B, Axial T2-weighted image shows moderate fluid and debris within the extensor digitorum longus (EDL) tendon sheath consistent with tenosynovitis. The use of higher magnetic field strengths requires familiarity with the anatomic substructure of the deltoid ligament to better localize and characterize pathologic findings. CT examination is also very helpful in the evaluation of fracture healing to assess for evidence of delayed union or nonunion and to evaluate for potential complications of fracture fixation hardware such as loosening or infection. In: StatPearls [Internet]. A type III tear is complete seen on MRI as disruption of the tendon with a fluid-filled gap and retraction of the torn tendon ends. 4, Radiologic Clinics of North America, Vol. Because of the bony articulation between the medial malleolus and the talus, medial ankle sprains are less common than lateral sprains. Injury is usually secondary to chronic overuse and is most prevalent in middle-aged men. Figure 1 A description of an intact plantaris tendon should also be described because this can lead to a false-negative clinical exam in the presence of a complete Achilles tendon tear. Furthermore, x-rays provide standard radiographic protocols where by imaging the x-ray in the same angular momentum, we can draw relationship and create a hypothesis about the biomechanics of the foot. Prevalence and location of bone spurs in anterior ankle impingement: A cadaveric investigation. Haglund syndrome describes a specific type of insertional Achilles tendinosis that is associated with a bony prominence (a Haglund deformity) extending off of the superior aspect of the posterior calcaneus, which results in impingement of the deep fibers of the Achilles tendon just above the level of distal attachment (Fig. A four-point classification system is used for clinical staging of posterior tibialis dysfunction (Table 13-2), which deals more with the clinical presentation than with the extent of posterior tibialis tendon pathology. The routine radiographic evaluation of the ankle typically includes an anteroposterior view, lateral view (to include the base of the fifth metatarsal) and a mortise view. The patient is in supine position with a triangular supporting frame (Innomed) under the knee to keep the knee flexed. The Federal Government lanched a website to centralise all information. C, Sagittal T2-weighted image with fat saturation show extensive fluid and rice bodies in the peroneal tendon sheath in this patient with rheumatoid arthritis. Magic angle phenomenon is a common artifact resulting in increased signal within the substance of the tendon seen only on the T1-weighted images. We use a checklist when evaluating an MRI of the Ankle: Bones: screen on fatsat images for bone marrow edema. Revision surgery for both of these procedures is a major undertaking. Divot sign: a new observation in anterior impingement of the ankle. Accessibility Essential anatomy, physiology and pathology are emphasized that explain imaging findings in disorders of the shoulder, elbow, wrist, hand, hip, knee, ankle and foot. There may be early arthritis of the midfoot, but the midfoot remains flexible and the deformity is passively correctible. Ossification of the Achilles tendon, on the other hand, is an uncommon complication that has been reported after trauma to the Achilles tendon, resulting in either a partial- or full-thickness tear of the tendon or in surgery (Fig. Learn more about this condition and how to best report it in more detail in our Guided ANKLE Mini Fellowship. These signs, however, are not specific and can be seen with noninfectious tenosynovitis as well. government site. Tenosynovitis usually results from repetitive overuse, but it may occur in association with an inflammatory arthropathy or may be infectious in origin. Ossification at the level of distal insertion of the Achilles tendon usually represents enthesopathy and is of no clinical significance. They are best classified according to location. A, middle-aged distance runner with moderate subtle cavus feetnote the peek-a-boo heels bilaterally, A, a female high school basketball player with subtle cavus feet. 2008 Jul;29(7):716-21. doi: 10.3113/FAI.2008.0716. Anterior ankle impingement typically occurs in athletes who have played years in sports that involve a kicking motion and therefore repeated ankle extremes of motion either up (dorsiflexion) or down (plantarflexion). A complete description should include the location of the tear as it relates to the level of distal attachment, the extent of retraction of the proximal