BRP Lower Maret April 2021

1. PATELLOFEMORAL INSTABILITY
PEMBIMBING :
Dr. Krisna Yuarno Phatama, SpOT (K)
LOWER : MARET – APRIL 2021
FEB/ RAS/ SAF/ ROD

2. BASIC ANATOMY
• The biggest sesamoid bone
• Linking the powerful quadriceps muscle to the patellar tendon
• Function :
• Main function : to improve the quadriceps efficiency by
increasing the lever arm of the extensor mechanism
• To centralize the divergent forces coming from the four heads of
the quadriceps, and to transmit tension around the femur, in the
frictionless way, to the patellar tendon and tibial tuberosity
• Hyaline articular cartilage provides an insensitive (aneural), thick,
avascular tissue that is specifically adapted to bearing high
compressive loads
• Cosmetics of the knee

3. BASIC ANATOMY
Bone structures :
• The patellofemoral joint consists of :
• The sulcus of the femur and the patellar articular surface
(137° ± 8°)
• Articular surface :
• 3 medial; 3 lateral; and 1 extra, nonarticulating facet
on the medial side (the odd facet)

4. BASIC ANATOMY
Variant type of Patella (Wiberg Classification)

5. LIGAMENTS AND THE EXTENSOR MECHANISM
• The extensor mechanism of the knee consists of the quadriceps
muscle group, the patella, the patellar ligament, and the tibial
tubercle
• The mechanism is responsible for the extension of the knee and
relies upon the patella as a fulcrum for a mechanical advantage
• The patellofemoral articulation centralizes the entire mechanism on
the anterior surface of the femur.

6. VASCULARIZATION & INNERVATION
• Six main arteries compound this ring: the supreme genicular artery, the
medial & lateral superior & inferior genicular arteries, and the anterior
tibial recurrent artery
• The anterior cutaneous innervation : nerve roots from L2 through L5
• The anteromedial innervation : genitofemoral, femoral, obturator, &
saphenous nerves
• The anterolateral inervation : lateral femoral and the lateral sural
cutaneous nerves

7. COMPONENTS OF PATELLAR STABILITY
• Static Structures
• MPFL primary restraint to lateral translation in 20° of flexion
• Patellotibial ligament
• Patellomeniscal ligament
• Retinaculum
• Dynamic Structures
• Quadriceps muscle

8. BIOMECHANICS
KNEE EXTENSION MOMENT ARM

9. BIOMECHANICS
PFJ FORCES

10. BIOMECHANICS
PFJ CONTACT AREA

11. BIOMECHANICS
PFJ CONTACT PRESSURE :
• Is the ratio of the PFJR force to the contact are
• Normal knee pressure : same on both the lateral & medial facets
• 20° flexion : 2.0 Mpa
• 30° flexion : 2.4 MPa
• 60° flexion : 4.1 MPa
• 90° flexion : 4.4 Mpa
• 120° flexion : 3.5 Mpa

12. BIOMECHANICS
PATELLAR TRACKING :
• In full extension : "screw home" mechanism of the tibia  rotating externally in the terminal 30° of
extension, displaces the tibial tubercle laterally
• This produces the Q angle
• Tension on the quadriceps  lateral displacement vector of the patella ("valgus vector“)
• VMO, extending distally and inserting medially in the patella  Medial force
• Full extension :
• Quadriceps contracted
• Patella lies proximal to trochlea
• 10° Flexion :
• The patella is drawn into the trochlea
• The first articular contact
• Because ofthe Q angle, the patella enters
• The trochlea from the lateral side.
• 20° Flexion :
• Tibia derotates  decrease Q angle & decrease lateral vector

13. PATELLOFEMORAL INSTABILITY;
INTRODUCTION
• A condition characterized by repeated dislocation or subluxation of the patella secondary to minimal
trauma
• Annual incidence : 7/100.00011 & 43/200.000155
• More common in females (10-17 YO)
• Often bilateral
• Most commonly dislocates laterally
• Medial dislocation is usually iatrogenic, either as a result of excessive lateral release or overtightening
of medial structures
• Multifactorial

14. Most commonly occurs in 2nd-3rd decades of life
Risk factors
• previous patellar instability event
• increased Q angle
• femoral anteversion
• genu valgum
• external tibial torsion / pronated feet

