lateral patellar dislocation radiology

[13] Twenty-one (70%) and 27 (90%) out of our 30 cases were positive for decreased trochlear depth when measured at the level of trochlear bone and cartilage, respectively, while 18 (60%) and 27 (83.33%) out of 30 cases were positive for trochlear facet asymmetry when measured at the level of trochlear bone and cartilage, respectively. Vertebra plana (plural: vertebrae planae), also known as the pancake, silver dollar or coin-on-edge vertebra, is the term given when a vertebral body has lost almost its entire height anteriorly and posteriorly, representing a very advanced compression fracture.. doi: 10.1148/rg.304095755. Knee Surgery, Sports Traumatology, Arthroscopy, Arthroscopy: The Journal of Arthroscopic & Related Surgery, Vol. 40, No. Findings: The extensor mechanism, including the quadriceps tendon, patella, and patellar tendon, is normal. 3, Orthopaedic Journal of Sports Medicine, Vol. 33, No. Subchondral marrow edema was present underlying the chondral defects in 10 (100%) patients. 8, Orthopaedics & Traumatology: Surgery & Research, Vol. 11, No. Furthermore, in our study, female patients predominated (56.7%) over male (43.3%), which clearly corresponds to available literature. A value of more than 20 mm was taken as a cutoff and indicated marked lateralization of the tuberosity [Figure 7]. #selected_lang_name {float: none;} 7) [4]. 89-B, No. 1, 13 November 2018 | RadioGraphics, Vol. A rehabilitation program aiming to reduce this unbalance may decrease the incidence of type C patella in young patients. 38, No. 15, No. 24, No. Twelve out of 30 cases (40 %) were positive for patella alta in our study. 15, No. The .gov means its official. 25, No. 12, Medicine & Science in Sports & Exercise, Vol. Twenty-eight (93.7%) out of 30 cases showed more than 1 risk factors (multifactorial) for patellar instability, out of which 12 patients (40%) had two risk factors, 9 patients (30%) had three risk factors, 5 patients (16.6%) had four risk factors, and 2 patients (6.7%) had all the five risk factors [Table 3]. Enter your email address below and we will send you your username, If the address matches an existing account you will receive an email with instructions to retrieve your username. articulation: ball and socket joint between the head of the femur and the acetabulum ligaments: ischiofemoral, iliofemoral, pubofemoral and transverse acetabular ligaments, and the ligamentum teres 1 movements: thigh flexion and extension, adduction and abduction, internal and external rotation blood supply: branches of the medial and lateral 1, Arthroscopy: The Journal of Arthroscopic & Related Surgery, Vol. 37, No. This area of the lateral femoral condyle should be closely evaluated for osteochondral injury on both sagittal and coronal MR images in all patients with evidence of prior transient dislocation of the patella. 40, No. Two of the high-field-strength magnets were Horizon LX units (GE Healthcare) and the third was a Signa (GE Healthcare). document.write(theYear) | Predisposing factors to objective patellar instability include trochlear dysplasia, patella alta, patellar tilt and elevated tibial tuberosity-femoral groove distance. Radiology Masterclass, Department of Radiology, The Horizontal Beam Lateral view allows identification of a knee joint effusion or lipohaemarthrosis (fat and blood in the joint), Tibial plateau fractures can be very subtle and lipohaemarthrosis may be the only visible sign, The patella is often not clearly seen on this view, The Horizontal Beam Lateral view is useful for assessing soft tissues as well as bones, The quadriceps and patellar tendons are visible, Note the normal suprapatellar pouch between fat pads above the patella (, Not usually indicated in the context of trauma, More helpful to assess knee pain due to suspected patellofemoral compartment osteoarthritis, Normal patellofemoral compartment spacing (, The fracture fragment is displaced and depressed from its normal position (dotted line), Lipohaemarthrosis (fat and blood in the joint), Increased density separating the fat pads indicates a joint effusion due to leakage of blood (haemarthrosis), The roll over image shows its normal position, A fabella is a normal sesamoid bone of the lateral head of gastrocnemius tendon - not to be mistaken for a fracture or loose body, The patella is bipartite (in 2 parts) - a common normal variant, Note: Injury to the interface of the 2 components is possible which may be symptomatic. Bookshelf The significance of these findings is that when evaluating the MR images of a patient with bone contusions indicative of a prior transient dislocation of the patella, the radiologist should carefully evaluate the articular cartilage at the level of the posterior margin of the bone contusion because this is the most likely location for a femoral osteochondral injury to occur. MRI: Magnetic resonance imaging, TT-TG: Tibial tubercle-trochlear groove. 6, Journal of Manipulative and Physiological Therapeutics, Vol. Ten cases (33.33%) were positive for decreased lateral trochlear inclination. Other examination findings in LPDs included contusions of the lateral femoral condyle (66 [80%] of 82 examinations) or medial patella (50 [61%] of 82), intraarticular bodies (12 [15%] of 82), effusion (45 [55%] of 82), medial collateral injury (nine [11%] of 82), and meniscal tear (nine [11%] of 82). All radiologists must keep in mind all the risk factors for patellar instability measurable on MRI and should document them in their reports so that the appropriate treatment can be selected. They should not be confused with fatigue fractures which are due to abnormal stresses on normal bone, or with pathological fractures, the result of diseased, weakened bone due to The angle between these two lines is the lateral trochlear inclination. 1, Revue de Chirurgie Orthopdique et Traumatologique, Vol. 4A and 4B). The depth of the lateral femoral notch sign has been shown to correlate with anterior cruciate ligament (ACL) tear 2. 2A, 2B, 2C, 3A, 3B, and 3C). 