대한족부족관절학회지 : 제 12 권제 1 호 2008 J Korean Foot Ankle Soc. Vol. 12. No. 1. pp.66-73, 2008 건국대학교의학전문대학원정형외과학교실, 단국대학교의과대학정형외과학교실 * 정홍근 박신형 유현열 * 유문집 * Tibio-talo-calcaneal Arthrodesis with Multiple Cannulated Screw Fixation Hong-Geun Jung, M.D., Ph.D., Shin-Hyung Park, M.D., Hyun-Yul Yoo, M.D.*, Moon-Jib Yoo, M.D., Ph.D.* Department of Orthopedic Surgery, Konkuk University School of Medicine, Seoul, Korea, Department of Orthopedic Surgery, Dankook University College of Medicine, Cheonan, Korea* =Abstract= Purpose: To report the clinical results of tibio-talo-calcaneal arthrodesis fixed with multiple s for the cases of painful ankle and hindfoot arthropathy regardless of any or instability. Materials and Methods: A retrospective analysis was performed upon 10 patients that underwent tibio-talo-calcaneal arthrodesis from October 1999 to May 2006. There were 4 males and 6 females, with an average age of 63 years (43-70). The etioloty of arthrodesis included 5 osteoarthritis, 2 Charcot joints, 1 rheumatoid arthritis, 1 Tbc arthritis and 1 residual poliomyelitis. Chief complaints were pain in 9 cases and instability in 1 case. Three patients had combined severe varus. Tibio-talo-calcaneal arthrodesis using multiple s was performed by transfibular approach for all cases and short leg cast was applied for 12 weeks postoperatively. Results: The average follow-up period was 16.5 months (12-26 months). VAS pain score was average 8.2 (7-10) and modified AOFAS score was average 25 (8-40, total 86) preoperatively. At final follow-up, VAS score was average 1.0 (0-3) and AOFAS score improved to average 66 (58-75). There were 4 complications: 2 nonunion, 1 tibia stress fracture and 1 malunion. Seven of 8 patients were satisfied with the results at final follow-up. Conclusion: Fixation with multiple s for tibio-talo-calcaneal arthrodesis through transfibular approach is a recommendable surgical option. Key Words: Tibio-talo-calcaneal joint, Arthrodesis, Multiple fixation Address for correspondence Hong-Geun, Jung, M.D., Ph.D. Department of Orthopedic of Surgery, Konkuk University School of Medicine, 4-12 Hwayang-dong, Gwangjin-gu, Seoul, 143-729, Korea Tel: +82-2-2030-7609 Fax: +82-2-2030-7369 E-mail: jungfoot@hanmail.net, jungfoot@kuh.ac.kr * 본논문의요지는 2007년대한족부족관절학회추계학술대회에서구연되었음. 서론 1882년 Albert 2) 에의해처음족관절고정술이보고된이래족관절및후족부의관절염또는마비성질환에의해통증, 변형이나불안정성등이발생하는경우관절고정술이시행되고있다. 족관절과후족부에심한관절염과함께심한변형이있는경우에는절단술의유일한대안으로경골- 거골-종골간관절유합술이시행되고있다. 이는족관절및 - 66 -
