In the quadruped stifle joint (analogous to the knee), based on its anatomical position, it is also referred to as the cranial cruciate ligament. Center for Foot and Ankle Restoration accepts majority of insurances. AAOS does not endorse any treatments, procedures, products, or physicians referenced herein. [16], USA Baseball, Major League Baseball and Little League Baseball have initiated the Pitch Smart program designed to lower the risk of elbow injuries in adolescent pitchers. Problems with knee instability in the weeks and months following PCL injury are not as common as instability following an ACL tear. The article Anterior Cruciate Ligament (ACL) Injury: Does It Require Surgery? Content is reviewed before publication and upon substantial updates. [1], The ulnar collateral ligament (UCL) can become stretched, frayed or torn through the repetitive stress of the throwing motion. This will depend on several factors, such as the severity of your injury and your activity level. In humans and other primates, the knee joins the thigh with the leg and consists of two joints: one between the femur and tibia (tibiofemoral joint), and one between the femur and patella (patellofemoral joint). It has been proposed that this is due to differences in physical conditioning, muscular strength, and neuromuscular control. Cruciate ligaments. Toe, Foot, and Ankle Problems, Noninjury. The rehabilitation process following surgery is typically divided into four separate phases. Prop 30 is supported by a coalition including CalFire Firefighters, the American Lung Association, environmental organizations, electrical workers and businesses that want to improve Californias air quality by fighting and preventing wildfires and reducing air pollution from vehicles. Surgical reconstruction of the PCL is controversial, and usually only recommended for grade III PCL tears. Interestingly, it is thought that PCL injuries account for up to 20 percent of knee ligament injuries, however, the PCL is seldom talked about because these injuries are often left undiagnosed.. PCL tears can be associated with other knee ligament injuries, including ACL tears, MCL tears, and LCL tears. We are proud to employ our own full time certified Orthotic Fitter, Richard Penn. Patients are generally able to walk normally twelve weeks after their surgery, and are also able to resume high impact sports activities. As of April 2015, the average amount of time between procedures is 4.97 years. The practice has a frontline presence in the field of foot and ankle surgery, with expertise in treating such conditions as Achilles tendon injuries, arthritis, flat feet, hammertoe, bunions, fractures, and ankle sprains. When patients have instability after a PCL injury they usually state that they can't "trust" their knee, or that it feels as though the knee may give out. Jason DelCollo, DO, is board-certified in family medicine and on the faculty of Philadelphia College of Osteopathic Medicine. PCL injuries are also commonly seen with severe trauma that can cause injury to many knee structures. During phase 3 (weeks nine to 13), the rehabilitation is focused on flexibility and neuromuscular control with a progression toward sports-related activities. When there is less deformity, the location of pain and X-rays help the doctor make the diagnosis. Anterior Cruciate Ligament (ACL) Surgery. They work and I have avoided foot surgery! Patients at Center for Foot and Ankle Restoration has access to their Patient Portal online. Antineoplastons (PDQ): Integrative, alternative, and complementary therapies - Health Professional Information [NCI] Tissue Flap Surgery for Breast Reconstruction. Illustration shows the normal bony anatomy of the shoulder area. The official journal of the American Physical Therapy Association. Players typically begin throwing about 16 weeks after surgery. If ignored, the swelling and pain may go away on its own. Anthrax. Click on the button below to discover the power of LIPOGEMS. By offering patients custom care on-site, it eliminates the need for patients to make multiple visits to multiple facilities. They act like strong ropes to hold the bones together and keep your knee stable. Anthrax. One of the most common knee injuries is an anterior cruciate ligament (ACL) sprain, or tear. [11] After one week, a brace is employed to protect the reconstruction for about six weeks following surgery. TO. Toe, Foot, and Ankle Injuries. A Grade 2 sprain stretches the ligament to the point where it becomes loose. A surgeon might recommend trimming back the end of the collarbone so it does not rub against theshoulder blade bone (acromion). X-rays and MRIs are also helpful in clarifying the diagnosis and detecting any other structures of the knee that may be injured. Read our, 6 Things That Can Make Your Knee Give Out, Posterolateral Rotatory Instability of the Knee, Determining the Need for Surgery When You Feel Better Post-ACL Tear, Surgery Treatments for Knee Pain and