Recurrent patellar dislocation after primary dislocation is seen in around 33% of patients and the risk of recurrence increases after 2 years (1). G Trochlear angle, A family pedigree of recurrent patella dislocation, Anatomical data of the patella femur in the family, ISI InsallSalvati index, CDI CatonDeschamps index, TTTG Tibial tubercletrochlear groove, TDC Trochlear dysplasia classification (Dejour), Statistical table of exon sequencing data, Clean readstotal reads after filtration; clean basestotal data amount after filtering low-quality reads from sequencing data; Q20proportion of bases with a mass value greater than 20; Q30proportion of bases with a mass value greater than 30; GC contentratio of sequencing data GC, Screening and functional enrichment analysis of mutant genes. We collected comprehensive data on these patients, including weight, height, age and the time of the first patellar dislocation, etc., but the impact on this study was not significant, so we did not analyze too much. 2007 Aug;15(8):994-1002 . A dislocation of the patella occurs when the patella comes completely out of its groove on the end of the thigh bone (femur), and comes to rest on the outside of the knee joint. https://www.sportsmedreview.com/by-joint/knee/, Incidence of Lower Extremity Injuries in the NFL on Grass versus Turf, Return to Play Following Achilles Tendon Rupture, Colvin, Alexis Chiang, and Robin V. West. new methods of evaluation were used to verify the extent of tubercle deviation in a group with patellar dislocation compared with that in a control group, the frequency of patients who demonstrated a cutoff value indicating that tubercle transfer was warranted on the basis of the control group distribution, and the validity of these methods of Clin Radiol 59:543557, Loredo R, Sanders TG (2001) Imaging of osteochondral injuries. These results indicated that isolated Fulkerson procedure should not be indicated for recurrent patellar dislocation with severe patella alta. In the absence of violence, the patella does not dislocate. The recurrence rate following a first-time dislocation is around 15-60%. The patella makes maximal osseous contact with the femur when the knee is in full extension and the patella and quadricep tendon provide maximal constraint in knee flexion (1). government site. Although the human exome region only accounts for 1% of the entire genome sequence, about 85% of disease-causing variants are located in this region [5]. All authors read and approved the final manuscript. 2022 ICD-10-CM Range M00-M99. Pfirrmann CW, Zanetti M, Romero J, Hodler J. Femoral trochlear dysplasia: MR findings. altered facet ratio and increased size of the lateral trochlear facet. Am J Sports Med 24:5260, Wessel LM, Scholz S, Rusch M (2001) Characteristic pattern and management of intraarticular knee lesions in different pediatric age groups. In: StatPearls [Internet]. Overall, this study found multiple patients with recurrent patellar dislocation in a family. Google Scholar, Quinn SF, Brown TR, Demlow TA (1993) MR imaging of patellar retinacular ligament injuries. The tear is leading to mildly laxed appearance of the Patients with a history of knee surgery, congenital knee malformation, recurrent patellar instability, patellar maltracking abnor- PubMed, doi:10.1016/j.arthro.2018.08.046. Exome sequencing has broad prospects in the genetic diagnosis of diseases and the research of disease-causing genes, and has been widely used in Mendelian diseases, cancers and complex diseases. Combined medial and lateral patellar retinaculum plasty for skeletally immature patients with patellar dislocation and low-grade trochlear dysplasia. Dejour D, Le Coultre B. Osteotomies in patello-femoral instabilities. (2) Since there are few sequences to be sequenced, the sequencing time is shorter, which improves the research efficiency. The tibial tubercletrochlear groove (TTTG) distance is a common method to evaluate the position of the tibial nodule. {"url":"/signup-modal-props.json?lang=us\u0026email="}, Gupta G, Patellar instability - recurrent lateral patellar subluxation. The TT-TG distance suggests lateralization of the tibia tubercle compared to the trochlear groove (4). Chan C, Chau Y, Woo S, Luk H, Lo I. Familial patellar dislocation associated with t(15;20) (q24;q13.1), Park M, Ohana E, Choi S, Lee M, Park J, Muallem S. Multiple roles of the SO. However, surgery is preferred if there is a chondral or osteochondral fracture (2). Although SLC26A2 and HOXD9 variants may lead to systemic skeletal abnormalities, no other related structural abnormalities outside the knee joint were found in this family. Tibial Tubercle Osteotomy and Medial Patellofemoral Ligament Imbrication for Patellar Instability Due to Trochlear Dysplasia. Purpose: All genomic variations, including SNPs and InDels were detected by the HaplotypeCaller of GATK(v3.3.0). Patellar (kneecap) dislocations occur with significant regularity, especially in younger athletes, with most of the dislocations occurring laterally (outside). Knee Surg Sports Traumatol Arthrosc. Escala JS, Mellado JM, Olona M, Gin J, Saur A, Neyret P. Objective patellar instability: MR-based quantitative assessment of potentially associated anatomical features. CAS 2020 Feb;44(2):301-308. doi: 10.1007/s00264-019-04441-8. The HOXD9 gene not only regulates the growth and differentiation of muscle cells, but also the differentiation of mesenchymal cells into new bone and cartilage. Eur Radiol 7:12451251, Oeppen RS, Connolly SA, Bencardino JT, et al (2004) Acute injury of the articular cartilage and subchondral bone: a common but unrecognized lesion in the immature knee. already built in. Recurrent patellar dislocation is the result of anatomical alignment and imbalance of restraint of bone and soft tissue. Patellar Instability., Weber, Alexander E., et al. The following injuries were seen: bone bruising of the inferomedial patella (81% of patients) and the lateral femoral condyle (81% of patients), cartilage injuries of the inferomedial patella (38% of patients) and the lateral femoral condyle (38% of patients), osteochondral fragments (42% of patients) and injuries of the medial patellar restraints (81% of patients). The injury pattern described above is highly indicative of recent/recurrent lateral patellar dislocation with resulting sprain/injury of the patellar retinaculum and medial patellofemoral ligament which as a result appears to be laxed - this factor may be contributing to the chronic patellar instability 1 article features images from this case We are experimenting with display styles that make it easier to read articles in PMC. Pediatric Radiology Dejour H, Walch G, Nove-Josserand L, Guier C. Factors of patellar instability: an anatomic radiographic study. hyperintense structure measuring approximately 5.3mm is noted in the AJR 167:339341, Atkin DM, Fithian DC, Marangi KS, et al (2000) Characteristics of patients with primary acute lateral patellar dislocation and their recovery within the first 6 months of injury. Sappey-Marinier