Vol 28, No 3 (2022)

CLINICAL STUDIES

Outcomes of Revision Hip Replacement After Resection Arthroplasty With a Non-Free Muscle Flap Transfer for Difficult-To-Treat Periprosthetic Infection

Liventsov V.N., Bozhkova S.A., Tikhilov R.M., Artyukh V.A.

Abstract

Background. Resection arthroplasty with non-free muscle flap transfer allows to quickly eliminate the infection, but resulting in functional impairment of hip joint. To date, there are only a few publications with a small number of observations, where the proportion of patients who underwent the second stage of the revision hip arthroplasty (rTHA) is extremely small.

The aim of the study was to evaluate the effect of resection arthroplasty on the functional outcomes and incidence of adverse outcomes in patients with difficult-to-treat (DTT) periprosthetic infection who had previously undergone resection arthroplasty with a non-free transfer of the axial flap fom the vastus lateralis muscle.

Methods. The prospective study included 24 patients. During the period 2011–2021, at the first stage of the treatment for chronic recurrent DTT PJI of the hip, resection arthroplasty was performed with a non-free transfer of an island flap from the vastus lateralis muscle. Subsequent reimplantation of the endoprosthesis was performed in at least 1 year after the infection remission. The functional outcomes, degree of the lower limb shortening immediately before and in two or more years after revision arthroplasty (rTHA), the results of the microbiological cultures at the first and second stages of PJI treatment, technical aspects of the surgery as well as the postoperative period and long-term PJI remission were studied.

Results. Revision arthroplasty resulted in a statistically significant improvement of the postoperative functional outcome and quality of life in patients. The average Harris score agter rTHA increased from 53 to 83 points after surgery, EQ-5D degree of the quality of life increased from 50 points to 80, the overall score from 0.61 to 0.74 and average intensity of pain via VAS decreased from 3 points to 1 point in 3.1 years after rTHA (p<0.05). After reEP, complete restoration of the limb length was achieved in 29.1% of cases (n = 7) with an average compensation of the limb length for 4.5 cm. In 66.7% of patients (n = 16), the results of the intraoperative tissue biopsy microbiological analysis during reEP were culture negative. The recurrence rate of PJI was 12.5% (n = 3) up to 30 days after rTHA and 4.2% (n = 1) with a follow-up period of 3.1 years (IQR 2.1–4.1). With a single revision surgery performed without a delay, stable remission of DTT PJI was 95.8%.

Conclusion. Complex two-stage surgical treatment using resection arthroplasty with a non-free muscle flap transfer at the stage of debridement and subsequent revision has demonstrated high efficiency in eliminating the infectious process as well as restoring weight-bearing capacity and extremity function. It could be recommended as a method of choice in the treatment of patients with DTT PJI of hip joint.

Traumatology and Orthopedics of Russia. 2022;28(3):5-15
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Posteromedial Approach in Fracture Fixation of Malleoli and Posterior Edge of Tibia

Belenkiy I.G., Maiorov B.A., Kochish A.Y., Sergeev G.D., Refitskii Y.V., Savello V.E., Smirnov S.S.

Abstract

Background. Surgical treatment of malleoli injuries is performed according to the principles of articular fractures management. It is particularly true for ankle injuries involving fractures of posterior edge of the tibia. The posteromedial approach enables to improve the results of surgical treatment of patients due to the direct reduction of tibia fragments.

Aim of the study — to evaluate the efficacy and advisability of the modified posteromedial approach in patients with unstable fractures of malleoli and posterior edge of the tibia.

Methods. Twenty two patients with unstable fractures of malleoli and posterior edge of the tibia underwent surgical treatment via the posteromedial approach. The X-ray control was performed the next day after the surgery as well as 6, 12, 24 and 48 weeks from the osteosynthesis. The functional results were evaluated in 12, 24 and 48 weeks after the surgery with the use of AOFAS and Neer scales.

