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Vol.18, No.

6 June 1996

Continuing Education Article

Closed Repair of Tibial


FOCAL POINT
and Radial Fractures
★ Closed repair with Type II external
fixation and intraoperative skeletal
with External Skeletal
traction is useful for treating
radial and tibial fractures. Fixation
KEY FACTS
Washington State University
■ Closed repair and external Joseph Harari, MS, DVM Trevor Bebchuk, DVM
skeletal fixation provide fracture Bernard Seguin, DVM James Lincoln, DVM, MS
stability and tissue preservation,
which promote bone healing with
minimal complications.

■ Closed repair and external


skeletal fixation provide a
E xternal skeletal fixators have been described and used in human and vet-
erinary orthopedics for nearly 100 years. The concept of external skele-
tal fixation was introduced by Malgaigne in 1840. The first readily avail-
able fixator was devised by Parkhill in 1897 to stabilize open fractures and
malunions of the extremities.1 In the first half of this century, veterinarians,
physiologic surgical approach
that resembles the natural such as Ehmer, Leighton, Schroeder, and Stader, developed various designs for
evolution of vertebrate fracture external skeletal fixators.
healing. Because they were compact, lightweight, and technically easy to apply, fixa-
tors gained popularity during World War II for treating human casualties. To-
■ Intraoperative skeletal traction ward the end of the war, however, the Surgeon General banned the use of exter-
and joint realignment enhance nal fixators because of high infection rates and poor clinical results.1 In addition,
recovery of limb function. the Committee on Fracture and Trauma Surgery of the American Academy of
Orthopedic Surgeons recommended in 1950 that the use of external fixators be
■ A common problem associated limited to surgeons with extensive clinical experience or training.
with external skeletal fixation is A resurgence of interest in external skeletal fixation has occurred in human and
minor or major infection of the veterinary medicine during the past 10 years. This renewed interest can be at-
pin tract. tributed to an increased frequency of severe bone and soft tissue injuries caused
by motor vehicle and firearm trauma as well as an increased knowledge regarding
fixator equipment; techniques of application and maintenance; biomechanics;
and fracture healing.2–6 These factors have resulted in reduced patient morbidity
and improved clinical results. Benefits cited with the use of external skeletal fixa-
tion include affordability of equipment; technical ease in applying, maintaining,
and removing fixators; applicability to a wide variety of orthopedic conditions;
lack of surgical invasiveness; preservation of supportive tissues and vascularity
during healing; capability for unhindered treatment of open wounds; compatibil-
ity with other fixation devices, such as intramedullary pins; and enhancement of
osseous union by staged disassembly during postsurgical convalescence.1–6
Small Animal The Compendium June 1996

