20-1). The arthrodesis site should be stabilized with rigid internal fixation. Screw placement for the subtalar fusion is relatively simple because it can extend across the ankle joint. In chronic malunion/nonunion situations, the reduction could be difficult. 20-2B). The transverse tarsal joint motion demonstrated 60% loss of abduction and adduction compared with the uninvolved side. This placement provides maximum purchase in the talar neck from the screw. The extensor digitorum brevis muscle is closed over the area, creating a cover for the arthrodesis site. Under these circumstances, a small curet is used to remove the cartilage from the posterior facet. The incision is carried directly to bone, and slight stripping is done on each side of the pin to accommodate the washer. E, Distraction with a lamina spreader gives excellent exposure of the subtalar joint. I, An instrument tray under the calf to allow easy access to the posterior aspect of the heel for screw placement. The postoperative dressing is used for approximately 10 to 14 days before removing the sutures. If this occurs, a painful scar or dysesthesias distal to the injury can result in a dissatisfied patient despite a satisfactory fusion. The guide pin is removed, and the small bone fragments that have been mobilized are packed into the tarsal canal and the sinus tarsi area. E, Distraction with a lamina spreader gives excellent exposure of the subtalar joint. 6. N, Wound complications are not uncommon with distraction bone blocks. The larger side of the block should always go medial to create a valgus alignment. A particular arthrodesis is not always placed into a standard alignment; rather, it must be individualized for each patient. Coughlin et al3 believe the progress of the fusion cannot be determined accurately from standard radiographs. This is done by removing the internal fixation and the fibrous tissue between the bone ends, realigning the surfaces, performing a bone graft if necessary, and inserting rigid fixation, usually with a plate-and-screw construct. J Bone Joint Surg Br 2000; 82:1019 -1021 [Google Scholar] The subtalar joint is placed into 5 degrees of valgus while also correcting any peritalar rotation/subluxation, and the guide pin is drilled into the talus until it just penetrates the dorsal aspect of the neck of the talus. 2019 Mar;58(2):243-247. doi: 10.1053/j.jfas.2018.08.030. Placing a patient into a cast without adequate padding is not advisable. If a fully threaded screw is used, the calcaneus should be overdrilled to create a gliding hole. A thin, wide elevator then can be inserted into the joint to pry it open, after which a lamina spreader is inserted. After a triple arthrodesis, the talonavicular joint occasionally does not fuse, but because of a successful fusion of the subtalar and calcaneocuboid joints, it may not be a source of pain. By using our website, you consent to our use of cookies. An isolated subtalar joint arthrodesis is the workhorse procedure of the hindfoot and results in satisfactory correction of deformity and relief of pain that enables the patient to regain the ability to perform most activities. Orthotics do not work well because the transverse tarsal joint stays locked. SPECIFIC ARTHRODESES (Video Clips 26-30, 81, 82, 84, and 85) A large area of skin necrosis like this will need a thorough debridement, followed by a vacuum-assisted closure (wound-VAC) or skin flap. Using a curet will facilitate that. The guide is then set on the heel, after which a guide pin is placed across the subtalar joint. This results in a rigid internal fixation with maximum purchase and interfragmentary compression across the joint. Even when the bone surfaces have been adequately prepared, nonunion can occur if internal fixation is inadequate. The concept of what constitutes an adequate fusion deserves more extensive study, but it appears that fusion of more than 40% of the surface is adequate. The literature has demonstrated, however, that an isolated subtalar arthrodesis produces a superior result with less stress on the ankle joint than a triple arthrodesis. When performing a fusion, the hindfoot must be aligned to the lower extremity and the forefoot to the hindfoot to create a plantigrade foot. Temporary relief can be fairly reliably obtained with intermittent fluoroscopic- or ultrasound-guided cortisone injections. extra articular surface edema seen involving lateral talar process and calcaneal sulcus with areas of underlying sclerosis. 20-2D and E). Clipboard, Search History, and several other advanced features are temporarily unavailable. The larger side of the block should always go medial to create a valgus alignment. After an ankle or triple arthrodesis, approximately 30% of patients demonstrate arthroses distal or proximal to the fusion site within 5 years. 12. The only way to visualize the middle and anterior facets of the subtalar joint is to remove all the soft tissue from the sinus tarsi. The subtalar joint is placed into 5 degrees of valgus while also correcting any peritalar rotation/subluxation, and the guide pin is drilled into the talus until it just penetrates the dorsal aspect of the neck of the talus. However, in a situation with poor bone quality or correction of severe deformities, there are several excellent midfoot plating systems available. MRI of Ankle and Lateral Hindfoot Impingement Syndromes. A thin, wide elevator then can be inserted into the joint to pry it open, after which a lamina spreader is inserted. Case study, Radiopaedia.org (Accessed on 11 Dec 2022) https://doi.org/10.53347/rID-47551. Twenty-eight cases (37%) of lateral hindfoot impingement were identified, including six talocalcaneal, eight subfibular, and 14 talocalcaneal-subfibular impingements. Patients must be made aware of the potential for nerve injury and the area where they can experience numbness. MR images from 75 patients (45 women and 30 men) with MRI evidence of posterior tibial tendon tears were evaluated for grade of posterior tibial tendon tear, hindfoot valgus angle, osseous contact or opposing marrow signal changes at the talus-calcaneus or fibula-calcaneus, peroneal tendon subluxation-dislocation, and presence of lateral malleolar bursa. Under these circumstances, this device provides excellent rigid fixation. A depth gauge is used to determine the length of the screw. The pin placement is confirmed by fluoroscopy. The potential for a skin slough can be minimized by creating full-thickness skin flaps, making incisions of adequate length to minimize tension on the skin edges, using postoperative drainage when appropriate, and applying a firm compression dressing postoperatively. If the surgery is being carried out for severe arthrosis or a talocalcaneal coalition, it is often not possible to open the subtalar joint very far. Nonunion of the subtalar joint occurs in 15% of cases, with a range of 1% to 45% in the reported literature. To determine the alignment, the surgeon first must evaluate the normal extremity. Treatment included a lateral calcaneal wall exostectomy and dbridement of the subfibular region. This is important because if a superficial wound slough occurs, it will be over an underlying bed of soft tissue rather than bone. Although cutaneous nerves tend to lie in certain anatomic areas, great variation exists. There is peritalar subluxation with the navicular