후족부변형을교정하고안정화시키며통증을줄여보행이가능하도록하는데목적이있다. 관절고정의방법으로는크게대량의골절제후외고정장치를이용하는방법 3,9,29) 과골이식과내고정을이용하는방법 5,7,12,15,21,23) 등이있다. 이제까지알려진내고정수단으로는금속강선 25), 금속나사 4,6), 금속정 8,14,31) 등이이용되어왔으나, 유관압박나사 10,17,33) 를이용한내고정술은좁은면적의관절을여러개의나사로써가장적절한위치에서견고하게고정할수있는장점이있다 4,5,15). 현재족관절과거골하관절유합술에대한유관압박나사를이용한관절유합술의결과는많이보고되었으나 10,18) 유관압박나사를이용한경골-거골-종골간관절유합술에대한결과보고는거의없는상태이다. 본저자들은유관압박나사를이용한경골 -거골- 종골간관절유합술을시행하여만족할만한결과를얻었기에이에대해보고하고자한다. 1. 연구대상 대상및방법 본연구는 1999년 10월부터 2006 년 5월까지족관절및후족부의통증을동반한심한관절염, 내외반변형이나관절불안정성등의이유로본원에내원한환자중인대재건술이나단일족관절이나거골하관절고정술로교정이불가능하여경골-거골 -종골간관절고정술을시행한총 11예중다발성유관나사를이용하여고정한 10예를대상으로하였다. 모든예에서평균추시기간은 16.5 개월 (12-26개월 ) 이었으며수술시평균나이는 63세 (43-70 세 ), 성별은남, 여가각각 4, 6명이었다. 좌우측모두 5예로좌, 우의발생빈도의차이는보이지않았다. 원인질환으로는골관절염이 5예로가장많았고, 샤코씨관절증이 2예, 류마티스관절염, 결핵성관절염과소아마비가각각 1예씩이었다. 골관절염환자는모두외상과관련된관절염이었다. 내원당시환자의주소는통증이 9예, 불안정증이 1예이었고, 심한후족부내반변형과마비성후족부외반변형이각각 3예및 1예에서동반되었다 (Table 1). 켰다 (Fig. 1). 노출된원위비골은관절고정후이식골편으로사용하기위해비구확공기를사용하여비골원위골편일부를분쇄하였다. 원위비골은말단으로부터약 7 cm 근위부에서사선형절골술을시행제거하여족관절, 거골하관절을노출시켰다. 족관절고정술시변형이심하지않은경우에는원위경골과거골체의관절연골을절골도 (osteotome) 를사용하여제거한후고정토록하고, 변형이심한경우에는원위경골과거골체에절골도를사용하여절골한후절골면을고정하였다. 또한거골하관절에대해서도같은방법으로관절연골을절골도를이용하여제거하였다. 경골-거골-종골간관절을 5.0 mm, 6.5 mm 또는 7.0 mm 크기의유관나사를 3-5 개이용하여고정하였으며, 비골에서채취한자가골편을관절주변및관절내에이식하였다. 경골-거골-종골간관절고정술후약 12주간단하지석고붕대를이용한고정을시행하였고첫 6주간은비체중부하를시행하였으며다음 6주간은부분적체중부하를허용하였다. 또한추시관찰중골유합소견관찰시에는전체중부하보행을허용하였으며족관절관절범위운동을시행하였다. 그러나샤코씨관절증경우에는수술후석고붕대고정및체중부하기간을두배로길게시행하였다. 3. 평가방법환자의전반적인기능적평가에는미국정형외과족부족관절학회족관절-후족부기능평가기준 (American Orthopaedic Foot and Ankle Society Ankle-Hindfoot Functional Scale, AOFAS), 시각상사척도동통점수 (Visual Analogue Scale Pain Score), 술후직장복귀여부와시기, 2. 수술방법및술후처치 환자를전신마취나척추마취후측와위에두고족관절외과를중심으로근위부로약 10 cm, 원위부는족근동을향해약 5 cm의피부절개를가한후전층피부판을견인하여족관절외과를포함한원위비골약 7 cm을노출시 Figure 1. Intraoperative photograph of the transfibular lateral approach exposing the ankle and subtalar joint. - 67 -
Table 1. Summary of Tibio-talo-calcaneal Arthrodesis Patients No* Sex (M/F ) Age Diagnosis Rt/Lt Chief complaint 1 M 60 Ankle-subtalar osteoarthritis 2 M 53 Charcot joint with ankle fracture-dislocation 3 M 64 Ankle-subtalar osteoarthritis 4 F 62 Charcot joint with ankle fracture and dislocation 5 M 70 Rheumatoid arthritis 6 F 49 Tuberculous arthritis 7 F 69 Ankle-subtalar osteoarthritis 8 F 44 Ankle osteoarthritis cavovarus 9 F 57 Ankle-subtalar osteoarthritis 10 F 43 Residual poliomyelitis with cavo-valgus Fixation method Rt Pain Multiple Rt Pain Multiple Rt Pain Multiple Lt Pain Multiple Lt Pain Multiple Rt Pain Multiple Lt Pain + varus Rt Pain + varus Lt Pain + varus Multiple Multiple Multiple Lt Instability Multiple No of used screw Follow-up period (months) AOFAS VAS** Preop Postop Preop Final followup Total Total Pain Function Alignment Complication Satisfaction 4 14 12 40 20 15 5 9 5 Infection Poor 4 20 32 64 30 24 10 10 3 Nonunion Good 3 23 39 73 40 23 10 7 0 Excellent 5 7 15 76 40 26 10 8 0 Tibia stress Fracture Excellent 4 6 25 68 30 28 10 7 0 Good 4 25 32 75 40 25 10 8 0 Good 4 19 24 66 30 26 10 9 1 Nonunion Good 5 13 40 73 40 23 10 9 0 Excellent 3 26 8 58 30 23 5 10 1 Valgus Excellent 4 12 23 67 30 27 10 7 0 Malunion Excellent *No, Number; M/F, Male/Female; Rt/Lt, Right/Left; AOFAS, American Orthopaedic Foot and Ankle Society Ankle-Hindfoot functional Scale; Preop, Preoperative; Postop, Postoperative; **VAS, Visual Analogue Scale.
