Radiological Assessment and Planning of Deformities

Volume 10 | Issue 2 | May-August 2024 | Page: 12-17 | Sudhanshu Bansal, Gaurav Gupta, Deepak Khurana 

DOI- https://doi.org/10.13107/ijpo.2024.v10.i02.184

Submitted: 05/03/2024; Reviewed: 02/04/2024; Accepted: 15/05/2024; Published: 10/08/2024

Authors: Sudhanshu Bansal MS Ortho [1], Gaurav Gupta MS Ortho [2], Deepak Khurana MS Ortho [3]

[1] Department of Paediatric Orthopaedic Surgery, CODS Clinic, Ludhiana, Amandeep Hospital, Amritsar, Punjab, India.
[2] Department of Paediatric Orthopaedic Surgery, Child Ortho Clinic, Delhi-NCR, India.
[3] Department of Paediatric Orthopaedic Surgery, JCPODS, Jeevan Rekha hospital, Jaipur, Rajasthan, India.

Address of Correspondence

Dr. Sudhanshu Bansal,
Consultant, Paediatric Orthopaedic Surgeon, CODS Clinic, Ludhiana, Amandeep Hospital, Amritsar, Punjab, India.
E-mail: drbansalsudhanshu@gmail.com

Abstract

Deformity correction is a fundamental aspect of orthopedic surgery, requiring a precise radiological assessment and systematic planning. This article provides an indepth overview of the radiological modalities available for deformity assessment, including X-rays, scannograms, computed tomography (CT), and magnetic resonance imaging (MRI). Proper radiographic techniques, such as standing fulllength X-rays and scannograms, are critical for accurate limb alignment assessment. Advanced imaging modalities, including CT and MRI, are necessary in cases of complex deformities or rotational abnormalities. Furthermore, various software applications are available for preoperative deformity planning, enabling precise correction strategies. This article also addresses approaches for managing deformities in limited-resource settings, emphasizing cost-effective and accessible imaging techniques. The objective is to enhance clinical decisionmaking and optimize surgical outcomes in deformity management.
Keywords: Alignment, Anatomic tibiofemoral angle, Deformity, Knee, Lower limb alignment, Mechanical axis angle, Radiography

References

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12. Solomin, L.N.; Utekhin, A.I.; Vilenskiy, V.A. Reference values of the femur and tibia mechanical axes and angles in the sagittal plane, determined on the basis of three-dimensional modeling. J. Limb Lengthen Reconstr. 2020, 6, 116–120. 
13. Guggenberger, R.; Pfirrmann, C.W.; Koch, P.P.; Buck, F.M. Assessment of lower limb length and alignment by biplanar linear radiography: Comparison with supine CT and upright fulllength radiography. AJR Am. J. Roentgenol. 2014, 202, W161–W167 
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15. Ahrend, M.D.; Baumgartner, H.; Ihle, C.; Histing, T.; Schröter, S.; Finger, F. Influence of axial limb rotation on radiographic lower limb alignment: A systematic review. Arch. Orthop. Trauma Surg. 2022, 142, 3349–3366. 
16. Buck FM, Guggenberger R, Koch pp, Pfirrmann CWA. Femoral and tibial torsion measurements with 3D models based on low-dose biplanar radiographs in comparison with standard CT measurements. AJR Am J Roentgenol 2012;199:W607–W612.
17. Kuiper, R.J.A.; Seevinck, P.R.; Viergever, M.A.; Weinans, H.; Sakkers, R.J.B. Automatic Assessment of Lower-Limb Alignment from Computed Tomography. J. Bone Jt. Surg. Am. 2023, 105, 700–712. 
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How to Cite this Article:  Bansal S, Gupta G, Khurana D | Radiological Assessment and Planning of Deformities | International Journal of Paediatric Orthopaedics | May-August 2024; 10(2): 12-17. https://doi.org/10.13107/ijpo.2024.v10.i02.184

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Basics of Paediatric Limb Reconstruction Surgeries

Volume 10 | Issue 2 | May-August 2024 | Page: 2-11 | Prateek Rastogi, Nitish Arora, Yogesh Patel 

