Ext Right DVRAXL DVR Anatomic Ext Left DVRASR DVR™ Anatomic Short Right with F.A.S.T. Guides DVRASL DVR™ Anatomic Short Left with F.A.S.T. Guides DVRANR DVR™ Anatomic Narrow Right with F.A.S.T. Guides DVRANL DVR™ Anatomic Narrow Left with F.A.S.T. Guides DVRANSR DVR™ Anatomic Narrow Short Right with F.A.S.T. Guides DVRANSL DVR™ Anatomic Narrow Short Left with F.A.S.T. Guides DVRAWR DVR™ Anatomic Wide Head Right with F.A.S.T. Guides DVRAWL DVR™ Anatomic Wide Head Left with F.A.S.T. Guides DVRAXXR DVR™ Anatomic Extra Ext Right with F.A.S.T. Guides DVRAXXL DVR™ Anatomic Extra Ext Left with F.A.S.T. Guides 18 BMET0011 DVRtech ST.indd 18 6/19/12 9:21 AM Smooth Pegs Screw Pegs (Non-Locking) P10000 Peg Smooth 2.0mm, 10mm SP10000 Peg Screw 2.5mm, 10mm P12000 Peg Smooth 2.0mm, 12mm SP12000 Peg Screw 2.5mm, 12mm P14000 Peg Smooth 2.0mm, 14mm SP14000 Peg Screw 2.5mm, 14mm P16000 Peg Smooth 2.0mm, 16mm SP16000 Peg Screw 2.5mm, 16mm P18000 Peg Smooth 2.0mm, 18mm SP18000 Peg Screw 2.5mm, 18mm P20000 Peg Smooth 2.0mm, 20mm SP20000 Peg Screw 2.5mm, 20mm P22000 Peg Smooth 2.0mm, 22mm SP22000 Peg Screw 2.5mm, 22mm P24000 Peg Smooth 2.0mm, 24mm SP24000 Peg Screw 2.5mm, 24mm P26000 Peg Smooth 2.0mm, 26mm SP26000 Peg Screw 2.5mm, 26mm P28000 Peg Smooth 2.0mm, 28mm SP28000 Peg Screw 2.5mm, 28mm P30000 Peg Smooth 2.0mm, 30mm SP30000 Peg Screw 2.5mm, 30mm Threaded Pegs Multidiectional threaded Pegs (MDTP) TP10000 Peg Thread 2.5mm, 10mm 131211110 Peg Thread Multidir 2.5X10Mm TP12000 Peg Thread 2.5mm, 12mm 131211112 Peg Thread Multidir 2.5X12Mm TP14000 Peg Thread 2.5mm, 14mm 131211114 Peg Thread Multidir 2.5X14Mm TP16000 Peg Thread 2.5mm, 16mm 131211116 Peg Thread Multidir 2.5X16Mm TP18000 Peg Thread 2.5mm, 18mm 131211118 Peg Thread Multidir 2.5X18Mm TP20000 Peg Thread 2.5mm, 20mm 131211120 Peg Thread Multidir 2.5X20Mm TP22000 Peg Thread 2.5mm, 22mm 131211122 Peg Thread Multidir 2.5X22Mm TP24000 Peg Thread 2.5mm, 24mm 131211124 Peg Thread Multidir 2.5X24Mm TP26000 Peg Thread 2.5mm, 26mm 131211126 Peg Thread Multidir 2.5X26Mm TP28000 Peg Thread 2.5mm, 28mm 131211128 Peg Thread Multidir 2.5X28Mm TP30000 Peg Thread 2.5mm, 30mm 131211130 Peg Thread Multidir 2.5X30Mm 19 BMET0011 DVRtech ST.indd 19 6/19/12 9:21 AM DVR ® Anatomic Volar Plating System Notes 20 BMET0011 DVRtech ST.indd 20 6/19/12 9:21 AM DVR ® Anatomic Plate Important This Essential Product Information sheet does not include all of the information necessary for selection and use of a device. Please see full labelling for all necessary information. • Do NOT open the volar wrist capsule. Doing so may cause devascularisation of the fracture fragments and destabilisation of the volar wrist ligaments. • If necessary, contour the DVR® Anatomic plate in small incre- Indications (DVR® Anatomic and DNP® Anatomic Systems) The Distal Radius Fracture Repair System is intended for the fixation of fractures and osteotomies involving the distal radius. ments. Excessive contouring may weaken or fracture the plate. • Exercise care when bending the fragment plates to avoid weakening or fracture of the plates. Indications (Fragment Plate System) The Fragment Plate System is intended