PT name and date: Julie Perumal 4/13/16 MD name and date: endobj Day by day recovery process - internal ankle brace augmentation repair. At that point, a formal physical therapy program is started. Unrestricted return to play as early as 8 weeks to 10 weeks postop can begin, but 12 weeks is recommended. Disclosures: Watson is a consultant for Arthrex, and receives no royalties for the internal brace and received no payment for this manuscript. Care is taken to keep the superior anchors sutures superior to the FiberTape, and the inferior anchors suture inferior as the needles are brought up through the cuff. Chronic lateral ankle instability can cause debilitating ankle pain and dysfunction in athletes and active individuals. After appropriate drilling and tapping, the 4.75-mm SwiveLock is then inserted with the attached FiberTape. We have had sportspeople returning eight weeks after ligament reconstruction, although the average recovery period would be ten to twelve weeks. 4010 West 65th Street, Edina, MN 55435 Phone: Fax:952-456-7000 952 -944 0460 www.tcomn.com Proprioception activities Phase III: Weeks 6-8 (cont.) The ATFL cuff has been dissected with suture anchors placed in fibula for typical modified Brostrm repair. The anchor is placed with the ankle held in a neutral position (Figure 5). Potential complications are relatively low and . In the untreated patient, chronic lateral ankle instability can potentially lead to late sequelae, such as ankle arthritis and deformity. The technique involves fixation of the healthy soft tissues proximally and the transfer of the bridging cabling through the damaged tissue before being fixed to the calcaneus using swivel locks in a neutral position. 1 0 obj The Internal Brace procedure implants a biocomposite anchor into the talus and fibula. 2 0 obj xko8{~9kQ)P6n&v3Cm^f8z^?_/`4cs}F/?|%cN_#2IIsO}wh30fBP,e v;[:K_vw>X6x 3 0 obj Although any method may be utilized for the modified Brostrm, the authors prefer an open modified Brostrm procedure performed by placing two 2.4-mm BiosutureTak suture anchors (Arthrex) in the anterolateral aspect of the distal fibula allowing room for later placement of a central 4.75-mm SwiveLock. After a typical wound closure, a posterior splint is applied and worn until the first postoperative visit at approximately 7 days after the procedure. 2016 Dec; 17(4): 353-360 3. W/ INTERNAL BRACE Postoperative Recovery Protocol Jeffrey Seybold, M.D. Initially, therapy focuses on ankle and foot edema control, passive/active range of motion, ankle strengthening and straight inline running during the first 2 weeks. <>/ExtGState<>/XObject<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI] >>/MediaBox[ 0 0 612 792] /Contents 4 0 R/Group<>/Tabs/S/StructParents 0>> ; ; ; The surgery is performed under a general anesthetic or spinal block and takes 1-2 hours. About Golfing Events Menu Close yoga and meditation near bengaluru, karnataka; federal voting rights Clinical results of an arthroscopic modified Brostom operation with and without internal brace. This can be used to augment partial trend and transfer, simplifying surgical repair of the spring ligament but also providing additional confidence for early mobilisation and an accelerative recovery. Get the latest news and education delivered to your inbox, Receive an email when new articles are posted on, Please provide your email address to receive an email when new articles are posted on. W/ INTERNAL BRACE Postoperative Recovery Protocol Jeffrey Seybold, M.D. Peroneal tendon pathologies, i.e., tenosynovitis or tears, are directly visualized and addressed during this procedure in conjuction with the ligament reconstruction. 2-4 weeks as long as you are comfortable and confident carrying out an emergency stop. This image demonstrates the appropriate drilling trajectory (cephalad and medial) for suture anchor placement at the ATFL talar attachment site just off of the articular surface of the lateral ridge of the talus. At week 6, change of direction, jumping and sport-specific exercises are implemented. This does not require later removal and is not something you should feel. The use of the 3.5-mm tap is recommended to the laser line to avoid compromising anchor fixation or anchor breakage during insertion in the dense bone of the talus. <>/Metadata 133 0 R/ViewerPreferences 134 0 R>> Z*dclzN??MgM|]~[++t\F'S,0y'u^M}j2h2 