Nonsteroidal anti-inflammatory drugs have failed to provide relief. Posterior sag sign. axis from center of femoral head to center of ankle. 5-20% of all knee ligamentous injuries. This is an AAOS Self Assessment Exam (SAE) question. Web(OBQ17.23) A 35-year-old male presents to your clinic with right knee pain after sustaining a twisting injury while playing basketball 3 weeks ago. The transplanted chondrocytes are viable and articular cartilage heals. can heal via fibrocartilage scar formation. evaluate menisci, cruciates, cartilage, extensor mechanism edema posterior to popliteus tendon can indicate an injury to the underlying structures of the PLC. axis from center of femoral head to center of ankle. Web(OBQ11.44) A 68-year-old healthy active male presents after falling and sustaining an injury to his right knee. You can rate this topic again in 12 months. Presentation. WebPCL Injury MCL Knee Injuries LCL Injury of the Knee LCL Injury of the Knee Orthobullets Team Knee & Sports - Snapping Hip (Coxa Saltans) Listen Now 14:22 min. Overall 84% of patients recover pre-injury strength and 89% recover pre-injury endurance. She has noted progressive leg deformity and episodes of giving way, and now has pain preventing activity. Treatment may be nonoperative with restricted weight bearing in children with open physis. 686 plays. She endorses snapping and clicking in the left hip with certain movements. (OBQ06.107) Graft fixation strength increases linearly with time until subchondral union at 3 months, Graft fixation strength initially decreases during the early healing phase, and then increases with subchondral bone healing, Graft fixation strength does not change during the first 3 months following surgery, Graft fixation strength is enhanced by early weight bearing, Graft fixation strength initially increases over the first 6 weeks, then recedes with bony remodeling. The surgeon has all the trial components in place and recognizes that the soft tissues are balanced in the coronal plane, but the knee is 10 degrees from reaching full extension. Tables and outline converted. Web(SBQ16HK.6) Figure A is the radiograph of an otherwise healthy 33-year-old female soccer player with a history of hip dysplasia. TKA - Parapatellar Approach PCL reconstruction using tibial inlay technique. Arthroscopic plica excision is indicated in refractory cases that fail nonoperative treatment. Following a medial femoral condyle osteochondral autograft mosaicplasty, which of the following statements best describes the fixation of the graft? Arthroscopic plica excision is indicated in refractory cases that fail nonoperative treatment. Poor prognostic variables . On examination, her knee range of motion (ROM) is limited to 10-75. 5-20% of all knee ligamentous injuries. WBC, ESR and C-reactive protein levels are normal. WebPCL Injury MCL Knee Injuries LCL Injury of the Knee Posterolateral Corner Injury Posteromedial Corner Injury Orthobullets Team Knee & Sports - Articular Cartilage Defects of Knee; Listen Now 37:19 min. Web(SBQ16HK.6) Figure A is the radiograph of an otherwise healthy 33-year-old female soccer player with a history of hip dysplasia. All of the following are contraindications for this surgery except: (OBQ13.99) A vertical line drawn from the femoral head through the center of the knee down to the center of the ankle, A valgus angle of 5-7 degrees created by two lines drawn down the shaft of the femur and tibia, A varus angle of 3 degrees created by two lines drawn down the shaft of the femur and tibia, A vertical line drawn from the femoral head passing 1.5 centimeters lateral to the center of the knee down to the center of the ankle, A vertical line drawn from the femoral head passing 1.5 centimeters medial to the center of the knee down to the center of the ankle. Treatment is usually bracing unless there is gross varus instability in which case repair or reconstruction is evaluate menisci, cruciates, cartilage, extensor mechanism edema posterior to popliteus tendon can indicate an injury to the underlying structures of the PLC. He denies fevers or mechanical knee symptoms. WebA tibial shaft stress fracture is an overuse injury where normal or abnormal bone is subjected to repetitive stress, resulting in microfractures. WebNotes migrated, complexity/importance set. Epidemiology. On examination, her knee range of motion (ROM) is limited to 10-75. WebTHA Vascular Injury & Bleeding Orthobullets Team Recon - TKA Postoperative Rehabilitation & Outpatient Management Technique Guide. WebPosterolateral Corner Injury Posteromedial Corner Injury Proximal Tib-Fib Dislocation Poor prognostic variables . 2023 Bobby Menges Memorial HSS Limb Reconstruction Course, Type in at least one full word to see suggestions list, Bobby Menges Memorial HSS Limb Deformity Course 2021, Discussion: Osteotomy Considerations & Innovation, Osteotomy: Innovations in Pain Management - Joseph R. Hsu, MD, Osteotomies Around the Knee: Tibia - Mitchell Bernstein, MD, Varus Knee with Cartilage and Meniscal Damage in 32 Year Old. A medial unloader brace can be used for therapeutic and diagnostic purposes. Physical examination reveals mild effusion, lateral sided tenderness, and range of motion from 10-85 degrees without any signs of instability. TKA - Parapatellar Approach PCL reconstruction using tibial inlay technique. You can rate this topic again in 12 months. WebMedial collateral ligament Injury of the knee (MCL Tear) are the most common ligament injuries of the knee and are frequently associated with ACL tears. Radiographs and representative CT scan images are shown in Figures A-D. What is the most appropriate treatment method for this patient's injury? ankle joint, show knee malalignment using mechanical axis line, young, active patient (<50 years) in whom an arthroplasty would fail due to excessive wear, pain and disability interfering with daily life, compliant patient that will be able to follow postop protocol, procedure will need >20 degrees of correction, unload the involved joint compartment by correcting tibial malalignment. Upon evaluation, he has difficulty bearing weight due to left hip pain and has tenderness to Which of the following statement is true with respect to Technique B and C? (OBQ09.60) Proximal tibia valgus osteotomy, microfracture to the MFC, and removal of loose osteochondral bodies, Distal femur varus osteotomy and autologous chondrocyte implantation to the MFC, Osteochondral autograft transplantation to the MFC, Removal of loose osteochondral bodies and osteochondral allograft transplantation to the MFC, Patellofemoral realignment osteotomy, removal of loose osteochondral bodies, and autologous chondrocyte implantation to the MFC. Compared to total knee arthroplasty (TKA), UKA more closely approximates native knee kinematics, Patients undergoing a UKA and TKA have equivalent blood loss and pain medication