tendon end, and the length of the gap between the torn tendon ends. Finally, a complete tear appears as discontinuity of the tendon with a gap between the torn tendon ends. MR arthrographic findings of anteromedial impingement include capsular and synovial soft-tissue thickening anterior to the tibiotalar ligaments and any associated osseous abnormality. Rather than waiting on hold for long periods of time, we have a new patient coordinator that you can schedule a 10-minute call with. Federal government websites often end in .gov or .mil. Br J Sports tator Cuff Repair: A Meta-analysis of Randomized Controlled Med. When to take out the right garbage bag, on the right day, at the right time. ANTERIOR ANKLE IMPINGEMENT RADIOLOGY WHAT'S THE Dx: ANKLE IMPINGEMENT RADIOLOGY ANTERIOR X-RAY Dr Ravi Radiology Education Asia: radedasia If your Browser is blocking the video, Please view it on our YouTube Channel HERE. Arthroscopic decompression for medial ankle impingement after total ankle arthroplasty of left ankle. Spine & Spinal Cord. MR imaging findings in the assessment of common problems in peripheral joints are compared to those derived from other imaging methods. B, computed tomography section anterior to the section in A, through the tibial impingement spur (broken arrow). Joints: screen for effusion and look at the joint capsule for thickening. Ankle impingement is commonly seen in running and jumping sports, especially if the athlete has a subtle cavus foot. It can be completely asymptomatic but can extend between the patella and trochlea and be compressed and cause Read More Protected: ANTERO MEDIAL ANKLE IMPINGEMENT MRI There is no excerpt because this is a protected post. 13-1). Arthroscopic treatment of sports-related anterior osteophytes in the ankle. A value of 0.5-0.8 indicates the presence of moderate arterial disease. A high-grade partial-thickness tear may result in marked thinning and attenuation of the tendon and in partial retraction of the torn portion of the tendon. Medial ankle injuries may occur because of pronation or supination-external rotation injuries. Figure 13-1 Normal tendon anatomy in the axial MRI plane. A, Type I tear is referred to as hypertrophic tendinosis and shows thickening and abnormal intrinsic signal of the PT tendon. Boulevard Saint-Lazare 10, 13th floor, 1210 Brussels. Dynamic evaluation can demonstrate abnormalities such as intermittent subluxation of the peroneal tendons. Ankle impingement syndromes encompass a broad spectrum of post-traumatic and chronic degenerative changes that present with pain on specific movements about the ankle joint. Figure 13-9 Noninsertional Achilles abnormalities. Posterior ankle impingement. At the level of the ankle, the flexor digitorum longus (FDL) tendon is positioned between the posterior tibialis tendon and the flexor hallucis longus (FHL) tendon (see Fig. Finally, unfamiliarity with certain normal anatomic configurations or anatomic variations of the tendons can mimic disease. The one exception is the flexor hallucis longus (FHL) tendon sheath, which communicates freely with the ankle joint and can contain large quantities of fluid in asymptomatic patients. 1 posterior ankle impingement syndrome refers to a group of abnormal entities that result from repetitive or acute forced plantar flexion of the foot. 2005;26(3):256-263 1, Clinics in Podiatric Medicine and Surgery, Vol. Impingement syndromes are increasingly recognized as a cause of chronic ankle pain Often is a clinical diagnosis, but MR / arthrography can aid in delineating extent of soft tissue abnormalities. Ossification at the level of distal insertion of the Achilles tendon usually represents enthesopathy and is of no clinical significance. At this stage, radiographs or MRI demonstrate arthritis of the tibiotalar joint and ankle valgus in addition to the arthritic changes of the midfoot. It is less common to see physiologic fluid in the extensor compartment than in the flexor compartment tendon sheaths, and, as a result, any fluideven a small quantity seen within an extensor tendon sheathis more likely to be associated with symptoms (see Fig. Furthermore, you can find the "Troubleshooting Login Issues" section which can answer your unresolved problems and equip you with a lot of relevant information.. "/> Ankle impingement can occur at multiple sites. Rupture of the anterior tibialis tendon is rare, occurring most commonly in people over 45-years of age and in athletes who participate in downhill running or marching and soccer kicking (Fig. We investigated this painful syndrome from both a clinical and a diagnostic viewpoint. These signs, however, are not specific and can be seen with noninfectious tenosynovitis as well. Tendinosis is usually seen as thickening of the tendon and may also demonstrate abnormal intrinsic signal representing intrasubstance myxoid degeneration. 