7N /S4,T()C 'MHQOq:Hx968*L^Dgp>bz| %PDF-1.7 The soft tissues can then be gently tacked around the scaffold. stream Journal of Orthop Traumatol. Caution must be taken to avoid penetration of the ankle joint or fracture of the fibula. time, was adapted from the protocol used at the Hospital for Special Surgery (HSS), where the modified Brostrom-Gould procedure is the preferred anatomical surgical procedure for the treatment of lateral ankle instability. The peroneal brevis and longus tendons are then identified in their sheaths as landmarks as they course distally from behind the lateral malleolus. An internal device may also be implanted to act as a brace that functions as a "check rein" to speed recovery. The successful principals of InternalBrace technology can also be applied to the medial aspect of the ankle to reinforce the spring ligament in patients who have developed flat feet. Open modified Brostrm ankle reconstruction with internal brace augmentation: A novel approach Orthopedics Today | Chronic lateral ankle instability can cause debilitating ankle pain and. cheap townhomes for rent near alabama. The drill hole is located between and superficial to the two BiosutureTak anchors. In conclusion, the authors have found that augmentation of an open modified Brostrm ligament reconstruction with the internal brace is a safe and reproducible procedure with favorable results. 2 0 obj NoSZNN|rT>}qz &g69Wgp )z;&Yqz|](a|?x(GuP"\jJj2N(/!,&L3JWop584pZS9 LPA*ZT JtV=[fy=6%'S3?~rR|YOy&H%r7lJ6TfF.ancS13D'G=C=O/ Ankle range of motion exercises are started at that point, avoiding inversion. James McWilliam, MD (New York, NY), provides a cadaveric demonstration of the Internal Brace 2.0 ligament augmentation procedure with DX FiberTak anchors with SutureTape following a Brostrom repair. It's also known as the Brostrom procedure. As with any anchor or screw insertion, caution must be taken with insertion of the anchor in the same axis of the prepared hole to avoid device breakage or fixation strength compromise. The device is a knotless, suture anchor-based system that can increase the ligament repair construct strength to 250 N, which is 1.6-times greater than the native ATFL (154 N) and 3.7-times greater than the traditional Brostrm repair (68 N). Additional prospective studies are in process to appropriately support our findings. 4 0 obj Lamour reports no relevant financial disclosures. <> <> Rehabilitation Guidelines for Lateral Ankle Reconstruction; Journal of Orthopaedic Surgery and Research: Treatment of chronic lateral ankle instability: a modified brostrom technique suing three suture anchors; Sports Physical Therapy: Return to Play in Athletes Following ankle injuries. Journal of Orthop Traumatol. Twin Cities Orthopedics - Foot and Ankle Surgery . fr*@ X6hy@gd,bTIh)rAO}kD>. Good spread of the suture limbs in the tissue should be achieved, approximately 10-mm to 15-mm apart. 264 Ho Nghinh, Phuoc My, Son Tra, Da Nang Hotline: 0905 999 160 / 02363 555 979 The Achilles tendon remains an area of some controversy as traditional outcomes following surgical management have shown modest improvement over conservative treatment with some well-recognised risks, including wound infection, although the risk of re-rupture was noted to be considerably lower. Ankle ligament injury is recognised as one of the most frequent sports-related injuries, often resulting in long-standing instability and secondary degenerative change within the ankle joint itself. The InternalBrace for Achilles repair has transformed surgical outcomes, ensuring the restoration of musculo-tendinous length and providing a repair which is at least three times as strong as a conventional repair. In addition, traditional rehabilitation after open modified Brostrm reconstruction is lengthy, which for competitive athletes, laborers or active individuals, can be costly with regard to time away from sport, work or a demanding lifestyle. 3 0 obj Brigham & Women's Hospital, Department of Rehabilitation Services, Modified Brostrom-Gould Repair for Chronic Lateral Ankle Instability Approved: 1/16/18 }~0bRR`L\Db(Nd.FM>C[T0k(h9kSOiwzDJvSJ> i)Ss*m*-h?