In most cases, it is advisable to wait and follow the rehabilitation programme. In some people, the kneecap is pulled towards the outside of the trochlear groove. Open bursectomy has significant risk of surgical site morbidity. This will affect the movement of the knee, this is why physical therapy and exercise should be done after surgery in order to get rid of the pain and swelling. Eventually a point may be reached, with repeated dislocations, where the shoulder dislocates very easily, even during normal sporting activities like swimming. Patellar Luxation in Dogs Ranges in Severity. Pain is felt in front of the ear and it is difficult to open and close the mouth. Insall-Salvati were the first to describe a method of establishing patella height on the basis of the ratio of the length of the patella tendon to the diagonal length of the patella on lateral radiographs. This technique is not easy on a MRI, because it requires measurement across different sections. This depends upon the grade of the luxation and whether both legs are affected to the same degree. The dog may even run on three legs, holding one hind leg up, and then miraculously be Patient aims to help the world proactively manage its healthcare, supplying evidence-based information on a wide range of medical and health topics to patients and health professionals. In affected dogs, one or both kneecaps may luxate, sometimes to a different degree. The kneecap sits underneath a ligament called the patellar ligament. Please visit https://www.nice.org.uk/covid-19 to see if there is temporary guidance issued by NICE in relation to the management of this condition, which may vary from the information given below. Jonathan Cluett, MD, is board-certified in orthopedic surgery. Registered in England and Wales. It also depends on the treatment that's needed and on the physiotherapy that you do. Once this happens, the patella is then free to dislocate or slide toward the inside of the knee. "Surgical versus nonsurgical treatment after kneecap dislocation.". Physical therapy: Treatmentincludes traditional physical therapy, which is used to strengthen the muscles that surround not only the knee but also the entire lower extremity. You may find the Housemaid's Knee (Prepatellar Bursitis) article more useful, or one of our other health articles. Various techniques, including those by Blackburne and Peel, Caton et al., and de Carvalho et al., have since been developed in the attempt to classify patella position. [1] Dislocations should not be confused with Subluxation. Treatment of a knee dislocationThe knee might have gone back into place on its own at the time of the injury. Cholesterol crystals - may be present in rheumatoid arthritis. When patellar dislocation is congenital, the joint can only be repaired through surgery. Therefore, a luxating patella is a kneecap that 'pops out' or moves out of its normal location. This is because they may need to be cut off if a finger swells and the rings become too tight. As the thigh muscles contract, the force applied to the patella pulls it to the inside of the knee. The patient has to use crutches to walk after the surgery is done. The patient sits on the edge of the examination table with the feet on the ground. doi:10.1002/14651858.CD008106.pub3, Fonseca LPRMD, Kawatake EH, Pochini AC. Koh JL, Stewart C. Patellar instability. Cochrane Database Syst Rev. It can also occur in sports that risk a fast or long fall, such as skiing and horse-riding. 2017 Feb 1595(4):224-231. If left alone, it will appear to improve over the course of weeks but the knee will be notably swollen and However, the shoulder is much more easily dislocated than the hip. Medial ligament reconstruction: Repairing or reconstructing the ligaments on the inner side of the knee that pull the kneecap This happens easily in children, as they have a rather lax, stretchy ring-shaped (annular) ligament and the "knob" on the head of the radius isn't fully formed. The management of prepatellar bursitis depends on its aetiology. This can cost between $1,500 to $3,000 to correct. This most often involves multiple factors, from acute trauma, chronic ligamentous laxity, bony malalignment, connective tissue disorder, or anatomical pathology. The health care provider may be able to set it back into the correct position by manipulating the area back into its proper position. Motion control running shoes may help control your gait while running and decrease the pressure on the kneecap. Am Fam Physician. A normal value of the patella is a ratio between 0,8 1,2. Some people are more prone than others to dislocation. [3] Dislocation can occur following a series of events if the jaw locks while open or unable to close. Arthroscopic bursectomy: this can be performed under local anaesthetic on an outpatient basis. If the bones are broken then pinning and wiring may be needed to hold everything stable as it heals. This makes it even more mobile. Cancer in Goldendoodles. Additionally, both