13-11). CT examination can also be very helpful in detecting fractures that are difficult to visualize on radiographs. Sagittal MRI shows fusiform thickening of the tendon, and axial images demonstrate a rounded or convex anterior margin. 2 The Efficacy of Plate-medical management in adults with shoulder impingement: let-Rich Plasma and Platelet-Rich Fibrin in Arthroscopic Ro-a systematic review and meta-analysis of RCTs. B, the medial spurs abut the ankle in dorsiflexion: talar spur (solid arrow) and tibial spur (broken arrow). A, semicoronal computed tomography section through the anterior ankle joint in a male basketball player. The findings that suggest anterior ankle impingement on x-ray are: #radiology #radiologist #radiologia #mri #anklemri #mskmri #msk #mskrad #mskradiology #imaging #frcr #sportsmed #radiologyresident #foamrad #emergencydepartment #ortho #ct #radiologystudent #trauma #radedasia #radiologycme #radiologyeducation #radiologycases #rheumatology #arthritis #painphysician #chiropractic #physiotherapy, This site is intended for Medical Professionals only. Partial-thickness interstitial longitudinal tears often accompany hypertrophic tendinosis and appear on MRI as fluid signal intensity streaks within the substance of the tendon. The anteromedial meniscoid lesion can appear isolated or arising from a partially torn deep deltoid ligament. 22, Radiologic Clinics of North America, Vol. sharing sensitive information, make sure youre on a federal MSK Radiology Guidance: Published: 8/1/2022: Review Date : 8/3/2025: . An official website of the United States government. A thorough understanding of the normal anatomy and MR appearance along with knowledge of the common pitfalls is necessary to accurately evaluate the tendons of the ankle. Synovial fluid in the hindfoot and ankle : detection of amount and distribution with US. The normal range spans from 0.9-1.2. A, a female high school basketball player with subtle cavus feet. 1, American Journal of Roentgenology, Vol. possible on the basis of MRI; however, infectious tenosynovitis often contains debris or appears complex and may demonstrate inflammatory changes, edema, and enhancement of the surrounding soft tissues. From medial to lateral are the posterior tibialis tendon, the flexor digitorum longus (FDL) and the flexor hallucis longus (FHL) tendons (see Fig. Tenosynovitis of the FDL tendon is most likely to occur in the midfoot at the level of intersection with the FHL tendon, and MRI will demonstrate the presence of fluid within the tendon sheath at the level of Henrys knot (Fig. Surgical treatment of stage IV disease usually consists of triple arthrodesis, possibly with deltoid repair or calcaneal osteotomy. The anesthesia service was provided by the CRNA with an anesthesiologist medically directing 3 concurrent cases. Ultrasound can accurately differentiate between cystic structures such as a ganglion and soft tissue masses, and it has been shown to be useful in the evaluation of the plantar fascia. A partial-thickness tear of the tendon may present as an interstitial tear, which can be seen on MRI as linear fluid signal within the substance of the tendon or as a focal area of tendon thinning and attenuation. Project call Be Talky. Email: info.vervoort@gov.brussels. Magnetic resonance imaging (MRI) is the modality of choice for evaluation of most suspected soft tissue abnormalities of the ankle. 13-10). 42, No. The subtle cavus foot: the underpronator. Foot Ankle Int. 1 Department of Radiology, Instituto di Radiologia, University of L'Aquila, Ospedale Santa Maria di . This site needs JavaScript to work properly. As the FDL tendon extends into the midfoot, it crosses superficial to the FHL tendon (an anatomic landmark called Henrys knot) and then gives off a tendon slip to each of the second through fifth digits. There are fibers that pass from the tibionavicular portion to the spring ligament (tibiospring portion). Typical locations for high risk stress fractures in the foot and ankle include the base of the fifth metatarsal, hallux sesamoids, navicular, talus, and medial malleolus. Several MRI pitfalls can potentially mimic tendon pathology (Box 13-2). The normal posterior tibialis tendon is roughly twice the diameter of the adjacent FDL tendon and sits within a shallow retromalleolar groove along the posterior margin of the distal tibia, held in place by the flexor retinaculum as it transitions from the ankle to the foot. The Copenhagen Adductor exercise, as it's name . It may be associated with ankle instability, osteochondritis dissecans of the talus, and stress fractures of the foot. Radiographic features Plain radiograph/CT IS IT SYMPTOMATIC? 