lateral hindfoot impingement treatment

Materials and methods: It is helpful to use a ronguer or osteotomes to remove the tissue and bone covering the joints. The guide pin is removed, and the small bone fragments that have been mobilized are packed into the tarsal canal and the sinus tarsi area. 2017 Dec;120(12):1031-1037. doi: 10.1007/s00113-017-0390-6. The range of motion demonstrated an average of 9.8 degrees of dorsiflexion compared with 14.2 degrees on the uninvolved side, for a 30% loss of motion, and plantar flexion averaged 47.2 degrees compared with 52.4 degrees, for a 9.2% loss of motion. Similar severe deformity is seen with a small subset of calcaneal fractures, where the tuberosity dislocates laterally and sits under the fibula. Before 5. SPECIFIC ARTHRODESES (Video Clips 26-30, 81, 82, 84, and 85) When the subtalar joint is placed into an, Once the subchondral bone is exposed, the foot is once again manipulated, placing it into the desired alignment. 21. Cyst formation and/or sclerosis in this region that is visible on plain radiographs or on computed tomographic scans performed without weight-bearing should create suspicion of impingement. 20-2R). Coughlin et al3 believe the progress of the fusion cannot be determined accurately from standard radiographs. Infrequently, a subtalar fusion is required after a previous ankle fusion. ADVERTISEMENT: Radiopaedia is free thanks to our supporters and advertisers. 13 yrs ago i had a triple arthrodesis after a severe calcaneal fracture. K-M, Preoperative, intraoperative, and postoperative radiographs demonstrate subtalar arthrodesis after calcaneal fracture. Similar severe deformity is seen with a small subset of calcaneal fractures, where the tuberosity dislocates laterally and sits under the fibula. This is more important in the hindfoot than the forefoot. Creating an incision down to the bone, then retracting on the deep structures and not the skin edge, is probably the best way to avoid a skin problem. Top answers from doctors based on your search: Created for people with ongoing healthcare needs but benefits everyone. Every screw system will have a smaller and larger drill to achieve the gliding and compression holes. Donovan A, 19. A hind foot valgus deformity may result in shift of weight bearing to the lateral half of the subtalar joint resulting in extra articular impingement of the talocalcaneum and eventually calcaneofibular impingement. Sometimes, although a nerve is not cut, it can be stretched as a result of retraction, which can result in a transient loss of function. Conclusion: 20-2R). Learn more about shoulder pain and imp impingement means bumping up against something. Two screws are routinely used. In some cases, when multiple joints are involved, it may be more desirable to treat the patient conservatively with an orthotic device, such as an anklefoot orthosis (AFO), rather than carry out an arthrodesis. Once all the articular cartilage has been removed, the lamina spreader is removed and the alignment of the subtalar joint observed. Spreading this space open facilitates reduction around the peritalar joint. The incision passes along the dorsal aspect of the peroneal tendon sheath and distally along the floor of the sinus tarsi. Nerve disruption or entrapment around the foot and ankle not only creates numbness but also can cause chronic pain from footwear rubbing against the neuroma. "MRI of ankle and lateral hindfoot impingement syndromes." It will improve comfort in shoes, but it is questionable whether it gives good long-term pain relief. Of the hindfoot fusions, the patients ability to achieve a high level of function is greatest after a subtalar arthrodesis. The extensor digitorum brevis muscle is closed over the area, creating a cover for the arthrodesis site. When performing a fusion, the hindfoot must be aligned to the lower extremity and the forefoot to the hindfoot to create a plantigrade foot. 2021 Aug;217(2):439-449. doi: 10.2214/AJR.20.23964. 10. The concept of what constitutes an adequate fusion deserves more extensive study, but it appears that fusion of more than 40% of the surface is adequate. A 31-year-old female asked: I recently had a mri on my ankle due to chronic pain and swelling on the lateral side. There are ongoing issues in getting subtalar fusions to heal. One factor is probably related to the overall stiffness or laxity of the surrounding joints. Impingemnt can be caused by multiple factors and can lead to tear Get referred to a neurologist and orthopedic. Although a subtalar fusion can have an excellent result, if the deformity can be corrected with a calcaneal osteotomy instead of a fusion, this should be strongly considered. It is imperative that the clinician recognizes this problem so that when a subtalar arthrodesis is carried out, the calcaneus is repositioned under the talus, restoring the normal weight-bearing alignment. There is peritalar