DOI- https://doi.org/10.13107/ijpo.2024.v10.i02.182

Submitted: 18/05/2024; Reviewed: 14/06/2024; Accepted: 19/07/2024; Published: 10/08/2024

Authors: Prateek Rastogi MS Ortho [1], Nitish Arora MS Ortho [2], Yogesh Patel MS Ortho [3]

[1] Department of Orthopaedics, Sharda Hospital, Greater Noida, Uttar Pradesh, India.
[2] Department of Orthopaedics, Medicover Hospital, Khargar, Navi Mumbai, Maharashtra, India.
[3] Department of Orthopaedics, Sagar Multispeciality Hospital, Bhopal, Madhya Pradesh, India.

Address of Correspondence

Dr. Prateek Rastogi,
Paediatric Orthopaedics and Limb Reconstruction Surgeon, Department of Orthopaedics, Sharda Hospital, Greater Noida, Uttar Pradesh, India.
E-mail: prateek.rastogi12@gmail.com

Abstract

Paediatric limb reconstruction surgeries play a pivotal role in managing congenital and acquired deformities, limb length discrepancies, and complex musculoskeletal disorders in children. These procedures aim to restore alignment, function, and length while preserving growth potential and minimizing long-term disability. Unlike adult cases, paediatric reconstructions demand unique considerations due to ongoing skeletal development, necessitating precise planning to avoid growth plate damage. This review outlines the evolving indications for reconstruction—including congenital conditions like various hemimelia and bony deficiency, as well as acquired deformities from trauma, infection, and tumors. Foundational principles such as anatomical and mechanical axes and their deviation, CORA (Center of Rotation of Angulation), and ACA (Angulation Correction Axis) are discussed alongside osteotomy planning and execution. Techniques of gradual deformity correction such as growth modulation, and distraction osteogenesis are examined in depth, highlighting the roles of devices like Ilizarov fixators, hexapods, and intramedullary lengthening nails. Recent advancements in imaging, surgical planning, and implant design have significantly improved outcomes, although complications such as joint stiffness, infection, and secondary deformities persist. With increasing precision and a growing array of tools, paediatric limb reconstruction continues to evolve, offering promising outcomes and functional restoration to affected children.
Keywords: Paediatric limb reconstruction, Deformity Correction, Limb Lengthening, Growth Modulation, Distraction Osteogenesis, Osteotomy Techniques

References

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12. Boero S, Riganti S, Marrè Brunenghi G, Nasto LA. Hexapod External Fixators in Paediatric Deformities. In: Massobrio M, Mora R, eds. Hexapod External Fixator Systems. Springer International Publishing; 2021:133-152. doi:10.1007/978-3-030-40667-7_8
13. Georgiadis AG, Rossow JK, Laine JC, Iobst CA, Dahl MT. Plate-assisted Lengthening of the Femur and Tibia in Pediatric Patients. Journal of Pediatric Orthopaedics. 2017;37(7):473-478. doi:10.1097/BPO.0000000000000645
14. Iobst C. Advances in Pediatric Limb Lengthening: Part 1. JBJS Rev. 2015;3(8). doi:10.2106/JBJS.RVW.N.00101
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16. Paley D. Problems, obstacles, and complications of limb lengthening by the Ilizarov technique. Clin Orthop Relat Res. 1990;(250):81-104.
17. Shabtai L, Specht SC, Standard SC, Herzenberg JE. Internal Lengthening Device for Congenital Femoral Deficiency and Fibular Hemimelia. Clin Orthop Relat Res. 2014;472(12):3860-3868. doi:10.1007/s11999-014-3572-3
18. Fuller CB, Shannon CE, Paley D. Lengthening Reconstruction Surgery for Fibular Hemimelia: A Review. Children (Basel). 2021;8(6):467. doi:10.3390/children8060467
19. Chong DY, Paley D. Deformity Reconstruction Surgery for Tibial Hemimelia. Children (Basel). 2021;8(6):461. doi:10.3390/children8060461
20. Paley D. Paley Cross-Union Protocol for Treatment of Congenital Pseudarthrosis of the Tibia. Operative Techniques in Orthopaedics. 2021;31(2):100881. doi:10.1016/j.oto.2021.100881
21. Gaber K, Mir B, Shehab M, Kishta W. Updates in the Surgical Management of Recurrent Clubfoot Deformity: a Scoping Review. Curr Rev Musculoskelet Med. 2022;15(2):75-81. doi:10.1007/s12178-022-09739-6
22. Qin S, Zang J, Wang Y, Jiao S, Qin X, Pan Q. Traumatic Sequelae of Lower Limb. In: Qin S, Zang J, Jiao S, Pan Q, eds. Lower Limb Deformities. Springer Singapore; 2020:433-470. doi:10.1007/978-981-13-9604-5_10
23. Belthur MV, Esparza M, Fernandes JA, Chaudhary MM. Post Infective Deformities: Strategies for Limb Reconstruction. In: Belthur MV, Ranade AS, Herman MJ, Fernandes JA, eds. Pediatric Musculoskeletal Infections. Springer International Publishing; 2022:411-493. doi:10.1007/978-3-030-95794-0_23
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How to Cite this Article:  Rastogi P, Arora N, Patel Y| Basics of Paediatric Limb Reconstruction Surgeries| International Journal of Paediatric Orthopaedics | May-August 2024; 10(2): 02-11. https://doi.org/10.13107/ijpo.2024.v10.i02.182

