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surgical technique Ascension ® Silicone MCP Ascension ® Silicone MCP surgical technique WW
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Ascension® Silicone MCP
surgical technique
WW
ASCENSION ORTHOPEDICS, INC.
8700 CAMERON ROAD, SUITE 100
AUSTIN, TEXAS, USA 78754
512.836.5001 512.836.6933 fax
CUSTOMER SERVICE: 877.370.5001 (toll-free in U.S.)
www.ascensionortho.com
Caution: U.S. federal law restricts this deviceto sale by or on the order of a physician.
© 2006 LC-04-507-001 rev C WW
SMCP_SrgTchWW-C_Cover 3/8/06 9:30 AM Page 2
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Surgical TechniqueStep One:Joint ExposureFor single joint involvement:Make a longitudinal incision over the dorsum ofthe metacarpophalangeal (MCP) joint (FIGURE 2).
For multiple joint involvement:A curving transverse incision across the dorsumof the MCPs is recommended (FIGURE 2).
Cut the extensor hood on the radial side of thecentral tendon or through its center if no dislocation/subluxation of the tendon is present. Dissect theextensor tendon free from the joint capsule radiallyand ulnarly. This may not be possible in advanceddisease. Split the capsule longitudinally and dissect itto expose the joint, preserving the capsule as muchas possible for later repair. The dissection should becontinued so that the dorsal base of the proximalphalanx and the metacarpal head with the collateralligament origins are visible.
Step Two:Opening the Metacarpal Medullary CanalUse the starter awl to make the initial puncture ofthe metacarpal head (FIGURE 3). This punctureshould be placed volar to the dorsal surface of themetacarpal head a distance 1/3 the sagittal heightof the head (FIGURE 4) and centered across thewidth of the head. The resulting puncture shouldbe aligned with the long axis of the metacarpalmedullary canal.
Step Three:Establishing Metacarpal Medullary Canal AlignmentAttach the alignment guide to the alignment awl,insert the alignment awl into the puncture (FIGURE 5),and advance it 1/2 to 2/3 the length of the metacarpal(FIGURE 6). The alignment guide should be parallel tothe dorsal surface of the metacarpal and in line withthe long axis of the bone.
FIGURE 2: INCISIONS
FIGURE 3: METACARPAL PUNCTURE
Incision for multiple joint involvement
Incision for single joint involvement
FIGURE 5:ALIGNMENT AWLINSERTION
FIGURE 6: ALIGNMENT AWL ADVANCE
FIGURE 4: CANAL ALIGNMENT
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FIGURE 1A – Ascension® Silicone MCPIntroductionThis manual describes the sequence of techniquesand instruments used to implant the Ascension®
Silicone MCP (FIGURE 1A). Successful use of thisprosthesis depends on proper patient selection,surgical technique, and post-operative therapy.
If questions arise, please contact AscensionOrthopedics at 877-370-5001 (toll-free in U.S.) or e-mail [email protected].
Ascension®
Silicone MCPThe Ascension® Silicone MCP is a single-componentmetacarpophalangeal silicone spacer consisting ofproximal and distal intramedullary stems and a centralflexible hinge. It is provided sterile and available infive sizes. Guided osteotomies are made first to themetacarpal head and then the proximal phalanx base.The medullary canals are then progressively broachedto the desired size. The phalanx is broached firstbecause it generally determines the sizing of theimplant. Trial implants (FIGURE 1B) are then inserted,and the joint is reduced. Once the trial reduction issatisfactory, the trial implants are removed, and thefinal implants are inserted.
Pre-OperativeAssessmentAscension® Silicone MCP arthroplasty is appropriatefor patients with osteo, post-traumatic andrheumatoid arthritis. In patients with rheumatoidarthritis, soft tissue imbalance may be more severe,and the surgeon must determine that correction ofvolar subluxation deformities and ulnar deviationdeformities can be achieved with standard MCPreconstruction techniques. In patients with severeintercarpal supination and radial deviation of thewrist, ulnar deviation of the digits may not becorrectable with soft tissue surgery and in theseinstances, it is recommended that corrective wristsurgery be performed first at a separate setting.
Standard AP, lateral and oblique x-rays should beused to template the size of the prosthesis likely tobe required at surgery.