for essentially non-load bearing stabilization and fixation of small bone fragments in fresh fractures, revision procedures, joint fusion and reconstruction of small bones of the hand, foot, wrist, ankle, humerus, scapula, finger, toe, pelvis and craniomaxillofacial skeleton. • Ensure removal of all F.A.S.T. Guide® inserts after use. • Do NOT use fully threaded pegs (FP) with the DVR® Anatomic and DNP® Anatomic plates. The fully threaded pegs (FP) are designed for use with the fragment plates. • Do NOT use peg/screw lengths that will excessively protrude Contraindications If any of the following are suspected, tests are to be performed prior to implantation. Active or latent infection. Sepsis. Insufficient quantity or quality of bone and/or soft tissue. Material sensitivity. Patients who are unwilling or incapable of following post operative care instructions. through the far cortex. Protrusion through the far cortex may result in soft tissue irritation. • SP series screws are NOT intended to provide subchondral support and use should be limited to capture of remote bone fragments where partially or fully threaded pegs cannot be used. Warning and Precautions Although the surgeon is the learned intermediary between the company and the patient, the important information conveyed in this document should be conveyed to the patient. The patient must be cautioned about the use, limitations and possible adverse effects of these implants. The patient must be warned that failure to follow postoperative care instructions may cause the implant or treatment to fail. • Do NOT permanently implant K-wires through the holes of the plate as they may back out and cause tissue damage. Use of the K-wires allows you to provisionally secure the plates to the anatomy. • Do NOT use the MDTPs in the distal row of the DVR® Anatomic Plate. The MDTPs are intended to be used only with the DVR® Anatomic plates. Ensure the MDTPs An implant must never be reused. Previous stresses may have created imperfections that can potentially lead to device failure. Protect implant appliances against scratching or nicking. Such stress concentration can lead to failure. are installed after insertion of the fixed angle pegs. Adverse Effects The following are possible adverse effects of these implants: Orthopaedic instrumentation does not have an indefinite functional life. All re-usable instruments are subjected to repeated stresses related to bone contact, impaction, routine cleaning and sterilization processes. Instruments should be carefully inspected before each use to ensure that they are fully functional. Scratches or dents can result in breakage. Dullness of cutting edges can result in poor functionality. Damaged instruments should be replaced to prevent potential patient injury such as metal fragments into the surgical site. Care should be taken to remove any debris, tissue or bone fragments that may collect on the instrument. Most instrument systems include inserts/trays and a container(s). Many instruments are intended for use with a specific implant system. It is essential that the surgeon and operating theatre staff are fully familiar with the appropriate surgical technique for the instruments and associated implant, if any. potential for these devices failing as a result of loose fixation and/or loosening, stress, excessive activity, load bearing particularly when the implants experience increased loads due to a delayed union, nonunion, or incomplete healing. Note: It is NOT required to remove F.A.S.T. Guide® inserts to sterilize the plate. 