|}K19rd6aL'TUu|&2=n8z:P x]o8 >_XM,4=zI|M3HJp8f/?QQkk$%k(+azOB8+"Buqv/*65).;^q(P#DJN Using a free needle, the FiberTape suture is passed through the ATFL and extensor retinaculum cuff of tissue to ensure that the suture will lie extra-articularly. common method is called a modified Brostrom procedure. However, the course of the extensor retinaculum is different from those of the ATFL and CFL. Internal brace ligament augmentation: Biomechanical testing of an anterior talofibular ligament repair, insertion order vs. SwiveLock anchor size (white paper). 1 0 obj The suture is pulled through the cuff of tissue and laid over the fibula to determine the accurate placement of the suture anchor and ATFL cuff. endobj Troy S. Watson, MD, is founder, Foot and Ankle Institute and director, Las Vegas Orthopaedic Foot and Ankle Fellowship. My surgeon was Dr. Kruelen of UC Davis, and I would recommend him to other runners. The 2.7-mm drill bit with provided guide sleeve is used to drill with an approximately 45 medial and cephalad trajectory for placement of the 3.5-mm anchor in the talar body (Figure 2). The results have been dramatic, not only ensuring minimal muscle wasting in optimal outcome but achieving this in less than half of the conventional time period if it was ever to be restored. endobj The Brostrom procedure for tightening anterior-inferior talofibular ligament has long been the standard treatment for ankle instability. The second internal brace suture anchor is placed with the hemostat placed underneath the FiberTape to allow for slack in the system with the ankle in neutral position. This transforms the patients experience by diminishing pain and swelling, restoring function rapidly and can reduce recovery times by 50%. The proximal attachment of the ATFL on the anterolateral aspect of the distal fibula is prepared by removing soft tissue with rongeur for later repair. If you have other procedures at the same time (ankle arthroscopy, tendon repair, For patients who have failed initial attempts at nonoperative treatment, i.e., physical therapy, bracing, etc., surgical management with an open modified Brostrm reconstruction is a well-accepted technique with good to excellent outcomes. <>/ExtGState<>/XObject<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI] >>/MediaBox[ 0 0 612 792] /Contents 4 0 R/Group<>/Tabs/S/StructParents 0>> Ryan B. Rigby, DPM (Logan, UT), performs a clinical demonstration of an InternalBrace ligament augmentation and Brostrom repair with DX FiberTak all-suture. In general, the repaired ligament is strengthened using the extensor retinaculum (Gould technique). cK"B85spZ|X)H)6>Y-rrT1dgVmbV(Y(gtt K 3fk[S3Cw)k'_aki @yUBb>+L\{LI#)`VI_Lh KR+hU^;egN[e28BdMpm$Msxe?>'!vJ>L6 jMqC27Q3I$Wb07;~E1@csA6jz.N]@+`/!$whv$+J In a similar fashion, the deltoid ligament medially can also be repaired without the morbidity of donor site harvest minimising the risks of soft tissue and wound breakdown. Gates NT. surgeon Professor Gordon Mackay, is Scotlands leading sports injuries clinic. The fat pad in the anterolateral ankle is abundant in some patients and is partially excised for better visualization. Internal brace - ligament augmentation repair. Weeks 2-3 If wound is healthy - sutures out and may full weight bear in CAM walker boot If painful - 50% WB with crutches May ride stationary bike or elliptical with boot on. At 4 weeks, the boot may be removed and the ankle placed in a lace-up brace and regular shoe. 2 0 obj How successful is brostrom surgery? Professor Mackay is also the inventor of the InternalBrace, his gold standard in ligament and tendon repair. endobj He can be reached at Desert Orthopaedic Center, 2800 E. Desert Inn Rd., Las Vegas, Nevada 89121; email: Richard J. Lamour, MD, can be reached at Foot & Ankle Surgery/Sports Medicine, Sierra Pacific Orthopedic Center, 1630 E. Herndon Ave., Fresno, CA 93720; email. Jae-Sung Yoo and Eun-Ah Yang. Appropriate adjustments of drill angle should be made to avoid violation of the tibiotalar or subtalar joints. <>/ExtGState<>/XObject<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI] >>/MediaBox[ 0 0 792 612] /Contents 4 0 R/Group<>/Tabs/S/StructParents 0>> The InternalBrace restores immediate stability, providing equivalent strength to the uninjured anterior talofibular ligament. The sutures from each BiosutureTak suture anchor are tied completing the modified Brostrm. PT name and date: Julie Perumal 4/13/16 Arthrex Research and Development. A more rapid return to sports and work has been noticed without fracture or recurrent instability. 2. 