Although open fracture repair and stabilization using ADVANTAGES


pins and wires or plates and screws have remained vi- External fixa-
able treatments for orthopedic injuries in humans and tion and closed re-
animals, more attention has been given recently to pair of long bone
minimum surgical invasive- fractures have nu-
ness and external fracture merous benefits
Advantages of stabilization. The reason for because of the dis-
Closed Reduction this new emphasis is that tinct characteris-
and External Fixation surgeons are attempting to tics of the equip-
encourage and enhance natu- ment and method
■ Preservation of ral biological healing. 4,5,7 of fixation2–7 (see
periosseous soft tissue This article will review cur- the box). Fixators
rent concepts and treatments are useful in pre-
and neurovascular serving bone and
for the frequently injured ra-
elements dius and tibia in dogs by use limb length as
■ Avoidance of surgical of closed repair and external well as joint mo-
trauma to injured or skeletal fixation. tion proximal and
normal tissues distal to the frac-
■ Avoidance of surgical INDICATIONS tured bone. Exter-
The goal of fracture repair nal fixation pro- Figure 1—A comminuted mid-dia-
infections associated motes vascular physeal tibial fracture is being re-
is early return of limb func-
with buried implants tion, leading to ambulation and lymph circu- duced by external skeletal traction
■ Provision of natural of the patient. This goal can lation after trau- via suspension from an intravenous
healing with a be achieved by functional or ma, minimizes soft fluid stand that is covered with ster-
periosteal/endosteal anatomic realigning of frac- tissue and osseous ile elastic bandaging material.
callus ture segments and establish- atrophy, and avoids
ing parallel joints above and joint ankylosis. In addition, this method permits unhin-
■ Versatility of a dered treatment of wounds and focal infection during
below the injured bone. 8,9
technique that is Open or closed fractures of the healing of open fractures. Unlike internal fixation
applicable to numerous the radial and tibial diaphy- (in which plates, screws, pins, and wires are used), exter-
kinds of fractures ses, in which functional axial nal fixation uses no implants at the fracture site; im-
■ Affordability of alignment and proximal and plants can adversely affect healing or serve as a nidus for
equipment that is easy distal joint congruencies can infection. External fixation involves basic instrumenta-
be obtained, are therefore tion and can be easily applied and sequentially removed
to apply, maintain, and to enhance fracture remodeling by loading the bone.
injuries that can be treated
remove by external skeletal fixation The variability in fixator designs permits application for
■ Reduction of fixation and closed repair. Specific stabilization of numerous fractures.
during bone healing examples include open, type With closed surgical reduction, the periosseous vas-
and fracture remodeling III, infected fractures with cular supply and adjacent supportive soft tissues are
■ Usefulness of fixation segmental bone defects; preserved. This closed technique limits iatrogenic tissue
closed, comminuted frac- trauma, necrosis, and surgical infections due to
in preserving bone overzealous manipulations and prolonged open proce-
tures; single transverse or
length and alignment oblique fractures; and distal dures. In addition, comminuted bone fragments can
diaphyseal radial fractures in provide autogenous, in situ cortical chip grafts and
toy breeds.4,10,11 bone marrow, which enhance callus production.12,13
Animals with poor healing potential (resulting from Closed repair and external skeletal fixation provide a
senility, avascularity, neoplasia, or systemic illness) need physiologic surgical approach that resembles the natural
cancellous bone grafting to enhance osteogenesis and evolution of vertebrate fracture healing because soft tis-
therefore should not be treated with external skeletal sue and vascular supply are usually preserved and callus
fixation and closed repair. An alternative approach for formation is stimulated.7 Direct (primary) bone union
these patients would be a “mini” open (limited expo- with contact or gap healing (as obtained with rigid
sure) approach for bone manipulation, debridement, plate fixation) occurs infrequently with closed repair
and grafting.4 and external skeletal fixation.14

PROPER CASE SELECTION ■ EQUIPMENT CHARACTERISTICS


The Compendium June 1996 Small Animal

APPLICATION OF THE FIXATOR duce edema and limit displacement of fragments, per-
WITH CLOSED REDUCTION forming surgery within 7 days of injury to avoid severe
Closed repair with external skeletal fixation of radial muscle contraction and displacement of bones, and
and tibial fractures is based on functional limb realign- sound knowledge of regional anatomy to avoid major
ment using external skeletal traction; external manipu- neurovascular bundles and muscles and to gain maxi-
lation of fragments; and, if possible, percutaneous frac- mum bone purchase.15
ture reduction with pointed pelvic reduction forceps. Before surgery, the limb is clipped, scrubbed, and
Key elements for successful results include presurgical suspended in a hanging position from a ceiling hook or
support of the limb with a Robert-Jones bandage to re- intravenous fluid stand4,15,16 (Figure 1). Suspension of
the limb provides circumferential access
for pin placement and proximal and dis-
tal joint alignment in a parallel plane; in
addition, suspension overcomes muscu-
lar contractions and thus permits frac-
ture reduction. Suspension can be en-
hanced by lowering the surgical table
after connecting the paw to the stand or
ceiling hook, thereby elevating the ani-
mal’s body off the table. This technique
uses the weight of the patient to main-

Figure 2— Comminuted radial and ulnar


fractures in a 10-year-old Labrador retriev-
er. Craniocaudal views before surgery (A),
immediately after surgery (B), 4 weeks after
surgery (C), and 12 weeks after surgery
(D). A lateral view taken 12 weeks after
surgery (E) is also shown.
Figure 2A Figure 2B