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Editorial

Volume 10 | Issue 2 | May-August 2024 | Page: 01 | Jayanth S. Sampath

DOI- https://doi.org/10.13107/ijpo.2024.v10.i02.180

Authors: Jayanth S. Sampath FRCSEd (Tr & Orth) [1]

[1] Department of Orthopaedics, Rainbow Children’s Hospital, Bangalore, Karnataka, India.

Address of Correspondence

Dr. Jayanth S. Sampath,
Rainbow Children’s Hospital, Bangalore, Karnataka, India.
E-mail: editor.posi.ijpo@gmail.com

Editorial

Limb reconstruction surgery in children has evolved into the treatment of choice for complex deformities of the limb and foot. The power of gradual correction with stable fixation devices of varying complexity have overcome the limitations of traditional open surgery. It is an important and potent skill in the hands of the paediatric orthopaedic surgeon.
This issue of IJPO presents an overview of the principles and practice in modern limb reconstruction surgery. We start with an article on basic deformity correction principles followed by a detailed description of radiological assessment of deformity. The subsequent articles provide a comprehensive overview of the management of Blount disease, hip instability, complex foot deformities, arthrogryposis and limb deficiencies. We are proud that the authors are from institutions across the world, each offering a unique perspective to the management of these difficult problems. Please share the articles with your trainees and fellows. IJPO issues are easily downloadable free of charge and in full-text format from our website www.ijpoonline.com
We invite your suggestions and comments for any improvements to the journal. Kindly write to us editor.ijpo@gmail.com or editor@posi.org.in
It is my pleasure to acknowledge the contributions of authors, reviewers, editors, and the backend team who have been instrumental in bringing out this issue. The cover page artwork by Dr Easwar T R, POSI Webmaster illustrates the correction of a child with tibia vara using an external fixator. It emphasises that the most successful treatments in our armamentarium are not necessarily complicated but are based on a firm understanding of the pathological anatomy of deformity and the application of a standardised method in practice.

Sincerely


Dr Jayanth S Sampath
Editor,

International Journal of Paediatric Orthopaedics

 

 

How to Cite this Article:  Sampat JS | Editorial | International Journal of Paediatric Orthopaedics | May-August 2024;10(2): 01. https://doi.org/10.13107/ijpo.2024.v10.i02.180

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Management of Hip Instability in Children

Volume 10 | Issue 2 | May-August 2024 | Page: 18-23 | Parmanand Gupta, Deepak Kumar

DOI- https://doi.org/10.13107/ijpo.2024.v10.i02.186

Submitted: 02/06/2024; Reviewed: 26/06/2024; Accepted: 16/07/2024; Published: 10/08/2024

Authors: Parmanand Gupta MS Ortho [1], Deepak Kumar MS Ortho [1]

[1] Department of Orthopaedics, Government Medical College and Hospital, Chandigarh, India.