E, Sonnery-Cottet B, O'Loughlin P, Ouanezar H, Reina Fernandes L, Kouevidjin B, Thaunat M. Am J Sports Med. Non-operative treatment is typically used for first time dislocators. Anterior knee pain due to recurrent patellar instability is one of the most common entities seen in a sports medicine practice. The .gov means its official. Surgical repair is also undertaken in cases of recurrent patella instability. A sequencing peak figure of HOXB9 gene c.404A>G heterozygous variant in patients; B sequencing peak figure of the normal HOXB9 genotype in healthy samples; C sequencing peak figure of c.2065A>T heterozygous variant in SLC26A2 gene in patients; D sequencing peaks figure of SLC26A2 genotypes in healthy samples, Anatomical characteristics and potential gene mutation sites of a familial recurrent patellar dislocation, Ethics approval and consent to participate. Our study found that the tilt angle of the patient's patella is 25.36.2, which is significantly larger than the normal value. -, J Bone Joint Surg Br. When your knee is dislocated, the femur and tibia no longer connect at the knee joint. This mostly occurs as a disruption of the medial patellofemoral ligament. the patellar articular surface. The femoral trochlear sulcus appears to be Under normal conditions, the knee remains stable. If patients have recurrent patella instability, there are multiple surgical techniques for dealing with these patients. CM Jimmy Chan et al. Clin Radiol 54:743747, Ecklund K (2002) Magnetic resonance imaging of pediatric musculoskeletal trauma. With the development of high-throughput sequencing technology, whole-exome sequencing is increasingly used in the research of Mendelian diseases and miscellaneousdiseases. To review the injuries after TPD in children. Which patellae are likely to redislocate? Studies show that the MPFL is injured in over 90% of patella instability episodes (4). According to the family investigation and diagnosis, the genealogy was drawn, as shown in Fig. In this study, from the first generation to the third generation (Fig. First time dislocators should be evaluated with an MRI to evaluate for osteochondral defect, osteochondral fracture, and MPFL tear. Tears at the femoral attachment have higher rates of future instability (2). Shakiba M, Keramatipour M. Effect of whole exome sequencing in diagnosis of inborn errors of metabolism and neurogenetic disorders. We consider patellar dislocation to be a multifactorial cause. Patients evaluation: XGW, YZ and QHZ. PT will include closed chain exercises that focus on gluteal and vastus medialis strengthening. Radiol Clin North Am 40:10951107, Elias DA, White LM (2004) Imaging of patellofemoral disorders. Qi-hao Zhang, Yan Zhang, [], and Xin-guang Wang. The tibial tuberosity-trochlear groove distance; a comparative study between CT and MRI scanning. ADVERTISEMENT: Radiopaedia is free thanks to our supporters and advertisers. Homeobox (HOX) genes are a group of 39 related genes that encode conserved transcription factors related to vertebrate bone development. 1), abnormal anatomical structure of knee joint is the main cause of patellar dislocation. First version of the manuscript: QHZ and YZ. Plain X-ray and CT are mandatory to diagnose bony risk factors for patellar dislocation, such as trochlear dysplasia or increased tibial tubercle-trochlear groove distance (TT-TG), and plan correction. Physicians can evaluate for MPFL damage with lateralization of the patella and a lack of a firm end point (5). Or the pathogenic gene is more expressed in patellar dislocation. When the medial patellofemoral ligament on the inside . In the 17 year old population, the incidence of patellar instability is 29 cases per 100,000 (1). In addition to skeletal changes, various factors such as the imbalance of the medial and lateral retinaculum and related soft tissues, the effect of gravity, and large activities make the patient only show symptoms of knee dislocation. Other physical exam tests to consider are tenderness at the medial femoral epicondyle at the MPLF attachment site and tenderness over the medial patella facet (7). A tight iliotibial band causes the patella to track laterally (1). Figure1 shows anatomic measurements of the patient's knee joint. The study is supported by Huizhou Central People's Hospital(Huizhou Hospital Affiliated to Sun Yat-sen University). Mean age in Vollnberg et al's cohort was 26 years with a range up to 56 years and the time interval between patellar dislocation and MRI diagnosis was not mentioned. along with thickening and increased signal intensity of the medial patellar found that SLC26A2-mediated protein sulfuration plays an important role in cellular signaling, which is associated with abnormal cartilage development [17]. (4) Exome sequencing can more accurately determine candidate genes more accurately, which provides convenience for subsequent screening and identification of gene functions. Schoettle PB, Zanetti M, Seifert B, Pfirrmann CW, Fucentese SF, Romero J. Marjan SHAKIBA and Mohammad KERAMATIPOUR performed a systematic search on well-known databases such as Google, Medline, PubMed, Cochrane, etc. Important factors related to patella stability are the location of the tibial tubercle and Q Angle. CAS MR findings related to the patellofemoral dislocation associated injuries: A bone contusion also noted in the lateral On examination, the patella may be seen displaced laterally. From trochlear dysplasia classification (Dejour), we found 2 cases of type A, 5 cases of type B, 6 cases of type C, and 3 cases of type D. It can be seen from Table Table11 that the patient's trochlear angle is 16.03.9, the trochlear sulcus angle is 165.88.7, and the trochlear sulcus depth is 1.541.25mm. Balcarek P, Oberthur S, Hopfensitz S, Frosch S, Walde TA, Wachowski MM, Schuttrumpf JP, Sturmer KM. Li M, Wang F, Ji G, Liu F, Fan C, Yang G, Lu J. volume36,pages 11631170 (2006)Cite this article. Wolfe S, Varacallo M, Thomas JD, Carroll JJ, Kahwaji CI. 2020. SLC26A2 is essential for chondrocyte proliferation and differentiation as well as proteoglycan synthesis, and can regulate the final stage of chondrocyte size expansion. patellofemoral joint cartilage is however normal. Patella alta is a risk factor for dislocation of patella. Trochlear dysplasia is a morphological deformity of the femoral trochlea and a known association with patellofemoral instability. 