Results. The average duration of postoperative period (9.3±3.8 days) was mainly determined by the state of the soft tissues. 91% of patients had anatomical reduction of posterior edge fragment of the tibia, 17 (77%) from 22 patients demonstrated fracture consolidation in X-rays 12 weeks after the surgery and all 22 patients (100%) 24 weeks after surgery. There were no cases of postoperative complications in patients 24 weeks after the surgery. While managing patients the range of motion in the ankle joint increased from 41.1±6.9° 12 weeks after the surgery to 57.3±4.6° 48 weeks after the surgery, that was statistically significant (p<0.01). The functional results improved as well according to both AOFAS and Neer scales and this improvement was also statistically significant (p<0.01).

Conclusion. The is rather effective in Patients with unstable fractures of malleoli and posterior edge of the tibia had a statistically significant improvement in function after posteromedial approach.

Traumatology and Orthopedics of Russia. 2022;28(3):16-28
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Trends in Revision ACL Reconstruction: Analysis of 257 Procedures

Saprykin A.S., Ryabinin M.V., Kornilov N.N.

Abstract

Background. Despite the anterior cruciate ligament reconstruction (ACL-R) is considered to be routine and successful procedure the burden of patients who needs revision surgery is growing worldwide.

Purpose — to describe the gender and social-demographic characteristics of this cohort of patients, analyze the reasons leading to revision ACL-R (re-ACL-R), estimate survival-ship of primary procedure as well as highlight clinically relative aspects of revision surgery.

Methods. The database of Vreden Orthopaedic Center for the period from 01.01.2011 to 31.12.2021 searched for patients admitted for re-ACL-R. 234 patients (257 knees) agreed to take part in the study. Patient records with surgery reports, clinical exams and PROM’s were analyzed.

Results. There was a tendency to annual increase of re-ACL-R while the time between primary and revision procedures was just 4.0 years in average. Young males dominated among re-ACL-R cohort (75.2%, 31.0 years). The acute trauma prevailed over other reasons of ACL-R failure however, it was absent in 39.1% of cases. Patients who injured performing sports were significantly younger than the rest of the cohort (p = 0.005). Allografts were the most popular choice both for first re-ACL-R (53.0%) and re-revision ACL-R (60.9%). Interestingly that majority of re-ACL-R were performed in one stage while two-staged approach implemented only in 4.3% of cases.

Conclusion. The main cause for re-ACL-R is repeated injury but significant percentage of patients develops recurrence of instability without trauma in middle-term period after ACL-R. Therefore to reduce the numbers of re-ACL-R both the proper post-op sport injury prevention program and improvement of surgical technique are of the same importance.

Traumatology and Orthopedics of Russia. 2022;28(3):29-37
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Factors Associated with Revision Surgery in Long Bones Metastases

Wang J., Kharchenko N.V., Zapirov G.M., Kaprin A.D., Bukharov A.V., Derzhavin V.A., Yadrina A.V.

Abstract

Background. Bones as an organ are one of the most common targets for tumor metastasis. Currently, the number of patients undergoing surgical treatment for metastatic bone lesions is steadily increasing. In most patients, after surgical treatment, the manifestation of clinical symptoms decreases, primarily pain syndrome, which improves their quality of life. However, it should be noted that the number of patients with bone metastases who underwent revision surgery is also increasing. This article retrospectively analyzes the factors leading to revision after surgical treatment of metastases in long bones.

The aim of this study was to identify factors leading to revision after surgical treatment of patients with metastases in long bones.

Methods. A retrospective medical records analysis of 247 patients who underwent surgical treatment for metastases in long bones on the basis of the P.A. Herzen Moscow Research Institute of Oncology in 2006–2020 was performed. Of these, 33 patients underwent revision surgery. The median age was 62 years. The localization of the primary tumor was as follows: breast cancer — 10 cases, kidney cancer — 13, lung cancer — 3, prostate cancer — 2, rectal cancer — 3, liver cancer and Ewing’s sarcoma with bone metastases — 1 case each.

Results. The following factors led to revision surgery: mistakes in preoperative diagnosis (3 patients); postoperative infectious complication (6 patients); dislocation of the endoprosthesis (4 patients); continued growth of solitary metastasis after osteosynthesis (5 cases); aseptic instability after intramedullary osteosynthesis (14 patients); traumatic fracture of the endoprosthesis stem (1 patient).