Address of Correspondence

Dr. Parmanand Gupta,
Department of Orthopaedics, Government Medical College and Hospital, Chandigarh, India.
E-mail: drpgupta123@gmail.com

Abstract

Post septic resorption and neglected hip dislocation due to hip dysplasia are the common causes of hip instability in children. The goal in such cases is to create a joint which is stable, painless and mobile hip and mimics the function of the original hip. Hip arthrodesis takes away the mobility of the hip whereas excision arthroplasty of the femoral head only addresses pain but not instability. Pelvic Support Osteotomy overcomes these limitations and addresses pain, instability as well as limp. A big drawback of this procedure remains failure to address limb length discrepancy as well as valgus at the knee. Adding a second osteotomy to the distal femoral shaft region addresses the problem of shortening as well as valgus malalignment of the limb resulting from the pelvic support osteotomy component. This procedure should preferably be performed in a child older than 12 years as doing it prior to this age often results in remodeling at the osteotomy site, thereby leading to less than optimal results with passage of time.
Keywords: Hip instability, Pelvic support osteotomy, Ilizarov HipConstruction

References

1. Garrett JC, Epstein HC, Harris WH, Harvey JP Jr, Nickel VL. Treatment of unreduced traumatic posterior dislocations of the hip. J Bone Joint Surg Am. 1979 Jan;61(1):2-6. PMID: 759430.
2. Hartofilakidis G, Stamos K, Karachalios T, Ioannidis TT, Zacharakis N (1996) Congenital hip disease in adults. Classification of acetabular deficiencies and operative treatment with acetabuloplasty combined with total hip arthroplasty. J Bone Joint Surg Am 78:683–692
3. Vaquero-Picado A, Gonzalez-Moran G, Garay EG, Moraleda L (2019) Developmental dysplasia of the hip: update of management. Efort Open Rev 4:548–556
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5. Kim Y-J, Mamisch TC, editors. Hip magnetic resonance imaging. New York, NY: Springer; 2016.
6. Choi IH, Shin YW, Chung CY, et al. Surgical treatment of the severe sequelae of infantile septic arthritis of the hip. Clin Orthop Relat Res. 2005;434:102–109.
7. MacKenzie JR, Kelley SS, Johnston RC (1996) Total hip replacement for coxarthrosis secondary to congenital dysplasia and dislocation of the hip Long-term results. J Bone Joint Surg Am 78(1):55–61
8. Hallel T, Salvati EA. Septic arthritis of the hip in infancy: end result study. Clin Orthop. 1978;132:115-28.
9. Milch H (1941) The ‘pelvic support’ osteotomy. J Bone Joint Surg Am 23(3):581–595
10. Kadykalo OA, Kuftyev LM. Some biomechanical principles of the hip reconstruction with defect on head and neck of the femur by Ilizarov method. The Value of General Biological Patterns in Regeneration Tissue Opened by G.A. Ilizarov. Kurgan All-Union Scientific Center: Rehabilitation Traumatology and Orthopaedics; 1988:124–129.
11. Rozbruch SR, Paley D, Bhave A, et al. Ilizarov hip reconstruction for the late sequelae of infantile hip infection. J Bone Joint Surg Am. 2005;87-A:1007–1018.
12. Krieg AH, Lenze U, Hasler CC. Ilizarov hip reconstruction without external fixation: a new technique. J Child Orthop. 2010;4(3):259-266.
13. Pafilas D, Nayagam S. The pelvic support osteotomy: indications and preoperative planning. Strategies trauma limb reconstruction.2008;3(2):83-92.
14. Saleh M, Milne A (1994) Weight-bearing parallel-beam scenography for the measurement of leg length and joint alignment. J Bone Joint Surg Br 76(1):156–157
15. Choi IH, Cho TJ, Yoo WJ, Shin CH. Recurrent dislocations and complete necrosis: the role of pelvic support osteotomy. J Pediatr Orthop. 2013 Jul-Aug;33 Suppl 1:S45-55
16. Paley D. Hip joint considerations. Principles of Deformity Correction. Heidelberg: Springer-Verlag; 2002:647–694.
17. Hosny GA, Ahmed A. Is arthroplasty inevitable after Ilizarov hip reconstruction of unstable hip joints in adolescents and young adults? Long-Term Evaluation of 136 Cases. Genij Ortopedii, Vol. 27 (3), 2021.
18. Sabharwal S, Macleod R. Ilizarov hip reconstruction for the management of advanced osteonecrosis in an adolescent with leukemia. J Pediatr Orthop B. 2012;21:252–259.
19. El-Mowafi H. Outcome of pelvic support osteotomy with the Ilizarov method in the treatment of the unstable hip joint. Acta Orthop Belg. 2005 Dec;71(6):686-91.
20. Huang Y, Xie H, Yi J, Yang M, Kong X, Chai W. Is PSO suitable for high riding dysplasias? Int Orthop. 2024 Apr 15.
21. Shetty GM, Song HR, Lee SH, Kim TY. Bilateral valgus-extension osteotomy of hip using hybrid external fixator in spondyloepiphyseal dysplasia: early results of a salvage procedure. J Pediatr Orthop B. 2008 Jan;17(1):21-5.