2, Sports Medicine and Arthroscopy Review, Vol. The precise location of the osteochondral defect is thus dependent on the degree of flexion of the knee at the time of dislocation. Examinations at three of the centers were obtained using high-field-strength (1.5 T) magnets, and examinations at the other three centers were obtained using low-field-strength (0.2 T) magnets. Nonetheless, both the MRI and surgical results suggest that lateral femoral condyle osteochondral lesions are common, and a search pattern should include an evaluation of the femoral condyle articular surface in both the sagittal and coronal imaging planes after transient dislocation of the patella. Trochlear dysplasia with medial condyle hypoplasia was observed. Seventeen (56.7%) out of 30 cases were female and 13 (43.7%) were male. sharing sensitive information, make sure youre on a federal CONCLUSION: Injury to the medial retinaculum, MPFL, and VMO may be identified at MR imaging after acute LPD. See also. A skyline view can only be acquired if the patient can tolerate knee flexion. Anomalies of dynamic and static factors, including excessive patellar height, tibial tubercle lateralisation or trochlear dysplasia, may influence the development of the patella. The average size of the defects was 1.2 cm in the anteroposterior diameter and 1.0 cm in the transverse diameter. Radiology Masterclass 2007 - now=new Date 2, 4 July 2010 | RadioGraphics, Vol. Transient lateral patellar dislocation is a common injury that typically occurs in the young, athletic individual. Three lines were drawn perpendicular to the aforementioned line. .switcher .option a.selected {background:#fff;} When a person has a dislocated jaw it is difficult to open and close the mouth. 41, No. Another line from the midpoint of tibial tubercle was drawn parallel to the aforementioned line. Knee Surg Sports Traumatol Arthrosc. Because the diagnosis of lateral patellar dislocation is often unsuspected, MR provides valuable diagnostic information in such cases. 30, No. Prevalence of patellar instability is higher in younger population, more frequently involving age equal to or <25 years. Hemarthrosis is common and loose intraarticular bodies are occasionally present [1-3]. 2022 Aug 22. doi: 10.1007/s00167-022-07120-1. 11, Journal of Clinical Orthopaedics and Trauma, Vol. 4, Operative Techniques in Sports Medicine, Vol. 6, Journal of Pediatric Orthopaedics, Vol. Patients with absence of these anatomical risk factors and mild grade damage to medial stabilizers can be treated conservatively without any need for surgical intervention. One hundred and five patients (140 knees) with objective patellar instability were retrospectively reviewed to identify a possible association between the above-mentioned predisposing factors and patellar shape. 13, No. Joint effusion was present. | 6). Radiographic features Sonography on injury of the medial patellofemoral ligament after acute traumatic lateral patellar dislocation: Injury patterns and correlation analysis with injury of articular cartilage of the inferomedial patella. In addition to the bone contusion pattern, osteochondral injuries of the patella have also been reported, and these range from mild articular cartilage surface irregularity to large displaced osteochondral fractures [1-4]. 3, The American Journal of Sports Medicine, Vol. 2022 Dec 4. doi: 10.1007/s00167-022-07245-3. (http://dx.doi.org/10.1590/S1413-78522011000100008). Patellar instability is a condition in which patella is unable to contain itself in the femoral trochlea during normal movement of knee joint. 1, Arthroscopy: The Journal of Arthroscopic & Related Surgery, Vol. New Hall Hospital, Salisbury, Wiltshire, UK, SP5 4EY. How to cite this article: Arora V, Kakkar A. MRI evaluation of predisposing factors in patellar instability. Patellar instability is more prevalent in females than males. Campbells Operative Orthopaedics:4-Volume Set. 11, EMC - Techniques chirurgicales - Orthopdie - Traumatologie, Vol. Trochlear dysplasia was diagnosed if trochlear depth was less than or equal to 3.0 mm [Figures 5 and 6]. Classification. 205, No. This site needs JavaScript to work properly. Of the 25 patients for whom there was MRI evidence of prior transient dislocation of the patella, 10 (40%) were found to have chondral defects involving the articular surface of the lateral femoral condyle. This work is licensed under aCreative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. 22, No. Each of the original interpretations was performed by one of four experienced, fellowship-trained musculoskeletal radiologists. 2017 Jul;45(9):2105-2110. doi: 10.1177/0363546517704178. 2, No. [3] British volume, Vol. Careers. .switcher .selected a:after {height:16px;display:inline-block;position:absolute;right:5px;width:15px;background-position:50%;background-size:7px;background-image:url("data:image/svg+xml;utf8,");background-repeat:no-repeat;content:""!important;transition:all .2s;} 7, Knee Surgery, Sports Traumatology, Arthroscopy, Vol. In cases of high-riding patella (patella alta), contact between the femoral trochlea and patella is reduced during early phase of knee flexion which leads to patellar dislocation.13Patellar height can be evaluated using different parameters. The Patellar is the largest sesamoid bone in the body, and it resides within the complex of the quadriceps and patellar tendons. All patients were assessed for various risk factors for patellar instability including trochlear facet asymmetry (at the level of trochlear bone and trochlear cartilage), trochlear depth (at the level of trochlear bone and trochlear cartilage), lateral trochlear inclination, patellar height ratio, and TTTG distance. Careers. 20, No. 10, No. 2022. The configuration of the articular surface of the patella is convex, whereas that of the trochlear groove is concave. 15, No. 33, No. [10] and Pfirrmann et al.[15]). This also corresponds to our study with only 4 out of 30 cases (13.3%) of age more than 30 years. Epidemiology. 2013 Dec;44(12):1892-8. doi: 10.1016/j.injury.2013.08.027. 33, No. 2, EMC - Tcnicas Quirrgicas - Ortopedia y Traumatologa, Vol. [18] in their study showed that TT-TG distance was increased in 5693% of patients suffering from patellar instability. 1, Revista Chilena de Ortopedia y Traumatologa, Clinical Journal of Sport Medicine, Vol. 51, No. Privacy Policy, Dr Graham Lloyd-Jones BA MBBS MRCP FRCR - Consultant Radiologist -. The location of the lateral femoral condyle marrow edema was recorded relative to the position of the chondral defect. 2, Chinese Medical Journal, Vol. and transmitted securely. Not all fractures that extend to the growth plate are Salter-Harris fractures. These MRI examinations were performed at six different outpatient imaging facilities. However, only 7 cases (23.3 %) were positive for increased TT-TG distance in our study. Low-field-strength magnets are limited in their ability to detect chondral abnormalities. .switcher .option a {color:#000;padding:3px 5px;} Am J Sports Med. Recurrent patellofemoral dislocation due to patellofemoral instability, Brought to you by the European Society of Radiology (ESR) -. 45, No. 10, International Orthopaedics, Vol. RESULTS: Eighty-two examinations were performed in 81 patients with LPD (mean age, 20 years; age range, 957 years). Insufficiency fractures are a type of stress fracture, which are the result of normal stresses on abnormal bone. Department of Radiology, Centro Hospitalar Universitrio Lisboa Central/ Lisboa 2019, Ana Lusa Proena, Department of Radiology, Centro Hospitalar Universitrio Lisboa Central/ Lisboa 2019, Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. 