Figure 2C Figure 2D Figure 2E

FIXATOR APPLICATION ■ SURGICAL REQUIREMENTS ■ LIMB SUSPENSION


Small Animal The Compendium June 1996

(50% cortical bone overlap, less


than 5˚ of spatial malalignment)
have been recommended for
closed reduction, although clini-
cal results have not always been
deleteriously affected by fracture
angulation (detected radiographi-
cally).4,14
Selection of pin size is based
on patient size (i.e., bone diame-
ter). In general, the pin should
not exceed 20% of the bone di-
ameter, which will avoid iatro-
genic bone fractures associated
with stress concentration at the
bone hole.17,18 Sizes of pin clamps
and metal connecting bars are di-
rectly related to the percutaneous
Figure 3A Figure 3B pin size. Sizes of fixator sets
(Imex Veterinary—Longview,
TX) (small, medium, or large)
are based on respective patient
categories: cats and small dogs,
medium to large dogs, and giant
breeds. In our clinic, small exter-
nal fixators have been used for
patients ranging in weight from
3 to 10 kilograms and medium-
sized fixators have been used for
patients weighing 10 to 50 kilo-
grams.
Specific pin characteristics that
contribute to enhanced fixator
stability include positive-profile
(thread raised above the pin di-
ameter), threaded pins (Imex Vet-
Figure 3C Figure 3D erinary—Longview, TX), which
Figure 3—A transverse tibial fracture in a 5-year-old Doberman cross stabilized with
are screwed into the bone for
closed repair and external skeletal fixation. Craniocaudal and lateral radiographic views maximum purchase and im-
before surgery (A), after traction and percutaneous reduction with pelvic bone forceps proved pin–bone interface stabil-
17,18
(B), 4 weeks after surgery (C), and 12 weeks after surgery (D). Excellent realignment ity. Pins with a cancellous
of the bone was obtained. thread design (few coarse threads
per unit of length) are used in
the proximal aspect of the tibia,
tain limb alignment. To avoid iatrogenic varus and val- and cortical pins (many fine threads per unit of length)
gus deformities of the limb below the fracture(s), limb are used in the distal tibia and proximal and distal as-
suspension can be decreased and percutaneous bone pects of the radius (Figures 2 and 3). In most instances,
alignment performed using proximal and distal uncon- a type II (bilateral-uniplanar) fixator is used for stabi-
nected transfixation pins or, for long oblique fractures, lization of radial and tibial fractures and, therefore, cen-
using externally applied pelvic reduction forceps. trally threaded pins are used in the proximal and distal
Palpation of the limb to produce parallel orientation positions.10,19 Smooth pins are used in the central posi-
of the joints above and below the fracture(s) is impor- tions of frames because they are technically easy to
tant in preventing limb deformities. Specific guidelines place through pin clamps and to withdraw during

PREVENTING LIMB DEFORMITIES ■ PIN CHARACTERISTICS ■ FIXATOR SETS


Small Animal The Compendium June 1996

For construction of a type II


frame, visual acuity or a guide
bar is necessary.20,21 Because full-
pin configurations are stronger
than half-pin frames, an attempt
should be made to use the for-
mer configuration. Centrally po-
sitioned half-pins are useful if
bone and contralateral pin clamp
purchase is difficult to obtain
(e.g., cranial curvature of the ra-
dius) and in staged disassembly.
Stability of the frame is enhanced
by using three to four pins per
fragment spread across the bone
shafts and by placing connecting
bars within 1 to 2 centimeters of
the skin surface.
Insertion of pins requires skin
incisions and creation of inter-
Figure 4A Figure 4B muscular channels with Kelly
forceps to reduce pin–tissue con-
tact during drilling. If soft tissues
are traumatized during pin inser-
tion, necrosis and subsequent
sepsis of the pin tract may occur.
A drill sleeve can be used to pro-
tect soft tissues during drilling
and placement of the most proxi-
mal and distal pins before con-
necting bars and clamps are at-
tached. An additional measure
that should be taken to avoid tis-
sue damage as pins exit the bone
is the creation of soft tissue chan-
nels with forceps. Smooth pins
are placed via slow-speed power
drilling, and threaded pins are
placed by hand drilling after
high-speed predrilling with a
smaller drill bit (approximately 1
millimeter diameter less than the
threaded pin diameter).
Figure 4C Figure 4D
Pins are placed in the most
Figure 4—Closed repair and external fixation of a comminuted diaphyseal tibial frac- proximal and distal positions ini-
ture in a 3-year-old Labrador retriever. Craniocaudal radiographic views before surgery tially, followed by attachment of
(A), immediately after surgery (B), 6 weeks after surgery (C), and 12 weeks after
surgery (D). Note the healing of the comminuted bone fragments within the callus.
connecting bars with open
clamps for centrally placed pins.
Before tightening of the proxi-
staged disassembly (as the bone is loaded during heal- mal and distal pin clamps, the fracture is reduced man-
ing). Combining proximally and distally placed thread- ually or with percutaneously applied pelvic reduction
ed pins with centrally placed smooth pins provides forceps. After the proximal and distal clamps are tight-
frame rigidity and pin–bone interface stability.18 ened, the centrally placed pins are inserted into the ma-

