Evaluation of Joint Position Sense after ACL Reconstruction with Hamstring Tendon Auto Graft

Gholam A. Ghasemi, Vahid Zolaktaf, Khosravi Ibrahim, Minasian V

  Open Access OPEN ACCESS  Peer Reviewed PEER-REVIEWED

Evaluation of Joint Position Sense after ACL Reconstruction with Hamstring Tendon Auto Graft

Gholam A. Ghasemi1,, Vahid Zolaktaf1, Khosravi Ibrahim2, Minasian V1

1Department of Exercise science , University of Isfahan, Isfahan, Iran

2Department of Exercise Rehab, Faculty of Exercise Sciences, University of Isfahan, Isfahan, Iran

Abstract

Background: Use of STG (Semitendinosus and gracilis) graft is one of the standard techniques for anterior cruciate ligament (ACL) reconstruction. The purpose of this study was the comparison of joint position sense (JPS) in involved and uninvolved knees of ACL reconstructed athletes and control group. Methods: Fifteen elite athletes (7 handballs, 8 soccer players) with a unilateral ACL rupture who had received a hamstring tendon auto grafts ACL reconstruction, matched by motor dominance and sport to fifteen healthy elite athletes, were subjects of our study. The injured group experienced an average of 19.9 months from surgery to participation in the research.The Biodex System III Isokinetic dynamometer and Active Angle Reproduction test with angle of 30° knee flexion were used for evaluation of knee JPS. Results: No significant difference was found between involved and uninvolved knees of ACL reconstructed group and between involved knee of ACL reconstructed and control group (p<0/05). Conclusion: The present study revealed that athletes with ACL reconstructed knee may have not experience JPS malfunction. This fact suggests that proprioceptive acuity has multimodal characteristics and is not always primarily dependent on the sensory information of ligament mechanoreceptors. There is the possibility of offsetting this deficit by regeneration of sensory neurons in the reconstructed ligament or by rehabilitation program.

Cite this article:

  • Ghasemi, Gholam A., et al. "Evaluation of Joint Position Sense after ACL Reconstruction with Hamstring Tendon Auto Graft." American Journal of Sports Science and Medicine 1.3 (2013): 52-55.
  • Ghasemi, G. A. , Zolaktaf, V. , Ibrahim, K. , & V, M. (2013). Evaluation of Joint Position Sense after ACL Reconstruction with Hamstring Tendon Auto Graft. American Journal of Sports Science and Medicine, 1(3), 52-55.
  • Ghasemi, Gholam A., Vahid Zolaktaf, Khosravi Ibrahim, and Minasian V. "Evaluation of Joint Position Sense after ACL Reconstruction with Hamstring Tendon Auto Graft." American Journal of Sports Science and Medicine 1, no. 3 (2013): 52-55.

Import into BibTeX Import into EndNote Import into RefMan Import into RefWorks

1. Introduction

ACL injury is more frequent in athletes, and usually causes long time absence from sports activities, and is associated with an increased risk of recurrent knee injury [1, 2]. Estimated rates of reconstructions performed per year in the United States ranges from 60,000 to 175,000 [3, 4]. Previous studies reported that in athletes the rate of return to sports was 70-80% [5, 6]. However, there are some complications after ACL reconstruction. Contralateral ACL injury is one of the most serious complications after reconstruction [7].

Knee joint function is complex and does not depend on ligament stability alone, but also on the dynamic interaction between the central nervous system and the periarticular muscles. This is achieved by means of various mechanoreceptors and free nerve endings, which have been identified in the articular and periarticular knee joint structures [8]. They are found in particularly high numbers in the area close to the insertion of the ACL [9].

Proprioreceptors are the components of somatosensation that provides information about the orientation and motion of body segments and the state of the muscles. This information is conveyed largely through muscle spindles and Golgi tendon organs [10]. To investigate the role that Proprioreceptors plays in planning and controlling movements, proprioception has been removed through either surgery or by studying rare sensory neuropathy conditions, or has been distorted by the use of vibration [10]. Following the pioneering findings of Mott and Sherrington [10], many studies have examined the role of proprioception in movement control by examining movements in non-human primates who have undergone partial dorsal rhizotomy surgery, including the studies of Gilman et al. [11], Taub et al. [12], Polit and Bizzi [13] and Gauthier and Mussa Ivaldi [10], among others. It has been well established that animals proprioceptively differenced in this way show substantial impairments in accuracy and coordination during multijoint reaching and natural unrestricted movements [10].