Injuries, Isolated posterior cruciate ligament tears: an update of management, Posterior cruciate ligament: current concepts review, Posterior cruciate ligament injuries: evaluation and management. If the PCL is deficient or torn, the tibia will slide too far backward, and indicate an injury to the PCL. Grade II: Isolated, complete tear to the PCL. Pain with swelling. The ligament has been torn in half or pulled directly off the bone, and the knee joint is unstable. It is common to find other ligament injuries or cartilage damage when a PCL tear is found. Its most often done as an outpatient surgery, so you can go home the same day. Copyright 1995-2021 by the American Academy of Orthopaedic Surgeons. For more information:Anterior Cruciate Ligament (ACL) Injuries - Clinical Practice Guideline | American Academy of Orthopaedic Surgeons (aaos.org). They can also be found with complex ligament injury patterns such as posterolateral rotatory instability. Posterior cruciate ligament injuries: evaluation and management. By Jonathan Cluett, MD Along with the ACL which keeps the tibia from sliding too far forward, the PCL helps to maintain the tibia in a position below the femur (thigh bone). If the force is severe enough, the ligaments attaching to the underside of the clavicle are torn. 2017;2(4):8996. [7], Jobe has stated that if he had invented the technique 10 years earlier, it might have been nicknamed Sandy Koufax surgery, after Dodgers hall of famer Sandy Koufax, who retired with "essentially the same thing as Tommy John. A shoulder separation is not truly an injury to the shoulder joint. You can opt-out at any time. EFORT Open Rev. The injury actually involves the acromioclavicular joint (also called the AC joint). We are ready to care for you and your family in our hospitals, surgery centers, and through in-person clinic and online video visits. This level of convenience is another reason the Center for Foot and Ankle Restoration is considered a standout practice. The Center for Foot and Ankle Restoration offers LIPOGEMS. Magnetic resonance imaging (MRI) scan. The most common mechanism of injury of the PCL is the so-called "dashboard injury." A mild shoulder separation involves a sprain of the AC ligaments that does not move the collarbone and looks normal on X-rays. I am also glad that I found the Center for Foot, Whatever service they are treating you for, you cant go wrong in their hands, They are very knowledgeable and experts with feet! About half of all injuries to the anterior cruciate ligament occur along with damage to other structures in the knee, such as articular cartilage, meniscus, or other ligaments. [14], Over the past two decades, the number of UCLR surgeries has increased threefold, a rate that is expected to rise in upcoming years. Ankle fracture surgery: If you have fractured bones in your ankle (a broken ankle), surgery can stabilize the breaks and help the bone heal. Cosgarea AJ, Jay PR. Nonsurgical treatments, such as a sling, cold packs, and medications can effectively help manage the pain in almost all patients. Compared to athletes who play other sports, baseball players are at elevated risk of overuse injuries and injuries caused by early sports specialization among children and teenagers. You may begin driving at 6-8 weeks if surgery on right foot, automatic transmission only for left post op; Use a lace up ankle brace for any cutting sports or uneven surfaces for 6 months following surgery; At 8 to 12 weeks post-op you may begin swimming and gently begin an elliptical trainer; progress to advanced strengthening as tolerated For example, a young athlete involved in agility sports will most likely require surgery to safely return to sports. This causes the separation of the collarbone and the shoulder blade. Our multidisciplinary approach to care makes us uniquely able to provide comprehensive care for both routine and complex foot and ankle problems. Jonathan Cluett, MD, is a board-certified orthopedic surgeon with subspecialty training in sports medicine and arthroscopic surgery. The knee is a modified hinge joint, which permits flexion and extension as well as slight internal and external rotation. "[22], Surgical procedure in which an elbow ligament is replaced with a donor tendon, Fleisig, G.S., The biomechanics of baseball pitching, in, Learn how and when to remove this template message, List of baseball players who underwent Tommy John surgery, "The post-Tommy John surgery calculus that is changing the game", "Fit Young Pitchers See Elbow Repair as Cure-All", "Tommy John surgery/UCL reconstruction (graphic surgical video)", "Dr. Frank Jobe, Tommy John and the Surgery That Changed Baseball Forever", "State of the Union on Ulnar Collateral Ligament Reconstruction in 2020: Indications, Techniques, and Outcomes", "Management of Ulnar Collateral Ligament Injuries in Overhead Athletes", "Prevention of elbow injuries in youth baseball pitchers", "A year of rehab for Tommy John patients", "Dr. Frank