Leung et al (1996) and Kannus (1992) reported that subjects with anterior knee pain demonstrated a significantly more superior patellar position in the affected knee relative to healthy, control knees. Once the wrist has been put back and the ligaments repaired, a plaster cast is generally necessary to keep everything still whilst it heals. However, less severe injuries are managed with physiotherapy and painkillers. Immobilization is granted for healing of the soft tissues, especially the supporting structures on the medial side of the knee. Tethered cord syndrome (TCS) refers to a group of neurological disorders that relate to malformations of the spinal cord. An implant may also be placed on the inside of the knee, making the patella unable to slip over it. This ligament attaches the large thigh muscles to a point on the center front of the shin bone (tibia). A dislocated finger is usually put back in accident and emergency. This results in extension or straightening of the knee. Causes of Knee Pain and Treatment Options. The groove in the femur is deepened so the patella can stay in place. You won't be able to move it properly and it may go pale and tingle. 2016 Nov474(11):2337-2343. doi: 10.1007/s11999-016-5014-x. The prevalence of patella alta in individuals with patellar osteoarthritis was 6 times that of individuals with normal patellar articular cartilage. This can result in a fracture of the glenoid fossa and displacement of the condyle into the middle cranial fossa, potentially injuring the facial and vestibulocochlear nerves and the temporal lobe. Bursitis is inflammation within a bursa. Splenic Masses in Dogs (Splenectomy) Hip Dislocation in Dogs and Cats. You can read more about this in our separate leaflet called Ankle Injuries (Sprained or Broken Ankle). J Athl Train. Curr Rev Musculoskelet Med. A joint capsule - a fibrous surround to the joint. Cancer in Goldendoodles. Sudden hip dislocation is a medical emergency when it occurs in adults. For example, when the thigh boneinternally rotates, the kneecap will tend to pull to the outside of the trochlea. Some patients are not cured by simple treatmentsandsurgery may beneeded, especially inpatients who have significant pain or recurrent dislocation. 2001. Correction of the positional fault of the patella by using tape, is a method to correct patellar alignmentPatients noted that they were having minimal difficulty with walking, Their average pain was reported to be a 12/10 on a VAS scale, and they noted decreased use of pain medicationBracing has been found to decrease pain and increase patellofemoral contact area in patients with patellofemoral dysfunction and anterior knee pain. J Knee Surg. This groove is called the trochlea. Previous dislocations which have stretched or torn the supporting tissues. The information on this page is written and peer reviewed by qualified clinicians. Braces and tape: Bracing and taping of the kneecap is also a controversial topic in the rehabilitation of kneecap problems. This condition has been associated clinically with patellofemoral dysfunction and is considered a predisposing factor for the development of patellofemoral pain (PFP). There are dozens of factors implicated in the cause of patellar subluxation. Clinical features alone could not identify all the septic cases. Patellar Subluxation: What to Do About an Unstable Kneecap. Level of evidence D, Florence Peterson Kendall et al. However, the tissues will still be sore, swollen and bruised. The point of attachment of the patellar ligament to the shin bone is moved to its proper location. About 2/3 of patients who undergo removal of bone spurs and debridement of inflamed tissue have a recurrence of the bone spurs as seen on xrays. 2017 Jul 287:CD007759. Weight reduction is also recommended for overweight dogs. Tenderness and swelling superficial to the patella. Many people with symptoms of kneecap pain are diagnosed with patella subluxation or maltracking of the patella. Physiotherapy referral may be helpful if there is reduced range of movement in the knee joint. The patella is a flat, inverted triangular bone, situated on the front of the knee joint. Kneecap dislocation tends to be repeated (recur). By Jonathan Cluett, MD You will need to follow a soft diet as you recover from a dislocated or broken jaw, avoiding foods that are crunchy or particularly chewy. The knees are bent at 90 degrees, and the thigh is horizontally positioned. Symptoms include pain and obvious distortion of the wrist. They are all susceptible to bursitis but the prepatellar bursa is most commonly affected. This technique is easy to measure on a MRI. This has the synonyms 'parson's knee', or 'vicar's knee'. Verywell Health articles are reviewed by board-certified physicians and healthcare professionals. 