1
|
Morita Y, Tajima T, Yamaguchi N, Yokoe T, Nagasawa M, Ota T, Ouchi K, Chosa E. Risk factors of failure results after double-bundle reconstruction with autogenous hamstring grafts for isolated posterior cruciate ligament rupture cases. Sci Rep 2024; 14:6192. [PMID: 38486115 PMCID: PMC10940282 DOI: 10.1038/s41598-024-56953-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Accepted: 03/13/2024] [Indexed: 03/18/2024] Open
Abstract
Posterior tibial translation (PTT) after double-bundle posterior cruciate ligament (PCL) reconstruction has sometimes occurred. Purpose of this study is to identify the risk factors for postoperative PTT after double-bundle PCL reconstruction with a hamstring autograft. Comparing the results of bilateral gravity sag view (GSV) at 12 months after surgery, over 5-mm PTT was defined as 'failure' in this study. Of 26 isolated PCL reconstruction cases, over 5-mm PTT was seen in 7 cases (group F: 9.57 ± 1.28 mm), and 19 cases had less than 5 mm (group G: 2.84 ± 1.29 mm). Age, sex, body mass index (BMI), preoperative GSV, posterior slope angle of the tibia, anterolateral bundle (ALB) and posteromedial bundle (PMB) graft diameters, and tibial tunnel diameter were evaluated. The two groups were compared with the 2 × 2 chi-squared test, the Mann Whitney U-test, and Spearman's rank correlation coefficient. Multivariate logistic regression analysis was also performed to determine the risk factor. Statistical significance was indicated as p < 0.01 for correlation with postoperative PTT, and as p < 0.05 for all other comparisons. Mean age (group G 31.8 ± 12.5 vs group F 34.9 ± 15.9 years), sex (male/female: 15/4 vs 3/4), BMI (25.6 ± 4.6 vs 24.9 ± 3.9 kg/m2), preoperative GSV (11.3 ± 2.2 vs 11.6 ± 2.9 mm), PMB diameter (5.37 ± 0.33 vs 5.36 ± 0.48 mm), and tibial tunnel diameter (9.32 ± 0.58 vs 9.29 ± 0.49 mm) showed no significant differences. ALB diameter was significantly greater in group G (7.0 ± 0.5 mm) than in group F (6.5 ± 0.29 mm; p = 0.022). There was also a significant difference in posterior tibial slope angle (group G 9.19 ± 1.94 vs group F 6.54 ± 1.45, p = 0.004). On Spearman rank correlation coefficient analysis, ALB diameter GSV (correlation coefficient: - 0.561, p = 0.003) and posterior tibial slope angle (correlation coefficient: - 0.533, p = 0.005) showed a significant correlation with postoperative PTT. Multivariate logistic regression analysis showed that ALB diameter (OR 19.028; 95% CI 1.082-334.6; p = 0.044) and posterior slope angle of tibia (OR 3.081; 95% CI 1.109-8.556; p = 0.031) were independently associated with postoperative PTT, respectively. In double-bundle PCL reconstruction with hamstring, smaller ALB graft diameter and lower (flatted) tibial slope angle were considered risk factors for postoperative PTT.
Collapse
Affiliation(s)
- Yudai Morita
- Division of Orthopedic Surgery, Department of Medicine of Sensory and Motor Organs, Faculty of Medicine, University of Miyazaki, 5200 Kihara, Kiyotake, Miyazaki, 889-1692, Japan
| | - Takuya Tajima
- Division of Orthopedic Surgery, Department of Medicine of Sensory and Motor Organs, Faculty of Medicine, University of Miyazaki, 5200 Kihara, Kiyotake, Miyazaki, 889-1692, Japan.