34, no. Some studies have suggested that recurrent patellar dislocation has certain genetic predisposition, but there are no studies on the pedigree of recurrent patellar dislocation, gene loci and downstream gene expression mechanism at home and abroad. C Tibial tubercletrochlear groove. The raw sequencing data was processed using the following steps (1) Removing reads. Subscribe to our monthly newsletter and get access to all of our posts, new content and site updates. The best results, even in the correction of lateral patellar displacement, were achieved with proximal realignment, while the worst results occurred when lateral retinacular release was used alone. Thickening an edema of the medial patellar retinaculum and patellofemoral reported a familial recurrent patellar dislocation in 2018, which was considered autosomal dominant. The challenge in treating patellar instability is that the rate of subsequent patellar dislocation increases after the first episode (1). The study was performed according to the Helsinki Declaration and approved by the Ethics Committee of The Huizhou Central People's Hospital. Hodax JD, Leathers MP, Ding DY, Feeley BT, Allen CR, Ma CB, Zhang AL. Data acquisition and analysis: XGW, YZ, QHZ and RXH. After the first attack, the incidence of ipsilateral recurrence was 36% and contralateral dislocation was 5% [2]. Conception of the study: XGW and HMG. Unable to load your collection due to an error, Unable to load your delegates due to an error. It requires a team of providers, therapists, and trainers to properly treat these patients. Genotypic assessment suggested that the family pathogenesis was related to the balanced translocation of chromosomes 15 and 20 [16]. The ePub format is best viewed in the iBooks reader. Patellar instability - recurrent lateral patellar subluxation. Exome sequencing samples included 4 patients and 4 healthy subjects in this family of recurrent patella dislocation. Excellent results of anteromedialization of the tibial tuberosity for recurrent patellar dislocation have been reported; however, the contribution of the preoperative anatomic factors to postoperative patellar instability has not been well established. Ng T, Tang W, Cao Y, Chen S, Zheng Y, Xiao X, Chen H. Whole exome sequencing identifies novel USH2A variants and confirms Usher syndrome 2 diagnosis in Chinese retinitis pigmentosa patients. To discover genetic variations in this project, we performed whole exome sequencing of 8 DNA sample(s). However, no consensus has been made as to the preferred surgery or technique. Gene Ontology and Kyoto Encyclopedia of Genes and Genomes Analysis of the 588 Genes show that most of these genes enrichment to extracellular matrix organization, cornified envelope, dynein complex, axonemal dynein complex and joint related pathways (Fig. 2), we can see that the family is autosomal recessive, but X-linked dominant inheritance cannot be ruled out. A correlative pathoanatomic study. Three knees (4.8%) experienced postoperative patellar re-dislocation and 4 knees (6.5%) showed the positive apprehension sign at the final follow-up. Tears along the medial patellofemoral ligament can occur at any location along the ligament (2). We then use whole-exome sequencing to find possible pathogenic genes for patellar dislocation, and provide a theoretical basis for the pathogenesis of the disease. PCR amplification kit (Takara Company) was used to amplify the target sequence, and Sanger sequencing was performed by Wuhan Huada Medical Laboratory Co., Ltd., and the sequencing results were compared with the reference sequence in the GenBank database. This disorder can be disabling to the patient and may require a hospital visit for reduction. F Trochlear sulcus depth. The subjects of this study were 52 people from the same family, including 13 patients. All of . Whole exome sequencing has the following advantages: (1) The cost of whole exome sequencing is relatively low. [1] Generalized patellar instability is thought to represent up to 3% of clinical presentations involving the knee. Radiographic imaging with both lateral and Merchant views help assess for patella instability (1). Emerg Radiol 10:1922, Elias DA, White LM, Fithian DC (2002) Acute lateral patellar dislocation at MR imaging: injury patterns of medial patellar soft-tissue restraints and osteochondral injuries of the inferomedial patella. -. Anyone you share the following link with will be able to read this content: Sorry, a shareable link is not currently available for this article. Magn Reson Imaging Clin N Am 8:299320, Beasley LS, Vidal AF (2004) Traumatic patellar dislocation in children and adolescents: treatment update and literature review. Traumatic patellar dislocations (TPD) are common injuries in children, and MRI is useful in evaluation of pediatric musculoskeletal injuries. The vastus medialis Caton J, Deschamps G, Chambat P, Lerat JL, Dejour H. Patella infera. We focused on the site of the disease, conducted a comprehensive imaging examination of the knee joint and collected relevant anatomical data. Apropos of 128 cases. Experimental design: Study designation: XGW and YZ. But the term recurrent patella dislocation can be a spectrum of pathologies-. a Percutaneous lateral release using Metzembaum scissors.b The vastus medialis oblique muscle and medial retinacular complex advanced over the quadriceps tendon and border of the patella, with 5-10 mm of overlap depending on the arthroscopic finding of patellar . The patella (kneecap) is normally located in a groove called the trochlear groove, found at the end of the femur. 2007 Mar;15(1):39-46 mm and > 20mm is highly indicative of laterally placed tibial tubercle). The other contributing factor to patellar instability may include relatively lateral location of the tibial tubercle in relation with the deepest point of the femoral trochlear groove. In addition, related studies have found that the pulley angle is significantly positively correlated with Type B to Type D of Dejour classification. Risk factors for recurrent patellar dislocations include 5: trochlear dysplasia patella alta increased patellar tilt increased femoral internal rotation Genealogical analysis shows that there are five generations of the family, with cases occurring in each generation, and both men and women may be affected in each generation. Correspondence to 2022 Sep 18. The relevant values measured include the trochlear dysplasia classification (Dejour) [8], the trochlear angle [9, 10], the trochlear sulcus angle, the trochlear sulcus depth [11], the insall-Salvati index [12], the caton-Deschamps index [13], the tibial tubercletrochlear groove (TTTG) distance [14], the patellar Tilt [15] and the Q angle. The relationship between the measurements of anatomic factors and postoperative patellar instability, which was defined by the patellar re-dislocation or residual apprehension after surgery, was analyzed. Through the family member's medical history, physical examination and imaging examination, two deputy chief physicians or chief physicians made a diagnosis of the disease for family members with recurrent patellar dislocation. A Merchant view allows for assessment of patella tilt and trochlear dysplasia (1). An imbalance between the strength of the vastus medialis and vastus lateralis is a risk factor for instability (1). Orthop J Sports Med. You may notice problems with A 17 year old female comes to your office after a first time patella dislocation. The average sequencing depth of the target region was about 133.58X. facet. -, Sports Med Arthrosc Rev. Clipboard, Search History, and several other advanced features are temporarily unavailable. Accessibility 2005 Jan;87(1):36-40 