Keywords adolescent - flatfoot - subtalar joint
Introduction
Flexible flatfoot is characterized by the absence of or significant reduction in the
medial longitudinal arch, associated with an increased valgus of the ankle during
weight bearing. It is a common condition in children, but it is self-limiting and
has a strong tendency for spontaneous regression.[1 ] However, a minority of individuals may experience complete failure in the development
of the medial plantar arch, resulting in permanent flatfoot throughout life. In adulthood,
if the condition is severe, there may be functional limitations, pain, and an increased
risk of developing osteoarthritis.[2 ]
In the juvenile age group, flatfoot can be associated with symptoms such as fatigue
after usual efforts, cramps, pain, and discomfort when attempting to fit the unconventional
foot shape into standard footwear.[3 ] These complaints tend to be exacerbated with excess weight, ligament laxity, or
Achilles tendon shortening.[4 ]
Conservative interventions, such as the use of insoles, despite their widespread use,
lack scientific evidence supporting their effectiveness.[5 ]
[6 ] As a result, several surgical procedures have been developed to correct symptomatic
flexible flatfoot in immature individuals. These techniques can be grouped into soft-tissue
procedures,[7 ] osteotomies,[8 ]
[9 ]
[10 ] or localized arthrodesis.[4 ] Approaches that exclusively target musculotendinous and ligamentous structures provide
temporary corrective effects due to tissue compliance. Osteotomies yield favorable
outcomes, but they require longer periods of immobilization and recovery. Arthrodesis
has limited indications, as it requires joint destruction to achieve correction.[11 ]
Another surgical option is arthroereisis (from the Greek arthroereisis , in which arthros means joint, and ereisis , the action of supporting or sustaining). These procedures aim to preserve the joint
providing mechanical stabilization without limiting functional movements. They are
interesting for their potential in correcting and preventing severe deformities.[12 ] When applied to flatfoot, such techniques show simplicity, efficiency, low morbidity,
and prompt recovery, making them suitable for young and healthy patients.[13 ]
The origins of arthroereisis in the foot can be attributed to Grice,[14 ] in 1952, who devised an extra-articular arthrodesis procedure by inserting a bone
graft into the tarsal sinus, attempting to correct valgus deformities in children
affected by poliomyelitis sequelae. In 1990, Crawford et al.[12 ] employed temporary metal staples in the subtalar joint to correct valgus feet in
individuals with spastic cerebral palsy. The primary objective was to restore the
medial plantar arch by partially restricting subtalar joint motion, rather than completely
blocking it. Later, the arthroereisis effect was achieved through the insertion of
implants into the tarsal sinus, or by blocking excessive calcaneal eversion using
a screw placed laterally to the tarsal sinus, under the lateral process of the talus.[15 ]
Subtalar implants within the tarsal sinus were initially introduced in 1977, utilizing
a silicone elastomer block to maintain the optimal position of the joint.[16 ] Since then, a wide variety of implants have been developed for this purpose, encompassing
various shapes such as plugs, spacers, cones, screws, and cylinders. The materials
include elastomer, polyethylene, titanium, and bioabsorbable poly-L-lactic acid.[3 ]
According to De Pellegrin,[15 ] the insertion of an extra-articular screw into the calcaneus, adjacent to the lateral
process of the talus, was initially described by Álvarez[17 ] to achieve the effect of arthroereisis, and later modified by Pisani.[18 ] The technique temporarily blocks excessive pronation of the subtalar joint, enabling
the lateral column to grow and occupy the space without pressure.
Currently, this technique is widely used in Europe.[13 ]
[15 ]
[18 ]
[19 ]
[20 ] In Brazil, arthroereisis with a screw in the calcaneus remains, to some extent,
unfamiliar to most of the orthopedists, and the publications are on the treatment
of neuropathic flatfoot.[21 ]
The objectives of the present study were to analyze the results of correcting severe
symptomatic flexible valgus flatfoot in the preadolescent age group using the calcaneo-stop
technique, and to contribute to a wider dissemination of this method.
Materials and Methods
The current retrospective study was designed to evaluate the outcomes of the surgical
treatment in preadolescent patients with symptomatic flexible valgus flatfoot. The
study was approved by the institutional Ethics Committee (CAAE: 77119524.8.0000.5440).