requirements, Compared to their TKA counterparts, UKA patients have a slower return to function, There is no difference in range of motion at short or long term follow-up when compared with TKA, Postoperative hospital stay is equivalent for UKA and TKA patients, 2023 Bobby Menges Memorial HSS Limb Reconstruction Course, Type in at least one full word to see suggestions list, ISTA: New Early-Career Webinar Series 2020, The Utility of Virtual Reality as a Learning Tool for Trainees in Unicompartmental Knee Arthroplasty: A Randomized Controlled Trial - Musa Zaid, Single Upright Unloader Brace Improves Medial Joint Space in Unicompartmental OA Subjects - Garret Dessinger, 2018 Orthopaedic Summit Evolving Techniques, Evolving Technique: Converting The UKA To A Total Knee: When, How - Tips & Tricks - Michael J. Kaplan, MD (OSET 2018), Recon | Unicompartmental Knee Replacement, Knee osteoarthritis in 56F - Lateral unicompartmental arthritis, Knee Osteoarthritis in 51M - Medial unicompartmental disease. WebPatellar instability is a condition characterized by patellar subluxation or dislocation episodes as a result of injury, ligamentous laxity or increased Q angle of the knee. If a patient benefits from the brace, they are likely to benefit from surgery. Which of the following factors is the best predictor of successful non-operative management of an osteochondritis dissecans lesion in the knee? 288 plays. 288 plays. Articular cartilage defects of the knee comprise of a spectrum of disease entities from single, focal defects to advanced degenerative disease of articular (hyaline) cartilage. It is predominately done to correct for varus deformities in young patients but can also be done to correct valgus deformities. She reports 6 weeks of left groin pain that has not improved with physical therapy. Orthobullets Team Trauma - Knee Dislocation; Listen Copyright 2022 Lineage Medical, Inc. All rights reserved. Diagnosis may be made radiographically (notch view) but MRI usually required to determine size and stability of lesion, and to document the degree of cartilage injury. Web(OBQ08.99) A 59-year-old female librarian complains of progressively worsening left knee pain over the last 4 months. WebFemoroacetabular impingement (FAI) is the abnormal contact between the femur and acetabulum which may lead to labral damage, various degrees of chondral injury and progressive hip pain. WebSinding-Larson-Johansson (SLJ) syndrome is an overuse injury seen in adolescents leading to anterior knee pain at the inferior pole of patella at the proximal patella tendon attachment. (OBQ11.1) WebAfter discussion of the surgical options, she undergoes the procedure shown in Figure A. Web(SBQ16SM.17) A 13-year-old boy falls from a trampoline and feels immediate left knee pain. Web(SBQ16SM.17) A 13-year-old boy falls from a trampoline and feels immediate left knee pain. Diagnosis can often be made on radiographs alone but MRI studies should be obtained in patients with normal radiographs with a high degree of suspicion for stress fracture. Diagnosis generally requires an MRI to accurately assess the location of specific defects. All of the following technical errors likely contributed to this complication EXCEPT? WebPatellar instability is a condition characterized by patellar subluxation or dislocation episodes as a result of injury, ligamentous laxity or increased Q angle of the knee. WebAfter discussion of the surgical options, she undergoes the procedure shown in Figure A. Made Live as 2.0. Summary written. All of the following technical errors likely contributed to this complication EXCEPT? Grafts in Technique C are transferred to an antibiotic solution to kill microorganisms and stored at 4C until use. She initially does well but returns to clinic 3 months post-operatively with significantly increased medial-sided knee pain and the injury shown in Figure B. She initially does well but returns to clinic 3 months post-operatively with significantly increased medial-sided knee pain and the injury shown in Figure B. WebPosterolateral Corner Injury Posteromedial Corner Injury Proximal Tib-Fib Dislocation Figures 1 and 2 are representative MRI slices of his right knee. All of the following technical errors likely contributed to this complication EXCEPT? He notes that the pain occurs on a daily basis with any significant activity. Additionally, she describes intermittent episodes of an inability to fully extend her knee. Primary or secondary medial knee arthrosis is the most common indication, Isolated lateral compartment osteoarthritis is much less common, Angular deformity in the knee leads to abnormal distribution of weight bearing stresses, accelerate wear in medial or lateral compartments, HTO is commonly combined with cartilage restoration procedures, can be assessed by drawing can heal via fibrocartilage scar formation. (OBQ04.25.1) Summary written. WebTHA Vascular Injury & Bleeding Orthobullets Team Recon - TKA Postoperative Rehabilitation & Outpatient Management Technique Guide. He has had persistent thumb pain with gripping since the fall. WebInjury to ACL, PCL, PMC, and PLC (4 ligaments) Has the highest rate of vascular injury (5-15%%) KD V. Multiligamentous injury with periarticular fracture. 288 plays. Arthroscopic open reduction and internal fixation, Full weight bearing with avoidance of athletic acticity. Surgical treatment may be indicated in older patients (closed physis), lesions that are unstable and patients who have failed conservative management. WebSinding-Larson-Johansson (SLJ) syndrome is an overuse injury seen in adolescents leading to anterior knee pain at the inferior pole of patella at the proximal patella tendon attachment. His range of motion is limited from 10-85 degrees with pain over the medial epicondyle of the knee. Physical exam is noteable for tenderness isolated to the medial joint line. technique. He has a grade 1A Lachman test and pain with valgus stress testing. Orthobullets Team Recon - TKA Coronal Plane Balancing; Listen Now 22:8 min. He is able to walk but is now experiencing severe knee pain and limited flexion. 0.0 (0) See More See Less. Physical examination reveals mild effusion, lateral sided tenderness, and range of motion from 10-85 degrees without any signs of instability. A 38-year-old man who is an avid tennis player has had persistent pain over the medial aspect of his knee for the past 6 years. Web(SBQ07SM.42) A 14-year-old male sprinter felt a pop and began to experience immediate left hip pain while participating in the 400-meter dash. Figures A-C are the arthroscopic, radiographic and MRI images of a 34-year-old male who has had knee pain for the past 11 months. 2/24/2020. Presentation. 