Jobe: 'It could have been Sandy Koufax surgery', Anterior cruciate ligament reconstruction, https://en.wikipedia.org/w/index.php?title=Ulnar_collateral_ligament_reconstruction&oldid=1112505245, Short description is different from Wikidata, Articles needing additional references from September 2022, All articles needing additional references, Articles with unsourced statements from September 2022, Creative Commons Attribution-ShareAlike License 3.0, UCL reconstruction, Tommy John surgery (TJS). The kneecap sits in front of the joint to provide some protection. Most patients, even with very severe injuries, are often managed effectively without surgery. A more serious injury tears the AC ligaments and sprains or slightly tears the coracoclavicular (CC) ligament, putting the collarbone out of alignment to some extent with a smaller bump. Published 2017 Apr 27. doi:10.1302/2058-5241.2.160009. Facing the table, slowly bend your knee about 45 degrees against the resistance of the tubing. Toe, Foot, and Ankle Problems, Noninjury. They cross each other to form an X, with the anterior cruciate ligament (ACL) in front and the posterior cruciate ligament (PCL) in back. A more serious injury tears the AC ligaments and sprains or slightly tears the coracoclavicular (CC) ligament, putting the collarbone out of alignment to some extent with a smaller bump. The knee is made up of four main things: bones, cartilage, ligaments, and tendons. There are four primary ligaments in your knee. The Journal of Foot & Ankle Surgery is the leading source for original, clinically-focused articles on the surgical and medical management of the foot and ankle. The red arrow points to the ligaments that are around the joint itself, called the AC ligaments. In this injury, the knee is hyper flexed (bent all the way back), with the foot held pointing downwards. Within 24 hours, your knee will swell. Once these symptoms have settled, physical therapy is beneficial to improve knee motion and strength. The anterior cruciate ligament (ACL) is one of a pair of cruciate ligaments (the other being the posterior cruciate ligament) in the human knee.The two ligaments are also called "cruciform" ligaments, as they are arranged in a crossed formation. Learn more: Vaccines, Boosters & Additional Doses | Testing | Patient Care | Visitor Guidelines | Coronavirus. About Our Coalition. Hello, and welcome to Protocol Entertainment, your guide to the business of the gaming and media industries. Specific treatment options are discussed, and the patient has the opportunity to get their questions answered. Knowing the story of the injury (for example, the position of the leg and the action taking place) will help in making the diagnosis. Generally, surgical PCL reconstruction is reserved for patients who have injured several major knee ligaments, or for those who cannot do their usual activities because of persistent knee instability. For a consultation or to receive a superior foot and ankle care, call today for an appointment. I would recommend this practice, I had surgery by Dr. Noack in 2015 for my unstable ankle and it's the best decision I made. Antineoplastons (PDQ): Integrative, alternative, and complementary therapies - Health Professional Information [NCI] Tissue Flap Surgery for Breast Reconstruction. If you have injured your ACL, you may require surgery to regain full function of your knee. As a result, orthopedic surgeons have reported that parents of young pitchers have asked them to perform the procedure on their uninjured sons in the hope that it will increase performance. About OrthoInfoEditorial Board Our ContributorsOur Subspecialty Partners Contact Us, Privacy PolicyTerms & Conditions Linking Policy AAOS Newsroom Find an Orthopaedist. All material on this website is protected by copyright. Some baseball pitchers believe that they can throw harder after ulnar collateral ligament reconstruction than they did beforehand. The red arrow points to the joint that comes apart in a shoulder separation injury. These operations can be done arthroscopically or open, with a plate or without. These types of injuries stress the PCL, and if the force is high enough, a PCL tear can be the result. Often these more severe patterns of injury occur with a knee dislocation. Find more COVID-19 testing locations on Maryland.gov. The most severe shoulder separation completely tears both the AC and CC ligaments and puts the AC joint noticeably out of position, with a larger bump. The most common cause for a separation of the AC joint is from a fall directly onto the shoulder. Most ligament injuries can be diagnosed with a thorough physical examination of the knee. Trying to place a new PCL graft in this position is difficult, and over time these grafts are notorious for stretching out and becoming less functional. [19] By 2009, the odds of complete recovery had risen to 8592%.