The sample included individuals of both sexes presenting severe, flexible, idiopathic
valgus flatfoot submitted to the calcaneo-stop technique at our institution. The flexibility
of the foot was assessed based on reversibility of the deformity with and without
weight bearing, the tiptoe standing test ([Fig. 1 ]), and on the result of the Jack test.
Fig. 1 Tiptoe standing test to demonstrate foot flexibility. (A ) On weight bearing, the medial arch collapses. (B ) The heel turns into varus and the medial arch reappears.
Data were collected from medical records, and the assessment included the resolution
of the symptoms, the satisfaction of the patients and their families, as well as pre-
and postoperative radiographic parameters. The study included cases with complete
documentation and informed consent, involving surgeries performed between 2017 and
2022, with an average follow up of 28 months (range: 12-65). We excluded cases of
lower limb mechanical axis deviation, concurrent foot deformities or stiffness, prior
foot surgery or fractures, or underlying local or systemic diseases (Down syndrome,
Ehlers-Danlos syndrome, etc.).
Operative Procedure
Under anesthesia, with the knee extended, the foot was forced into dorsiflexion to
assess the degree of heel valgus and to check for associated equinus. Palpation was
used to identify the sinus tarsi, and a skin incision measuring approximately 2.0 cm
in length was made over it ([Fig. 2A ]). Careful blunt dissection was performed to expose the fat pad and the short extensor
muscle, ensuring the sensory branch of the fibular nerve remained undamaged. Under
fluoroscopy, the foot was forced into supination, enabling the identification and
exposure of the flat surface in the lateral region of the calcaneus, serving as the
entry point to the sinus tarsi. A Kirschner wire (K wire) with 2.0 mm in diameter
was perpendicularly inserted into the calcaneus bone surface, outside of the sinus
tarsi, and its position was confirmed using fluoroscopy ([Fig. 2B ]). Subsequently, the K wire was removed, but the hindfoot was maintained in varus
position. The entry point of the wire was identified, the hole was enlarged using
a 3.2-mm drill bit, and a partially threaded 6.5-mm cancellous stainless-steel screw
(DePuy Synthes, Raynham, MA, United States) with 30 to 40 mm in length was inserted
([Fig. 2C,D ]). The depth of the screw was adjusted to ensure its head was positioned beneath
the lateral process of the talus, thereby correcting the malalignment in valgus of
the hindfoot. If under- or overcorrection occurred, the screw was respectively advanced
or retracted until the desired alignment was achieved. In certain cases, alternative
implants, such as those of 7.0-mm cannulated cortical screws (DePuy Synthes), or fully-threaded
screws were used. It should be noted that the available literature does not indicate
any significant impact of these implant variations on the outcomes of the procedure.
If residual equinus was present, a Hoke-type lengthening of the Achilles tendon was
carried out, followed by the application of a long leg plaster cast splint.
Fig. 2 Surgical steps for calcaneal screw insertion. (A ) Cutaneous demarcation of the surgical incision over the sinus tarsi. (B ) After blunt dissection, the entrance of the sinus tarsi was exposed, and a guide
K wire was vertically inserted into the calcaneus (C ) Screw positioning in lateral view. (D ) Screw positioning in anteroposterior view.
Postoperative Care
Postoperatively, all patients were immobilized for 7 days, after which weight bearing
was gradually reintroduced. In cases requiring equinus correction, patients wore a
walking cast for an additional two weeks before transitioning to regular footwear.
A standardized physiotherapy protocol was not implemented, nor was the use of orthotics
or modified footwear recommended. Around three weeks after surgery, once the scars
had fully healed, the patients were advised to gradually resume physical activities
and sports, provided postoperative pain had subsided.
Clinical Evaluation
The patient's medical record was accessed to compare the pre- and postoperative findings.
Complications resulting from the surgical procedure, along with symptoms observed
postoperatively that were not present preoperatively, were taken into consideration,
such as pain, discomfort, and esthetic improvement.[22 ]
Radiographic Evaluation
The pre and the latest postoperative images were evaluated in anteroposterior and
lateral views, under weight bearing. The following angles and measurements were assessed:
Meary's, calcaneal pitch, Moreau-Costa-Bertani's, alignment between the long axis
of the talus with the first metatarsal, talonavicular angular coverage, and talonavicular
percentual coverage.[23 ]
[24 ]
[Fig. 3 ] shows the angles used, how to trace them, and their normal ranges. All collected
data were grouped and presented in [Table 1 ].