subluxing lateral and dorsal, while the calcaneus rotates lateral and posterior, creating a hindfoot valgus. If the surgeon fails to recognize this malalignment and places a bone block into the lateral side of the subtalar joint, wedging it open will not reposition the calcaneus into correct anatomic alignment (Fig. The possibility of infection is always a postsurgical concern. The hole in the talar neck is tapped, and a fully threaded, 7.0-mm cannulated screw of appropriate length is inserted. How do you fix a labral tear and impingement. In placing the screw, the surgeon should not have more than 2 to 3 mm of screw exposed on the neck of the talus. Deep skin necrosis after a medial incision in a diabetic patient. D, Also easy exposure of the posterior facet. Every screw system will have a smaller and larger drill to achieve the gliding and compression holes. Lateral hindfoot impingement is often seen in patients with severe . Sometimes With impingment, the rotator cuff is being pinched, without necessarily being torn, between the acromion of the shoulder blade and the top of the hume Impingement implies the cuff not having enough room to move vs tearing of the cuff. This is done by removing the internal fixation and the fibrous tissue between the bone ends, realigning the surfaces, performing a bone graft if necessary, and inserting rigid fixation, usually with a plate-and-screw construct. The incision passes along the dorsal aspect of the peroneal tendon sheath and distally along the floor of the sinus tarsi. The most appropriate option for a specific situation should be used. Before Extraarticular lateral hindfoot impingement with posterior tibial tendon tear: MRI correlation. Discuss the pathophysiology and clinical presentation of extraarticular lateral impingement of the hindfoot Kim SH, Ha KI. 20-2A and Video Clips 26 and 27) 19. The screw placement is a little simpler because there is no concern about penetrating the ankle joint with the screw (Fig. The patient is placed in the supine position with a support under the ipsilateral hip to facilitate exposure of the subtalar joint. Of the hindfoot fusions, the patients ability to achieve a high level of function is greatest after a subtalar arthrodesis. The subchondral surfaces are heavily feathered or scaled with a 4- or 6-mm osteotome, which creates a broader, bleeding cancellous surface required for successful fusion. Orthotics do not work well because the transverse tarsal joint stays locked. With the pin properly placed, a 2- to 3-cm transverse incision is made over the entrance of the guide pin into the heel pad. This resulted in a 14% loss of sagittal plane motion. It can also place increased stress along the medial aspect of the ankle joint and pronation of the foot. The posterior and middle facets, along with the bone in the base of the sinus tarsi, are heavily scaled. The impingement occurs lateral to the ankle joint as a result of flatfoot deformity with resulting talocalcaneal subluxation and valgus hindfoot malalignment. Lateral hindfoot impingement (LHI) is a subtype of ankle impingement with classic MRI findings (1). The patients dressing is changed approximately 10 to 14 days after surgery, and the sutures are removed. My dr. says that my nct indicates "nerve impingement." HealthTap uses cookies to enhance your site experience and for analytics and advertising purposes. 2 When severe deformity exists, these problems can rarely . The agreement between the two methods was poor. eCollection 2022 Jan-Mar. Recognizing a dysvascular problem also helps to predict the outcome for the patient. a CT scan or MRI can be orderedtohelp narrow the differential for etiology of symptoms. 12. However, alignment is possible in the majority of cases, even when a significant deformity is present, by complete mobilization of the involved joints, followed by manipulation to create a plantigrade foot. The incision passes along the dorsal aspect of the peroneal tendon sheath and distally along the floor of the sinus tarsi. Aiyer A, 2003-2022 ESR - European Society of Radiology, https://dx.doi.org/10.26044/essr2019/P-0173. There should be caution not to overdistract because this will force the hindfoot in varus (Fig. When dealing with dysvascular bone preoperatively, it is important to identify the areas of potential problems and create a surgical plan that will help solve the problem. government site. A triple arthrodesis is not necessary to obtain a satisfactory result, even in the presence of beaking of the talonavicular joint. When making an incision, the surgeon must always be cognizant of the location of the cutaneous nerves about the foot and ankle. The impingement in the lateral aspect of the hindfoot may first occur within the sinus tarsi and then involve the calcaneofibular region. The fat pad is dissected out of the sinus tarsi and reflected dorsally. The patient is placed into a compression dressing incorporating two plaster splints. Although cutaneous nerves tend to lie in certain anatomic areas, great variation exists. Once all the articular cartilage has been removed, the lamina spreader is removed and the alignment of the subtalar joint observed. Clinical presentation It presen. Journal of Bone and Joint Surgery (Am) 2002 November 84-A: 2005-2009. A large area of skin necrosis like this will need a thorough debridement, followed by a vacuum-assisted closure (wound-VAC) or skin flap. Screw placement is carried out by placing an aiming guide with the sharp tine in the anterior aspect of the posterior facet of the subtalar joint (Fig. The guide pin is advanced through the talar neck, appears on the dorsal aspect of the ankle, and is secured with a clamp. Infrequently, a subtalar fusion is required after a previous ankle fusion. When a skin slough occurs, it is important to treat it vigorously with local debridement and application of wet-to-dry dressings to promote granulation tissue, followed by coverage with a split-thickness skin graft. 20-2B). There are multiple fixation options available, including screws, staples, and locking and nonlocking plates. In a deformity-correcting fusion, however, the surgeon must decide the precise alignment that must be obtained to produce a plantigrade foot. There is significant interest lately in doing the subtalar fusion arthroscopically. The transverse tarsal joint motion demonstrated 60% loss of abduction and adduction compared with the uninvolved side.6 This is not always possible, particularly on the dorsum of the foot, where bone lies directly beneath the skin. Malalignment after a fusion is a problem that usually can be avoided by meticulous bone preparation and rigid internal fixation. ADVERTISEMENT: Supporters see fewer/no ads. The usual curved incision for a calcaneal exposure have a much higher wound complication rate because of tension on the distal limb after distraction. The popliteal block may be repeated after 18 to 24 hours if the patient has too much breakthrough pain. Unable to process the form. The fat pad previously dissected from the sinus tarsi and retracted dorsally is placed back into the sinus tarsi area. therefore improving surgical outcomes. 31, 32 Physicians should screen for . Unlike some other lower extremity joints, there are limited surgical options short of arthrodesis of the affected joints. There is little evidence that midfoot fusion results in accelerated surrounding joint arthritis. 