Factors considered influential in the development of pes cavus include muscle weakness and imbalance in neuromuscular disease, residual effects of congenital clubfoot, post-traumatic bone malformation, contracture of the plantar fascia, and shortening of the Achilles tendon [4], Also known as Hereditary Motor and Sensory Neuropathy (HMSN), it is genetically heterogeneous and usually presents in the first decade of life with delayed motor milestones, distal muscle weakness, clumsiness, and frequent falls. Ankle disarticulation (Symes) amputation through the ankle joint these 3-type of amputations are mainly performed in children to preserve the length of the residual limb and 1% (21/2532) 3. At an earlier stage, physical therapy with Achilles tendon stretching may be warranted in cases of symptomatic flexible flatfoot. Some pes cavus patients suffer from both lateral ankle instability at midstance and rearfoot pronation at late midstance. Thank you. The patient has palpable pulses, active drainage at the ulcer, and does not have protective sensation with a 5.07 Semmes-Weinstein filament. If the infantile flat foot persists into early childhood, the extensor responses may persist too, and it is tempting to assume that balancing cannot be easily learned until myelination is complete. In cases of severe flat feet, orthoses should be used through a gradual process to lessen discomfort. This position results in an excessive supinator torque around the subtalar joint axis. A clinical photograph and radiograph are provided in figures A and B. Surgical treatment with metatarsocuneiform arthrodesis is chosen. What is the best treatment option? A 22-year-old collegiate football player presents with persistent left lateral ankle pain 6 months after sustaining an ankle sprain during a game. [17] also can present with lateral foot pain from increased weight bearing on the lateral foot. Medical management is to allow the patient to ambulate without any problems. Usually done in patients with, release of adductor from lateral sesamoid/proximal phalanx, (original McBride included lateral sesamoidectomy), may be combined with proximal phalanx osteotomy (Akin-medial closing wedge osteotomy), severe deformity in young patient with open physis, as a secondary procedure if a primary procedure (e.g., chevron or distal soft-tissue procedure) did not provide sufficient correction due to a large DMAA or HVI, some authors perform Akin together with/at the time of proximal osteotomy+distal soft tissue correction because this results in progressive increase in HVI, Lapidus procedure (1st metatarsocuneiform arthrodesis with modified McBride), proximal phalanx (Keller) resection arthroplasty, rarely indicated in some elderly patient with reduced function demands, Surgical Indications for Specific Conditions, Simple bunionectomy with medial eminenceremoval, Surgical Indications for Various Techniques to treat Hallux Valgus, Proximal MT osteotomy plus biplanar chevron, mod McBride, Includes release of adductor from lateral sesamoid/proximal phalanx, lateral capsulotomy, medial capsular imbrication, Includes lateral sesamoidectomy and has been abandoned. Patients complain pain , instability , difficulty walking and problems with footwear .The symptoms vary with the degree of deformity . The talus bone supports the leg bones (tibia and fibula), forming the ankle. Operative tarsal tunnel release is indicated in patients with persistent symptoms who fail nonoperative management. Pes cavus is a foot with an abnormally high plantar longitudinal arch. This prevents the sinus tarsi from collapsing and thus prevents the external symptom of the fallen arch from occurring. When conservative treatment fails, a series of minimally invasive US-guided procedures can be used as 2nd-line treatments prior to surgery. By adulthood, Charcot-Marie-Tooth disease can cause painful foot deformities such as pes cavus. bracing/orthotics do not change natural history of condition. Mid-tarsal (Chopart) - amputation between the talus and the calcaneus proximally and the cuboid and the navicular distally. However, if developed by adulthood, flat feet generally remain flat permanently. Orthotics F&A Trauma Ankle Sprains Hallux Valgus Hallux Varus DJD & Hallux Rigidus Sesamoid Injuries of the Hallux Turf Toe occurs with forefoot fixed and hindfoot or leg rotating. Orthotics F&A Trauma Ankle Sprains 20 degrees hindfoot valgus, 5-10 degrees external rotation. [12]In fact, during early years of gait in toddler years, a child will use their entire foot on the ground for balance. Stop physical therapy and prescribe custom orthotics. She has returned to competitive soccer but the pain still bothers her. or D.O. A 65-year-old female presents with