TYPE II FRAME CONSTRUCTIONS ■ PIN INSERTION & PLACEMENT


The Compendium June 1996 Small Animal

Figure 5A Figure 5B

Figure 5—Bilateral distal diaphy-


seal fractures of the radius and
ulna in a 7-month-old Pomera-
nian. Craniocaudal radiograph-
ic views after surgery (A), ap-
pearance of the patient 3 days
after surgery (B), and cranio-
caudal radiographic views of the
healed fractures in the right (C)
and left (D) forelimbs 4 weeks
later.

jor bone fragments in an alter-


nating fashion above and below
the fractures. With transverse
fractures stabilized by full pins,
compression of the bone by
squeezing together pins above
and below the fracture before Figure 5C Figure 5D
clamping will reduce stress on
the transfixation pins and fixator
and increase axial loading of the bone column.18,20 palement and hemorrhage have caused a delay in
surgery and limb bandaging for 24 to 48 hours. Be-
RADIAL AND TIBIAL ANATOMY cause the radius is a narrow bone with a cranial bow, it
The radius is a flat bone. The largest diameter of the is often necessary to use half-pins from either the lateral
radius is oriented in a craniomedial to caudolateral or medial aspect of the bone in the center of a type II
plane, and major extensor muscles are located on the fixator (Figure 3). This arrangement allows maneuver-
craniolateral aspect of the bone. For the type II frame ability in attaching the central pins to straight metal
configuration, pins are placed in a craniomedial to cau- connecting rods.
dolateral direction to maximize pin–bone contact. The entire medial and proximal cranial aspects of the
Significant complications associated with proximal tibia are safe for pin placement, although cranial
transfixation pins in the radius have included acute branches of the saphenous artery and vein as well as the
perforation of interosseous branches of the median saphenous nerve run along the middle medial aspect of
artery and excessive soft tissue irritation.22 Vascular im- the bone. Pin insertion from medial to lateral is used to