1 The Internal Brace 2.0 surgical technique provides surgical versatility with added size and material options. The arthritis damage is less easy to fix, but a technique called 'micro-fracturing' of the bone makes it possible for the body red blood cells to escape and regrow some insulating material where the cartilage had formerly been. Long-term studies on the modified-Brostrom procedure show 85-95% success rates. Brostrom ankle surgery is a reconstruction of one or more lateral ankle ligaments. The 3.4-mm drill bit is placed on the anterolateral fibula and angled in a cephalad trajectory to ensure appropriate placement of the internal brace suture anchor in bone. Jae-Sung Yoo and Eun-Ah Yang. The torn ligament or ligaments are surgically removed and replaced with either cadaver, or a patient's own, tendons. Recovery also required an extended period of immobilisation as the dead tissue became revascularised. Brigham & Women's Hospital, Department of Rehabilitation Services, Modified Brostrom-Gould Repair for Chronic Lateral Ankle Instability Approved: 1/16/18 The Mackay Clinic, headed up by world-renowned. endobj I was put in a . <>/Metadata 208 0 R/ViewerPreferences 209 0 R>> %PDF-1.5 x\o8"aE""@vP p{PdUq\IN/%YvY/kG4Co>g7Xpuf?Bd3dZHVgS0!xL !!SZ$f_-jx([_qO?gdpqQ7b'iD Springfield House, Laurelhill Business Park, Polmaise Road, Stirling, FK7 9JQ. Similar to the standard ligament repair, also known as the Brostrom procedure, the Internal Brace ligament augmentation repair addresses the ankle instability by repairing or tightening the ligaments. The completed repair is shown after excess FiberTape is cut and all sutures are tied. The goal is to repair the loose lateral ligaments. <> Recovery from ankle ligament surgery requires wearing a cast or splint for a minimum of two weeks, and in this initial period it is crucial to rest your ankle as much as you can. H`Ut+h C`gZnt]tV%#-i%St]j902p2.LA!qjd6g`~.B$vf* VEWaFEJt_{]x$gA!Gl|` LE q uj#CA8br3(BY9@oNL(PmmvDL`1se +0:*D0bDw1@KWElKD RbQj(Ss"5&p. At 24-week follow-up, the anterior drawer test showed grade 0 laxity in 19 patients (86.4 %) and grade 1 in three patients (13.6 %). The patient usually takes around 3-6 months to return to their normal activities, and as many as 10-15% of patients must reduce their activity level to accommodate their ankle. 2016 Dec; 17(4): 353-360 3. stream Augmentation of this repair with Internal Brace has shown better results with faster recovery. The Mackay Clinic, headed up by world-renowned orthopaedic surgeon Professor Gordon Mackay, is Scotlands leading sports injuries clinic. The ankle should then be reduced in the neutral position. For a desk job 2-4 weeks, for a more physical job 6-8 weeks with modified duties. N3X^?f+x4FWz4^eTE*H\g. The excess FiberTape is cut, and an absorbable suture is typically used to repair the sleeve of tissue to the neighboring periosteum to bolster the repair (Figure 6). An advance on this approach was the restoration of normal anatomy using the Brostrom approach, but this still required abnormal tensioning of the tissues with tightening of the retinaculum the prolonged period of immobilisation. 4 0 obj 1 0 obj endobj endobj The increased construct strength allows the surgeon to consider implementation of an accelerated rehabilitation program, earlier return to desired activity and decreased recurrent instability noticed by the authors in early findings. Brostrom repair with the Internal Brace procedure provides additional fixation of the repaired ligament backdown to bone during the healing process, allowing early mobility during recovery and a quicker return to activity. However, the procedure depends on the quality of the remnant ligament. The invention of the InternalBrace has transformed the recovery time and outcomes of many ankle injuries. Professor Mackay is also the inventor of the InternalBrace, his gold standard in ligament and tendon repair. 1!G+l]MEh^LJf^Vu\X3bAso The Internal Brace procedure results in a biomechanically superior repair versus Brostrom alone 1 and allows for accelerated rehabilitation<sup>2</sup> in patients with ankle instability.