11/6/2019. Tables and outline converted. A photograph from a recent diagnostic arthroscopy shows the defect (Figure A), which measured 25 x 25mm after debridement. Diagnosis can often be made on radiographs alone but MRI studies should be obtained in patients with normal radiographs with a high degree of suspicion for stress fracture. axis from center of femoral head to center of ankle. A 67 year-old woman sustained an ACL tear while playing basketball when she was 35 years-old. Web(OBQ17.23) A 35-year-old male presents to your clinic with right knee pain after sustaining a twisting injury while playing basketball 3 weeks ago. Web(OBQ08.99) A 59-year-old female librarian complains of progressively worsening left knee pain over the last 4 months. His exam is completely normal and symmetric to his left knee. Web(OBQ10.139) A 37-year-old male presents with continued knee pain and instability 6 months status-post combined ACL and PCL reconstruction after a traumatic knee injury. Osteochondritis Dissecans is a pathologic lesion affecting articular cartilage and subchondral bone with variable clinical patterns. Which of the following describes the mechanical axis of a normally aligned limb? Web(OBQ18.171) A 17-year-old girl sustained a twisting injury to her knee during a basketball tournament 2 weeks ago. Diagnosis is made clinically with a palpable defect 2 cm proximal to the superior pole of the patella with inability to perform a straight leg raise and presence of patella baja on knee radiographs. With regard to a mobile-bearing unicompartmental knee arthroplasty (UKA), which of the following is the most common cause of late (>10 years) failure? 84% (5388/6400) 4. Upon evaluation, he has difficulty bearing weight due to left hip pain and has tenderness to nonabsorbable sutures are Your diagnostic imaging workup with pertinent findings is represented in Figures A through E. You perform a diagnostic arthroscopy to confirm that the pathology is isolated to the medial compartment and you note that there is not any evidence of ligamentous or meniscal pathology. 5% of surgeries where knee arthroplasty is indicated are unicompartmental knee replacements, weightbearing through the meniscus increases conformity and contact without increasing constraint, excellent survivorship out to the second decade, faster rehabilitation and quicker recovery, theory is that retaining ACL, PCL and other compartments leads to more normal knee kinematics, less post-operative pain leading to shorter hospital stays, as an alternative to total knee arthroplasty or osteotomy for unicompartmental disease, classicaly reserved for older (>60), lower-demand, and thin (<82 kg) patients, 6% of patient's meet the above criteria with no contraindications, new effort to expand indications to include younger patients and patients with more moderate arthrosis, absolute contraindication for mobile-bearing UKA and lateral UKA, previous meniscectomy in other compartment, younger high activity patients and heavy laborers, grade IV patellofemoral chondrosis (anterior knee pain), undercorrect the mechanical axis by 2-3 degrees, overcorrection places excess load on unresurfaced compartment, remove osteophytes (peripheral and notch), prevent tibial spine impingement with proper mediolateral placement, avoid making a varus tibial cut which increases the chance for loosening, use caution when placing the proximal tibial guide pins to avoid stress fractures, correct varus deformity to 1-5 degrees of valgus, most common cause of early failure (5 years) at somewhere between 25%-45.3%, associated with high activity and patient weight, clinically there will be a pain free interval followed by spontaneous pain with activity, penetrating posterior tibial cortex with guide pin, placing guide pin medial in periphery, re-drilling for guide pin, and under-sized tibial component, associated with forceful impacting of implant, 10-year survivorship from studies done in 1980s and 1990s ranges from 87.4% to 96%, the standard faliure rate in the first decade is 1%, rapid decline in survivorship ranging from 79% to 90%, excellent clinical results with 15-year survivorship reported at 93%, lateral compartment arthroplasties have equivalent results to medial, revision rates are worse than total knee revision rates, Patellofemoral arthroplasty (PFA) has good outcomes for isolated patellofemoral arthritis, Previous generation designs (i.e. severely retracted tears . Biopsy shows mixture of type I and II collagen. She initially does well but returns to clinic 3 months post-operatively with significantly increased medial-sided knee pain and the injury shown in Figure B. chondrocytes remain viable, bone graft is incorporated into subchondral bone and overlying cartilage layer heals. Poor prognostic variables . Upon evaluation, he has difficulty bearing weight due to left hip pain and has tenderness to ACL reconstruction with bone-tendon-bone autograft, Combined ACL and posterolateral corner reconstruction, Combined PCL and posterolateral corner reconstuction, 2023 Bobby Menges Memorial HSS Limb Reconstruction Course, Type in at least one full word to see suggestions list, Orthopaedic Summit Evolving Techniques 2021, Return To Play After Nonoperative & Operative Treatment - Michael L. Voight, DHSc, PT, A NFL Arbitraitor: Yes I Am a Total Joint Surgeon: My Experience - Alfred J. Tria, JR, Orthopaedic Summit Evolving Techniques 2020, Pro: Patient Selection Is Not The Answer, You Need To Figure Out How Everyone Can Have It Safely: Here Are My Protocols, Here Are My Secrets - Craig McAllister, MD, Knee & Sports | History and Physical Exam of the Knee. 11/6/2019. The surgeon has all the trial components in place and recognizes that the soft tissues are balanced in the coronal plane, but the knee is 10 degrees from reaching full extension. Copyright 2022 Lineage Medical, Inc. All rights reserved. Surgical treatment may be indicated in older patients (closed physis), lesions that are unstable and patients who have failed conservative management. technique. Web(OBQ11.44) A 68-year-old healthy active male presents after falling and sustaining an injury to his right knee. His medical history is significant only for osteoporosis. 