Herbert Mini Bone Screw Surgical Technique

Transcription

1
®
™
®
Zimmer
Herbert
Zimmer
Bone
Screw™and
Herbert
Zimmer
Herbert
Cannulated
Mini
Bone
Screw
Bone
Screw
Surgical Technique
2
Zimmer® Herbert™ Bone Screw and Zimmer Herbert Mini Bone Screw
Table of Contents
Indications for Use................................................................ 3
Instrumentation.................................................................... 4
Herbert Bone Screws Surgical Techniques:
Huene Alignment Guide Technique.........................................4
Calibration Check...................................................................4
Straight Blade.........................................................................4
1. Apply Huene Alignment Guide.........................................5
2. Check Alignment.............................................................5
3. Drill the Pilot Hole...........................................................5
4. Drill the Main Hole...........................................................6
5.Tap..................................................................................6
6. Read Calibration..............................................................6
7. Insert Screw....................................................................7
Open Procedure for Free-Hand Guide......................................8
1. Apply Free-Hand Guide....................................................8
2. Temporary K-Wrie Fixation................................................9
3. Drill the Pilot Hole...........................................................9
4. Drill the Main Hole...........................................................9
5.Tap................................................................................10
6. Insert Screw...................................................................10
Herbert Mini Bone Screw Surgical Technique:
Open Procedure with Free-Hand Guide..................................11
1. Apply Free-Hand Guide..................................................11
2. Drill the Pilot Hole.........................................................11
3. Drill the Main Hole.........................................................12
4.Tap................................................................................12
5. Select the Appropriate Screw.........................................13
6. Insert Screw..................................................................13
Technique Variations – Cortical Bone Fixation...................... 14
Ordering Information........................................................... 15
Indications for Use
The Herbert™ Mini Bone Screw (2.5mm diameter,
non-cannulated) and the Herbert Bone Screw (3.0mm
diameter, non-cannulated) are indicated for fixation of
intra-articular and extra-articular fractures, avulsions,
non-union, and osteotomies of small bones and small
bone fragments; as well as arthrodeses of small joints.
3
4
Instrumentation
Herbert Instruments
Huene Alignment Guide
For use with the Herbert Bone Screw (3.0mm)
Whenever possible, the Herbert Bone Screw is inserted
through the Huene Alignment Guide (Figure 1). When
the Alignment Guide cannot be applied, refer to page 8
for the Free-Hand Technique. This Alignment Guide locks
the two bone fragments together and ensures accurate
positioning of the screw.
The barrel of the Alignment Guide is designed to
precisely guide the instrumentation and clamps onto
the near fragment of the bone. The blade hooks around
the far bone fragments and has a small point to lock it
into place. Thumb pressure is then used to tighten the
Alignment Guide and compress the two bone fragments
together. Once it has been satisfactorily applied, the
Alignment Guide aligns the instruments and ensures
accurate placement of the Herbert Screw within the
bone.
Calibration Check
The calibration of the Huene Alignment Guide should
be checked periodically as it is possible for the blade to
become distorted. (The Blade is extremely thin at its tip,
and it should not be used as a lever.)
Assemble the Alignment Guide and insert the long Drill
into the barrel. Apply tension to the blade as shown.
Check to be sure that the blade tip is centered on the tip
of the Drill within a 1 mm diameter range (Figure 2). Set
the barrel between 22-30mm and check the calibration
with the scale on the case.
Incorrect position indicates blade
damaged by bending
Blade
Figure 2: Procedure for
checking blade
Straight Blade
This may be used when it is possible to apply the
Alignment Guide for fixation of bones.
Examples of its use have included:
• Bennett’s fracture dislocations of the base of the first
metacarpal
• Radial head fractures
• Fractures of the trapezium
• Intercarpal fusions
Lock the Blade in the single (upright) position, and
carefully hook into the far fragment of the bone after it
has been suitably exposed. Align the Alignment Guide
and clamp it firmly onto the near fragment of the bone
(Figure 3). Carefully check the line and length before
drilling.
The barrel is calibrated to indicate a screw of the correct
length to be buried within the bone.