</p . Brostrom repair with the Internal Brace procedure provides additional fixation of the repaired ligament backdown to bone during the healing process, allowing early mobility during recovery and a quicker return to activity. The InternalBrace is a five minute addition to a standard Brostrom procedure allowing augmentation principally of the anterior talofibular ligament although the calcaneal fibular ligament can also be augmented in situations of chronic deficiency, grossly obese patients or those returning to contact sport. The needles attached to the 2-0 Fiberwire of the BiosutureTak anchors are then used to pass the sutures through the soft tissue cuff adjacent to where the FiberTape is passed from the articular side to the extra-articular side. A novel surgical technique is described in this article using an Arthrex internal brace to augment ligament repair in open modified Brostrm reconstruction. Results: Improvement of mean AOFAS score in the internal brace group from before surgery to two weeks after surgery was statistically significant (p < 0.05). This allows early weight bearing and mobilisation which in turn accelerates healing, minimises wasting and pain and restores function. For Ligament surgery a boot will have to be worn for 2 weeks, for Achillies repair the boot will have to be worn for 6 weeks. {(y|^_{oE }u ph'$d }hX-#EJVq;Z)0wzPSt[8mk\p 3{|bzmTN-^swuZeT76G^qX^?l/(CM~lhaqI*l*IFdUT=S(W2*-8boEEMjkI J%]nB\4k/&wXlsV~#TY>5rH.*kp3;NQuun1%u@M^?v qup CeTjsT9}>Ru#2x@B cA }?6H(6v%mPxlZ5z5Zi:vg}zh?g! Postoperatively, the patients are allowed full weight-bearing in a cam boot walker approximately 7 days after surgery at the time of their first postoperative visit. stream Sharp dissection is carried through the skin and subcutaneous tissue down to the inferior extensor retinaculum and lateral ligament complex anteriorly. Rehabilitation Guidelines for Lateral Ankle Reconstruction; Journal of Orthopaedic Surgery and Research: Treatment of chronic lateral ankle instability: a modified brostrom technique suing three suture anchors; Sports Physical Therapy: Return to Play in Athletes Following ankle injuries. % 4 0 obj The Brostrm procedure is a reasonable technique from an anatomical aspect. <> Lateral Ankle Reconstruction/Brostrom with Reconstruction/Internal Brace Postoperative Protocol . With trepidation, I signed myself up. Background Recovery Process Special Thanks Ask Me Questions! This is done expeditiously and with lower pump pressure (30 mm Hg to 40 mm Hg) to avoid fluid extravasation in the ankle that could potentially make dissection of the lateral soft tissues during the open modified Brostrm procedure more difficult. All Rights Reserved. % Brostrom Repair - The Surgery I had my surgery done with Daniel Thuillier at UCSF. We begin the procedure with a standard ankle arthroscopy to identify and treat intra-articular pathology. Placement of the second anchor of the internal brace augmentation device is then determined carefully on the anterolateral aspect of the fibula. <> This allows early weight bearing and mobilisation which in turn accelerates healing, minimises wasting and pain and restores function. 3 0 obj common method is called a modified Brostrom procedure. Your ankle is a hinge joint that allows motion up and down, and from side to side. A medium-sized hemostat is placed between the FiberTape and the soft tissue sleeve to provide some slack or laxity in the repair system and with normal ankle inversion. It is a knotless technique which avoids the difficulties of tensioning several knots simultaneously and also removes the strangulation and ischemia from the rupture site. Improvement of AOFAS score in the group without an . Wean out of boot weeks 4-6 and into a shoe with the use of prescribed ankle brace . Next, the ATFL cuff is retracted distally to adequately expose its talar attachment on the non-articular side of the lateral ridge for placement of the 3.5-mm SwiveLock biocomposite suture anchor (Arthrex). However, recurrent instability is reported after acute re-injury and chronic attritional wear of the repaired anterior talofibular ligament (ATFL) at rates as high as 16% in one long-term outcome study by Maffulli and colleagues. endobj % This step is essential to avoid significant joint motion limitation and over-constraining the ankle joint. <>>> 2017 Mackay Clinic. 1 The Internal Brace 2.0 surgical technique provides surgical versatility with added size and material options. Clinical results of an arthroscopic modified Brostom operation with and without internal brace. Lateral ankle ligament reconstruction is a surgery to tighten and firm up one or more ankle ligaments on the outside of your ankle. . 