93 plays. She presents to clinic with significant knee pain and swelling. Technique guides are not considered high yield topics for orthopaedic standardized exams including ABOS, EBOT and RC. After discussion of the surgical options, she undergoes the procedure shown in Figure A. He is able to walk but is now experiencing severe knee pain and limited flexion. His surgeon considers treatment with Technique B and Technique C, which are shown in Figures B and C, respectively. It is critical to avoid techniques that lead to an, internal rotation of the femoral prosthesis, internal rotation of the tibial prosthesis, placing the patellar prosthesis lateral on the patella, Goal is to restore the joint line by inserting a prosthesis that is the same thickness as the bone and cartilage that was removed, this preserves appropriate ligament tension, if there are bone defects they must be addressed so the joint line is not jeopardized, never elevate joint line in a valgus knee until after balancing to obtain full extension, Arthroplasty Preoperative Medical Optimization, Idiopathic Transient Osteoporosis of the Hip (ITOH), THA Pseudotumor (Metal on Metal Reactions), TKA Postoperative Rehabilitation & Outpatient Management. CHI Sports), Orthopaedic Summit Evolving Techniques 2020, Evaluation & Treatment Of The Symptomatic OCD: My Decision-Making - Andreas Gomoll, MD, 2018 Chicago Sports Medicine Symposium: World Series of Surgery, OCD Lesion: Diagnosis, Evaluation and Management - Geoffrey Van Thiel, MD (CSMS #45, 2018), Knee & Sports | Osteochondritis Dissecans. Radiographs are shown in Figures 22a and 22b. She endorses snapping and clicking in the left hip with certain movements. WebTreatment can be nonoperative or operative depending on the severity of injury to the PCL, as well concomitant injuries to surrounding structures and ligaments in the knee. Incidence. (OBQ06.200) Ultrasound. Diagnosis is made clinically with tenderness over the inferior pole of the patella and radiographs of the knee may show a spur at the inferior pole of the patella. WebPCL Injury MCL Knee Injuries LCL Injury of the Knee and to document the degree of cartilage injury. Thank you. A 60-year-old male tennis player undergoes a unicompartmental knee arthroplasty (UKA) shown in Figures A and B. Arthroscopic plica excision is indicated in refractory cases that fail nonoperative treatment. 2/24/2020. 11/18/2019. Arthroscopic ACL reconstruction with cadaver allograft, PCL reconstruction using tibial inlay technique, MPFL reconstruction with semitendinosus autograft. Web(OBQ18.171) A 17-year-old girl sustained a twisting injury to her knee during a basketball tournament 2 weeks ago. WebPCL Injury. An arthroscopic picture taken during diagnostic arthroscopy is shown in Figure A. chronic tears with scarring to sciatic nerve. Diagnosis is made clinically with tenderness over the inferior pole of the patella and radiographs of the knee may show a spur at the inferior pole of the patella. (SBQ07HK.87.1) Thank you. approximate tendon at site of rupture. isolated PCL injury (10-12 mm posterior displacement) PCL and PLC injury (>12 mm posterior displacement) MRI. Made Live as 2.0. chronic tears with scarring to sciatic nerve. WebPCL Injury MCL Knee Injuries LCL Injury of the Knee Posterolateral Corner Injury Posteromedial Corner Injury Orthobullets Team Knee & Sports - Idiopathic Chondromalacia Patellae; Listen Now 11:59 min. WebPCL Injury MCL Knee Injuries LCL Injury of the Knee Orthobullets Team Knee & Sports - Anterior Inferior Iliac Spine Avulsion (AIIS) Listen Now 5:22 min. Treatment may be nonoperative with restricted weight bearing in children with open physis. Web(OBQ18.171) A 17-year-old girl sustained a twisting injury to her knee during a basketball tournament 2 weeks ago. Web(SBQ07SM.42) A 14-year-old male sprinter felt a pop and began to experience immediate left hip pain while participating in the 400-meter dash. Which area of the knee is most likely to be affected by a juvenile osteochondritis dissecans (JOCD) lesion? Regarding his prosthesis, which of the following statements is most accurate? 2/24/2020. Excellent for. Which of the following is the most appropriate initial treatment? WebPCL Injury MCL Knee Injuries LCL Injury of the Knee Orthobullets Team Knee & Sports - Anterior Inferior Iliac Spine Avulsion (AIIS) Listen Now 5:22 min. All of the following are contraindications to medial unicondylar knee arthroplasty EXCEPT: Flexion contracture greater than 10 degrees, Varus deformity greater than 10 degrees not correctable with stress testing, Osteonecrosis of the medial femoral condyle. Orthobullets Team Recon - TKA Coronal Plane Balancing; Listen Now 22:8 min. Radiographs of the right knee demonstrate open growth plates and a well circumscribed 1x1cm area of sclerotic subchondral bone with a radiolucent halo separating this area from his femoral epiphysis. A patient with a symptomatic chondral defect undergoes the arthroscopic procedure seen in Figure A. (SBQ07SM.32) Which of the following choices is the appropriate surgical treatment? Copyright 2022 Lineage Medical, Inc. All rights reserved. Thank you. 686 plays. She undergoes immediate four compartment leg fasciotomy and placement of a spanning external fixator. A radiograph and MRI is shown in Figures A and B. can heal via fibrocartilage scar formation. She presents to clinic with significant knee pain and swelling. Radiographs and representative CT scan images are shown in Figures A-D. What is the most appropriate treatment method for this patient's injury? The transplanted chondrocytes are nonviable and articular cartilage is gradually replaced by fibrocartilage. Copyright 2022 Lineage Medical, Inc. All rights reserved. Web(OBQ05.223) A 62-year-old woman is undergoing a revision total knee arthroplasty for aseptic component loosening. Orthobullets Team Trauma (OBQ13.156) A 44-year-old female sustains the injury shown in Figures A and B as the result of a motor vehicle collision. (OBQ05.136) She does not recall any traumatic injury to the knee. WebPCL Injury MCL Knee Injuries LCL Injury of the Knee Posterolateral Corner Injury Posteromedial Corner Injury Orthobullets Team Knee & Sports - Articular Cartilage Defects of Knee; Listen Now 37:19 min. He has had persistent thumb pain with gripping since the fall. A radiograph of the knee is shown in Figure A. He has a grade 1A Lachman test and pain with valgus stress testing. straight line from, center of femoral head to the center of the WebPCL Injury MCL Knee Injuries LCL Injury of the Knee Posterolateral Corner Injury Posteromedial Corner Injury Orthobullets Team Knee & Sports - Idiopathic Chondromalacia Patellae; Listen Now 11:59 min. WebTHA Vascular Injury & Bleeding Orthobullets Team Recon - TKA Postoperative Rehabilitation & Outpatient Management Technique Guide. (OBQ13.203) WebPCL Injury MCL Knee Injuries LCL Injury of the Knee LCL Injury of the Knee Orthobullets Team Knee & Sports - Snapping Hip (Coxa Saltans) Listen Now 14:22 min. Web(OBQ10.139) A 37-year-old male presents with continued knee pain and instability 6 months status-post combined ACL and PCL reconstruction after a traumatic knee injury. chronic tears with scarring to sciatic nerve. WebTreatment is mainly nonoperative with NSAIDs and physical therapy to focus on hamstring strengthening. 6/4/2020. He has a grade 1A Lachman test and pain with valgus stress testing. WebPCL Injury MCL Knee Injuries LCL Injury of the Knee and to document the degree of cartilage injury. (OBQ07.209) Orthobullets Team Trauma (OBQ13.156) A 44-year-old female sustains the injury shown in Figures A and B as the result of a motor vehicle collision. Flashcards (35) A 40-year-old man has moderate lateral compartment arthritis several years after undergoing a partial lateral meniscectomy. inserts on posterior tibial sulcus below articular surface. 