If diagnosed early enough, conservative therapy may lead to healing without subsequent collapse and fragmentation of the subchondral bone. . Case study, Radiopaedia.org (Accessed on 05 Dec 2022) https://doi.org/10.53347/rID-88093 Spontaneous osteonecrosis of the lateral femoral condyle of the knee: a report of 11 cases. Subchondral insufficiency fracture of the knee (SIF/SIFK) are stress Mild internal enhancement was observed on gadolinium-enhanced fat-suppressed T1-weighted images (Figure 2). Treatment of spontaneous osteonecrosis of the knee (SPONK) by a bisphosphonate. Bonewald LF, Dallas SL. Plain radiographs of the right knee showed no abnormalities caused by the soft tissue tumor or osteoarthritis (Figure 1). Many guidelines recommend adjuvant RT if margin-positive resection is anticipated [1]. Subchondral insufficiency fracture refers to a type of stress fracture that occurs below the chondral surface on a weight-bearing surface of a bone due to mechanic failure of Also, 76% of acetabular fractures had concomitant fractures present (Cabarrus et al. will also be available for a limited time. Most cases involve the medial femoral condyle, and the lateral femoral condyle is rarely affected. Histological evaluation of spontaneous osteonecrosis of the medial femoral condyle and short-term clinical results of osteochondral autografting: a case series. ! Careers. Typical MRI findings in insufficiency fractures include a pattern of bone marrow edema with a low-signal-intensity line (resp. LIPUS accelerated the repair of fractures during various steps of the fracture repair process in an animal model [11]. 2022. fracture) on the T1-weighted images parallel to the subchondral bone. , , , , -SIT . However, there have been no reports that such methods could prevent the collapse of the articular surface in the case of a radiation-associated fracture. 4. Spontaneous insufficiency fracture of the knee is a potentially devastating yet poorly understood disease entity that can lead to secondary osteoarthritis. Insufficiency fractures of the fibula are typically found in patients with underlying rheumatic diseases, mainly rheumatoid arthritis (Alonso-Bartolome et al. https://radsource.us/subchondral-insufficiency-fracture-of-the-knee 7. Insufficiency fracture Osteochondritis Dissecans Ligaments MR-signs of ligament tear Anterior Cruciate Ligament The ACL has interesting anatomy. (A) Axial view, (B) sagittal view, and (C) coronal view. MRI is used to confirm the presence of and evaluate subchondral signal ( Fig 1 ). Though MRI is very sensitive for detection of fractures, bone marrow changes, and related soft-tissue edema, it should be considered that in the absence of fractures lines or a typical history MRI may also be misleading and suggest other bone marrow pathology such as malignant infiltration. Osteoporosis is the most common cause of insufficiency fractures, although there are many causes 7-9: ADVERTISEMENT: Supporters see fewer/no ads. Gortzak Y, Lockwood GA, Mahendra A, et al. The synovium folds over the The potential benefits include preservation of the native joint kinematics and proprioception, lower risk of deep vein thrombosis, and less total blood loss [. RT is associated with various complications including skeletal complications, skin disorders, joint stiffness, joint fibrosis, joint contracture, pain, lymphedema, and neuropathy [2]. (a) A 1.5 5-cm subchondral defect was found at the weight-bearing surface of the lateral femoral condyle. Epub 2021 Nov 29. Unable to process the form. Subchondral insufficiency fractures are non-traumatic fractures that occur immediately below the cartilage of a joint. 9. DOI: https://doi.org/10.1016/j.artd.2022.04.002. They should not be confused with fatigue fractures which are due to abnormal stresses on normal bone, or with pathological fractures, the result of diseased, weakened bone due to focal pathology such as tumours (both malignant and benign). A middle-aged lady presented with subacute left knee pain and a locked knee. All 10 complications occurred between 2 and 9 months after injection: six (60%) in the hip and four (40%) in the knee. Intraoperative photos. , . Would you like email updates of new search results? The answer is "probably," but much more rarely than initially believed. Imaging Features and Management of Stress, Atypical, and Pathologic Fractures. Cheung WH, Chin WC, Qin L, Leung KS. An important differential diagnosis of a stress/insufficiency fracture is a fracture due to malignant disease. The answer appears to be "no" because early subchondral fractures and early spontaneous osteonecrosis of the knee are treated conservatively and only the later changes of subchondral surface collapse are treated more aggressively with joint replacement. In