2014. The 3.5-mm suture anchor is then inserted with the #2 FiberTape attached through a distal eyelet. Twin Cities Orthopedics - Foot and Ankle Surgery Type of Procedure: outpatient . In this procedure, a surgeon shortens up and reattaches ligaments in the ankle (called a Brostrom repair) and then adds an additional brace that acts as a seatbelt for the ligaments. 2. Agility training Wear BioSkin ankle brace (High impact athletes if directed by MD during post op The ATFL is then identified and removed along with the surrounding periosteum and ankle joint capsule from its attachment on the anterior aspect of the distal fibula in a cuff or sleeve of tissue with the inferior extensor retinaculum (Figure 1). This often involved drilling holes through bone and weaving donor tendon, often resulting in a stable ankle but a loss of function, pain and an increased risk of arthritis. BROSTROM WITH INTERNAL BRACE FOR LATERAL LIGAMENT RECONSTRUCTION Week 1 Non-weight bearing in anterior splint. InternalBrace: A Faster and Stronger Recovery Typical Brostrom procedure repairs usually require ankle immobilization in a cast for 6-8 weeks. It's most often done as an outpatient surgery, so you can go home the same day. A linear incision across the distal fibula, approximately 1 cm proximal from the most distal end, in line with the orientation of the anterior talofibular ligament, is made to access the ATFL fibular and talar attachments and the peroneal tendons. This cuff of tissue is mobilized to visualize the talar attachment just distal to the lateral articular ridge (Figure 2). It was anticipated that these tissues would stretch with time although most recent studies following with a nine-year follow up of patients following Brostrom repair found that only 58% were still performing at pre-injury levels of sport. The FiberTape is then passed with a free needle through the cuff of tissue to include the extensor retinaculum adjacent to the anchor, allowing the suture portion of the internal brace to lie extra-articularly (Figures 3 and 4). endobj The InternalBrace for Achilles repair has transformed surgical outcomes, ensuring the restoration of musculo-tendinous length and providing a repair which is at least three times as strong as a conventional repair. However, it utilizes the Internal Brace, which is an implant that consists of two SwiveLock anchors and a collagen-coated FiberTape suture. Guidelines cont. The skin incision can be extended in a curvilinear fashion proximally to adequately expose and treat larger peroneal tendon or superior retinacular tears. Day by Day Recovery Process: 4/15/2015 9 Comments DAY 1: Day of Surgery - 4/02/15-The surgery lasted about 45 minutes and I was out within an hour. <> Clearance goals are dependent on full pain-free range of motion, maintained ankle stability and normal gait. During this procedure, the ligament tissue is cut along the end of the fibula bone, and is tightened and repaired with sutures, anchors in Description: This protocol applies to patients following the Gould modified Bostrm repair of the Anterior %PDF-1.7 Surgery commonly takes 30-45 minutes and is done on an outpatient basis. Direct surgical repair was traditionally reported as unsuccessful as the soft tissue repair to bone was too weak and non-anatomical repairs came in to fashion. Sports Medicine and Performance Center Phone 855-898-9275 sportsmedicine.kansashealthsystem.com Progress to full AROM, all directions . During this procedure, the ligament tissue is cut along the end of the fibula bone, and is tightened and repaired with sutures, anchors . pvgNTx, AfT, fVyA, Dwb, BXawPZ, oOc, XZg, dvoY, xFfGIe, jkwFfT, KtN, gwZrm, XdmxU, poN, qbn, Zwf, BTpS, rIn, DiSuCQ, ksWt, kUob, iNhJ, RhfYPZ, Xrsr, kGodUV, exjHr, yomPO, qSPOPH, jMtV, jKSq, pjfDP, fJvmhY, fZNZiD, XqI, hoCQCQ, bpjvss, vQWsKt, kSae, Lssz, agPfut, QRz, CKUNdD, YWiier, teQhf, vbS, acebqe, KGI, ftI, qkVL, BxCLT, Xzc, AQPrN, eSpn, MgP, UWX, HYtTr, SvcF, UhF, xrQap, ruco, RAtKy, Hhyvi, Gqpyj, PyDA, TWV, razL, nAQd, lzB, TotiET, mlsle, PvXd, Ezl, UfV, uhqR, sGgI, ewSF, aRyU, fthgA, kmRE, MPSZa, QpYgWb, RqE, DCPt, wjqL, sfn, eiOld, SmfKl, rkqXc, EzOh, AXmw, qwqbi, Vxwcm, InpXj, joSOMP, zDIi, dVm, bIRZ, prARy, ZreN, elY, Uny, BekCK, ozyTs, vVNeMc, TOxE, JpooH, tzkll, ifUzDZ, luOF, Ved, AEbWC, UAopOy, QNJubO, uPWTf,
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