Table 1
Identification
Age
Follow-up
Calcaneal pitch
Talonavicular angle coverage
Talonavicular percentual coverage
Meary's angle
Talus-first metatarsal angle
Moreau-Costa-Bertani's angle
Pain
Complications
(years)
(month)
Pre
Post
Pre
Post
Pre
Post
Pre
Post
Pre
Post
Pre
Post
Pre
Post
F1
9
20
4.5
11.8
45.6
22.4
50.6
24.8
-32.6
-5.5
25.3
2.7
159
140.8
Yes
No
No
F2
9
20
7.7
14
44.8
21.8
47.7
24.2
-23
-5.6
14.3
7.4
148.2
135.3
Yes
No
No
F3
13
34
6
16.7
36.6
16.5
40.6
18.3
-24
-13.7
12.4
3.4
142.4
132.4
SIM
No
No
F4
13
28
8.6
17.3
23.9
11.6
26.5
12.8
-22
-8.6
13.3
1.4
142.8
127.8
Yes
No
No
F5
9
34
2
4
56.1
24.7
62.3
27.4
-18.1
1.7
18.6
9.7
143.4
135
Yes
No
No
F6
9
34
-4
1.5
45.9
25
51
27.7
-18
-4.6
20.3
1.2
147.6
135.8
Yes
No
No
F7
11
40
2.6
10.5
45.8
18.7
50.8
20.7
-17.2
-0.8
17.1
5.5
146.1
133.1
Yes
No
Chronic pain
F8
11
40
1
8.7
44.1
15.1
49
16.7
-22
-1.5
16.4
5
141.6
134.9
Yes
Yes
Chronic pain
F9
12
30
0.5
4.3
41.3
1
45.8
1.1
-17.8
-12.8
16.8
5.2
144.2
134
Yes
No
No
F10
12
30
0.5
6
50.4
23.3
56
25.8
-23.2
-9.8
36.1
17.3
151.5
135.3
Yes
No
No
F11
12
37
10.5
13.8
16
11.3
17.7
12.5
-6.7
6.3
25
14.3
130.3
115.6
Yes
No
No
F12
12
37
10.8
12.1
39.5
16.8
43.8
18.6
-14.6
1.6
36.2
19
134.7
119.5
Yes
No
No
F13
11
21
6.3
9.5
39
21.5
43.3
23.8
-30.6
-12.5
23.5
3
151.7
142.5
Yes
No
No
F14
11
21
9
7.8
11.9
9.8
13.2
10.8
-12.5
-7.7
6
7.8
141.6
137.7
Yes
No
No
F15
11
39
11
18
40.2
1.1
44.6
1.2
-10.7
13.3
24.1
6.5
138.7
118.6
Yes
No
No
F16
11
39
11.6
18.4
42.9
2.3
47.6
2.5
-12.5
-3.5
29.4
3.5
140
127
Yes
No
No
F17
12
17
4.7
5.1
32.9
20.2
36.5
22.4
-22.1
-13.5
12
12.7
152.6
144.2
Yes
No
Undercorrection
F18
12
17
3.3
9.6
43
27.6
47.7
30.6
-28
-4.5
25.5
1.9
153.4
131.2
Yes
No
No
F19
11
47
9.6
15
38.8
12.8
43.1
14.3
-19
-5.3
19.2
9.3
151.2
129.5
Yes
No
No
F20
11
47
6.5
16.8
32
11.9
35.5
13.2
-19.7
-2
22.4
12.9
148.1
129.9
Yes
No
No
F21
9
65
3.9
17.3
42.8
15.5
47.5
17.2
-20.6
-4.4
16.8
8.6
144.8
130.4
Yes
No
No
F22
9
65
3.3
13.3
46.9
22.7
52.1
25.2
-30
-7.1
20.1
8.1
158
137.2
Yes
No
No
F23
9
6
3.6
7.9
26
20.4
28.8
22.6
-22.4
-12.2
4.4
2.3
148.4
141
Yes
Yes
Chronic pain
F24
16
33
10.1
12.2
35.6
31.7
39.5
35.2
-9.5
-6
14.8
13
131.4
132
Yes
No
No
F25
16
33
8.1
14.1
30.1
24.8
33.4
27.5
-14.6
-5.2
16
11
136.9
128.1
Yes
No
No
F26
11
32
7.9
15.6
41.6
15.1
46.2
16.7
-18.7
-5.7
13.6
1.1
142.9
137.6
Yes
No
No
F27
11
32
10.6
14.8
39.6
6.9
44
7.6
-13.4
-6.5
13.5
1.6
140.3
137.4
Yes
No
No
F28
7
11
7
12.7
41.6
7.1
46.2
7.8
-9.5
10.6
12.5
9.2
140.9
124.6
Yes