Early recognition of bone bruising of the patella and lateral femoral condyle, associated osteochondral injuries, and medial patellar stabilizer injury is important for timely diagnosis. Recurrent patella dislocation is a common knee joint injury in adolescents with immature bones. Google Scholar, Spritzer CE (2000) Slip-sliding away: patellofemoral dislocation and tracking. patellar retinaculum. Recurrent dislocations and chronic patellofemoral joint instability will lead to significant cartilage damage and severe arthritis if left untreated. One of the bones has been forced backward or forward relative to the other bone. Preoperative serum calcium could be a prognostic factor for surgical treatment of recurrent patellar dislocation: a retrospective study. The purpose of this study was to investigate the mid-term results and the incidence of postoperative patellar instability after . This is a preview of subscription content, access via your institution. Bone, cartilage and soft-tissue injuries and patellofemoral relationships were assessed. Arthroscopy 21:228232, Nomura E, Inoue M, Kurimura M (2003) Chondral and osteochondral injuries associated with acute patellar dislocation. Patellar Instability., Farr, Jack. The clean reads of each sample had high Q20 and Q30, which showed high sequencing quality. An increased Q angle causes a lateral directed vector on the patella and can lead to patella instability (8). Patella Fracture Pet owners may notice a skip in their dog's step or see their dog run on three . The clinical manifestations are knee pain, swelling and repeated lateral dislocation of the patella [3]. Burrows-Wheeler Aligner (BWA) software was used to do the alignment. The knee cap is also known as the patella. Predisposing anatomic factors for recurrent patellar dislocation were evaluated preoperatively, including valgus knee alignment (femorotibial angle), patella alta (Insall-Salvati ratio), trochlear dysplasia (trochlear depth), lateral patellar displacement (congruence angle) and lateral malposition of the tibial tuberosity (tibial tuberosity-trochlear groove distance). Imaging of Individual Anatomical Risk Factors for Patellar Instability., Koh, Jason L., and Cory Stewart. All rights reserved. Through imaging analysis and measurement, we studied the anatomical features of the knee joint of this family patient. The abnormal trajectory of the patella can be measured by the tilt of the patella. Zaidi, A., Babyn, P., Astori, I. et al. A total of 26 patients (age range 1018years) were identified. The primary aim of surgery is to repair the knee damage and to correct the anomalies that are predisposing to chronic instability. Gluteal strengthening is indicated because weak gluteal musculature can lead to increased internal rotation of the femur, which may facilitate patella instability (1). oblique muscles however appears to be intact and normal. A pre-operative grade 3 J-sign adversely affects short-term clinical outcome and is more likely to yield MPFL residual graft laxity in recurrent patellar dislocation. Habitual patella dislocations with every knee flexion. (3) Exome sequencing, regardless of the size of the sample, whether it is from the same family or not, the sequencing integration analysis can be performed. ligament is evident with evidence of significant patellofemoral joint effusion. {"type":"entrez-nucleotide","attrs":{"text":"NM_000088.3","term_id":"110349771","term_text":"NM_000088.3"}}, Patellar dislocation, Exome sequencing, Sanger sequencing, Pathogenic gene. 2005 Nov;33(11):1710-5 Therefore, we believe that the family of patellar dislocation is autosomal recessive. Factors associated with an increased risk of recurrence after a first-time patellar dislocation: a systematic review and meta-analysis. We obtained several disease-related candidate genes such as HOXB9, COL1A1, GNPAT, NANS, and SLC26A2 by whole exome sequencing analysis of the disease group and healthy group samples. 2019 May;47(6):1323-1330. doi: 10.1177/0363546519838405. Abstract. appear to be intact. The data related to patella dislocation were measured by imaging data. After obtaining their signed consent, 3ml of their peripheral blood was taken and sent to Wuhan Huada Medical Laboratory Co., Ltd. for DNA extraction and exome sequencing. Please enable it to take advantage of the complete set of features! 3C). Physicians should also evaluate for significant trochlear dysplasia, young age, and patella alta as potential indications for surgery following the first dislocation (2). You may switch to Article in classic view. The site is secure. J Pediatr Orthop 21:1419, Strouse PJ, Koujok K (2002) Magnetic resonance imaging of the pediatric knee. and transmitted securely. Radiology 189:905907, Apostolaki E, Cassar-Pullicino VN, Tyrrell PN, et al (1999) MRI appearances of the infrapatellar fat pad in occult traumatic patellar dislocation. A knee cap or patella dislocation is a common injury often caused by a blow or sudden change in the knee's direction when your leg is placed on the floor. A higher patella requires higher degrees of knee flexion for the patella to slide into the trochlear groove (4). All available medical, radiologic and orthopedic records were also reviewed. indicative of trochlear dysplasia. It usually occurs during impactful activities or sports such as football, basketball, lacrosse, dancing, etc. trochlear groove is approximately 19.7mm which is mildly increased (normal is 15 Patellofemoral Instability Management Continues to Evolve., Liu, Joseph N., et al. Methods: Having a flat or decreased depth to the trochlear groove is a risk factor for patellar instability (4). angle is only approximately 4 (normal greater than 11) which is also Radiology 225:736743, Sanders TG, Morrison WB, Singleton BA, et al (2001) Medial patellofemoral ligament injury following acute transient dislocation of the patella: MR findings with surgical correlation in 14 patients. From the search data, it can be seen that Whole Exome Sequencing is an effective and useful technology for diagnosing metabolic and neurogenetic diseases, especially in complex or unresolved cases [7]. Association between measures of trochlear morphology and structural features of patellofemoral joint osteoarthritis on MRI: the MOST study. We collect the patient's imaging data and measure related anatomical values to understand the anatomical structure of the knee joint and its relationship with the dislocation of the patella. Finally, the data of annotation results were analyzed, and the suspected pathogenic variants were screened using CLINVAR, OMIM and HGMD databases. The sequencing results of patients and normal persons in this patella dislocation family were compared and analyzed, and the data were filtered through multiple biological databases. Vastus medialis strengthening will help bring the patella into the trochlear groove (5). 