15. FACTORS IN PATELLAR INSTABILITY
Four major anatomic factors leading to instability
(Henri Dejour et al. In 1994) :
• Trochlear Dysplasia
• Excessive TT-TG Distance
• Patellar Tilt
• Patella Alta
• Another important factor : MPFL disruption

19. ANATOMICAL FACTORS
BONE :
• Patella alta --> not articulate with
sulcus, losing its constraint effects
• Trochlear dysplasia
• Excessive lateral patellar tilt
• Lateral femoral condyle hypoplasia

22. ANATOMICAL FACTORS
MUSCLE
• Dysplastic vastus medialis oblique
(VMO) muscle
• overpull of lateral structures
• Iliotibial band
• Vastus lateralis

23. Passive stability
• Medial patellofemoral ligament (MPFL)--> avulsion of MPFL
• femoral origin-insertion is between medial epicondyle and adductor tubercle
• patellar-femoral bony structures account for stability in deeper knee flexion
• Trochlear groove morphology, patella height, patellar tracking
Dynamic stability
• Provided by vastus medialis (attaches to MPFL)

24. PHYSICAL EXAMINATION OF THE PFJ;
STANDING EXAMINATION
PELVIC :
• Women : exaggerates the quadriceps (Q) angle, resulting in a valgus force on the
patella
• Hip flexion contracture
FEMUR :
• Femoral anteversion or internal rotation contractures  “Squinting or Outfacing
patellae“
KNEE :
• Genu valgum or recurvatum (laxity)
• Flexion contracture
• External tibial torsion
FEET & ANKLE :
• Hindfoot valgus with or without pes planus
• Equinous deformity

25. SYMPTOMS AND EXAMINATION
Symptoms
• Complaints of instability
• Anterior knee pain
PE
• Acute dislocation usually associated with a
large hemarthrosis
• Medial sided tenderness (over MPFL)
• Patellar apprehension (+)
• Increased Q angle
• J sign

26. PHYSICAL EXAMINATION OF THE PFJ;
SEATED EXAMINATION
• Patella Alta
• Patella Baja
• J-Sign (Instability of patella : subluxation, during flexion to
extension)
• Grasshopper eyes Sign

27. PHYSICAL EXAMINATION OF THE PFJ;
Q-ANGLE
• Normal : (14°)
• Female : 10° - 20°
• Male : 8° - 10°
• Abnormal (Insall) : > 20°

28. PHYSICAL EXAMINATION OF THE PFJ;
STATIC & DYNAMICS
DYNAMIC EXAMINATION :
• Flexion & Extension Knee
• Normal patellar engages at the femoral sulcus : 30° - 40° of flexion
• At terminal extension  sublux laterally out of the femoral sulcus
• J-Sign
• Active quadriceps pull test :
• Knee extension  quadriceps contracted  patella move pulled superiorly in a straight line

29. PHYSICAL EXAMINATION OF THE PFJ;
STATIC & DYNAMICS
STATIC EXAMINATION :
• PatelloFemoral grind test (Clarke Sign); Active & Passive
• Indicative of articular injury and when coupled with crepitus
and recurrent effusion, is suggestive of degenerative
changes
• Passive Patellar Glide Test
• indicative of the tension of both the medial and lateral
retinacular structures
• Passive Patellar Tilt Test
• evaluates the tightness of the lateral retinaculum
• F : +5 - +10 deg, M : 0 - +5 deg
• Inc tilt : too loose, instability
• Apprehension test / Fairbanks test / Smillie test

30. PHYSICAL EXAMINATION OF THE PFJ;
OTHERS TEST
• Ober's test
• Evaluate contracture of the ITB

31. IMAGING OF THE PATELLOFEMORAL JOINT;
X RAY
AP View
• Natural standing position
• Knee full extension
• Evaluate :
• Patellar displacement
• Bone quality
• Alignment
• Femorotibial-associated pathology
• Malformations such as bipartite / multipartite patella or fractures
• Loose bodies in the lateral gutter

32. IMAGING OF THE PATELLOFEMORAL JOINT;
X RAY
Lateral view
• Supine
• Weight bearing 15-20° flexion / full extension, superimposition of both the
posterior femoral condyles
• Evaluate :
• Blumensaat line is continued anteriorly by the TG line, which should stay
posterior to the projection of the femoral condyles (facets)
• Crossing sign, supra-trochlear spur, double-contour
• Trochlear sulcus line
• Trochlear dysplasia
• Patellar tilt / no
• Shape of the patella
• Patellar height (patella alta / baja)
• Location of the patella in relation to the trochlea