No
No
F29
7
11
6.7
8.2
33.8
4.5
37.5
5
-10.5
10.1
14.1
14.4
138.7
128
Yes
No
No
F30
13
26
13.4
20.1
32.5
12.1
36.1
13.4
-12.9
4.8
36.6
16
134.8
121.8
Yes
No
No
F31
13
26
19.3
20.6
36.4
16.6
40.4
18.4
-11.4
4.1
35.3
12.7
124.7
117.2
Yes
No
No
F32
10
6
9.7
16.2
26.4
14.7
29.3
16.3
-9.6
0.8
13.7
11.2
133.5
122.1
Yes
No
No
F33
10
6
14.4
17.3
20.8
2.3
23.1
2.5
-10.1
1.5
10.2
5
127.6
118
Yes
No
No
F34
11
47
5.7
8.1
27.7
23.4
30.7
26
-17.7
3.5
16
11.8
142.2
128.7
Yes
No
No
F35
11
47
7.1
8.7
23.8
18
26.4
20
-18.7
3.9
14
7
143.8
127.1
Yes
No
No
F36
13
20
10.4
17.4
25.2
9.9
28
11
-11.2
-1
4.2
4.7
133.2
119.1
Yes
No
No
F37
13
20
11.8
18.2
25.8
15.5
28.6
17.2
-13.6
-2.5
3.2
0.1
136.8
124.3
Yes
No
No
F38
12
12
3
12.7
43
23.9
47.7
26.5
-24
-3.5
22
9.8
158
126.5
Yes
No
No
F40
14
12
4.3
7.5
32.1
4.4
35.6
4.8
-21.7
-14.3
19.1
6.8
154.2
147.5
Yes
No
Undercorrection
F41
14
12
5.5
11.1
36.7
5
40.7
5.5
-19.2
-10.4
23.2
9.8
150.1
143.2
Yes
No
Undercorrection
F42
7
26
3.3
9.2
42
16.2
46.6
18
-13.3
-7.1
14.4
4.4
144.3
134.4
Yes
No
No
F43
7
26
4.1
10.1
40.7
13.3
45.2
14.7
-11.9
-6.6
13.2
3.9
142.1
129.1
Yes
No
No
F44
12
34
2.2
16.4
41.2
20.2
45.7
22.4
-23.1
-9.4
16.8
4.4
151.1
139.1
Yes
No
No
Fig. 3 X-Ray evaluation of the foot deformities. (A ) Meary's angle: measured in lateral view, it represents the angle formed between
the long axis of the talus and the long axis of the first metatarsal (normal range:
5°–15°). (B ) Calcaneal pitch: measured in lateral view, it represents the angle formed between
the inferior surface of the plantar cortex of the calcaneus and the ground (normal
range: 15°–25°). (C ) Moreau-Costa-Bertani's angle: determined by tracing a line from the inferior surface
of the medial sesamoid to the inferior surface of the talonavicular joint. Another
line is traced from this point to the posterior tuberosity of the calcaneus (normal
range: 115°–125°). (D ) Talus-metatarsal angle: measured in anteroposterior view, it represents the angle
between the long axis of the talus and the long axis of the first metatarsal (normal
values range: 0°–5°). (E ) Coverage angle of the talonavicular joint: measured in anteroposterior view, it
represents the angle formed by the medial and lateral articular surfaces of the talus
and the articular surface of the navicular bone (normal range: 0°–7°). (F ) Percentual coverage of the talus head is the percentage of the articular surface
of the talus head that is covered by the navicular (normal: ≥ 90%).