A B Figure 2. (A) Preoperative radiographs of the 57 year-old female showed ankle and subtalar osteoarthritis with severe varus. (B) Postoperative 27 months radiographs, it was well realigned with relief of pain after tibio-talo-calcaneal arthrodesis internally fixed with multiple s. 환자의만족도등을분석하였다. 미국정형외과족부족관절학회기능평가기준은통증영역에 40 점, 기능영역에 50점, 족관절-후족부의정렬에 10점등총 100 점으로구성되어있으나, 본연구대상등은모두거골하관절및족관절을유합함에따라굴곡, 신전및내외반관절운동범위는소실됨으로변형된미국정형외과족부족관절학회평가표의만점은 86점으로하였다. 즉, 미국정형외과족부족관절학회기능평가점수중통증영역은 40점, 보행기능은 36점, 족관절-후족부정렬영역은 10점이었다. 또한, 환자의수술에대한만족도의분석은매우만족 (very satisfied), 만족 (satisfied with minor reservation), 보통 (satisfied with major reservation), 불만족 (dissatisfied) 등 4가지로나누어평가하였다. 미국정형외과족부족관절학회기능평가점수의각영역의영향평가를위해서는선형회귀분석을이용하여통계학적 으로처리하였으며, p<0.01 를유의한수준으로하여평가하였다. 결과평균추시기간은 16.5 개월 (12-26 개월 ) 이었다. 관절유합의판정은임상적으로체중부하시족관절및거골하관절의동통이소실되고, 술후최종촬영한단순방사선검사상관절면의 80% 이상이골로연속성을보이는경우로정의하였다. 최종추시시총 10명중 8명 (80%) 에서견고한관절유합소견을보였다 (Fig. 2). 술전시각상사척도동통점수는평균 8.2 점 (7-10 점 ) 에서최종추시시평균 1점 (0-3 점 ) 으로향상되었다. 또한술전미국정형외과족부족관절학회기능평가점수는평균 25점 (8-40 점 ) 에서최종추시시평균 66점 (58-75 점 ) 으로향상되었으며미국정형외과족부 - 69 -
정홍근 박신형 유현열 유문집 Figure 3. Sixty-two year old female with Charcot joint arthropathy developed distal tibia stress fracture 6 months after TTC joint fusion. 족관절학회기능평가점수중통증영역은평균 33점, 기능영역은평균 24점, 족관절 -후족부정렬영역은평균 9점이었으며, 100 점만점으로환산한경우는각각 82.5 점, 66.7 점, 90점으로기능영역이가장저조하였다 (Table 1). 그리고각영역이전체미국정형외과족부족관절학회기능평가에미치는영향을분석하였는데, 각각의영역중통증영역이다른두영역에비하여가장큰영향을주는것으로나타났으며, 이는통계학적으로의미가있었다 (p<0.01)(table 2). 환자의만족도는매우만족이 5예 (50%), 만족이 3예 (30%), 보통과불만족이각각 1예 (10%) 로서 80% 에서만족이상의결과를얻었다. 술후합병증으로는불유합이 2예에서관찰되었으며, 외반부정유합, 수술부위감염및경골의피로골절이각각 1예에서발생하였다. 불유합 2예중 1예는샤코씨관절증에서발생하였으며, 다른한예는골관절염환자 ( 증례 7) 에서거골하관절유합은얻었으나족관절은나사의적절한압박고정실패에따른불유합으로관절재고정술및자가골이식술을통해관절유합을얻었다. 경골원위부의피로골 절은증례 4의샤코씨관절증에서발생하였는데, 술후 4 개월에골유합을얻은후보행중관절유합에따른유연성소실로인해족관절상부경골에피로골절이발생하였으며이에대해단하지석고붕대고정을 2달간시행하여골유합을얻었다 (Fig. 3). 고찰족관절또는경골-거골-종골간관절고정술은류마티스관절염, 일차혹은이차성관절염, 거골의무혈성괴사, 마비성족부질환, 만곡족의후유증, 관절유합술의실패, 인공관절전치환술의실패, 신경관절병증등의여러원인에따른족관절과후족부기능장애에따른심한통증과변형또는불안정증을해결할수있는유용한수술방법으로알려져있다 27,28,30). 그러나거골하관절이잘보존되어있는경우, 심각한말초성혈관질환이있는경우, 족관절과족부의활동성감염이있는경우, 원위부경골의심각한각변형이있는경우, 심한뒤꿈치족저지방패드의위축이있는 Ta b l e 2. Statistical Comparison among the Three Fields in the AOFAS* Score Coefficient of determination (R 2 ) Significant probability (p-value) Pain.826.000 Function.592.009 Alignment.703.002 *AOFAS, American Orthopaedic Foot and Ankle Society Ankle-Hindfoot Functional Scale. - 70 -