33. IMAGING OF THE PATELLOFEMORAL JOINT;
X RAY
Lateral view
The commonly used methods of assessment of Patella height :
1. Blumensaat's Technique
2. Insall-Salvati
3. Blackburne-Peel
4. Norman, Egund, and Ekelund
5. Caton-Deschamps
6. Grelsamer
7. Bernageau
8. New Method (Chareancholvanich)

34. IMAGING OF THE PATELLOFEMORAL JOINT;
AXIAL TANGENTIAL VIEW
1. Merchant View (45° flexion)
• Measured :
• Sulcus angle : (N : 138° ± 6° , >150° : Abnormal)
• Congruence angle : (−6° ± 11°)
2. Laurin View (20° flexion)
• Measured :
• Lateral patellofemoral angle (LPFA) : (N : 97% open laterally & 3% parallel)
• PF index : (N : 1.6 or less)

35. IMAGING OF THE PATELLOFEMORAL JOINT;
AXIAL TANGENTIAL VIEW
3. Malghem & Maldague Lateral Rotation View (30° Lateral Rotation)
Evaluated :
• Acute or chronic patellofemoral instability
• Medial patellar avulsions

36. IMAGING OF THE PATELLOFEMORAL JOINT;
CT SCAN
• Many parameters observed in CT images are similar to those observed in axial views
Evaluation :
• Anatomic abnormalities
• Alignment measures
• Posterior femoral condyles
• Trochlear shape (axial & sagittal views)
• Torsional deformities such as femoral anteversion & external tibial torsion
• By superimposing images
• Tibial tubercle–trochlear groove (TT-TG) distance
• Patellar tilt

37. CT SCAN ;
TIBIAL TUBERCLE–TROCHLEAR GROOVE DISTANCE
• TT-TG distance is a direct measure of the extensor mechanism valgus alignment,
but it incorporates information about the forces acting on the patella produced
by femoral and tibial torsion
• TT-TG distance is calculated from superimposes two cuts :
• The bottom of the TG (proximal trochlea)
• The most proximal part of the TT
• Average normal value
• Full extension : 12 mm
• One episode of patellar dislocation : excess of 20 mm
• Uppermost limit : 20 mm

38. CT SCAN ;
PATELLAR TILT
• Two lines :
• one tangent to the posterior femoral condyles
• through the transverse axis of the patella, (alternatively, one cut
through the Roman arch level and another through the patellar
longer transverse axis can be superimposed)
• Patellar tilt angle in dislocation majority : >20°

39. CT SCAN ;
FEMORAL ANTEVERSION & EXTERNAL TIBIAL TORSION
• FA :
• Mean value : 10.8 ± 8.7°
• 15.6 ± 9° (in at least one patellar dislocation)
• ETT :
• Mean value : 33° in the patellar instability

40. THE LYON’S PROTOCOL
The following specific axial sections should be acquired for measurement:
• Section through both femoral necks at the top of the trochanteric fossa
• Section through the center of the patella, through its larger transverse axis
• Section through the proximal trochlea (where the intercondylar notch looks like a Roman arch, and a slight
condensation of the trochlear lateral facet subchondral bone can be observed)
• Section through the proximal tibial epiphysis, just beneath the articular surface
• Section through the proximal part of the tibial tuberosity
• Section near the ankle joint, at the base of the malleoli

41. IMAGING OF THE PATELLOFEMORAL JOINT;
MRI
• Common indication in young patients with knee pain
Evaluation :
• Cartilage and Soft Tissue
• Trochlear shape
• Tibial Tubercle–Trochlear Groove Distance
• Patellar Tilt (and Subluxation)

42. ALGORITHM FOR TREATMENT OF PATELLAR INSTABILITY
ASSOCIATED WITH MPFL
a. For patients with closed physes
b. For patients with open physes