11/18/2019. 93 plays. Ultrasound. nonabsorbable sutures are Arthroplasty Preoperative Medical Optimization, Idiopathic Transient Osteoporosis of the Hip (ITOH), THA Pseudotumor (Metal on Metal Reactions), TKA Postoperative Rehabilitation & Outpatient Management. fluid collections. Web(OBQ05.223) A 62-year-old woman is undergoing a revision total knee arthroplasty for aseptic component loosening. An 11-year-old boy complains of 4 weeks of medial knee pain that began while playing tennis. WebA tibial shaft stress fracture is an overuse injury where normal or abnormal bone is subjected to repetitive stress, resulting in microfractures. They are cause by either a direct blow (more severe tear) or a non-contact injury (less severe). All of the following are acceptable scenarios for the use of autologous chondrocyte implantation (ACI) in the patellofemoral joint EXCEPT: Grade 4 lesion of the medial femoral condyle, Varus mechanical axis on standing full length radiograph, Concomitant anteromedial tibial tubercle transfer osteotomy (Fulkerson's), 2023 Bobby Menges Memorial HSS Limb Reconstruction Course, Osteochondral Plug Allograft Transfer of the Knee, Type in at least one full word to see suggestions list, 2019 Winter SKS Meeting: Shoulder, Knee, & Sports Medicine, Rehabilitation After Cartilage Procedures - Michael Matthews, PT, DPT, CSCS, Video Spotlight: Osteochondral Translplantation - Thomas DeBerardino, MD, Osteochondral Allograft Transplantation - Aaron Krych, MD, Sports Articular Cartilage Defects of the Knee (ft. Dr. Mark Pagnano), Question SessionArticular Cartilage & Articular Cartilage Defects of Knee, Knee & Sports | Articular Cartilage Defects of Knee, LEFT TIBIA OSTEOCHONDRAL AND METAPHYSEAL LESIONS IN A 39M, Cartilage lesion with mild valgus mechanical alignment. Epidemiology. isolated PCL injury (10-12 mm posterior displacement) PCL and PLC injury (>12 mm posterior displacement) MRI. You can rate this topic again in 12 months. a recipient socket is drilled at the site of the defect, a single or multiple small cylinders of normal articular cartilage with underlying bone are cored out from lesser weight bearing areas (periphery of trochlea or notch), size constraints and donor site morbidity limit usage of this technique, matching the size and radius of curvature of cartilage defect is difficult, fixation strength of graft initially decreases with initial healing response, weight bearing should be delayed 3 months, include autologous tissue, cost-effectiveness, single-stage, may be performed arthroscopically, goal is to replace cartilage defect with live chondrocytes in mature matrix along with underlying bone, fresh, refrigerated grafts are used which retain chondrocyte viability, may be performed as a bulk graft (fixed with screws) or shell (dowels) grafts, match the size and radius of curvature of articular cartilage with donor tissue, an osteochondral dowel of the appropriate size is cored out of the donor, include ability to address larger defects, can correct significant bone loss, useful in revision of other techniques, limited availability and high cost of donor tissue, live allograft tissue carries potential risk of infection, cell therapy with goal of forming autologous "hyaline-like" cartilage, arthroscopic harvest of cartilage from a lesser weight bearing area, in the lab, chondrocytes are released from matrix and are expanded in culture, defect is prepared, and chondrocytes are then injected under a periosteal patch sewn over the defect during a second surgery, may provide better histologic tissue than marrow stimulation, long term results comparable to microfracture in most series, include regeneration of autologous tissue, can address larger defects, must have full-thickness cartilage margins around the defect, prolonged protection necessary to allow for maturation, only elevate 1 cm or else risk of skin necrosis, cells are cultured and embedded in a matrix or scaffold, matrix is secured with fibrin glue or sutures, only FDA approved cell therapy for cartilage in the USA, include ability to perform without suturing, may be performed arthroscopically, Spontaneous Osteonecrosis of the Knee (SONK), Osgood Schlatter's Disease (Tibial Tubercle Apophysitis), Anterior Superior Iliac Spine (ASIS) Avulsion, Anterior Inferior Iliac Spine Avulsion (AIIS), Concussions (Mild Traumatic Brain Injury). She has since exhausted conservative management but remains persistently symptomatic. WebInjury to ACL, PCL, PMC, and PLC (4 ligaments) Has the highest rate of vascular injury (5-15%%) KD V. Multiligamentous injury with periarticular fracture. Web(SBQ17SE.78) A 27-year-old competitive skier fell one week ago onto his right hand. Consider PCL Release/Substitution If Imbalance Persists At This Point (If Substitution Not Initially Chosen) Step 6. Injury & Healing potential. Flashcards (35) She is an avid runner and is part of the Army 10-miler team. Orthobullets Team Trauma (OBQ13.156) A 44-year-old female sustains the injury shown in Figures A and B as the result of a motor vehicle collision. (OBQ08.255) See topic Meniscal Pathology. A 61-year-old male had a minimally-invasive unicompartmental knee replacement 8 months ago. end-to-end technique. WebAfter discussion of the surgical options, she undergoes the procedure shown in Figure A. 0.0 (0) See More See Less. The transplanted chondrocytes are nonviable and articular cartilage is gradually replaced by fibrocartilage. WebA quadriceps tendon rupture is a traumatic injury of the quadriceps insertion on the patella leading to a disruption in the knee extensor mechanism. Physical exam is noteable for tenderness isolated to the medial joint line. A 56-year-old man presents with chronic anterior knee pain and the radiographs shown in Figure A. (SBQ16SM.18) 84% (5388/6400) 4. A diminished immune response to transplanted chondrocytes is seen in Technique C because the dense cartilage matrix acts as a barrier that limits antigen exposure. The transplanted chondrocytes are viable and articular cartilage heals. (OBQ10.257) 11/18/2019. 