21 BMET0011 DVRtech ST.indd 21 6/19/12 9:21 AM References 1. Biomet Internal Sales Data All trademarks herein are the property of Biomet, Inc. or its subsidiaries unless otherwise indicated. This material is intended for the sole use and benefit of the Biomet sales force and physicians. It is not to be redistributed, duplicated or disclosed without the express written consent of Biomet. For product information, including indications, contraindications, warnings, precautions and potential adverse effects, see the product labeling. P.O. Box 587, Warsaw, IN 46581-0587 • 800.348.9500 x 1501 ©2012 Biomet Orthopedics • biomet.com Form No. BMET0011.0 • REV053112 BMET0011 DVRtech ST.indd 22 6/19/12 9:21 AM
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xmp.iid:F223BFAE26206811871F9958E7C1FABF, xmp.iid:323E1DC326206811871F9958E7C1FABF, xmp.iid:FE20D0B00D2068118A6DFC63AF21424F, xmp.iid:DFF3C9EB2A2068118A6DFC63AF21424F, xmp.iid:E0F3C9EB2A2068118A6DFC63AF21424F, xmp.iid:EDED5501152068118A6DEDC33ECDE605, xmp.iid:E9B31DB5112068118A6DA4AFA1BAE163, xmp.iid:574B456E142068118A6DA4AFA1BAE163 History When : 2009:08:03 14:58:38-04:00, 2009:08:03 14:58:38-04:00, 2009:08:03 15:01:40-04:00, 2009:08:03 15:17:03-04:00, 2009:08:03 15:37:36-04:00, 2009:08:03 15:42:35-04:00, 2009:08:03 15:53:15-04:00, 2009:08:03 15:59:40-04:00, 2009:08:03 16:13:26-04:00, 2009:08:03 16:16:58-04:00, 2009:08:03 16:19:34-04:00, 2009:08:03 16:33:12-04:00, 2009:08:03 16:42:54-04:00, 2009:08:03 16:48:34-04:00, 2009:08:03 16:50:57-04:00, 2009:08:19 08:03:21-04:00, 2009:08:19 08:06:46-04:00, 2009:08:19 08:07:51-04:00, 2009:08:19 08:13:15-04:00, 2009:09:17 13:31:12-04:00, 2009:09:17 13:31:12-04:00, 2009:09:22 12:59:19-04:00, 2009:09:22 12:59:19-04:00, 2009:09:22 13:04:09-04:00, 2009:09:22 13:05:40-04:00, 2009:09:22 13:06:19-04:00, 2009:10:22 11:30:53-04:00, 2009:10:22 11:31:33-04:00, 2010:02:10 11:18:17-05:00, 2010:02:10 11:18:17-05:00, 2010:02:10 11:21:16-05:00, 2010:02:10 11:24:11-05:00, 2010:02:10 11:24:17-05:00, 2010:02:10 11:25:13-05:00, 2010:02:10 11:29:54-05:00, 2010:02:10 11:30:23-05:00, 2010:02:10 11:31:28-05:00, 2010:02:10 11:32:58-05:00, 2010:02:10 11:33:04-05:00, 2010:02:10 11:39:29-05:00, 2010:02:10 11:39:56-05:00, 2010:02:10 11:40:04-05:00, 2010:02:10 11:46:42-05:00, 2010:02:10 11:51:27-05:00, 2010:02:10 11:54:15-05:00, 2010:02:10 11:55:43-05:00, 2010:02:10 11:56:20-05:00, 2010:02:10 12:01:19-05:00, 2010:02:10 12:03:42-05:00, 2010:02:10 12:04:56-05:00, 2010:02:10 12:05:36-05:00, 2010:02:10 12:05:49-05:00, 2010:02:10 12:11:26-05:00, 2010:02:10 13:45:32-05:00, 2010:02:10 13:49:04-05:00, 2010:02:10 13:53:07-05:00, 2010:02:10 13:54:50-05:00, 2010:02:10 13:55:57-05:00, 2010:02:10 13:56:25-05:00, 2010:02:10 14:38:04-05:00, 2010:02:10 