POLSKI PRZEGLĄD CHIRURGICZNY 2013, 85, 12, 721–726
10.2478/pjs-2013-0110
CASE REPORTS
Unsuccessful replantation of metacarpal hand after venous thrombosis – case report Ahmed Elsaftawy, Jerzy Jabłecki Department of General Surgery, Subdepartment of Limb Replantation, Microsurgery and Hand Surgery, St Hedwig Hospital in Trzebnica Ordynator: prof. dr hab. J. Jabłecki Trans-metacarpal hand replantation is one of the most complex and difficult procedures in the reconstructive microsurgery. As far as we know the arrangement of the palmar arterial network, the problem lies in the absence of accurate venous maps at the dorsum of the hand. The quality of venous circulation structure at the replanted hand determine the success of the surgery. In this paper we present a case of a failed replantation of a metacarpal hand after early thrombosis at the venous microcirculation system. Key words: metacarpal hand amputations, replantation, venous microcirculation thrombosis, microsurgical anastomosis
Amputation on the level of metacarpal hand belong to the most frequently occurring amputation of the upper limb, after finger and thumb amputations. In Poland, this type of amputations is most often a result of „inappropriate” operation of a circular saw. Hand replantations on the level of metacarpal hand are classified as the most complicated ones due the vessel caliber as well as the number of microsurgical unions, both vascular and neural ones, which are indispensable for the operation to be ended with success. Another problem is the one posed by the proximity of MCP joints, which makes the possibility of stable osseous union with no interference into ligament apparatus highly difficult to achieve. An incredibly important element is the quality of venous unions, as it may determine the success or failure of replantation. Our target is to present a case of un unsuccessful replantation in a patient who had his hand amputated on the level of metacarpus when working with a circular saw.
Case report Patient aged 17 (medical history no.: 6743/12) was admitted during replantation emergency service due to full amputation on the level of right metacarpal hand (dominating hand) caused by a circular saw. The amputation was a combination of levels 4 and 5 according to Tamai (running slantwise from the middle of p1 of the index finger to the level just below MCP joints of fingers 3-5) (fig. 1). The patient got injured at 9 in the morning, and was brought to our hospital at around 5 p.m.. Therefore the period of cold ischaemia amounted to approximately 8 hours. After preparing the part of amputated hand as well as the stump and all other elements and marking all elements needed for unions, we commenced the operational procedure from shortening the metacarpus bone, thus obtaining the possibility of tension-free microsurgical union. Osseous union was done by means of „K” wires sized 1.2 and 1.4, two wires for each bone Unauthenticated Download Date | 12/10/16 6:16 AM
722
A. Elsaftawy, J. Jabłecki
Fig. 1. A – amputated hand, B – View of fingers just after replantation
„closed type”- below skin. Tendons of extensors, which were prepared earlier, were united by means of modified Bunnel stitch, and deep flexors by modified Kessler stitch and simple running stitch of the sutured tendons of fingers 2-5, 3 common digital nerves by stitches 8:0.3 common digital arteries by stitches 8:0 and 3 dorsal veins by stitches 9:0. The operation took 9 hours and 35 minutes, and it resulted in the following: proper vascularization of the replanted part was achieved- saturation on all amputated fingers amounted to above 95% (fig. 1). This state was maintained throughout 5 post-operative days (fig. 2). As far as pharmacological treatment is concerned: We used low molecural-weight heparyn in curative dose, aspirin in cardiological dose, 500 ml of Dekstran 40 000 once a day, Polfilin in dose 2x 300 mg, prophylactic antibiotic therapy and analgesic medicines. In 6th post-operative day we observed a sudden turning purple in the
Fig. 2. iew of hand in 5 post-operative day th