1, Orthopaedic Journal of Sports Medicine, Vol. They represent neither a true bursa nor a true cyst, as they occur 3, Russian Pediatric Journal, Vol. One recent report describes seven patients in whom lateral femoral condyle shearing fractures were identified on conventional radiography after lateral patellar dislocation. This finding further supports the theory that the shearing injury occurs during the first stage of dislocation with the knee in a greater state of flexion, and as the knee extends, the patella rebounds and impacts the lateral aspect of the lateral femoral condyle anterior to the site of the chondral shearing injury. Increased lateral stresses may produce a Wiberg type C patella, with a hypoplastic medial facet and a more developed lateral facet. If only those patients with injuries isolated to the lateral trochlear groove are included, the incidence in our series is 12%, which is more in line with the 5% incidence reported by Elias et al. Treatment and prognosis. Epub 2016 Dec 27. 4, No. 2022 Sep 14;17(1):416. doi: 10.1186/s13018-022-03310-2. Radiology 1999; 213(P):115. The role of this study was to recognize the predisposing factors of patellar instability on MRI. Patella alta is evaluated by Insall-Salvati index, which is abnormal if >1,2 (Fig. Osteochondral injuries involving the more posteriorly located midlateral weight-bearing portion of the lateral femoral condyle suggest that the patient's knee was in a greater degree of flexion at the time of dislocation, whereas a more anteriorly located osteochondral injury involving the trochlear groove suggests that the knee was more extended at the time of dislocation. [14] and Diederichs et al. Necessary cookies are absolutely essential for the website to function properly. MPFL ligament injuries are best seen in MRI, appearing disrupted and hyperintense on T2-WI [2]. 1, Arthroscopy: The Journal of Arthroscopic & Related Surgery, Vol. CT is commonly necessary for fracture characterization of the fragment size, the degree of anteromedial involvement, and complex fracture-dislocation. After the injury, the patient usually seeks medical attention because of persistent pain and swelling, which is typically located along the medial joint line, and the patient occasionally complains of a locking or catching sensation. 22, No. The MPFL femoral origin was identified in 87% (71 of 82); of these, 49% (35 of 71) showed injury. 1, Archives of Orthopaedic and Trauma Surgery, Vol. Patellar sleeve fractures occur in the pediatric population between 8 and 16 years of age, with a peak incidence at ~13 years 6, predominantly boys (3:1).Adolescents are more susceptible due to rapid growth, increased sports activity, and relative patella instability. Copyright 2022 Indian Journal of Musculoskeletal Radiology All rights reserved. 203, No. 24, No. Unlike study conducted by Pfirrmann et al. Tuberculosis or Not Tuberculosis: Temporal Evolution of, The Role of Diffusion-weighted Magnetic Resonance Imaging in, Evaluation of Occult Femoral Neck Fractures Computed, Trochlear facet asymmetry at cartilage level. Eighty-two examinations were performed in 81 patients with LPD (mean age, 20 years; age range, 9-57 years). Knee Surg Sports Traumatol Arthrosc. A normal sulcus is located within 10 mm of Blumensaat's line on lateral projection 3. best detected on the lateral view; Waters view is useful in assessing the nasal arch 4; CT. sensitivity is 100% 6; Treatment and prognosis. Get an accredited certificate of achievement by completing one of our online course completion assessments. Zhang GY, Zheng L, Feng Y, Shi H, Liu W, Ji BJ, Sun BS, Ding HY. .switcher .option {position:relative;z-index:9998;border-left:1px solid #ccc;border-right:1px solid #ccc;border-bottom:1px solid #ccc;background-color:#eee;display:none;width:161px;max-height:198px;-webkit-box-sizing:content-box;-moz-box-sizing:content-box;box-sizing:content-box;overflow-y:auto;overflow-x:hidden;} Written informed patient consent for publication has been obtained. 1A, 1B, 1C, 2A, 2B, and 2C). Spritzer CE, Courneya DL, Burk DL Jr, Garrett WE, Strong JA. By clicking Accept, you consent to the use of ALL the cookies. According to our study, trochlear dysplasia is the most common predisposing factor of patellar instability (100%) followed by patella alta (40%) and TT-TG distance (23.3%). Sulcus depth, congruence angle, Wiberg index, TT-TG distance, and CDI are strong predictors of recurrent patellar dislocation. An 8-year-old female patient presented with a spontaneous patellar dislocation that was manually reduced by paramedics. 32, No. [1,2] Lewallen et al. 32, No. 1, Singapore Medical Journal, Vol. Tarsometatarsal dislocation may also occur in the diabetic neuropathic joint . AP radiograph showing laterally dislocated patella. 1, The Open Orthopaedics Journal, Vol. 28, No. In two (20%) of the 10 patients, the osteochondral defects involved the articular surface of both the trochlear groove and the midlateral weight-bearing portion of the lateral femoral condyle. These osteochondral injuries typically involve the inferomedial pole, the median eminence of the patella [5], or both and can result either from a shearing injury at the time of dislocation or reduction or from an impaction injury as the patella strikes the nonarticular surface of the anterolateral femoral condyle. The most important differential diagnosis is that of a lunate dislocation which can mimic a perilunate dislocation, especially on AP projection. Eighteen (60%) and 25 (83.33%) cases were positive for trochlear facet asymmetry when measured at trochlear bone and cartilage, respectively. Treatment depends on the degree of displacement. The quadriceps and patellar tendons are visible. The dimensions of the chondral defects were described in the operative report in only three of those six patients. Acute traumatic patellar dislocation is the second most frequent cause of traumatic hemarthrosis of the knee, after anterior cruciate ligament tear, and accounts for 3% of all traumatic knee lesions [1], [2]. Twenty-four (80%) out of 30 cases were of age equal to or <25 years and only 4 (13.3%) out of 12 cases were of age more than 30 years. 10, No. CT scans are important to calculate TT-GT distance. 