How to Cite this Article:  Gupta P, Kumar D | Management of Hip Instability in Children| International Journal of Paediatric Orthopaedics | May-August 2024; 10(2): 18-23. https://doi.org/10.13107/ijpo.2024.v10.i02.186

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Blount’s Disease: Review Article

Volume 10 | Issue 2 | May-August 2024 | Page: 24-33 | Yashwant Singh Tanwar, Sirazul Haque Malik, Karolina Siwicka, Nando Ferreira, Pieter Herman Maré 

DOI- https://doi.org/10.13107/ijpo.2024.v10.i02.188

Submitted: 02/05/2024; Reviewed: 29/05/2024; Accepted: 21/06/2024; Published: 10/08/2024

Authors: Sudhanshu Yashwant Singh Tanwar MS Ortho., DNB, MRCS [1], Sirazul Haque Malik MS Ortho. [2], Karolina Siwicka MD, PhD (T & O) [3], Nando Ferreira FC Orth (SA), MMed (Orth), PhD [3], Pieter Herman Maré FC Orth (SA), PhD [4]
[1] Department of Orthopedics, Indraprastha Apollo Hospital, New Delhi, India.
[2] Department of Orthopedics, Himalayan Institute of Medical Sciences, Swami Rama Himalayan University, Jollygrant, Uttarakhand, India.
[3] Division of Orthopedics, Department of Surgical Sciences, Faculty of Medicine and Health Sciences, Tygerberg Hospital, Stellenbosch University, Cape Town, 7505, South Africa.
[4] Paediatric Orthopaedics Unit, Grey’s Hospital, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Pietermaritzburg, South Africa.

Address of Correspondence

Dr. Yashwant Singh Tanwar
Department of Orthopedics, Indraprastha Apollo Hospital, New Delhi, India.
E-mail: tanwar_yashwant@yahoo.co.in

