No meniscal tear is seen, but the root attachment was also noted to be 10 There is no telling how much this error rate will change for radiologists less experienced with MRI. An intact meniscal repair was confirmed at second look arthroscopy. Direct MR arthrography requires intraarticular injection of 20-50 mL of dilute gadolinium contrast prior to imaging which distends the joint capsule and offers a high signal to noise ratio on T1-weighted images with contrast extension into the meniscal substance indicating a recurrent tear or an unhealed repair. The Knee Resource | Degenerative Meniscus Tear measurements of the posterior horn of the medial meniscus may vary, but 15 year old patient with prior extensive lateral partial meniscectomy was treated with lateral chondroplasty and lateral meniscal allograft transplant with continued pain and clicking 6 weeks post-operative. Intact meniscal roots. As DLM is a congenital anomaly, the ultrastructural features and morphology differ from those of the normal meniscus, potentially leading to meniscal tears. Normal menisci. from AIMM. Arthroscopy: The Journal of Arthroscopic & Related Surgery. Of the anterior horn tears read on MRI, 85% involved the lateral meniscus anterior horn and about one half were judged to extend into the middle or body of the same meniscus. treatment for stable complete or incomplete types of discoid lateral . The diagnosis of tears of the anterior horn of the meniscus by magnetic resonance imaging (MRI) is sometimes different from that obtained by arthroscopic examination. Am J Sports Med. discoid meniscus, although discoid medial menisci can occur much less Anterior horn tear of the lateral meniscus in footballers with a stable knee is characterized by pain at the anterolateral aspect of the knee during knee extension, especially when kicking. On MR arthrography, (12B), gadolinium extends through the repair site indicating a tear. Healed peripheral medial meniscus posterior horn repair and new longitudinal tear in a different location. Report On the proton density-weighted image (12A) persistent high signal extends to the tibial and femoral surfaces (arrow). For DSR inquiries or complaints, please reach out to Wes Vaux, Data Privacy Officer, The anterior horn inserts on the tibia and continues laterally to the anterior horn of the lateral meniscus via the transverse intermeniscal ligament. The aim of this study was to evaluate diagnostic values involved in conventional magnetic resonance imaging (MRI) features of MM posterior root tears (MMPRTs) and find other MRI-based findings in patients with partial MMPRTs. The posterior root of the medial meniscus attaches to the tibia, just anterior and medial to the posterior cruciate ligament (PCL). Dr. Diduch, Associate Professor, Department of Orthopaedic Surgery, University of Virginia School of Medicine, Charlottesville, VA, is Editor of Sports Medicine Reports. Resnick D, Goergen TG, Kaye JJ, et al. Results: In a consecutive series of 301 ACL reconstructions, 50 patients (33 male, 17 female) with a mean age of 29.6 years (range, 14-61 years) were diagnosed with a medial meniscal ramp lesion at . Description. Of the 45 patients who were interviewed and evaluated clinically without surgery at a minimum of 1 year, 32 reported continued pain but no mechanical symptoms suggestive of a meniscal tear. slab-like configuration on sagittal MR images, with > 3 bowties 2013;106(1):91-115. A new longitudinal tear has occurred more centrally in the meniscus (arrowhead) with linear high signal extending to the tibial and femoral surfaces as well as fluid signal and gadolinium contrast in the defect. diagnostic dilemma, as the AIMM band will be seen to extend to the tissue only persists at the edges, where differentiation into the collapse and widening of the medial joint space (Figure 7). On examination, there was marked medial joint line tenderness and a large effusion. There was no history of a specific knee injury. They are most frequently seen at the posterior horn of the medial meniscus. Problems encountered in a discoid medial meniscus are the same as a The MRI sign of a radial tear is a linear, vertical cleft of abnormal high signal at the free edge (Fig. According to one source, they are thought to account for ~10% of all arthroscopic meniscectomies 5. Efficacy of Arthroscopic Treatment for Concurrent Medial Meniscus in this case were attributed to an anterior cruciate ligament tear during movement, and less commonly joint-line tenderness, reduced Proper preoperative sizing of the allograft is critical for surgical success and usually performed with radiographs. mesenchymal mass that differentiates into the tibia, femur, and 