43. ALGORITHM FOR TREATMENT OF PATELLAR
INSTABILITY

44. MANAGEMENT;
FIRST DISLOCATION
• Avoid subsequent dislocation
• Prevent persistent symptoms
• Allowing full recovery to sports as promptly as possible
• Classic Treatment : Conservative (Immobilization & Rehabilitation)
• Ideal ranging period should achieve a compromise between healing (stability) and mobility  2-6 weeks
• Arthrocentesis (Haemarthrosis)
• ROM exercise
• Quadriceps strengthening
• Contraindication : Dislocated Osteochondral Fracture
• Surgical treatment : Acute repair of torn MPFL & Retinacula or primary reconstruction

45. LATERAL PATELLAR DISLOCATION;
PATHOMECHANISM
• MPFL Disruption
• Most frequent at its femoral side  Redislocation by reducing the obliquity of
vastus medialis obliqus (VMO) musce vector and its medially pull
• Less frequent : Avulsion fracture of the medial structure (Retinaculum, Capsule or
MPFL)
• Osteochondral Fracture
• Occur during dislocation or relocation
• Repairable fragment should be fix to prevent Osteoarthrosis

46. MANAGEMENT;
CHRONIC/RECURRENT DISLOCATION
• Surgical Treatment
• Based on the root of abnormalities (single or combine procedures)
• SOFT TISSUE PROCEDURE :
• MPFL repair or reconstruction
• Lateral retinacular release
• Proximal VMO realignment
• BONY PROCEDURE :
• Tibial tubercle transfers
• Medial tibial tubercle transfer
• Distal tibial tubercle transfer
• Patellar tendon tenodesis
• Trochleoplasties
• Lateral-facet elevating trochleoplasty
• Sulcus-deepening trochleoplasty
• Bereiter’s trochleoplasty
• Patellar osteotomy
• Femoral and tibial osteotomies

47. SURGERY;
MPFL REPAIR OR RECONSTRUCTION
• The goal : to restore the loss of medial patellar soft tissue stabilizer
• An ideal candidate for an isolated MPFL repair or reconstruction :
• Normal or type A trochlear dysplasia
• Tibial tubercle - Trochlear sulcus angle 0-5° valgus or a TT-TG
distance ˂20 mm (at 0° of knee flexion)
• Absence of “excessive” patella alta :
- Caton-Deschamps index : ˂1.2, or
- Insall-Salvati index : ˂1.3, and
- Engagement factor <12%
• Patellar tilt <20°

48. SURGERY;
MPFL REPAIR - TECHNIQUE
• Diagnostic arthroscopy is first performed
• Torn from its femoral origin (Most common) :
• Longitudinal incision is made in the deep fascia & periosteum just proximal to the medial
epicondyle
• Identify of MPFL : by holding tension on the tissue with forceps, the patella is translated
laterally
• Identify inserting site by fluoroscopy
• Identify Schottle’s Point (when reconstruction will be perform)
• Two suture anchors  placed into the femoral attachment
• Repair using Mattress suture with knee 30-40° flexion
• Torn from off the patella :
• Traction on the medial end of the ligament will not restore patellar stability
• So, MPFL is repaired back to the patella
• use of nonabsorbable sutures placed through drill holes or suture anchors in the patella
• After the sutures are tied, patellar tracking is again assessed and a firm end point to lateral
patellar displacement should be appreciated
• The investing fascia is repaired prior to skin closure
• Ensure that there is no secondary site tearing  complication after repair : Residual laxity

49. SURGERY;
MPFL RECONSTRUCTION
GRAFT SELECTION :
• Autograft
• Gracilis (more preferable; near normal stiffness & strength to native MPFL)
• Semitendinosus (More stiffness & strength)
• Quadriceps
• Semimembranosus
• Medial retinacular tissues
• Allograft
• Synthetic graft

50. SURGERY;
SCHOTTLE’S POINT

51. SURGERY;
MPFL RECONSTRUCTION
PROCEDURES :
• Double-Strand Gracilis Autograft
• Combined Medial Patellar Tibial Ligament Reconstruction
• Single-Strand Middle Third Quadriceps Tendon Autograft
• Single-Strand Adductor Magnus Split Tendon Transfer
• Adductor Sling Technique
• Medial Collateral Ligament Sling Technique

