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El-Gammal TA, El-Sayed Ali A, Kotb MM, Saleh WR, Ragheb YF, Refai OA, Morsy MM, El-Gammal YT. Free Vascularized Proximal Fibular Epiphyseal Transfer For Hip Reconstruction Following Septic Necrosis In Children. J Pediatr Orthop 2024; 44:308-315. [PMID: 38462889 DOI: 10.1097/bpo.0000000000002634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/12/2024]
Abstract
BACKGROUND Septic necrosis of the femoral head and neck in children represents a challenging problem. Several reconstructive techniques have been described but with disappointing long-term results. Vascularized epiphyseal transfer utilizing the proximal fibula have been successfully used for reconstruction of the proximal humerus and distal radius and only scarcely used for hip reconstruction. This cohort represents the largest reported series of epiphyseal transfer for hip reconstruction following septic necrosis in children. METHODS A total of 18 patients with an average age at surgery of 5.4 years were included. The average follow-up was 3.6 years (range 2.3 to 6.8 y). RESULTS Transient postoperative foot drop was observed in 4 patients. Radiographic resorption of the transferred fibula occurred in 2 cases. Longitudinal growth averaged 7.3 mm/year, and the physis width increased by an average of 2.7 mm/year. The rate of longitudinal growth was fastest after the age of 10 years (18.5 mm/y), which coincides with the pubertal growth spurt. All successful transfers had an open growth plate on final follow-up radiographs. Ten patients had limb length discrepancy of an average 2.8 cm (range 1 to 8 cm). Thirteen patients had satisfactory functional according to the criteria of Hunka et al. Three patients had unsatisfactory results; one had painful nonunion at the fibula-femur junction, and the other two had limited flexion range of 45 degrees. The average postoperative neck-shaft angle was 96.4 degrees which decreased by an average of 8 degrees at the final follow-up. Three patients underwent a valgus subtrochanteric osteotomy to correct a severe varus deformity. The final neck-shaft angle correlated significantly with the functional results where it averaged 96 degrees in the satisfactory group and 57 degrees in the unsatisfactory group. CONCLUSION Vascularized epiphyseal transfer presents a promising treatment for children with septic necrosis of the femoral head and neck in whom other methods have failed to provide satisfactory long-term results. We recommend the procedure be done before the age of 5 years for optimum results. LEVEL OF EVIDENCE Level-IV.
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Affiliation(s)
- Tarek Abdalla El-Gammal
- Department of Orthopedics and Traumatology, Hand and Reconstructive Microsurgery Center, Assiut University Hospitals and School of Medicine, Assiut, Egypt
- Department of Orthopedics, University of Louisville, Louisville, KY
| | - Amr El-Sayed Ali
- Department of Orthopedics and Traumatology, Hand and Reconstructive Microsurgery Center, Assiut University Hospitals and School of Medicine, Assiut, Egypt
| | - Mohamed Mostafa Kotb
- Department of Orthopedics and Traumatology, Hand and Reconstructive Microsurgery Center, Assiut University Hospitals and School of Medicine, Assiut, Egypt
| | - Waleed Riad Saleh
- Department of Orthopedics and Traumatology, Hand and Reconstructive Microsurgery Center, Assiut University Hospitals and School of Medicine, Assiut, Egypt
| | - Yasser Farouk Ragheb
- Department of Orthopedics and Traumatology, Hand and Reconstructive Microsurgery Center, Assiut University Hospitals and School of Medicine, Assiut, Egypt
| | - Omar Ahmed Refai
- Department of Orthopedics and Traumatology, Hand and Reconstructive Microsurgery Center, Assiut University Hospitals and School of Medicine, Assiut, Egypt
| | - Mohamed Mohamed Morsy
- Department of Orthopedics and Traumatology, Hand and Reconstructive Microsurgery Center, Assiut University Hospitals and School of Medicine, Assiut, Egypt
- Department of Orthopedics, University of Birmingham at Alabama, AL
| | - Yousif Tarek El-Gammal
- Department of Orthopedics and Traumatology, Hand and Reconstructive Microsurgery Center, Assiut University Hospitals and School of Medicine, Assiut, Egypt
- Kleinert-Kutz Institute of Hand and Microsurgery, Louisville, KY
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Lee CJ, Tiourin E, Khoshab N, Leis AR, Nassif NA, Misaghi A, Vyas RM. Vascularized Fibular Epiphyseal Transfer for Pediatric Limb Salvage: Review of Applications and Outcomes. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2023; 11:e5354. [PMID: 37859637 PMCID: PMC10584290 DOI: 10.1097/gox.0000000000005354] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Accepted: 09/08/2023] [Indexed: 10/21/2023]