2, Journal of Pediatric Orthopaedics, Vol. Li J, Chen C, Zhou H, Zhai J, Zhao H, Li L. Evid Based Complement Alternat Med. 4, BMC Musculoskeletal Disorders, Vol. Conry KT, Cosgarea AJ, Tanaka MJ, Elias JJ. Published by Scientific Scholar on behalf of Musculoskeletal Society (MSS), India, 2021 Published by Scientific Scholar on behalf of Indian Journal of Musculoskeletal Radiology. In this study, we have attempted to evaluate the predisposing factors of patellar instability on magnetic resonance imaging (MRI) and to compare the significance of measurement at the level of trochlear bone versus cartilage for trochlear dysplasia. Correlation analysis between injury patterns of medial patellofemoral ligament and vastus medialis obliquus after acute first-time lateral patellar dislocation. MPFL repair after acute first-time patellar dislocation results in lower redislocation rates and less knee pain compared to rehabilitation: a systematic review and meta-analysis. Two centers with low-field-strength magnets used Lunar Escan units (GE Healthcare), and the third center used a Magnetom Jazz (Siemens Medical Solutions). J Orthop Surg Res. Patients complain of the knee suddenly giving way, and inability to weight-bear or extend the knee and are often in considerable pain. Comparison of measurement at the level of trochlear bone versus cartilage for trochlear facet asymmetry and trochlear depth. A major strength of our study was measuring trochlear facet asymmetry and trochlear depth both at the level of trochlear bone and trochlear cartilage and comparing their results, since it has always been a matter of conflict whether to use trochlear bone or cartilage for these measurements. 46, No. AJR Am J Roentgenol 1993; 161:109-113. Imaging of Anterior Cruciate Ligament Repair and Its Complications, Pictorial Essay. Online ahead of print. The patella then proceeds to bounce back into its normal position within the trochlear groove. As we move distally, the TG deepens, so the chances of patellar dislocation are less likely in distal trochlea. Prevalence of various predisposing factors in patellar instability on MRI. Injury. Triquetral body fracture 1, Orthopaedics & Traumatology: Surgery & Research, Vol. 46, No. 4, Contemporary Diagnostic Radiology, Vol. 27, No. Normal trochlear sulcus B Abnormal increased throclear sulcus. Our results highlight that the most critical factor responsible for patellar instability is trochlear dysplasia. 6, No. The fact that the patella sits atop the anterior surface of the femoral condyles, increases the angle at which the quadriceps tendon pulls on the shaft of the tibia. Based on the known mechanism of injury and on the location and pattern of osteochondral injuries and marrow contusions recorded in our Results section, we propose the following mechanism of injury regarding lateral femoral condyle osteochondral injuries. Subtypes. Magnetic resonance imaging (MRI) plays a key role in recognition of these anatomical risk factors associated with patellar instability, thereby guiding for subsequent treatment. Tsuda E, Ishibashi Y, Yamamoto Y, Maeda S. Knee Surg Sports Traumatol Arthrosc. cartilage injury with associated subchondral fracture but without detachment 455, Sports Medicine and Arthroscopy Review, Vol. All courses are CME/CPD accredited in accordance with the CPD scheme of the Royal College of Radiologists - London - UK. According to our study, trochlear dysplasia is the most common predisposing factor of patellar instability (100%) followed by patella alta (40%) and TT-TG distance (23.3%). Christensen TC, Sanders TL, Pareek A, Mohan R, Dahm DL, Krych AJ. Lateral patellar dislocation most commonly occurs in young, active individuals as the result of a twisting injury to the knee during participation in an athletic event. HHS Vulnerability Disclosure, Help 2, Archives of Orthopaedic and Trauma Surgery, Vol. Unbalance between dynamic medial and lateral stabilisers may act as an additional factor. Azar FM, Canale ST, Beaty JH. Purpose: To assess magnetic resonance (MR) imaging findings after acute lateral patellar dislocation (LPD) with emphasis on the medial patella restraints and to describe a medial patellar impaction deformity. Knee - Patellar fracture - AP. [4] 2, Techniques in Knee Surgery, Vol. Although individual parameters varied slightly from examination to examination, the routine MRI performed on the high-field-strength magnets consisted of coronal inversion-recovery (TR/TE range, 5,800-3,016/25-39; inversion time, 150 msec; field of view range, 140-149 mm; matrix range, 256-320 224 pixels; slice thickness, 4.0 mm; skip, 1.0 mm), coronal proton-density (2,000/15; field of view, 150 mm; matrix, 320 224 pixels; slice thickness, 4.0 mm; skip, 1.0 mm), or coronal T1 (500/16; field of view, 140 mm; matrix, 384 224 pixels; slice thickness, 4.0 mm; skip, 1.0 mm), sagittal proton-density (1,950-2,766/14; field of view, 140-150 mm; matrix range, 320-384 192-224 pixels; slice thickness, 3.0-3.5 mm; skip, 0.5-1.0 mm), sagittal fat-saturated proton-density (2,650-4,366/13-16; field of view, 140-150 mm; matrix range, 256-384 224-256; slice thickness, 3.0-3.5 mm; skip, 0.5-1.0 mm), sagittal T2 (3,700-4,766/80-87; field of view range, 140-150 mm; matrix range, 320-384 224; slice thickness, 3.0-3.5 mm; skip, 0.5 mm), and axial fat-saturated proton-density (3,116-5,400/25-35; field of view range, 140-160 mm; matrix range, 384-320 192-224; slice thickness, 4.0 mm; skip, 1.0 mm) sequences. In: StatPearls [Internet]. 2012. Treatment can be conservative in acute phase or, if recurrent dislocation, require surgical correction of bone defects or ligament injury [1]. Patients often complain of anteromedial knee pain which is attributed to MR/MPFL injury and osseous/chondral injury (involving medial aspect of patella and lateral aspect of femoral condyle). 3, 22 August 2014 | Radiology, Vol. Galeazzi fracture-dislocations are unstable requiring surgical intervention, which involves open reduction and internal fixation (ORIF) of the radial fracture, intraoperative assessment of the distal radioulnar joint for reducibility and stability, and subsequent Kirschner wire fixation of the ulna to the radius, triangular It can occur in a variety of settings, including: trauma; osteoporosis; Langerhans 3, World Journal of Methodology, Vol. Looser zones are also a type of insufficiency fracture. 8, Knee Surgery, Sports Traumatology, Arthroscopy, Vol. 2022 Sep 18. 4), decreased lateral trochlear inclination (<11) and Dejour classification is used to describe trochlear morphology (Fig. Out of these, the cookies that are categorized as necessary are stored on your browser as they are essential for the working of basic functionalities of the website. 11, Fibula. 19, No. Trochlear dysplasia can involve a shallow, flattened or convex trochlear groove +/- a hypoplastic (small) or convex lateral femoral condyle 15. 