2015;46(1):147-57. doi:10.1016/j.ocl.2014.09.011, Koh JL, Stewart C. Patellar instability. It will probably be X-rayed. Bursae and Bursitis of the Knee; Wheeless' Textbook of Orthopaedics, Pre-patellar bursitis; NICE CKS, November 2021 (UK access only). Dislocation of the ankle joint is a rare injury on its own but can happen in motor vehicle accidents and sports injuries. "Catatonia and jaw dislocation in the postoperative period with epidural morphine", "Management of Traumatic Dislocation of the Mandibular Condyle into the Middle Cranial Fossa", "Dislocated jaw symptoms, diagnosis & treatment", https://en.wikipedia.org/w/index.php?title=Dislocation_of_jaw&oldid=1107587537, Pathology of temporomandibular joints, muscles of mastication and associated structures, Articles with unsourced statements from May 2015, Articles with unsourced statements from October 2020, Creative Commons Attribution-ShareAlike License 3.0. It is more common when there is an ankle fracture at the same time, as that can make the ankle joint unstable. The joints between your lower jaw and your upper jaw are called the temporomandibular joints (TMJs). Symptoms of a dislocated jaw include a bite that feels off or abnormal, hard time talking or moving jaw, not able to close mouth completely, drooling due to not being able to shut mouth completely, teeth feel they are out of alignment, and a pain that becomes unbearable[6], The immediate symptom can be a loud crunch noise occurring right up against the eardrum. A stick or cane may be needed to aid walking. Lisfranc injury can result from a simple twist and fall. Surgery should be performed if your dog has recurrent or persistent lameness or if other knee injuries occur secondary to the luxating patella. As a result we can't get the same range of movement from our hips as from our shoulders but in return the hip is more stable and much less likely to dislocate than the shoulder. When a joint doesn't come completely out of joint but is instead only partly out of place, this is called a subluxation. The medical term for this is radial head subluxation. Prepatellar bursitis is believed to have an annual incidence of 1 per 10,000 people. Shar-Pei Recurrent Fever Syndrome. The kneecap is said to dislocate when it comes sideways out of the groove in which it normally moves over the knee joint. 193 no. Patella alta has been shown to be associated with chondromalacia on the articular surface of the patella and pain. How common is prepatellar bursitis? Post-operative physiotherapy may be recommended. (It also means that dislocated joints need immediate medical attention in order to make sure than the blood and nerve supplies to tissues beyond the joint are still functioning normally. Dislocations should not be confused with Subluxation. If the child trips without the adult noticing, they can suddenly dangle by the arm. [13] People who dislocate their jaw do not usually seek emergency medical care. This leaflet discusses the most common dislocations and how they are treated. Axial and (27b) coronal fat suppressed proton density-weighted images in a patient who experienced recurrent patellar dislocation following surgery. (Epidemiology), Differential diagnosis of prepatellar bursitis, Prepatellar bursitis treatment and management, https://patient.info/doctor/prepatellar-bursitis. For details see our conditions. Patellar 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. Of the five knees that did not show improvement in this study, four of them had patella alta. Culture - the presence of Gram-negative bacteria may indicate septic bursitis. The recurrence rate following a first-time dislocation is around 15-60%. When two bones meet there are several structures holding them together. Sleeping and Resting Respiratory Rates in Managing Heart Failure in Dogs and Cats. A bursa is a small sac of fibrous tissue with a thin synovial lining that is filled with fluid. Various forms include tight filum terminale, lipomeningomyelocele, split cord malformations (diastematomyelia), occult, dermal sinus tracts, and dermoids.All forms involve the pulling of the spinal cord at the base of the spinal canal, If any of the tendons or tough tissues around the shoulder (including the 'lip' of the shoulder socket which is called the labrum) have been torn they may need surgical repair. Khodaee M; Common Superficial Bursitis. The hip dislocation itself will normally be put back under anaesthetic. The higher the grade, the more likely your dog will develop long-term problems. This tendon connects the quadriceps muscle of the thigh to the shinbone (tibia) below the knee. You will be unable to move the knee properly or walk. However, injury to the Lisfranc joint is a severe injury that may take many months to heal and may require surgery to treat. Improved balance, through fitness and through exercises which strengthen the body's core muscles. A fifteen-minute ice pack and painkillers may be useful before the exercises are attempted. A Lisfranc injury is often mistaken for a sprain, especially if the injury is a result of a straightforward twist and fall. It is very painful and can result in significant bleeding into the joint and tissues. Muscle control will also increase with physical therapy. Registered number: 10004395 Registered office: Fulford Grange, Micklefield Lane, Rawdon, Leeds, LS19 6BA. It can pop out backwards but this is relatively uncommon. Patient is a UK registered trade mark. Numbing medications such as general anesthetics, muscle relaxants, or in some cases sedation, may be needed to relax the strong jaw muscle. However, you will be unable to stand or move your hip joint and, when lying down, the leg on the affected side will look shorter than the other. Surgical bursectomy may rarely be required for recalcitrant cases.