Acutrak 2 Headless Compression Screw System

Headless Compression
Screw System
Acutrak 2® Headless Compression Screw
Acumed® is a global leader of innovative
orthopaedic and medical solutions.
We are dedicated to developing products,
service methods and approaches that improve
patient care.
Since its introduction in 1994, the Acutrak®
Headless Compression Screw has revolutionized
the way surgeons gain fixation. By incorporating
the best features of the original Acutrak® screw
with a number of system improvements, the
Acutrak 2® Headless Compression Screw,
has become the standard of care for
multiple indications.
The Acutrak 2® Headless Compression Screw is the next
generation in fixation for fractures, fusions and osteotomies of the
extremities. Long term surgeon feedback has helped us develop a
superior implant with an innovative instrumentation set that both
eases the surgical technique and increases
instrumentation reliability.
Contents
Introducing the Acutrak 2®
2
Acutrak 2® Headless Compression
Screw Features
3
Lower Extremity Indications
4
Upper Extremity Indications 5
2
Acutrak 2® Families
6
Acutrak 2® Volar Scaphoid Technique
8
Acutrak 2® Dorsal Scaphoid Technique
10
Acutrak 2® - 5.5 Technique
12
Biomechanical Data
13
Systems Compatible with Acutrak 2®
13
Indications for Acutrak 2® Standard, Mini
and Micro
14
Acutrak 2® - 5.5 Indications
15
Acutrak 2® Instrumentation
16
Ordering Information
17
The Acutrak 2® System introduces expanded screw size options
to fit a wider variety of fractures, including longer Acutrak
2® Standard and Acutrak 2® Mini screws and a screw sized for
larger indications, the Acutrak 2® - 5.5. The system has also been
extended for smaller indications with the cannulated Acutrak 2®
Micro screw system.
Acutrak 2® Headless Compression Screw Features
Large Guide Wires
5.5
Stout guide wires make provisional stabilization of the fixation
site and accurate screw placement a successful step with
each surgery.
Standard
Mini
Micro
Large Hex Drivers
Acutrak 2® screws accept a larger size hex driver than the
traditional Acutrak®screws. The instrumentation is surgeon
friendly, with an improved driver handle that maximizes
comfort and compatibility.
Acutrak 2®
Acutrak®
Self-Drilling Screw Tip
After placing the guide wire and opening the near cortex with
a profile drill, the self-drilling Acutrak 2® cuts its way into the
bone when advanced with the hex driver, eliminating any
concerns with over-drilling.
Fully-Threaded Length: Biomechanical studies have shown that
fully-threaded screws better handle the cyclic loading that may occur
during healing. In addition, this feature allows a fracture or osteotomy
site to lie almost anywhere along the length of the screw.
Cannulated: Facilitates accurate
percutaneous insertion with
minimal soft tissue dissection.
Headless: Allows the titanium screws
to be implanted in and around
articular regions with minimal risk of
impingement or soft tissue irritation.
Variable Thread Pitch: The wider thread pitch at
the tip of the screw penetrates the bone faster than
the finer trailing threads, compressing the two
fragments gradually as the screw is advanced.
3
Lower Extremity Indications
Lower Extremity Indications:
• Jones Fractures
• Talus Fractures
• Malleolar Fractures
• Midfoot Fusions
• MTP Fusions
• Calcaneal Osteotomy
• Talonavicular Fusion
• Bunionectomies
The holding power of the Acutrak 2® Headless Compression Screw
is extremely beneficial in the weight bearing area of the body. Its
fully threaded length provides bony engagement along a greater
portion of the screw. This translates into a greater ability to maintain
compression once the patient begins bearing weight.
All of the Acutrak 2® Headless Compression Screw Systems can be
utilized in the lower extremity. Whether used for subtalar arthrodesis,
bunions, Jones fractures or a wide variety of other indications in the
lower extremity, the benefits of the screw consistently contribute to
great results throughout the foot and ankle. With greater bending and
pullout strength than its headed competitors*, the Acutrak® provides
a reliable means to fix everyday indications, as well as the more
challenging cases a surgeon sees in their practice.
* Data on File at Acumed®
4
Upper Extremity Indications
The excellent compression, holding power, and straightforward
surgical instrumentation of the Acutrak® system has enabled surgeons
to treat fractures, fusions and osteotomies with efficiency and
effectiveness. With rigid fixation in place, patients may be able to
return to normal activities sooner.