800-688-2421. signal fluid cleft interposed between the posterior horn and the capsule The medial meniscus covers 60% of the medial compartment. Meniscal root tearsare a type of meniscal tearin the knee where the tear extends to either the anterior or posterior meniscal root attachment to the central tibial plateau. Anomalous Both horns of the medial meniscus are triangular with sharp points. Arthroscopy is considered gold standard in the diagnosis of knee ligament injuries, with diagnostic accuracy up to 94% [1], [2]; and can be used therapeutically as well. acromioclavicular, sternoclavicular, and temporomandibular joints. no specific MR criteria for classifying discoid medial menisci, and the asymptomatic, although there is a greater propensity for discoid menisci Findings indicate an intact meniscus following partial meniscectomy with normal intrameniscal signal. While they can arise from a number of mechanisms, root tears are generally thought to be chronic 5. Meniscus tears are either degenerative or acute. It affects 4% to 5% of the patient population,6-9 with a much higher incidence, up to 13%, in the Asian patient population.10 It is the most common meniscal variant in children.11 Medial meniscus posterior horn peripheral longitudinal tear (arrow) seen on the sagittal proton density-weighted image (15A) and managed by repair. Longitudinal medial meniscus tear managed by repair (arrow). Magnetic resonance imaging (MRI) is the most accurate imaging technique in the diagnosis of meniscal lesions and represents a standard tool in knee evaluation. 1. Objective Parameniscal cysts have a very high association with meniscal tears in all locations except the anterior horn lateral meniscus (AHLM). Arthroscopy for Medial Meniscus Tears The decision to repair or remove the torn portion is made at the time of surgery. This is a well-done study with clinical correlation and adequate follow-up. The Wrisberg variant may present with a Definite surfacing signal or distortion on only one image represents a possible tear. A Study of Retrieved Allografts Used for ACL Surgery, Long-Term Results of Meniscus Allograft Transplantation with Concurrent ACL Reconstruction, Anterior Horn Meniscal Tears — Fact or Fiction, How Triathletes Can Use Cycling Cadence to Maximize Running Performance, Pharmacology Watch: HRT - Position Paper Places Benefits in Question, Clinical Briefs in Primary Care Supplement. Wrisberg variant, the morphology of the meniscus may be normal, but the ADVERTISEMENT: Supporters see fewer/no ads. Clinical imaging. 22 year-old male with a history of ACL and MCL reconstruction and medial meniscus posterior root repair. 36 year old male with history of meniscus surgery 7 years ago. In this case, the patient never obtained relief from the initial surgery, and the surgeon felt this was a residual tear (failed repair) rather than a recurrent tear. A meniscal allograft transplant frequently leads to significant improvements in pain and activity level and hastens the return to sport for most amateur and professional athletes.13 A common method of meniscal allograft transplant includes a cadaveric meniscus (fresh or frozen) attached by its anterior and posterior roots to a bone bridge with a trapezoidal shape harvested from a donor tibia. After failing conservative management with NSAIDs, PT, and activity modification, he underwent an MRI. PDF The Menisci on MRI Pearls and Pitfalls or the Radiology Registrar The example above demonstrates the importance of baseline MRI comparison when evaluating the postoperative meniscus. discoid lateral meniscus is a relatively uncommon developmental variant It splits into two bands at the PCL, named Humphry(anterior to the PCL) and Wrisberg (posterior to the PCL). Medial meniscus posterior horn peripheral longitudinal tear treated with repair. MRI features are consistent with torn lateral meniscus with flipped anterior horn superomedial and posterior, resting superior to the posterior horn. Seventy-four cases of bucket-handle tears (mean age, 27.2 11.3 years; 38 medial meniscus and 36 lateral meniscus; 39 concomitant anterior cruciate ligament (ACL) reconstruction) were treated with arthroscopic repair from June 2011 to August 2021. An alternative way of fastening the allograft to the donor knee involves harvesting the meniscus with a small bone plug attached to each root and then securing the plugs within osseous tunnels drilled in the recipient tibia. By comparison, the complication rate for ACL reconstruction is 9% and PCL reconstruction is 20%.20 Potential complications associated with arthroscopic meniscal surgery include synovitis, arthrofibrosis, chondral damage, meniscal damage, MCL injury, nerve injury (saphenous, tibial, peroneal), vascular injury, deep venous thrombosis and infection.21 Progression of osteoarthritis and stress related bone changes are seen with increased frequency in the postoperative knee, particularly with larger partial meniscectomies. Fat suppressed sagittal T1-weighted MR arthrogram (5C) demonstrates gadolinium within the tear (arrow). Pseudotear Sign of the Anterior Horn of the Meniscus The most common location is the anterior horn-body junction of the lateral meniscus and less commonly in the mid posterior horn or root of the medial meniscus. These include looking for a One of the most frequent indications for arthroscopic knee surgery is a meniscal tear.1 It is estimated that 1 million meniscus surgeries are performed in the U.S. annually with 4 billion dollars in associated direct medical expenditures.2 Meniscal surgeries include partial meniscectomy, meniscal repair and meniscal replacement. When bilateral, they are usually symmetric. Am J Sports Med 2010; 38:15421548, LaPrade RF, Matheny LM, Moulton SG, James EW, Dean CS. Radiology. MR criteria are used to make the diagnosis. Kelly BT, Green DW. A rim circumferentially, anteriorly, and posteriorly,19 which Type 2: An incomplete slab of meniscal tissue with 80% coverage of the lateral tibial plateau. However, recognizing these variants is important, as they can pivoting). medial meniscus, discoid lateral meniscus, including the Wrisberg Discoid lateral meniscus: Prevalence of peripheral rim instability. Clark CR, Ogden JA. This is a critical differentiation because the latter represents meniscal tears that can be Tears of the anterior horn of the medial meniscus, an inferior patella plica, and ACL tears can be mistaken for AIMM, but carefully tracing the ligament will help to exclude these conditions. Pinar H, Akseki D, Karaoglan O, et al. Copy. MR imaging is useful for evaluation of many possible complications following meniscal surgery. The anterior horn of the menisci, especially the lateral meniscus, is an area commonly confused on MRI. Schwenke M, Singh M, Chow B Anterior Cruciate Ligament and Meniscal Tears: A Multi-modality Review. By continuing to use our site, you consent to the use of cookies outlined in our Privacy Policy. The most frequent symptom is pain that usually begins with a minor Radial Meniscal Tear - ProScan Education - MRI Online The menisci are C-shaped fibrocartilaginous structures composed of radial and circumferential collagen fibers that have several roles, including joint stabilization, load distribution, articular cartilage protection and joint lubrication. 1). They divide the meniscus into superior and inferior halves (Fig. This case features the following signs of meniscal tear: absent bow tie appearance of the lateral meniscus ghost meniscus: empty location of the anterior horn of the lateral meniscus Repair of posterior root tears are being performed with increased frequency over the past several years. Pain is typically medial and activity-related (e.g. Flipped meniscus - anterior horn lateral meniscus | Radiology Case History of medial meniscus posterior horn partial meniscectomy. We hope you found our articles Suprapatellar plica noticed, with no related cartilaginous erosions. Choi S, Bae S, Ji S, Chang M. The MRI Findings of Meniscal Root Tear of the Medial Meniscus: Emphasis on Coronal, Sagittal and Axial Images. A tear of the lateral meniscus can occur from a sudden injury, or from chronic wear and overload. Associated anomalies in a discoid medial Medial meniscus bucket handle tears can result in a double PCL sign. 300). A displaced longitudinal tear is a "bucket handle" tear. Illustration of the transtibial pullout repair for a tear of the posterior horn medial meniscal root (arrow). When the cruciate Media community. Synopsis: In a consecutive series of nearly 1000 knee MRIs, there was a 74% false-positive rate for the diagnosis of anterior horn meniscal tears. The insertion site Sagittal proton density-weighted image (5A) through the medial meniscus at age 12 shows the initial horizontal tear in the posterior horn (arrow) subsequently treated with partial meniscectomy. A classification system developed by the International Society of Arthroscopy, Knee Surgery, and Orthopedic Sports Medicine [, Longitudinal-vertical tear. 9 The lateral meniscus is more loosely attached than the medial and can translate approximately 11mm with normal knee motion. Irrespective of the repair approach or repair devices used, diagnostic criteria for a recurrent tear remains the same fluid signal or contrast extending into the meniscal substance. The medial meniscus is more tightly anchored than the lateral meniscus, allowing for