[20]. Along with being the Editor-in-Chief of the Journal of Vascular Surgery, he is a Section Editor of Rutherfords Textbook of Vascular Surgery. The posterior cruciate ligament (PCL), is one of four ligaments important to the stability of the knee joint. Grade 3 Sprains. [5] A 2016 study explained 22% of the variation in those needing ulnar collateral ligament reconstruction, identifying handedness, standard deviation of release point, days lost to arm and shoulder injuries, previous ulnar collateral ligament reconstruction, number of hard pitches, ERA- and age as the known risk factors. These are found inside your knee joint. These are found on the sides of your knee. ; The less common medial ankle sprain is caused by an eversion injury (the foot turns out) to the deltoid ligament on the inside of the ankle. This is often referred to as a partial tear of the ligament. Tendons are the soft, band-like tissues that connect muscles to bone. Inversion-type, lateral ligament injuries represent approximately 85% of all ankle sprains. They control the side-to-side motion of your knee and brace it against unusual movement. A Grade 2 sprain stretches the ligament to the point where it becomes loose. Injury was founded in 1969 and is an international journal dealing with all aspects of trauma care and accident surgery.Our primary aim is to facilitate the exchange of ideas, techniques and information among all members of the trauma team. TO. Arch Bone Jt Surg; 6(1):818. This occurs when the knee is bent, and an object forcefully strikes the shin backward. Injured ligaments are considered sprains and are graded on a severity scale. Northwell Health is New York's largest healthcare provider, serving NYC, Long Island and Westchester with compassionate care through research and innovation. There was only a weak correlation between throwing mechanics perceived as bad and injury-prone. Before his surgery, John had won 124 games. [13] Early attempts at UCL repair yielded poor results and were largely abandoned until anchor fixation was improved in 2008.[13]. However, an MRI is usually not required to make the diagnosis of a torn ACL. The grade is determined by the extent of laxity measured during your examination. Anyone seeking specific orthopaedic advice or assistance should consult his or her orthopaedic surgeon, or locate one in your area through the AAOS Find an Orthopaedist program on this website. Abnormal contact between the bone ends when the joint is in motion, Injury to the cartilage between the clavicle and acromion. Partial tears of the anterior cruciate ligament are rare; most ACL injuries are complete or near complete tears. Rotator Cuff and Shoulder Conditioning Program, Rotator Cuff and Shoulder Rehabilitation Exercises. One of the most common denominators among virtually all pitchers is "reaching back" with the throwing arm prior to release and follow-through. Reconstruction: For reconstruction surgery, a surgeon will repair the torn ligament with stitches. The goal is to repair the loose lateral ligaments. This may be due to: It is often worthwhile to wait and see if reasonable function returns without surgical treatment. [citation needed], Increasingly often, pitchers require a second procedure after returning to pitching. About OrthoInfoEditorial Board Our ContributorsOur Subspecialty Partners Contact Us, Privacy PolicyTerms & Conditions Linking Policy AAOS Newsroom Find an Orthopaedist. ; Sprains can range from tiny tears in the Grade 3 Sprains. We are vaccinating all eligible patients. AAOS does not endorse any treatments, procedures, products, or physicians referenced herein. The shoulder blade (scapula) moves downward from the weight of the arm, creating a bump or bulge above the shoulder. The fall injures the ligaments that surround and stabilize the AC joint. The practice has a frontline presence in the field of foot and ankle surgery, with expertise in treating such conditions as Achilles tendon injuries, arthritis, flat at the Center for Foot and Ankle Restoration include total ankle replacement, platelet-rich plasma (PRP) injections, ligament reconstruction, shockwave therapy, and Lipogems. The PCL keeps the shinbone from moving backward too far. Because of the technical difficulty of the surgery, some orthopedic surgeons do not see the benefit of PCL reconstruction. The procedure is common among collegiate and professional athletes in several sports, particularly in baseball. This information is provided as an educational service and is not intended to serve as medical advice. The following article provides in-depth information about anterior cruciate ligament injuries. Normal knee anatomy. Bones are connected to other bones by ligaments. Three bones meet to form the knee joint: the femur (thighbone), tibia (shinbone), and patella (kneecap). In addition, PCL injuries may be associated with meniscus tears and cartilage damage. The surgery is performed under a general anesthetic or spinal block and takes 1-2 hours. An ankle sprain is where one or more of the ligaments of the ankle are partially or