Abstract
Vascularized fibular epiphyseal transfer (VFET) offers a functional advantage in pediatric limb salvage due to the preservation of growth potential and an articular surface for remodeling. This review summarizes the available evidence on the clinical characteristics and outcomes of pediatric reconstruction applying VFET at different recipient sites and with varying techniques. VFET was used to reconstruct the proximal humerus, distal radius or ulna, proximal femur, distal fibula, calcaneus, and mandible. Although most often harvested on the anterior tibial artery, VFET has also been performed using the peroneal artery, the inferior lateral genicular artery, and a dual pedicle. Recipient site flap inset most often involved fixation with plates and/or screws as well as soft tissue reconstruction using a retained slip of biceps femoris tendon. Outcomes included limb growth, range of motion, and strength. The most common reported complications were bone flap fracture and peroneal nerve palsy. The anterior tibial artery was the most applied pedicle with reliable limb growth, but with the added risk of postoperative peroneal palsy. Bone flap fracture most often occurred at the proximal humerus and femur recipient sites. Plate fixation and the combined use of allograft had lower instances of bone flap fracture. This review highlights how the anticipated dynamic growth and remodeling this free flap offers in the long term must be weighed against its complexity and potential complications.
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Affiliation(s)
- Christine J. Lee
- From the Department of Plastic Surgery, University of California, Irvine Medical Center, Orange, Calif
| | - Ekaterina Tiourin
- From the Department of Plastic Surgery, University of California, Irvine Medical Center, Orange, Calif
| | - Nima Khoshab
- From the Department of Plastic Surgery, University of California, Irvine Medical Center, Orange, Calif
| | - Amber R. Leis
- From the Department of Plastic Surgery, University of California, Irvine Medical Center, Orange, Calif
- Division of Plastic Surgery, Children’s Hospital Orange County, Orange, Calif
| | | | - Amir Misaghi
- Division of Orthopedic Surgery, Children’s Hospital Orange County, Orange, Calif
| | - Raj M. Vyas
- From the Department of Plastic Surgery, University of California, Irvine Medical Center, Orange, Calif
- Division of Plastic Surgery, Children’s Hospital Orange County, Orange, Calif
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Lovic A, Ortiz-Cruz EJ, Pérez-Rodríguez J, Bolado-Gutiérrez P, Manzanares-Retamosa ML. Total hip reconstruction after sarcoma resection in children with a free vascularized fibula without osteotomy of the bone flap: Technique description and case series. J Plast Reconstr Aesthet Surg 2022; 75:3140-3148. [PMID: 35760707 DOI: 10.1016/j.bjps.2022.04.074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Revised: 03/17/2022] [Accepted: 04/12/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND Hip joint reconstruction following intra-articular resection of the femoral head in children is a highly demanding challenge. We aimed to describe the outcomes of hip reconstruction in paediatric patients with a free fibular epiphyso-diaphyseal flap based on both anterior tibial and peroneal vessels within a radius allograft. PATIENTS AND METHODS Four patients underwent hip reconstruction following this technique between 2013 and 2020 at La Paz University Hospital (Madrid, Spain). The postoperative follow-up period ranged between 12 months and seven years. Two of the patients were diagnosed with Ewing's sarcoma and two with osteosarcoma. The median age at the time of surgery was eight years (six to nine). RESULTS Three patients remained to be disease-free at the time of this study, and one died shortly after surgery, so he was excluded from the reconstruction analysis of results. No postoperative complications requiring reintervention were recorded. Imaging studies (X-ray and MRI) showed three-dimensional growth of the flap and integration of the allograft. Mean leg length discrepancy was 1.3 cm (0 to 2.3). At the last follow-up visit, all patients were able to ambulate. CONCLUSION For children following oncological resection of the femoral head, reconstruction with a vascularized epiphyso-diaphyseal fibula flap combined with radius allograft is a safe option. This procedure provides encouraging functional results and avoids the complications of previously published techniques or implants.