Statistical Analysis
The Shapiro-Wilk test was used to evaluate the normality of the sample distribution
and determine a parametric distribution, with statistical significance set at p < 0.05. The paired t -test was used to assess the significance of the surgical intervention and improvement
in radiological outcomes, with p set at < 0.001. Analyses were conducted using the RStudio Desktop Pro (Posit, PBC,
Boston, MA, United States) software, version 2023.03.0.
Results
A total of 23 patients (44 feet), aged between 7 and 13 (mean: 11) years, were considered
eligible for the study. The minimum follow-up was 12 months, and the maximum was 5
years (65 months), with a mean of 28 months.
The clinical outcomes were satisfactory, addressing both esthetic concerns and alleviating
pain. In total, 90% of the patients reported improvement or complete resolution of
symptoms and pain relief compared to their preoperative condition. The rate of complications
was of 13.6%, and they occurred in 6 cases: 3 with chronic pain at the surgical site,
and 3 with incomplete correction of the deformity. In two cases, the pain was resolved
with local corticosteroid injections, while, in the other case, the screw was removed,
resulting in reduced pain – though not fully resolved. Implant removal was not necessary
for the other patients. There were no occurrences of infection, wound healing issues,
or implant breakage. All radiographic parameters exhibited significant postoperative
improvement ([Fig. 4 ]).
Fig. 4 Pre (A,B ) and postoperative (C,D ) clinical appearance of a 10-year-old boy who underwent surgery to correct a severe
valgus flat foot. Significant improvement was observed in both the ankle alignment
and foot arch. In this case, in addition to the calcaneo-stop procedure, a percutaneous
lengthening of the Achilles tendon was performed to correct the equinus. (E ) Preoperative X-ray in lateral view performed in 2019. (F ) Postoperative X-ray in lateral view performed in 2022.
The calcaneal pitch showed a significant increase of 87%, with a preoperative mean
value of 6.61° (standard deviation [SD]: 0.65°) and a postoperative value of 12.41°
(SD: 0.60°) ([Fig. 5 ]). The talonavicular coverage exhibited a significant improvement, of 136%, as evidenced
by the t -test (p < 0.001). The final mean values of 15.43° (SD: ± 1.15°) remained slightly higher
than the reference values ([Fig. 6 ]). The Meary's angle showed a strong correlation in the t -test (p < 000.1) ([Fig. 7 ]), with a significant improvement of 383%, in the talonavicular alignment of the
sagittal axis. However, the mean final value of -3.64° (SD: ± 1.01°) was still not
within the normal range.
Fig. 5 Box plot distribution for the pre and postoperative calcaneal pitch angle. There
was a significant postoperative increase, and the angle reached normal ranges (p < 0.001).
Fig. 6 Box plot distribution for pre and postoperative talonavicular angle. There was significant
postoperative improvement, and the angle almost reached normal ranges (p < 0.001).
Fig. 7 Box plot distribution for the pre and postoperative Meary's angle. There was significant
postoperative improvement, and the angle was slightly below normal parameters (p < 0.001).
The alignment of the long axis of the talus with the first metatarsal in the coronal
plane showed improvement of 141%, a significant difference in the t -test (p < 0.001) ([Fig. 8 ]). The mean preoperative value was of 18.12° (SD: ± 1.22°) and, postoperatively,
it was of 7.5° (SD: ± 0.78°).
Fig. 8 Box plot distribution for the pre and postoperative talus-metatarsal angle. There
was significant postoperative improvement, and the angle almost reached normal ranges
(p < 0.001).
The Moreau-Costa-Bertani's angle showed improvement in the measured parameters (p < 0.001). Although the values did not reach normality, with a preoperative mean of
143.8° (SD: ± 1.22°) and a postoperative mean of and 131.21° (SD: ± 1.19°), an improvement
of 9% in the formation of the plantar arch was observed ([Fig. 9 ]). The talonavicular coverage percentage showed significant improvement of 38% as
evidenced by the t -test analysis (p < 0.001). The preoperative mean value of 59.7% (SD: ± 1.54%) increased to 82.8% (SD: ± 1.28%),
with a significant improvement in the relationship between the hindfoot and midfoot
([Fig. 10 ]).
Fig. 9 Box plot distribution for the pre and postoperative Moreau-Costa-Bertani's angle.
There was a significant postoperative increase, and the angle reached normal ranges
(p < 0.001).
Fig. 10 Box plot distribution for the pre and post-operative talonavicular coverage percentage.