This dimension should
not be larger than
approximately 2mm
clearance
Check that blade and drill
tips are within 1-2mm
Drill #2
Figure 1: Huene Alignment Guide (00-1154-011-00) with curved blade
has right & left orientation
Figure 3: Use of the Alternate Blade (00-1154-019-000) and the Huene
Alignment Guide to reduce Bennett’s fracture
5
Herbert Bone Screws Surgical Techniques:
Huene Alignment Guide Application
1
Apply Huene Alignment Guide
Set the blade of the Alignment Guide and firmly tighten the
locking screws. Place the hook and barrel of the Alignment
Guide perpendicular to the fracture and push the guide onto
the bone using firm thumb pressure.
2
Check Alignment
Visually check the alignment of the Alignment Guide to
ensure that the screw will lie in the optimum position. Also,
check the reduction of the fracture and make any necessary
adjustments. This position of the Alignment Guide can be
checked with the image intensifier.
Alignment Check with Guide Wire (Optional)
Free-Hand
Guide
Straight
Blade
Free-Hand
Guide
Insert SLeeve
Insert Sleeve
Guide Wire
Barrel
Figure 4: Optional use of the Free-Hand Guide Insert Sleeve and a
K-wire to verify correct alignment of the Guide
Place the Free-Hand Guide Insert Sleeve (00-1152-052-00)
into the barrel of the Alignment Guide. Drive a Guide Wire
through the Insert Sleeve (Figure 4), to center the guide wire
within the Alignment Guide and verify the position by x-ray or
image intensifier. Remove the Guide Wire and Insert Sleeve.
Read Measurement directly from the
Alignment Guide
3
Drill the Pilot Hole
Insert the 2.4mm Pilot Drill (00-1154-001-00) into the barrel
of the Alignment Guide. Turn the handle and advance the Drill
until it bottoms out (Figure 5). Continue to turn the Drill in a
clockwise direction during removal as this will remove bone
and facilitate further instrumentation.
Pilot Drill
Figure 5: Determine the screw length from the calibrations on the
Alignment Guide, and drill the pilot hole for the trailing threads
6
4
Drill the Main Hole
Insert the 2.0mm Main Drill (00-1154-002-00) into the
Alignment Guide. Turn the Drill in a clockwise direction to
maximize efficiency in cutting and chip removal. Advance
the Drill until it bottoms out (Figure 6). If the bone is
hard, withdraw the Drill periodically in a clockwise
direction to remove bone fragments.
5
Tap
Main Drill
Figure 6: Drill the main hole for the leading threads, and the shaft of the
bone screw
Tap the leading screw threads, using Herbert Bone
Screw Tap (00-1154-005-00) when performing bicortical
fixation. Insert the Tap using a clockwise movement until
it bottoms out (Figure 7). Remove the Tap by turning in a
counter-clockwise direction. It is essential that the Tap be
inserted to the full drill depth in order to achieve the full
compressive action of the screw.
6
Read Calibration
The screw length can be read directly from the
calibrations on the Alignment Guide (Figure 7 Inset).
This reading is the longest possible screw that should be
used. If a shorter screw can be chosen without having
threads present across the fracture site, selection of
the shorter screw will reduce the risk of penetration.
This is the reason for the preoperative calibration check
recommended and described on page 4. However, too
short a screw selection will result in threads present
across the fracture line especially if the fracture is a
proximal one. Screw threads across the fracture line can
distract the bone fragments and contribute to failure of
the device.
Read Measurement directly
from the Alignment Guide
Tap
Figure 7: Tap the full depth of the main drill hole for the leading threads
7
Insert Screw
Select the appropriate length screw and lift it out of the
sterilization rack with the Screwdriver (Figure 8). Check
the length of the screw against the calibrated scale
located in the screw rack. (Packaged bone screws are
presterilized.)
Insert the screw through the Alignment Guide and turn
the Screwdriver (00-1154-006-00) clockwise (Figure
9). As the trailing thread enters the bone, increased
resistance will be felt and further reduction at the
fracture site will be visible. Remove the Alignment Guide
and turn the screw an additional one or two turns. This
will apply additional reduction and/or compression at
the fracture site and completely bury the screw head.
If the screw has been placed in an articular joint, put the
joint through a full range of movements to confirm secure
fixation and to ensure that the screw has not penetrated.
A check with the image intensifier at this stage verifies
the position of the screw on the radiograph at the
termination of the operative procedure.