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Affiliation(s)
- Aleksandar Lovic
- Plastic and Reconstructive Surgery, La Paz University Hospital, Madrid Spain.
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van der Heijden L, Farfalli GL, Balacó I, Alves C, Salom M, Lamo-Espinosa JM, San-Julián M, van de Sande MA. Biology and technology in the surgical treatment of malignant bone tumours in children and adolescents, with a special note on the very young. J Child Orthop 2021; 15:322-330. [PMID: 34476021 PMCID: PMC8381388 DOI: 10.1302/1863-2548.15.210095] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Accepted: 06/02/2021] [Indexed: 02/03/2023] Open
Abstract
PURPOSE The main challenge in reconstruction after malignant bone tumour resection in young children remains how and when growth-plates can be preserved and which options remain if impossible. METHODS We describe different strategies to assure best possible long-term function for young children undergoing resection of malignant bone tumours. RESULTS Different resources are available to treat children with malignant bones tumours: a) preoperative planning simulates scenarios for tumour resection and limb reconstruction, facilitating decision-making for surgical and reconstructive techniques in individual patients; b) allograft reconstruction offers bone-stock preservation for future needs. Most allografts are intact at long-term follow-up, but limb-length inequalities and corrective/revision surgery are common in young patients; c) free vascularized fibula can be used as stand-alone reconstruction, vascularized augmentation of structural allograft or devitalized autograft. Longitudinal growth and joint remodelling potential can be preserved, if transferred with vascularized proximal physis; d) epiphysiolysis before resection with continuous physeal distraction provides safe resection margins and maintains growth-plate and epiphysis; e) 3D printing may facilitate joint salvage by reconstruction with patient-specific instruments. Very short stems can be created for fixation in (epi-)metaphysis, preserving native joints; f) growing endoprosthesis can provide for remaining growth after resection of epi-metaphyseal tumours. At ten-year follow-up, limb survival was 89%, but multiple surgeries are often required; g) rotationplasty and amputation should be considered if limb salvage is impossible and/or would result in decreased function and quality of life. CONCLUSION Several biological and technological reconstruction options must be merged and used to yield best outcomes when treating young children with malignant bone tumours. LEVEL OF EVIDENCE Level V Expert opinion.
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Affiliation(s)
- Lizz van der Heijden
- Department of Orthopedic Surgery, Leiden University Medical Center, Leiden, the Netherlands,Correspondence should be sent to Lizz van der Heijden MD PhD, Department of Orthopaedic Surgery, Leiden University Medical Centre, Postal Zone J11-R70, P.O. Box 9600, 2300 RC Leiden, the Netherlands. E-mail:
| | - Germán L. Farfalli
- Department of Orthopedic Surgery, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Inês Balacó
- Department of Pediatric Orthopedics – Hospital Pediátrico, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Cristina Alves
- Department of Pediatric Orthopedics – Hospital Pediátrico, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Marta Salom
- Department of Pediatric Orthopedics, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | | | - Mikel San-Julián
- Department of Orthopedic Surgery, Clinica Universidad de Navarra, Pamplona, Spain
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Bachy M, Mascard E, Dana C, Salon A, Glorion C, Pannier S. Clinical and radiological results of vascularized fibular epiphyseal transfer after bone tumor resection in children. Orthop Traumatol Surg Res 2020; 106:1319-1324. [PMID: 33051168 DOI: 10.1016/j.otsr.2020.03.037] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Revised: 03/11/2020] [Accepted: 03/13/2020] [Indexed: 02/03/2023]
Abstract