FIGURE 1B: ASCENSION® SILICONE MCP
TRIAL SET
SIZE CATALOG NUMBER
10 SMCP-500-10
20 SMCP-500-20
30 SMCP-500-30
40 SMCP-500-40
50 SMCP-500-50
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Surgical TechniqueStep One:Joint ExposureFor single joint involvement:Make a longitudinal incision over the dorsum ofthe metacarpophalangeal (MCP) joint (FIGURE 2).
For multiple joint involvement:A curving transverse incision across the dorsumof the MCPs is recommended (FIGURE 2).
Cut the extensor hood on the radial side of thecentral tendon or through its center if no dislocation/subluxation of the tendon is present. Dissect theextensor tendon free from the joint capsule radiallyand ulnarly. This may not be possible in advanceddisease. Split the capsule longitudinally and dissect itto expose the joint, preserving the capsule as muchas possible for later repair. The dissection should becontinued so that the dorsal base of the proximalphalanx and the metacarpal head with the collateralligament origins are visible.
Step Two:Opening the Metacarpal Medullary CanalUse the starter awl to make the initial puncture ofthe metacarpal head (FIGURE 3). This punctureshould be placed volar to the dorsal surface of themetacarpal head a distance 1/3 the sagittal heightof the head (FIGURE 4) and centered across thewidth of the head. The resulting puncture shouldbe aligned with the long axis of the metacarpalmedullary canal.
Step Three:Establishing Metacarpal Medullary Canal AlignmentAttach the alignment guide to the alignment awl,insert the alignment awl into the puncture (FIGURE 5),and advance it 1/2 to 2/3 the length of the metacarpal(FIGURE 6). The alignment guide should be parallel tothe dorsal surface of the metacarpal and in line withthe long axis of the bone.
FIGURE 2: INCISIONS
FIGURE 3: METACARPAL PUNCTURE
Incision for multiple joint involvement
Incision for single joint involvement
FIGURE 5:ALIGNMENT AWLINSERTION
FIGURE 6: ALIGNMENT AWL ADVANCE
FIGURE 4: CANAL ALIGNMENT
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FIGURE 1A – Ascension® Silicone MCPIntroductionThis manual describes the sequence of techniquesand instruments used to implant the Ascension®
Silicone MCP (FIGURE 1A). Successful use of thisprosthesis depends on proper patient selection,surgical technique, and post-operative therapy.
If questions arise, please contact AscensionOrthopedics at 877-370-5001 (toll-free in U.S.) or e-mail [email protected].
Ascension®
Silicone MCPThe Ascension® Silicone MCP is a single-componentmetacarpophalangeal silicone spacer consisting ofproximal and distal intramedullary stems and a centralflexible hinge. It is provided sterile and available infive sizes. Guided osteotomies are made first to themetacarpal head and then the proximal phalanx base.The medullary canals are then progressively broachedto the desired size. The phalanx is broached firstbecause it generally determines the sizing of theimplant. Trial implants (FIGURE 1B) are then inserted,and the joint is reduced. Once the trial reduction issatisfactory, the trial implants are removed, and thefinal implants are inserted.
Pre-OperativeAssessmentAscension® Silicone MCP arthroplasty is appropriatefor patients with osteo, post-traumatic andrheumatoid arthritis. In patients with rheumatoidarthritis, soft tissue imbalance may be more severe,and the surgeon must determine that correction ofvolar subluxation deformities and ulnar deviationdeformities can be achieved with standard MCPreconstruction techniques. In patients with severeintercarpal supination and radial deviation of thewrist, ulnar deviation of the digits may not becorrectable with soft tissue surgery and in theseinstances, it is recommended that corrective wristsurgery be performed first at a separate setting.
Standard AP, lateral and oblique x-rays should beused to template the size of the prosthesis likely tobe required at surgery.
FIGURE 1B: ASCENSION® SILICONE MCP
TRIAL SET
SIZE CATALOG NUMBER
10 SMCP-500-10
20 SMCP-500-20
30 SMCP-500-30
40 SMCP-500-40
50 SMCP-500-50
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Step Six:Establishing Phalangeal Medullary Canal AlignmentWith the joint flexed, insert the alignment awl inthe puncture and advance it 1/2 to 2/3 the lengthof the phalanx (FIGURES 12, 13). The alignmentguide should be parallel to the dorsal surface of thephalanx and in line with the long axis of the bone.