completely torn. The other common mechanism of injury is a sports injury when an athlete falls on the front of their knee. This type of sprain is most commonly referred to as a complete tear of the ligament. The anterior cruciate ligament runs diagonally in the middle of the knee. This information is provided as an educational service and is not intended to serve as medical advice. Our website is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Other suggested causes include differences in pelvis and lower extremity (leg) alignment, increased looseness in ligaments, and the effects of estrogen on ligament properties. This Friday, were taking a look at Microsoft and Sonys increasingly bitter feud over Call of Duty and whether U.K. regulators are leaning toward torpedoing the Activision Blizzard deal. For any coverage-related questions, please reach out to the practice today. Simply raising the pitching arm and bringing it forward with a complete follow-through produces the same levels of spin rate, velocity, movement and location while helping to protect the UCL from unnecessary injury. 2022 Dotdash Media, Inc. All rights reserved. Treatment for an ACL tear will vary depending on the patient's individual needs. These medical reviewers confirm the content is thorough and accurate, reflecting the latest evidence-based research. [11] A harvested tendon, such as the palmaris tendon[12] from the forearm of the same or opposite elbow, the patellar tendon, hamstring, toe extensor or a donor tendon (allograft), is then woven in a figure-eight pattern through the holes and anchored. Knee pain, swelling and decreased motion are common with both injuries. Topics covered include: trauma systems and management; surgical procedures; epidemiological studies; surgery (of Brostrom ankle surgery is a reconstruction of one or more lateral ankle ligaments. Whether treated nonsurgically or with surgery, the shoulder will require rehabilitation to restore and rebuild motion, strength, and flexibility. provides in-depth information about treatment for ACL injuries and is recommended as a follow-up to this article.. One of the most common knee injuries is an anterior cruciate ligament (ACL) sprain, or tear. Verywell Health's content is for informational and educational purposes only. [10] Jobe believed that, rather than allowing pitchers to gain speed, the surgery and rehab protocols merely allow pitchers to return to their pre-injury levels of performance. Verywell Health uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. Verywell Health articles are reviewed by board-certified physicians and healthcare professionals. The articleAnterior Cruciate Ligament (ACL) Injury: Does It Require Surgery? If this complaint of instability is a problem after a PCL injury, it may be an indication to proceed with surgery. The initial operation, John's successful post-surgery career, and the relationship between the two men was the subject of a 2013 ESPN 30 for 30 documentary. It is called a 'dashboard injury' because this can be seen in car collisions when the shin forcefully strikes the dashboard. This is often referred to as a partial tear of the ligament. All rights reserved. The ligament has been torn in half or pulled directly off the bone, and the knee joint is unstable. For more details, see our Privacy Policy. The medial collateral ligament (MCL) is on the inside, and the lateral collateral ligament (LCL) is on the outside. Grade 1 Sprains. The anterior cruciate ligament can be injured in several ways: Several studies have shown that female athletes have a higher incidence of ACL injury than male athletes in certain sports. The cruciate ligaments control the front and back motion of your knee. It has been slightly stretched but is still able to help keep the knee joint stable. Screws, metal plates, and small metal wires may hold the broken bone in place during healing. These are found inside your knee joint. from the American Academy of Orthopaedic Surgeons. [11] The ulnar nerve is usually moved to prevent pain, as scar tissue can apply pressure to the nerve. All material on this website is protected by copyright. The most common symptoms of a PCL tear are quite similar to the symptoms of an ACL tear. [6], In younger athletes whose epiphyseal plate (growth plate) is still open, the force on the inside of the elbow during throwing is more likely to cause the elbow to fail at this point than at the ulnar collateral ligament. In general, grading of the injury corresponds to the following: Treatment of PCL tears is controversial, and, unlike the treatment of an ACL tear, there is little agreement about the optimal treatment for all patients. Initial treatment of the pain and swelling consists of the use of crutches, ice, and elevation. Rehabilitation phase 1 (postoperative weeks zero to three) consists of prevention of stiffness, promotion of healing and simultaneous protection of the reconstructed graft with a hinged elbow brace. Most people with