INTRODUCTION Vascularized fibular proximal epiphyseal transfer associated to a diaphyseal segment is used to treat childhood epiphyseal defect. The aim of the present study was to analyze surgical technique and long-term clinical and radiological results. MATERIAL AND METHOD Between 1997 and 2008, 7 patients with a mean age of 5.7 years (range, 2-8 years) were operated on for bone malignancy with vascularized fibular epiphyseal transfer: 5 Ewing sarcomas and 2 osteosarcomas, located in the proximal femur (n=3), proximal humerus (n=3) or distal radius (n=1). Mean transplant size was 13.8cm. Vascularization involved a single artery in 5 cases (3 peroneal, 2 anterior tibial) and both in 2 cases. Internal fixation used intramedullary nailing in 6 cases and screwed plate in 1. All patients underwent pre- and post-operative chemotherapy following French Pediatric Oncology Society (SFOP) protocols. RESULTS Mean follow-up was 11 years (range, 3 years 11 months to >17 years). All patients were alive and in tumor remission. Reconstructed joint function was satisfactory in 85% of cases. Graft thickening indicated integration in all cases. The transferred cartilage had recovered growth in 4 cases. Complications comprised postoperative infection (n =1), consolidation defects (n = 2), fractures (n = 8), malalignment requiring surgical revision (n = 1), and spontaneously resolving common peroneal nerve palsies (n = 2). DISCUSSION In young children, vascularized fibular epiphyseal transfer fills bone defect, reconstructs a functional joint and allows continued growth in the resected segment. Growth prostheses, in the authors' experience, always give poor results in this age-group, and fusion fails to address the growth problem. Patients should be informed about the risk of fracture, persisting over the long term. CONCLUSION Vascularized fibular epiphyseal transfer is a difficult technique, subject to complications, but enables reconstruction of a bone segment involving the epiphysis in young children, conserving function and growth. LEVEL OF EVIDENCE III, retrospective clinical study.
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Affiliation(s)
- Manon Bachy
- Service de Chirurgie Orthopédique Pédiatrique, Université de Paris, Hôpital Necker- Enfants Malades, AP-HP, Paris, France; Service de Chirurgie Orthopédique et Réparatrice de l'Enfant, Hôpital Armand Trousseau - Sorbonne Université, APHP, Paris, France.
| | - Eric Mascard
- Service de Chirurgie Orthopédique Pédiatrique, Université de Paris, Hôpital Necker- Enfants Malades, AP-HP, Paris, France
| | - Caroline Dana
- Service de Chirurgie Orthopédique Pédiatrique, Université de Paris, Hôpital Necker- Enfants Malades, AP-HP, Paris, France
| | - Arielle Salon
- Service de Chirurgie Orthopédique Pédiatrique, Université de Paris, Hôpital Necker- Enfants Malades, AP-HP, Paris, France
| | - Christophe Glorion
- Service de Chirurgie Orthopédique Pédiatrique, Université de Paris, Hôpital Necker- Enfants Malades, AP-HP, Paris, France
| | - Stéphanie Pannier
- Service de Chirurgie Orthopédique Pédiatrique, Université de Paris, Hôpital Necker- Enfants Malades, AP-HP, Paris, France
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Ou Q, Wu P, Zhou Z, Pan D, Tang JY. Complication of osteo reconstruction by utilizing free vascularized fibular bone graft. BMC Surg 2020; 20:216. [PMID: 33008361 PMCID: PMC7531124 DOI: 10.1186/s12893-020-00875-9] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Accepted: 09/21/2020] [Indexed: 12/19/2022] Open
Abstract
The success of free vascularized fibular bone graft (FVFBG) has accelerated the osteo reconstruction which results from trauma, resection of a tumor or an infectious bone segment, or correction of congenital deformity. But the complication behind should not be overlooked. The failure could necessitate a second surgery, which prolong the rehabilitation period and produce further health cost. Worst, the patients may suffer a permanent impaired ankle function, or a sustained morpho-functional loss on reconstructive area which are hard to save. To provide an overview of the complication related to reconstruction by FVFBG, a narrative review is conducted to identify the complications including their types and rates, the contributing factors, the approaches to measure and the techniques to avoid. Methodologically, by quick research on Pubmed and abstract reading of reviews, we characterize five reconstructive areas where FVFBG were most frequently applied: extremities, mandible, spine, osteonecrosis of femoral head, and penile. Following, the complications on different reconstructive areas are retrieved, studied and presented in five (or more specifically, six) separate sections. By the way, meaningful difference between FVFBG and other bone flap was presented in a few words if necessary. Donor-site morbidities were studied and summarized as a whole. In these literatures, the evidences documented on limb and mandibular reconstruction have the fullest detail, followed by the spine and lastly the penile. In conclusion, FVFBG, though a mature technique, needs further deep and comprehensive study and maybe device-based assistance to achieve better reconstructive effect and minimize donor-site damage.