20. The surgeon should also consider correcting severe limb alignment before a hindfoot fusion. Rosenberg ZS. Malalignment after a triple arthrodesis is seen most often. There is significant interest lately in doing the subtalar fusion arthroscopically. It is important to inform the patient who is about to undergo an arthrodesis that the surgery should render the specific joint painfree, but it might result in arthritis and pain elsewhere in the foot because of increased stress. If the surgery is being carried out for severe arthrosis or a talocalcaneal coalition, it is often not possible to open the subtalar joint very far. J Bone Joint Surg Br 2000; 82:1019 -1021 [Google Scholar] You may have gone for steroid shots, nsaids & physical therapy. Extraarticular lateral hindfoot impingement is associated with advanced posterior tibial tendon tears and increased MRI hindfoot valgus angle. If a previous calcaneal fracture is present in which the lateral wall needs to be decompressed, the peroneal tendons are elevated from the lateral aspect of the calcaneus as far posteriorly and plantarward as possible. The sinus tarsi is usually unaffected. A particular arthrodesis is not always placed into a standard alignment; rather, it must be individualized for each patient. The screw begins off the weight-bearing area of the heel. The patient is placed into a compression dressing incorporating two plaster splints. The alignment of the extremity distal to the fusion site is also important to be sure a plantigrade foot is created. If any tension is noticeable on the skin edge, some type of a relaxing skin suture should be used. The recognition of imaging findings associated with this entity is paramount in order to make an early diagnosis and to choose the appropriate surgical procedure, These are difficult to revise, and a takedown and redo of the fusion is necessary. Epub 2022 Feb 10. This is important so that when the holes are drilled, the guide pin cannot come out, which can result in loss of alignment. The most common indication for a subtalar arthrodesis is arthrosis secondary to trauma, usually a calcaneal fracture, rheumatoid arthritis, primary arthrosis, or talocalcaneal coalition that cannot be resected. The subtalar arthrodesis should be placed in approximately 5 degrees of valgus. Arthroscopic treatment of anterior and posterior ankle impingement syndrome through Tang's approach can shorten the operation time, simplify the procedures, and obtain good effectiveness and patient satisfaction. The two most common complications are nonunions and varus malalignment. K-M, Preoperative, intraoperative, and postoperative radiographs demonstrate subtalar arthrodesis after calcaneal fracture. Screw placement for the subtalar fusion is relatively simple because it can extend across the ankle joint. This is corrected by placing a lamina spreader in the sinus tarsi between the lateral process of the talus and the anterior process of the calcaneus. Coughlin et al3 did a study comparing standard radiographs to computed tomography (CT) scan in evaluating subtalar fusions. Conservative surgery consists of removal of bone spurs and osteophytes from the midfoot joints. The fat pad previously dissected from the sinus tarsi and retracted dorsally is placed back into the sinus tarsi area. C, Exposure of subtalar joint with Weitlaner retractor. 3. At other times, if the nonunion site has resulted in loss of alignment, the area needs to be revised. The extensor digitorum brevis muscle origin is detached and the muscle belly reflected distally, exposing the underlying sinus tarsi, subtalar joint, and calcaneocuboid joint (Fig. The reported nonunion rate varies from 5% to 45%. The mean observed fusion of the posterior facet of the subtalar joint ranged from 41% at 6 weeks to 61% at 12 weeks and to 86% at 6 months on the radiographs; the mean fusion of the posterior facet on the CT scans ranged from 23% to 48% to 64% at the same time intervals. The surgeon should consider the options and might even slightly overcorrect the fusion to unload the compromised side of the ankle joint. Talk to a doctor now . A guide pin is drilled into the calcaneus until it is visible in the posterior facet of the subtalar joint. The main complications after an attempted arthrodesis include infection, skin slough, nerve disruption or entrapment, nonunion, and malalignment. Other techniques may be equally effective, but reproducibly good results have been achieved with subtalar arthrodesis, talonavicular arthrodesis, double arthrodesis, triple arthrodesis, naviculocuneiform arthrodesis, and tarsometatarsal arthrodesis. Video chat with a U.S. board-certified doctor 24/7 in less than one minute for common issues such as: colds and coughs, stomach symptoms, bladder infections, rashes, and more. Several recent papers with further information on the topic are listed.5,8 The theoretic advantages of an arthroscopic fusion are a more cosmetic approach and fewer wound complications.1,7 In experienced hands, the results appear to be comparable to open fusions, but there are several pitfalls as well. Vol. 20-2I). This complex alignment creates a technically challenging situation for the surgeon. 11. imaging findings and management strategies.Kaplan, Arthroscopic treatment for impingement of the anterolateral soft tissues of the ankle. The subtalar joint is placed into 5 degrees of valgus while also correcting any peritalar rotation/subluxation, and the guide pin is drilled into the talus until it just penetrates the dorsal aspect of the neck of the talus. Subtalar Arthrodesis (Fig. A nonunion of an attempted fusion site is always an unfortunate event. 20-2C). If 7.0-mm cannulated screws are used, the initial hole is drilled with a 4.5-mm bit, just penetrating the neck of the talus. The usual malalignment after a triple arthrodesis is varus of the heel and adduction or supination (or both) of the forefoot. Pathology. The popliteal block may be repeated after 18 to 24 hours if the patient has too much breakthrough pain. 9. The articular surfaces to be arthrodesed are brought together and stabilized with provisional fixation. The guide pin is advanced through the talar neck, appears on the dorsal aspect of the ankle, and is secured with a clamp. The two basic types of arthrodeses are an in situ fusion and one that corrects a deformity. This sometimes depends on the surgeons ingenuity in creating a stable construct, particularly if poor bone stock is present. A depth gauge is used to determine the length of the screw. Patients undergoing a subtalar arthrodesis for talocalcaneal coalition generally do very well. In the largest study in the literature, by Myerson and coworkers, the union rate was 84% (154 of 184) overall, 86% (134 of 156) after primary arthrodesis, and 71% (20 of 28) after revision arthrodesis.4 This alignment permits the screw to pass through the anterior aspect of the posterior facet and into the neck of the talus, but the screw does not penetrate the sinus tarsi area. It is most common after a previous talus fracture, but it could also be due to excess stress after an ankle arthrodesis. 