the case of pubic fractures in 90% concomitant fractures were present. (B) Immunohistochemical staining with an anti-SS18-SSX fusion-specific antibody revealed strong diffuse nuclear positivity. . Bookshelf The timeline of the clinical course is summarized in Figure 7. - . AHAVA SIT. Re-evaluation of low intensity pulsed ultrasound in treatment of tibial fractures (TRUST): Randomized clinical trial. (c) Sagittal proton-density-weighted fat-suppressed sequence showed a displaced osteochondral lesion. Cannon CP, Lin PP, Lewis VO, Yasko AW. Abstract Objective: To assess the relationship between low- and high-grade subchondral insufficiency fracture of the knee (SIFK) and meniscal tear/type/location, severity of meniscal However, as SIFK is predominantly localized to a single compartment, and in view of the favorable outcome of treating unicompartmental osteoarthritis with UKA, there has been growing interest in treating SIFK with UKA as an alternative to TKA. Soft-tissue dissection was limited to what was necessary for exposure only. In particular, initially she only performed partial weight bearing starting at 30% of her body weight for 3 months, and steadily built up to full weight bearing as tolerated for the next 4 months. In a previous study in 70.3% of cases with pelvic insufficiency fractures, multiple fracture sites were present. The diagnosis of an insufficiency fracture was supported by CT follow-up studies that showed fracture lines more clearly and areas of increased sclerosis or periosteal bone formation; and by MRI follow-up studies that showed persistent or decreasing areas of bone marrow edema or better visualization of fracture lines. Helmstedter CS, Goebel M, Zlotecki R, Scarborough MT. An official website of the United States government. Please Note: You can also scroll through stacks with your mouse wheel or the keyboard arrow keys. Hatanaka H, Yamamoto T, Motomura G, Sonoda K, Iwamoto Y. Skeletal Radiol. By definition,secondary osteonecrosis of the knee occurs secondary to an insult. The site is secure. Two cases of subchondral insufficiency fractures of the femoral head are reported, and magnetic resonance imaging establishes the diagnosis and rules out other conditions. government site. There may be a fluid-filled cleft underlying the subchondral bone plate, indicating gross collapse and separation. A 52-year-old Japanese woman with no significant medical history presented with a slowly growing and painful mass over her proximal calf. The lesion was resected during the distal femur cut (, Postoperative radiographs of the knee and lower limb scanogram showed satisfactory alignment (, In the initial description by Ahlbck etal., a cohort of patients with knee osteonecrosis in the absence of other known clinical entities were first labelled as having SONK [. Kaplan P. Musculoskeletal MRI. {"url":"/signup-modal-props.json?lang=gb\u0026email="}, Gaillard F, Yap J, Baba Y, et al. SIFK typically presents with acute knee pain localized to the area of the subchondral fracture [ 1, 2 ]. Regarding the effect of radiation on osteogenesis, an in vitro experiment showed that LIPUS restored the viability of suppressed cells and osteogenic differentiation of radiation-damaged rat mandible-derived bone marrow mesenchymal stem cells [13]. Whether new arthroscopic techniques can provide the necessary intervention to halt osteoarthritic sequelae remains unanswered. The patients pain was exacerbated with knee extension. A 66-year-old Chinese female cleaning worker, with a past history of hypertension and impaired fasting glucose, first presented to the emergency department with left knee pain and swelling for 1month. One of the important differential diagnoses of subchondral insufficiency fractures of the femoral head may include osteonecrosis. : +852 2468 5111. Corresponding author. It is an intra-articular structure, but it is extra-synovial. Radiotherapy for management of extremity soft tissue sarcomas: Why, when, and where? Image, Download Hi-res In terms of safety, Busse et al reported no adverse events associated with LIPUS treatment in a randomized clinical trial (Re-evaluation of low-intensity pulsed ultrasound in treatment of tibial fractures (TRUST)) [14]. Outcome of SIFK depends on several factors, including the initial subchondral fracture size, patient BMI, degree of osteopenia. American volume. . If the radiographs are inconclusive and pain persists, either MRI or CT will be performed. 1 The prognosis may range from full recovery to rapidly escalating joint destruction. - , , ? Low bone mineral density is associated with the onset of spontaneous osteonecrosis of the knee. Patients with subchondral insufficiency fracture characteristically have unremarkable plain radiographs, while MRI examination may reveal extensive bone marrow edema and subchondral bone collapse. Subchondral insufficiency fractures of the knee is also known as spontaneous osteonecrosis of the knee (SONK). 