Conclusions. Revision after surgical treatment of metastases in long bones, in addition to postoperative complications, lead to mistakes in diagnosis and incorrect choice of surgical treatment method. To reduce the risk of revision surgical interventions, a multidisciplinary approach is needed with the development of surgical treatment tactics in consultation and the use of specialized scales of oncological prognosis.

Traumatology and Orthopedics of Russia. 2022;28(3):38-48
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Assessment of the Foot Donor Site Morbidity After Non-Vascularized Toe Phalanx Transfer to the Hand

Matveev P.A., Shvedovchenko I.V., Smirnova L.M., Koltsov A.A.

Abstract

Background. Non-vascularized is one of the available methods of reconstructive surgery for the treatment of the hand congenital anomalies. The the impact of toe phalanx transfer on the appearance and functionality of the donor site in the long term is relevant.

Aim of the study — an objective assessment of the appearance, shape and functional state of the foot in the long-term period after the toe phalanx transfer into defects of the fingers in congenital and obtained hand pathologies.

Methods. On the basis of the Federal Scientific Center for the Rehabilitation of the Disabled named after G.A. Albrecht 40 patients were examined, who, aged from 8 months to 11 years (in the period 2013-2022), underwent 54 toe phalanx transfer to the hand. The proximal or middle phalanx of the IV and II toes were used as a graft. To assess the condition of the feet in the long term, all patients underwent clinical and radiological studies. 12 patients aged 3 to 13 years underwent computerized plantography, podometry and barodynamoplantography.

Results. After donor feet examination in the long-term period, lots of them showed a linear shortening of the donor toes compared to the contralateral foot, which was recorded by a computer planto-podometric method for evidence. The barodinamoplantographic study did not show significant signs of a decrease in the support ability of the foot, which could be associated with non-vascularized toe phalanx transfer. When walking, there were no obvious signs of impaired motor functions of the donor foot.

Conclusion. It was objectively confirmed that the non-vascularized toe phalanx transfer to the hand does not significantly affect the shape and statodynamic function of the foot in the long-term follow-up period, despite the shortening of the donor toes.

Traumatology and Orthopedics of Russia. 2022;28(3):49-62
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CASE REPORTS

Ceramic Liner Fracture in Total Hip Arthroplasty: A Case Report

Tashtanov B.R., Korytkin A.A., Pavlov V.V., Shubnyakov I.I.

Abstract

Background. Ceramic component fracture is a severe complication of primary and revision total hip arthroplasty, leading to multiple revision surgeries.

Case report. This report of rare clinical case of ceramic liner fracture. Fifteen months after a planned left hip replacement, the patient experienced anterior surface pain in the area of the operated joint accompanied by creaking, so the patient went for a consultation. Based on the results of the consultation, the patient was urgently hospitalized and underwent a delayed surgery for revision arthroplasty. Radiologically, there was varus position of the femoral component, dislocation of the bearings. MSCT showed ceramic liner fracture and fragment dislocation. Intraoperatively, the multifragmentary fracture of the liner, significant damage to the head, and retroversion of the acetabular component (retroversion was detected on the preoperative CT scan) were identified. All components of the endoprosthesis and tribologic bearings were replaced with identical ones, total synovectomy was performed, and the wound was cleaned and sanitized.

Conclusion. The presented case report demonstrates the danger of incorrect positioning of the components when using a ceramic bearings. In this case, retroversion of the acetabular component and varus position of the femoral component resulted in a reduced contact area between the head and the liner, which caused the ceramic to fracture. The described observation confirms the need for further in-depth study of the ceramic bearings in order to prevent ceramic component fracture, as it leads to severe complications and significant economic costs.

Traumatology and Orthopedics of Russia. 2022;28(3):63-73
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Reverse Shoulder Arthroplasty After Communited Humerus Fracture: А Case Report

Frolov A.V., Logvinov A.N., Burtsev M.E., Maysigov M.N., Olchev A.A., Kadantsev P.M., Korolev A.V.