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Affiliation(s)
- Qifeng Ou
- Department of Orthopedics, Hand and Microsurgery, Xiangya Hospital, Central South University, No.87 XiangYa Road, Changsha, 410008, Hunan, China
| | - Panfeng Wu
- Department of Orthopedics, Hand and Microsurgery, Xiangya Hospital, Central South University, No.87 XiangYa Road, Changsha, 410008, Hunan, China
| | - Zhengbing Zhou
- Department of Orthopedics, Hand and Microsurgery, Xiangya Hospital, Central South University, No.87 XiangYa Road, Changsha, 410008, Hunan, China
| | - Ding Pan
- Department of Orthopedics, Hand and Microsurgery, Xiangya Hospital, Central South University, No.87 XiangYa Road, Changsha, 410008, Hunan, China
| | - Ju-Yu Tang
- Department of Orthopedics, Hand and Microsurgery, Xiangya Hospital, Central South University, No.87 XiangYa Road, Changsha, 410008, Hunan, China.
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Barrera-Ochoa S, Soldado F, Knörr J. Eight-year follow-up after vascularized fibular epiphyseal transfer for hip reconstruction. Microsurgery 2017; 37:743-744. [PMID: 28419553 DOI: 10.1002/micr.30183] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2016] [Revised: 03/20/2017] [Accepted: 04/06/2017] [Indexed: 11/07/2022]
Affiliation(s)
- Sergi Barrera-Ochoa
- Orthopedic Surgery Department, Pediatric Upper Extremity Surgery and Microsurgery, Hospital Sant Joan de Deu, Barcelona, Spain
- Hand and Microsurgery Unit, Hospital Universitari Quiron-Dexeus, ICATME, Barcelona, 08028, Spain
| | - Francisco Soldado
- Orthopedic Surgery Department, Pediatric Upper Extremity Surgery and Microsurgery, Hospital Sant Joan de Deu, Barcelona, Spain
| | - Jorge Knörr
- Orthopedic Surgery Department, Pediatric Upper Extremity Surgery and Microsurgery, Hospital Sant Joan de Deu, Barcelona, Spain
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Microvascular Free Tissue Transfer for Head and Neck Reconstruction in Children. J Craniofac Surg 2016; 27:846-56. [DOI: 10.1097/scs.0000000000002515] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Medrykowski F, Barbary S, Gibert N, Lascombes P, Dautel G. Vascularized proximal fibular epiphyseal transfer: two cases. Orthop Traumatol Surg Res 2012; 98:728-32. [PMID: 23000036 DOI: 10.1016/j.otsr.2012.05.009] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2011] [Revised: 03/19/2012] [Accepted: 05/21/2012] [Indexed: 02/02/2023]
Abstract
Vascularized proximal fibular epiphyseal transfer in children enables reconstruction of long-bone epiphyseal defect, while conserving axial growth potential. This technique was applied in two children for diaphyseal-epiphyseal reconstruction of the proximal humerus and distal radius respectively, using a graft vascularized only by the anterior tibial artery. There were no major complications during harvesting. Both cases showed transplant growth, of a mean 0.5cm/year. Joint function in the proximal humerus reconstruction was satisfactory, with functional range of motion. In the distal radius reconstruction, range of motion was almost zero; insufficient transplant growth induced radial club hand, requiring partial correction by progressive lengthening using an external fixator. In case of severe bone loss, fibular epiphyseal-diaphyseal graft vascularized only by the anterior tibial artery is a feasible attitude.
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Affiliation(s)
- F Medrykowski
- Children's Orthopedic Surgery Department, Brabois Children's Hospital, Nancy, France.
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Soldado F, Fontecha CG, Haddad S, Corona P, Collado D, Llusá M, Rego P. Composite vascularized fibular epiphyseo-osteo-periosteal transfer for hip reconstruction after proximal femoral tumoral resection in a 4-year-old child. Microsurgery 2012; 32:489-92. [DOI: 10.1002/micr.21988] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2012] [Revised: 03/01/2012] [Accepted: 03/05/2012] [Indexed: 11/08/2022]
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