Acutrak 2® Headless Compression Screws have become a highly
respected solution for scaphoid fractures and non-unions. Whether a
surgeon uses a dorsal or volar, percutaneous or mini-open, direct or
arthroscopic approach, the Acutrak 2® provides excellent fixation for
this indication.
Upper Extremity Indications:
• Carpal Fractures
• Metacarpal Head Fractures
• Proximal Pole Scaphoid Fractures
• Radial Head Fractures
• Scaphoid Fractures and Nonunions
• Capitellum Fractures
• MCP Fusions
• Radial Styloid Fractures
• Phalangeal Fractures
Benefits of the Acutrak 2® translate equally well to a variety of other
indications that are commonly seen in the upper extremity. IP fusions,
carpal arthrodeses, radial head fractures, interphalangeal fractures and
many others all benefit from the headless profile, strong compression
and excellent holding power of the Acutrak 2® Headless Compression
Screw Systems.
5
Acutrak 2® Micro
Ideal For:
Properties:
• Phalangeal Fractures
• Use in lieu of a 2.0 2.4 mm Headed Screw
• Carpal Fractures
• Metacarpal
Head Fractures
• 1.5 mm Hex Driver
• .035” (.88 mm)
Guide Wire
• Proximal Pole
Scaphoid Fractures
• Radial Head Fractures
2.5 mm
20 mm
18 mm
16 mm
14 mm
13 mm
11 mm
12 mm
10 mm
9 mm
8 mm
2.8 mm
Guide Wire: .035” (.88 mm)
Hex Size: 1.5 mm
Material: Titanium Alloy
Acutrak 2® Mini
Ideal For:
Properties:
• Scaphoid Fractures
and Nonunions
• Use in lieu of a 3.5 4.0 mm Headed Screw
• Radial Styloid Fractures
• 2.0 mm Hex Driver
• Radial Head Fractures
• .045” (1.1 mm)
Guide Wire
• Avulsion Fractures
• Carpal Fusions
• OCD Repair
3.5 mm
• Phalangeal Fractures
30 mm
28 mm
26 mm
24 mm
22 mm
20 mm
18 mm
16 mm
3.6 mm
Guide Wire: .045” (1.1 mm)
6
Hex Size: 2.0 mm
Material: Titanium Alloy
Acutrak 2® Standard
Properties:
Ideal For:
• Scaphoid Fractures
and Nonunions
• Use in lieu of a 3.5 4.0 mm Headed Screw
• Capitellum Fractures
• 2.5 mm Hex Driver
• Bunionectomies
• .054” (1.4 mm)
Guide Wire
• Carpal Fusions
• MCP Fusions
4.0 mm
16 mm
18 mm
20 mm
22 mm
24 mm
28 mm
26 mm
30 mm
32 mm
34 mm
4.1 mm
Guide Wire: .054” (1.4 mm)
Hex Size: 2.5 mm
Material: Titanium Alloy
Acutrak 2® - 5.5
Ideal For:
Properties:
• Jones Fractures
• Talus Fractures
• Malleolar Fractures
• Midfoot Fusions
• MTP Fusions
• Use in lieu of a 4.5 6.5 mm Headed Screw
• 3.0 mm Hex Driver
• .062” (1.6 mm)
Guide Wire
5.2 mm
• Greater Tuberosity
Fractures
• Calcaneal Osteotomy
• Talonavicular Fusions
25 mm
30 mm
35 mm
40 mm
45 mm
50 mm
55 mm
60 mm
5.5 mm
Guide Wire: .062” (1.6 mm)
Hex Size: 3.0 mm
Material: Titanium Alloy
7
Surgical Technique - Acutrak 2® Volar Scaphoid Technique
The key to the volar approach is to position the screw as close
to the central axis as possible. This has been shown to both
improve the stability of the fixation and to speed bone healing.
1
The procedure can be carried out using the volar traction
approach or using a conventional volar type approach with
the arm supine on a hand table. The volar traction approach
facilitates reduction of a displaced fracture and permits
arthroscopy to ensure accuracy of the reduction. Fluoroscopy
is used throughout.