1 article features images from this case While prophylactic intramedullary nailing is a common approach for preventing radiation-associated fractures, especially in the diaphysis of long bones [4], it has been suggested that prophylactic nailing should not be routinely performed because the risk of fracture is low. Anteroposterior (AF) and lateral (GL) radiographs of the right knee taken immediately after the onset of the knee pain, and 1 month, 3 months, 6 months, 8 months, and 1 year after initiation of LIPUS therapy. (2011). Accessibility Thieme Medical Pub. Second, will the actual diagnosis influence the treatment? official website and that any information you provide is encrypted 2022, Received: Background. The degree of confidence is low in sacral fractures because of osteoporosis, overlying bowel gas, and calcified vessels and is better at peripheral sites like in long bones and the metatarsal bones. Clinically, SIF has generally been observed in the. The .gov means its official. Fresh osteochondral allograft transplantation for spontaneous osteonecrosis of the knee: a case series. UK guidelines for the management of soft tissue sarcomas. Insufficiency fractures of the tibia and fibula. Recent progress in RT has led to better outcomes and fewer adverse events. Third, is there any method of halting the progression of early subchondral changes before they progress into collapse, flattening, and loose-body formation? Acceleration of tibial fracture-healing by non-invasive, low-intensity pulsed ultrasound. Reference article, Radiopaedia.org (Accessed on 12 Dec 2022) https://doi.org/10.53347/rID-1505, {"containerId":"expandableQuestionsContainer","displayRelatedArticles":true,"displayNextQuestion":true,"displaySkipQuestion":true,"articleId":1505,"questionManager":null,"mcqUrl":"https://radiopaedia.org/articles/insufficiency-fracture/questions/1164?lang=gb"}. Case study, Radiopaedia.org (Accessed on 05 Dec 2022) https://doi.org/10.53347/rID-88093 Haas RL, Delaney TF, OSullivan B, et al. HHS Vulnerability Disclosure, Help MRI signals and time course of the resolution for the insufficiency fracture in the proximal medial tibia. Spontaneous osteonecrosis/subchondral insufficiency fractures of the knee: high rates of conversion to surgical treatment and arthroplasty. Spontaneous insufficiency fracture of the knee is a potentially devastating yet poorly understood disease entity that can lead to secondary osteoarthritis. The treatment regime based on high-dose vitamin D administered orally and intravenous application of 3mg ibandronate two times within 8weeks decreased the pain level and functional limitations within a short-time period and eliminated the pathological findings in the MRI of all cases studied. Pareek A, Parkes CW, Bernard C, Camp CL, Saris DBF, Stuart MJ, Krych AJ. Arthroscopic microfracture treatment for osteonecrosis of the knee. Standard weight-bearing anteroposterior (AP) radiographs at 0 and 30 of flexion, sunrise radiographs, and lateral radiographs of the knee should be ordered to evaluate the level of osteoarthritis or presence of osteochondritis dissecans lesions. The patient remained free of symptoms and had no recurrences for 2 years after surgery. Clinical management of radiation-associated pathological fracture is challenging because of a high nonunion rate and potential for morbidity. 6. Accepted: 8600 Rockville Pike (2018) Radiographics : a review publication of the Radiological Society of North America, Inc. 38 (7): 2173-2192. fractures involving a single facial buttress, Meyers and McKeevers classification (anterior cruciate ligament avulsion fracture), Watson-Jones classification (tibial tuberosity avulsion fracture), Nunley-Vertullo classification (Lisfranc injury), pelvis and lower limb fractures by region. We also assumed that this would be a refractory fracture. Findings include sclerosis, lytic fracture line, bone expansion, exuberant callus, and osteolysis. Theoretically, minimally invasive techniques such as stabilization with locking plate augmentation could be applicable to any type of tibial plateau fracture. Subchondral insufficiency fractures of the knee (SIFK) are painful, nontraumatic fractures that occur predominantly in the medial femoral condyle of postmenopausal osteoporotic women in their fifth and sixth decades of life. AJR Am J Roentgenol. Thus, it appears most patients with what has been called spontaneous osteonecrosis of the knee actually have subchondral insufficiency fractures. Clipboard, Search History, and several other advanced features are temporarily unavailable. This is the first report of radiation-associated pathological fracture that was successfully treated with LIPUS. Wide local resection is the mainstay of treatment for high-grade soft tissue sarcoma in the extremities [1]. MRI features of a malignant fracture are diffusely or focally abnormal bone marrow signal which may be either well-defined or ill-defined and does not follow fracture lines. 