Proprioception appears have critical role for controlling other aspects of limb mechanics, in addition to the effects of intersegmental dynamics. For example, Ghez et al. [14], showed that deafferented patients were unable to account for direction dependent variations in limb inertia during reaching movements, which resulted in substantial errors in movement distance and direction. Because direction dependent variations in limb inertia vary with limb configuration, this finding underscored the importance of proprioception in providing configuration information [14], showed that deafferented patients were unable to account for direction dependent variations in limb inertia during reaching movements, which resulted in substantial errors in movement distance and direction. Because direction dependent variations in limb inertia vary with limb configuration, this finding underscored the importance of proprioception in providing configuration information [14]. The critical role of proprioception in providing initial information of the postural state of the motor apparatus for movement planning is also supported by the study of Larish et al. [15]. This study also showed that when the limb was vibrated in the absence of visual feedback prior to the movement, final position was systematically altered [15]. Barrack et al.[16] reported decreased proprioception in knees with a ruptured ACL on the basis of an evaluation of the joint position sense. Ochi et al.[17] also studied joint position sense in knees with a ruptured ACL and demonstrated decreased joint position sense in patients with marked knee instability. However, there are also reports denying a relationship between ACL injury and changes in proprioception [5].

However, ACL injuries induces changes in the kinematics of the knee joint, instability, and proprioception impairment [18]. Injury to the ACL will result in a loss of both mechanical stability and proprioceptive feedback at the knee, directly affecting functional joint stability and can lead to further deterioration of the knee joint integrity [19]. Due to instability of the joint, repetitive injury and degenerative changes occur and the sports activity and even the daily life of the person are confused [20]. These cases determine the necessity for the ACL reconstruction surgery.

Therefore, it is becoming increasingly clear that knees with ruptured ACL gradually develop changes not only in performance but also in proprioception. However, as reported by Noyes et al. [21], we encounter individuals who readily perform high levels of athletic activities despite injury to the ACL [22].

Previous studies revealed that an integral element in achieving a favorable outcome following ACL reconstruction is participation in the postoperative rehabilitation [23]. The mechanical restraint and proprioceptive function of the ACL both help to provide functional joint stability of the knee during movement. Therefore, it is essential to monitor the restoration of proprioception after an ACL injury or ACL reconstruction/rehabilitation for safe and functional return to sport and should be considered in the evaluation of surgery results by orthopedic surgeons [24].

Although, different types of autograft and allograft have been used in ACL reconstruction for many years, recently the hamstring tendon has become the preferred autogenous graft [25, 26]. In our comprehensive survey, we found that a few research has been done for the assessment of knee joint proprioceptive function after ACL reconstruction with STG graft. Hence, the aim of this research was to evaluate knee joint proprioception in elite athletes after ACL reconstruction with STG graft.

2. Materials and Methods

The participants were 30 male soccer and handball elite players who competing at premier leagues and Iranian national teams, and were classified as control (non-injured) and ACL-reconstructed (injured) groups. The participants in the control group consisted of 15 healthy elite athletes (8 soccer and 7 handball aged 23.06 ± 3.1 years, height 184.4 ± 7.8 cm, Weight of 85.2 ± 1.1 kg; mean ± s) with no previous history of lower-extremity orthopedic pathology. The participants in the ACL-reconstructed group consisted of 15 elite athletes (8 soccer and 7 handball mean aged 23.8 ± 3.5 years, Height 180.4 ± 7.6 cm, & Weight 76.4 ± 1.02 kg) who had undergone a unilateral ACL reconstruction with STG tendon graft. The injured group matched by motor dominance and sport with fifteen healthy elite athletes. The “accessible” sampling method was used for selecting the samples. The injured group experienced an average of 19.9 months (range 8 ± 60 months) from surgery to participation in the research. In this study we have some limitations to initiate the testing protocols, such as subjects and physicians permissions, and the number of subjects ready to take part in this study. All participants demonstrated a full, pain-free range of motion at the knee joint at the time of testing, and were excluded if they experienced any pain, effusion or edema during the test procedure.