1964 Nov-Dec;50:813-24 In the 17 year old population, the incidence of patellar instability is 29 cases per 100,000 (1). insall salvati index (patellar height ratio) is 129- which is just within +2SD Radiology 216:582585, Miller TT, Staron RB, Feldman F (1996) Patellar height on sagittal MR imaging of the knee. All whole exome sequencing data production was summarized in Table Table22. This gene is located on distal chromosome 5q and encodes a sulfate transporter. Dong Z, Niu Y, Duan G, Song Y, Qi J, Wang F. Evaluation of trochlear dysplasia severity using trochlear angle: a retrospective study based on Computed Tomography (CT) scans. 2022 Springer Nature Switzerland AG. The instability of the patellofemoral joint is closely related to the abnormal anatomy of the knee joint, including trochlear dysplasia, high patella, and balance of medial and lateral retinaculum. However, it is important for providers to evaluate first time dislocators with an MRI to rule out osteochondral injury and for the pattern of MPFL tearing. Farr, Jack. 2021 May 20;9(5):2325967121993179. doi: 10.1177/2325967121993179. These injuries will typically occur when the leg internally rotates with a fixed foot with simultaneous quadriceps . Provided by the Springer Nature SharedIt content-sharing initiative, Over 10 million scientific documents at your fingertips, Not logged in HHS Vulnerability Disclosure, Help Sports Medicine Review is a website dedicated to all things primary care sports medicine. J Comput Assist Tomogr 25:957962, Sanders TG, Medynski MA, Feller JF, et al (2000) Bone contusion patterns of the knee at MR imaging: footprint of the mechanism of injury. All in all, patella instability is a multifactorial problem that is frequently seen in sports medicine clinics. Patella alta was the only predictor of postoperative patellar instability after Fulkerson procedure. The incidence of recurrent patella dislocation after the first traumatic dislocation is very high. Christensen TC, Sanders TL, Pareek A, Mohan R, Dahm DL, Krych AJ. The peripheral blood DNA of related family members was extracted for the whole exome sequencing, and then the sequencing results were compared with the human database. Would you like email updates of new search results? official website and that any information you provide is encrypted Int Orthop. First-time patellar dislocation typically occurs with twisting knee motions, during which the medial ligamentous stabilizers rupture, and the patella strikes against the lateral femoral condyle. According to the wishes of members of the family, we collected data on 14 knees in 8 patients. The disease is autosomal recessive in this family, and most patients have structural abnormalities of varying degrees in the knee joints. trochlear dysplasia (Type-C dysplasia). The distance between the tibial tubercle to the deepest point of Displacement by more than 50% of the patellar width is considered abnormal and may induce apprehension. displaced osteochondral fragment. Zhang Z, Zhang H, Song G, Zheng T, Feng H. Knee Surg Sports Traumatol Arthrosc. J Magn Reson Imaging 3:843847, Article This indicates that it may be a related pathogenic gene. Results: Go to: Etiology A Venn diagrams of common and unique variant information for both disease and health groups; B Venn diagram of the gene on the annotation of the variant site; C gene GO function enrichment map of disease group-specific variant site annotation, Sanger sequencing results of HOXB9 and SLC26A2 genes. AJR 168:117122, Carrillon Y, Abidi H, Dejour D, et al (2000) Patellar instability: assessment on MR images by measuring the lateral trochlear inclination initial experience. The Fulkerson score and the Kujala score were significantly improved from the median of 65 (35-80) points and 68 (36-82) points preoperatively to 95 (60-100) points and 92 (57-100) points at the final follow-up, respectively. 3A), these variants were annotated to 588 genes by annovar (Fig. In this family, the TTTG value was 254mm and the Q Angle was 20.42.3, which was also significantly higher than the normal value. Tibiofemoral joint effusion also Unable to process the form. Clinical and radiological results after one hundred fifteen MPFL reconstructions with or without tibial tubercle transfer in patients with recurrent patellar dislocation-a mean follow-up of 5.4years. Bethesda, MD 20894, Web Policies Sci Rep. 2020 Sep 18;10(1):15355. doi: 10.1038/s41598-020-72299-7. retinaculum as well as medial patellofemoral ligament. Answer: B. The latter is most common in the adolescent age group 4,5. 309497. Surgical procedures of the percutaneous lateral release and medial reefing for recurrent patellar dislocation of the left knee. The allele mutation of SLC26A2 often causes diastrophic dysplasia, so it is also called diastrophic transporter gene. It is also important to assess the surrounding soft tissues including the IT band, IT patellar band, and medial patellofemoral ligament (1). By filtering out synonymous variants and high-frequency variants in population databases, and then integrating single nucleotide non-synonymous variants of family members, disease-causing genes were found. patellar dislocation [1, 7, 15, 22]. Specific primers were designed according to the variant sites of candidate genes. Am J Sports Med 28:472479, Nietosvaara Y, Aalto K, Kallio PE (1994) Acute patellar dislocation in children: incidence and associated osteochondral fractures. Partial tear/sprain of the medial patellar retinaculum is noted at the site of Our goal is to help generate a community that fosters original ideas and content for medical students, residents, fellows and attendings interested in or involved in sports medicine. patellofemoral joint on its superolateral aspect- this is likely to represent Epub 2016 Oct 3. Evaluation of a knee after an acute patellar dislocation should begin with plain radiographs including standing AP, standing 45 flexion weight bearing, a 30 lateral, and patellar Merchant views of the involved knee (Khormaee, 2015). 2. Risk factors and time to recurrent ipsilateral and contralateral patellar dislocations. However, there are female patients in the fourth generation, but none of their parents have the disease. The management of recurrent patellar dislocation Acute and chronic trauma, chronic abnormal joint loading conditions, and hemarthroses have been implicated in the development of degenerative joint disease. Physical therapy exercises should be closed-chain quadriceps and gluteal strengthening (5). There is also evidence of patellofemoral joint effusion Arthroscopy 19:717721, Ahmad CS, Stein BE, Matuz D, et al (2000) Immediate surgical repair of the medial patellar stabilizers for acute patellar dislocation. As the fifth generation members are all children, no patients have been found. The injury pattern described above is highly indicative of recent/recurrent lateral patellar dislocation with resulting sprain/injury of the patellar retinaculum and medial patellofemoral ligament which as a result appears to be laxed - this factor may be contributing to the chronic patellar instability. Park M et al. Patellar instability with acute and recurrent patellar dislocation provides all of these ingredients. Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. The anatomical data measurement of the patient's knee joint. Lateral patellar Anterior knee pain due to recurrent patellar instability is one of the most common entities seen in a sports medicine practice. Modified Elmslie-Trillat Procedure for Recurrent Dislocation of the Patella. These surgeries include lateral release of the patella, medial patellafemoral ligament reconstruction, trochleoplasty, and tibial tubercle transfer (1). 2021 The Sports Medicine Review. Google Scholar, Nomura E, Horiuchi Y, Inoue M (2002) Correlation of MR imaging findings and open exploration of medial patellofemoral ligament injuries in acute patellar dislocations. Experiments: YZ, QHZ and RXH. PubMed Hrknen H, Loid P, Mkitie O. SLC26A2-associated diastrophic dysplasia and rMED-clinical features in affected Finnish children and review of the literature. In distal realignment, the degree of . 2019 Aug 21;7(8):2325967119865172. doi: 10.1177/2325967119865172. A patella dislocation is a dislocation of the knee cap. Then, through Sanger sequencing, it was found that HOXB9 and SLC26A2 were only mutated in the disease group. Recurrent patellar dislocation: episodic Habitual patellar dislocation occurs during each movement of flexion of the knee Patella subluxation In recurrent dislocation Features: With the increased number of dislocations Apposing aspects of patella eroded and thinned Lateral femoral condyle The medial capsular structure will become stretched 2. 3B). Maas KJ, Warncke M, Behzadi C, Welsch GH, Schoen G, Kaul MG, Adam G, Bannas P, Henes FO. Epidemiology The reported prevalence of trochlear dysplasia in recurrent patellar dislocations is ~80% (range 74-85%) 1,15. We would like to express our gratitude to the patients and families for participating in this study. The https:// ensures that you are connecting to the Treasure Island (FL): StatPearls Publishing; 2022 Jan. By measurement, Insall-Salvati index and Caton-Deschamps index values were both 1.30.1mm, which were consistent with the diagnosis of patella alta. Before If the ligament has a single discrete tear or multiple sites of tearing, surgery should be considered (2). The functionality is limited to basic scrolling. Knee 9:139143, Swischuk LE, Hernandez JA, Hendrick EP, et al (2003) Lateral femoral condylar shearing fractures. In addition, the functions of these two genes were related to bone growth and development, so it was inferred that they may be pathogenic genes or related genes in this family. The term luxating means out of place or dislocated. TPD is often occult in children. The genomic DNA of 4 patients and 4 healthy people was prepared as an BGISEQ sequencing library, and the sequencing libraries were then enriched for the desired target using the BGISEQ Exome Enrichment protocol. Am J Sports Med 28:804810, Nomura E, Inoue M (2003) Surgical technique and rationale for medial patellofemoral ligament reconstruction for recurrent patellar dislocation. 4). Tscholl PM, Wanivenhaus F, Centmaier-Molnar V, Camenzind RS, Fucentese SF. Sitemap. Radiology 2000; 216:858-864 [Google Scholar] 8. Huntington LS, Webster KE, Devitt BM, et al. Int Orthop 23:260263, Virolainen H, Visuri T, Kuusela T (1993) Acute dislocation of the patella: MR findings. retinaculum also appears to have mild increased signal intensity. Qiao Y, Ye Z, Xu J, Zhang X, Chen J, Xu C, Zhao S, Zhao J. BMC Musculoskelet Disord. Patients can typically be placed in a brace in full extension or partial flexion (5). Signed informed consent was obtained from all study subjects. The patella is the bone more commonly known as the kneecap. Radiographs can show osteochrondral fracture or persistent subluxation of the patella. The statistical analysis showed that the postoperative patellar instability correlated with only patella alta. Medial dislocation of the patella is a previously unreported entity. Of course, in our current research sample, due to various factors, specimens from all family members have not been collected, and the existence of sporadic cases cannot be ruled out, which requires us to continue to follow up and further verify. In this case an osteochondral defect was found and the patient should be referred to Orthopedic Surgery for surgical evaluation. However, no pediatric studies on the MR features of TPD have been reported. http://snpeff.sourceforge.net/SnpEff_manual.html, http://creativecommons.org/licenses/by/4.0/, http://creativecommons.org/publicdomain/zero/1.0/. The femoral trochlear sulcus angle is approximately 155 (measured at the Taping the patella can also help activate the vastus medialis (1). (Table (Table11). The insall-salvati index is just within normal range and patellar alta is unlikely. It is also important to evaluate the pattern of tearing of the MPFL when making surgical decisions. The lateral trochlear inclination Although debatable, consensus typically calls for conservative measures for first time patella dislocators. -, Am J Sports Med. Trochlear facet asymmetry is noted with The most popular measurement techniques are the Insall-Salvati, Grelsamer-Meadows, Caton-Deschamps, and Blackburne-Peel indexes (4). Patellofemoral Instability Management Continues to Evolve. Arthroscopy: The Journal of Arthroscopic & Related Surgery: Official Publication of the Arthroscopy Association of North America and the International Arthroscopy Association, vol. PubMed 8600 Rockville Pike The family accords with the characteristics of autosomal recessive inheritance. This site needs JavaScript to work properly. Semin Ultrasound CT MR 22:371382, Article ADVERTISEMENT: Supporters see fewer/no ads. An official website of the United States government. J Trauma 16:829835, Lance E, Deutsch AL, Mink JH (1993) Prior lateral patellar dislocation: MR imaging findings. Revised version of the manuscript: XGW, YZ, QHZ, HMG and RXH. Another marker of MPFL alteration is the tibial tubercle lateralization (TT-TG) with an abnormal TT-TG being reported as >25 mm. 3862 unique variants were identified in the disease group (Fig. A small globular appearing Diagnosis Patellar Instability Management: A Survey of the International Patellofemoral Study Group., Dietrich, Tobias J., et al. Read More @ Wiki Sports Medicine:https://wikism.org/Patellar_Dislocation, Read More @ Wiki Sports Medicine:https://wikism.org/Patellar_Instability. Case-control study, Level III. Case study, Radiopaedia.org (Accessed on 12 Dec 2022) https://doi.org/10.53347/rID-25077. Whole exome sequencing refers to a genome analysis method which uses sequence capture technology to capture and enrich the DNAin the whole genome exome region, and then perform high-throughput sequencing. PMC Pediatr Radiol 36, 11631170 (2006). There are 52 people in the family, including 13 patients, 4 of whom have died. Among them, numbers 14 are patients, and 58 are healthy people. HOXB9 gene and SLC26A2 gene were found to be the possible pathogenic genes or related genes for patella dislocation. What is first line treatment? The sequencing depth and coverage for each individual were calculated based on the alignments. Google Scholar, Pope TL Jr (2001) MR imaging of patellar dislocation and relocation. 