Figure 8: Lift the Herbert Screw from rack, Screwdriver fully engaged in
hexagonal socket
Screwdriver
Figure 9: Insert the Herbert Bone Screw into the bone through the
Alignment Guide
7
8
Open Procedure with Free-Hand Guide
The technique should be used whenever the Alignment Guide cannot be applied.
When using this technique, a Guide Wire should be used to maintain reduction and x-ray may be used to confirm
proper position. The Free-Hand Guide and Insert Sleeve may be used both to direct the Guide Wire and also the
accessory fixation wires parallel to the intended screw axis.
It is imperative that the two fragments are held firmly together during free-hand insertion of the screw. This can usually
be achieved by applying manual pressure on the handle of the Guide, and/or using the bone holding forceps as the
fracture reduction clamp.
1
Apply Free-Hand Guide
Following fracture reduction use the Free-Hand Guide
(00-1154-092-00) to compress the bone fragments and
align the instruments (Figure 10). The Insert Sleeve
(00-1152-052-00) can be inserted into the Free-Hand
Guide, a Guide Wire may then be passed through the
Insert Sleeve to check the exact alignment. Remove the
Insert Sleeve. The Free-Hand Depth Gauge is then used in
conjunction with the Guide Wire to determine the proper
screw length. Insert the Gauge over the primary Guide
Wire and into the barrel of the Free-Hand Guide until the
tip touches the surface of the bone (Figure 11). Then
read the screw length directly from the calibrations on
the gauge. This reading is the longest possible screw that
should be used. If a shorter screw can be chosen without
having threads present across the fracture site, selection
of the shorter screw will reduce the risk of penetration.
The Guide Wire is then removed. It is imperative that only
the wires included with the set are used to perform this
procedure. These wires are sized appropriately for the
Depth Gauges and the Free-Hand Guide Insert Sleeve.
Free-Hand Guide
Figure 10: Apply manual pressure to firmly hold anatomic reduction of
the fracture fragment
Read Measurement
Free-Hand Depth Gauge
FIgure 11: Optional measurement of the penetration depth of the K-wire
(less 2mm). This may be helpful when determining the drill depth or
ultimate screw length
9
2
Temporary K-Wire Fixation
Whenever possible, place a second (accessory) wire
through one of the alignment holes located on either
side of the Free-Hand Guide to further secure the bone
fragments (Figure 12). This will prevent any displacement
or fragment rotation during the procedure. Use of these
guide holes will ensure that the K-wires are parallel.
They can accept a stabilization K-wire up to 1.1mm in
diameter.
3
Guide Wire
Free-Hand Guide Insert Sleeve
Figure 12: Optional use of accessory stabilization wires. The Free-Hand
Insert Sleeve may be used to insert a central K-wire and verify correct
alignment of the Guide with image intensification or x-ray evaluation
Insert the 2.4mm Pilot Drill (00-1154-001-00) into the
barrel of the Free-Hand Guide. Turn the handle and
advance the Drill until it bottoms out (Figure 13). This will
remove a small amount of bone from the cortical surface
and facilitate further instrumentation. If drilling into very
dense cortical bone, use the Herbert 3.2mm Power Drill.
4
Accessory Wire
Pilot Drill
Figure 13: Drill the proximal cortex for the trailing threads with the Pilot
Drill
Drill the Main Hole
Insert the 2.0mm Main Drill (00-1154-002-00) into
the Guide and advance it into the appropriate depth.
Withdraw the Drill in a clockwise direction to maximize
efficiency in cutting and chip removal. If the bone is
hard, withdraw the Drill periodically to remove bone
fragments. If a Guide Wire has not been used, the length
of screw can be determined by reading directly off the
calibrated scale the depth to which the Drill has been
inserted (Figure 14).
Read Measurement
Main Drill
Figure 14: Drill the main hole for the core diameter of the leading threads
and the shaft
10
5
Tap
Read Measurement
Tap the leading screw threads. Insert the Tap (00-1154005-00) using a clockwise turning movement until the
appropriate depth is read on the calibrated barrel (Figure
15). Remove the Tap by turning in a counter-clockwise
direction. It is essential that the Tap be inserted to the
full drill depth, otherwise the compressive action of the
screw may be lost.
6
Tap
Insert Screw
Figure 15: Tap the full depth of the main drill hole for the leading thread
form
Select the appropriate length screw and lift it out of the
sterilization rack with the Screwdriver (00-1154-00600). Check the length of the screw against the calibrated
scale adjacent to the screw rack. (Packaged bone screws
are presterilized.)