Exclusion criteria included multiple surgical procedures in the involved knee, contralateral knee pathology, and age less than 18 years, limited ROM due to surgery, injury of the ankle and hip joint, time lapse of less than 6 months after ACL reconstruction, patellofemoral joint dysfunction and unstable co-existing cardiovascular, neurological, psychiatric or psychological conditions.

Biodex System 3 Isokinetic Dynamometer (Biodex Medical Inc., Shirley, NY, USA.) and active angle reproduction test were used to assess knee JPS. Visual cues were eliminated by a blindfold.

On the test day participants have to wear light clothes, and they completed a consent form. Personal information list completed with the investigator. Each subject was seated on the biodex isokinetic dynamometer with hip flexion of 100° and the axis of their knee joint aligned with the axis of the dynamometer arm. The ankle strap of the dynamometer arm was applied to the ankle 2 inches above the medial malleolus. The thigh strap also was applied. The dynamometer was calibrated by asking the participant to hold the knee at 0 degrees of extension, and the position checked using a hand held goniometer. The participant’s knee was then returned to an angle of 90 degrees. Starting at 90° of knee flexion, the subject actively moved the limb to the target angle of 30° of flexion at an angular velocity approximating 5°·s. This angle is in the working range of the knee during daily weight-bearing activities. Subjects were instructed to voluntarily contract their muscles. The limb was maintained at the target angle for 10 seconds to enable the subject to remember the position. After the limb was passively returned to 90°, there was a 5-second pause, and the cycle was performed again. This time the subject activated a handheld stop button when he felt the target angle had been achieved. Once the button had been activated, patients were not permitted to correct the angle. The angle was identified from the onscreen goniometer. Three readings were taken, and the absolute difference between the perceived angle and the target angle was calculated for each reading. We used the average of these three scores as the error score for each subject.

SPSS software (ver. 16) was used for data analyzing. One-way ANOVA was used for comparing the average absolute error of the target angle for the operated knee, as regards with the healthy leg of the person himself and the matched knee of control group. Statistics significance were carried out at an alpha level of P < 0.05.

3. Results

Demographic data of the injured and healthy groups are shown in Table 1. The mean values and standard deviation of the reproduced angle absolute error for the injured and healthy group are shown in Table 2. Kolmogorov-Smirnov test (P < 0.05) was used to analyze the normality of the data and the Q-Q plots and box plots were also used for more assurance. ANOVA test showed that there is no significant difference between the average values of error score in ACL reconstructed knee as compare to contralateral knee and the knee of control group. (F = 1.21, P = 0.3).

Table 1. Demographics characteristics of Subjects (mean± standard deviation)

Table 2. Absolute error of active angle reproduction test (Mean ± standard deviation)

4. Discussion

According to the results of this research, there was no significant difference between the JPS at the injured knee in comparison with contralateral knee and the knee of control group. As mentioned before the most important role of ligaments like ACL is providing the joint mechanical stability. Disruption of this support mechanism changes the joint kinematics and induces joint instability and osteoarthritic changes [27].

However, Kennedy et al. [28] reported that clinical symptoms characteristic of knees with ACL injury occur due to the disappearance of mechanoreceptor feedback in addition to altered kinematics. This report was followed by studies on proprioception of knees with a ruptured ACL [16, 29, 30]. Also some researcher like Barrack et al. [16] demonstrated a correlation between the magnitude of joint instability and the reduction of proprioception in knees with a ruptured ACL, and Ochi et al. [17] performed an electrophysiological study of knees with a ruptured ACL using somatosensory evoked potential (SEP) and concluded that SEP was low in patients with reduced joint position sense. Their findings also showed that sensory reinnervation occurred in the reconstructed human ACL and was closely related to the function of the knee [17]. Fremerey et al. [31] assessed knee proprioception using the angle reproduction test after reconstruction of the ACL. Six months after reconstruction, restoration of proprioception was seen near full extension and full flexion. In the intermediate motion range, no improvements could be demonstrated. Al-Othman [32] also demonstrated the complete recovery of proprioception following ACL. In a research by Hopper et al. [33] no significant difference observed in JPS between reconstructed and uninjured knees or between the flexion and extension tasks, that is compatible with the findings of our study.