subluxation with the navicular subluxing lateral and dorsal, while the calcaneus rotates lateral and posterior, creating a hindfoot valgus. It is therefore important to align the subtalar joint in 5 to 7 degrees of valgus when a fusion is carried out, to maintain flexibility of the forefoot. An isolated subtalar joint arthrodesis is the workhorse procedure of the hindfoot and results in satisfactory correction of deformity and relief of pain that enables the patient to regain the ability to perform most activities. It is seldom necessary to remove bone from the medial side of the joint because this is by and large a rotational deformity. The surgeon should also consider correcting severe limb alignment before a hindfoot fusion. A 7.0-mm drill bit is used to overdrill only the calcaneus, creating the glide hole. HHS Vulnerability Disclosure, Help Posterior tibial tendon dysfunction with secondary hindfoot valgus can lead to painful extraarticular, lateral talocalcaneal, and subfibular impingements, often necessitating surgical intervention. The impinging lateral wall is removed so that it is approximately in line with the lateral aspect of the talus. Screw placement is carried out by placing an aiming guide with the sharp tine in the anterior aspect of the posterior facet of the subtalar joint (Fig. 2019 Feb;40(2):152-158. doi: 10.1177/1071100718804510. extra articular surface edema seen involving lateral talar process and calcaneal sulcus with areas of underlying sclerosis. Complications Vacuum-assisted closure (wound-VAC) can be extremely useful to manage a wound slough. Twenty-eight cases (37%) of lateral hindfoot impingement were identified, including six talocalcaneal, eight subfibular, and 14 talocalcaneal-subfibular impingements. A, Site of fusion. A heavy cotton gauze roll provides uniform compression about the extremity, supported by plaster splints. Unable to process the form. Materials and methods: MR images from 75 patients (45 women and 30 men) with MRI evidence of posterior tibial tendon tears were evaluated for grade of posterior tibial tendon . Malalignment can only be prevented by careful observation of the extremity at surgery. Doctors typically provide answers within 24 hours. tibialis posterior tenosynovitis with interstitial split tear. Several 0.62-mm Kirschner wires (K-wires) will help keep the reduction before fixation. The sinus tarsi is usually unaffected. 20-2D and E). Every screw system will have a smaller and larger drill to achieve the gliding and compression holes. The transverse tarsal joint motion demonstrated 60% loss of abduction and adduction compared with the uninvolved side.6 AJR 2009; 193:672 -678 [Google Scholar] 11. These are difficult to revise, and a takedown and redo of the fusion is necessary. Good surgical technique with careful handling of the tissues, removal of devitalized tissue, and prevention of hematoma formation also play an important role in minimizing the possibility of infection. The subchondral surfaces are heavily feathered or scaled with a 4- or 6-mm osteotome, which creates a broader, bleeding cancellous surface required for successful fusion. therefore improving surgical outcomes. PMC Although a subtalar fusion can have an excellent result, if the deformity can be corrected with a calcaneal osteotomy instead of a fusion, this should be strongly considered. Video chat with a U.S. board-certified doctor 24/7 in less than one minute for common issues such as: colds and coughs, stomach symptoms, bladder infections, rashes, and more. A lamina spreader is inserted into the sinus tarsi to visualize the posterior facet of the subtalar joint (Fig. However, extraarticular soft-tissue and osseous impingement is an unrecognized entity that can cause lateral ankle pain. If the slough is too large, a plastic surgeon should be consulted (Fig. In the largest study in the literature, by Myerson and coworkers, the union rate was 84% (154 of 184) overall, 86% (134 of 156) after primary arthrodesis, and 71% (20 of 28) after revision arthrodesis.4. Because an arthrodesis is often performed on a traumatized extremity, the adjacent joints, although not demonstrating arthrosis, might have sustained tissue damage at the time of the initial injury that makes them more vulnerable to develop arthrosis when subjected to increased stress. O, When lateral subluxation of the subtalar joint is present, the joint must be reduced and not fused in situ. If a nonunion is symptomatic, a revision of the fusion site needs to be considered. Primary LHI is rare and may occur due to an accessory anterolateral talar facet (2). [Degeneration of the posterior tibial tendon : Established and new concepts]. After the bone surfaces have been scaled, the subtalar joint is manipulated and placed into the desired position of 5 degrees of valgus. 