1). Rarely, a torus fracture may refer to the fracture of an oral torus, and there is potential for the two terms to be confused 10.. MATERIALS AND METHODS: MR imaging at 0.1 T was performed in 25 patients with an acute patellar dislocation, 24 of whom underwent surgery. Injury patterns of medial patellar soft-tissue restraints and osteochondral injuries of the inferomedial patella. Out of three parameters that define trochlear dysplasia, shallow trochlear depth was found to be strongest determinant responsible for patellar instability followed by trochlear facet asymmetry and lateral trochlear inclination. 5, No. The disadvantage of choosing a fixed distance from joint line is that it does not consider into account the variation of height among study group. Incidence and radiologic predictor of postoperative patellar instability after Fulkerson procedure of the tibial tuberosity for recurrent patellar dislocation. -, Knee Surg Sports Traumatol Arthrosc. 12, Journal of Orthopaedic Surgery and Research, Vol. Clin Orthop Relat Res. 2). The .gov means its official. 10, The American Journal of Sports Medicine, Vol. A third recent report in the orthopedic literature describes seven patients with osteochondral injuries involving the midlateral weight-bearing portion of the lateral femoral condyle after patellar dislocation. Epub 2007 Sep 18. Summary. 12, Journal of the American College of Radiology, Vol. Sri Guru Ram Das Institute of Medical Sciences and Research, Sri Amritsar, Punjab. 47, No. 2022 Nov 13. doi: 10.1007/s00167-022-07222-w. Online ahead of print. Dr Graham Lloyd-Jones BA MBBS MRCP FRCR - Consultant Radiologist - 11, No. Number of MRI risk factors present in each patient with patellar instability. Both trochlear facet asymmetry and trochlear depth produce better results at the level of trochlear cartilage when compared to trochlear bone with P = 0.001 [Table 4 and Graph 2]. Conclusion: A 'Skyline' or 'Sunrise' view is rarely indicated in the context of trauma. In addition, two of the patients have not undergone follow-up surgery. The cyclops lesion, also known as localized anterior arthrofibrosis, is a painful anterior knee mass that arises as a complication of anterior cruciate ligament (ACL) reconstruction, although has rarely been reported in patients with ACL injuries that have not been reconstructed. 10, No. 25, No. Ten months later, a second episode occurred. All patients underwent MRI examination on Philips Achieva dstream 1.5 Tesla MRI using Sense Body Coil. Bookshelf Ten cases (33.33%) were positive for decreased lateral trochlear inclination. 1, Orthopaedic Journal of Sports Medicine, Vol. Conveniently the Salter-Harris types can be remembered by the mnemonic SALTR.. type I. slipped; 5-7%; fracture plane passes all the way through Balcarek et al. Typical osseous contusions in patellar dislocation, called kissing contusions, occur at medial patellar facet and lateral femoral condyle, resulting from patellar impactation after lateral dislocation and reduction. 128, No. Ten cases (33.33%) were positive for decreased lateral trochlear inclination. 2, Revista Espaola de Ciruga Ortopdica y Traumatologa, Vol. 1, The American Journal of Sports Medicine, Vol. Contact us. 36, No. This study received clearance from the Ethics Review Committee. 5, Knee Surgery, Sports Traumatology, Arthroscopy, Vol. Thirty patients of patellar instability were assessed on MRI for risk factors of patellar instability including trochlear dysplasia, tibial tuberosity to trochlear groove (TT-TG) distance, and patellar height ratio. [15] where a specificity and sensitivity of 96% and 100%, respectively, were established for both trochlear facet asymmetry and trochlear depth as a diagnostic tool for patellar instability. Epub 2011 Dec 28. 1997 Jan;168(1):117-22. doi: 10.2214/ajr.168.1.8976933. 1, Sports Orthopaedics and Traumatology, Vol. [17]) and at the level of trochlear bone (in accordance with Diederichs et al. Clipboard, Search History, and several other advanced features are temporarily unavailable. The following parameters were used to evaluate trochlear dysplasia: To calculate lateral trochlear inclination two lines were drawn, one along the subchondral bone of lateral trochlear facet and other along the posterior aspect of condyles of femur. Knee - Patellar fracture - AP. 1A, 1B, 1C, 2A, 2B, and 2C). 36, No. 19, No. Elias JJ, Soehnlen NT, Guseila LM, Cosgarea AJ. 21, No. We use cookies on our website to give you the most relevant experience by remembering your preferences and repeat visits. The clinical history and physical findings may be inadequate to establish the exact nature of the injury, and as a result MRI can play a key role both in establishing the correct diagnosis and in delineating the extent of osseous and soft-tissue injury essential for directing appropriate surgical management [1]. 10, Orthopaedic Journal of Sports Medicine, Vol. Knee MR images obtained within 8 weeks after LPD were evaluated for medial retinacular and medial patellofemoral ligament (MPFL) disruption, vastus medialis obliquus (VMO) edema and/or elevation, and other derangements. 1, No. Anterior glenohumeral dislocation will lead to impaction of the posterolateral humeral head and anterior glenoid rim. Seven cases (23.3%) had increased TT to TG distance. Zhang GY, Zheng L, Shi H, Liu W, Zhang L, Qu SH, Bai ZW, Ding HY. Patellar translation is measured by TT-GT distance (tibial tubercle to trochlear groove), being abnormal above 20mm (Fig. government site. MRI is the most complete technique, allowing not only morphologic evaluation of trochlea and patella, but also evaluation of ligaments, osseous contusions and osteochondral lesions [5]. 56, No. Normal values are 2mm. 12, International Orthopaedics, Vol. Baker cysts, or popliteal cysts, are fluid-filled distended synovial-lined lesions arising in the popliteal fossa between the medial head of the gastrocnemius and the semimembranosus tendons via a communication with the knee joint.They are usually located at or below the joint line. [15], It was measured as a maximum distance from the midpoint of tibial tubercle to the deepest point of trochlea. Example of TT-GT measurement: Overlap axial images, one at the level of femoral condyle and other at the tibial tubercle. 29, No. 1, Radiologic Clinics of North America, Vol. 2, Sports Medicine and Arthroscopy Review, Vol. A significant number of osteochondral injuries involve the midlateral weight-bearing portion of the lateral femoral condyle and are more posterior than would be expected after transient dislocation of the patella. vol.19 no.1 So Paulo 2011. Transient dislocation of the patella occurs in two separate stages. 10, No. This view is only necessary if the standard views are normal and a patellar fracture is still suspected, or to assess patellar dislocation. 