Step Seven:Phalangeal OsteotomyAttach the distal osteotomy guide on the alignmentawl and reinsert the awl along the previouslyestablished medullary axis. Advance the guide untilthe cutting plane is positioned 0.5 to 1.0 mm distalto the dorsal edge of the proximal phalanx. Thedistal guide provides a 5° distally tilt from vertical(FIGURE 14). Rotational alignment of osteotomyguide is achieved when the volar surface of the guideis parallel to the dorsal surface of the phalanx.
Collateral ligament integrity should be retained asfar as possible. A conservative osteotomy should bemade and then altered later if necessary. This allowsfor joint space adjustment during the fitting of thetrial implants (Step 10). A conservative osteotomygenerally removes only the joint articular surface.
With the distal osteotomy guide held steady, makethe cut by passing the saw blade through the slotof the guide (FIGURE 15). Because of the presence ofthe alignment awl, only a partial (dorsal) osteotomycan be performed. Remove the alignment awl andcomplete the osteotomy by following the planeestablished by the guided cut (FIGURE 16).
Step Eight:Phalangeal Medullary CanalBroachingThe phalangeal opening is initially expanded andshaped with the starter awl. Then, insert the size 10distal broach (FIGURE 17). Use of a side-cutting burrmay be necessary to assist in proper insertion of thebroaches. Rotational alignment of the broach isachieved when the dorsal surface of the broach isparallel to the dorsal surface of the phalangeal bone.The alignment guide mounted on the broach should beparallel to the dorsal surface of the phalanx and in linewith the long axis of the bone. Continue broaching
FIGURE 12: ALIGNMENT AWL
INSERTION
FIGURE 13: FLEXED FOR ALIGNMENT
AWL ADVANCE
FIGURE 15: GUIDED OSTEOTOMY
FIGURE 16: COMPLETING THE OSTEOTOMY
FIGURE 14: CUT TILT
Step Four:Metacarpal OsteotomyAttach the proximal osteotomy guide on thealignment awl and reinsert the awl along the previouslyestablished medullary axis. Advance the guide untilthe cutting plane is positioned 1.5 to 2.0 mm distalto the dorsal attachments of the collateral ligaments.Rotational alignment of the guide is achieved whenthe volar surface of the guide is parallel to the dorsalsurface of the metacarpal bone. The proximal guideprovides a 27.5° distal tilt from vertical (FIGURE 7).
Collateral ligament integrity should be retained as faras possible. A conservative osteotomy at least 1.5mmdistal to the dorsal attachment of the collateralligaments should be made and then altered laterif necessary. This allows for joint space adjustmentduring the fitting of the trial implants (Step 10).
Special Thin Blade Requirements:It is strongly recommended that a small,thin oscillating saw blade be used (7mm x 29.5mm x 0.4mm).
With the proximal osteotomy guide held steady,make the cut by passing the saw blade through theslot of the guide (FIGURE 8). Because of the presenceof the alignment awl, only a partial (dorsal) osteotomycan be performed. Remove the alignment awl andcomplete the osteotomy by following the planeestablished by the guided cut (FIGURE 9).
Step Five:Opening the Phalangeal Medullary CanalWith the joint flexed, use the starter awl to makethe initial puncture of the proximal phalanx base(FIGURE 10). This puncture should be placed volarto the dorsal surface of the proximal phalanx adistance 1/3 the sagittal height of the proximalphalangeal base (FIGURE 11) and centered acrossthe width of the base. The resulting puncture shouldbe aligned with the long axis of the proximalphalangeal’s medullary canal.
CAUTION:During puncture, the joint must be flexed toavoid damage by impingement to the dorsal edgeof the metacarpal osteotomy (FIGURE 11).
FIGURE 8: GUIDED OSTEOTOMY
FIGURE 9: COMPLETING THE
OSTEOTOMY
FIGURE 7: CUT TILT
FIGURE 10: PROXIMAL PHALANX PUNCTURE
FIGURE 11: CANAL ALIGNMENT
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Step Six:Establishing Phalangeal Medullary Canal AlignmentWith the joint flexed, insert the alignment awl inthe puncture and advance it 1/2 to 2/3 the lengthof the phalanx (FIGURES 12, 13). The alignmentguide should be parallel to the dorsal surface of thephalanx and in line with the long axis of the bone.