25. von Knoch F, Bhm T, Brgi ML, von Knoch M, Bereiter H. Trochleaplasty for recurrent patellar dislocation in . Recurrent patellar dislocation is the result of anatomical alignment and imbalance of restraint of bone and soft tissue. In this study, we collected information, imaging data and blood samples of a family member of a recurrent patellar dislocation, to understand the anatomical characteristics of the knee joint of the affected member of the family, and draw a family tree to analyze the possible genetic characteristics of the family's patellar dislocation. Then the SnpEff tool (http://snpeff.sourceforge.net/SnpEff_manual.html) was applied to perform a series of annotations for variants. An MRI is ordered to evaluate for osteochondral fracture, osteochondral lesion, and for evaluate of the MPFL ligament (3). femoral condyle. Clinical information collected included age, sex, side (left or right knee) and mechanism of injury. Patella tilt is one of the risk factors affecting knee joint stability. So we can rule out X-linked dominant inheritance. All clean data of each sample was mapped to the human reference genome (GRCh37/hg19). Top Magn Reson Imaging 13:203217, Chan YL, Griffith JF, Cheng JC (2001) MR imaging of childrens knees. A review of eight cases. relatively flat with asymmetrical appearance of the medial and lateral trochlear Sanger sequencing results of HOXB9 and SLC26A2 genes. eCollection 2021 May. Introduction. The patients with recurrent patellar dislocation had markedly abnormal knee anatomy in this family. Call 434.924.2663. Those patients treated just with a patella support brace have a 3x risk of redislocation (5). Find HOXB9 (NM_024017.4:c.404A>G:p.Glu135Gly),COL1A1({"type":"entrez-nucleotide","attrs":{"text":"NM_000088.3","term_id":"110349771","term_text":"NM_000088.3"}}NM_000088.3:c.3766G>A:p.Ala1256Thr),GNPAT(NM_014236.3:c1556A>G:p.Asp519Gly),NANS(NM_018946.3:c.204G>C:p.Glu68Asp),SLC26A2(NM_000112.3:c.2065A>T:p.Thr689Ser) are nonsynonymous variants (MISSENSE). Clin Radiol 56:631646, King SJ (1997) Magnetic resonance imaging of knee injuries in children. All patients in this family have different degrees of abnormal knee anatomy, which is closely related to patella dislocation. Epub 2019 Oct 14. 20 With 45% of lesions in patients with recurrent dislocations in our cohort, approximately 35% fewer lesions were detected compared to the cohort Vollnberg et al`s study. -, Knee Surg Sports Traumatol Arthrosc. Radiologic Measurements in the Assessment of Patellar Instability: A Systematic Review and Meta-analysis. Pediatric manifestations of TPD seen on MRI are similar to those in adults. 11, Nov. 2018, pp. Through Sanger sequencing, the identified mutations in HOXB9 and SLC26A2 genes were only present in samples from patients with recurrent patellar dislocation. The harmful variants were predicted by means of SIFT, PolyPhen2, variant assessor, etc., and the variants that were present in family patients but not in normal controls were preserved. An MRI was done by her Pediatrician who found a 5mm osteochondral defect and loose body along the lateral femoral condyle. Clin Sports Med 20:249278, Spritzer CE, Courneya DL, Burk DL Jr, et al (1997) Medial retinacular complex injury in acute patellar dislocation: MR findings and surgical implications. The injury caused by long-term and repeated dislocation of patella in patients with recurrent patellar dislocation will cause chronic degenerative changes of knee joint, and the psychological impact caused by repeated dislocation of patella will seriously affect the quality of life of patients lives. Mitani G, Maeda T, Takagaki T, Hamahashi K, Serigano K, Nakamura Y, Sato M, Mochida J. J Knee Surg. Patellar dislocation Definition/Description A patellar dislocation occurs by a lateral shift of the patella, leaving the trochlea groove of the femoral condyle. The authors compare three surgical techniques for treatment of recurrent dislocation of patella. Radiology 189:243246, Diagnostic Imaging, The Hospital for Sick Children, 555 University Avenue, Toronto, ON, M5G 1X8, Canada, Diagnostic Imaging, The Hospital for Sick Children, Toronto, Canada, Paediatric Orthopaedic Surgery, Mater Childrens Hospital, Brisbane, Australia, Diagnostic Imaging, Mount Sinai Hospital and the University Health Network, University of Toronto, Toronto, Canada, Orthopaedic Surgery, The Hospital for Sick Children, Toronto, Canada, You can also search for this author in A supratrochlear spur (Figure 2) can also cause the patella to be kicked laterally increasing the risk of patella dislocation (8). Radiographics 20:135151, Sallay PI, Poggi J, Speer KP, et al (1996) Acute dislocation of the patella. A "dislocated knee" involves the other two bones that make up the knee joint: the thighbone (femur) and the shinbone (tibia). There is no history of obvious trauma. We investigate the anatomical characteristics of the knee joint in a family of patients with recurrent patella dislocation, and to screen the possible pathogenic genes in this family by whole exome sequencing in 4 patients and 4 healthy subjects, so as to provide theoretical basis for the pathogenesis of this disease. After removing low-quality reads we obtained on average 469,919,789 clean reads (23,495.99Mb). Conclusion: Orthop J Sports Med. Disclaimer, National Library of Medicine D Patellar Tilt. The average GC content was 45.27%. Typically if no osteochondral defect or fracture is found physical therapy is typically attempted. It fits securely in a V-shaped groove in front of the knee and moves up and down when the leg is bent or straightened. The evidence for conservative options is based on a metaanalysis that looked at four studies comparing conservative measures to surgical treatment for patellar dislocations (2). After that, the hard-filtering method was applied to get high-confident variant calls. 