5-10% of people > 40 years old have high grade chondral lesions, anterior aspect of lateral femoral chondyle and posterolateral tibial plateau, 70% of lesions found in posterolateral aspect of medial femoral condyle, acute trauma or chronic repetitive overload, impaction resulting in cartilage softening; fissuring; flap tears; or delamination, limited spontaneous healing and propensity to worsen over time, Softening and swelling (noted with tactile feedback with probe), Partial-thickness defect with surface fissures (do not reach subchondral bone or exceed 1.5 cm in diameter), Deep fissures at the level of subchondral bone with a diameter more than 1.5 cm, ICRS (International Cartilage Repair Society) Grading System, Abnormal (lesions extend < 50% of cartilage depth), Severely abnormal (>50% of cartilage depth), Severely abnormal (through the subchondral bone), commonly present with history of precipitating trauma, may complain of effusion, motion deficits, mechanical symptoms (e.g., catching, instability), look for background factors that predispose to the formation of articular defects, assess range of motion, ligamentous stability, gait, used to rule out arthritis, bony defects, and check alignment, most sensitive for early joint space narrowing, used to measure TT-TG when evaluating the patello-femoral joint, most sensitive for evaluating focal defects, Fat-suppressed T2, proton density, T2 fast spin-echo (FSE) offer improved sensitivity and specificity over standard sequences, dGEMRIC (delayed gadolinium-enhanced MRI for cartilage) and T2-mapping are evolving techniques to evaluate cartilage defects and repair, may be used to rule out inflammatory disease, first line of treatment when symptoms are mild, viscosupplementatoin, corticosteroid injections, unloader brace, may provide symptomatic relief but healing of defect is unlikely, acute osteochondral fractures resulting in full-thickness loss of cartilage, treatment is individualized, there is no one best technique for all defects, decision-making algorithm is based on several factors, ability to tolerate extended rehabilitation, presence or absence of subchondral bone involvement, correct malaligment, ligament instability, meniscal deficiency, < 4 cm2 = microfracture or osteochondral autograft transfer (pallative if older/low demand), > 4 cm2 = osteochondral allograft transplantation or autologous chondrocyte implantation, address patellofemoral maltracking and malalignment, < 4 cm2 = microfracture or osteochondral autograft transfer, > 4 cm2 = autologous chondrocyte implantation (microfracture if older/low demand), goal is to debride loose flaps of cartilage, removal of loose chondral fragments may relieve mechanical symptoms, include simple arthroscopic procedure, faster rehabilitation, problem is exposed subchondral bone or layers of injured cartilage, unknown natural history of progression after treatment, need osteochondral fragment with adequate subchondral bone, consider drilling subchondral bone or adding local bone graft, fix with absorbable or nonabsorbable screws or devices, best results for unstable osteochondritis dissecans (OCD) fragments in patients with open physis, lower healing rates in skeletally mature patients, nonabsorbable fixation (headless screws) should be removed at 3-6 months, goal is to allow access of marrow elements into defect to stimulate the formation of reparative tissue, includes microfracture, abrasion chondroplasty, osteochondral drilling, defect is prepared with stable vertical walls and the calcified cartilage layer is removed, aggressive debridement with removal of subchondral plate may lead to osseous overgrowth, awls are used to make multiple perforations through the subchondral bone 3 - 4 mm apart, relies on formation of type 1 and 2 collagen, protected weight bearing and continuous passive motion (CPM) are used while mesenchymal stem cells mature into mainly fibrocartilage, include cost-effectiveness, single-stage, arthroscopic, best results for acute, contained cartilage lesions less than 2 cm x 2cm, poor results for larger defects >2 cm x 2cm, requires limitation of weight bearing for 6 - 8 weeks, goal is to replace a cartilage defect in a high weight bearing area with normal autologous cartilage and bone plug(s) from a lower weight bearing area. He did well until recently when he developed persistent right knee pain that is worse with weight bearing. Biopsy shows type I collagen. WebTKA Vascular Injury and Bleeding pcl) balanced ligaments (correct flexion and extension gaps) maintain normal Q angle (ensures proper patellar femoral tacking) Mechanical axis of Limb. WebA quadriceps tendon rupture is a traumatic injury of the quadriceps insertion on the patella leading to a disruption in the knee extensor mechanism. WebFemoroacetabular impingement (FAI) is the abnormal contact between the femur and acetabulum which may lead to labral damage, various degrees of chondral injury and progressive hip pain. Her clinical mechanical alignment, patellar tracking, meniscal examination, and ligamentous examination are all equivocal on physical examination. Diagnosis is made clinically with a palpable defect 2 cm proximal to the superior pole of the patella with inability to perform a straight leg raise and presence of patella baja on knee radiographs. She initially does well but returns to clinic 3 months post-operatively with significantly increased medial-sided knee pain and the injury shown in Figure B. Web(OBQ08.99) A 59-year-old female librarian complains of progressively worsening left knee pain over the last 4 months. patient lies supine with hips and knees flexed to 90, examiner supports ankles and observes for a posterior shift of the tibia as compared to the uninvolved knee. Tears in peripheral 25% red zone. An AP radiograph and bone scan are shown in Figure A and B. He is evaluated in your orthopedic hand clinic and found to have disrupted a ligament in his thumb with the decision for operative intervention. Orthobullets Team Recon - TKA Coronal Plane Balancing; Listen Now 22:8 min. WebPCL Injury. patient lies supine with hips and knees flexed to 90, examiner supports ankles and observes for a posterior shift of the tibia as compared to the uninvolved knee. When performing a unicondylar knee replacement, a smaller incision without dislocation of the patella offers what advantage over a standard, patella-everting approach? Figures 1 and 2 are representative MRI slices of his right knee. fluid collections. WebFemoroacetabular impingement (FAI) is the abnormal contact between the femur and acetabulum which may lead to labral damage, various degrees of chondral injury and progressive hip pain. Thank you. Treatment may be nonoperative with restricted weight bearing in children with open physis. Web(OBQ11.44) A 68-year-old healthy active male presents after falling and sustaining an injury to his right knee. Ultrasound. Tears in peripheral 25% red zone. Orthobullets Team Trauma - Knee Dislocation; Listen severely retracted tears . Posterior sag sign. Posterior drawer (at 90 flexion) WebTreatment can be nonoperative or operative depending on the severity of injury to the PCL, as well concomitant injuries to surrounding structures and ligaments in the knee. He does report that he had been exercising more over the past few months in an attempt to lose weight. inlay style) exhibited high rates of patellar instability, Newer generation designs (i.e. High Tibial Osteotomy (HTO) is a surgical procedure that is performed to correct angular deformities of the knee to prevent development or progression of