Step Seven:Phalangeal OsteotomyAttach the distal osteotomy guide on the alignmentawl and reinsert the awl along the previouslyestablished medullary axis. Advance the guide untilthe cutting plane is positioned 0.5 to 1.0 mm distalto the dorsal edge of the proximal phalanx. Thedistal guide provides a 5° distally tilt from vertical(FIGURE 14). Rotational alignment of osteotomyguide is achieved when the volar surface of the guideis parallel to the dorsal surface of the phalanx.
Collateral ligament integrity should be retained asfar as possible. A conservative osteotomy should bemade and then altered later if necessary. This allowsfor joint space adjustment during the fitting of thetrial implants (Step 10). A conservative osteotomygenerally removes only the joint articular surface.
With the distal osteotomy guide held steady, makethe cut by passing the saw blade through the slotof the guide (FIGURE 15). Because of the presence ofthe alignment awl, only a partial (dorsal) osteotomycan be performed. Remove the alignment awl andcomplete the osteotomy by following the planeestablished by the guided cut (FIGURE 16).
Step Eight:Phalangeal Medullary CanalBroachingThe phalangeal opening is initially expanded andshaped with the starter awl. Then, insert the size 10distal broach (FIGURE 17). Use of a side-cutting burrmay be necessary to assist in proper insertion of thebroaches. Rotational alignment of the broach isachieved when the dorsal surface of the broach isparallel to the dorsal surface of the phalangeal bone.The alignment guide mounted on the broach should beparallel to the dorsal surface of the phalanx and in linewith the long axis of the bone. Continue broaching
FIGURE 12: ALIGNMENT AWL
INSERTION
FIGURE 13: FLEXED FOR ALIGNMENT
AWL ADVANCE
FIGURE 15: GUIDED OSTEOTOMY
FIGURE 16: COMPLETING THE OSTEOTOMY
FIGURE 14: CUT TILT
Step Four:Metacarpal OsteotomyAttach the proximal osteotomy guide on thealignment awl and reinsert the awl along the previouslyestablished medullary axis. Advance the guide untilthe cutting plane is positioned 1.5 to 2.0 mm distalto the dorsal attachments of the collateral ligaments.Rotational alignment of the guide is achieved whenthe volar surface of the guide is parallel to the dorsalsurface of the metacarpal bone. The proximal guideprovides a 27.5° distal tilt from vertical (FIGURE 7).
Collateral ligament integrity should be retained as faras possible. A conservative osteotomy at least 1.5mmdistal to the dorsal attachment of the collateralligaments should be made and then altered laterif necessary. This allows for joint space adjustmentduring the fitting of the trial implants (Step 10).
Special Thin Blade Requirements:It is strongly recommended that a small,thin oscillating saw blade be used (7mm x 29.5mm x 0.4mm).
With the proximal osteotomy guide held steady,make the cut by passing the saw blade through theslot of the guide (FIGURE 8). Because of the presenceof the alignment awl, only a partial (dorsal) osteotomycan be performed. Remove the alignment awl andcomplete the osteotomy by following the planeestablished by the guided cut (FIGURE 9).
Step Five:Opening the Phalangeal Medullary CanalWith the joint flexed, use the starter awl to makethe initial puncture of the proximal phalanx base(FIGURE 10). This puncture should be placed volarto the dorsal surface of the proximal phalanx adistance 1/3 the sagittal height of the proximalphalangeal base (FIGURE 11) and centered acrossthe width of the base. The resulting puncture shouldbe aligned with the long axis of the proximalphalangeal’s medullary canal.
CAUTION:During puncture, the joint must be flexed toavoid damage by impingement to the dorsal edgeof the metacarpal osteotomy (FIGURE 11).
FIGURE 8: GUIDED OSTEOTOMY
FIGURE 9: COMPLETING THE
OSTEOTOMY
FIGURE 7: CUT TILT
FIGURE 10: PROXIMAL PHALANX PUNCTURE
FIGURE 11: CANAL ALIGNMENT
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days to help with edema control. Encourage activerange of motion (AROM) of the shoulder and elbow.
Accepted practices for post-operative care andrehabilitation exercises for silicone MCP arthroplastyshould be followed. In osteoarthritic and post-traumatic cases, early motion may be prescribed.For rheumatoid arthritis cases, late motion initiationmay be appropriate.