BONE ANATOMY ■ PIN PLACEMENT ■ COMPLICATIONS


The Compendium June 1996 Small Animal

build the type II configuration (Figures 4 and 5). Proxi- Infection of the pin tract can be a major or minor
mal pins placed in the mediolateral plane of the tibia are condition, based on degree of inflammation, patient
inserted in the wide, massive caudal aspect of the bone. discomfort, and character of the drainage.22,23 Excessive
As with radial pin placement, lateral soft tissue channels pin motion and skin or soft tissue tension contribute
can be created to guide pins exiting from the bone. directly to infection. Minor infection of the pin tract is
characterized by a slight, serous drainage with little pa-
POSTSURGICAL CARE tient discomfort. It is often a normal consequence of
After pins are placed, any tension of the skin around transfixation, and controversy remains regarding the
a pin should be relieved with a small stab incision. need for treatment. Some surgeons advocate letting a
Controversy exists regarding proper postsurgical care of crust form around the pins, whereas others prefer daily
a limb treated with external skeletal fixation.20,22 Some cleaning with an antiseptic solution. Major infection of
surgeons use bandages to minimize swelling around the the pin tract consists of a persistent, copious, purulent
pins, and sterile gauze is packed around the pins and discharge with considerable patient discomfort. Major
under the connecting bar for variable times.20,23,24 An- sepsis of the pin tract is characterized by bacterial infec-
tibacterial ointment can be placed at the junction of tion, necrosis of soft tissues, and possibly, focal os-
the pin–skin interface to reduce bacterial contamina- teomyelitis. Treatment includes cleansing of affected
tion. Elastic bandage material should be placed around sites with an antiseptic solution, applying topical an-
the external skeletal fixator to keep the sponges in place tibiotics and bandages, removing loose pins, and ad-
and to prevent damage to the frame. Some surgeons ministering systemic antibiotics based on the results of
prefer to leave the limb uncovered and to control post- deep bacterial culture and antimicrobial sensitivity test-
surgical swelling and reactions at the junction of the ing.
pin–skin interface with daily hydrotherapy.21,25 Premature loosening of pins is corrected by removing
At our clinic, the pin–skin site is covered by antibiot- the pin. This complication is the result of improper
ic-ladened gauze sponges, and the limb is wrapped with drilling (excessive speeds or hand motion) or location
soft, padded bandages for 24 to 48 hours to control of the pin in fissures. If the pin is still essential to the
swelling from the original trauma and surgery. Daily stability of the external skeletal fixation, another pin
hydrotherapy is then performed to maintain cleanliness should be inserted in the bone in the same vicinity.
of skin tracts and to reduce swelling, pain, and muscle Pressure necrosis of the skin occurs when clamps and
spasm.26 For home care, clients are instructed to clean connecting rods are placed too close to the skin surface,
pin–skin sites daily with cotton-tipped applicators and thus not allowing sufficient space for postsurgical tissue
dilute chlorhexidine or warm water. swelling. The clamps should be placed 1 to 2 centime-
Pin clamps should be checked weekly to ensure tight- ters away from the skin surface. Treatment for skin
ness. Radiographs should be obtained at approximately necrosis consists of hydrotherapy and physical therapy
4- to 6-week intervals to evaluate healing. Examina- to reduce swelling. In addition, topical medication
tions are based on signalment of the patient and type of should be applied to affected sites and the bandage at
fracture. As bone healing progresses, the fixator can be the pin–skin interface should be packed to reduce mo-
disassembled by removing pins to decrease stiffness, tion.
which enhances fracture remodeling. Loose pins (usual- Soft tissue impalement increases patient morbidity.
ly smooth, centrally positioned pins or the most proxi- Percutaneous pins usually push aside rather than trans-
mal threaded pin near the high-motion region of the fix neurovascular bundles. If profuse hemorrhage due
stifle or elbow joint) are removed first, and tight pins to vascular laceration occurs during surgery, treatment
are removed after confirmation of clinical and radio- includes pin removal, temporary cancellation of
graphic union. Experimental data reveal increased me- surgery, and application of a Robert-Jones bandage for
chanical strength and primary bone remodeling in tib- 24 to 48 hours. Percutaneous pins can also be placed
ial osteotomies destabilized by reducing type III to type through myotendinous structures, which leads to mus-
I fixators at 6 weeks after surgery.27 cle pain, reduced physical activity, and decreased joint
mobility. Treatment involves pin removal and insertion
COMPLICATIONS at another site or selection of an alternate mode of fixa-
Potential complications with the use of an external tion.
skeletal fixator can be avoided by adhering to the basic
guidelines and principles of external skeletal fixation CLINICAL CASES
application. Common problems often relate to the fixa- A summary of 14 dogs with radial and tibial fractures
tor and not to fracture healing. treated with external skeletal fixation applied in a

POSTSURGICAL CONCERNS ■ PIN TRACT SEPSIS ■ LOOSE PINS ■ PRESSURE NECROSIS


TABLE I
Summary of Radial and Tibial Fractures Treated with Closed Repair and External Skeletal Fixation30
Limb
Small Animal

Signalment History Fractures Fixator Type a Concurrent Injuries Follow-Up Functionb


Pomeranian Jumped out Bilateral transverse distal radius and ulna II None 5 years IV
7 months old, 3 kg of truck (both limbs)

Labrador retriever Hit by car Comminuted mid-shaft left radius and II, double None 6 years IV
9 years old, 33 kg ulna lateral bar

Labrador retriever Hit by car Comminuted midshaft left tibia and II None 4 months III
3 years old, 21 kg fibula

Sheltie cross Hit by car Oblique midshaft right radius and distal II Pulmonary contusion and 3 months III
2 years old, 24 kg ulna edema

Oblique midshaft right tibia II III

Great Dane Hit by car Open comminuted distal right tibia II Metatarsal and phalangeal 2.5 years III
1 year old, 40 kg fractures; degloving injuries
on the left shoulder and hock