The entry point is then located using a 12 or 14 gauge IV
needle introduced on the antero-radial aspect of the wrist just
radial to and distal to the scaphoid tuberosity. This serves as a
trochar for the guide wire and is a directional aid to establish a
central path along the scaphoid. The needle is then insinuated
into the scapho-trapezial joint, tilted into a more vertical
position and the position is checked on the under image
intensifier. By gently levering on the trapezium this maneuver
brings the distal pole of the scaphoid more radial and thus
ultimately facilitates screw insertion. The entry point should
be approximately 1/3 the way across the scaphoid from the
tuberosity in the A/P plane and central in the lateral plane.
2
Pass the guide wire through the needle and drill it across the
fracture, continually checking the direction on the image
intensifier and correcting as necessary, aiming for the radial
aspect of the proximal pole. It is extremely important not to
bend the guide wire and any adjustments in direction should
be made using the needle as a guide rather than attempting to
alter the line of the guide wire alone.
3
Advance the guide wire to stop just short of the articular
surface and the wire should not breach it at this stage. The
position, alignment and length are checked once more. Make a
simple stab incision at the entry point of the wire, and deepen
this down to the distal pole of the scaphoid using a small
hemostat and blunt dissection. This is a relatively safe zone
with minimal risk to the adjacent neuro-vascular structures.
Determine the length of the screw either with the appropriate
depth gauge or by advancing a second guide wire of the same
length up the distal cortex of the scaphoid and subtracting the
difference between the two. When using the volar approach,
the correct screw size is 2-4 mm shorter than the measured
length so as to ensure that the proximal tip of the screw is fully
buried below the cartilage and the cortical surface.
8
Written by Nicholas Goddard, MB, FRCS
4
Advance the guide wire through the proximal pole of the
scaphoid so as to exit on the dorsal aspect of the wrist. This is
a precautionary measure to minimize the risk of inadvertent
withdrawal of the wire during the reaming process and screw
insertion and to facilitate removal of the proximal portion if
the wire were to break. A second de-rotation wire can then be
inserted in those cases where it is felt that there is a possibility
of rotational instability of the fracture.
5
Remove the 12 gauge needle and pass the cannulated profile
drill over the wire using either a power drill or hand reamer
stopping 1-2 mm short of the articular surface. In hard bone it
may be necessary to use the long drill to slightly expand the
entry point to accommodate the trailing edge of the screw.
6
The self-tapping screw is then advanced over the guide wire
and the wire removed. Compression can then be confirmed
radiographically on the image intensifier.
9
Surgical Technique - Acutrak 2® Dorsal Scaphoid Technique
The keys to this procedure are to place the screw as near as is feasible
to the central axis of the scaphoid and to insert the longest screw
possible. Both of these factors have been shown to enhance the
stability of the fixation and to increase the rate of healing of
the fracture.
1
The entry point in the proximal pole is at the tip of the scaphoid
immediately adjacent to the sacpho-lunate ligament. This can
be located either using an arthroscopy or mini open dorsal
approach between the 3rd and 4th extensor compartments.
Whichever approach is employed, it is essential to ensure
that the guide wire does not transfix an extensor tendon.
Having established the entry point, introduce the appropriate
guide wire aiming for the base of the thumb and check the
position on the fluoroscope. Aim to place the leading edge
of the guide wire in the subchondral surface of the distal
pole of the scaphoid. Confirm the wire placement and depth
under imaging.
Optional: A 14 gauge IV cannula is a useful aid in
determining the entry point and acts as both a guide and soft
tissue protector.
2
3
10
If the fracture is unstable it may be helpful to place a second
parallel guide wire using the parallel wire guides which are
available for all three Acutrak 2® screw families.
Measure guide wire length using either the percutaneous
screw sizer, or by placing a second wire at the entry point
and subtracting the difference. The screw sizer cannot be
used with the arthroscopic technique due to the limited
access. 4 mm should be subtracted from the measured length
to ensure that both ends of the screw are buried within
the bone.
4
Written by Nicholas Goddard, MB, FRCS
Advance the guide wire through the far cortex so that it lies in
the subcutaneous tissues. This minimizes the risk of accidental
withdrawal of the guide wire while drilling and facilitates wire
removal if it should break.
Tip: For most adult males the screw should not be longer
than 26 mm, and in females 22 mm.
5
Open the near cortex with the appropriate profile drill.