this injury even professional athletes return to normal function with nonsurgical treatments, even if there is a persistent, significant deformity/bump. Posterior Cruciate Ligament Tears and Treatment. It is the largest joint in the human body. Ulnar collateral ligament reconstruction, colloquially known as Tommy John surgery (TJS), is a surgical graft procedure where the ulnar collateral ligament in the medial elbow is replaced with either a tendon from elsewhere in the patient's body, or with one from a deceased donor. Athletes who participate in high demand sports like soccer, football, and basketball are more likely to injure their ACL. Posterior cruciate ligament: current concepts review. Jonathan Cluett, MD, is board-certified in orthopedic surgery. [citation needed], Research into throwing injuries in young athletes has led to age-based recommendations for pitch limits. This website also contains material copyrighted by third parties. A Grade 2 sprain stretches the ligament to the point where it becomes loose. The most reliable is the posterior drawer test. Anterior cruciate ligament reconstruction (ACL reconstruction) is a surgical tissue graft replacement of the anterior cruciate ligament, located in the knee, to restore its function after an injury. This website also contains material copyrighted by third parties. Citations may include links to full text content from PubMed Central and publisher web sites. For more details about recovering from ankle ligament reconstruction surgery, read our downloadable patient information leaflet. Click on the button below to explore frequently performed procedures by the orthopedic surgeons at Center for Foot and Ankle Restoration. [17] The main risk factors for elbow injury from overhand throwing include number of pitches per game, innings pitched per season, months pitched per year and poor pitching biomechanics that may increase torque and force on the elbow. It is named after the first baseball player to undergo the surgery, major league pitcher Tommy John, whose record of 288 career victories ranks seventh among left-handed pitchers. If you would like to re-order orthotics, email Richard Penn directly by clicking below. However, if you attempt to return to sports, your knee will probably be unstable, and you risk causing further damage to the cushioning cartilage (meniscus) of your knee. [12] The procedure is performed on an outpatient basis allowing discharge the same day, with the arm in a splint to protect the repair for the first week. Sometimes having the patient hold a weight in the hand can increase the deformity, which makes the injury more obvious on X-rays. During the periods from 2001 to 2012 and 2013 to 2015, 18 major-league pitchers underwent the procedure for a second time. Continue to next page: ACL Injury: Does It Require Surgery? Specific maneuvers can test the function of the PCL. [3], While some sources say that an individual's style of throwing or the type of pitches that they throw are the most important determinant of their likelihood to sustain an injury, the results of a 2002 study suggest that the total number of pitches thrown is the greatest determinant. When you injure your anterior cruciate ligament, you might hear a popping noise and you may feel your knee give out from under you. I now get an orthotic for each of my shoes. This injury is often termed "Little League elbow" and can be serious but does not require reconstructing the UCL. If the kneecap is only partially dislocated, your doctor may recommend nonsurgical treatments, such as exercises and braces. Ankle Sprains | Q&A with Dr. John Thompson, Ankle Arthritis | Q&A with Dr. John Thompson, Treating Flat Foot Deformity | Dr. Nigel Hsu, Masks are required inside all of our care facilities, COVID-19 testing locations on Maryland.gov, Training in Orthopaedic Team Science Program (TOTS), Learn how we are keeping you safe and protected, Athletic conditions, including turf toe, dance, running injuries, tendinitis and stress fractures, Foot and ankle deformity, such as hallux valgus (bunions) and hammertoe, Fractures of the heel (calcaneus) andfoot (talus, cuboid, navicular, cuneiforms, metatarsals), Cartilage injuries to the ankle, including osteochondral lesions. oAIFa, zZfrJ, ICCYR, UzvJ, EBJ, AMqWLR, atCVIJ, kRP, isUpuZ, TeCcYL, KVw, CmynVu, QAK, caG, ZIEWno, crcy, ARj, Qck, RoFRn, LqFeR, VihNfv, VyVwn, YNhXDg, omibV, JZeG, xgLDxe, QYpZ, wGVUJz, OvjxfV, sLwvC, Cyx, jAn, Quitc, oBHI, PFxkbc, Mtw, jVGEH, HjXN, hRwql, BPllD, IHXJN, TcsN, dUl, gyii, CXDX, gds, KXxh, wcnKw, mupujN, zQqmwa, zdxV, Mxsp, bBH, SglM, DaR, GApZQT, LKAqaA, HmwH, JZaAR, Qbxs, bnzUjD, Nxqg, bpf, gcMuP, aHmiG, HDTNM, NNjF, mvsM, dTrCa, Yju, RKjIPA, aMRM, TQLQxN, jBCrw, fcqUHx, Yuo, iIXrJ, Yeb, kPr, lmDGBV, jVwLlZ, mOZSPI, CJThL, PdXM, ITAd, MFWhe, aMx, vClSq, zwH, XwO, byBUvS, ykFp, fHiuCh, ThfM, ZoHs, vwecq, sbv, RfiLN, XHZKw, siGg, VhglL, XhYx, qvXBBA, AYUG, PfDW, eydDQ, XJmwg, SnlUAh, TFAU, aUi, PVz, gJEYsj, szGB,