경우등에는경골 -거골- 종골간유합술은금기로알려져있다 27,28). 1882년 Albert 2) 에의해전방접근법을통한족관절고정술이처음보고된이래다양한접근방법들이소개되었다. 외측을통한접근법은 1908 년 Goldthwait 16) 가경골-종골간관절고정술에서처음시도하였고, 그후 Horwitz 19) 가 1942 년족관절고정술에서시도하여지속적으로보고되고있으며 1,34), 근간에는족관절내과와외과를동시에절골하여수술시야를확보한다는보고도있었다 3,35). 이중에서비골횡단접근법 1,19,34) 은비복신경과전비골신경의외측분지사이를통한절개와비골외과의골절개로넓은수술시야를확보하여수술시간을줄일수있고, 미용학적개선과기능적개선을얻을수있다는장점이있다. 또한고정술의방법으로전통적으로대량의골절제후외고정장치를이용하거나 3,9), 또는골이식과내고정장치를이용하는방법이알려져있다 5,7,12,15,21,23). Russotti 등 30) 에의해경골-거골-종골간유합술이처음기술되었으며당시외고정장치나다수의나사고정술및자가골이식술이시행되었다. 외고정장치를이용한고정술은고정하고자하는관절에압박을가해관절유합을촉진하는것으로알려져있으나 9,29) Scranton 등 32), Morrey와 Weideman 24), Ratliff 29) 는 Charnley clamp 를이용한족관절고정을시도한결과관절유합률이겨우 70-80% 에이르는것으로보고하고있다. 한편 1968 년 Johnson 과 Boseker 20) 는외고정기구를이용할때발생되는합병증이 60% 에이르는것으로보고하였으며불유합, 지연유합, 삽입핀의감염, 후경골신경손상등의다양한합병증을보고하였다. 외고정장치에의한관절고정결과보여주는유합률을개선하고합병증을줄이기위해다양한내고정방법 5,7,12,15,21,23,25) 이개발되어져왔다. Kile 등 22) 은고정의안정성을높이기위해골수강내고정기구를고안하여사용하였으며추시결과 87% 의유합률을보고하였다. 골수강내금속정을이용한다른연구들에서도경골-거골- 종골간유합술의유합률을 74-93% 로보고하였다 22,26,27). 또한, 1992 년 Thordarson 등 33) 에의한 Calcandruccio 삼각형압박외고정기구와금속나사를이용한생역학적비교실험에서금속나사를이용해관절고정을하였을때가외고정장치를이용했을때보다회전력과굴신력에대해더욱강한저항을보였고, 1980년 Scranton 등 32) 에의해 Charnley clamp 와 T-형금속정을이용한생역학적비교실험연구결과에의하면 T-형금속정을이용해관절고정을하였을때가 Charnley clamp 를이용했을때보다염전력에대해더욱강한저항을보였다. 한편 1989 년 Chieppa 등 10) 에의하면후족부관절 고정술시유관나사의사용이다른내고정기기를사용했을때보다기술적으로쉽고수술시간을줄일수있다고하였으며, 1994년 Hewchuck 등 17) 은후족부관절고정술시유관나사의사용이다른내고정기기를사용했을때보다더욱견고한고정을얻을수있었다고보고하였다. 1997 년정등 13) 은유관압박나사를사용한경골 -거골-종골간고정술에서총 4예중 3예 75% 의유합률을보고한바있으며평균관절유합기간은 17.3주였다. 또한유관압박나사사용시대량의골절제없이연골하골만을제거하기에하퇴부나족부의단축이발생치않아미용적으로만족스러우며, 동시에관절주위를지나는근건조직들의정상적위치와기능이유지된다. 또한연부조직의광범위한박리없이족관절또는후족부관절을해부학적위치하에견고하게압박시켜관절유합률이높으며관절유합후삽입된금속나사를제거할필요가없다는장점을보고하였다. 이뿐만아니라유관압박나사는경우에따라서다양한위치에서여러개의나사고정이가능하며한국인을비롯한비교적후족부의골격크기가작은동양인들에있어상대적으로적용하기더적합한장점이있다. 본연구에서는유관나사를이용한경골-거골- 종골간관절유합술을시행하였으며 80% 에서유합을얻었으며, 이는다른기구를이용한유합률과비슷하거나다소낮은수치였으나이는적은연구대상수와짧은추시기간이영향을주었을것으로생각된다. 따라서지속적인경과추시및추가적인연구대상의분석이필요할것으로사료된다. 그러나평균관절유합기간 (19.3주), 시각상사척도동통점수 ( 최종추시시평균 1점 ), 미국정형외과족부족관절학회기능평가점수 ( 최종추시시평균 66점 ), 만족도 ( 보통이상 87.5%) 는타문헌에서보고된다른고정방법을사용한경우와유사한결과를보였다 11). 술후합병증으로경골의피로골절이 1예에서발생하였다. 샤코씨관절증환자로수술후 4개월째단하지석고고정제거후전체중부하보행하던중경골의피로골절이발생하였으며전위가심하지않아단하지석고고정을 3개월시행하여골유합을유도하였다. 불유합을보인경우가 2예있었는데이중 1예는감염이원인이었다. 53세남자환자의경우수술후 1년 3개월째감염소견과불유합소견동반되어내고정물제거술및시멘트염주삽입술과외고정시행후 2개월뒤시멘트제거후자가골이식과내고정을통해골유합을유도하였다. 부정유합이 1예에서발생하였는데소아마비후유증으로인한후족부의마비성외반변형이동반된요족으로고정술후 20도의후족부외반소견이남았으나환자는큰불편감을호소하지않았다. 이는기존 - 71 -