Research by Risberg et al. [34] also indicates that there were no significant differences in proprioception between the ACL-reconstructed knee and the contra-lateral uninvolved knee 1 year or more after surgery. Bonfim et al. [20] did not find an improvement of proprioceptive function following ACL reconstruction in comparison with a control group. Other authors also report persistent impairment of proprioception [35, 36]. Wilke and Froböse [37] found that the patient’s position influenced the results of the joint position sense test. Proprioceptive information is different in the supine position as compared with standing and sitting positions because muscle recruitment is altered in the horizontal position.

Regarding the position of the knee, there are various results among different studies. The selected angle for the present research was chosen according to Grood and Noyes [38] investigation. The reason for this selection is that at 30° flexion of the knee, this joint is in a loose-packed position, where the ACL mechanical function is at its minimum. Hence, the neuromuscular mechanisms related to the joint stability of this ligament around this angle are most important. One research [33] also indicates that muscle-tendon receptors have greater role regarding joint receptors in providing JPS. Lephart et al. stated that the knee JPS could be improved by balance exercises [39]. In this study we examined subjects who were given rehabilitation by strength training, in the acute period after ACL injury and had no marked difficulty in daily activities including walking.

The existing differences between the studies could be related to the numbers of subjects involved, the surgery methods used in reconstruction of ACL, different angles in performing the test, rehabilitation programs, sport skills patterns and testing methods (active or passive, weight bearing or non-weight bearing). Therefore, regarding the unification between the two groups by consideration of sport activity levels, age and sex; it seems that lack of Proprioceptive information resulted from the reconstructed ligament to be offset by other proprioceptive sources. Also, there is the possibility for the joint mechanical receptors not to have a primary role in provision of JPS, or for the regeneration of sensory nerves in the reconstructed ligament to offset the loss of proprioception.

5. Conclusion

The following conclusions were reached from the results of our study, the results by this study showed that there is no significant difference in the knee JPS at the injured knee in comparison with contra-lateral knee and the knee of control group. It seems that the knee joint proprioception has a multimodal characteristic, not limiting to sensory information of the ligaments mechanoreceptors. There is also the possibility that the rehabilitation program or innervations of reconstructed ligament could offset this deficit.

References

[1]  Roi GS NG, Tencone F. Time to return to professional soccer matches after ACL reconstruction. Sport Sci Health. 2006;1:142-5. doi: 10.1007/s11332-006-0025-8
In article      CrossRef
 
[2]  Walden M HM, Ekstrand J. High risk of new knee injury in elite footballers with previous anterior cruciate ligament injury. Br J Sports Med. 2006;40:158-62. doi: 10.1136/bjsm.2005.021055
In article      CrossRefPubMed/NCBI
 
[3]  Frank CB JD. The science of reconstruction of the anterior cruciate ligament. J Bone Joint Surg Am. 1997;79:1556-76.
In article      PubMed/NCBI
 
[4]  Spindler KP WR. Clinical practice. Anterior cruciate ligament tear. N Engl J Med. 2008;359:2135-42. doi: 10.1056/NEJMcp0804745
In article      CrossRefPubMed/NCBI
 
[5]  Katayama M HH, Kimura M, Kobayashi A, Hatayama K, Terauchi M, Takagishi K. Proprioception and performance after anterior cruciate ligament rupture. International Orthopaedics (SICOT). 2004;28:278-81. doi: 10.1007/s00264-004-0583-9
In article      CrossRefPubMed/NCBI
 
[6]  Nakase Junsuke TH, Kitaoka Katsuhiko,. Contralateral anterior cruciate ligament injury after anterior cruciate ligament reconstruction: a case controlled study. Sports Medicine, Arthroscopy, Rehabilitation, Therapy & Technology. 2012;4(46):1-4.
In article      
 
[7]  Akoto Ralph HJ. Anterior cruciate ligament (ACL) reconstruction with quadriceps tendon autograft and press-fit fixation using an anteromedial portal technique. Musculoskeletal Disorders. 2012;13(161):1471-2474.
In article      
 
[8]  Raunest J SM, Burgener E. Proprioceptive mechanisms in the cruciate ligaments: an electromyographic study on reflex activity in the thigh muscles. J Trauma. 1996;41:488-93. doi: 10.1097/00005373-199609000-00017
In article      CrossRef
 
[9]  Adachi N OM, Uchio Y, Iwasa J, Ryoke K, Kuriwaka M. Mechanoreceptors in the anterior cruciate ligament contribute to the joint position sense. Acta Orthop Scand. 2002;73:330-4. doi: 10.1080/000164702320155356
In article      CrossRefPubMed/NCBI
 