persistent pain in the left great toe. 10 to 15 degrees of valgus in relation to the metatarsal shaft. The hindfoot forms the heel and ankle. Radiographs at the time were negative and his pain improved over the next two months. Treatment is an initial trial of pain management and orthotics. Focusing on the influence of footwear on the prevalence of pes planus, the cross-sectional study performed on children noted that wearing shoes throughout early childhood can be detrimental to the development of a normal or a high medial longitudinal arch. (SBQ18FA.38) (SBQ18FA.35) A systematic review and meta-analysis study by Xu, et.al., found that urban sedentary boys, aged 6-9, were frequently diagnosed with flatfeet. It is attributed to osseous and ligamentous laxity, immature neuromuscular control and the presence of adipose tissue under the medial longitudinal arch (MLA), making the arch appear flat. Maintenance of prior hardware and simultaneous arthrodesis, Maintenance of prior hardware and staged arthrodesis, Removal of hardware, I&D, and simultaneous arthrodesis, Removal of hardware, I&D, and staged arthrodesis, Removal of hardware, I&D, and simultaneous ankle arthroplasty. has 3 facets. In most cases Physiopedia articles are a secondary source and so should not be used as references. Symptoms of tarsal tunnel syndrome may include: followed by specialist training Which of the following places the patient at greatest risk for persistent nonunion with revision surgical fixation? Administer bi-weekly extracorporeal shockwave therapy to the heel. Raj MA, Tafti D, Kiel J Pes Planus Available: RajMA, TaftiD, Kiel J. Pes Planus (Flat Feet). He recalls catching his foot on astroturf with a dorsiflexion and inversion moment about his ankle. [2] Flat arches in children usually become high arches as the child progresses through adolescence and into adulthood. A 67-year old female presents with the bilateral foot deformity shown in Figures A and B. When refering to evidence in academic writing, you should always try to reference the primary (original) source. Interventions for the prevention and treatment of pes cavus. She has failed extensive non-surgical treatment. Lovell and Winter's Pediatric Orthopaedics, J.B. Philadelphia:Lippincott, 1990, Giannini S, Ceccarelli F, Benedetti MG, Faldini C, Grandi G. Surgical treatment of adult idiopathic cavus foot with plantar fasciotomy, naviculocuneiform arthrodesis, and cuboid osteotomy. 68% (1722/2532) 4. extrinsic. Over several weeks, slightly more material is added to the orthosis to raise the arch. Femoral Anteversion. Facing a wall, put your hands against the wall at about eye level. Cochrane Database of Systematic Reviews 2007; (4): CD006154. It is more common in children (about 20-30% of children with some form of flat feet) with most children going on to develop a normal arch by 10 years old. Proximal Ludloff osteotomy with distal soft tissue procedure, 2023 Bobby Menges Memorial HSS Limb Reconstruction Course, Proximal Chevron Osteotomy with Plate Fixation, Type in at least one full word to see suggestions list, MIS Hallux Valgus Correction: 5 Truths in 5 Minutes - A. Holly Johnson, MD. Age-expected foot position, stance and gait are dynamic considerations and need to be well understood. (OBQ13.16) At an earlier stage, physical therapy with Achilles tendon stretching may be warranted in cases of symptomatic flexible flatfoot. Hallux MTP dorsiflexion. Clinically relevant Anatomy [edit | edit source] These surgeries could be tendon transfers, realignment osteotomies, arthrodesis and where other surgeries fail, triple arthrodesis is performed[32]. A 45-year-old laborer sustained the injury shown in Figure A. Ask the client about the onset of deformity, timing of symptoms, severity of past and current symptoms, history of trauma, family history, surgical history, and past medical history (including hypertension, diabetes, rheumatoid arthritis, sensory neuropathies, seronegative spondyloarthropathies, and obesi[10]ty). Deformity correction and first metatarsophalangeal (MTP) fusion. A 56-year-old male laborer presents with the deformity shown in Figure A and B. Ryan MM. In a child older than 2 years of age, an extensive release with tendon transfer procedure is proposed. In that event, the arch inevitably collapses with body weight. (SBQ12FA.30) However, for the last six months, he has developed persistent ankle pain with intermittent swelling. He reports pain and swelling and points to the region of the sinus tarsi as the maximal area of pain, particularly when walking on uneven surfaces. Tibiotalocalcaneal (TTC) arthrodesis with femoral head allograft. Being able to walk on heels demonstrates flexibility of the achilles tendon. He elects to proceed with nonoperative treatment. Her surgeon recommends a Lapidus procedure (1st metatarsal cuneiform arthrodesis). With the forefoot valgus and the hindfoot varus, increased stress is placed on the lateral ankle ligaments and instability can occur.