20-2I). Other techniques may be equally effective, but reproducibly good results have been achieved with subtalar arthrodesis, talonavicular arthrodesis, double arthrodesis, triple arthrodesis, naviculocuneiform arthrodesis, and tarsometatarsal arthrodesis. In the authors experience, more hardware is better, and thus a combination of screws, staples, and plates is recommended for the talonavicular joint. Once the subchondral bone is exposed, the foot is once again manipulated, placing it into the desired alignment. The extensor digitorum brevis muscle origin is detached and the muscle belly reflected distally, exposing the underlying sinus tarsi, subtalar joint, and calcaneocuboid joint (Fig. The reported nonunion rate varies from 5% to 45%. Assessment of Bony Subfibular Impingement in Flatfoot Patients Using Weight-Bearing CT Scans. Ligamentous ankle pathology mainly involve the lateral ligaments and to a lesser extent the. Initial treatment could include shoe and activity modifications as well as the addition of orthotics. These are difficult to revise, and a takedown and redo of the fusion is necessary. All the soft tissue is removed from the sinus tarsi and a Freer is placed in the middle facet. The most appropriate option for a specific situation should be used. Occasionally, an asymptomatic nonunion occurs and can be treated with observation. The skin incision begins at the tip of the fibula and is carried distally toward the base of the fourth metatarsal. Extra-articular lateral hindfoot impingement with posterior tibial tendon tear: MRI correlation. 10. If a varus deformity needs to be corrected, bone is removed from the lateral aspect of the posterior facet to correct the deformity. If there is a fixed forefoot varus with the hindfoot well aligned, it can be corrected by carrying out a simultaneous naviculocuneiform and/or cuneiformfirst metatarsal fusion. Objective: Although this chapter discusses arthrodesis of the joints of the foot and ankle, the clinician should always remember that, if possible, arthrodesis should be avoided, particularly in patients younger than 50 years. Methods Between August 2010 and September . Peroneal tendinopathy is an under-recognized cause of lateral hindfoot pain and can go undiagnosed, especially when associated with lateral ankle sprains. 20-2G). 20-2C). Donovan A, Rosenberg ZS. Seventy percent participated in recreational sports (e.g., walking for pleasure, biking, skiing, swimming), and 14% were able to play sports that required running and pivoting (e.g., basketball, racquet sports). A hindfoot arthrodesis places more stress on the surrounding joints and could accelerate degenerative changes of these joints. Biomechanically, LHI is the sequela of lateral transfer of weight bearing from the central talar dome to the lateral talus and fibula. It is also indicated for a muscle imbalance (e.g., loss of peroneal muscle function) or posterior tibial tendon dysfunction with an unstable subtalar joint but normal transverse tarsal joint motion and a fixed forefoot varus deformity of less than 12 degrees. This is not always possible, particularly on the dorsum of the foot, where bone lies directly beneath the skin. Donovan A, If the subtalar joint is placed into excessive valgus, it can impinge against the fibula, causing pain over the peroneal tendons. Malicky ES, The prevalence of impingement was significantly increased with greater MRI hindfoot valgus angle (p < 0.001). A thigh tourniquet is applied. the mri shows the peroneal tendons are dislocated, impingement, and degene. It is unusual to remove more than 3 to 5 mm of bone when correcting a deformity, although occasionally more bone needs to be removed. Once all the articular cartilage has been removed, the lamina spreader is removed and the alignment of the subtalar joint observed. When a talonavicular arthrodesis is performed, the surgeon must remember that motion in the subtalar joint will no longer occur. Single leg tip toe test (heel raise): Check for errors and try again. 22. 20-2K-M). The guide pin is removed, and the small bone fragments that have been mobilized are packed into the tarsal canal and the sinus tarsi area. With a fully threaded screw, the maximum number of threads is placed in the neck of the talus, maximizing the compression. Disclaimer, National Library of Medicine The soft tissue envelope of the foot and ankle often contains little or no fatty tissue. Understand the clinical importance of extraarticular lateral impingement of the hindfoot. 50% off with $15/month membership. 2. The dense bone in the floor of the sinus tarsi is deeply scaled and is mobilized so that it can be packed into the tarsal canal after the internal fixation has been inserted. The surgeon should consider the options and might even slightly overcorrect the fusion to unload the compromised side of the ankle joint. When an isolated subtalar arthrodesis is carried out, the incision usually stops at about the level of the calcaneocuboid joint (Fig. Although an external fixator can provide excellent fixation, if possible, a closed system without an external fixator is safer because of possible pin-tract problems with prolonged immobilization. Lateral Impingement. By overdrilling the calcaneus, intrafragmentary compression at the arthrodesis site is achieved. If significant realignment is to be achieved, it must not be at the expense of proper wound approximation. The navicular can develop evidence of avascular changes either spontaneously (Kohlers or Mueller-Weiss syndrome) or secondary to previous injury. When dealing with dysvascular bone preoperatively, it is important to identify the areas of potential problems and create a surgical plan that will help solve the problem. If placement is satisfactory, the guide is removed; if not, another attempt is made to place the guide pin correctly (Fig. When evaluating the patient for an arthrodesis, the surgeon should also examine the surrounding joints as well as the limb alignment. There is a lot going on in this case: hindfoot valgus with extra-articular talocalcaneal impingement; suggestion of developing calcaneofibular impingement with subortical cysts present at the lateral malleolar tip. 20-2D and E). AJR Am J Roentgenol. P and Q, Lateral and AP radiographs showing correction of the calcaneal dislocation with a combination of a subtalar bone block fusion and calcaneocuboid fusion. The initial postoperative dressing is very important and should support the soft tissues as well as the arthrodesis site. There are ongoing issues in getting subtalar fusions to heal. The https:// ensures that you are connecting to the The physical examination demonstrated that the alignment averaged 5.7 degrees of valgus, and the one patient with fusion in varus was dissatisfied. 2021 May;27(3):432-439. doi: 10.5152/dir.2021.20268. Specific Arthrodeses Primary LHI is rare and may occur due to an accessory anterolateral talar facet (2). This is important because if a superficial wound slough occurs, it will be over an underlying bed of soft tissue rather than bone. 20-2D and E). Most often, the lateral half of the navicular is avascular, whereas the medial half still has good healthy bone. {"url":"/signup-modal-props.json?lang=us\u0026email="}, Babu V, Extra-articular hindfoot impingement syndrome. 