Insert the screw and Screwdriver through the Free-Hand
Guide, turning the Screwdriver clockwise (Figure 16). As
the trailing thread enters the bone, increased resistance
will be felt and further reduction at the fracture site
will be visible. Remove the Free-Hand Guide. To apply
additional reduction and/or compression at the fracture
site, or to completely bury the screw head, rotate the
screw one or more revolutions with the Screwdriver.
Screwdriver
Figure 16: Implant the Herbert Bone Screw into the distal radius
through the Free-Hand Guide
11
Herbert Mini Bone Screw Surgical Technique:
Open Procedure with Free-Hand Guide
The free-hand technique must be used with the Herbert Mini Bone Screw.
The Free-Hand Guide is used to direct the instruments and screw.
It is imperative that the two fragments are pre-compressed firmly together during free-hand insertion of the screw. This
can usually be achieved by applying manual pressure on the handle of the Guide only using the Bone-Holding Forceps
as a fracture reduction clamp. Use temporary K-wires to maintain the reduction.
1
Apply Free-Hand Guide
Once the fracture is reduced, apply the Free-Hand Guide
(00-1150-051-00) to the bone (Figure 17). Whenever
possible, place one or two accessory wires through
the alignment holes on the Free-Hand Guide to further
secure the bone fragments. This will prevent any
displacement or fragment rotation during the procedure.
Use of these guide holes will ensure that the K-wires
are parallel. They can accept a stabilization K-wire up to
1.1mm in diameter.
2
Free-Hand Guide
Accessory Wire
Figure 17: Apply manual pressure to firmly hold the anatomic reduction
of the fracture fragment. Inset shows holes used to place parallel
accessory fixation wires through the Guide
Insert the 2.3mm Pilot Drill (00-1150-003-00) into
the barrel of the Free-Hand Guide. Turn the handle
and advance the Drill until it bottoms out (Figure 18).
Removing the Drill in a clockwise direction will remove
bone fragments and facilitate further instrumentation.
Pilot Drill
Figure 18: Drill the pilot hole through the proximal cortex
12
3
Drill the Main Hole
Read Measurement
Insert the 1.5mm Main Drill (00-1150-004-00) into
the Free-Hand Guide to the appropriate depth as read
on the calibrated barrel (Figure 19). Turn the Drill in a
clockwise direction to maximize efficiency in cutting
and chip removal. If the bone is hard, withdraw the Drill
periodically to remove bone fragments.
Main Drill
4
Figure 19: Drill the main hole for the core diameter of the leading
threads and the shaft
Tap
Tap the leading screw threads. Insert the Tap (00-1150005-00) using a clockwise turning movement until the
appropriate depth is read on the calibrated barrel (Figure
20). Remove the Tap by turning in a counter-clockwise
direction. It is essential that the Tap be inserted to the
full drill depth, otherwise the compressive action of the
screw may be lost.
Tap
Figure 20: Tap the full depth of the Main Drill for the leading threads
and the shaft
13
5
Select the Appropriate Screw
Select the appropriate length screw, lifting it out of the
sterilization rack with the Screwdriver (00-1150-006-00).
Note that the calibrated barrel is designed to countersink
the screw end(s) 1mm to 2mm below the cortical surfaces.
If maximum bicortical fixation is desired, select a bone
screw 2mm longer than the calibration read when drilling.
Check the length of the screw against the calibrated scale
adjacent to the screw rack. (Packed bone screws are presterilized.)
6
Insert Screw
Insert the screw and Screwdriver through the Free-Hand
Guide (Figure 21), turning the Screwdriver clockwise. As the
trailing thread enters the bone, increased resistance will be
felt and further reduction at the fracture site will be visible.
Remove the Free-Hand Guide.
To apply additional reduction and/or compression at the
fracture site or to completely bury the screw head, rotate
the screw one or more revolutions with the Screwdriver.
Screwdriver
Figure 21: Implant the Herbert Mini Bone Screw through the Free-Hand
Guide (Bennett’s Fracture fixation)
14
Technique Variations
Cortical Bone Fixation
(For the Herbert and Herbert Mini Bone Screws)
The Herbert Bone Screw System was designed
specifically for fixation of cancellous bone fragments and
its use in cortical bone is not normally recommended.