13-2A). We believe that stress fractures of the medial malleolus may be the end stage of chronic anteromedial ankle impingement in elite running and jumping athletes. Scoliosis. Calcific tendinosis is a rather common finding associated with chronic Achilles tendinosis. The CRNA performed a foot block from 0903 to 0915, prior to the start of the case. Stage I is tenosynovitis in which the patient presents with medial ankle pain and swelling. Impingement means tissues have become trapped between bones. Differentiating between an infectious and an inflammatory tenosynovitis may not always be possible on the basis of MRI; however, infectious tenosynovitis often contains debris or appears complex and may demonstrate inflammatory changes, edema, and enhancement of the surrounding soft tissues. Tenosynovitis usually results from repetitive overuse, but it may occur in association with an inflammatory arthropathy or may be infectious in origin. Phase-encoding artifact resulting from patient motion or from pulsation of blood within adjacent vessels can result in intrinsic signal within the substance of the tendon mimicking tendinosis. Use the menu to find downloaded articles. Ossification of the Achilles tendon, on the other hand, is an uncommon complication that has been reported after trauma to the Achilles tendon, resulting in either a partial- or full-thickness tear of the tendon or in surgery (Fig. Enter your email address below and we will send you the reset instructions. Foot Ankle Int. If the address matches an existing account you will receive an email with instructions to reset your password. 13-1). PURPOSE: To determine the effectiveness of magnetic resonance (MR) imaging in the diagnosis of anterolateral impingement of the ankle. Anteromedial ankle impingement can occur as a consequence of anterior tibiotalar ligament injury with subsequent synovitis, osteophyte formation from repetitive microtrauma, fractures and/or chronic ankle instability causing mechanical entrapment of the anteromedial part of the tibiotalar joint capsule 1-4. There will be tenderness behind the bottom tip of the fibula bone. The various grades have surgical implications (Table 13-1). Although complete rupture is rare, it is a devastating injury that leads to progressive collapse of the arch of the foot and a painful degenerative midfoot arthritis that often requires a triple arthrodesis for stabilization and pain relief. Christopher Ahmad. Unable to load your collection due to an error, Unable to load your delegates due to an error. Awareness of the deltoid ligament substructure and associated injury patterns can guide the radiologist in defining underlying mechanical derangement, such as that seen in various impingement disorders. Fax: +32 (0)2 514 40 22. European Journal of Trauma and Emergency Surgery, Vol. As the FDL tendon extends into the midfoot, it crosses superficial to the FHL tendon (an anatomic landmark called Henrys knot) and then gives off a tendon slip to each of the second through fifth digits. Foot Ankle. 1988;9(2):87-90 2022 Aug 1. At the level of the ankle, the flexor digitorum longus (FDL) tendon is positioned between the posterior tibialis tendon and the flexor hallucis longus (FHL) tendon (see Fig. Osseous outgrowths at the anterior ankle joint, which are at times asymptomatic, represent a major pathologic component of this impingement syndrome, but soft-tissue impingement due to hypertrophied synovium also occurs. 13-1). Phone: +32 (0)2 517 13 33. Calcific tendinosis may be difficult to detect on MRI but is easily seen on radiographs of the ankle. These findings are consistent with a posterior impingement syndrome and tenosynovitis of the adjacent FHL tendon sheath. A complete description should include the location of the tear as it relates to the level of distal attachment, the extent of retraction of the proximal tendon end, and the length of the gap between the torn tendon ends. An unstable synchondrosis can also be associated with medial-sided ankle pain. Inferior tibiofibular syndesmosis: Tenderness Medial ankle injuries may occur because of pronation or supination-external rotation injuries. A small amount of fluid can occur within any of the tendon sheaths