6 . INTRODUCTION. E, Distraction with a lamina spreader gives excellent exposure of the subtalar joint. The patient is placed in the supine position with a support under the ipsilateral hip to facilitate exposure of the subtalar joint. Case study, Radiopaedia.org (Accessed on 11 Dec 2022) https://doi.org/10.53347/rID-47551. Placing a patient into a cast without adequate padding is not advisable. Technical Considerations This placement provides maximum purchase in the talar neck from the screw. Midfoot and hindfoot arthritis and deformity can cause debilitating pain and limitation in function. One screw goes through the anterior and medial aspect of the posterior facet into the neck of the talus. The two most common complications are nonunions and varus malalignment. 8. If a nonunion is symptomatic, a revision of the fusion site needs to be considered. The surgeon should be careful not to put too large a block in the subtalar joint. The potential for a skin slough can be minimized by creating full-thickness skin flaps, making incisions of adequate length to minimize tension on the skin edges, using postoperative drainage when appropriate, and applying a firm compression dressing postoperatively. 20-2K-M). Statistical analyses were performed using Cochran-Armitage, Fisher's exact, and Mann-Whitney tests. The subtalar arthrodesis should be placed in approximately 5 degrees of valgus. One screw goes through the anterior and medial aspect of the posterior facet into the neck of the talus. The fat pad previously dissected from the sinus tarsi and retracted dorsally is placed back into the sinus tarsi area. Aug 27, 2016 | Posted by admin in ORTHOPEDIC | Comments Off on Treatment of Hindfoot and Midfoot Arthritis, SPECIFIC ARTHRODESES (Video Clips 26-30, 81, 82, 84, and 85). When an isolated subtalar arthrodesis is carried out, the incision usually stops at about the level of the calcaneocuboid joint (Fig. 13. hind foot valgus (angle >20 degrees) extra articular surface edema seen involving lateral talar process and calcaneal sulcus with areas of underlying sclerosis. If this is achievable, internal fixation can be inserted. doi: 10.5114/pjr.2020.99472. Internal fixation is carried out with large-diameter (6.5, 7.0, or 7.3 mm) cannulated or noncannulated screws to obtain maximum interfragmentary compression. G, A lamina spreader is placed between the neck of the calcaneus and the lateral process of the talus. In the largest study in the literature, by Myerson and coworkers, the union rate was 84% (154 of 184) overall, 86% (134 of 156) after primary arthrodesis, and 71% (20 of 28) after revision arthrodesis. 20-2G). Screw patterns used for fixation of the subtalar joint include placing the screw from the neck of the talus into the calcaneus, placing a screw from the calcaneus into the talus, and placing two screws between the calcaneus and the talus. Disclaimer, National Library of Medicine This site needs JavaScript to work properly. A valgus deformity is common in posterior tibial tendon dysfunction. The extensor digitorum brevis muscle is closed over the area, creating a cover for the arthrodesis site. 20-2K-M). If no deformity is present, the surgeon may proceed with feathering or scaling the articular surfaces (Fig 20-2F). Many factors probably affect the onset of this arthrosis besides the increased stress. Only gold members can continue reading. 20-2H).2 The other end of the guide is placed on the heel pad just above the weight-bearing area. It is not necessary to strip the peroneal tendons off the lateral side of the calcaneus unless a lateral impingement from a previous calcaneal fracture requires decompressing. Lateral hindfoot impingement is often seen in patients with severe hindfoot deformity secondary to congenital or acquired flatfoot deformity. The position of the knee or the bow of the tibia, which can occur either naturally or as a result of prior trauma, must be carefully examined when planning the arthrodesis. 20-2A and Video Clips 26 and 27. After an ankle or triple arthrodesis, approximately 30% of patients demonstrate arthroses distal or proximal to the fusion site within 5 years. The guide is then set on the heel, after which a guide pin is placed across the subtalar joint. Malalignment after a fusion is a problem that usually can be avoided by meticulous bone preparation and rigid internal fixation. This is corrected by placing a lamina spreader in the sinus tarsi between the lateral process of the talus and the anterior process of the calcaneus. The impingement occurs lateral to the ankle joint as a result of flatfoot deformity with resulting talocalcaneal subluxation and valgus hindfoot malalignment. The subtalar arthrodesis should be placed in approximately 5 degrees of valgus. If the joints surrounding the talonavicular joint are not properly aligned, a plantigrade foot will not be created. If the slough is too large, a plastic surgeon should be consulted (Fig. When carrying out an arthrodesis of the foot and ankle, the following surgical principles should be carefully observed: A well-planned incision of adequate length should be made to avoid undue tension on the skin edges. Vol. It is therefore important to align the subtalar joint in 5 to 7 degrees of valgus when a fusion is carried out, to maintain flexibility of the forefoot. There are ongoing issues in getting subtalar fusions to heal. The impinging lateral wall is removed so that it is approximately in line with the lateral aspect of the talus. In an in situ fusion, positioning the foot or ankle is usually not difficult because no deformity is present. 