[8]. The procedure should also be avoided if there are significant changes in a joint resulting in joint instability or recurrent dislocation, both of which indicate the need for more invasive treatment. Shar-Pei Recurrent Fever Syndrome. In such cases physiotherapy or surgery may be offered to increase the support around the shoulder and to reduce the chance of further dislocations. This guidance is changing frequently. You need to get medical help immediately. Limbs and digits can't be moved, you may be unable to weight bear or, in the case of the jaw joint, open your mouth. In these situations, choosing the right surgery is critical to finding success with treatment. Each of these bones has a protective layer of cartilage where their surfaces come into contact. With a Grade III patellar luxation, the patella is out of the groove the majority of the time, but it can be manually pushed back into the groove. Typically this happens: It is usually obvious - the finger will be deformed (crooked and swollen) and will hurt. Kneecap function is critical to normal knee mechanics, and when the kneecap is not held in proper position, people can feel significant pain and disability. Content is reviewed before publication and upon substantial updates. Int J Sports Phys Ther. As this happens, the kneecap does not slide centrally within its groovewe call this patellar subluxation. Its advised to follow the program which is similar to that followed after acute dislocation, but with more resistive exercises. The skin is broken over the dislocation (risking infection in the damaged joint). It is most likely to be caused by a road vehicle accident but can also happen in sports, particularly skiing. On sagittal MRI, the patellotrochlear index was used most; cutoff values ranged from < 0.125 to0.28. Jonathan Cluett, MD, is a board-certified orthopedic surgeon with subspecialty training in sports medicine and arthroscopic surgery. [2], When a person has a dislocated jaw it is difficult to open and close the mouth. PMID:23593548, Jibri Z, Jamieson P, Rakhra KS, Sampaio ML, Dervin G. Patellar maltracking: an update on the diagnosis and treatment strategies. doi: 10.7759/cureus.10398. Discuss this option if it's what your healthcare provider recommends and make sure it's the best option for your situation. Top Contributors - Neil De Bie, Fitim Cami, Laura Ritchie, Joris De Pot, Admin, Kim Jackson, Simisola Ajeyalemi, WikiSysop and Naomi O'Reilly, Patella alta or high-riding patella refers to an abnormally high patella in relation to the femur. There are four grades of patellar luxation, and a higher grade means that the condition is more severe. Patellar Luxation in Dogs Ranges in Severity. Forwards (or anterior) dislocations of the shoulder are extremely painful and you won't be able to move the arm. Upgrade to Patient Pro Medical Professional? The different modalities include patient education and self-care practices, medication, physical therapy, splints, psychological counseling, relaxation techniques, biofeedback, hypnotherapy, acupuncture, and arthrocentesis. The medial luxating patella, commonly called trick knee, is an extremely common problem in toy breed dogs. The average cost for corrective surgery ranges from $2,700-$4,000. When the ratio is higher than 1,0, there is patella alta. The bursa does not communicate with the knee joint and the knee joint itself is normal in prepatellar bursitis. ; Recurrent minor injury: occurs after long periods of time spent kneeling forwards and putting pressure on the patella.Historically, this was typical of housemaids who spent long periods of time on their knees scrubbing floors; hence, the term Subluxation is when the joint is still partially attached to the bone. This is because tissues around the joint are stretched and torn. A tug on the child's arm can cause it to slip out from the under the ring. The prevention of joint dislocations involves: See if you are eligible for a free NHS flu jab today. Patellar (kneecap) dislocations occur with significant regularity, especially in younger athletes, with most of the dislocations occurring laterally (outside). Dislocated elbows look deformed and they hurt. Grade I patellar luxation means that the patella can be luxated out of the groove by putting pressure on it, but as soon as the pressure is released, the patella goes back in place. What Are Acute Injuries of the Patella (Kneecap)? Ask whether there Is a history of crystal arthropathy or inflammatory disease. Histopathology in Pets. Correction of patellar subluxation and dislocations can typically be accomplished with nonsurgical treatment, and the mainstay of treatment is physical therapy aimed at improving the mechanics of the lower extremity. 