ulnar part of the hand from the dorsal part and so we immediately implemented hirudotherapy with medical leeches according to a pattern designed by our Division (8) (fig. 3). Faced with clear lack of improvement in fingers vascularization, and the incessant purpleness, in 7th day qualified the patient for venous union revision. When the operation was in progress we noticed a clot in common venous microunion from 4th and 5th finger, and performer evacuation of thrombosis, as well as rinsed both venous vessels (also backwards) by saline solution with addition of heparin, we harvested from the left foot dorsum a venous graft which was used to reconstruct the previous union, and after making sure about its permeability, we concluded the operation. However, microclots of capillaries forming due to a sudden venous thrombosis were still a problem which we couldn’t solve. Thrombosis originating in one radius of the hand spread over the remaining replanted fingers. Morphology tests revealed a sudden considerable increase in thrombocytes number, starting from 1st post- operative day, however they were still levels that fitted in the norm limits (fig. 4). The remaining lab tests results from the entire period of hospital treatment (fig. 5, 6) had no alarming features. We believe that the reason for this sudden increase of thrombocytes may be compensatory marrow reaction to a sudden considerable blood loss by the patient. Unfortunately, despite all our attempts and actions aiming at saving the hand, we decided on its amputation in 20th day after the replantation. The autopsy view the amputated part indi-
Fig. 3. View of hand in 6th day after replantation, implementation of hirudotherapy with medical leeches Unauthenticated Download Date | 12/10/16 6:16 AM
Unsuccessful replantation of metacarpal hand after venous thrombosis – case report
Fig. 4. Diagram showing the level of thrombocytes during hospitalization
cated a disseminated thrombosis in the venous system of fingers. Discussion Amoutations in zones V and IV according to Tamai present the worst prognosis with
723
regard to function restoration, however a loss of 4 fingers as in the case described above means losing up to 65% grasping function of the hand (2, 3). The probability of success after replantation is higher after guillotine amputations and virtually full ones, and lower after full, avulsive and crushing ones, in cases of long time of ischaema (> 10 hours) and lack of limb cooling during transport (4). In case of limb ischaema due to its amputation which does not yet cause tissue thrombosis, crucial disturbances occur not during ischaema, but only after restoring blood flow. One of the first phenomena that develop in the limb after restoring blood flow is the sudden increase of permeability of capillaries, which leads to swelling, pressure increase in the so-called “area III”, which can finally result in acute compartment syndrome. It is mainly conditioned by the damaging activity of free radicals emerging after blood flow restoration. There also exist a number of mechanical reasons for venous microcirculation after replantations, which may result from a couple of reasons:
Fig. 5. Diagrams presenting the most crucial morphology parameters Unauthenticated Download Date | 12/10/16 6:16 AM
724
A. Elsaftawy, J. Jabłecki
Fig. 6. Diagrams showing parameters of the coagulation system
a) lack of any venous union or its original occlusion – wrong microsurgical technique, b) too few united veins (the so called abnormal arteriovenous relation), c) considerable damage both in the amputated part and in the stump (1, 5). Lack of any actions aiming at improvement of venous circulation in consequence leads to a loss of the replanted hand. Apart from visual examination of the limb, microcirculation estimation should be correctly performer, monitored and documented. It is indispensable for the complete evaluation of the limb lifetime and success of the operation. The most frequently used methods for diagnosing microcirculation in the replanted limb include: 1. Pulse oximetry: it has certain clinical limitations in use. Method of apparatuses calibration was established based on a group of volunteers., comparing readings of oximeter with gasometry results. The level of hemoglobin oxidation below 70% is a clear
indication of hypoxia, and it was not induced among the tested volunteers, this is why also mass produced pulse oximeters take measurements up to 70% of hemoglobin saturation, and when obtaining a lower result they display the following message:’ signal too weak”; 2. Laser Doppler Flowmetry – LDF: this device allows to measure flow at very low speeds (ranged from 0.004 mm/s) regardless of its direction in capillaries below 50 mm diameter, at the depth from 0.6 to 1.5 mm and within the radius of 1 mm from the head. Unfortunately, the device is extremely expensive, which is a curb on its regular use; 3. Comparative gasometry: in case of slowing the flow due to decreased arterial inflow or venous stasis there occur changes which may be compared to gasometry of blood taken from the same finger of a healthy limb. 4. Termography and thermovision: it is about measurement of infrared radiation emitted Unauthenticated Download Date | 12/10/16 6:16 AM
Unsuccessful replantation of metacarpal hand after venous thrombosis – case report