Border collie Railroad tie Comminuted midshaft right radius and II None 2 years III
4 years old, 14 kg fell on leg transverse midshaft ulna

Siberian husky Hit by car Transverse midshaft right radius and ulna II None 7 months IV
7 years old, 30 kg
Transverse midshaft femur; delayed union I Refracture due to
second trauma

Pomeranian Jumped off Bilateral transverse distal radius and ulna II None 1.5 years IV
1 year old, 3 kg bed (both limbs)

Vizsla Jumped out Comminuted midshaft right tibia and II None 6 months IV
8 years old, 24 kg of truck fibula

Labrador retriever Jumped out Comminuted midshaft left radius and II with None 2 years IV
3 years old, 40 kg of boat oblique midshaft ulna intramuscular
pin in ulna

Labrador retriever Hit by car Comminuted midshaft right radius and II Right hip dislocation 1.5 years III
10 years old, 30 kg transverse distal ulna
The Compendium June 1996
The Compendium June 1996 Small Animal

closed fashion is presented in Table I. Two animals had


Functionb malunions, which were previously treated with in-
tramedullary pins.
Limb

IV

IV

IV
Patients ranged in age from 7 months to 10 years and

function: I = no functional limb usage; limb carried most of the time. II = slight functional limb usage; limb carried during running but set down during walking.
varied in weight from 3 to 40 kilograms. Labrador re-
trievers were the breed most frequently seen, probably be-
cause of their popularity in the Northwest. Motor vehicle
Follow-Up

injuries were the most frequent cause of bone fractures.


1.5 years

1 year

1 year
The open or closed nature of the fractures could not al-
ways be discerned from the medical records and, excluding
one case, all injuries involved the radius and ulna or tibia
and fibula. A type II (bilateral-uniplanar) fixator was used
in all animals to stabilize the fractures. In dogs treated be-
Concurrent Injuries

fore 1992, smooth pins were used; after 1992, a combina-


tion of centrally positioned smooth pins and positive-pro-
None

None

None

III = moderate functional limb usage and partial weight bearing; lameness evident. IV = complete, normal functional limb usage. file, threaded pins in proximal and distal positions was
used. Metal connecting bars were used in all dogs.
At the time of follow-up, 9 of 14 dogs were charac-
terized by a lameness score of IV (normal function). In
the remaining 5 dogs, which were characterized by a
grade III (moderate function) lameness score, 3 dogs
Fixator Type a

had ipsilateral joint injuries or concurrent fractures of


other bones, 1 dog was evaluated for only a short peri-
II

II

II
TABLE I (continued)

od (3 months), and the remaining dog had moderate


function of limb usage 2 years after the injury.
In general, it seems that the prognosis for surgery is
good for animals with single-limb fractures of the ra-
dius or tibia that were treated with closed repair and ex-
Transverse midshaft right tibia; delayed

ternal skeletal fixation. In two toy breeds with bilateral


Comminuted midshaft left tibia and

Comminuted midshaft left tibia and

radial and ulnar fractures, closed repair with external


skeletal fixation provided bone healing (Figure 5).
These injuries are frequently associated with nonunion
resulting from poor healing as a result of inadequate
transverse midshaft fibula
Fractures

bone and soft tissue mass.28

CONCLUSION
Closed reduction, external skeletal fixation, and in-
traoperative skeletal traction are useful approaches for
type II = bilateral-uniplanar configuration.

the treatment of radial and tibial fractures in small ani-


union

fibula

mals. Proper adherence to technical guidelines and case


selection ensures successful clinical outcome with mini-
mum patient morbidity.
Hit by car

Hit by car
Labrador retriever Kicked by
History

2.5 years old, 27 kg cow

About the Authors


Drs. Harari, Seguin, and Lincoln are affiliated with the De-
partment of Veterinary Clinical Sciences, College of Veteri-
Labrador retriever

Labrador retriever
3 years old, 40 kg

2 years old, 33 kg
Signalment

nary Medicine, Washington State University, Pullman,


Washington. Dr. Bebchuk was an intern at Washington
State University and is currently associated with Affiliated
aFixator

Veterinary Specialists in Winter Park, Florida. Dr. Harari is a


bLimb

Diplomate of the American College of Veterinary Surgeons.

CLINICAL CASES ■ OUTCOMES ATTAINED


Small Animal The Compendium June 1996

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