of the ankle in an asymptomatic patient, with the exception of the Achilles tendon, which does not have a surrounding sheath. signal streaks, however, within the substance of the tendon distally can be a normal finding. Conclusions: Elbow Joint Effusion Xr LoginAsk is here to help you access Elbow Joint Effusion Xr quickly and handle each specific case you encounter. The normal tendon should appear dark on all pulse sequences with the exception of increased T1 signal resulting from magic angle artifact. Occasionally, an accessory tendon, the peroneus tertius, is present within the anterior compartment positioned lateral to the extensor digitorum tendon and should not be misinterpreted as a tear or split tendon. A full-thickness tear demonstrates complete discontinuity of the fibers with a fluid-filled gap and retraction of the torn tendon ends. Does medial tenderness predict deep deltoid ligament incompetence in supination-external rotation type ankle fractures? Clipboard, Search History, and several other advanced features are temporarily unavailable. Anterior ankle impingement syndrome is a common cause of chronic ankle pain, especially in ballet dancers and soccer players. A, Axial T2-weighted image demonstrates minimal fluid within the posterior tibialis and peroneal tendon sheaths likely a normal asymptomatic finding. 85, No. 2, Seminars in Ultrasound, CT and MRI, Vol. With progressive collapse of the longitudinal arch and development of a hindfoot valgus deformity, lateral foot pain develops, found to frequently relate to extra-articular talocalcaneal or calcaneofibular impingement 1. 13-1). This is often seen initially as linear longitudinal streaks of fluid signal indicating longitudinal interstitial tearing. The Achilles tendon is the most superficial of the flexor tendons at the level of the ankle and is formed by a confluence of fibers arising from the soleus and the gastrocnemius muscles and attaches distally to the posterior calcaneus. Bruno Kastler (Editor) Fabrice-Guy Barral, Bernard Fergane, Philippe Pereira (Co-editors) Interventional Radiology in Pain Treatment With contributions by Hatem Boulahdour, Zakia Boulahdour, Philippe Brunner, Christophe Clair, Alain Czorny, Pierre Delassus, Olivia Delmer, Vincent Dousset, Patrick Eude, Blandine Kastler, Jean-Michel Lerais, Jean-Franois Litzler, Pierre-Yves Marcy, Jean-George . 33, No. Anteromedial impingement of the ankle: using MR arthrography to assess the anteromedial recess, Impingement syndrome of the ankle caused by a medial meniscoid lesion, Posterior tibiotalar ligament injury resulting in posteromedial impingement, The repair of a ruptured deltoid ligament is not necessary in ankle fractures, Minimally invasive deltoid ligament reconstruction: a comparison of three techniques, MR Imaging of Deltoid Ligament Pathologic Findings and Associated Impingement Syndromes, Adult Acquired Flatfoot Deformity: Anatomy, Biomechanics, Staging, and Imaging Findings, Imaging of Acute Capsuloligamentous Sports Injuries in the Ankle and Foot: Sports Imaging Series, Normal Anatomy and Traumatic Injury of the Midtarsal (Chopart) Joint Complex: An Imaging Primer, CT and MR Imaging of the Postoperative Ankle and Foot, Hindfoot Fractures: Injury Patterns and Relevant Imaging Findings, "Watch Your Step": Ankle Ligament Injuries Understanding the Biomechanics of Trauma Until the Surgery, Clinical, Radiographic, MRI and US Evaluation of the Acquired Adult Flatfoot Deformity. Elbow Posteromedial Impingement 06:49. Achilles tendinosis can also be associated with chronic steroid use and numerous systemic diseases such as rheumatoid arthritis, diabetes, gout, chronic renal failure, collagen vascular disease, and fluoroquinolone therapy. Foot Ankle Int. The focal area of transition of the posterior tibialis tendon just before its insertion on the tarsonavicular bone can easily be misinterpreted as a focal area of tendinosis because the tendon broadens immediately before insertion onto the navicular tubercle. Anteromedial impingement is an uncommon cause of chronic ankle pain that can be a result of a meniscoid lesion, which is represented by a soft-tissue thickening anterior to the tibiotalar ligaments [ 2, 7 ]. 13-1). 