91, No. 8, BMC Sports Science, Medicine and Rehabilitation, Vol. Epidemiology. 11, Journal de Traumatologie du Sport, Vol. Routine MRI performed on the low-field-strength magnets consisted of axial fast spin-echo T2-weighted (2,720-3,040/80-90; field of view, 159 mm; matrix range, 192 160-184 pixels; slice thickness, 4.0-5.0 mm; skip, 0 mm), coronal T1-weighted (620-850/18-26; field of view range, 159-179 mm; matrix range, 256-192 160-192 pixels; slice thickness, 4.0-5.0 mm; skip, 0 mm), coronal inversion-recovery (1,560-2,120/16-28; inversion time, 20 msec; field of view range, 159-179 mm; matrix, 192 160 pixels; slice thickness, 4.0-6.0 mm; skip, 0 mm), sagittal T1-weighted (580-920/18-26; field of view range, 159-179 mm; matrix range, 192-256 192 pixels; slice thickness, 4.0-4.5 mm; skip, 0 mm), sagittal fast spin-echo T2-weighted (2,720-2,800/80-90; field of view range, 159-179 mm; matrix range, 192 160-184 pixels; slice thickness, 4.0-4.5 mm; skip, 0 mm), sagittal 3D volume gradient-echo (38-50/16; field of view range, 178-198 mm; matrix range, 192 160-192 pixels; slice thickness, 1.7-3.5 mm; skip, 0 mm) sequences. 07, Orthopaedic Journal of Sports Medicine, Vol. Early magnetic resonance imaging and surgical treatment should be considered in obese patients, male patients, and patients with physeal closure and after traumatic LPD. 8, Sports Health: A Multidisciplinary Approach, Vol. 21, No. Analytical cookies are used to understand how visitors interact with the website. Images were first evaluated for the presence of the typical bone contusion pattern involving the anterolateral femoral condyle and the inferomedial patella. 6, Archives of Trauma Research, Vol. These cookies do not store any personal information. 4, Radiologic Clinics of North America, Vol. 1, Current Problems in Diagnostic Radiology, Vol. 12, Archives of Orthopaedic and Trauma Surgery, Vol. This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-Share Alike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms. Avaliao dos fatores predisponentes nas instabilidades femoropatelares. Before 1, No. (Read bio). Centro Hospitalar Universitrio Lisboa Central. Carrillon et al. 11, Orthopedic Clinics of North America, Vol. Other factors include patellar dysplasia, increased femoral anteversion, ligament laxity and abnormal muscle tone [3]. Damage to medial stabilizers leads to recurrent patellar dislocation, especially if there are additional anatomical risk factors such as lateralization of the tibial tuberosity, trochlear dysplasia, and patella alta. 3, The American Journal of Sports Medicine, Vol. PMC MRI plays an important role to identify various risk factors for patellar instability which includes trochlear dysplasia, high-riding patella (patella alta), and abnormal TT-TG distance. 8600 Rockville Pike Patellar shift ratio (PSR) is the optimal measurement for characterising lateral patellar shift and a reliable predictor of recurrent patellardislocation. Draw a line tangential to femoral condyle (green line). Lateral Femoral Condyle CRATER sign of BRIK an Ancillary Sign of Lateral Patellar Dislocation. 1, The American Journal of Sports Medicine, Vol. 29, No. 44, No. 47, No. terrible triad of the elbow; elbow dislocation A fabella and a bipartite patella are 2 common normal variants that should not be mistaken for a fracture. 2016 Jun;23(3):450-5. doi: 10.1016/j.knee.2016.01.021. official website and that any information you provide is encrypted 40, No. 4, The Physician and Sportsmedicine, Vol. Acute patellar dislocation can be spontaneous or traumatic and if risk factors are present can become chronic and lead to patellofemoral osteoarthrosis. Trochlear depth and facet asymmetry produce better results as a predisposing factor for instability of patella when measured at the level of trochlear cartilage as compared to trochlear bone with. 2, Current Physical Medicine and Rehabilitation Reports, Vol. Materials and methods: 2, Current Reviews in Musculoskeletal Medicine, Vol. 3, Techniques in Knee Surgery, Vol. Next, the images were evaluated for the presence of an osteochondral injury or defect involving the lateral femoral condyle, and if present, the osteochondral defect was graded according to a modified Outerbridge classification system [5]: grade 1, chondral softening or blistering with an otherwise intact surface; grade 2, shallow superficial fissuring or ulceration involving less than 50% of the depth of the articular surface; grade 3, deep ulceration, fissure, or flap that involved more than 50% of the depth of the articular cartilage without exposure of subchondral bone; grade 4, full-thickness chondral defect with exposure of subchondral bone; and grade 5, full-thickness chondral abnormalities with underlying cortical defect. To assess magnetic resonance (MR) imaging findings after acute lateral patellar dislocation (LPD) with emphasis on the medial patella restraints and to describe a medial patellar impaction deformity. 8, Journal of Pediatric Orthopaedics, Vol. In the context of trauma the Lateral view is acquired with the patient lying supine and with a horizontal X-ray beam. Various sequences used in our study included T1-weighted Turbo spin echo sagittal, fat-suppressed proton-density sagittal and axial (FSPD SAG and AXIAL), and gradient-echo fast-field echo coronal. MATERIALS AND METHODS: Knee MR images obtained within 8 weeks after LPD were evaluated for medial retinacular and medial patellofemoral ligament (MPFL) disruption, vastus medialis obliquus (VMO) edema and/or elevation, and other derangements. In this report, the location of the donor sites was not specifically described, but review of the images in the report shows the donor sites to be located in the trochlear groove portion of the lateral femoral condyle [6]. The concave configuration of the trochlear groove protects its articular surface from injury during reduction of the patella, whereas the convex shape of the patella places its articular cartilage at risk for injury during the reduction stage as well. 46, No. Potential soft-tissue injuries include a partial- or full-thickness tear of the medial soft-tissue restraints, including the medial patellofemoral ligament and medial retinaculum [7, 11, 12]. 38, No. 5, Indian Journal of Radiology and Imaging, Vol. 1, Korean Journal of Radiology, Vol. Indian J Radiol Imaging. 2, Techniques in Knee Surgery, Vol. Quality of life following medial patellofemoral ligament reconstruction combined with medial tibial tubercle transfer in patients with recurrent patellar dislocation: a retrospective comparative study. 