through the skin. The intensity is directly proportional to skin temperature of the limb under examination, read its blood flow. It is a method used more rarely because it also depends on ambient temperature, possible infection present, trauma or other factors. Results presenting successful upper limb replantation on the level of metacarpus- zone V according to Tamai, may be deemed as similar in literature. Paavilainen presented results of revascularization and/or replantation of metacarpal hand in 160 patients. Original survival rate of replanted hands was recorded in 137 (86%) patients (12). On the other hand, Gerostathopoulos (8) presented effects of replantations after complete amputations in 22 patients, with successful replantations amounting to 20. Weinzweig (5) described results of 9 revascularizations and 4 replantations in 12 patients, where all hands survived. We are aware that the arterial system of the fingers is anatomically well described, and so usually there are no difficulties when preparing and performing microsurgical unions. Difficulties though occur when manipulating, known as “random venous system” on vascular placenta of the dorsal part of hand (9, 10, 11). A detailed preparation of the amputated part for replantation is extremely important for the success of operation. After preparating anteriolas for the union and rinsing of the
725
whole amputated part, one should observe the outflow of liquid on the dorsal side and mark the efficient veins from each “rinsed” arteriola. It allows to make right decisions regarding unions within the venous network. A venous union may be however redundant in very distal replntations (II and III subzones according to Ishigaw), as microvascular venous system should develop within 5-7 days after replantation, in such cases the most important part is the one played by efficient arterial union and distal venous outflow obtained intentionally, mainly via nail matrix after its removal (12, 13). In case of more proximal amputations, an efficient venous union plays one of the most important roles in success of the operation, because microclots that may form in an incompetent union may add to thrombosis of the whole replanted hand. In situations when concerns arise about efficiency of venous microunion, we are glad to have good results in implementing hirudotherapy, still no non-operative method known to us is able to eliminate the clots that already formed after limbs replantation procedures (10, 11, 12). Mechanical removal of the clot as well as another uniting by means of a venous thrombosis seemed to be the most optimal solution saving the hand, yet symptoms of thrombosis of the other fingers in later days determined our decision to re-amputate the hand in 20th post-operative day.
references 1. Paruzel M, Jabłecki J: Zastosowanie pijawek w leczeniu zaburzeń mikrokrążenia replantowanych palców. Doniesienie wstępne. Pol Przegl Chir 2007; 79(8): 987-97. 2. Jabłecki J, Kaczmarzyk J, Łapczyński D et al.: Digital Replantation In The V 5th Zone According To Tamai Classification. Pol Przegl Chir 1996; 68: 166-72. 3. Jabłecki J, Kaczmarzyk L, Orzechowski P et al.: Attempted Solution Of The Problem Of Lack Of A Venous Drainage After Finger Replantation, 2000, PL ISNN – 0860 – 2204 4. Żyluk A, Walaszek I: Ocena wyników replantacji kończyn górnych. Chir Narządów Ruchu i Ortop Pol 2007; 72(3): 165-73. 5. Weinzweig N: Replantation and revascularization at the transmetacarpal level: long-term functional results, J Hand Surg Am 1996; 21(5): 877-83.
6. De Weerd L, Weum S, Mercer JB: Locating perforator vessels using dynamic infared thermography. Ann Plast Surg 2012, 13. 7. Ozcelik I: The results of digital replantations at the level of the distal interphalangeal joint and the distal phalanx. Acta Orthop Traumatol Turc 2006; 40(1): 62-66. 8. Gerostathopoulos N: Long- term results of transmetacarpal complete amputation. Session C ASRM/ HSRM. The Preliminary Program for 2003 Annual Meeting. 9. Hasuo T: Fingertip replantations: importance of venous anastomosis and the clinical results. Hand Surg 2009; 14(1): 1-6. 10. Hattori Y: Significance of venous anastomosis in fingertip replantation. Plast Reconstr Surg 2003; 111(3): 1151-58. Unauthenticated Download Date | 12/10/16 6:16 AM
726
A. Elsaftawy, J. Jabłecki
11. Smith DO, Oura C, Kimura C, Toshimori K: The distal venous anatomy of the finger. J Hand Surg (Am) 1991; 16: 303-07. 12. Paavilainen P: Long-term results of transmetacarpal replantation. J Plast Reconstr
Aesthet Surg 2007; 60(7): 704-09. Epub 2007 Apr 26. 13. Sukop A: Clinical Anatomy of the Dorsal Venous Network in Fingers With Regard to Replantation. Clinical Anatomy 19:000–000 (2006).