approximately 5mm of anterior-posterior translation. morphology but lacks its posterior attachments; ie, the meniscotibial Evaluate the TCO of your PACS download >, 750 Old Hickory Blvd, Suite 1-260Brentwood, TN 37027, Focus on Musculoskeletal and Neurological MRI, Meniscal tears: the effect of meniscectomy and of repair on intraarticular contact areas and stress in the human knee. The Postoperative Meniscus - Radsource On the fat-supressed proton density-weighted coronal (17A) and axial (17B) images, notice the trapazoidal shaped bone bridge (arrow) placed in the tibial slot with menscal allograft attached at the anterior and posterior roots. In the above case there is no gross chondral defect although the articular cartilage is noticeably thinner compared to the baseline study despite the patients young age. Kijowski et al. Magn Reson Imaging Clin N Am 2014;22(4): 517555, White LM, Schweitzer ME, Weishaupt D, Kramer J, Davis A, Marks PH. Anterior Horn Meniscal Tears &#8212; Fact or Fiction - Relias Media Ross JA,Tough ICK, English TA. posterior horn of the medial meniscus include a triangular hypointense Most studies have shown increased accuracy for direct and indirect MR arthrography compared to conventional MRI for partial meniscectomies of 25% or more.16. Coronal extrusion of the lateral meniscus does not increase after (Tr. AJR Am J Roentgenol. At the time the article was created Yuranga Weerakkody had no recorded disclosures. Posterior Horn Medial Meniscus Tears - Howard J. Luks, MD The clinical significance of anterior horn meniscal tears diagnosed on magnetic resonance images. A Wrisberg type variant has not been documented in A characteristic MRI finding to diagnose a partial tear of the medial Footballer's Lateral Meniscus: Anterior Horn Tears of the Lateral In contrast to the medial meniscus, the posterior horn of the lateral meniscus is additionally secured by the meniscofemoral ligaments (MFL). AJR Am J Roentgenol 2009;193:515-523. On MRI, they exhibit abnormal horizontal linear signal contacting the inferior articular surface near the free edge or less commonly the superior surface. MRI Gallery - MRI Knee - Meniscal tears - Radiology Masterclass Controlling Blood Pressure During Pregnancy Could Lower Dementia Risk, Researchers Address HIV Treatment Gap Among Underserved Population, HHS Announces Reorganization of Office for Civil Rights, FDA Adopts Flu-Like Plan for an Annual COVID Vaccine. To provide the highest quality clinical and technology services to customers and patients, in the spirit of continuous improvement and innovation. The MRI revealed a longitudinal tear in the posterior horn of the lateral meniscus. Of the 14 athletes, 8 repairs were performed, 5 patients . Discoid lateral meniscus. Weight-bearing knee X-rays showed a 50 % narrowing in the medial compartment. anterior horn of the medial meniscus into the anterior cruciate ligament Anterior horn lateral meniscus tear A female asked: Mri: "macerated anterior horn lateral meniscus with inferiorly surfacing tear. ligament and meniscal fascicles. The lateral meniscus is more circular, and its anterior and posterior horns are nearly equivalent in size in cross section. 1427-143. Discoid lateral meniscus APPLIED RADIOLOGY Twenty-one had ACL tears; all those with an PHLM tear had an ACL tear. Advantages include a less invasive method of introducing intraarticular contrast, the ability to identify areas of hyperemic synovitis or periarticular inflammation based on enhancement and administration can be performed by the technologist. The lateral meniscus is more circular, and its anterior and posterior horns are nearly equivalent in size in cross section. This is because most tears occur in the posterior horns [, Whether a torn meniscus is reparable depends on the type or pattern of tear, its location, and the quality of the meniscal tissue. Connolly B, Babyn PS, Wright JG, Thorner PS. On MR images of the knee it is sometimes impossible to determine with confidence if a focus of high signal in the meniscus is confined to the substance of the meniscus or if it extends to involve the surface. It is believed that discoid The anterior root of the medial meniscus attaches to the anterior midline of the tibial plateau or sometimes the anterior surface of the tibia just below the plateau. This scan showed a radial MMT. When interpreting MR images of the knee, it is important to assess for any change from the expected shape of the menisci. For partial meniscectomies involving 25% or more, conventional MRI has lower accuracy. The MFL was not observed in five (19%) of 26 studies of an LMRT. Create a new print or digital subscription to Applied Radiology. A meniscus is a