However, on certain occasions it may be desirable to
insert the screw through a hard cortical surface, e.g.:
• Interphalangeal fusion of digits
• Fixation of oblique metatarsal osteotomies
• Fixation of very small or delicate bones
1. In very small or delicate bones, cortical bone
may provide better fixation than cancellous. The
resistance to pull-out and the capability of applying
and maintaining rigid fixation is greater. It is
desirable to capture cortical bone at both ends of the
bone screw to optimize the reductive capabilities of
these Herbert Mini Bone Screws. The surgeon should
drill and tap for the leading threads through the
opposite cortex. This will prevent the bone screw from
accidentally stripping the cancellous thread purchase
within the inner cortical wall. (Stripping the threads
with excessive torque could result in distraction of
the fracture fragment which has been previously
reduced.) However, it is sometimes more difficult
to fully seat the self-reducing and self-compressing
Herbert and Herbert Mini Bone Screws bicortically in
this type of bone. When using the Herbert Mini Bone
Screws, this difficulty occurs when the cortices on
both sides are greater than 5mm in thickness.
2. For use of the Herbert Bone Screw in dense cortical
bone, use the 3.2mm Drill (00-1154-070-00) with
power drill in place of the 2.4mm Pilot Drill. This
facilitates entry of the trailing thread and prevents it
from splitting the cortex.
For use of the Herbert Mini Screw in dense cortical
bone, the 2mm Drill (00-1154-071-00) should be
used in place of the 1.5mm Mini Main Drill. Drill
completely through both cortices.
Figure 22: Showing correct method of drilling through cortical bone
(power may be preferred) with the Free-Hand Guide located in a
“hollow” created in the cortex with a rongeur or large drill
Note: These alternative Drills do not fit into the Mini
System’s Free-Hand Guide.
3. Tap completely through both cortices before inserting
the screw. If the bone is too hard for the points of
the drill guide to engage, gouge out a small hollow to
assist in location of the guide (Figure 22). Then drill
and tap the medulla in the normal fashion. Take care
to ensure that the leading end of the screw does not
abut the opposite cortex.
CAUTION: If complete reduction is attained prior to
insertion of the bone screw, it is possible to generate
torques which will cause failure of the tip of the
Screwdriver prior to fully seating the bone screw. To
avoid instrument breakage, one of two steps must be
taken:
A. Accept that the trailing threads of the bone screw will not fully seat. Closely monitor the hex tip of the Screwdriver. Be sure to stop torqueing the handle when you feel the hex tip begin to slip or deform.
B. Counterbore the proximal cortex with the Herbert 3.2mm diameter Power Pilot Drill for a depth of 2mm to 3mm.
NOTE: When attempting to maximize cortical fixation on
both ends of the bone screw, a screw 2mm longer than
indicated by the guide calibration should then be used
to ensure that the leading threads are purchased in the
cortical bone.
Zimmer® Herbert Bone Screw and Zimmer Herbert Mini Bone Screw
Ordering Information
Implants
Herbert Bone Screw System
Prod. No.
Description
Quantity
47-1154-012-00
Herbert Bone Screw, 3.0mm Dia X 12mm
2
47-1154-014-00
2
47-1154-016-00
2
47-1154-018-00
2
47-1154-020-00
2
47-1154-022-00
2
47-1154-024-00
2
47-1154-026-00
2
47-1154-028-00
2
47-1154-030-00
2
Herbert Mini Bone Screw System
Prod. No.
Description
00-1150-010-00
Herbert Mini Bone Screw 2.5mm Dia X 10mm
2
00-1150-012-00
2
00-1150-014-00
2
00-1150-016-00
2
00-1150-018-00
2
00-1150-020-00
2
00-1150-022-00
2
00-1150-024-00
2
15
16
Instruments
Herbert Mini Bone Screw Instruments
Prod. No.
Description
Quantity
00-1150-003-00
Herbert Mini Bone Screw Pilot Drill 2.3mm Diameter
1
00-1150-004-00
Herbert Mini Bone Screw Main Drill 1.5mm Diameter
1
00-1150-005-00
Herbert Mini Bone Screw Tap
1
00-1150-006-00
Herbert Mini Bone Screw Screwdriver
1
00-1150-007-00
Herbert Mini Bone Screw Trephine
1
00-1150-051-00
Herbert Mini Bone Screw Free-Hand Guide
1
00-1150-095-00
Herbert Mini Bone Screw Screw/Instrument Case
1
00-1154-071-00
Herbert Bone Screw System Drill 2.0 mm Dia.