5. Similar severe deformity is seen with a small subset of calcaneal fractures, where the tuberosity dislocates laterally and sits under the fibula. If the neuroma is too bothersome, it requires resection to a more proximal level. The position of the screw is verified with fluoroscopy. It is imperative that the clinician recognizes this problem so that when a subtalar arthrodesis is carried out, the calcaneus is repositioned under the talus, restoring the normal weight-bearing alignment. Postoperative Care 14. Crary JL, When avascular bone is present, it is often not possible to obtain a fusion to the dysvascular bone, and an attempt must be made either to bypass the avascular area or to determine the portions of the talus that still have adequate vascularity and attempt a fusion using these areas. Malalignment can only be prevented by careful observation of the extremity at surgery. It is not necessary to strip the peroneal tendons off the lateral side of the calcaneus unless a lateral impingement from a previous calcaneal fracture requires decompressing. When avascular bone is present, it is often not possible to obtain a fusion to the dysvascular bone, and an attempt must be made either to bypass the avascular area or to determine the portions of the talus that still have adequate vascularity and attempt a fusion using these areas. Once the joints have been mobilized and it is determined that bone does not need to be removed, the articular surfaces are meticulously debrided of their articular cartilage and any fibrous tissue to subchondral bone. Several ankle ligaments ensure the static and dynamic stability of the ankle joint, but they are prone to injury due to acute trauma as well as repetitive ankle sprains. Using a curet will facilitate that. There is a higher risk of nerve a vascular injury, and there is a very steep learning curve. The stiffer the surrounding joints, the less the patient is able to dissipate the increased stress created by the fusion compared with a patient who has more joint laxity. By carrying out a fusion in this manner, broad bleeding surfaces of cancellous bone are brought together, which provides the best possible chance for a successful arthrodesis. Posterior tibial tendon dysfunction with secondary hindfoot valgus can lead to painful extraarticular, lateral talocalcaneal, and subfibular impingements, often necessitating surgical intervention. This requires the patient to walk on the lateral aspect of the foot, causing patient dissatisfaction. 20-2R). The subcutaneous tissue and skin are closed in a routine manner. The most common area of avascular necrosis in the midfoot is the navicular. in the context of clinical history and physical examination findings, Using the patella as a reference point makes alignment at surgery much easier and more precise. The potential for a skin slough can be minimized by creating full-thickness skin flaps, making incisions of adequate length to minimize tension on the skin edges, using postoperative drainage when appropriate, and applying a firm compression dressing postoperatively. Occasionally, in the patient with rheumatoid arthritis, severe subluxation occurs at the subtalar joint. Lateral hindfoot impingement is believed to be secondary to a lateral shift of weight-bearing forces from the talar dome to the lateral talus and fibula . If the slough is too large, a plastic surgeon should be consulted (Fig. Epub 2020 Sep 16. There are ongoing issues in getting subtalar fusions to heal. J, Postoperative anteroposterior (AP) and mortise radiographs demonstrate subtalar fusion using two 6.5-mm screws. By overdrilling the calcaneus, intrafragmentary compression at the arthrodesis site is achieved. Figure 20-2 Subtalar joint fusion. With good bone quality and well-apposed bone surfaces screws or compression, staples will suffice. decreased joint space involving lateral aspect of posterior talocalcaneal joint. Initial treatment could include shoe and activity modifications as well as the addition of orthotics. J Med Ultrasound. It is also advisable to confirm reduction in all planes with fluoroscopy before definitive hardware placement. If there are reasons not to do a popliteal block, an ankle block could give fairly similar pain relief, as long as all the nerves are included (deep and superficial peroneal, tibialis, sural, and saphaneous). In some cases, when multiple joints are involved, it may be more desirable to treat the patient conservatively with an orthotic device, such as an anklefoot orthosis (AFO), rather than carry out an arthrodesis. When the subtalar joint is placed into an, Once the subchondral bone is exposed, the foot is once again manipulated, placing it into the desired alignment. A lamina spreader is inserted into the sinus tarsi to visualize the posterior facet of the subtalar joint (Fig. Because of soft bone or soft tissue problems, however, it may become necessary to use an external fixator. The surgical approach should be as precise as possible to avoid placing undue tension on the skin edges. Complications Two screws are routinely used. R, Preoperative radiograph demonstrating subtalar and talonavicular arthrosis in a patient with prior ankle fusion. Calcaneal offset index to measure hindfoot alignment in pes planus. Bone graft from the iliac crest is rarely necessary when carrying out a foot or ankle arthrodesis. SURGICAL PRINCIPLES AOFAS 4. B, The universal lateral incision is made from the tip of the fibula and extends toward the base of the fourth metatarsal so as to place it in the interval between a branch of the superficial peroneal nerve dorsally and the sural nerve plantarly. Results: The bone along the lateral aspect of the calcaneus that forms the anterior process may be mobilized to within about 0.5 cm of the calcaneocuboid joint and used for bone graft. The most common area of avascular necrosis in the midfoot is the navicular. If the joints surrounding the talonavicular joint are not properly aligned, a plantigrade foot will not be created. This gives exposure to the subtalar (ST) and calcaneocuboid (C-C) joints. official website and that any information you provide is encrypted Acquired extraarticular lateral hindfoot impingement is typically associated with flatfoot and hindfoot valgus and can be related to multiple etiologies including PTT dysfunction, healed intraarticular calcaneal fractures, . This incision must be made wide enough to accommodate the screw(s) and, if used, the washer(s) to prevent compressing the skin and fat of the heel pad. I, An instrument tray under the calf to allow easy access to the posterior aspect of the heel for screw placement. 5. Sometimes bone has been lost, making a bone graft necessary, but in an in situ fusion, grafting is not usually required. The degree of internal or external rotation, varus or valgus, and abduction or adduction is carefully noted. This section presents the techniques and principles the authors group uses and believes can achieve satisfactory outcomes with careful adherence to technique. If the overall alignment of the nonunion is satisfactory, bone grafting by inlaying bone across the nonunion site often results in a fusion if internal fixation is adequate. Before going for Might help to see a physical therapist if an ortho has made DX of impingement. 15. The skin incision begins at the tip of the fibula and is carried distally toward the base of the fourth metatarsal. 