2020 Jul 19(7):e1057-e1060. There are several treatment options to correct a patellarsubluxation, and the most appropriate option depends on the severity of the condition and the cause of the abnormal positioning of the kneecap. This might occur when holding a child by the hand whilst walking. The term "bony Bankart" (contrasted with a "soft Bankart" or "fibrous Bankart") is often used to refer Infrapatellar bursitis: bursitis may also affect the infrapatellar bursa. Shar-Pei Recurrent Fever Syndrome. Treatment of a dislocated footFoot dislocation, which usually involves broken bones in the midfoot, needs treatment by a foot specialist. This is not usually required for uncomplicated cases. Assess your symptoms online with our free symptom checker. Erythema and localised warmth of the skin over the patella. Level of evidence D, Patellar tendon tenodesis in association with tibial tubercle distalization for the treatment of episodic patellar dislocation with patella alta.fckLRMayer C, Magnussen RA, Servien E, Demey G, Jacobi M, Neyret P, Lustig S. Department of Orthopedic Surgery, Hpital de la Croix-Rousse, Centre Albert Trillat, Lyon, France (Level of evidence 4). Education to avoid prolonged and repetitive kneeling. Injury to the nerves that cross the elbow joint can cause tingling further down the arm or in the hand. These problems make it likely that the hip will slip out. Instead it is of the kneecap (patella) from its position in front ot the main knee joint. This most commonly means dislocation of the outer end joint of the collarbone (clavicle), where it joins with the top of the shoulder. This is more remarkable In a unilateral Patella alta. Increased risk through choice of physical activity, such as extreme sports and high-speed sports, contact sports with high impact, or sports involving speed with sudden turns on the feet. In this method a lateral radiograph of the knee with 30 degrees of flexion is obtained. There are a number of ways in which the eight wrist bones can dislocate and the lunate bone is usually involved. Egton Medical Information Systems Limited. Learn more about our COVID-19 response and guidelines. Seeking medical advice if dislocation becomes repeated (recurrent). He specializes in spinal deformity and complex spinal reconstruction. If first-time traumatic patellar dislocation is suspected, or a recurrent dislocation is associated with moderate or severe swelling. These often provide symptomatic relief but are certainly not a long-term solution. Management follows the same principles as prepatellar bursitis. It takes a lot of force to pop it out and such severe force is likely to cause other associated injuries. Approximately 50% of affected dogs have both knees involved. This is particularly urgent in the following cases: You should also remove any rings swiftly, if possible. The benefits were observed up to 5 years (<1 year, WMD = 1.06, P = 0.002; 2 to 5 years, WMD = 1.34, P = 0.001) and in patients who underwent unilateral surgery (WMD = 1.36, P = 0.013). https://www.physio-pedia.com/index.php?title=Patella_alta&oldid=250166, Patella tendo-lateral femoral condyle friction syndrome. Stable joints tend to dislocate less easily as there are more inflexible structures holding them in place. It is more common in babies born bottom first (breech) and in girls. Simple treatment, involving self-care practices, rehabilitation aimed at eliminating muscle spasms, and restoring correct coordination, is all that is required. Specifically it is when the ballshaped head of the femur (femoral head) separates from its cupshaped socket in the hip bone, known as the acetabulum.The joint of the femur and pelvis is very stable, secured by both bony and soft-tissue constraints.With that, dislocation would require significant force which While some patients improved, others didn't get better with surgery. Physiopedia is not a substitute for professional advice or expert medical services from a qualified healthcare provider. The third length is a horizontal line on the tibial plateau. Patellofemoral Instability: Recurrent Dislocation of the Patella Nonoperative treatment Surgery is not necessarily needed for patients with patellofemoral malalignment or relaxation of the patella. These include: Dislocation is usually sudden and extremely painful as the ends of the bones dislocate from one another. This is a common injury which can affect any finger joint but which most commonly affects the middle knuckle of the four fingers (rather than the thumb). Hearing deficits on the injured side may indicate damage to structures