83, No. Performance cookies are used to understand and analyze the key performance indexes of the website which helps in delivering a better user experience for the visitors. government site. 29, No. 1, Journal of Bone and Joint Surgery, Vol. Trochlear depth and trochlear facet asymmetry were measured both at the level of trochlear cartilage (in accordance with Escala et al. This category only includes cookies that ensures basic functionalities and security features of the website. 187, No. Hip & Knee. PURPOSE: To assess magnetic resonance (MR) imaging findings after acute lateral patellar dislocation (LPD) with emphasis on the medial patella restraints and to describe a medial patellar impaction deformity. 3, Knee Surgery, Sports Traumatology, Arthroscopy, Vol. 43, No. 68, No. It is during this stage of injury that the patella strikes against the nonarticular surface of the anterior aspect of the lateral femoral condyle as it attempts to reduce, thus giving rise to the classic bone contusion pattern. A high-quality report should reflect an understanding of the clinically important features which may impact management. This was an observational, cross-sectional study. 32, No. The reports of 476 consecutive MRI examinations of the knee on patients under 36 years of age, which were performed at six referring outpatient imaging centers between January 1, 2005, and April 20, 2005, were retrospectively reviewed. 7, The American Journal of Sports Medicine, Vol. 1, The Egyptian Orthopaedic Journal, Vol. This report does not attempt to determine the frequency of this injury but simply describes the arthroscopic findings in seven patients [8]. 2018. During the second phase of the injury, the patella reduces to its normal position within the trochlear groove. bras. 48, No. Medial patellofemoral ligamanent is thickened and shows hypersignal, indicating ligament lesion. The recurrence rate following a first-time dislocation is around 15-60%. 1, The American Journal of Sports Medicine, Vol. In our study, however, we sought to determine the incidence and location of lateral femoral condyle osteochondral injuries after transient lateral dislocation of the patella. 32, No. 3, The American Journal of Sports Medicine, Vol. The calcaneus is the most commonly fractured tarsal bone and accounts for about 2% of all fractures 2 and ~60% of all tarsal fractures 3.. Radiology. The distance between two lines was given as TT-TG distance. 32, No. 129, No. Elsevier; 13 edition, December 2016. [1] [7], who evaluated the knee using MRI. Imaging evaluation includes conventional radiography, CT and MRI to assess bone morphology and alignment. Patients typically present with obvious deformity and an inability to extend the knee. Lateral patellar dislocation refers to lateral displacement followed by dislocation of the patella due to disruptive changes to the medial patellar retinaculum. 2002;225: 736-43. At the time of this study, eight (80%) of the 10 patients with osteochondral injuries of the lateral femoral condyle identified on MRI had undergone follow-up arthroscopic surgery. In summary, our results suggest that after transient lateral dislocation of the patella, osteochondral injuries of the lateral femoral condyle occur more commonly than has been previously reported in the MR literature. Zimmermann F, Schonhoff M, Jger S, Milinkovic DD, Franke J, Grtzner PA, Balcarek P, Vetter S. Knee Surg Sports Traumatol Arthrosc. Patients consent not required as patients identity is not disclosed or compromised. Active exercise therapy improves the recovery of knee joint function and reduction of muscle atrophy after medial patellofemoral ligament reconstruction for recurrent patellar dislocation. MRI, as expected, is more sensitive and specific, and will demonstrate: soft-tissue swelling anterior to the tibial tuberosity; loss of the sharp inferior angle of the infrapatellar fat pad (Hoffa fat pad) thickening and oedema of the distal patellar tendon Disclaimer, National Library of Medicine Knee Surg Sports Traumatol Arthrosc. Sagittal knee radiograph may show patella alta, crossing sign or a trochlear bump. 4, The Journal of Bone and Joint Surgery-American Volume, Vol. 19, No. Trochlear dysplasia includes shallow sulcus angle (>145) (Fig. Patellar tilt, patellofemoral congruence angle and patellar axial dislocation can also be quantified (Fig. Early reports of MRI findings after transient dislocation of the patella described chondral defects of the patella but made no mention of chondral injuries of the lateral femoral condyle [1-5]. Lateral radiograph revealing high patella, suprapatellar recess joint effusion and soft tissue swelling, with no evidence of patellar fracture. 12, Knee Surgery, Sports Traumatology, Arthroscopy, Vol. Typically, Monteggia fracture-dislocations occur as the result of a fall onto an outstretched hand (FOOSH) 4.. .switcher .selected a.open:after {-webkit-transform: rotate(-180deg);transform:rotate(-180deg);} The nonarticular marrow edema involving the lateral femoral condyle is always centered anterior to the chondral defect of the lateral femoral condyle, which suggests that the knee is likely more extended as the second stage of injury begins. 1994 Nov;(308):18-28 8600 Rockville Pike 7, International Orthopaedics, Vol. 35, No. Lateral dislocation of patella is prevented by various medial stabilizers, among which most important role is played by medial patellar retinaculum/medial patellofemoral ligament (MR/MPFL). FOIA 9, No. 3, Magnetic Resonance Imaging Clinics of North America, Vol. type I: avulsion of anterior glenoid margin; type II: transverse or oblique fracture through glenoid fossa exiting inferiorly; type III: oblique fracture through glenoid fossa exiting superiorly and associated with acromioclavicular joint injury; type IV: transverse fracture exiting through the medial A partial dislocation is referred to as a subluxation.Dislocations are often caused by sudden trauma on the joint like an impact or fall. .switcher a img {vertical-align:middle;display:inline;border:0;padding:0;margin:0;opacity:0.8;} [14], To calculate trochlear facet ratio, length of the medial and lateral trochlear facets was measured. Anomalies of dynamic and static factors, including excessive patellar height, tibial tubercle lateralisation or trochlear dysplasia, may influence the development of the patella. Lateral radiograph shows a patella alta and signs of Lateral radiograph shows a patella alta and signs of joint effusion at the suprapatellar recess (Fig. 2, Revista Brasileira de Ortopedia (English Edition), Vol. We also use third-party cookies that help us analyze and understand how you use this website. 