Step Eleven:Implantation, Final Reduction and Soft Tissue ClosureWith the joint flexed, insert the final implant, distalstem first, until the collars seat against the bones(FIGURE 22). Reduce the joint and recheck stability,joint axial alignment, and range of motion (ROM).Full digit extension should be possible. Check intrinsictightness and release as necessary. As in all MCPsurgery, the goal is to centralize the extensormechanism and imbricate it radially to prevent ulnardeviation of the digits. In addition, the soft tissueenvelope should be “tightened”. Attempt a capsularrepair, if possible, to provide support and to preventvolar subluxation/dislocation. The collateral ligamentsmay be repaired as necessary. Release the intrinsictendons following implant reduction as appropriate,and transfer according to the surgeon’s preference(rarely needed). The extensor tendon must becentralized and snug which can usually beaccomplished by “pants over vest” imbrication ofthe radial hood. It may be necessary to incise thehood on both sides of the central tendon, then repairthe ulnar hood to the radial hood followed by sutureof the central tendon to the middle of the repairedhood to achieve a proper correction of severe ulnardislocation (of the central tendon). Occasionally, thecentral tendon can be advanced and sutured intothe dorsal base of the phalanx to increase stabilityof the implant against volar subluxation. At theconclusion of closure and application of the dressing,take x-rays to confirm the correct implant position.
Post-Operative CarePlace the hand in a bulky dressing. If possible, main-tain the wrist at 10-15° of dorsiflexion and slightulnar deviation. MCPs should be held in fullextension and PIPs in slight flexion (5-10°). If Swan-neck deformities were present pre-operatively, the PIPsshould be placed in the maximum flexion possible.Use a palmar plaster splint to maintain this position,with the final wrap over the entire hand leaving thedistal tips of the digits exposed during the first two
FIGURE 22: PROXIMAL STEM INSERTION
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until the seating plane of the broach is flush to 1mmdeeper than the osteotomy (FIGURE 18). Duringbroaching, assess fit and movement resistance. If alarger size is needed, repeat the broaching processwith the next larger size broach until the largest sizepossible can be fully inserted.
The size of the phalangeal medullary canal isgenerally the limiting factor in implant sizedetermination. Use clinical judgment and thex-ray templates to assess implant sizing.
Step Nine:Metacarpal Medullary CanalBroachingThe metacarpal opening is initially expanded andshaped with the starter awl. Then, insert the size 10proximal broach (FIGURE 19). Rotational alignmentof the broach is achieved when the dorsal surface ofthe broach is parallel to the dorsal surface of themetacarpal bone. The alignment guide mounted onthe broach should be parallel to the dorsal surface ofthe metacarpal and in line with the long axis of thebone. Continue broaching until the seating planeof the broach is 1mm deeper than the osteotomy(FIGURE 20). Repeat the broaching process withthe next larger size broach until the same size asthe largest distal broach is used.
Step Ten:Trial Insertion and ReductionThe color-coded silicone trials produce the same fitas the final component. With the joint flexed, insertthe appropriate size trial implant, distal stem first(FIGURE 21), until the collars seat against the bones.Reduce the joint and assess stability, joint laxity, andrange of motion. Full extension of the joint shouldbe possible.
To improve extension or relieve tension, increase thedepth of the osteotomies to increase the joint space.Generally the metacarpal osteotomy should be adjustedfirst. Mount the osteotomy guide on the appropriatebroach and reinsert in the canal to make an adjustmentcut. Remove bone in small increments to avoid jointlaxity or instability. Reinsert the trial. Reduce the jointand assess stability, joint laxity, and range of motion.
After a satisfactory reduction, use a pick-up toremove the trial.
FIGURE 17: DISTAL BROACH INSERTION
FIGURE 19: PROXIMAL BROACH INSERTION
FIGURE 21: DISTAL STEMINSERTION
FIGURE 18: DISTAL BROACH
ALIGNMENT
FIGURE 20: PROXIMAL
BROACH ALIGNMENT
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days to help with edema control. Encourage activerange of motion (AROM) of the shoulder and elbow.
Accepted practices for post-operative care andrehabilitation exercises for silicone MCP arthroplastyshould be followed. In osteoarthritic and post-traumatic cases, early motion may be prescribed.For rheumatoid arthritis cases, late motion initiationmay be appropriate.