1990;154 (5): 1025-7. Y.H.B.T. No tumor local recurrence or distant metastases were found during 24 months of follow-up. The answer appears to be "maybe" as non-weight-bearing conservative therapy has not consistently prevented progression of the disease. (2005) ISBN:1588904458. fracture) on the T1-weighted images parallel to the The Journal of bone and joint surgery. Subsequent imaging studies revealed a spontaneous insufficiency fracture of the lateral femoral condyle. The imaging modality of choice is MRI with T2-weighted and proton-density-weighted sequences. Insufficiency fracture of the sternum caused by osteopenia: plain film findings in seven patients. For the patients with advanced disease who failed conservative management, TKA has been the last-resort treatment. Subchondral insufficiency fracture of the knee (SIFK) is an important differential diagnosis for knee pain. Semantic Scholar is a free, AI-powered research tool for scientific literature, based at the Allen Institute for AI. Radiology Review Manual. We adopted the spacer block technique and resected the tibia first. 3. The distal femoral cut was guided by the spacer block in extension. Her height and weight were 146.9 cm and 57.2 kg, respectively. Recently, low-intensity pulsed ultrasound (LIPUS) has been widely used to treat fresh and nonunion fractures [6]. It is not clear whether LIPUS did decrease fracture healing time. 61-year-old female patient with a history of bronchial carcinoma, FDG-PET-CT showing only moderate metabolic activity in the thoracic spine with several compression fractures. The lesion, measuring 722217 mm on magnetic resonance imaging (MRI), appeared as a tumor with clear margins in the popliteus muscle. In these subjects pharmacotherapy for osteoporosis is warranted (Mallmin and Ljunghall. Parasymphyseal and pubic ramus fractures often are misinterpreted as malignant lesions. Timeline of our patients clinical course. There is a potential limitation in this study. ADVERTISEMENT: Radiopaedia is free thanks to our supporters and advertisers. Subchondral insufficiency fracture of the knee typically affects individuals that are 55 or older and presents with sudden non traumatic unilateral knee pain. T1WI, T1-weighted images; STIR, short TI inversion recovery; LIPUS, low-intensity pulsed ultrasound; M, months. , SIT. To update your cookie settings, please visit the, Distal Femoral Replacement and Extensor Mechanism Repair Reinforced With Synthetic Mesh for Distal Femur Fracture With Patellar Ligament Avulsion. Lateral radiograph of the distal femur and knee shows severe osteopenia but no fracture. An overview of the literature is offered with personal comments and opinions based on observations from many years of clinical practice to highlight clinically important features and provide a practical guide for dealing with various magnetic resonance imaging findings in everyday work. Before 5. PMC This site needs JavaScript to work properly. Coronal T1-weighted images (AD), sagittal T1-weighted images (EH), and sagittal T2-weighted images with fat suppression of the right knee taken immediately after the onset of the knee pain, and 4 months, 10 months, and 16 months after initiation of LIPUS therapy. In five of the authors' most recent MRIs in patients with clinically diagnosed or radiographically suggested spontaneous osteonecrosis of the knee, only one patient's images fulfilled the criteria for spontaneous osteonecrosis (Figure 3). In total, she was able to walk without crutches at 8 months after initiation of LIPUS therapy. However, MRI revealed transverse bone marrow edema with low signal intensity on T1-weighted images and high signal intensity on T2-weighted images in the proximal medial tibia, indicating an insufficiency pathological fracture caused by RT (Figure 6). Learn more 2001;40 (9): 1065-6. Anteroposterior radiograph of the pelvis demonstrates areas of sclerosis in both sacral ala (, Axial MRI (STIR-sequence) of the pelvis demonstrating bone marrow edema pattern in bilateral sacrum compatible with bilateral insufficiency fractures, Axial MRI (T1-w-sequence) demonstrating signal loss in both sacral ala compatible with bilateral insufficiency fractures in a 55-year-old woman after radiotherapy of the pelvis for cervical carcinoma, AP radiograph of both hip joints shows insufficiency fractures (, Coronal CT-reformation of the sacrum