6
Next, drill into the far fragment with the long drill. To be
effective the drill only has to advance 4-5 mm past the
fracture site.
Tip: The long drill is recommended to mitigate the effects of
varying bone density and distraction upon screw insertion.
7
Insert the correctly sized screw with the appropriate hex
driver. If resistance is met upon insertion or if distraction
occurs, stop, remove the screw, redrill with the long drill and
re-insert the screw. Confirm placement and length of the
screw on imaging, ensuring that both leading and trailing
edges of the screw are beneath the articular surfaces. Finally
remove the guide wires.
11
Surgical Technique - Acutrak 2® - 5.5
1
2
Insert a guide wire at desired screw placement location and
advance through the near cortex and into the medullary
canal. Check for proper guide wire placement and continue
advancing guide wire to desired depth.
Measure wire depth to indicate screw length.
Tip: Measure off laser mark closest to the end of the
guide wire.
3
Advance the guide wire past desired drill depth prior
to drilling.
4
Open the near cortex with the profile drill. An optional long,
straight drill is available with the Acutrak 2® - 5.5 for use in
dense bone.
5
12
Install screw with the 3.0 mm hex driver provided in the set.
Biomechanical Data
The biomechanical properties of the Acutrak® Headless Compression
Screw System have contributed to the systems overall success. The
Acutrak 2® offers a next generation headless compression screw.
In addition to improved instrumentation and a straightforward
surgical technique, laboratory results demonstrate that the Acutrak 2®
Headless Compression Screw System offers surgeons biomechanical
advantages. The Acutrak 2® is an example of innovation and function
combined into one versatile system for both the upper and
lower extremities.
The Acutrak 2® Headless Compression Screw exceeds the
biomechanical properties of the traditional Acutrak® Screw in pull-out
strength. The Acutrak 2® Standard offers more pull-out strength than
the Original Acutrak® Standard while continuing to maintain
excellent compression.
Pull-Out Resistance*
100
* Data on File at Acumed®
Average Load (lbs.)
80
Average Compression (lbs.)
Compression*
15
10
60
40
20
5
0
0
Acutrak 2® Standard
Acutrak® Standard
Acutrak 2®
Standard
Acutrak®
Standard
Systems Compatible with Acutrak 2®
•
•
•
•
•
•
•
•
•
Anatomic Radial Head
Acu-loc® 2 Distal Radius Plates
Polarus® PHP®
Elbow Plating System
Calcaneal Plating System
Fibula Rod System
Locking Ankle Plating System
Forefoot/Midfoot Plating System
Lower Extremity Modular System
Scaphoid and Acu-Loc® VDR Plate
13
Indications for Acutrak 2® Standard, Mini and Micro
Four Corner Fusion
DIP Fusion
Radial Head Fracture
Proximal Pole Scaphoid Fracture
14
Ulnar Osteotomy
Phalangeal Fracture
Radial Styloid & Provisional Fixation for
Scaphoid Lunate Instability
Scaphoid Fracture with Callos® Bone Void Filler
Indications for Acutrak 2® 5.5
Bi-Lateral Malleolar Fracture
The fully threaded, headless features of the Acutrak 2® - 5.5 screws are
ideal for malleolar fractures. This X-ray (right) shows a combination of
the Acutrak 2® - 5.5 screws with the Acumed Fibula Rod.
Jones Fracture
The cannulated, headless features of the Acutrak 2® - 5.5 screws are
ideal for Jones Fractures. Based on clinical evidence*, Acutrak® and
Acutrak® 2 screws have become the “gold” standard for
many surgeons.
* Data on File at Acumed®
15
Unmatched Tray Versatility
The Acutrak 2® Headless Compression Screw System is available in
a modular format, allowing it to be placed inside multiple Acumed
plating sets for ease of use. Our newest Acutrak 2® Standard, Mini
and Micro tray can be used in any of our universal trays, making it
easy to bundle the Acutrak 2® system with other cases. The
Acutrak 2® - 5.5 Screw System is housed in a separate satellite tray
and can also be used in the Acutrak 2® family tray. Other instruments
including the ratcheting handle, screw sizer, cannula and probe can
also be placed within the Acutrak 2®
family tray.
Acutrak 2® - 5.5 Satellite Tray
Universal Acutrak 2® Std, Mini & Micro Instrument Platter
Ratcheting Handle
Ratcheting handles are available to assist with
screw insertion. The ergonomic handle and
precision ratcheting mechanism reduce user
fatigue during screw insertion.