7. This complex alignment creates a technically challenging situation for the surgeon. and transmitted securely. Several 0.62-mm Kirschner wires (K-wires) will help keep the reduction before fixation. Jeng CL, Rutherford T, Hull MG, Cerrato RA, Campbell JT. If an infection occurs, it is important to recognize and treat it promptly with appropriate antibiotics. The transfer occurs due to collapse of the medial arch of the foot, most commonly from posterior tibial tendon (PTT) and spring ligament (SL) insufficiency . J Foot Ankle Surg. The agreement between the two methods was poor. H, The anterior cruciate guide is placed into the subtalar joint with the tine in posterior facet, as marked on the model. J Bone Joint Surg Br 2000; 82:1019 -1021 [Google . Chapter Contents Unable to load your collection due to an error, Unable to load your delegates due to an error. The posterior and middle facets, along with the bone in the base of the sinus tarsi, are heavily scaled. Therefore the subtalar joint must be aligned into 5 degrees of valgus, after which the talonavicular joint is aligned while taking into account abduction or adduction of the transverse tarsal joint as well as correcting any forefoot varus that might be present. Rarely is bone harvested from the iliac crest. The incision should be straight. Download Citation | MRI of lateral hindfoot impingement | Lateral hindfoot impingement (LHI) is a subtype of ankle impingement syndrome with classic MRI findings. If you are referring to the hip, a trial of physical therapy, nsaids, and activity modification is attempted. For safety, a curet of appropriate size is used to remove the cartilage posterior and posteromedial and from the middle and anterior facets. F, The opposing surfaces are deeply feathered. The position of the subtalar joint determines the flexibility of the transverse tarsal (talonavicularcalcaneocuboid) joint, and therefore it is imperative that a subtalar arthrodesis be positioned in about 5 degrees of valgus to permit mobility of the transverse tarsal joint. The purpose of this study was to correlate findings of lateral hindfoot impingement with grading of posterior tibial tendon tears and severity of hindfoot valgus on MRI. This is corrected by placing a lamina spreader in the sinus tarsi between the lateral process of the talus and the anterior process of the calcaneus. The screw placement is a little simpler because there is no concern about penetrating the ankle joint with the screw (Fig. 2019 Jan;48(1):11-27. doi: 10.1007/s00256-018-2976-7. 193: 672-678. It is seldom necessary to remove bone from the medial side of the joint because this is by and large a rotational deformity. A valgus deformity is common in posterior tibial tendon dysfunction. Sonographic Finding of Medial Ankle Subcutaneous Edema and Its Association with Posterior Tibial Tenosynovitis. Posterior tibial tendon dysfunction is the most common cause of acquired flatfoot and hindfoot valgus and may lead to medial and, with advanced disease, lateral ankle pain [1, 2].This lateral ankle pain has been attributed to extraarticular lateral hindfoot impingement including talocalcaneal (between the lateral talus and calcaneus) [3, 4] and subfibular (between the calcaneus and fibula . All patients underwent tomosynthesis, radiography, and computed tomography . With the patient in a supine position, the patella is aligned to the ceiling, giving the surgeon a reference point from which all measurements are made. A small elevator is passed along the lateral side of the posterior facet of the subtalar joint. Regular sharp. This mobilizes the joints, allowing the surgeon to realign the foot. With a fully threaded screw, the maximum number of threads is placed in the neck of the talus, maximizing the compression. To accommodate this, the patient often walks with the extremity in external rotation. While deepening the incision, the surgeon should be cautious, because the anterior branch of the sural nerve may be crossing the operative site plantarly and the superficial peroneal nerve dorsally. 16. As a general rule, of the joints around the foot and ankle, the talonavicular probably has the highest incidence of nonunion. CT scanscan better identify cystic changes and sclerosis iwhen compared to plain radiographs. Varus should be avoided because it results in increased stiffness of the transverse tarsal joint. Magnetic resonance imaging of the ankle and foot. The patient is placed in the supine position with a support under the ipsilateral hip to facilitate exposure of the subtalar joint. Soft breast tissue. Once the first metatarsocuneiform joint is stabilized, the other joints need to be aligned, both in the transverse and in the dorsoplantar direction. The screw begins off the weight-bearing area of the heel. "MRI of ankle and lateral hindfoot impingement syndromes." This creates a rigid forefoot and increased stress under the lateral aspect of the foot. The transfer occurs due to collapse of the medial arch of th To learn more, please visit our. Likewise, bone substitutes or other materials are rarely required if the bone preparation is carried out correctly. The surgeon should be careful not to put too large a block in the subtalar joint. It was previously believed that an isolated subtalar arthrodesis should not be carried out and that a triple arthrodesis would be the procedure of choice when a hindfoot fusion was indicated. Also be careful not to force the hindfoot into varus. Technical Considerations An isolated subtalar joint arthrodesis is the workhorse procedure of the hindfoot and results in satisfactory correction of deformity and relief of pain that enables the patient to regain the ability to perform most activities. Lateral hindfoot impingement. 2021 Apr 23;30(1):20-25. doi: 10.4103/JMU.JMU_4_21. After exposure of the fusion site, the soft tissues surrounding the joints are removed. The bone along the lateral aspect of the calcaneus that forms the anterior process may be mobilized to within about 0.5 cm of the calcaneocuboid joint and used for bone graft. The skin closure after a fusion is very critical. This creates a rigid forefoot and increased stress under the lateral aspect of the foot. Many factors probably affect the onset of this arthrosis besides the increased stress. The literature has demonstrated, however, that an isolated subtalar arthrodesis produces a superior result with less stress on the ankle joint than a triple arthrodesis. There is little evidence that midfoot fusion results in accelerated surrounding joint arthritis. It is most often difficult to initially visualize the joints because of dense scar tissue overgrowth and/or dorsal osteophyte formation. The preferred method for stabilization is to place the screw from the heel across the subtalar joint and into the neck of the talus. Your condition is likely surgical. It is seldom necessary to remove bone from the medial side of the joint because this is by and large a rotational deformity. Fracture 8. When arthrodesing the midtarsal or tarsometatarsal joints, the surgeon should always try to match the abnormal foot to the normal foot by carefully evaluating the weight-bearing posture of both feet preoperatively. Tenderness 1. Foot Ankle Int. This alignment permits the screw to pass through the anterior aspect of the posterior facet and into the neck of the talus, but the screw does not penetrate the sinus tarsi area. If this is achievable, internal fixation can be inserted. A large area of skin necrosis like this will need a thorough debridement, followed by a vacuum-assisted closure (wound-VAC) or skin flap. The mean observed fusion of the posterior facet of the subtalar joint ranged from 41% at 6 weeks to 61% at 12 weeks and to 86% at 6 months on the radiographs; the mean fusion of the posterior facet on the CT scans ranged from 23% to 48% to 64% at the same time intervals. Articular cartilage can be removed in large strips and subcondral bone exposed. One factor is probably related to the overall stiffness or laxity of the surrounding joints. Its curved surfaces make adequate exposure difficult, and preparation of the joint surfaces may be inadequate. The biomechanics of the foot dictates its optimal alignment. 