52. SURGERY;
CONSIDERATION

53. SURGERY;
GRAFT CONSIDERATION
Technique Femoral attachment Patellar attachment Tensile strength;
Normal MPFL :
208 N
Consideration / Disadvantages /
Complication
Gracilis
tendon grafting
Anatomical MPFL insertion site Superomedial border, proximal
one-third of the patella
↑ N (837 ± 207 Graft size; susceptible to
rupture
Semitendinosus
tendon grafting
Anatomical MPFL site; tenodesis
on the adductor magnus tendon
Superomedial border, proximal
one-third of the patella
↑ N (1216 N) Patella fracture
Patellar
tendon grafting
Area between the medial
epicondyle and adductor tubercle
Periosteum between the proximal
and middle-third of the patella
↑ N (1403 N) Extensor mechanism weakness;
anterior knee pain; patella baja
Quadriceps
tendon grafting
Just distal to the adductor tubercle
and superoposterior to medial
femoral epicondyle (anatomical
MPFL insertion site)
Superomedial border, proximal
one-third of the patella
↑ N (2352 N) Graft length; quadriceps muscle
shortening
Medial Collateral
Ligament
the femoral insertion of the MPFL
than its anatomic
Location & more vertical arm does not
anatomically duplicate the MPTL
transferred tendon is
sutured to the anterior surface of the
patella with the knee
flexed to 30 degrees
↑ N (799 ± 209 N) Less strength & not ture anatomical
insertion
Adductor
Magnus
Spli from origin (split tech); dissection
of distal tendon insertion (sling tech)
Superomedial aspect of patella (Split
tech); Mid point of medial aspect
(Sling tech)
↑ N (350 N) The disadvantage of this technique
is also that one cannot always predict
the length of the tendon
that can to be harvested, which may
compromise the ultimate
patellar fixation.

54. CONTRIBUTING FACTOR FAILED
MPFL RECONSTRUCTION
• Trochlear dysplasia
• Femoral anteversion
• Ligamentous laxity
• Biomechanics : <142 N

55. MEDIAL PATELLAR INSTABILITY
• Due to tightness of the lateral patellar structure
• One of the most common provoking incapaciting anterior knee pain
• Major cause is Extensive LRR  iatrogenic medial subluxation
• Lateral retinacular release & additional ligament reconstruction Should not be universally performed
because MPFL reconstruction alone is sufficient to control patellar dislocation

56. MANAGEMENT MEDIAL PATELLAR INSTABILITY
NON OPERATIVE :
• Quadriceps strengthening
• Stretching of the Medial retinacular ligament
OPERATIVE :
• Medial retinacular release (Functional surgery)
• Lateral retinacular repair (Reconstructive surgery)

57. DISTAL REALIGNMENT PROCEDURE
• Medialization
• Soft Tissue Medialization or Medial Reconstruction (Immature skeletal)
• Roux-Goldthwait procedure
• Galeazzi semitendinosus tenodesis
• Bony procedure (Tuberosity Transfers)
• Roux-Elmslie-Trillat procedure
• Hughston procedure
• Distalization
• Hauser Procedure
• Anteriorization
• Maquet Technique
• Anteromedialization
• Fulkerson Technique

58. PROXIMAL PATELLAR REALIGNMENT PROCEDURES
Indications :
• Recurrent subluxation, failed with physiotherapy
• Recurrent dislocation
• Acute dislocation in a young, athletic patient, especially if there is an avulsion fracture from the
medial border of the patella, or lateral subluxation or lateral tilt following a closed reduction (axial
radiograph )

59. PROXIMAL PATELLAR REALIGNMENT PROCEDURES
QUADRICEPSPLASTY :
• MADIGAN PROCEDURE
• INSALL TUBE PROCEDURE
• CAMPBELL PROCEDURE

60. TROCHLEAR DYSPLASIA
• The abnormal shape of the trochlea  loss of the osseous guide to patellar tracking
• Single factor most associated with patellar instability (up to 96% of patients with OPI)
• Instead of being concave, the trochlea is flat or convex
• The normal trochlear constraint to lateral patellar displacement is lost and, as a
consequence, dislocations can occur

61. DEJOUR CLASSIFICATION TROCHLEAR DYSPLASIA

62. LATERAL FACET–ELEVATING TROCHLEOPLASTY
(ALBEE PROCEDURE)
• Oblique osteotomy under the lateral facet
• Corticocancellous bone wedge is interposed, with the apex medial & the base
lateral
• The osteotomy advances to the base of the trochlear groove but does not
disrupt it, producing a hinge in its medial aspect
• The result is that it elevates the more lateral aspect of the trochlear lateral facet
and increases its obliquity, thus increasing the containment force acting on the
patella. At least 5 mm of subchondral bone should be maintained to avoid
trochlear necrosis
• Effective for patellar containment, but it increases the patellofemoral reaction
force when it increases the trochlear protuberance