[10]  Sarlegna FS, R. The Roles of Vision and Proprioception in the Planning of Reaching Movements. Adv Exp Med Biol. 2009;629:317-35. doi: 10.1007/978-0-387-77064-2_16
In article      CrossRefPubMed/NCBI
 
[11]  Gilman S CD, Hollenberg J. Kinematic effects of deafferentation and cerebellar ablation. Brain. 1976;99:99:311-30. [PubMed: 825186]. doi: 10.1093/brain/99.2.311
In article      CrossRefPubMed/NCBI
 
[12]  Taub E GI, Taub P. Deafferentation in monkeys: pointing at a target without visual feedback. Exp Neurol. 1975 46( ):178-86. [PubMed: 1109336].
In article      
 
[13]  Polit A BE. haracteristics of motor programs underlying arm movements in monkeys. J Neurophysiology. 1979;42:183-94. [PubMed: 107279].
In article      PubMed/NCBI
 
[14]  14.Ghez C FM, Ghilardi MF, Gordon J, Bermejo R, Pullman S. Discrete and continuous planning of hand movements and isometric force trajectories. Exp Brain Res. 1997;115:217-33. doi: 10.1007/PL00005692
In article      CrossRef
 
[15]  Larish DD VC, Wallace SA. An empirical note on attaining a spatial target after distorting the initial conditions of movement via muscle vibration. J Mot Behav. 1984;16:76-83. doi: 10.1080/00222895.1984.10735312
In article      CrossRef
 
[16]  Barrack RL SH, Buckley SL. Proprioception in the anterior cruciate deficient knee. Am J Sports Med. 1989;17:1-6. doi: 10.1177/036354658901700101
In article      CrossRef
 
[17]  Ochi M IJ, Uchio Y, Adachi N, Sumen Y. The regeneration of sensory neurones in the reconstruction of the anterior cruciate ligament. J Bone Joint Surg [Br]. 1999;81:902-6. doi: 10.1302/0301-620X.81B5.9202
In article      CrossRef
 
[18]  Angoules AG MA, Dimitriou R, Karzis K, Drakoulakis E, Michos J, Papagelopoulos PJ. Knee proprioception following ACL reconstruction: a prospective trial comparing hamstrings with bone-patellar tendon-bone autograft. knee. 2011;18:76-82. doi: 10.1016/j.knee.2010.01.009
In article      CrossRefPubMed/NCBI
 
[19]  Lephart S SC, Fu F, Huxel K. Reestablishing neuromuscular control. Rehabilitation techniques for sports medicine and athletic training. 5 ed. new york: McGraw-Hill; 2011. 122-43 p.
In article      
 
[20]  Bonfim TR JPCCBJ. Proprioception and behavior impairments in individuals with anterior cruciat ligament reconsruction knees. Archive of physical medicine rehabilitation. 2003;84:1217-23. doi: 10.1016/S0003-9993(03)00147-3
In article      CrossRef
 
[21]  Noyes FR BS, Mangine RE. Abnormal lower limb symmetry determined by function hop tests after anterior cruciate ligament rupture. Am J Sports Med. 1991;19:513-8. doi: 10.1177/036354659101900518
In article      CrossRef
 
[22]  Fitzgerald GK AM, Snyder-Mackler. A decisionmaking scheme for returning patients to high-level activity with nonoperative treatment after anterior cruciate ligament rupture. Knee Surg Sports Traumatol Arthrosc. 2000;8:76-82. doi: 10.1007/s001670050190
In article      CrossRefPubMed/NCBI
 
[23]  Shaw T WM, Chipchase LS. Do early quadriceps exercises affect the outcome of ACL reconstruction? A randomized controlled trial. Aust J Physiother. 2005;51:9-17. doi: 10.1016/S0004-9514(05)70048-9
In article      CrossRef
 
[24]  Cerulli G BD, Caraffa A, Ponteggia F (2001) Proprioceptive training and prevention of anterior cruciate ligament injuries in soccer. J Orthop Sports Phys Ther. 2001;31:655-61. doi: 10.2519/jospt.2001.31.11.655
In article      CrossRefPubMed/NCBI
 