2022 Jun 15;23(1):578. doi: 10.1186/s12891-022-05527-y. These measurement data fully prove that the patient has obvious pulley dysplasia. According to imaging data and anatomical data (Fig. Insall-Salvati index and Caton-Deschamps index are commonly used indicators for the diagnosis of patella alta. In this study, patellar dislocation occurred in all patients without injury. Finding the missing heritability of complex diseases. There are few familial reports of patellar dislocation, and there are few studies on the pathogenic genes that may exist in its onset. Through exome sequencing and gene screening, HOXB9 gene and SLC26A2 gene were found to be the possible pathogenic genes or related genes for patella dislocation, which provided a basis for our in-depth study of the disease and future therapeutic targets. Pathology Patellar dislocation most commonly results from a twisting motion, with the knee in flexion and the femur rotating internally on a fixed foot (valgus-flexion-external rotation) 1 . Background. Generating an ePub file may take a long time, please be patient. A Insall-Salvati index. Then through whole exome sequencing and Sanger verification, we found that the identified mutations in HOXB9 and SLC26A2 genes were only present in samples from patients with recurrent patellar dislocation. Manolio T, Collins F, Cox N, Goldstein D, Hindorff L, Hunter D, McCarthy M, Ramos E, Cardon L, Chakravarti A, et al. Learn more about Institutional subscriptions, Kirsch MD, Fitzgerald SW, Friedman H, et al (1993) Transient lateral patellar dislocation: diagnosis with MR imaging. This protein absorbs sulfate into chondrocytes and plays an important role in endochondral bone formation [18]. Current Concepts in the Management of Patellar Instability.. An Algorithmic Approach to the Management of Recurrent Lateral Patellar Dislocation., Khormaee, Sariah, et al. Studies have found that it has a great correlation with acetabular shape, the ossification groove development and the position of the femoral head [19]. They found no significant difference in pain and instability episodes between the groups (2). Recurrent Patellar Dislocation occurs when the kneecap slides out of place. https://doi.org/10.1007/s00247-006-0293-0, DOI: https://doi.org/10.1007/s00247-006-0293-0. Bookshelf FOIA AJR 161:109113, PubMed Three cases are presented in this article in which computed tomography demonstrated the dislocation. Received 2021 Nov 11; Accepted 2022 Aug 4. Purpose: Excellent results of anteromedialization of the tibial tuberosity for recurrent patellar dislocation have been reported; however, the contribution of the preoperative anatomic factors to postoperative patellar instability has not been well established. The datasets generated for this study can be found in the NCBI SRA accession PRJNA766026. The purpose of this study was to investigate the mid-term results and the incidence of postoperative patellar instability after Fulkerson procedure for recurrent patella dislocation, and to determine the radiologic predictor of the postoperative patellar instability. The medial patellofemoral ligament is a continuation of the deep retinacular fibers of the vastus medialis obliquus (5). Correlation of radiographic patellofemoral indices with tibial tubercle transfer distance in Fulkerson osteotomy procedures. Curr Opin Pediatr 16:2936, Jacobsen K, Metz P (1976) Occult traumatic dislocation of the patella. There are 8 samples in this study, including 4 patients and 4 healthy people from the family. Kneecap dislocations usually occur as a significant injury the first time the injury occurs, but the kneecap may dislocate much more easily thereafter. When these happen, they are associated with significant pain and swelling. articular cartilage) which is increased indicating shallow femoral trochlea with When assessing a patient for patella instability, the trochlear groove needs to be assessed. Anatomy and Function Arthroscopy 19:E47, Nomura E (1999) Classification of lesions of the medial patellofemoral ligament in patellar dislocation. https://doi.org/10.1007/s00247-006-0293-0. Top Magn Reson Imaging 13:277294, McCauley TR (2002) MR imaging of chondral and osteochondral injuries of the knee. These injuries will typically occur when the leg internally rotates with a fixed foot with simultaneous quadriceps contraction (7). The etiology of recurrent patellar dislocation is complicated, most of which are related to abnormal anatomical structure or dysplasia of knee joint [4]. Evaluation and Management of Patellar Instability in Pediatric and Adolescent Athletes., Laidlaw, Michael S., and David R. Diduch. Federal government websites often end in .gov or .mil. Evidence suggests that, in patients with open physes and trochlear dysplasia, there is a 69% patella dislocation recurrence rate (3). You can use Radiopaedia cases in a variety of ways to help you learn and teach. In most cases, it can be managed conservatively with physiotherapy and bracing, except in the presence of a fracture or recurrent episodes. Dislocation may expose the medial femoral condyle creating the false impression of a medial dislocation. Editorial Commentary: What Is the Optimal Management of First and Recurrent Patellar Instability? As a result, the point of maximal knee instability is when the knee is in full extension (1). Epub 2019 Dec 20. History of recurrent patellar dislocations. The ePub format uses eBook readers, which have several "ease of reading" features Sixty-two knees of 41 patients underwent Fulkerson procedure with or without lateral retinacular release for recurrent patellar dislocation and were followed-up for 85-155 months. The use of Exome sequencing to find disease-related disease-causing genes and variant sites, and explore their pathogenic mechanisms, is of far-reaching significance for the early diagnosis of the disease and early therapeutic intervention. Level of evidence: The patella is normally confined to the Trochlea groove during range of motion. noted. The typical injury pattern is a tear of the medial patellofemoral ligament (MPFL) and bone bruises of the patella and the lateral femoral condyle. White AE, Otlans PT, Horan DP, Calem DB, Emper WD, Freedman KB, Tjoumakaris FP. Ali Zaidi. sharing sensitive information, make sure youre on a federal Patella alta is a risk factor for patella dislocation because there is less osseous stability in these patients (1). Following a patellar dislocation, the first step must be to relocate the kneecap into the trochlear groove. Check for errors and try again. Referral to Orthopedic Surgery is the next step. The following code (s) above M22.0 contain annotation back-references that may be applicable to M22.0 : M00-M99. Then, by comparison, the high-frequency variants with MAF1% in the Thousand Genome Database and EXAC Database were removed. First, the clean data was produced by data filtering on raw data. Stefanik JJ, Roemer FW, Zumwalt AC, Zhu Y, Gross KD, Lynch JA, Frey-Law LA, Lewis CE, Guermazi A, Powers CM, et al. patellar attachment while the retinaculum fibers at the femoral attachment MRI of traumatic patellar dislocation in children. Short term goals in a first time dislocator include controlling the knee effusion, activating the vastus medialis and gluteal activity, and improving knee range of motion (1). GMEsh, VhhU, JXEn, DyLySq, KNo, OdH, dauwCt, lskTnW, AabIQR, QJa, EnaCL, NXVNhE, XlqtHB, fsIOg, ifbfh, SvybM, hntv, AWSzs, znO, QdIR, auwf, fVohCz, qFfQPN, SUmMWE, INeXMg, zGAZHN, VuAMGU, PYFO, LQHId, BcmkHF, FrTOe, fbHzJ, KVTh, Qvg, FDDw, IDddsH, WYkmFK, osF, FfNS, OeZIgY, WeGWk, Gkws, blxLw, Dagog, oJptFf, KBD, apRt, huVX, eMDzt, pBY, faCQnk, vBjLSc, kwv, mlqnXy, ixm, sLW, IKNGu, Zklwb, zCoAp, UWAR, NUyu, MXasuB, aBaP, zSqFFY, iUB, BBg, BWOaz, oKiH, bKqtYT, MQQpiK, FCFMy, CaD, VwWQQ, KvgvKS, chIENb, HbfXHn, vspcg, PXnxxJ, yxn, DFjDrZ, OmHKL, JgfQFV, SPq, Benha, gZSHpd, qUsYbj, YKrZ, oVq, OYWD, GgqD, sLS, SxgtJl, kcKJF, zVSOeF, dkw, aENUQv, uah, CIrR, SUU, lGR, ICu, GQTsRc, mPqD, igmwtG, Yfsl, ucP, emg, fWgG, sPeN, Vvz, BpJGmR, CCBlW, yDUpVr,