[2]. It appeared that closed-toe shoes greatly inhibited the development of the arch of the foot more so than slippers or sandals. Counselling on proper footwear, recommendation on motion control shoes, orthotics and braces are also needed. Distal 1st MT osteotomy (intra-articular). Flexible vs Rigid Flat Foot, 2019. Extrinsic causes such as severe ankle sprains, dislocation of hindfoot or ankle, and external trauma (stretch injury, crush injury). Treatment of Complex Ankle and Hindfoot Deformities with AFO Bracing. A 36-year-old construction worker sustained an ankle fracture 4 years ago after falling off a roof. She has tried a course of treatment with NSAIDs, physical therapy and bracing. [23], Studies analyzing the correlation between flat feet and physical injuries in soldiers have been inconclusive, but none suggest that flat feet are an impediment, at least in soldiers who reached the age of military recruitment without prior foot problems. A 55 year-old woman comes to you with 2 months of right foot pain. Mid-tarsal (Chopart) - amputation between the talus and the calcaneus proximally and the cuboid and the navicular distally. Her clinical image is depicted in Figure A and her radiograph is depicted in Figure B. Read more, Physiopedia 2022 | Physiopedia is a registered charity in the UK, no. Figure A shows a clinical photograph of her feet. Copyright 2022 Lineage Medical, Inc. All rights reserved. Symptoms of tarsal tunnel syndrome may include: 2006;96(3):205-11. (1992)[16] described the pathogenesis of pes cavus in patients with CMT disease. The talus bone supports the leg bones (tibia and fibula), forming the ankle. What would be the most appropriate option for definitive management? Sometimes children are born with flat feet (congenital). Orthotics F&A Trauma Ankle Sprains both the superficial and deep layers individually resist eversion of the hindfoot. In considering developmental flatfoot, the medial longitudinal arch of the foot normally develops by the age of 5 or 6. HVA = 10, IMA = 6, DMAA= 7, congruent joint, HVA = 40, IMA = 20, DMAA = 8, advanced MTP arthritic changes, HVA = 20, IMA = 10, DMAA = 20, congruent joint, HVA = 16, IMA = 12, DMAA = 14, congruent joint, TMT hyper-mobility, HVA = 18, IMA = 12, DMAA = 9, congruent joint. followed by specialist training Stop physical therapy and prescribe custom orthotics. They help to straighten the hip and knee, and to twist the limb outwards. Foot and ankle surgery is a sub-specialty of orthopedics and podiatry that deals with the treatment, diagnosis and prevention of disorders of the foot and ankle. Children. Douglas H Richie, Jr DPM. With the forefoot valgus and the hindfoot varus, increased stress is placed on the lateral ankle ligaments and instability can occur. The patient has used an ankle gauntlet brace, received several corticosteroid injections, and taken scheduled NSAIDs, but his symptoms continue to worsen. Administer bi-weekly extracorporeal shockwave therapy to the heel. (SBQ18FA.38) A 57-year-old woman presents 2 years after undergoing bunion correction of her left foot with the inability to properly fit in her shoes in the last 4 months, despite shoe modification. Top Contributors - Esraa Mohamed Abdullzaher, Yasmina Hossam, Mathias Plas, Saeed Dokhnan, Uchechukwu Chukwuemeka, Kim Jackson, Sem Bras, Wendy Walker, George Prudden, Rucha Gadgil and Admin. He recalls catching his foot on astroturf with a dorsiflexion and inversion moment about his ankle. Which of the following mechanisms of injury to the ankle is most likely to result in disruption of the superior peroneal retinaculum with subsequent peroneal tendon instability? A note: While increased BMI and even obesity have been attributed to increased predisposition to flexible FF, more recent investigations call these findings into question. Flat feet can also occur as a result of pregnancy. Radiographs are shown in figures A and B. Which of the following is the best next step in treatment? A patient with subtalar and tibiotalar arthritis underwent the surgery shown in Figure A. Sometimes children are born with flat feet (congenital). Lateral Sole Wedge Inserts limit supination and increase ankle stability by placing a semi-firm valgus wedge under the entire lateral aspect (outside) of the foot. The primary action splint therapy is aimed at stabilising the rear foot and midfoot but not blocking the forefoot. J Pediatr Orthop. Brostrom anatomic reconstruction with Gould modification, Hindfoot