Updated Surgical Instrumentation
Extensive surgeon feedback has helped Acumed
develop an innovative instrumentation set
that both facilitates the surgical technique
and increases instrumentation reliability. The
Acutrak 2® Screw System contains specialized
instrumentation to accommodate the versatility
of the screw and aid the surgeon during each
procedure. All drills and drivers are quick release,
featuring a driver handle that is designed for
surgeon comfort. The Plunger holds the guide
wire in place as the drill is removed. Arthroscopic
Instrumentation is included for all screw families.
16
Ordering Information
Acutrak 2® Micro Implants
Acutrak 2® Mini Implants
Sterile 8 mm Micro Acutrak 2®
AT2-C08-S
Sterile 16 mm Mini Acutrak 2®
AT2-M16-S
Sterile 9 mm Micro Acutrak 2®
AT2-C09-S
Sterile 18 mm Mini Acutrak 2®
AT2-M18-S
Sterile 10 mm Micro Acutrak 2®
AT2-C10-S
Sterile 20 mm Mini Acutrak 2®
AT2-M20-S
Sterile 11 mm Micro Acutrak 2®
AT2-C11-S
Sterile 22 mm Mini Acutrak 2®
AT2-M22-S
Sterile 12 mm Micro Acutrak 2®
AT2-C12-S
Sterile 24 mm Mini Acutrak 2®
AT2-M24-S
Sterile 13 mm Micro Acutrak 2®
AT2-C13-S
Sterile 26 mm Mini Acutrak 2®
AT2-M26-S
Sterile 14 mm Micro Acutrak 2®
AT2-C14-S
Sterile 28 mm Mini Acutrak 2®
AT2-M28-S
Sterile 16 mm Micro Acutrak 2®
AT2-C16-S
Sterile 30 mm Mini Acutrak 2®
AT2-M30-S
Sterile 18 mm Micro Acutrak 2®
AT2-C18-S
Non Sterile 16 mm Mini Acutrak 2®
AT2-M16
Sterile 20 mm Micro Acutrak 2®
AT2-C20-S
Non Sterile 18 mm Mini Acutrak 2®
AT2-M18
Non Sterile 8 mm Micro Acutrak 2®
AT2-C08
Non Sterile 20 mm Mini Acutrak 2®
AT2-M20
Non Sterile 9 mm Micro Acutrak 2®
AT2-C09
Non Sterile 22 mm Mini Acutrak 2®
AT2-M22
Non Sterile 10 mm Micro Acutrak 2®
AT2-C10
Non Sterile 24 mm Mini Acutrak 2®
AT2-M24
Non Sterile 11 mm Micro Acutrak 2®
AT2-C11
Non Sterile 26 mm Mini Acutrak 2®
AT2-M26
Non Sterile 12 mm Micro Acutrak 2®
AT2-C12
Non Sterile 28 mm Mini Acutrak 2®
AT2-M28
Non Sterile 13 mm Micro Acutrak 2®
AT2-C13
Non Sterile 30 mm Mini Acutrak 2®
AT2-M30
Non Sterile 14 mm Micro Acutrak 2®
AT2-C14
Acutrak 2® Mini Instruments
Non Sterile 16 mm Micro Acutrak 2®
AT2-C16
Non Sterile 18 mm Micro Acutrak 2®
AT2-C18
Non Sterile 20 mm Micro Acutrak 2®
AT2-C20
Acutrak 2® Micro Instruments
Micro AT2 Parallel Wire Guide Assy
.035" x 6.0" K-Wire
Micro Acutrak 2® Profile Drill
AT2-3500
WS-0906ST
AT2-4500
.045" x 6.0" K-Wire
WS-1106ST
Mini Acutrak 2® Profile Drill
AT2M-1813
Mini AT2 Long Drill
2.0 mm Cannulated Hex Driver
At2 Mini X-ray Template
AT2M-L1813
HT-1120
ACT70-03
AT2-1509
Micro Acutrak 2® Long Profile Drill
80-0100
1.5 mm Cannulated Hex Driver
HT-0915
AT2 Micro X-ray Temp
Mini AT2 Parallel Wire Guide Assy
ACT70-02
Additional Standard, Mini and Micro Instruments
Arthroscopic Cannula Assembly
AT2- Arthroscopic Probe
AT2 Perc. Screw Sizer (STD, Mini, Micro)
Plunger Assembly
80-0519
AT2-0402
AT2-SMCZ
AT-7060
17
Acutrak 2® Standard Implants
Universal Platter Standard, Mini and Micro Tray
Additional Inst.