[25]  Freedman K DAM, Nedeff D, Ari Kaz, Bach B. Arthroscopic anterior cruciate ligament reconstruction: a metaanalysis comparing patellar tendon and hamstring tendon autografts. Am J Sports Med. 2003;31:2-11.
In article      PubMed/NCBI
 
[26]  Valentin A EmB, Werner S. ACL reconstruction: patellar tendon versus hamstring grafts economical aspects. Knee Surg Sports Traumatol Arthrosc. 2006;4:536-41.
In article      
 
[27]  Hawkins RJ MG, Merritt TR. Followup of the acute nonoperated isolated anterior cruciate ligament tear. Am J Sports Med. 1986;14:205-10. doi: 10.1177/036354658601400305
In article      CrossRef
 
[28]  Kennedy JC AI, Hayes KC. Nerve supply of the human knee and its functional importance. Am J Sports Med. 1982;10:329-35. doi: 10.1177/036354658201000601
In article      CrossRef
 
[29]  Corrigan JP CW, Brady MP. Proprioception in the cruciate deficient knee. J Bone Joint Surg [Br]. 1992;74:247-50.
In article      PubMed/NCBI
 
[30]  Friden T RD, Movin T, Wredmark T. Function after anterior cruciate ligament injuries. Influence of visual control and proprioception. Acta Orthop Scand. 1998;69:590-4. doi: 10.3109/17453679808999261
In article      CrossRefPubMed/NCBI
 
[31]  Fremerey RW LP, Zeichen J, Skutek M, Bosch U, Tscherne H. Proprioception after rehabilitation and reconstruction in knees with deficiency of the anterior cruciate ligament. A prospective longitudinal study. J Bone Joint Surg Br. 2000;82:801-6. doi: 10.1302/0301-620X.82B6.10306
In article      CrossRefPubMed/NCBI
 
[32]  AA A-O. Clinical measurement of proprioceptive function after anterior cruciate ligament reconstruction. Saudi Med J. 2004;25:195-7.
In article      PubMed/NCBI
 
[33]  Hopper Dm CM, Formby Pa, Goh Sc, Boyle Jj, Strauss Gr. Functional measurement of knee joint position sense after anterior cruciate ligament reconstruction. Arch Phys Med Rehabil. 2003;84(6):868-72. doi: 10.1016/S0003-9993(03)00007-8
In article      CrossRef
 
[34]  Risberg Ma BB, Peura Gd, Uh Bs. Proprioception after anterior cruciate ligament reconstruction with and without bracing. Knee Surg Sports Traumatol Arthrosc. 1999;7:303-9. doi: 10.1007/s001670050168
In article      CrossRefPubMed/NCBI
 
[35]  Carter ND JT, Wilson D, Jones DW, Torode AS. Joint position sense and rehabilitation in the anterior cruciate ligament deficient knee. Br J Sports Med. 1997;31:209-12. doi: 10.1136/bjsm.31.3.209
In article      CrossRefPubMed/NCBI
 
[36]  MacDonald PB HD, Pacin O, Sutherland K. Proprioception in anterior cruciate ligament-deficient and reconstructed knees. Am J Sports Med. 1996;24:774-8. doi: 10.1177/036354659602400612
In article      CrossRefPubMed/NCBI
 
[37]  37.Wilke C FI. Quantifizierung propriozeptiver Leistungen von Kniegelenken (Quantification of proprioceptive skills of the knee joint). Dtsch Z Sportmed. 2003;54:49-54.
In article      
 
[38]  Grood ES NF. Diagnosis of knee ligaments injuries: Biomechanical precepts. In The Crucial Ligaments: Diagnosis and Treatment of Ligamentous Injuries About the Knee: New York: Churchill Livingstone; 1988. 245-60 p.
In article      
 
[39]  Lephart Sm PD, Giraldo Jl, Fu FH. The role of proprioception in the management and rehabilitation of athletic injuries. Am J Sports Med. 1997;25(1):130-7. doi: 10.1177/036354659702500126
In article      CrossRefPubMed/NCBI
 
  • CiteULikeCiteULike
  • Digg ThisDigg
  • MendeleyMendeley
  • RedditReddit
  • Google+Google+
  • StumbleUponStumbleUpon
  • Add to DeliciousDelicious
  • FacebookFacebook
  • TwitterTwitter
  • LinkedInLinkedIn