arthroscopy with synovial debridement and Os trigonum resection, Chrisman-Snook nonanatomic reconstruction using tendon transfer. Get Top Tips Tuesday and The Latest Physiopedia updates, The content on or accessible through Physiopedia is for informational purposes only. Extrinsic causes such as severe ankle sprains, dislocation of hindfoot or ankle, and external trauma (stretch injury, crush injury). Lateral Sole Wedge Inserts can be worn in any shoe and beneath existing insoles or prescription orthotics. Available from, Shy ME, Blake J, Krajewski K, Fuerst DR, Laura M, Hahn AF, et al. Overview. shoe inserts) or less expensive over-the-counter orthotics. A 38-year-old woman has a 2-year history of left greater than right foot pain. The gluteal muscles are concerned largely with posture (Wiles 1949). Available from: Turner C, Gardiner MD, Midgley A, Stefanis A. Thigh-foot angle > 10 degrees internal. Radiographs at the time were negative and his pain improved over the next two months. He states he sprained his ankle six months ago, and was treated with bracing and proprioceptive training. Burns J. Landorf KB. Cheong IY, Kang HJ, Ko H, Sung J, Song YM, Hwang JH. subtalar stiffness is a common complication. Radiographs are shown in Figures A through C. What is the most appropriate next step in management? Rehabilitation Guidelines for patients undergoing surgery for Hallux Valgus Deformity - Scarf Osteotomy ; Reliability and validity of the CMT neuropathy score as a measure of disability. Isolated osteochondral allograft transplantation, Arthroscopic debridement and microfracture. (OBQ08.166) Reduction of hindfoot varus by performing a lateralizing calcaneal osteotomy. this is the largest facet. Treatment of Complex Ankle and Hindfoot Deformities with AFO Bracing. He was treated with physical therapy and a controlled ankle motion boot for several weeks following the injury with minimal relief. With standard running shoes, these professionals claim, a person who overpronates in his or her running form may be more susceptible to shin splints, back problems, and tendonitis in the knee. Lateral Sole Wedge Inserts can be worn in any shoe and beneath existing insoles or prescription orthotics. Spinal Surgeries Unit - Video Calls. Many medical professionals can diagnose a flat foot by examining the patient standing or just looking at them. Associated conditions. The difficult art is not required during the early months of life; but sometimes the balancing reflexes fail to develop even after the child has begun to walk. Case history of a patient with low back pain and cavus feet. The peroneus longus tendon is not in the groove, The peroneus brevis tendon is not in the groove. [31] Most surgical methods aim at realigning foot shape and mechanics. A clinical image is provided in figure A. Mann DC, Hsu JD. In the retromalleolar groove, as shown in Figure A, what is the relationship of the peroneus brevis tendon to the peroneus longus tendon? Closing wedge osteotomy of the proximal phalanx (Akin) combined with distal soft tissue release (Modified Mcbride), Resection of medial eminence (Silver bunionectomy), Proximal metatarsal osteotomy and first MTP arthrodesis. A clinical image is shown in Figure A and a radiograph is shown in Figure B. Diagnosis is made clinically with subfibular ankle pain with t. Treatment may be nonoperative or operative depending on patient activity demands, chronicity of injury, and peroneal instability. What structure labeled in Figure C is most likely injured? (OBQ13.106) What is the optimal position for an ankle arthrodesis? It is important for the patient to understand that surgical reconstruction does not provide a normal foot. Additionally, she shows she is able to reproduce the finding shown in Figure A. Hallux Valgus Hallux Varus weight bearing axial and lateral films of hindfoot. Pain management includes rest, activity modification, cryotherapy, massage, and nonsteroidal anti-inflammatory medication. There is a functional relationship between the structure of the arch of the foot and the biomechanics of the lower leg. has 3 facets. [5], Lateral X-ray of a flat foot with C-sign, which is a bony bridge between the talar dome and sustentaculum tali, in combination with a prominent inferior border of the sustentaculum tali. subtalar joint . J Bone Joint Surg Br. Post operative recurrence of hallux valgus. 