Sterile 16 mm Standard Acutrak 2®
AT2-S16-S
Sterile 18 mm Standard Acutrak 2®
AT2-S18-S
1.5 mm Easyout, QR
80-0598
Sterile 20 mm Standard Acutrak 2®
AT2-S20-S
2.0 mm Easyout, QR
80-0599
Sterile 22 mm Standard Acutrak 2®
AT2-S22-S
2.5 mm Easyout, QR
80-0600
Sterile 24 mm Standard Acutrak 2®
AT2-S24-S
Medium Ratcheting Driver Handle
80-0663
Sterile 26 mm Standard Acutrak 2®
AT2-S26-S
6 mm Graft Removal Paddle Assembly
BG-8064
Sterile 28 mm Standard Acutrak 2®
AT2-S28-S
7 mm Bone Graft Drill Assembly
PL-BG07
Sterile 30 mm Standard Acutrak 2®
AT2-S30-S
Sterile 32 mm Standard Acutrak 2®
AT2-S32-S
Universal AT2 Std, Mini & Micro
Instrument Base
80-0808
Sterile 34 mm Standard Acutrak 2®
AT2-S34-S
Universal AT2 Std, Mini & Micro
Instrument Platter Lid
80-0809
Non Sterile 16 mm Standard Acutrak 2®
AT2-S16
Non Sterile 18 mm Standard Acutrak 2®
AT2-S18
Non Sterile 20 mm Standard Acutrak 2®
AT2-S20
Non Sterile 22 mm Standard Acutrak 2®
AT2-S22
Non Sterile 24 mm Standard Acutrak 2®
AT2-S24
Non Sterile 26 mm Standard Acutrak 2®
AT2-S26
Non Sterile 28 mm Standard Acutrak 2®
AT2-S28
Non Sterile 30 mm Standard Acutrak 2®
AT2-S30
Non Sterile 32 mm Standard Acutrak 2®
AT2-S32
Non Sterile 34 mm Standard Acutrak 2®
AT2-S34
Acutrak 2® Standard Instruments
Standard AT2 Parallel Wire Guide Assy
.054” x 7.0” K-Wire
Standard Acutrak 2® Profile Drill
Standard AT2 Long Drill
2.5 mm Cannulated Hex Driver
Acutrak 2® STD X-ray Temp
AT2-5400
WS-1407ST
AT2-2515
AT2-L2515
HT-1725
ACT70-01
Acutrak 2® 5.5 - Implants
Sterile 25 mm Acutrak 2® - 5.5 Screw
30-0021-S
Sterile 30 mm Acutrak 2® - 5.5 Screw
30-0023-S
Sterile 35 mm Acutrak 2® - 5.5 Screw
30-0025-S
Sterile 40 mm Acutrak 2® - 5.5 Screw
30-0027-S
Sterile 45 mm Acutrak 2® - 5.5 Screw
30-0029-S
Sterile 50 mm Acutrak 2® - 5.5 Screw
30-0031-S
Sterile 55 mm Acutrak 2® - 5.5 Screw
30-0084-S
Sterile 60 mm Acutrak 2® - 5.5 Screw
30-0085-S
Acutrak 2® 5.5 Instruments
.062” x 8” K-wire
80-0413
Acutrak 2® - 5.5 Profile Drill
80-0055
Acutrak 2® - 5.5 Long Drill
80-0056
3.0 mm Cannulated Driver
HT-3010
3.0 mm Solid Driver
HT-3012
Cannula/Tissue Protector
MS-2000
Probe
AP-0402
Plunger (for guide wire)
AT-7060
Percutaneous Screw Sizer
AP-0204
Forceps
AT-7005
Acutrak 2® - 5.5 Satellite Tray Assy
80-0389
5885 NW Cornelius Pass Road
Hillsboro, OR 97124
(888) 627-9957
www.acumed.net
Distributed by:
SPF00-02-C
Effective: 12/2011
© 2011 Acumed® LLC
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