Step Eleven:Implantation, Final Reduction and Soft Tissue ClosureWith the joint flexed, insert the final implant, distalstem first, until the collars seat against the bones(FIGURE 22). Reduce the joint and recheck stability,joint axial alignment, and range of motion (ROM).Full digit extension should be possible. Check intrinsictightness and release as necessary. As in all MCPsurgery, the goal is to centralize the extensormechanism and imbricate it radially to prevent ulnardeviation of the digits. In addition, the soft tissueenvelope should be “tightened”. Attempt a capsularrepair, if possible, to provide support and to preventvolar subluxation/dislocation. The collateral ligamentsmay be repaired as necessary. Release the intrinsictendons following implant reduction as appropriate,and transfer according to the surgeon’s preference(rarely needed). The extensor tendon must becentralized and snug which can usually beaccomplished by “pants over vest” imbrication ofthe radial hood. It may be necessary to incise thehood on both sides of the central tendon, then repairthe ulnar hood to the radial hood followed by sutureof the central tendon to the middle of the repairedhood to achieve a proper correction of severe ulnardislocation (of the central tendon). Occasionally, thecentral tendon can be advanced and sutured intothe dorsal base of the phalanx to increase stabilityof the implant against volar subluxation. At theconclusion of closure and application of the dressing,take x-rays to confirm the correct implant position.
Post-Operative CarePlace the hand in a bulky dressing. If possible, main-tain the wrist at 10-15° of dorsiflexion and slightulnar deviation. MCPs should be held in fullextension and PIPs in slight flexion (5-10°). If Swan-neck deformities were present pre-operatively, the PIPsshould be placed in the maximum flexion possible.Use a palmar plaster splint to maintain this position,with the final wrap over the entire hand leaving thedistal tips of the digits exposed during the first two
FIGURE 22: PROXIMAL STEM INSERTION
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until the seating plane of the broach is flush to 1mmdeeper than the osteotomy (FIGURE 18). Duringbroaching, assess fit and movement resistance. If alarger size is needed, repeat the broaching processwith the next larger size broach until the largest sizepossible can be fully inserted.
The size of the phalangeal medullary canal isgenerally the limiting factor in implant sizedetermination. Use clinical judgment and thex-ray templates to assess implant sizing.
Step Nine:Metacarpal Medullary CanalBroachingThe metacarpal opening is initially expanded andshaped with the starter awl. Then, insert the size 10proximal broach (FIGURE 19). Rotational alignmentof the broach is achieved when the dorsal surface ofthe broach is parallel to the dorsal surface of themetacarpal bone. The alignment guide mounted onthe broach should be parallel to the dorsal surface ofthe metacarpal and in line with the long axis of thebone. Continue broaching until the seating planeof the broach is 1mm deeper than the osteotomy(FIGURE 20). Repeat the broaching process withthe next larger size broach until the same size asthe largest distal broach is used.
Step Ten:Trial Insertion and ReductionThe color-coded silicone trials produce the same fitas the final component. With the joint flexed, insertthe appropriate size trial implant, distal stem first(FIGURE 21), until the collars seat against the bones.Reduce the joint and assess stability, joint laxity, andrange of motion. Full extension of the joint shouldbe possible.
To improve extension or relieve tension, increase thedepth of the osteotomies to increase the joint space.Generally the metacarpal osteotomy should be adjustedfirst. Mount the osteotomy guide on the appropriatebroach and reinsert in the canal to make an adjustmentcut. Remove bone in small increments to avoid jointlaxity or instability. Reinsert the trial. Reduce the jointand assess stability, joint laxity, and range of motion.
After a satisfactory reduction, use a pick-up toremove the trial.
FIGURE 17: DISTAL BROACH INSERTION
FIGURE 19: PROXIMAL BROACH INSERTION
FIGURE 21: DISTAL STEMINSERTION
FIGURE 18: DISTAL BROACH
ALIGNMENT
FIGURE 20: PROXIMAL
BROACH ALIGNMENT
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Ascension® Silicone MCP
surgical technique
WW
ASCENSION ORTHOPEDICS, INC.
8700 CAMERON ROAD, SUITE 100
AUSTIN, TEXAS, USA 78754
512.836.5001 512.836.6933 fax
CUSTOMER SERVICE: 877.370.5001 (toll-free in U.S.)
www.ascensionortho.com
Caution: U.S. federal law restricts this deviceto sale by or on the order of a physician.
© 2006 LC-04-507-001 rev C WW
SMCP_SrgTchWW-C_Cover 3/8/06 9:30 AM Page 2