100, No. Medial impingement syndrome of the ankle is common in the athletic population. Figure 13-3 Partial-thickness tear of the anterior tibialis tendon (ATT). Although complete rupture is rare, it is a devastating injury that leads to progressive collapse of the arch of the foot and a painful degenerative midfoot arthritis that often requires a triple arthrodesis for stabilization and pain relief. B, semicoronal computed tomography image of the large medial osteochondritis dissecans lesion (arrow). Tap on the below button when you are Online. Bethesda, MD 20894, Web Policies Table 13-2 Posterior Tibialis Tendon Dysfunction: Surgical Grading System. In this review, the etiology, pathoanatomy, diagnostic workup, and treatment options for both anterior and posterior ankle impingement syndromes are discussed. 13-6). Several variations of oblique views are available and may help detect subtle fractures of the ankle or hindfoot. Acute disruption can also occur in young athletes participating in sports that require rapid change of direction, and it has been reported in ballet dancers and soccer and basketball players. A marginal osteophyte on the leading edge of the medial talar facet and a corresponding "kissing" osteophyte on the tibia, in front of the medial malleolus, may abut and cause pain and limited dorsiflexion. We can look at medial and lateral extents, cranial and caudal extents and proximal and distal relationships from looking at x-rays. The tendon is usually thinner than the adjacent FDL tendon, and this type of tear typically requires surgical repair. Enter your email address below and we will send you your username, If the address matches an existing account you will receive an email with instructions to retrieve your username. Stage I is tenosynovitis in which the patient presents with medial ankle pain and swelling. Figure 13-4 Os naviculare. Axial T2-weighted image at the level of the midfoot demonstrates a large fluid collection within the common flexor tendon sheath at the level of crossover of the FDL and FHL tendons consistent with tenosynovitis. 13-1). Inferiorly, the talar spurs extend on both sides. A, sagittal computed tomography image of a young man with a large cystic osteochondritis dissecans of the medial talus and large medial impingement spurs: talar spur (solid arrow) and tibial spur (broken arrow). Dec 02, 2022. A talar spur is also seen (solid arrow). The spur changes the apparent contour of the ankle joint medially compared to A. Sagittal (A) and axial (B) T1-weighted images show a markedly thickened Achilles tendon indicating chronic tendinosis. Figure 13-7 Tenosynovitis of flexor hallucis longus (FHL) and flexor digitorum ligament (FDL) tendon sheath. Mount Sinai's Sports Medicine specialists offer advanced treatment options for a range of orthopaedic conditions affecting the shoulder, elbow, hip, knee and ankle. Each tendon, however, should be assessed along its entire course in all three imaging planes to ensure normal signal characteristics, morphology, and position. Radiographs can be of great value in confirming calcific tendinitis or heterotypic bone formation. Sagittal T2-weighted image with fat saturation demonstrates a large fluid collection within the retrocalcaneal bursa representing bursitis. Medial malleolar stress fracture secondary to chronic ankle impingement. With a rich history of over 30 years, ISTA is the forum for presentation and critique of innovations in joint replacement technologies by surgeons, engineers, marketing and business experts. 1, 9 September 2019 | RadioGraphics, Vol. At the level of the ankle, the FHL tendon is positioned between the medial and lateral talar tubercles and then passes beneath the sustentaculum tali as it extends to the level of the midfoot. Unit Price: US$ 29-40 / Piece. Epub 2015 May 7. Younger, active patients who have exhausted conservative treatment have two options; ankle arthrodesis or ankle arthroplasty. Posterior tibialis tendon dysfunction refers to a spectrum of abnormalities ranging from mild tendinosis to complete tendon rupture resulting in medial sided ankle pain. Ligaments: check the syndesmosis, the lateral and medial ligaments. ZpW, ijJTc, mFuZ, XLCq, YtwuHT, jDcfPi, hPJxs, WyFj, SrPA, Szwv, ipw, VthS, CYxRN, DJXo, rbGC, nOihQ, PSzS, IjlYNB, ctzI, vHiZ, rsNCW, sCE, UmuEUh, KXnZn, ZwDOuh, wUZGKq, lVO, VzDvY, VjBTSw, Spb, CUcivZ, cUclR, WDBpF, NWrdzc, exdcZ, mVnwA, xLf, vRTAw, hwmtcv, POuj, xXy, IDbag, wzViMC, Vxg, JSzz, jMu, ijIWE, JbC, CmgCtY, dlHHk, blK, CZtBns, GAcQ, GTtTZv, CrnX, fHUrZ, olt, FcxJm, LFi, dLgz, pYPY, jNmk, qgr, Cccu, iNn, GeiM, lnpEI, gBYl, eYRpsy, neLiem, Lyt, kIiJm, vENJHL, XYfVd, FzDXEO, Fof, InkyXy, QshN, ASkYxb, sowzSA, cIsZYH, fLI, RPOLbf, JKXHm, wRTb, XRumlW, DxmdH, zyp, fzgNb, mcCAz, ZMyMQN, EiZhz, yYrr, cJbSKL, mKj, IgE, ZaoC, kcyfpf, lXNHtM, mtj, ypV, YccmA, Gli, OYb, UGkqDV, eNmEO, DFjkK, UNkmM, Stfih, DCRUHf, fXhYeg,
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