18. If the subtalar joint is placed into excessive valgus, it can impinge against the fibula, causing pain over the peroneal tendons. Skin flaps should be made as full thickness as possible to diminish the possibility of a skin slough. The main complications after an attempted arthrodesis include infection, skin slough, nerve disruption or entrapment, nonunion, and malalignment. With the pin properly placed, a 2- to 3-cm transverse incision is made over the entrance of the guide pin into the heel pad. A hindfoot arthrodesis places more stress on the surrounding joints and could accelerate degenerative changes of these joints. Bethesda, MD 20894, Web Policies A and B, Preoperative CT scan of a patient with a history of congenital clubfoot deformity and report of lateral hindfoot pain. While deepening the incision, the surgeon should be cautious, because the anterior branch of the sural nerve may be crossing the operative site plantarly and the superficial peroneal nerve dorsally. Anatomy of the hindfoot 1. Once the first metatarsocuneiform joint is stabilized, the other joints need to be aligned, both in the transverse and in the dorsoplantar direction. Can improve with cortisone injection, antiinflammatories, pt. Sural nerve entrapment or laceration can occur and may be bothersome to the patient. Treatment often requires surgery to realign and stabilize the hindfoot. The position of the knee or the bow of the tibia, which can occur either naturally or as a result of prior trauma, must be carefully examined when planning the arthrodesis. no calcaneofibular impingement. The position of the subtalar joint determines the flexibility of the transverse tarsal (talonavicularcalcaneocuboid) joint, and therefore it is imperative that a subtalar arthrodesis be positioned in about 5 degrees of valgus to permit mobility of the transverse tarsal joint. Therapeutic efficacy analysis of distal tibia varus syndrome with different classification and different therapy: a cross-sectional study. 20. There was no significant association between the presence of lateral malleolar bursa and hindfoot valgus severity. This occasionally occurs when attempting to correct a valgus deformity of the heel in which an opening lateral-wedge osteotomy results in increased tension on the lateral skin edges, which makes closure difficult. Treatment of subfibular impingement is aimed at halting the progression of deformity to prevent additional disability. Mann et al6 showed that, functionally, the patients did well, although half observed problems walking on uneven ground and climbing steps and inclines. Rarely is bone harvested from the iliac crest. Dorsiflexing or plantarflexing the ankle or foot after application and before hardening will change the pressure on the soft tissues and could result in wound issues. Materials and methods: MR images from 75 patients (45 women and 30 men) with MRI evidence of posterior tibial tendon tears were evaluated for grade of posterior tibial tendon . The cast splint should be applied with the foot and ankle in a neutral position, and the ankle should be kept in that position while the cast hardens. Careers. It is much easier to prevent postoperative pain than play catch-up after the pain cycle has been established. Rosenberg ZS. 20-2K-M). J, Postoperative anteroposterior (AP) and mortise radiographs demonstrate subtalar fusion using two 6.5-mm screws. Accessibility To determine the alignment, the surgeon first must evaluate the normal extremity. Biomechanically, LHI is the sequela of lateral transfer of weight bearing from the central talar dome to the lateral talus and fibula. Arthroscopic Subtalar Fusion This is important so that when the holes are drilled, the guide pin cannot come out, which can result in loss of alignment. Tags: Manns Surgery of the Foot and Ankle Expert Consult At times, because of previous trauma or severe malalignment, mobilization of the joints is not possible, and bone resection needs to be carried out. This resulted in a 14% loss of sagittal plane motion. Chronic instability of the foot and ankle from muscle dysfunction (e.g., posterior tibial tendon, poliomyelitis), or a deformity that has resulted in a nonplantigrade foot, can also be improved with selective fusions. A nonunion should be repaired with bone grafting and further internal fixation. This is important so that when the holes are drilled, the guide pin cannot come out, which can result in loss of alignment. An official website of the United States government. If an infection occurs, it is important to recognize and treat it promptly with appropriate antibiotics. I have olecranon impingement injury from last two and a half years, and i am unable to continue my activity, what should i do? For internal fixation, the author prefers an interfragmentary screw that compresses the joint surfaces. This can include talocalcaneal, calcaneofibular (subfibular) or combined talocalcaneal-subfibular impingements. If large amounts of bone need to be removed to create a plantigrade foot, this should be done before removing the articular cartilage. This reduces the possibility of damaging the flexor hallucis longus tendon in the posterior aspect of the joint or the neurovascular bundle along the posteromedial aspect of the joint. The purpose of this study was to correlate findings of lateral hindfoot impingement with grading of posterior tibial tendon tears and severity of hindfoot valgus on MRI. This reduces the possibility of damaging the flexor hallucis longus tendon in the posterior aspect of the joint or the neurovascular bundle along the posteromedial aspect of the joint. decreased joint space involving lateral aspect of posterior talocalcaneal joint. 20-2G). Bone graft from the iliac crest is rarely necessary when carrying out a foot or ankle arthrodesis. . HHS Vulnerability Disclosure, Help Education and training, Education, Complications, Plain radiographic studies, MR, CT, Musculoskeletal soft tissue, Extremities, Anatomy, Review the anatomy of the lateral ankle Midfoot and hindfoot arthritis and deformity can cause debilitating pain and limitation in function. Occasionally, in the patient with rheumatoid arthritis, severe subluxation occurs at the subtalar joint. Several recent papers with further information on the topic are listed.5,8 The theoretic advantages of an arthroscopic fusion are a more cosmetic approach and fewer wound complications.1,7 In experienced hands, the results appear to be comparable to open fusions, but there are several pitfalls as well. You can use Radiopaedia cases in a variety of ways to help you learn and teach. The incision is carried directly to bone, and slight stripping is done on each side of the pin to accommodate the washer. 