Abstract

Background. Fractures of the proximal humerus are common injury, especially among older age group patients. For the treatment of most cases, conservative tactics are required, some require surgery: osteosynthesis, arthroplasty. Proximal humerus fractures with extension to the metadiaphyseal and diaphyseal zones uncommon, and treatment of this type of injuries is complex for trauma surgeons.

The aim of the study is to demonstrate successful experience of two-stage treatment of the proximal humerus fracture with extension to the diaphysis middle third in an older age group patient.

Case presentation. The clinical case presents successful two-stage treatment of the proximal humerus fracture with extension to the middle third of the diaphysis in an older age group patient. The first stage was performed osteosynthesis of the humerus with the PHILOS Long plate, the second stage — reverse shoulder arthroplasty.

Conclusion. Consistent performing of osteosynthesis and total reverse shoulder arthroplasty allows to achieve satisfactory treatment results with restoration of the injured limb function and relief of pain syndrome.

Traumatology and Orthopedics of Russia. 2022;28(3):74-82
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REVIEW

Surgical Treatment of Congenital Radioulnar Synostosis in Children: Systematic Review

Fedorova Y.A., Vissarionov S.V., Proschenko Y.N., Gevorgiz S.A., Zakharyan E.A.

Abstract

Background. Congenital radioulnar synostosis (CRUS) may have a negative impact on the function of the upper limb and cause disability. The main aim of the surgical treatment is to correct the forearm position for diminishing functional limitations.

The study aimed to analyze the variety of surgical methods for correction of the pronation forearm deformity in children with congenital radioulnar synostosis based on the literature data.

Methods. We have searched publications in eLIBRARY, PubMed (MEDLINE), Ovid, ScienceDirect, Google Scholar databases. The analysis has included the age at surgery, indications for surgery, the target functional forearm position, the time of consolidation of the forearm bones, the frequency of neurovascular complications.

Results. Most authors considered subjective complaints as the main indication for surgical treatment, while some researchers recommended taking into account the forearm hyperpronation position. The median age of the surgical treatment was 5.17 years (3.25-9.46). The medians of the recommended forearm positions for unilateral CRUS were 0-10° of pronation for the dominant, and 0-12.5° of supination for the non-dominant limb; with bilateral cases — 0-17.5° pronation for the dominant and 0-12° supination for the non-dominant limb. Median of the osteotomy consolidation time varied from 6 to 8 weeks. The maximal time of forearm bone consolidation was significantly higher (p = 0.024) in the group with osteotomies through the synostosis site. Though the target forearm position was achieved in all cases, the number of complications in the proximal osteotomy group was statistically significantly different (p<0.01). The chances of neurovascular complications were 20.5 times higher in the group of patients who underwent osteotomy through the synostosis (95% CI: 2.7-155.6).

Conclusions. The problem of surgical treatment of children with CRUS in the world medical practice remains relevant despite the wide range of proposed methods. The development of an algorithm regarding the need for surgical treatment and its methodology requires further high-quality research.

Traumatology and Orthopedics of Russia. 2022;28(3):83-96
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Leg Length Measurement: Review

Petrova D.A., Kenis V.M.

Abstract

Background. Measurement of the length of the lower extremities is an important part of the assessment of the musculoskeletal system. If there is a discrepancy in the length of the legs, the accuracy of the measurement technique will determine the choice of further tactics for treating the patient. However, to date, there is no consensus among experts regarding the optimal and accurate method for assessing this clinical condition.

The aim is to analyze foreign and domestic researches about measurement of limb length discrepancy and to determine the optimal method for measuring the lengths of the lower extremities.

Methods. More than 70 scientific articles were selected from 1983 to 2021 in the PubMed/MEDLINE and eLIBRARY databases in Russian and English languages.

Results. An analysis of the literature data did not reveal the optimal method for measuring the length of the lower extremities. Clinical evaluation procedures have demonstrated poor reproducibility and high measurement errors. Radiation imaging techniques also have measurement errors, additionally exerting radiation exposure on the patient. Imaging techniques such as ultrasound and MRI are described in several studies, which does not allow to fully determine all the advantages and disadvantages of these methods when measuring the lengths of the lower extremities.