63. SULCUS-DEEPENING TROCHLEOPLASTY;
DEJOUR
• The main goal is to decrease the prominence of the trochlea and to create
a new groove with normal depth & orientation
• Advantage : corrects the abnormal patterns underlying the different grades
of trochlear dysplasia
• It is recommended for patients with types B & D dysplasia, in which the
prominence of the trochlea is important
• Goals :
• Create a thick osteocartilaginous flap (to minimize potential damage to
the cartilage)
• Remove the supratrochlear spur
• Create a more narrow trochlear sulcus, and
• Improve PF alignment by lateralizing the trochlear sulcus, thus
decreasing the TT-TG

64. BEREITER’S TROCHLEOPLASTY
• Similar to the sulcus deepening trochleoplasty, but with a thinner
and malleable osteochondral flap
• Osteochondral flap is fixed with vicryl stripes
• immediate weight bearing is permitted after trochleoplasty. No
limitation is placed on the ROM

65. PATELLAR OSTEOTOMY;
MORSCHER
• Anterior closing-wedge osteotomy
• Fixed with transosseous sutures
• To restore the two facets of the patella
• Risk of necrosis and nonunion
• Indication : Patellar dysplasia such as Wiberg type III & “Jaegerhut” patella,
when the articular surface is flat
• Unpopular procedure
• In such cases, the reshaping of the patella is an adjunct to trochleoplasty

66. FEMORAL AND TIBIAL OSTEOTOMIES
• Lower limb malalignment in excessive valgus or in torsion
• Valgus deformity increases the Q angle & enhances the dislocating pull on the
patella (>10°)
• Corrected by a lateral opening wedge or a medial closing-wedge osteotomy at the
distal femur
• Excessive femoral anteversion or external tibial rotation are most likely the torsional
deformities
• Femoral derotation osteotomy is best performed at the intertrochanteric level,
while the preferred site for tibial derotation osteotomy is proximal to the TT

67. POST OPERATIVE CARE;
SOFT TISSUE PROCEDURE
• No evidence to specific postoperative rehabilitation regimen
• Restricted ROM using a hinged brace from 2 to 6 weeks
• Weight-bearing status varies ranging from minimal to full weight bearing
• Demanding rehabilitation tasks from the 10- to 12-week
• Unrestricted activities commencing from 4 months onward

68. POST OPERATIVE CARE;
SOFT TISSUE PROCEDURE
• 1st week : The knee is immobilized in a 0° splint
• 2nd weeks : Brace at 60° flexion
• 3rd weeks : Brace at 90° flexion
• Immediate after op : Quadriceps tensioning exercise
• First 3 weeks : PWB at 15–30 kg with crutch
• 4-6 weeks : Full ROM
• After 3 moths : Normal activity
• After 6 moths : Contact sports

69. POST OPERATIVE CARE;
BONY PROCEDURE
• Trochleoplasty does not need weight protection or range of motion limitation
• Movement  improve cartilage healing and further molding of the trochlea; continuous passive movement (CPM) is
usually used during the first days
• First 2 weeks :
• PWB, allowed with an extension brace and aided by crutches
• The brace must be removed during the exercises
• First 6 weeks :
• Encouraged to perform exercises for range of motion, as tolerated, including isometric quadriceps and hamstring
strengthening
• Quadriceps strengthening with weights on the feet or tibial tubercle is discouraged

70. • After 6 weeks :
• Closed-chain & weight-bearing proprioception exercises
• Cycling with weak resistance initially
• Active ascension of the patella can be performed seated, with the leg stretched and the knee unlocked, by static &
isometric quadriceps contractions
• Quadriceps strengthening with weights on the feet or tibial tubercle is still discouraged
• Weight-bearing proprioception exercises are started when full extension is complete, first in bipodal stance and
in monopodal stance when there is no pain
• Radiograph control :
• X ray : after 6 weeks
• CT scan : after 6 months
POST OPERATIVE CARE;
BONY PROCEDURE

71. THANK YOU