Pracę nadesłano:14.04.2013 r. Adress correspondence: 55-100 Trzebnica, ul. Prusicka 53/55 e-mail: [email protected]
Unauthenticated Download Date | 12/10/16 6:16 AM
10.2478/pjs-2013-0110
CASE REPORTS
Unsuccessful replantation of metacarpal hand after venous thrombosis – case report Ahmed Elsaftawy, Jerzy Jabłecki Department of General Surgery, Subdepartment of Limb Replantation, Microsurgery and Hand Surgery, St Hedwig Hospital in Trzebnica Ordynator: prof. dr hab. J. Jabłecki Trans-metacarpal hand replantation is one of the most complex and difficult procedures in the reconstructive microsurgery. As far as we know the arrangement of the palmar arterial network, the problem lies in the absence of accurate venous maps at the dorsum of the hand. The quality of venous circulation structure at the replanted hand determine the success of the surgery. In this paper we present a case of a failed replantation of a metacarpal hand after early thrombosis at the venous microcirculation system. Key words: metacarpal hand amputations, replantation, venous microcirculation thrombosis, microsurgical anastomosis
Amputation on the level of metacarpal hand belong to the most frequently occurring amputation of the upper limb, after finger and thumb amputations. In Poland, this type of amputations is most often a result of „inappropriate” operation of a circular saw. Hand replantations on the level of metacarpal hand are classified as the most complicated ones due the vessel caliber as well as the number of microsurgical unions, both vascular and neural ones, which are indispensable for the operation to be ended with success. Another problem is the one posed by the proximity of MCP joints, which makes the possibility of stable osseous union with no interference into ligament apparatus highly difficult to achieve. An incredibly important element is the quality of venous unions, as it may determine the success or failure of replantation. Our target is to present a case of un unsuccessful replantation in a patient who had his hand amputated on the level of metacarpus when working with a circular saw.
Case report Patient aged 17 (medical history no.: 6743/12) was admitted during replantation emergency service due to full amputation on the level of right metacarpal hand (dominating hand) caused by a circular saw. The amputation was a combination of levels 4 and 5 according to Tamai (running slantwise from the middle of p1 of the index finger to the level just below MCP joints of fingers 3-5) (fig. 1). The patient got injured at 9 in the morning, and was brought to our hospital at around 5 p.m.. Therefore the period of cold ischaemia amounted to approximately 8 hours. After preparing the part of amputated hand as well as the stump and all other elements and marking all elements needed for unions, we commenced the operational procedure from shortening the metacarpus bone, thus obtaining the possibility of tension-free microsurgical union. Osseous union was done by means of „K” wires sized 1.2 and 1.4, two wires for each bone Unauthenticated Download Date | 12/10/16 6:16 AM
722
A. Elsaftawy, J. Jabłecki
Fig. 1. A – amputated hand, B – View of fingers just after replantation
„closed type”- below skin. Tendons of extensors, which were prepared earlier, were united by means of modified Bunnel stitch, and deep flexors by modified Kessler stitch and simple running stitch of the sutured tendons of fingers 2-5, 3 common digital nerves by stitches 8:0.3 common digital arteries by stitches 8:0 and 3 dorsal veins by stitches 9:0. The operation took 9 hours and 35 minutes, and it resulted in the following: proper vascularization of the replanted part was achieved- saturation on all amputated fingers amounted to above 95% (fig. 1). This state was maintained throughout 5 post-operative days (fig. 2). As far as pharmacological treatment is concerned: We used low molecural-weight heparyn in curative dose, aspirin in cardiological dose, 500 ml of Dekstran 40 000 once a day, Polfilin in dose 2x 300 mg, prophylactic antibiotic therapy and analgesic medicines. In 6th post-operative day we observed a sudden turning purple in the
Fig. 2. iew of hand in 5 post-operative day th