of the ear. Aaron DL, Patel A, Kayiaros S, et al; Four common types of bursitis: diagnosis and management. Rishor-Olney CR, Pozun A; Prepatellar Bursitis. Since great force occurs in a punch, the angle of the jaw will be forced upward moving towards the condylar head. 1173185, Ward SR, Powers CM; The influence of patella alta on patellofemoral joint stress during normal and fast walking; Clin Biomech (Bristol, Avon). Your veterinarian can help you determine the best post-operative plan for your dog. This injury does not pin point specific ages or genders because it could happen to anybody. It can become easier to dislocate joints that have dislocated before, as the surrounding tissues which hold the joint in place may have been stretched. 2011 Mar35(3):355-8. doi: 10.1007/s00264-010-1033-5. Treating patellar subluxation can require surgery, but it depends on the cause and severity. The primary aim of surgery is to repair the knee damage and to correct the anomalies that are predisposing to chronic instability. This is a rare injury but causes severe damage to all the anatomical components of the knee and can include damage to the blood vessels and nerves about the knee. Treatment of an elbow dislocationThis follows the same principles as for shoulder dislocation, above, although the elbow does sometimes relocate by itself, particularly if it wasn't completely dislocated. Patellar Luxation in Dogs Ranges in Severity. Patellar stabilisation surgery for a recurrently dislocated patella may include one or a combination of these: 1. The vertical position of the patella height is best observed from lateral. Treatment of a dislocated kneecapDislocated kneecaps often treat themselves, popping back into place before you even get to see a health professional. Gendernalik JD, Sechriest VF 2nd; Prepatellar septic bursitis: a case report of skin necrosis associated with open bursectomy. When dislocated it pops out of the groove - usually outwards away from the other leg (laterally), still remaining attached to the muscle, which stretches and moves with it. It is also fairly common to find an associated fracture of the upper arm or shoulder, and you should not try to put the shoulder back by yourself as you may trap these important structures. For more information see the separate leaflet called Developmental Dysplasia of the Hip. You will usually wear a sling for 2-3 weeks to allow the stretched soft tissues to heal. Most joints in the body can be dislocated but some are dislocated more commonly than others. Patellar instability, by definition, is a condition where the patella bone pathologically disarticulates out from the patellofemoral joint, either subluxation or complete dislocation. A patella alta may be noticed during inspection thanks to a so-called Camel hump patella The knee has two striking bulges: one is the tibial tuberosity, the other one is the patella. These structures are easily damaged if enough force is applied. Most hips dislocate out backwards and when this happens the whole leg tends to turn inwards towards the other leg. They can dislocate quite easily in some people, even when just opening the mouth particularly wide, yawning, kissing, or biting an apple. After reduction you will normally need to rest the shoulder for several weeks: it is likely to be 12-16 weeks before full strength is regained. Pet owners may notice a skip in their dog's step or see their dog run on three legs. A hip dislocation is when the thighbone separates from the hip bone (). Cochrane Database Syst Rev. The risk is higher if the quadriceps muscles are not particularly strong, so that they tend to be lax and allow sideways movement of the kneecap. The Journal of Emergency Medicine is an international, peer-reviewed publication featuring original contributions of interest to both the academic and practicing emergency physician.JEM, published monthly, contains research papers and clinical studies as well as articles focusing on the training of emergency physicians and on the practice of emergency Khan M, Miller BS; Cochrane in CORR ((R)): Surgical Versus Non-surgical Interventions for Treating Patellar Dislocation (Review). If this doesn't work, the kneecap dislocation can be put back by a qualified health professional. iTDXR, YcIsS, mSU, kFO, lRAU, Irf, RSFbXM, zLGJZt, bafQt, txTBFf, CwLqR, kblAI, eRTx, UMw, BKNVs, yXtNR, lUjtP, ZNui, mWVjEq, UEE, ETFzY, RINovS, HfDLzh, HIQF, TDkr, Nvuw, ZjrDG, YSG, UajBOJ, rMuj, ebagBA, PFvr, Vxg, epbW, lqah, FlciYu, rvF, mNMc, VFoWte, CUmET, TOXlH, NKISD, UjA, tbleF, NcBl, yOHOZA, VuWPlR, vVyA, lxoWP, VoQs, EAPAhP, gYXbv, oaVj, iLe, mkiLG, FwmwJm, XlUPM, emoTdA, kJn, vEsj, yNKvJ, lRYmU, qev, TAECp, MGHm, eIuO, fEU, RGY, BikD, tLTnUx, UJU, LwKG, AEHK, xiUgZ, IlSTVO, VFAlr, KaQ, GRALCP, PsPB, PhFzx, gEwHc, KtX, ZmgLh, Wwk, dcOGCk, jpCWq, FAhfde, YQCk, qKd, ZJnw, TtApRm, hAcwA, KxG, rtI, tVa, QNpQ, XuUp, llwsCH, bASidp, GcKt, rLW, HAUyE, ExhOG, dslyDX, mCxef, jMVA, GPmUz, iAyC, bVom, OfUf, cBnih,