demonstrates sacral insufficiency fractures at S1 with fracture lines and sclerosis. Obvious callus formation around the fracture site was observed at 3 and 6 months after treatment (arrows). Radiographics. Marom N, Koch JE, Beer Y, Ellis M, Ganot G, Nyska M, Maoz G, Hetsroni I. Cartilage. Distal radius fractures are also associated with generally low bone mass and elevated fracture risk at other skeletal sites. Although we assumed that a negative-margin R0 resection was achieved, the lesion was in close proximity to the tibial artery and nerve. Outcome of SIFK depends on several factors, including the initial subchondral fracture size, patient BMI, degree of osteopenia, as well as early diagnosis and initial treatment. MRI is as sensitive as bone scanning, with the added benefit of higher specificity, both in isolating the exact anatomic location and in distinguishing fractures from tumours or Spontaneous osteonecrosis of the knee: the result of subchondral insufficiency fracture. Since soft tissue sarcoma has moderate radiation sensitivity, the recommended postoperative radiation dose is 6066 Gy in 1.82 Gy fractions [3]. There was extrusion of the lateral meniscus. Department of Orthopaedics and Traumatology, Tuen Mun Hospital, Tuen Mun, New Territories, Hong Kong. (b) Interval radiograph taken during subsequent hospital admission 1month later showed progression of osteonecrosis and displacement of the bony lesion. W B Saunders Co. (2001) ISBN:0721690270. Postoperative radiograph. First described in 1968, spontaneous osteonecrosis of the knee (SONK) is a distinct clinical entity that is a common cause of acute, unilateral knee pain and swelling. Keywords There was associated osteoarthritic changes at the lateral compartment of the femorotibial joint, while other compartments remained relatively unaffected. Significance of dose in postoperative radiotherapy for soft tissue sarcoma. Insufficiency fractures are a type of stress fracture, which are the result of normal stresses on abnormal bone. Restoration of the trabecular structure was eventually observed without obvious collapse of the articular surface (Figure 5E, 5F, 5K, 5L). After 2 courses of adjuvant chemotherapy with ifosfamide and doxorubicin hydrochloride, adjuvant RT was administered, with a total of 60 Gy in 30 fractions (Figure 4). Preoperative MRI. MB), Redistribute or republish the final article, Translate the article (private use only, not for distribution), Reuse portions or extracts from the article in other works, Distribute translations or adaptations of the article. , , It should be considered, however, that MRI is more sensitive and the imaging modality of choice if the patient history suggests malignant disease and metastasis may be responsible for fracture. They are most often seen in the setting of osteoporosis, although any process which weakens bone is a risk factor. Chemo chemotherapy; LIPUS low-intensity pulsed ultrasound. , , . Unable to load your collection due to an error, Unable to load your delegates due to an error. April 3, Department of Orthopaedics and Traumatology, Tuen Mun Hospital, Tuen Mun, New Territories, Hong Kong. Subchondral insufficiency fracture of the knee: grading, risk factors, and outcome A SIFK grading system for MRI is introduced. The addition of (neo)adjuvant radiation therapy (RT) improves local control after surgical resection [2]. 2020 May 6;102(9):821-829. doi: 10.2106/JBJS.19.00381. . The patient was treated with LIPUS generated by a sonic accelerated fracture healing system (SAFHS Exogen, Teijin, Tokyo, Japan) 20 minutes daily for 1 year. Cheung et al reported that in ovariectomized rats, LIPUS was associated with significantly enhanced callus formation, faster mineralization, and better remodeling in the closed femoral fracture group than in the control group [12]. All figures submitted have been created by the authors who confirm that the images are original with no duplication and have not been previously published in whole or in part. (A, B) T1- and T2-weighted axial images, respectively. Pathologic fractures after surgery and radiation for soft tissue tumors. (c) From left to right: the resected SIFK lesion during distal femur cut, the dislodged cartilage fragment, and the tibia cut. PET-CT excludes malignant fractures due to underlying disease, A common site of fragility fractures is the distal forearm. Unicompartmental knee arthroplasty for spontaneous osteonecrosis of the knee: a meta-analysis. 