ulnar part of the hand from the dorsal part and so we immediately implemented hirudotherapy with medical leeches according to a pattern designed by our Division (8) (fig. 3). Faced with clear lack of improvement in fingers vascularization, and the incessant purpleness, in 7th day qualified the patient for venous union revision. When the operation was in progress we noticed a clot in common venous microunion from 4th and 5th finger, and performer evacuation of thrombosis, as well as rinsed both venous vessels (also backwards) by saline solution with addition of heparin, we harvested from the left foot dorsum a venous graft which was used to reconstruct the previous union, and after making sure about its permeability, we concluded the operation. However, microclots of capillaries forming due to a sudden venous thrombosis were still a problem which we couldn’t solve. Thrombosis originating in one radius of the hand spread over the remaining replanted fingers. Morphology tests revealed a sudden considerable increase in thrombocytes number, starting from 1st post- operative day, however they were still levels that fitted in the norm limits (fig. 4). The remaining lab tests results from the entire period of hospital treatment (fig. 5, 6) had no alarming features. We believe that the reason for this sudden increase of thrombocytes may be compensatory marrow reaction to a sudden considerable blood loss by the patient. Unfortunately, despite all our attempts and actions aiming at saving the hand, we decided on its amputation in 20th day after the replantation. The autopsy view the amputated part indi-
Fig. 3. View of hand in 6th day after replantation, implementation of hirudotherapy with medical leeches Unauthenticated Download Date | 12/10/16 6:16 AM
Unsuccessful replantation of metacarpal hand after venous thrombosis – case report
Fig. 4. Diagram showing the level of thrombocytes during hospitalization
cated a disseminated thrombosis in the venous system of fingers. Discussion Amoutations in zones V and IV according to Tamai present the worst prognosis with
723
regard to function restoration, however a loss of 4 fingers as in the case described above means losing up to 65% grasping function of the hand (2, 3). The probability of success after replantation is higher after guillotine amputations and virtually full ones, and lower after full, avulsive and crushing ones, in cases of long time of ischaema (> 10 hours) and lack of limb cooling during transport (4). In case of limb ischaema due to its amputation which does not yet cause tissue thrombosis, crucial disturbances occur not during ischaema, but only after restoring blood flow. One of the first phenomena that develop in the limb after restoring blood flow is the sudden increase of permeability of capillaries, which leads to swelling, pressure increase in the so-called “area III”, which can finally result in acute compartment syndrome. It is mainly conditioned by the damaging activity of free radicals emerging after blood flow restoration. There also exist a number of mechanical reasons for venous microcirculation after replantations, which may result from a couple of reasons:
Fig. 5. Diagrams presenting the most crucial morphology parameters Unauthenticated Download Date | 12/10/16 6:16 AM
724
A. Elsaftawy, J. Jabłecki
Fig. 6. Diagrams showing parameters of the coagulation system
a) lack of any venous union or its original occlusion – wrong microsurgical technique, b) too few united veins (the so called abnormal arteriovenous relation), c) considerable damage both in the amputated part and in the stump (1, 5). Lack of any actions aiming at improvement of venous circulation in consequence leads to a loss of the replanted hand. Apart from visual examination of the limb, microcirculation estimation should be correctly performer, monitored and documented. It is indispensable for the complete evaluation of the limb lifetime and success of the operation. The most frequently used methods for diagnosing microcirculation in the replanted limb include: 1. Pulse oximetry: it has certain clinical limitations in use. Method of apparatuses calibration was established based on a group of volunteers., comparing readings of oximeter with gasometry results. The level of hemoglobin oxidation below 70% is a clear
indication of hypoxia, and it was not induced among the tested volunteers, this is why also mass produced pulse oximeters take measurements up to 70% of hemoglobin saturation, and when obtaining a lower result they display the following message:’ signal too weak”; 2. Laser Doppler Flowmetry – LDF: this device allows to measure flow at very low speeds (ranged from 0.004 mm/s) regardless of its direction in capillaries below 50 mm diameter, at the depth from 0.6 to 1.5 mm and within the radius of 1 mm from the head. Unfortunately, the device is extremely expensive, which is a curb on its regular use; 3. Comparative gasometry: in case of slowing the flow due to decreased arterial inflow or venous stasis there occur changes which may be compared to gasometry of blood taken from the same finger of a healthy limb. 4. Termography and thermovision: it is about measurement of infrared radiation emitted Unauthenticated Download Date | 12/10/16 6:16 AM
Unsuccessful replantation of metacarpal hand after venous thrombosis – case report