Abstract

Blount’s disease, or non-physiological idiopathic tibia vara, is a growth disturbance affecting the medial proximal tibial physis, leading to a progressive three-dimensional deformity characterized by varus, procurvatum, and internal rotation. While its precise etiology remains unclear, the condition has been closely linked to obesity, mechanical stress, and potential genetic predisposition. Infantile Blount’s typically presents between one and three years of age, often bilaterally, whereas late-onset forms occur in juveniles (4–10 years) or adolescents (>10 years) and are more commonly unilateral. Early differentiation from physiological bowing is essential, as untreated disease results in progressive deformity and joint instability.
Radiographic evaluation is critical in confirming the diagnosis and planning treatment. Key parameters, including the meta-diaphyseal (Drennan) angle, medial metaphyseal beak angle, and mechanical tibiofemoral axis deviation, provide objective measures to distinguish Blount’s disease from other causes of genu varum. Medial tibial plateau depression, best assessed using an arthrogram, is a key determinant in surgical planning, particularly in advanced cases.
Management strategies depend on the stage and severity of the disease. In early stages, guided growth using tension-band plating may modulate physeal development and prevent progression. However, in advanced or recurrent cases, surgical correction is required. Metaphyseal osteotomy, with or without internal fixation, remains the mainstay of treatment. In cases with significant medial plateau depression, a medial hemiplateau elevation osteotomy is indicated to restore joint congruency and knee stability. Severe or late-presenting cases may necessitate double osteotomy techniques, combining joint line realignment with metaphyseal correction. Acute correction methods, including oblique and dome osteotomies, are effective but carry risks of neurovascular compromise. In cases of complex multiplanar deformity, gradual correction using circular external fixation offers precise correction while minimizing complications.
Despite surgical intervention, recurrence remains a concern, particularly in cases with persistent medial physeal slope abnormalities. Strategies such as prophylactic lateral tibial and fibular epiphysiodesis, as well as controlled overcorrection, have been proposed to minimize recurrence risk. Perioperative considerations, including prophylactic fasciotomy and careful fibular osteotomy placement, play a role in preventing complications such as compartment syndrome and peroneal nerve palsy.
Blount’s disease is a progressive condition requiring early diagnosis and timely intervention to prevent long-term morbidity. A structured approach, incorporating clinical assessment, radiographic analysis, and stage-specific management, is essential to optimize outcomes. While current surgical techniques provide reliable correction, ongoing research into the pathophysiology and treatment of Blount’s disease remains essential to improving long-term prognosis.
Keywords: Blount’s disease, Infantile tibia vara, Adolescent tibia vara

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How to Cite this Article:  Tanwar YS, Malik SH, Siwicka K, Ferreira N, Maré PH | Blount’s Disease: Review Article | International Journal of Paediatric Orthopaedics | May-August 2024; 10(2): 24-33. https://doi.org/10.13107/ijpo.2024.v10.i02.188

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Understanding the Biomechanics of Lever Arm Disorders in Cerebral Palsy

Volume 10 | Issue 1 | January-April 2024 | Page: 09-13 | Jayanth Sampath, Taral Nagda

DOI- https://doi.org/10.13107/ijpo.2024.v10i01.172

Submitted: 01/02/2024; Reviewed: 14/02/2024; Accepted: 18/03/2024; Published: 10/04/2024

Authors: Jayanth Sampath MS Ortho [1], Taral Nagda MS Ortho [2]

[1] Department of Paediatric Orthopaedics, Rainbow Children’s Hospital, Bangalore, Karnataka, India.
[2] Department of Paediatric Orthopaedics, SRCC NH Children’s Hospital, Mumbai, Maharashtra, India

Address of Correspondence

Dr. Jayanth S. Sampath,
Rainbow Children’s Hospital, Bangalore, Karnataka, India.
E-mail: jayanthdoc@gmail.com

Abstract

Levers in the human body play an important role in facilitating efficient movement. Muscle forces act around the axis of movement of adjacent joints. The normal moment of a joint (M) is the product of the muscle force (F) and the length of lever arm (d). The primary neurological insult in cerebral palsy (CP) causes shortening of muscles, joint contractures, and torsional abnormalities in bones. The resulting ineffective lever arm leads to a failure to produce an appropriate torque and subsequent gait abnormalities. Therefore, the effects of lever arm dysfunction should be considered when gait improvement surgery is being offered to children with CP. This review will explain the role of levers in normal human biomechanics and the significance of lever arm dysfunction in the management of CP.
Keywords: Biomechanics, Lever arm, Disorder, Cerebral palsy

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How to Cite this Article:  Sampath J, Nagda T | Understanding the Biomechanics of Lever Arm Disorders in Cerebral Palsy | International Journal of Paediatric Orthopaedics | January-April 2024; 10(1): 09-13 . https://doi.org/10.13107/ijpo.2024.v10i01.172

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