Conclusion. The study and development of new methods for diagnostics different lengths of the lower extremities, as well as the improvement of existing methods, will improve the quality of diagnosis of this pathological condition, and therefore affect the quality of the treatment for its correction.

Traumatology and Orthopedics of Russia. 2022;28(3):97-105
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Surgical Approaches for Acetabulum Fracture Treatment: Analytic Review

Kolesnik A.I., Donchenko S.V., Surikov V.V., Ivanov D.A., Tarasov E.P., Yarmamedov D.M., Solodilov I.M.

Abstract

Background. The use of classical and modified surgical approaches to acetabulum is accompanied by serious intra- and postoperative complications associated with tissues, vessels, nerves, and lymphatic structures injury. The choice of approach to acetabulum affects the surgical time and the blood loss volume.

The aim of the review was to compare the surgical time and blood loss volume using different surgical approaches to the acetabulum based on the relevant literature analysis.

Methods. The search was carried out in PubMed/MEDLINE and Scopus databases from 1964 to 2022. When conducting a search for the phrases acetabular fractures, surgical approach to the acetabulum, 4368 articles were found. As a result of the selection, 12 publications containing the most complete information on the studied indicators were included in the quantitative analysis.

Results. The data of surgical treatment of 540 patients with acetabulum fractures were analyzed. The average age of the patients was 45.2±11.6 years. Among the causes of pelvic and acetabulum fractures, road accident (70.4%) and falls from height (21.3%) largely prevailed. The blood loss depended on the use of specific approaches or their combination, and the surgical time. The shortest surgical time (101.0±27.0 min.) was required using pararectal approach, the longest (264±56.4 min.) — with the use of ilio-inguinal approach. The largest volume of blood loss was observed with Pfannenstiel approach — 1057.1±377.9 ml. No statistically significant differences were found when comparing the Kocher-Langenbeck (793±328 ml), ilio-inguinal (828±64 ml) and pararectal (798±322 ml) approach. Performing the Kocher-Langenbeck approach in the patient’s lateral position reduces the surgical time by 16.8% and reduces blood loss by 12.4% compared to the patient’s prone position.

Conclusion. Comparative clinical studies are required to determine the safest surgical approaches to the acetabulum, depending on the type of fracture, the mechanism of injury and the age of the patient.

Traumatology and Orthopedics of Russia. 2022;28(3):106-115
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DISCUSSIONS

Dissection and Permissible Levels of Proximal Mobilization of Anterior Tibial Vessels During Island Flaps Transfer

Kochish A.Y., Ostapchenko A.A.

Abstract

The article presents a discussion with the authors of a previously published article (Zelyanin D.A. et al. Features of the Extraction of the Anterior Tibial Vessels in the Formation of Vascularized Bone Grafts. Traumatology and Orthopedics of Russia. 2022. Vol. 28, No 1. p. 89-99), as well as on the basis of our own topographic and anatomical studies, the information about the details of the topography of the branches of the anterior tibial vascular bundle (ATVB) and the permissible levels of its proximal mobilization during island flaps transfer are justified.

Topographic and anatomical study was performed on 32 non-fixed speciments of the lower extremities for substantiating plastic surgery with island skin flaps isolated on ATVB. The arterial bed of the lower leg was injected with black natural latex Revultex, followed by precision dissection and measurements of all branches of the anterior tibial artery (ATA) with a diameter of 0.3 mm or more using a binocular magnifier with a magnification of 3.3 times. All the studied branches of ATA were identified, the number of which varied from 26 to 49 (on average 38.5–3.2), and 88.7% of them went to the three muscles of the anterior group of the lower leg. At the same time, the average numbers of ATA branches departing in each of the 10% intervals of the length of the lower leg were determined, and the average total values of the cross-sectional area of arterial branches in these intervals were calculated. It was found that from 28% to 39% of the total cross-section of all branches of the ATA are localized in the first and second 10% intervals of the length of the lower leg, which makes it possible to justify the proximal limit of the mobilization of the ATVB. Reasonable criteria for choosing the level of proximal mobilization of the ATVB are: the location of the mobilization border is not higher than the level of the upper 20% of the length of the lower leg, the assignment of this border, at least 6 cm distal from the exit of the anterior tibial vessels into the anterior bone fascial sheath of the lower leg and the preservation of at least four feeding vascular bundles extending from the ATVB to the tibialis anterior muscle (two bundles) and to the extensor digitorum longus muscle (two bundles).