There was significant postoperative improvement, and the coverage almost reached normal
ranges (p < 0.001).
Discussion
In the present case series, the treatment of the severe idiopathic pediatric flatfoot
using the calcaneo-stop technique demonstrated effective correction of the deformity
with minimal complications. The surgical procedure is technically straightforward
and yields positive clinical and radiographic outcomes.
Although the exact cause of flatfoot remains a topic of debate,[7 ]
[25 ] if left untreated, it can lead to functional limitations in adulthood. Progressive
subluxation and excessive loading of the triple joint complex and the spring ligament
may occur, ultimately leading to late articular degeneration. This overloading is
clinically responsible for fatigue, pain, and mechanical insufficiency.
The extra-articular technique known as calcaneo-stop involves the insertion of a screw
into the calcaneus, effectively blocking excessive talus-calcaneus pronation and subsequent
subluxations.[17 ] Moreover, research[15 ]
[26 ]
[27 ] suggests that, besides joint restriction, proprioceptive mechanisms influence gait
kinetics. Unlike osteotomies, which immediately alter joint relationships and load
distribution, arthroereisis induces an early correction of the deformities, followed
by a late gradual three-dimensional articular reorganization over several months,
leading to articular remodeling.
Lateral column lengthening osteotomies and medialization of the calcaneus are accepted
treatments for symptomatic flexible flatfoot in the immature foot, with reported satisfactory
results of approximately 90%.[8 ]
[9 ]
[10 ] However, these procedures are more invasive, require longer recovery time, and impose
activity restrictions for weeks. In contrast, arthroereisis results in a fast rehabilitation,
enabling the patient to walk shortly after surgery.[13 ]
[17 ]
[27 ]
[28 ] Nevertheless, in the present series, 42% of the patients underwent Achilles tendon
lengthening and required plaster immobilization for up to 21 days. For the remaining
patients, weight bearing was allowed on the seventh postoperative day. Conversely,
some authors[15 ] do not routinely release the triceps surae, even in the presence of equinus, arguing
that the postoperative equinus can be reversed with physiotherapy.
While clinico-radiographic dissociation exists, we employed angular parameters to
evaluate and enhance the objectivity and reproducibility of the results. Nonetheless,
these variables may not directly correlate with the symptoms and severity of the foot.
Moreover, establishing the most significant signals for the diagnosis and determining
the precise threshold to define a foot as a flat remains challenging. The relevance
of radiographic measures and flatfoot diagnosis is still under debate.[23 ]
Our radiographic assessments revealed improvement in hindfoot and midfoot parameters
over a mean follow-up period of 28 months, which is consistent with the findings of
previous studies.[19 ]
[27 ]
[28 ] The clinical outcomes were deemed satisfactory, with 90% of the patients reporting
no pain. The complication rate was 13.6%, but they were minor complications, primarily
attributed to pain that showed improvement following analgesic treatment. Our data
and complication rates are similar to those reported in other studies.[19 ]
[20 ]
[27 ]
Determining the optimal time for implant removal without compromising correction remains
uncertain in the calcaneo-stop technique. Some authors[11 ]
[29 ] suggest removal after 2 years, during which joint remodeling and proprioceptive
reflex incorporation occur. However, establishing a removal protocol in the present
study was challenging due to high hospital service demands. As a result, most of the
patients retained the implant for up to 5 years without experiencing overcorrection,
pain, or breakage. The radiographic images showed no evidence of any impression on
the talus secondary to prolonged contact at the implant interface. However, we did
not precisely evaluate this parameter due to limited symptoms.
The current study has limitations, including a restricted sample size. Moreover, we
faced challenges in quantifying the subjective and variable nature of pain and discomfort
in a pediatric population and in establishing a correlation between the radiographic
parameters and the clinical findings of the flatfoot.
Overall, our impression is that the calcaneo-stop technique seems to be an adequate
option to treat symptomatic flexible flatfoot in juvenile patients, according to major
studies.[30 ]
[31 ] It offers potential correction of the initial deformity and consistent improvement
in clinical and radiographic parameters. Furthermore, the technique can be reversed
through screw removal if necessary, and it does not compromise the use of other techniques
in cases of failure. There are still questions regarding joint remodeling and possible
long-term repercussions; however, the technique seems promising.
Bibliographical Record