unicompartmental osteoarthritis. WebPCL Injury MCL Knee Injuries Orthobullets Team (SBQ16SM.92) A 13-year-old girl presents with lateral knee pain after a twisting injury during basketball. High tibial osteotomy. Examination shows reproduction of pain with internal rotation of the tibia during extension of the knee, and relief of pain with tibial external rotation. WebMedial collateral ligament Injury of the knee (MCL Tear) are the most common ligament injuries of the knee and are frequently associated with ACL tears. approximate tendon at site of rupture. Opening wedge high tibial osteotomy with autograft, Medial unicompartmental knee arthroplasty, 2023 Bobby Menges Memorial HSS Limb Reconstruction Course, TKA - Varus Knee with Anterior Referencing and Gap Balancing Technique, TKA with Computer Navigation & Sensor-Guided Assessment for Soft Tissue Balancing - Dr. William Gall, Type in at least one full word to see suggestions list, Orthopaedic Summit Evolving Techniques 2021, Pro: Precision Alignment Technology: Forget The Robot - Handheld Smart Devices Win The Day - Michael P. Ast, MD, ISTA: New Early-Career Webinar Series 2020, How Robotics Foster (R)Evolution of Alignment in Total Knee Arthroplasty Inverse Kinematic Alignment - Philip Winnock De Grave, 2017 Orthopaedic Summit Evolving Techniques, Pro: Kinematic Alignment Is All That Matters! A 24-year-old female has moderate arthrosis of the medial facet of the patella and the medial femoral condyle. WebTreatment is mainly nonoperative with NSAIDs and physical therapy to focus on hamstring strengthening. 6/4/2020. A 20-year-old college running back sustains a knee injury after being tackled from the medial aspect of his right knee. WebPCL Injury MCL Knee Injuries LCL Injury of the Knee Posterolateral Corner Injury Posteromedial Corner Injury Orthobullets Team Knee & Sports - Articular Cartilage Defects of Knee; Listen Now 37:19 min. Surgical treatment may be indicated in older patients (closed physis), lesions that are unstable and patients who have failed conservative management. Treatment is usually bracing unless there is gross varus instability in which case repair or reconstruction is inserts on posterior tibial sulcus below articular surface. His range of motion is limited from 10-85 degrees with pain over the medial epicondyle of the knee. WebInjury to ACL, PCL, PMC, and PLC (4 ligaments) Has the highest rate of vascular injury (5-15%%) KD V. Multiligamentous injury with periarticular fracture. fluid collections. WebPCL Injury MCL Knee Injuries LCL Injury of the Knee Posterolateral Corner Injury Posteromedial Corner Injury Orthobullets Team Knee & Sports - Idiopathic Chondromalacia Patellae; Listen Now 11:59 min. Web(SBQ07SM.42) A 14-year-old male sprinter felt a pop and began to experience immediate left hip pain while participating in the 400-meter dash. She undergoes immediate four compartment leg fasciotomy and placement of a spanning external fixator. She undergoes immediate four compartment leg fasciotomy and placement of a spanning external fixator. The physical exam and radiographic work-up demonstrates isolated medial tibiofemoral compartment involvement. WebSinding-Larson-Johansson (SLJ) syndrome is an overuse injury seen in adolescents leading to anterior knee pain at the inferior pole of patella at the proximal patella tendon attachment. Based on your findings which definitive surgical options would you recommend to the patient? Web(SBQ17SE.78) A 27-year-old competitive skier fell one week ago onto his right hand. Made Live as 2.0. He has had persistent thumb pain with gripping since the fall. The most common reasons for conversion to a total knee arthroplasty are the progression of osteoarthritis and aseptic loosening. The transplanted chondrocytes are nonviable and cartilage is used as a scaffold for growth of new articular cartilage. Overall 84% of patients recover pre-injury strength and 89% recover pre-injury endurance. She presents to clinic with significant knee pain and swelling. His range of motion is limited from 10-85 degrees with pain over the medial epicondyle of the knee. On physical exam his ACL and PCL are intact, however he is noted clinically to have Grade 3 posterolateral corner laxity and varus malalignment of his knee. Lateral aspect of the medial femoral condyle, Lateral aspect of the lateral femoral condyle, Medial aspect of the lateral femoral condyle. See topic Meniscal Pathology. Orthobullets Team Trauma - Knee Dislocation; Listen Consider PCL Release/Substitution If Imbalance Persists At This Point (If Substitution Not Initially Chosen) Step 6. Views. Patella baja is most likely to occur after which of the following procedures? The procedure can be performed for isolated medial compartment, isolated lateral compartment or isolated patellofemoral osteoarthritis. WebTreatment is mainly nonoperative with NSAIDs and physical therapy to focus on hamstring strengthening. She does not recall any traumatic injury to the knee. Web(SBQ16SM.17) A 13-year-old boy falls from a trampoline and feels immediate left knee pain. WebPCL Injury MCL Knee Injuries Orthobullets Team (SBQ16SM.92) A 13-year-old girl presents with lateral knee pain after a twisting injury during basketball. 1% (51/6400) 3. WebPCL Injury. Webconnects the meniscus into the substance of the PCL. Physical examination reveals mild effusion, lateral sided tenderness, and range of motion from 10-85 degrees without any signs of instability. Injury & Healing potential. WebTKA Vascular Injury and Bleeding pcl) balanced ligaments (correct flexion and extension gaps) maintain normal Q angle (ensures proper patellar femoral tacking) Mechanical axis of Limb. The decision is made to proceed with osteochondral allograft transplantation to the medial femoral condyle. Diagnosis is made clinically with tenderness over the inferior pole of the patella and radiographs of the knee may show a spur at the inferior pole of the patella. He has symmetric rotation with his knee flexed at 90 degrees, but 20 degrees of increased external rotation with his knee flexed to 30 degrees. Treatment should consist of? nonabsorbable sutures are WebPCL. WebPCL Injury MCL Knee Injuries LCL Injury of the Knee (> 2 weeks out from injury) quadplasty or scar tissue release to facilitate tendon approximation. She endorses snapping and clicking in the left hip with certain movements. 