1
Herbert Bone Screw Instruments
Prod. No.
Description
Quantity
00-1152-052-00
Herbert/Whipple Bone Screw System Free-Hand Guide Insert Sleeve
1
00-1152-055-00
Herbert/Whipple Bone Screw System Free-Hand Depth Gauge
1
00-1154-001-00
Herbert Bone Screw Instrumentation Pilot Drill 2.4mm Gauge
1
00-1154-002-00
Herbert Bone Screw Instrumentation Main Drill 2.0mm Dia.
1
00-1154-005-00
Herbert Bone Screw Instrumentation Tap
1
00-1154-006-00
Herbert Bone Screw Instrumentation Screwdriver
1
00-1154-009-00
Herbert Bone Screw Instrumentation Elevator
1
00-1154-010-00
Herbert Bone Screw Instrumentation Trephine
1
00-1154-011-00
Herbert Bone Screw Instrumentation Huene Alignment Guide*
1
00-1154-019-00
Herbert Bone Screw Instrumentation Straight Blade (For Huene Alignment Guide)*
1
00-1154-036-00
Replacement Barrel 80mm Length (Huene Alignment Guide)
1
00-1154-070-00
Herbert Bone Screw System Drill 3.2mm Dia. (Optional)
1
00-1154-092-00
Herbert/Whipple Bone Screw System Free-Hand Guide Base
1
00-1154-095-00
Herbert/Whipple Bone Screw System with Huene Alignment Guide Screw/Instrument Case
1
00-1156-095-00
Herbert Bone Screw System General Instrument Case
1
* The Huene Alignment Guide (00-1154-011-00) comes with the Scaphoid Left Right Blade (00-1154-017-00). This
blade is used with the Herbert/Whipple Screws. The Straight Blade (00-1154-019-00) is to be used with Herbert
Bone Screws.
17
Zimmer® Herbert Bone Screw and Zimmer Herbert Mini Bone Screw
Instruments
General Herbert/Herbert Mini Bone Screw Instruments
Prod. No.
Description
Quantity
00-1152-004-00
Flat Depth Gauge
1
00-1152-050-00
Guide Wire Diameter .038 in (.97mm) Length 5.9 in. (15cm) Co-Cr Alloy
1
00-1154-008-00
Herbert Bone Screw Instrumentation Dissector
1
00-1154-040-00
Herbert Bone Screw Instrumentation Double-Ended Retractor
2
00-1154-077-00
Herbert Bone Screw Hand Rasp
1
00-1154-078-00
Herbert/Whipple Bone Screw System, Small Retractor
1
00-2346-005-00
Quick-Connect Handle
1
00-2446-039-00
Sharp Hook
1
00-2910-002-00
Key Periosteal Elevator 1/4 in. (6.4mm) Blade Width
1
00-3027-000-00
Heiss Soft Tissue Retractor
1
00-3088-020-00
Hohmann Retractor Small 6mm Width
1
00-3088-021-00
Hohmann Retractor Small 8mm Width
1
00-4816-001-00
Reduction Forceps
1
00-4816-005-00
Reduction Forceps w/Points, Rachet, 130mm
1
00-4817-001-00
Sharp Hook
1
18
19
DISCLAIMER:
This documentation is intended exclusively for physicians and is not intended for laypersons.
Information on the products and procedures contained in this document is of a general nature and
does not represent and does not constitute medical advice or recommendations. Because this
information does not purport to constitute any diagnostic or therapeutic statement with regard to any
individual medical case, each patient must be examined and advised individually, and this document
does not replace the need for such examination and/or advise in whole or in part.
Please refer to the package inserts for important product information, including, but not limited to,
indications, contraindications, warnings, precautions, and adverse effects.
Contact your Zimmer representative or visit us at www.zimmer.com
The CE mark is valid only if it is also printed on the product label.
97-1150-102-00 Rev. 1 11-24-15 ©2015 Zimmer, Inc.

Herbert Mini Bone Screw Surgical Technique

Transcription

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