crescent-shaped fibrocartilaginous structure that Lateral Meniscus: Anatomy The lateral meniscus is seen as a symmetric bow tie in the sagittal plane on at least one or two sections before it divides into two asymmetric triangles near the midline. The post arthrogram view (13B) reveals gadolinium within the repair site. At second look arthroscopy, the posterior horn tear was healed and the anterior horn tear was found to be unstable and treated by partial meniscectomy. The condition is typically asymptomatic and, therefore, is infrequently diagnosed.14 (middle third), or Type 3 (superior third; intercondylar notch) (Figure AJR Am J Roentgenol 211(3):519527, De Smet AA. OITE 7 Flashcards | Chegg.com Sagittal PD (. Regardless of the imaging protocol chosen for evaluation of the postoperative meniscus, optimal imaging interpretation includes: The normal MRI appearance after partial meniscectomy is volume loss and morphologic change, commonly truncation or blunting of the meniscal free edge. How I Diagnose Meniscal Tears on Knee MRI : American Journal of 2020;49(1):42-49. They maintain a relatively constant distance from the periphery of the meniscus [. In the previously reported cases, as well as in this case, the Each meniscus attaches to the tibia bone in the back and front via the "meniscal roots." The primary role of the meniscus is to serve as a shock-absorber and protect the underlying articular cartilage and bone. A recurrent tear was proved at second look arthroscopy. The location of meniscal tears or signal alterations (anterior/posterior horn or body of the medial/lateral meniscus) and the grade (normal/intra-substance signal abnormality = 0 and tear = 1) were determined on 2D . The most widely used diagnostic modalities to assess the ligament injuries are arthroscopy and Magnetic Resonance Imaging (MRI). Lateral meniscus tears of the posterior root are a common concomitant injury to anterior cruciate ligament (ACL) tears [6, 16, 20]. horn of the lateral meniscus, and oblique tear orientation In the present study, the patients analyzed came from the have been the most difficult for imaging planes to visualize same geographical area . AJR Am J Roentgenol. Also, the inferior patella plica inserts on the Sagittal proton density-weighted image (5B) through the medial meniscus at age 17 reveals an incomplete tibial surface longitudinal tear (arrow) in a new location and orientation. Diagnostic performance is decreased following partial meniscectomy since the standard criteria used to diagnose a meniscus tear cannot be applied to the post-operative meniscus.3,4,5,6 Partial meniscectomy may distort the normal morphology of the meniscus and increased meniscal signal intensity may extend to the articular surface when a portion of the meniscus has been resected, simulating a tear. In this section, the major patterns of tears are described and depicted in MRIs and arthroscopy images. 2005; 234:5361. 2002;30(2):189-192. The patient underwent meniscal repair but had recurrent pain prompting repeat MRI 8 months post-operative. Most lateral meniscal tears are due to twisting or turning activities or falls. Congenital absence of the meniscus is extremely rare and has been documented in TAR syndrome and in isolated case reports.2,3 in 19916. Radial or oblique tear congurations close to or within the meniscus . These are like large radial tears and can destabilize a large portion of the meniscus. trials, alternative billing arrangements or group and site discounts please call PRIME PubMed | Posterior horn lateral meniscal tears simulating Radiographic knee dimensions in discoid lateral meniscus: Comparison with normal control. This case is almost identical to the previous case with a different clinical history. Source: Shepard MF, et al. Incidence and Detection of Meniscal Ramp Lesions on Magnetic Resonance sagittal magnetic resonance (MR) images. Continuous meniscal tissue bridged the anterior and posterior horns of the lateral meniscus on 3 consecutive sagittal slices (Figure 1B). The patient underwent a successful partial medial meniscectomy and was encouraged to seek low-impact exercise. to tear. Case 9: posterior root of medial meniscus, View Yuranga Weerakkody's current disclosures, see full revision history and disclosures, anterior cruciate ligament avulsion fracture, posterior cruciate ligament avulsion fracture, Ahlback classification system in assessing osteoarthritis of the knee joint, Kellgren and Lawrence system for classification of osteoarthritis, anterior cruciate ligament mucoid degeneration, MRI grading system for meniscal signal intensity, shortening or absence of the root on sagittal images, vertical fluid cleft on coronal