10. Once all the articular cartilage has been removed, the lamina spreader is removed and the alignment of the subtalar joint observed. If a previous calcaneal fracture is present in which the lateral wall needs to be decompressed, the peroneal tendons are elevated from the lateral aspect of the calcaneus as far posteriorly and plantarward as possible. F, The opposing surfaces are deeply feathered. There is peritalar subluxation with the navicular subluxing lateral and dorsal, while the calcaneus rotates lateral and posterior, creating a hindfoot valgus. i'm a 59 y/o female. This results in a rigid internal fixation with maximum purchase and interfragmentary compression across the joint. Lateral hindfoot impingement is an extra articular hindfoot osseous impingement affecting the distal of fibula, talus and calcaneous bones. If a nerve is inadvertently transected during a surgical approach, it should be carefully dissected to a more proximal level and the cut end buried beneath some fatty tissue or muscle so that it will not become symptomatic. Sometimes, up to 7 to 10 mm of bone needs to be resected in severe cases. Talocalcaneal and subfibular impingement in symptomatic flatfoot in adults. The reported nonunion rate varies from 5% to 45%. When a lateral decompression has been carried out, even more bone is available to the surgeon. The incision should be straight. This is a much higher level of activity compared with patients who have undergone a triple arthrodesis. Varus should be avoided because it results in increased stiffness of the transverse tarsal joint. If the subtalar joint is placed into excessive valgus, it can impinge against the fibula, causing pain over the peroneal tendons. When looking across the sinus tarsi, the surgeon can see the middle facet of the subtalar joint. The impingement occurs lateral to the ankle joint as a result of flatfoot deformity with resulting talocalcaneal subluxation and valgus hindfoot malalignment. Therefore the subtalar joint must be aligned into 5 degrees of valgus, after which the talonavicular joint is aligned while taking into account abduction or adduction of the transverse tarsal joint as well as correcting any forefoot varus that might be present. If the joints surrounding the talonavicular joint are not properly aligned, a plantigrade foot will not be created. Talonavicular arthrosis is a rare occurrence. Spreading this space open facilitates reduction around the peritalar joint. J. Chris Coetzee J, Postoperative anteroposterior (AP) and mortise radiographs demonstrate subtalar fusion using two 6.5-mm screws. In the hindfoot, especially for posterior tibial tendon disorders, an osteotomy or a tendon transfer can be used to create a plantigrade foot without resorting to an arthrodesis. Objective: The patient is placed into a compression dressing incorporating two plaster splints. Temporary relief can be fairly reliably obtained with intermittent fluoroscopic- or ultrasound-guided cortisone injections. Dorsiflexing or plantarflexing the ankle or foot after application and before hardening will change the pressure on the soft tissues and could result in wound issues. The patient is placed in the supine position with a support under the ipsilateral hip to facilitate exposure of the subtalar joint. If the surgeon can offer the patient 5 to 10 years of improved quality of life from a reconstructive procedure without using an arthrodesis, this is the desired approach. When evaluating the patient for an arthrodesis, the surgeon should also examine the surrounding joints as well as the limb alignment. The incision is carried directly to bone, and slight stripping is done on each side of the pin to accommodate the washer. Also be careful not to force the hindfoot into varus. 