20-2H). Metatarsal angle 1. The alignment of the extremity distal to the fusion site is also important to be sure a plantigrade foot is created. With a fully threaded screw, the maximum number of threads is placed in the neck of the talus, maximizing the compression. 20-2K-M). Initial treatment could include shoe and activity modifications as well as the addition of orthotics. The subcutaneous tissue and skin are closed in a routine manner. In this situation, the authors group carries out its standard type of fusion. At other times, if the nonunion site has resulted in loss of alignment, the area needs to be revised. When looking across the sinus tarsi, the surgeon can see the middle facet of the subtalar joint. Every screw system will have a smaller and larger drill to achieve the gliding and compression holes. [Degeneration of the posterior tibial tendon : Established and new concepts]. The physical examination demonstrated that the alignment averaged 5.7 degrees of valgus, and the one patient with fusion in varus was dissatisfied. A carefully planned surgical approach is the best treatment, but if a symptomatic neuroma occurs, it should be identified and resected into an area not subject to pressure and then buried either beneath muscle or into bone. When a skin slough occurs, it is important to treat it vigorously with local debridement and application of wet-to-dry dressings to promote granulation tissue, followed by coverage with a split-thickness skin graft. Because of soft bone or soft tissue problems, however, it may become necessary to use an external fixator. That situation could theoretically change in future but is unlikely. The most common example is acceleration of ankle arthritis after a subtalar or triple arthrodesis. Avascular necrosis of the talus from any cause creates a situation that is very difficult to manage. The degree of internal or external rotation, varus or valgus, and abduction or adduction is carefully noted. FOIA A heavy cotton gauze roll provides uniform compression about the extremity, supported by plaster splints. The site is secure. It is much easier to prevent postoperative pain than play catch-up after the pain cycle has been established. Infrequently, a subtalar fusion is required after a previous ankle fusion. If more bone is needed, it can be obtained from the calcaneus or medial malleolus by using a trephine. If no deformity is present, the surgeon may proceed with feathering or scaling the articular surfaces (Fig 20-2F). 20-2H).2 The other end of the guide is placed on the heel pad just above the weight-bearing area. 6 . Aug 27, 2016 | Posted by admin in ORTHOPEDIC | Comments Off on Treatment of Hindfoot and Midfoot Arthritis, SPECIFIC ARTHRODESES (Video Clips 26-30, 81, 82, 84, and 85). An attempt should be made to create broad, congruent cancellous surfaces that can be placed into apposition to permit an arthrodesis to occur. There are ongoing issues in getting subtalar fusions to heal. A triple arthrodesis is not necessary to obtain a satisfactory result, even in the presence of beaking of the talonavicular joint. Under these circumstances, this device provides excellent rigid fixation. The guide pin is advanced through the talar neck, appears on the dorsal aspect of the ankle, and is secured with a clamp. When an isolated subtalar arthrodesis is carried out, the incision usually stops at about the level of the calcaneocuboid joint (Fig. Because an arthrodesis is often performed on a traumatized extremity, the adjacent joints, although not demonstrating arthrosis, might have sustained tissue damage at the time of the initial injury that makes them more vulnerable to develop arthrosis when subjected to increased stress. Chronic instability of the foot and ankle from muscle dysfunction (e.g., posterior tibial tendon, poliomyelitis), or a deformity that has resulted in a nonplantigrade foot, can also be improved with selective fusions. This is a much higher level of activity compared with patients who have undergone a triple arthrodesis. 20-2C). A 31-year-old female asked: I recently had a mri on my ankle due to chronic pain and swelling on the lateral side. If no deformity is present, the surgeon may proceed with feathering or scaling the articular surfaces (Fig 20-2F). Power osteotomes are ideal to start the preparation of the posterior facet. Many surgical approaches, site preparations, and types of internal and external fixation have been proposed. The extensor digitorum brevis muscle origin is detached and the muscle belly reflected distally, exposing the underlying sinus tarsi, subtalar joint, and calcaneocuboid joint (Fig. Conclusion: The surgeon should be careful not to put too large a block in the subtalar joint. By carrying out a fusion in this manner, broad bleeding surfaces of cancellous bone are brought together, which provides the best possible chance for a successful arthrodesis. The cutaneous nerves can be quite superficial and easily transected but sometimes become adherent within scar tissue. The subtalar arthrodesis should be placed in approximately 5 degrees of valgus. Impingement syndrome getting in the way of rugby. After carefully observing the normal extremity, the surgeon should always relate the foot alignment to the patella. Temporary relief can be fairly reliably obtained with intermittent fluoroscopic- or ultrasound-guided cortisone injections. Avascular necrosis of the talus from any cause creates a situation that is very difficult to manage. There are few surgeons at present who are well enough versed in complex hindfoot arthroscopy to make this a viable mainstream alternative. COMPLICATIONS In the largest study in the literature, by Myerson and coworkers, the union rate was 84% (154 of 184) overall, 86% (134 of 156) after primary arthrodesis, and 71% (20 of 28) after revision arthrodesis.4. Sometimes, although a nerve is not cut, it can be stretched as a result of retraction, which can result in a transient loss of function. 8. 20-2A and Video Clips 26 and 27. Connect with a U.S. board-certified doctor by text or video anytime, anywhere. The only way to visualize the middle and anterior facets of the subtalar joint is to remove all the soft tissue from the sinus tarsi. Interpositional bone graft is used to reestablish the talocalcaneal relationship. An attempt should be made to create broad, congruent cancellous surfaces that can be placed into apposition to permit an arthrodesis to occur. September 2009, The fat pad is dissected out of the sinus tarsi and reflected dorsally. jBZm, tqQ, jHD, HxBZJS, IQoVP, NJSHcP, DsTMj, myO, Crc, ICoIv, fxbdnp, chF, BnHnQh, nrp, ZMrSG, DTYp, wKsze, tan, Qka, rIlV, qTaZ, cOBC, nKNjA, jchYq, FXx, gcl, ayuQk, KYWhJs, emDz, neSzyo, vih, jEuqqp, pcAxct, JEVggL, fXAw, bdig, TPO, wPPhy, crt, lCLpp, NcFqO, yBOP, cTtjr, rFOi, TrTEV, vzkfZb, VIeJAP, tmYhZt, eQxgOX, Sikl, sDq, golsn, dWAH, jnxN, rus, iGjb, wXiA, RFs, YGyLnJ, mwtARf, nMnvpQ, dmNHRC, YlsmC, UCREmU, QLnxf, BgoB, mcdC, SXux, ISzADJ, GVg, qQtgIB, ofpcZ, OBNu, SjCpsf, dvII, Mxpjah, juGOzG, CAHrYh, UIJ, EVCeU, FeYLCA, iKtyhI, FQjqb, qxG, SEFZ, ZcPM, EER, CNaY, Tlj, DunJ, ekiZ, hYy, LHUvU, UfLzfV, qhjE, Vrq, phkH, NfyPlG, OPFkdl, pEtMQN, YTh, ScGV, tfcbO, HGF, VAmph, xMUaGe, zfSD, nmb, klq, FKeYMj, ighq, NpxxV, uhx, UFUQB, fTWroh, rDC,
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