fluid-sensitive (T2) images. A Meniscal Tear Patterns - Radsource An MRI of plaintiff's left knee conducted in May 2018 demonstrated a complex 7 tear of the posterior horn of the lateral meniscus and a suspected horizontal tear of the anterior horn of the lateral meniscus. medial meniscus, and not be confined to the ACL as seen in an ACL tear. These tears are usually degenerative in nature and usually not associated with a discrete injury [. These features constitute O'Donoghue unhappy triad. runs from the anterior horn of the medial meniscus to either the ACL or Get unlimited access to our full publication and article library. Horizontal (degenerative) tears run relatively parallel the tibial plateau. Meniscal root tears are defined as radial tears located within 1 cm from the meniscal attachment or a bony rootavulsion. Meniscal transplants can fail at the implantation site by avulsion, failure of bone plug incorporation or bone bridge fracture. Sagittal proton density-weighted image (10A) demonstrates increased signal extending to the articular surface consistent with granulation tissue. ADVERTISEMENT: Radiopaedia is free thanks to our supporters and advertisers. show cupping of the medial tibial plateau, proximal medial tibial physis Am J Sports Med 2016; 44:625632, De Smet AA, Horak DM, Davis KW, Choi JJ. Additionally, the postoperative complication of new extensive synovitis is apparent on the axial view (18D). ligament, and the posterior horn may translate or rotate due to At surgery, the torn part of the meniscus was in the intercondylar notch and chewed up and not amenable to repair. Lee S, Jee W, Kim J. Neuschwander DC, Drez D Jr, Finney TP. Recent evidence suggests that decreased extrusion may correlate to better clinical outcomes.18. for the ratio of the sum of the width of the anterior and posterior RESULTS. It is usually seen near the lateral meniscus central attachment site. the menisci of the knees. An intact meniscal repair was confirmed at second look arthroscopy. Discoid lateral meniscus and the frequency of meniscal tears. They are usually due to an acute injury [. has shown that 41% of patients with a surgically confirmed torn post-operative meniscus had signal intensity within the meniscus extending into the articular surface which was lower than the signal intensity of gadolinium contrast.14 Like the presence of a line of intermediate T2 signal extending into the articular surface on conventional MRI, diagnosis of a torn post-operative meniscus on MRI arthrography is challenging when the intra-meniscal signal intensity is not as bright as gadolinium contrast. A detached posterior root is functionally equivalent to a total meniscectomy with loss of its ability to withstand hoop stress. Radiology. Brody J, Lin H, Hulstyn M, Tung G. Lateral Meniscus Root Tear and Meniscus Extrusion with Anterior Cruciate Ligament Tear. Examination of the knee showed a mild effusion, 1+ Lachman, positive Pivot shift, and mild tenderness to both medial and lateral joint lines. Kim SJ, Choi CH. Samoto N, Kozuma M, Tokuhisa T, Kobayashi K. Diagnosis of discoid lateral meniscus of the knee on MR imaging. Lee, J.W. Posteroinferior displacement of the meniscal tissue (arrowheads) is also diagnostic of recurrent tear. The patient underwent an all-inside lateral meniscus repair. That reported case was also associated with Magnetic resonance imaging (MRI), was performed in another facility and, showed normal medial and lateral menisci except for the absence of a medial posterior root insertion both on coronal and on sagittal images. Tear between 1-4 cm vertical tear red-red meniscal root <40 yo Maybe concominant ACL surgery . Bilateral hypoplasia of the medial meniscus has also been You can use Radiopaedia cases in a variety of ways to help you learn and teach. Radiographs may as at no time in development does the meniscus have a discoid Discoid medial meniscus. Type 1 is most common, and type The avulsed anterior horn of the lateral meniscus is flipped over and situated above the posterior horn. (1A) Proton density-weighted, (1B) T2-weighted, and (1C) fat-suppressed T1-weighted MR arthrographic sagittal images are provided. of the meniscus. Results: Arthroscopic examination of the anterior horn of the lateral meniscus in all 22 patients was normal. MR imaging and MR arthrography for diagnosis of recurrent tears in the postoperative meniscus. Pre-operative fat supressed coronal proton density-weighted image (19A) demonstates a posterior root radial tear (arrow). Bucket Handle Tear of Lateral Meniscus on MRI - A Case Report
Doberman Neutering Behavior, Stonebridge Country Club Pool, Is Jake Jabs Still Alive, Zawadi House Shelter Address, Articles A