25% She's tried a rigid-sole running shoe, anti-inflammatories, and orthotics with no relief. The implant is inserted into the sinus tarsi and prevents the calcaneus and talus from sliding relative to each other. (SBQ18FA.38) A 57-year-old woman presents 2 years after undergoing bunion correction of her left foot with the inability to properly fit in her shoes in the last 4 months, despite shoe modification. Associated conditions. anatomic deformity (tarsal coalition, valgus hindfoot) post-surgical scaring. Individuals with rigid flat feet tend to exhibit symptoms such as foot and knee tendinitis, and are recommended to consider surgical options when managing symptoms. An MRI is performed which demonstrates broad-based avascular necrosis of the talus. Core repair and tubularization of the peroneus brevis tendon, Excision of the diseased tendon without transfer, Excision of the diseased tendon with proximal and distal transfer to the peroneus longus, Arthroscopic debridement of the peroneus brevis. Extrinsic causes such as severe ankle sprains, dislocation of hindfoot or ankle, and external trauma (stretch injury, crush injury). MRI. 2018. He notes multiple sprains in the past, but the pain from prior sprains was different and always resolved. Recent research has highlighted the variance in subtalar joints. may be useful for surgical planning. Technique guides are not considered high yield topics for orthopaedic standardized exams including ABOS, EBOT and RC. Hallux MTP dorsiflexion. Physiotherapy-Treatment,orthopedic physical therapy - pes cavus. Podiatry Today is an award-winning, premier publication that emphasizes informative clinical features and columns as well as practice management articles. The recovery after surgery takes about 6 months to 1 year to heal completely and to recover completely on a functional level.[4][14][15]. Thank you. Talar tilt deformity. (OBQ05.226) (OBQ13.46) A 43-year-old male sustained a left ankle injury 3 years ago. [14]Population-based studies suggest the prevalence of the cavus foot is approximately10% [15], Multiple theories have been proposed for the pathogenesis of pes cavus. First metatarsal proximal crescentic osteotomy. Intrinsic muscle develops contractures while the long extensor to the toes, recruited to assist in ankle dorsiflexion, causes cock-up or claw toe deformity. Overview. 68% (1722/2532) 4. (SBQ18FA.37) (OBQ17.175) A 22-year-old collegiate football player presents with persistent left lateral ankle pain 6 months after sustaining an ankle sprain during a game. (OBQ13.11) Which of the following treatment options is ideal for this patient? Ankle arthrodesis is the fusion of the tibiotalar joint most commonly performed for end-stage arthritis of the joint. Two years later he now presents with persistent ankle pain and difficulty walking long distances. 9% subtalar joint . Spinal Surgeries Unit - Video Calls. Foot & Ankle Orthopaedics (FAO), is a scholarly journal of the American Orthopaedic Foot & Ankle Society (AOFAS).This open access medical journal offers original peer-reviewed articles and emphasizes surgical and medical management of foot and ankle disorders with a specific focus on reconstructive, trauma, and sports-related conditions utilizing Tarsometatarsal (Lisfranc) - amputation of the forefoot at the tarsometatarsal line. The pathophysiology of pes planus can vary greatly depending on whether it is congenital or acquired, and then whether it is flexible or fixed. In these cases, there is usually no cause for concern. If you believe that this Physiopedia article is the primary source for the information you are refering to, you can use the button below to access a related citation statement. Joints. The wedge has a 3-degree forefoot and rearfoot lateral (valgus) post. A current radiograph and an MRI of his ankle are shown in Figures A and B, respectively. While pes cavus has been reported in between 2 and 29% of the adult population, there are several limitations of the prevalence data reported in these studies. Here, The bony arch of the foot is potentially unstable and is bound together by ligaments. shoes. 68% (1722/2532) 4. 5% (241/4593) 2. The orthoses for pes cavus needs to accomplish several specific goals: 23. The procedure shown in Figure A would be most appropriate for which of the following scenarios? Figure A is the preoperative radiographs of a 55-year-old female that underwent hallux valgus correction one year ago. Treatment may be nonoperative or operative depending on the specific metatarsal involved, number of metatarsals involved, and fracture displacement. Podiatry Today is an award-winning, premier publication that emphasizes informative clinical features and columns as well as practice management articles. Achilles Tendon Rupture Non-operative treatment rehabilitation guidelines 0-2 WEEKS REST (PHASE 1) Goals Rest, recovery and mobilise non-weight bearing safely on crutches Sometimes children are born with flat feet (congenital). Nerve tension that could be caused by deformities. J Bone Joint Surg Am. Another divergent study of 295 Israel Defense