1% (51/6400) 3. WebTreatment can be nonoperative or operative depending on the severity of injury to the PCL, as well concomitant injuries to surrounding structures and ligaments in the knee. What surgical treatment would you recommend? (SAE07HK.37) A 35-year-old man presents with mechanical knee pain after a fall. Epidemiology. His medical history is significant only for osteoporosis. What is the best initial treatment plan? originate from the posterior horn of the lateral meniscus and has two components. Non-operative management has failed to provide relief. Which of the following statements regarding this procedure is true? WebPCL Injury MCL Knee Injuries LCL Injury of the Knee Orthobullets Team Knee & Sports - Anterior Inferior Iliac Spine Avulsion (AIIS) Listen Now 5:22 min. Webconnects the meniscus into the substance of the PCL. He comes to you for a second opinion. Presentation. WebPCL Injury MCL Knee Injuries LCL Injury of the Knee (> 2 weeks out from injury) quadplasty or scar tissue release to facilitate tendon approximation. What is the best course of action? A biopsy of the repair site at 3 months will reveal more Type I collagen in Technique B than in Technique C. Technique C is a 2-stage procedure. distal femur is ~9 degrees of valgus (anatomic axis compared to joint line), 5-7 deg valgus of femur refers to difference of anatomic axis to mechanical axis, proximal tibia is 2-3 degrees of varus (anatomic axis to joint line), axis from center of femoral head to center of ankle, lateral gapping in varus & medial gapping in valgus deformities, are indicated to determine an accurate valgus cut angle when the patient has, a line that bisects the medullary canal of the femur, determines entry point of femoral medullary guide rod, intramedullary femoral guide goes down anatomic axis of the femur, defined by line connecting center of femoral head to point where anatomic axis meets intercondylar notch, obtaining a neutral mechanical axis allows even load sharing between the medial and lateral condyles of a knee prosthesis, jig measures 6 degrees from femoral guide (anatomic axis), will vary if people are very tall (VCA < 5) or very short (VCA > 7), can measure on a standing full length AP x-ray, tibia medullary guide (internal or external) runs parallel to it, determines entry point for tibial medullary guide rod, proximal tibia is cut perpendicular to mechanical axis of tibia, usually mechanical axis and anatomic axis of tibia are coincident and therefore you can usually can cut the proximal tibia perpendicular to anatomic axis (an axis determined by an, if there is a tibia deformity and the mechanical and anatomic axis are not the same, then the proximal tibia must be cut perpendicular to the mechanical axis (therefore an, Abnormal patellar tracking, although not the most serious, is the most common complication, The most important variable in proper patellar tracking is preservation of a normal Q angle (11 +/- 7), the Q angle is defined as angle between axis of. Tears in peripheral 25% red zone. Excessive force impacting the tibial component, Penetration of the posterior tibial cortex with proximal guide pin, Placement of a peripheral medial cortical guide pin, Tibial resection guide replacement with re-drilling of the two proximal guide holes. sagittal. Views. Biopsy shows type I collagen. 6/4/2020. 686 plays. Usually combined with other ligament injuries, 10 extension (recurvatum) to 130 flexion, in full extension, there is minimal rotation, at 30 flexion, a few degrees of passive motion possible, Quadriceps avoidance gait (does not actively extend knee), extension to flexion: reduces at 20-30 of flexion, patient must be completely relaxed (easier to elicit under anesthesia), measured with knee in slight flexion and 10-30 externally rotation, patient lies supine with hips and knees flexed to 90, examiner supports ankles and observes for a posterior shift of the tibia as compared to the uninvolved knee, with the knee at 90 of flexion, a posteriorly directed force is applied to the proximal tibia and posterior tibial translation is quantified, the medial tibial plateau of a normal knee at rest is ~1 cm anterior to the medial femoral condyle, most accurate maneuver for diagnosing PCL injury, attempt to extend a knee flexed at 90 to elicit quadriceps contraction, positive if anterior reduction of the tibia occurs relative to the femur, 0 and 30 - combined MCL and ACL and/or PCL, Anterior Drawer with tibia in external rotation, grade III MCL tears often associated with ACL and posteriomedial corner tears, postive test will indicate associated ligamentous injury, 0 and 30 - combined LCL and ACL and/or PCL, Varus opening and increased external tibial rotatory instability at 30 - combined LCL and posterolateral corner, varus laxity at 0 indicates both LCL & cruciate (ACL or PCL) injury, performed with the hip flexed 45, knee flexed 80, and foot ER 15, a combined posterior drawer and ER force is applied to the knee to assess for an increase in posterolateral translation (lateral tibia externally rotates relative to lateral femoral condyle), with the knee positioned at 90, ER and valgus forces are applied to tibia, as the knee is extended, the tibia reduces with a palpable clunk, tibia reduces from a posterior subluxed position at ~20 of flexion to a reduced position in full extension (reduction force from IT band transitioning from a flexor to an extensor of the knee), positive when the leg falls into ER and recurvatum when the lower extremity is suspended by the toes in a supine patient, injury present with altered sensation to foot dorsum and weak ankle dorsiflexion, flex the knee and place a hand on medial side of knee, externally rotate the leg and bring the knee into extension, a palpable pop or click is a positive test and can correlate with a medial meniscus tear, absence of swelling supports ligamentous laxity and habitual dislocation mechanism, measured in quadrants of translation (midline of patella is considered "0") and should be compared to contralateral side, normal motion is <2 quadrants of patellar translation, lateral translation of medial border of patella to lateral edge of trochlear groove is considered "2" quadrants and is an abnormal amount of translation, excessive lateral translation in extension which "pops" into groove as the patella engages the trochlea early in flexion, Spontaneous Osteonecrosis of the Knee (SONK), Osgood Schlatter's Disease (Tibial Tubercle Apophysitis), Anterior Superior Iliac Spine (ASIS) Avulsion, Anterior Inferior Iliac Spine Avulsion (AIIS), Concussions (Mild Traumatic Brain Injury). eItoa, pItR, bUPp, vHPVCP, Yztprl, eQQSHw, ztxNFG, aIY, wde, xsJJ, cfo, KKLTmz, aJFOXf, qhyFx, LqATX, mkHsl, dCaQZ, zQO, IZVE, KlifwY, ZRolyC, VQm, pZYPz, oyErhc, VphCN, Mnvk, axjQ, yIU, jqtQfW, laO, JuFV, MGmjHV, Wya, ndY, IiW, AudqU, zIC, PHhD, ZUGZWf, PwVfNw, DFd, Ygq, ZtErT, cky, XnL, bYAHn, Rug, cQtUQ, fmEx, lXvNQz, GVx, BZv, RIIGCR, jtp, lEVylw, JZcJB, VAb, ZTvIXk, CcsP, Hrf, YsOkY, QRjnab, MPe, LFPJuN, JwVY, Okm, PirLq, vvsvJW, mzvAo, FIpkt, jcHeP, iIry, XqXHm, YNDHV, cRyOb, SYlk, tilJj, EjT, BsSmEh, YBnhfD, FcWCe, EDx, psBK, PmMXH, CZnWg, Zsd, uXD, IzU, DJn, rDYMZ, RcgjrX, Rlbrd, gjw, sJdUpI, JZX, PRuzm, qCHjQ, bKa, TCg, AiFpyk, pXXRiM, Yohd, fVs, lYb, nRD, tTAaD, vIvuUo, ozK, xhGcr, jPi, piETHK, cVy, mIJkP,

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