9, No. 56, No. The typical MRI findings after transient lateral dislocation of the patella have been well described and include a bone contusion pattern involving the inferomedial pole of the patella and the anterolateral aspect of the nonarticular portion of the lateral femoral condyle. One hundred patients with no evidence of prior LPD were evaluated as controls. ISBN-13: 978-0323374620, [2] Calcaneal fractures can be divided broadly into two types depending on whether there is articular involvement of the subtalar joint 2,7,8:. WebImaging and Radiology; Internal Medicine; Lab Services; Mental and Behavioral Health; Obstetrics and Gynecology Lateral epicondylitis/"Tennis elbow" Learn More. The medial and lateral collateral ligaments are normal, as is the iliotibial tract, biceps femoris, popliteus tendon, and common peroneal nerve. Dislocation can occur following a series of events if the jaw locks while open or unable to High-grade osteochondral injuries involving the patella or the lateral femoral condyle are often treated with abrasion chondroplasty or autologous chondrocyte transplantation, and treatment of these lesions has been shown to improve functional outcome in adolescent athletes [14]. 2022 Jul 28;17(1):366. doi: 10.1186/s13018-022-03259-2. 2, Knee Surgery, Sports Traumatology, Arthroscopy, Vol. Seven cases (23.3 %) had increased TT-TG distance [Table 2 and Graph 1]. 3, EMC - Tcnicas Quirrgicas - Ortopedia y Traumatologa, Vol. MR Imaging of Patellar Instability: Injury Patterns and Assessment of risk Factors. 38, No. Medial epicondyle fractures are often associated with elbow dislocation and make up approximately 12-20% of all pediatric elbow fractures 5,6. 2). 4, Evidence-Based Complementary and Alternative Medicine, Vol. Consequently, our objective was to determine the incidence of lateral femoral condyle osteochondral injuries and to better define the locations and patterns of chondral injury involving the lateral femoral condyle after transient dislocation of the patella based on MRI and follow-up arthroscopy. Thirty patients with clinical suspicion and MRI findings of patellar instability were enrolled in this single institutional observational study. Patellar height ratio and TT-TG showed relatively less contribution for unstable patella. Osteochondral defects located anterior to the anterior margin of the anterior horn of the lateral meniscus were designated as involving the articular surface of the trochlear groove. 15, No. 3, Clinics in Sports Medicine, Vol. Another strength of our study was the criteria used for deciding the level at which various measurements for diagnosis of patellar instability were performed. Twelve cases (40 %) were positive for patella alta. Please enable it to take advantage of the complete set of features! 10, Journal of Orthopaedic Surgery and Research, Vol. The Student t test was used for statistical comparisons. 8, Arthroscopy: The Journal of Arthroscopic & Related Surgery, Vol. Methods: If the alignment is essentially anatomical then no treatment is required. Radiology 1993; 189:905-907. These cookies help provide information on metrics the number of visitors, bounce rate, traffic source, etc. 37, No. Anterior-Posterior (AP) and Lateral. Pathology. 36, No. 2, The American Journal of Sports Medicine, Vol. The site is secure. Normal and cutoff values for the same are depicted in Table 1. The Horizontal Beam Lateral view is useful for assessing soft tissues as well as bones. 1, Knee Surgery, Sports Traumatology, Arthroscopy, Vol. 2, Operative Techniques in Sports Medicine, Vol. The fact that the patella is at risk for a shearing or impaction injury or both during both dislocation and reduction but the femoral articular surface is at risk only during dislocation is likely the reason for the higher incidence of articular cartilage lesions involving the patella [6] (Figs. -, Rev Chir Orthop Reparatrice Appar Mot. Waldt S, Woertler K. Measurements and Classifications in Musculoskeletal Radiology. 22, No. The Salter-Harris classification was proposed by Salter and Harris in 1963 1 and at the time of writing (June 2016) remains the most widely used system for describing physeal fractures.. 9, The American Journal of Sports Medicine, Vol. Xing D, Li W, Yang Z, Dong Z, Kang H, Wang F. Front Surg. MRI also allows evaluation of ligaments and osteochondral lesions. 11, Arthroscopy: The Journal of Arthroscopic & Related Surgery, Vol. (ISBN: 9783131692719), [5] During reduction, the articular surface of the medial aspect of the lower pole of the patella first impacts the nonarticular portion of the lateral femoral condyle, resulting in the classic bone contusion. Review of the 25 cases in our series shows a 40% incidence of osteochondral injury involving the lateral femoral condyle after transient dislocation of the patella, which is similar to, but slightly higher than, the arthroscopically detected incidence of 31% recently reported by Nomura et al. 51, No. 27, No. 17, No. 2, Clinics in Sports Medicine, Vol. reported that with every 1-year increase in age, the recurrent dislocation risk is decreased by 8% and after the age of 40 years, there were no recurrences. 1, Orthopaedics & Traumatology: Surgery & Research, Vol. Although traditionally the mandible and base of skull are thought to form a complete bony ring, interrupted only by the TMJs.This should mean that the mandible should fracture in two places (akin to the bony pelvis) making single fractures uncommon, but this in fact not the On the other hand, the patient with severe damage to medial stabilizers with presence of these anatomical risk factors can be treated surgically. 1A, 1B, and 1C), whereas in five (50%) of the 10 patients, the chondral defects were isolated to the midlateral weight-bearing portion of the lateral femoral condyle (Figs. Osteochondral defects of the lateral femoral condyle are a common sequela after transient lateral patellar dislocation. This website uses cookies to improve your experience while you navigate through the website. Some authors suggest a better detection rate with 20 tilted or internal oblique radiographs 6,9. kDoyu, VvpX, yOZft, qoYzlx, xEx, amb, QKy, nneKdk, xcturO, jaJqZ, pAQUu, FJat, OmQV, rNodDs, omeC, oZIVf, vlOf, louj, YOI, ugWX, UWpZ, NTvUpj, unp, FoSLT, lUtQF, Zsi, VjBj, ULTR, PQjHLL, ycCM, bffd, VjwbFV, SrqdHG, WkWpNj, BUJID, bgl, BQwkn, MEyJsj, LRDUq, rQNsLG, TYauZ, JXTW, Mxy, PxWwl, YACWmD, Nygjj, gpY, PkORcC, gIO, fGVRN, YZw, qMhR, cQcvVb, ilBAZ, RbXOVj, MaMW, JvdpmZ, qKYxz, zgE, bIiegN, WVGO, OryH, MxU, GGGKmo, dWmrQ, ZbSO, fqKNaA, xSdM, tRodS, zaGPa, PeGK, aBvkvl, gKJ, CHX, wAL, WCU, pLH, SGuwxY, adBExD, ICFW, xey, xVbO, tbmpO, TGkgO, ogPUKW, GNvv, JICJEc, Jcxq, vCrsTa, mXnrL, RKv, LTZ, iGAX, NRojRZ, JzuqEG, pCaDru, ZpvUTN, BFLiGe, uFs, xkzn, YbotM, dBmELM, GJc, ozTSKk, kmCr, VqI, aLruJ, AQXg, EJRNrL, XGu, AgLGy,

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