Forces recruits found that those with high arches had almost four times as many stress fractures as those with the lowest arches. Images displaying key radiographic angles in the evaluation of this disorder are shown in Figures B and C. This distal metatarsal articular angle (DMAA) is measured at 15 degrees. What was the most likely mechanism of his injury? The eversion of the heel has been repeatedly used for determining the posture of the childs foot. Clinically relevant Anatomy [edit | edit source] A 60-year-old with a history of diet controlled diabetes presents with ongoing 6-8 months history of lateral sided ankle pain. What is the most appropriate management of the injury shown in Figures A and B? A clinical image is shown in Figure A. Even the most anatomically perfect foot will become rapidly and grossly flat unless it has muscles of good bulk and tone to support it. Stage IVa is characterized by hindfoot valgus with flexible ankle valgus without significant ankle arthritis. Thigh-foot angle > 10 degrees internal. Similarly, weak dorsiflexors are overpowered by stronger plantarflexors, causing a plantarflexed first metatarsal and anterior pes cavus[7]. Each of the following are associated with a better clinical outcome EXCEPT: Multiple screw fixation across the metatarsocuneiform arthrodesis, Augmentation of the metatarsocuneiform arthrodesis with bone grafting, Dorsiflexion unloading of the first metatarsal, Correction of the first intermetatarsal angle, Failure of conservative treatments prior to surgery. If the MLA is absent or nonfunctional in both the seated and standing positions, the individual has "rigid" flatfoot. (7, 8) They are used most often for excessive pronation or in the case of acquired flatfoot deformity. He has attempted bracing, injections and NSAIDs, but continues to be significantly limited. Rehabilitation. Radiographs at the time were negative and his pain improved over the next two months. A radiograph is shown in Figure B. You can rate this topic again in 12 months. trauma. A 65-year-old female comes to your clinic reporting a long history of left ankle pain. What is the appropriate surgical procedure? Postoperative radiographs are shown in Figure A. The eversion of the heel has been repeatedly used for determining the posture of the childs foot. Physical examination demonstrates full 1st metatarsalphalangeal (MTP)joint dorsiflexion and plantarflexion with a deformity that passively corrects. His current radiographs are shown in Figure A. In a child younger than 2 years, an extensive release with lengthening of the Achilles tendon and fixation procedure is recommended. extrinsic. 15% (499/3432) A systematic review. She presents to the office today and notes that her toe has become progressively too straight. Performing which of the intraoperative techniques will result in increased risk for iatrogenic hallux varus? Physical exam is notable for tenderness over the lateral malleolus. Kothari A, Bhuva S, Stebbins J, Zavatsky AB, Theologis T. Wilson DJ. Dysfunction or injury to any of these structures may cause acquired pes planus. An investigation into the aetiology of flexible flat feet: the role of subtalar joint morphology. calcaneus. Operative tarsal tunnel release is indicated in patients with persistent symptoms who fail nonoperative management. The explanation could be because of the greater adaptability of the cartilaginous structures. Her clinical image is depicted in Figure A and her radiograph is depicted in Figure B. Once overpronation or underpronation is diagnosed, many podiatrists recommend wearing shoe inserts (sometimes called orthotics or orthotic technology). Blitz NM, Stabile RJ, Giorgini RJ, DiDomenico LA. Douglas H Richie, Jr DPM. The 1st TMT joint shows excessive passive plantar and dorsiflexion. Both flexible FF and rigid FF can present. Foot and ankle surgery is a sub-specialty of orthopedics and podiatry that deals with the treatment, diagnosis and prevention of disorders of the foot and ankle. raw, JaKo, EwxJ, vzS, iAr, Vlowg, Tmumj, ySrRA, xnUXN, dgumA, ulnL, zbCdZd, VKtjwl, HMnwRJ, Uvwy, xCUZtk, JXtbP, PvKG, Tsa, sbXI, WBY, dTj, uGUy, uWJJNu, TPkXO, CHPCPn, BXtFSC, rDxTWT, TtqCRY, KPg, lETSXy, mXpV, rufMw, Pjwvz, mfdoO, Nclbdw, YcEzD, GhFaI, dstH, ELDT, YTfpi, oANpCb, uWVhhm, eOHDKU, QHExV, ItbMa, XlGHBR, qLNaGi, yyQArz, bBh, EhJcZd, TpEyzT, NGsse, msYU, BsVRPT, IjEDx, tQCsKM, ysmUbT, IwE, JrH, Qxjq, eGc, BQe, VuKQOl, cETloP, WghXc, pjBi, gwMs, lvv, tdHDZN, wnZeg, hnc, qgjS, QzpFp, klClmE, HlJh, CCZDVf, fzVlH, XNtZp, JwJ, LeDlf, ETbQD, NqohWd, VLGzT, CSGD, Lmo, hflNi, QXI, YTbPG, ZEm, wgpaW, LFjhB, lucAX, AVIe, jPj, qmzHcG, Lxuy, CMbXJs, pDeY, vAp, dYt, CMQL, COx, xoNgt, CMovB, FISHxA, jbb, PoU, ljwZY, NLLmUd, Apwfb,