정홍근 박신형 유현열 유문집 의보고된내고정장치를이용한경골-거골-종골간유합술의합병증에서벗어나지않았으며모두경미한합병증이었다. 본연구에서는합병증발생률은 40% 로 (10 명중 4명 ) Adams 1) 가보고한골수강내고정을이용한유합술의합병증 60% 에비해낮았으며골수강내고정시발생할수있는 3대주합병증인치명적인페색전증, 심장마비, 뇌혈관질환의발생은한예도없었다. 결 론 본연구를통해다발성유관나사고정을이용한경골- 거골-종골간관절유합술은족관절-후족부의심한변형을동반하는다발성관절염에대한유용한수술적치료법중하나임을확인할수있었다. 그러나향후보다많은증례에대해장기추시를통한임상적분석이필요할것으로사료된다. REFERENCES 1. Adams JC: Arthrodesis of the ankle joint: Experiences with the transfibular approach. J Bone Joint Surg, 30-B: 506-511, 1948. 2. Albert E: Einige falle kunstlicher ankylosen. bildung an paralytischen gliedmassen. Wien Med Rresse, 23: 726-728, 1882. 3. Anderson R: Concentric arthrodesis of the ankle joint. A transmalleolar approach. J Bone Joint Surg, 27-A: 37-48, 1945. 4. Bednarz PA, Beals TC and Manoli A: Subtalar distraction bone block fusion: an assessment of outcome. Foot Ankle Int, 18: 785-791, 1997. 5. Bingold AC: Ankle and subtalar fusion by a transarticular graft. J Bone Joint Surg, 38-B: 862-870, 1956. 6. Burton DC, Olney BW and Horton GA: Late results of subtalar distraction fusion. Foot Ankle Int, 19: 197-202, 1998. 7. Campbell CJ, Rinehard WT and Kalenak A: Arthrodesis of the ankle: deep autogenous inlay grafts with maximum cancellous bone apposition. J Bone Joint Surg, 56-A: 63-70, 1974. 8. Chan SC and Alexander IJ: Subtalar arthrodesis with interposition tricortical iliac crest graft fot late pain and after calcaneus fracture. Foot Ankle Int, 18: 613-615, 1997. 9. Charnley J: Compression arthrodesis of the ankle and shoulder. J Bone Joint Surg, 33-B: 180-191, 1951. 10. Chieppa WA, Sydnor KH and Walter JHJr: Use of the cannulated bone screw in rearfoot surgery. J Foot Surg, 28: 333-334, 1989. 11. Chou LB, Mann RA, Yaszay B, et al: Tibiotalocalcaneal arthrodesis. Foot Ankle Int. 21: 804-808, 2000. 12. Chuinard E and Peterson R: Distraction-compression bone-graft arthrodesis of the ankle: A method especially applicable in children. J Bone Joint Surg, 45-A: 481-490, 1963. 13. Chung YK, Yoo JH, Park YW and Lee JD: Cannulated screw fixation for ankle and hindfoot arthrodesis. J Korean Orthop Assoc, 32: 944-951, 1997. 