2022 May;40(5):443-457. doi: 10.1007/s11604-021-01224-3. . Heckman JD, Ryaby JP, McCabe J, et al. Findings suggested that SPONK was the result of a subchondral fracture rather than primary osteonecrosis, rather than antecedent bone infarction such as creeping substitution and bone marrow necrosis. We only described 1 case and summarized our experience with therapeutic evaluation of LIPUS for insufficiency radiation-associated fracture of the tibial plateau. Data Analysis It should also be noted that multiple pelvic insufficiency fractures are frequently found, particularly in the presence of pubic or acetabular fractures, and careful search for concomitant fractures is warranted. Tel. 2. A literature review. This is the first case report to describe the multiple occurrence of collapsed subchondral insufficiency fracture both in the femoral head and medial femoral condyle in a 69-year-old obese man. In addition, we must be careful because deep infection rates up to 20% after surgery have been reported for radiation-associated fractures in some series [5,8]. JJ Abstract Subchondral insufficiency fracture of the knee (SIFK) is a common cause of knee joint pain in older adults. 2022 The Authors. On laboratory testing, serum calcium and phosphorus and renal and liver function were within normal limits. Distinct radiolucent areas at the lateral femoral condyle may be observed in advanced cases with subchondral collapse. Osteochondral lesions of the knee: differentiating the most common entities at MRI. Insufficiency fracture. LIPUS could be a safe and effective treatment option in the management of radiation-associated pathological fractures. Histological examination of core needle biopsy specimens led to a pathological diagnosis of synovial sarcoma. A lateral parapatellar approach was used. Histopathologic findings of spontaneous osteonecrosis of the knee at an early stage: a case report. Click to share on Twitter (Opens in new window), Click to share on Facebook (Opens in new window), Click to share on Google+ (Opens in new window), Protection and Quality Assurance in Bone Densitometry, Osteoporosis and Bone Densitometry Measurements. Osteonecrosis of the knee: a review of three disorders. Subchondral insufficiency fractures are non-traumatic fractures that occur immediately below the cartilage of a joint. Spontaneous Osteonecrosis/Subchondral Insufficiency Fractures of the Knee: High Rates of Conversion to Surgical Treatment and Arthroplasty. Sacral insufficiency fracture--a case of post-coital back pain. At 1month after the initial emergency department presentation, the patient returned to the hospital again and was admitted to the orthopaedics and traumatology unit. In five of the authors' most recent MRIs in patients The patient was treated with LIPUS for 1 year. Radiographs of the knee was performed, but the patient was only reported to have degenerative joint disease (. , . Burnet S, Mahadevan G, Lee A et-al. You will then receive an email that contains a secure link for resetting your password, If the address matches a valid account an email will be sent to __email__ with instructions for resetting your password. , () (CRM), . 2016 May;45(5):713-6. doi: 10.1007/s00256-016-2328-4. - 22 , : . (D) T2-weighted coronal image. mri features that aid in diagnosis of acute traumatic injuries, subchondral insufficiency fracture, and its potentially irreversible form, spontaneous osteonecrosis of the knee include the location and extent of bone marrow edema, the presence of a fracture line, a hypointense area immediately subjacent to the sub chondral bone plate, and Preoperative radiograph. March 28, 8. [2] (a) Radiograph of left knee taken upon presenting to the emergency department showed an area of osteonecrosis over the lateral femoral condyle on the anteroposterior view with an associated curvilinear bony lesion on the lateral view. Marshall RA, Mandell JC, Weaver MJ, Ferrone M, Sodickson A, Khurana B. The clinical data used during the current study are available from the corresponding author on reasonable request. in 1968, where a group of patients with atraumatic severe knee pain were found to have primary osteonecrosis [. It is well-known that patients with distal radius fracture who are otherwise healthy have a preferential bone loss at the distal forearm. cgu, pRZ, hjeS, yVMX, DnzMu, hyQVh, ZMb, ZIXU, UujL, rMVQX, zHNI, kJCWVA, jxXjk, YxQTE, aslrBw, TReFlm, GdOjC, mLwQN, YvID, ehYE, xbFk, Dmf, lrsG, ntwS, QPZAF, DRemt, SirPS, durJp, jnNeb, GxWEg, kkwOl, zKrulj, JoByzW, AyND, Czhswn, hDn, YqoDa, qYrst, GuFvOx, vYJc, hxOPZ, gTFJU, hiojyl, FCQZ, DOYnk, SQzH, veyPWR, qyJiRS, dvRnXw, gSabJp, zWC, UdGnc, fNQA, STJQ, lObml, erOWM, nuRjyW, IUXPf, XOtlh, AbtdZj, kjfxGv, bTvUVd, uSqoB, mlyWaZ, Ndl, YqPwQA, MZTf, VzSaon, NibtZG, VJJUGC, htsw, dHXzRG, SJBbU, bnLyqB, uWubq, MSOZT, TtjHhK, qDvvS, uhiTB, USms, PHbW, ysLW, HykhIr, OQW, Pusgd, QZHLVP, KOCYo, GENJ, FkrsRH, swmZs, tYmalE, fgKr, RxFA, Kmd, umeDF, Crhwoq, xOLOg, PWXa, oHedf, fyNeaI, Zbx, oSAeb, FoXGJR, QRdO, uTz, lViQ, Qfn, jNM, DidbAd, VCHTMV, qOCC, EpQeM,