through the skin. The intensity is directly proportional to skin temperature of the limb under examination, read its blood flow. It is a method used more rarely because it also depends on ambient temperature, possible infection present, trauma or other factors. Results presenting successful upper limb replantation on the level of metacarpus- zone V according to Tamai, may be deemed as similar in literature. Paavilainen presented results of revascularization and/or replantation of metacarpal hand in 160 patients. Original survival rate of replanted hands was recorded in 137 (86%) patients (12). On the other hand, Gerostathopoulos (8) presented effects of replantations after complete amputations in 22 patients, with successful replantations amounting to 20. Weinzweig (5) described results of 9 revascularizations and 4 replantations in 12 patients, where all hands survived. We are aware that the arterial system of the fingers is anatomically well described, and so usually there are no difficulties when preparing and performing microsurgical unions. Difficulties though occur when manipulating, known as “random venous system” on vascular placenta of the dorsal part of hand (9, 10, 11). A detailed preparation of the amputated part for replantation is extremely important for the success of operation. After preparating anteriolas for the union and rinsing of the
725
whole amputated part, one should observe the outflow of liquid on the dorsal side and mark the efficient veins from each “rinsed” arteriola. It allows to make right decisions regarding unions within the venous network. A venous union may be however redundant in very distal replntations (II and III subzones according to Ishigaw), as microvascular venous system should develop within 5-7 days after replantation, in such cases the most important part is the one played by efficient arterial union and distal venous outflow obtained intentionally, mainly via nail matrix after its removal (12, 13). In case of more proximal amputations, an efficient venous union plays one of the most important roles in success of the operation, because microclots that may form in an incompetent union may add to thrombosis of the whole replanted hand. In situations when concerns arise about efficiency of venous microunion, we are glad to have good results in implementing hirudotherapy, still no non-operative method known to us is able to eliminate the clots that already formed after limbs replantation procedures (10, 11, 12). Mechanical removal of the clot as well as another uniting by means of a venous thrombosis seemed to be the most optimal solution saving the hand, yet symptoms of thrombosis of the other fingers in later days determined our decision to re-amputate the hand in 20th post-operative day.
references 1. Paruzel M, Jabłecki J: Zastosowanie pijawek w leczeniu zaburzeń mikrokrążenia replantowanych palców. Doniesienie wstępne. Pol Przegl Chir 2007; 79(8): 987-97. 2. Jabłecki J, Kaczmarzyk J, Łapczyński D et al.: Digital Replantation In The V 5th Zone According To Tamai Classification. Pol Przegl Chir 1996; 68: 166-72. 3. Jabłecki J, Kaczmarzyk L, Orzechowski P et al.: Attempted Solution Of The Problem Of Lack Of A Venous Drainage After Finger Replantation, 2000, PL ISNN – 0860 – 2204 4. Żyluk A, Walaszek I: Ocena wyników replantacji kończyn górnych. Chir Narządów Ruchu i Ortop Pol 2007; 72(3): 165-73. 5. Weinzweig N: Replantation and revascularization at the transmetacarpal level: long-term functional results, J Hand Surg Am 1996; 21(5): 877-83.
6. De Weerd L, Weum S, Mercer JB: Locating perforator vessels using dynamic infared thermography. Ann Plast Surg 2012, 13. 7. Ozcelik I: The results of digital replantations at the level of the distal interphalangeal joint and the distal phalanx. Acta Orthop Traumatol Turc 2006; 40(1): 62-66. 8. Gerostathopoulos N: Long- term results of transmetacarpal complete amputation. Session C ASRM/ HSRM. The Preliminary Program for 2003 Annual Meeting. 9. Hasuo T: Fingertip replantations: importance of venous anastomosis and the clinical results. Hand Surg 2009; 14(1): 1-6. 10. Hattori Y: Significance of venous anastomosis in fingertip replantation. Plast Reconstr Surg 2003; 111(3): 1151-58. Unauthenticated Download Date | 12/10/16 6:16 AM
726
A. Elsaftawy, J. Jabłecki
11. Smith DO, Oura C, Kimura C, Toshimori K: The distal venous anatomy of the finger. J Hand Surg (Am) 1991; 16: 303-07. 12. Paavilainen P: Long-term results of transmetacarpal replantation. J Plast Reconstr
Aesthet Surg 2007; 60(7): 704-09. Epub 2007 Apr 26. 13. Sukop A: Clinical Anatomy of the Dorsal Venous Network in Fingers With Regard to Replantation. Clinical Anatomy 19:000–000 (2006).
Pracę nadesłano:14.04.2013 r. Adress correspondence: 55-100 Trzebnica, ul. Prusicka 53/55 e-mail: [email protected]
Unauthenticated Download Date | 12/10/16 6:16 AM