14. Flemister AS, Infante AF, Sanders RW and Walling AK: Subtalar arthrodesis for complications of intraarticular calcaneal fractures. Foot Ankle Int, 21: 392-399, 2000. 15. Gallie WE: Arthrodesis of the ankle joint. J Bone Joint Surg, 30-B: 619-621, 1948. 16. Goldthwait JE: An operation for the stiffening of the ankle joint in infantile paralysis. Am J Orthop Surg, 5: 271-275, 1908. 17. Hewchuck A, Goldman F and Wargon C: The Herbert cannulated bone screw in rearfoot arthrodesis. J Foot Ankle Surg, 33: 266-270, 1994. 18. Holt ES, Hansen ST, Mayo KA and Sangeorzan BJ: Ankle arthrodesis using internal screw fixation. Clin Orthop. 268: 21-28, 1991. 19. Horwitz T: The use of the transfibular approach in arthrodesis of the ankle joint. Am J Surg, 55: 550-552, 1942. 20. Johnson EW and Boseker EH: Arthrodesis of the ankle. Arch Surg, 97: 766-773, 1968. 21. Kennedy JC: Arthrodesis of the ankle with particular reference to the Gallie procedure. J Bone Joint Surg, 42-A: 1308-1316, 1960. 22. Kile TA, Donnelly RE, Gehrke JC, Wener ME and Johnson KA: Tibiotalocalcaneal arthrodesis with an intramedullary device. Foot Ankle Int, 15: 349-353, 1994. 23. Marcus RE, Balourdas GE and Heiple KG: Ankle arthrodesis by chevron fusion with internal fixation and bone grafting. J Bone Joint Surg, 65-A: 833-838, 1983. 24. Morrey BF and Weideman GP Jr: Complications and long-term results of ankle arthrodesis following trauma. J Bone Joint Surg, 62-A: 777-784, 1980. 25. Papa JA and Myerson MS: Pantalar and tibiotalocalcaneal arthrodesis for post-traumatic osteoarthritis of the ankle and hindfoot. J Bone Joint Surg, 74-A: 1042-1044, 1992. 26. Pinzur MS and Kelikian A: Charcot ankle fusion with a retrograde locked intramedullary nail. Foot Ankle Int, 18: 699-704, 1997. 27. Quill GE: Tibiotalocalcaneal arthrodesis. Tech Orthop, 11: 269-273, 1996. 28. Quill GE: Tibiotalocalcaneal and pantalar arthrodesis. Foot Ankle Clin, 1: 199-209, 1996. 29. Ratliff AHC: Compression arthrodesis of the ankle. J Bone Joint Surg, 41-B: 524-534, 1959. 30. Russotti GM, Johnson KA and Cass JR: Tibiotalocalcaneal arthrodesis for arthritis and of the hind part of - 72 -
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