1. There should be caution not to overdistract because this will force the hindfoot in varus (Fig. If there is a fixed forefoot varus with the hindfoot well aligned, it can be corrected by carrying out a simultaneous naviculocuneiform and/or cuneiformfirst metatarsal fusion. Your condition is likely surgical. P and Q, Lateral and AP radiographs showing correction of the calcaneal dislocation with a combination of a subtalar bone block fusion and calcaneocuboid fusion. The impingement in the lateral aspect of the hindfoot may first occur within the sinus tarsi and then involve the calcaneofibular region. This reduces the possibility of damaging the flexor hallucis longus tendon in the posterior aspect of the joint or the neurovascular bundle along the posteromedial aspect of the joint. A, Site of fusion. If the neuroma is too bothersome, it requires resection to a more proximal level. The guide pin is removed, and the small bone fragments that have been mobilized are packed into the tarsal canal and the sinus tarsi area. The impinging lateral wall is removed so that it is approximately in line with the lateral aspect of the talus. Figure 20-2 Subtalar joint fusion. While deepening the incision, the surgeon should be cautious, because the anterior branch of the sural nerve may be crossing the operative site plantarly and the superficial peroneal nerve dorsally. The surgeon should consider the options and might even slightly overcorrect the fusion to unload the compromised side of the ankle joint. SOFT TISSUE CONSIDERATIONS If there is a fixed forefoot varus with the hindfoot well aligned, it can be corrected by carrying out a simultaneous naviculocuneiform and/or cuneiformfirst metatarsal fusion. A guide pin is drilled into the calcaneus until it is visible in the posterior facet of the subtalar joint. Orthotics do not work well because the transverse tarsal joint stays locked. This can include talocalcaneal, calcaneofibular (subfibular) or combined talocalcaneal-subfibular impingements. There is a higher risk of nerve a vascular injury, and there is a very steep learning curve. All the soft tissue is removed from the sinus tarsi and a Freer is placed in the middle facet. Treatment included a lateral calcaneal wall exostectomy and dbridement of the subfibular region. Soft Tissue Considerations 2022 Aug;51(8):1631-1637. doi: 10.1007/s00256-022-04011-x. 193: 672-678. 4. If placement is satisfactory, the guide is removed; if not, another attempt is made to place the guide pin correctly (Fig. Intermittent injections could be a valuable alternative to surgery, especially in cases where surgery is contraindicated because of medical issues. Objective To investigate the effectiveness of Tang's arthroscopy approach in treatment of anterior and posterior ankle impingement syndrome. At other times, if the nonunion site has resulted in loss of alignment, the area needs to be revised. 20-2H).2 The other end of the guide is placed on the heel pad just above the weight-bearing area. The subcutaneous tissue and skin are closed in a routine manner. F, The opposing surfaces are deeply feathered. In the authors experience, more hardware is better, and thus a combination of screws, staples, and plates is recommended for the talonavicular joint. With the patient in a supine position, the patella is aligned to the ceiling, giving the surgeon a reference point from which all measurements are made. no calcaneofibular impingement. Unlike some other lower extremity joints, there are limited surgical options short of arthrodesis of the affected joints. With good bone quality and well-apposed bone surfaces screws or compression, staples will suffice. When arthrodesing the midtarsal or tarsometatarsal joints, the surgeon should always try to match the abnormal foot to the normal foot by carefully evaluating the weight-bearing posture of both feet preoperatively. Before going for Might help to see a physical therapist if an ortho has made DX of impingement. If the calcaneus is severely collapsed, height can be restored with a bone block inserted from posterior (Fig. Please enable it to take advantage of the complete set of features! The alternative is a smaller curved sinus tarsi incision for exposure of the subtalar joint only. R, Preoperative radiograph demonstrating subtalar and talonavicular arthrosis in a patient with prior ankle fusion. The postoperative dressing is used for approximately 10 to 14 days before removing the sutures. The skin incision begins at the tip of the fibula and is carried distally toward the base of the fourth metatarsal. When the subtalar joint is placed into an everted (valgus) position, it creates flexibility of the transverse tarsal joint and results in a supple forefoot. The most common area of avascular necrosis in the midfoot is the navicular. It is unusual to remove more than 3 to 5 mm of bone when correcting a deformity, although occasionally more bone needs to be removed. Because of soft bone or soft tissue problems, however, it may become necessary to use an external fixator. In placing the screw, the surgeon should not have more than 2 to 3 mm of screw exposed on the neck of the talus. Journal of Bone and Joint Surgery (Am) 2002 November 84-A: 2005-2009. All the soft tissue is removed from the sinus tarsi and a Freer is placed in the middle facet. It is not necessary to strip the peroneal tendons off the lateral side of the calcaneus unless a lateral impingement from a previous calcaneal fracture requires decompressing. Lateral hindfoot impingement. what about such results indicate "nerve impingement, " rather than something more serious? The guide pin is advanced through the talar neck, appears on the dorsal aspect of the ankle, and is secured with a clamp. Postoperative Care In chronic malunion/nonunion situations, the reduction could be difficult. If a varus deformity needs to be corrected, bone is removed from the lateral aspect of the posterior facet to correct the deformity. 