14:39:32-05:00, 2010:02:18 15:01:50-05:00, 2010:02:18 15:02:13-05:00, 2010:02:18 15:02:35-05:00, 2010:02:18 15:03:01-05:00, 2010:02:18 15:03:24-05:00, 2010:02:18 15:03:57-05:00, 2010:02:18 15:05:05-05:00, 2010:02:18 15:05:35-05:00, 2010:02:18 15:06:03-05:00, 2010:02:18 15:06:18-05:00, 2010:02:18 15:20:28-05:00, 2010:02:18 15:20:40-05:00, 2010:02:18 15:23:49-05:00, 2010:02:18 15:23:55-05:00, 2010:04:08 19:56:31-04:00, 2010:04:08 20:06:58-04:00, 2010:04:08 20:11:53-04:00, 2010:04:09 10:46:12-04:00, 2010:04:09 13:39:08-04:00, 2010:04:09 14:12:06-04:00, 2010:04:09 14:12:55-04:00, 2010:04:09 14:14:32-04:00, 2010:04:09 14:15:05-04:00, 2010:04:09 14:15:36-04:00, 2010:04:09 14:26:53-04:00, 2010:04:09 14:28:23-04:00, 2010:04:09 14:28:55-04:00, 2010:04:09 14:40:34-04:00, 2010:04:09 14:43:19-04:00, 2010:04:09 14:46:56-04:00, 2010:04:09 14:48:53-04:00, 2010:04:09 14:49:38-04:00, 2010:04:09 14:52:16-04:00, 2010:04:09 14:53:02-04:00, 2010:04:09 14:55:19-04:00, 2010:04:09 14:56:39-04:00, 2010:04:09 14:57:02-04:00, 2010:04:09 15:00:57-04:00, 2010:04:09 16:06:39-04:00, 2010:05:27 15:16:31-04:00, 2010:05:27 15:18:19-04:00, 2010:05:27 15:19:19-04:00, 2010:05:27 15:28:27-04:00, 2010:05:27 15:29:48-04:00, 2010:05:27 15:38:54-04:00, 2010:05:27 15:39:17-04:00, 2010:05:27 15:40:11-04:00, 2010:05:27 15:42:14-04:00, 2010:05:27 15:42:49-04:00, 2010:05:27 15:43:29-04:00, 2010:05:27 15:45:17-04:00, 2010:05:27 15:45:46-04:00, 2010:05:27 15:48:34-04:00, 2010:05:27 15:48:46-04:00, 2010:05:27 15:49:15-04:00, 2010:06:14 15:30:45-04:00, 2010:06:14 15:30:45-04:00, 2010:06:14 15:32:23-04:00, 2010:06:14 15:33:27-04:00, 2010:06:14 15:41:25-04:00, 2010:06:14 16:04:14-04:00, 2010:06:14 16:04:48-04:00, 2010:06:14 16:05:11-04:00, 2010:06:14 16:05:39-04:00, 2010:06:14 16:07:53-04:00, 2010:06:14 16:11:42-04:00, 2010:06:14 16:13:55-04:00, 2010:06:14 16:14:04-04:00, 2010:06:14 16:25:59-04:00, 2010:06:15 08:48:03-04:00, 2010:06:15 08:55:08-04:00, 2010:06:15 09:14:01-04:00, 2010:06:15 09:14:06-04:00, 2010:06:15 09:37:36-04:00, 2010:06:15 09:43:20-04:00, 2010:06:15 10:21:22-04:00, 2010:06:15 16:22:50-04:00, 2010:06:15 16:23:08-04:00, 2010:06:15 16:23:08-04:00, 2010:06:16 11:59:21-04:00, 2010:06:16 11:59:21-04:00, 2010:06:16 12:09:47-04:00, 2010:06:16 13:31:04-04:00, 2010:06:18 11:13:37-04:00, 2010:06:18 11:17:11-04:00, 2010:06:21 08:10:15-04:00, 2012:05:14 14:46:59-04:00, 2012:05:14 14:46:59-04:00, 2012:05:14 15:04:27-04:00, 2012:05:14 15:33:29-04:00, 2012:05:15 08:00:13-04:00, 2012:05:15 09:57:14-04:00, 2012:05:15 10:37:22-04:00, 2012:05:15 10:50:12-04:00, 2012:05:15 11:05:46-04:00, 2012:05:15 11:18:09-04:00, 2012:05:15 11:23:14-04:00, 2012:05:15 11:27:45-04:00, 2012:05:15 11:30:16-04:00, 2012:05:15 11:33:49-04:00, 2012:05:15 11:37:06-04:00, 2012:05:15 11:39:54-04:00, 2012:05:15 12:10:38-04:00, 2012:05:15 12:11:12-04:00, 2012:06:01 10:37:34-04:00, 2012:06:01 14:06:49-04:00, 2012:06:01 14:07:39-04:00, 2012:06:04 09:06:37-04:00, 2012:06:19 09:10:39-04:00, 2012:06:19 09:10:40-04:00 History Software Agent : 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Page Count : 24 Creator : Adobe InDesign CS5.5 (7.5)EXIF Metadata provided by EXIF.tools