Traumatology and Orthopedics of Russia. 2022;28(3):116-122
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ДЛЯ ПРАКТИЧЕСКИХ ВРАЧЕЙ

Diagnosis of Deep Periprosthetic Infection of the Hip

Murylev V.Y., Rudnev A.I., Kukovenko G.A., Elizarov P.M., Muzychenkov A.V., Alekseev S.S.

Abstract

Periprosthetic infection (PJI) is one of the most frequent and devastating complications of total hip arthroplasty (THA). Early and accurate diagnosis of PJI allows timely initiation of treatment. Various diagnostic tools and algorithms for hip PJI diagnosis are described. The available serum (ESR, CRP, D-dimer, etc.) and synovial (alpha-defensin, leukocyte esterase, D-lactate) biomarkers are listed, as well as their combinations for the purpose of PJI verification. Combined serum and synovial tests can significantly improve the efficiency of PJI hip diagnosis.

Traumatology and Orthopedics of Russia. 2022;28(3):123-135
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Prevention, Diagnosis and Treatment of Thromboembolic Complications in Traumatology and Orthopedics: Methodological Guidelines

Bozhkova S.A., Tikhilov R.M., Andriyashkin V.V., Akhtyamov I.F., Belov M.V., Dianov S.V., Kasimova A.R., Kaplunov O.A., Kopenkin S.S., Malanin D.A., Mushtin N.E., Tsed A.N.

Abstract

The guidelines describe modern approaches to the prevention, diagnosis, and treatment of thromboembolic complications in patients with injuries and after musculoskeletal surgery, in accordance with the interdisciplinary draft of the Clinical Guidelines (2022) “Deep vein thrombosis of the extremities”, which has passed public hearings and is being approved by the Russian Ministry of Health. The guidelines are designed for doctors of various specialties to provide medical care to specialized patients: orthopedic surgeons, anesthesiologists, resuscitators, clinical pharmacologists, health care organizers, medical students, residents, graduate students.

Traumatology and Orthopedics of Russia. 2022;28(3):136-166
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HISTORY OF MEDICINE

Rozov and Kessler Tendon Sutures: Common Properties and Differences

Berezin P.A., Zolotov A.S., Volykhin R.D., Evdokimova E.N., Morozov L.I., Lazarev I.A.

Abstract

Background. The Kessler suture is one of the most common tendon repair techniques and can be found schematically in most manuals of hand surgery, along with Bunnel and Tsuge sutures. In our country, the seam proposed by V.I. Rozov, while a number of authors believe that Rozov and Kessler sutures are very similar. Both techniques, both the Rozov’s suture and the Kessler suture, have a large number of modifications that differ significantly from the originals, but retain the author’s names, which confuses and hinders the analysis of the use of various methods for restoring the integrity of the tendons.

The aim — to find the correct author’s description of Rozov’s suture and Kessler’s suture, test original techniques on a tendon model, compare techniques, analyze common properties and differences.

Methods. Information was searched in domestic and foreign publications, manuals on traumatology and orthopedics, monographs, methodical letters, materials of congresses, Internet resources. Approbation of the methods was carried out on a tendon model, which was a silicone rod with a diameter of 1 cm.

Results. The first image of the Rozov’s suture discovered by us, dates back to 1958, the original “grasping” technique of flexor tendon repair was proposed by I. Kessler in 1969. These techniques have a number of significant differences in the location of nodes, methods of fixation and planes of threads in the thickness of the tendon.

Conclusion. The data of this study give reason to believe that V.I. Rozov and I. Kessler proposed two different ways of applying a tendon suture.

Traumatology and Orthopedics of Russia. 2022;28(3):167-175
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