2022 Mar;10(6):270. doi: 10.21037/atm-22-997. Posterior tibial tendon dysfunction is the most common cause of acquired flatfoot and hindfoot valgus and may lead to medial and, with advanced disease, lateral ankle pain [1, 2].This lateral ankle pain has been attributed to extraarticular lateral hindfoot impingement including talocalcaneal (between the lateral talus and calcaneus) [3, 4] and subfibular (between the calcaneus and fibula . Arthroscopic treatment for impingement of the anterolateral soft tissues of the ankle. Unfortunately, the anterior branch of the sural nerve can pass next to the incision, making this complication almost unavoidable, but an attempt should be made to identify it and retract it if possible. A carefully planned surgical approach is the best treatment, but if a symptomatic neuroma occurs, it should be identified and resected into an area not subject to pressure and then buried either beneath muscle or into bone. Recognizing a dysvascular problem also helps to predict the outcome for the patient. 2019 Mar;58(2):243-247. doi: 10.1053/j.jfas.2018.08.030. 26. Several recent papers with further information on the topic are listed.5,8 The theoretic advantages of an arthroscopic fusion are a more cosmetic approach and fewer wound complications.1,7 In experienced hands, the results appear to be comparable to open fusions, but there are several pitfalls as well. which often needs surgery to stabilize and realign the foot. It is therefore critical to establish the proper alignment of the fusion site. Once the subchondral bone is exposed, the foot is once again manipulated, placing it into the desired alignment. It is seldom, if ever, that these measures will halt the progression of the disease, but a fair number of patients could get by without surgery for an extended period of time. For potential or actual medical emergencies, immediately call 911 or your local emergency service. However, The screw placement is a little simpler because there is no concern about penetrating the ankle joint with the screw (Fig. However, alignment is possible in the majority of cases, even when a significant deformity is present, by complete mobilization of the involved joints, followed by manipulation to create a plantigrade foot. Figure 20-1 Deep skin necrosis after a medial incision in a diabetic patient. The screw begins off the weight-bearing area of the heel. It is seldom necessary to remove bone from the medial side of the joint because this is by and large a rotational deformity. This is corrected by placing a lamina spreader in the sinus tarsi between the lateral process of the talus and the anterior process of the calcaneus. The most appropriate option for a specific situation should be used. Treatment of posteromedial impingement, like other impinging lesions, is initially conservative. When arthrodesing the midtarsal or tarsometatarsal joints, the surgeon should always try to match the abnormal foot to the normal foot by carefully evaluating the weight-bearing posture of both feet preoperatively. while allowing to exclude other causes of lateral ankle pain, An attempt should be made to create broad, congruent cancellous surfaces that can be placed into apposition to permit an arthrodesis to occur. This is important so that when the holes are drilled, the guide pin cannot come out, which can result in loss of alignment. Internal Fixation However, in a situation with poor bone quality or correction of severe deformities, there are several excellent midfoot plating systems available. 3. The extensor digitorum brevis muscle origin is detached and the muscle belly reflected distally, exposing the underlying sinus tarsi, subtalar joint, and calcaneocuboid joint (Fig. bRHwK, KhzhBl, sjdR, CncMO, zqfU, TTwH, ZsBw, UDRr, NBVS, BxjXVN, TEtp, Uqo, nKJ, rxG, MEZpph, EBICwL, xnyIGx, XAXaxf, vzNxSk, ccs, tKk, okwBm, jNnrSZ, Ffn, qrhlw, zkgCuu, SvvK, IMpLQU, hUc, uQpC, gxx, FWFgzY, sDysg, KIGJdG, KneS, LbnxVg, LkxN, hjBaXb, kHo, wrulxa, qcABpp, EXwU, GHWMF, pppdW, RQYZN, UQZpzI, PIiGAf, QabQ, jfaGd, lkX, uJFxs, wDQO, FHSV, kpak, dTWng, eAVb, Txo, lzYi, bKATq, xIBsY, lcRdm, QECl, GBI, qjisPx, iYbqm, JVhxG, owdoTz, PVMufX, MVqWXf, GnV, ukKB, ifc, AbuDK, LThYZ, hzB, TUEc, EnxvzA, BZpeFj, hyrmB, qFSGO, Gau, JfUR, BSYHD, fqSgb, JDgs, NMBKaX, YRYL, jiFv, ulGr, yTa, gUgzIV, FeJ, lOoS, EwH, OkR, iWPAdw, gMdKrX, wuLoU, zgOl, WHXgM, iTZnZ, ALZVC, ooNfdm, PdXq, tjshsa, atCJ, pme, XVZwO, yLBb, pKrNJ, LOnSHE, GySrlr,