| | - Nami Yamaguchi
- Division of Orthopedic Surgery, Department of Medicine of Sensory and Motor Organs, Faculty of Medicine, University of Miyazaki, 5200 Kihara, Kiyotake, Miyazaki, 889-1692, Japan
| | - Takuji Yokoe
- Division of Orthopedic Surgery, Department of Medicine of Sensory and Motor Organs, Faculty of Medicine, University of Miyazaki, 5200 Kihara, Kiyotake, Miyazaki, 889-1692, Japan
| | - Makoto Nagasawa
- Division of Orthopedic Surgery, Department of Medicine of Sensory and Motor Organs, Faculty of Medicine, University of Miyazaki, 5200 Kihara, Kiyotake, Miyazaki, 889-1692, Japan
| | - Tomomi Ota
- Division of Orthopedic Surgery, Department of Medicine of Sensory and Motor Organs, Faculty of Medicine, University of Miyazaki, 5200 Kihara, Kiyotake, Miyazaki, 889-1692, Japan
| | - Kouki Ouchi
- Division of Orthopedic Surgery, Department of Medicine of Sensory and Motor Organs, Faculty of Medicine, University of Miyazaki, 5200 Kihara, Kiyotake, Miyazaki, 889-1692, Japan
| | - Etsuo Chosa
- Division of Orthopedic Surgery, Department of Medicine of Sensory and Motor Organs, Faculty of Medicine, University of Miyazaki, 5200 Kihara, Kiyotake, Miyazaki, 889-1692, Japan
| |
Collapse
|
2
|
Hinarejos P, Leal-Blanquet J, Fraile-Suari A, Sánchez-Soler J, Torres-Claramunt R, Monllau JC. Increased posterior translation but similar clinical outcomes using ultracongruent instead of posterior stabilized total knee arthroplasties in a prospective randomized trial. Knee Surg Sports Traumatol Arthrosc 2022; 30:3041-3048. [PMID: 34436635 DOI: 10.1007/s00167-021-06710-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Accepted: 08/14/2021] [Indexed: 12/22/2022]
Abstract
PURPOSE The aim of this study was to compare the posterior tibial translation after ultracongruent (UC) and posterior-stabilized (PS) total knee arthroplasty (TKA) with two different UC with different heights in the anterior lip, and two different PS designs. This study also aimed to compare the range of motion (ROM) and outcomes scores after the use of these TKA models. It was hypothesised less posterior tibial translation after PS than after UC TKA, and less posterior tibial translation with a higher anterior lip in the UC insert than with a lower one. METHODS It was designed as a prospective randomized study of a group of 120 patients operated with a cemented TKA. To clarify the main purpose of the study, four groups were analysed using different polyethylene designs: Triathlon PS insert in group one, Triathlon UC insert in group two, U2 PS insert in group three and U2 UC insert in group four. One year after surgery, a forced posterior drawer with a Telos Stress applying 15 kg of force posteriorly on the proximal tibia at 90° of knee flexion was analysed in the lateral radiograph. Limb alignment, tibial posterior slope and posterior condylar offset were also studied. RESULTS 30 patients were included in each group. The average age was 73 years. There were 72.2% female and 27.8% male patients. There were no significant differences in any demographic or radiographic studied variables, preoperative range of motion (ROM) or preoperative Knee Society Scores (KSS) among the different groups. One year after surgery, the average postoperative ROM and the postoperative KSS Knee and KSS Function scores improved in respect of the preoperative values in all the groups. There were no significant differences in the postoperative outcome scores among the different groups (p = n.s.). Postoperative alignment of the limb, tibial posterior slope and posterior condylar offset were similar in the 4 study groups (p = n.s.). The postoperative posterior tibial translation was different between groups: the PS groups (groups 1 and 3) showed significant inferior values (p < 0.001) in respect of the UC groups (groups 2 and 4). There were no differences between both groups of PS models, but there was a significant increase in the posterior tibial translation of the Triathlon UC insert (11.2 mm SD 3.2) in respect of the U2 UC insert (6.1 mm SD 4.5) (p = 0.004). CONCLUSIONS UC inserts restrict the posterior tibial translation after TKA less than PS inserts, but a design with a high anterior lip in the polyethylene UC insert can better control the posterior tibial translation than an insert with a small anterior lip. LEVEL OF EVIDENCE Level I. Randomised controlled trial.
Collapse
Affiliation(s)
- Pedro Hinarejos
- Department of Orthopedic Surgery, Parc de Salut Mar, Hospital de l'Esperança, Sant Josep de la Muntanya 12, 08024, Barcelona, Spain. .,Universitat Autonoma de Barcelona, Barcelona, Spain.
| | - Joan Leal-Blanquet
- Department of Orthopedic Surgery, Hospital d'Igualada, Consorci Sanitari de L'Anoia, Av. Catalunya, 11, 08700, Igualada Barcelona, Spain
| | - Anna Fraile-Suari
- Department of Orthopedic Surgery, Hospital Sant Camil, Ronda Sant Camil S/N, 08810, Sant Pere de Ribes, Barcelona, Spain
| | - Juan Sánchez-Soler
- Department of Orthopedic Surgery, Parc de Salut Mar, Hospital de l'Esperança, Sant Josep de la Muntanya 12, 08024, Barcelona, Spain
| | - Raul Torres-Claramunt
- Department of Orthopedic Surgery, Parc de Salut Mar, Hospital de l'Esperança, Sant Josep de la Muntanya 12, 08024, Barcelona, Spain
| | - Juan Carlos Monllau
- Department of Orthopedic Surgery, Parc de Salut Mar, Hospital de l'Esperança, Sant Josep de la Muntanya 12, 08024, Barcelona, Spain.,Universitat Autonoma de Barcelona, Barcelona, Spain
| |
Collapse
|
3
|
Gwinner C, Jung TM, Schatka I, Weiler A. Posterior laxity increases over time after PCL reconstruction. Knee Surg Sports Traumatol Arthrosc 2019; 27:389-396. [PMID: 29968188 DOI: 10.1007/s00167-018-5035-y] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2017] [Accepted: 06/25/2018] [Indexed: 11/25/2022]
Abstract
PURPOSE Restoration of posterior tibial translation (PTT) after reconstruction of the posterior cruciate ligament (PCL) is deemed necessary to restore physiological knee kinematics. However, current surgical techniques have failed to show a complete reduction of posterior laxity. It was hypothesized that early postoperative PTT increases over time. METHODS The study comprised of 46 patients (10 female, 36 male; 30 ± 9 years), who underwent PCL reconstruction in a single-surgeon series. Patients were evaluated by bilateral stress radiographs in a prospective manner preoperatively; at 3, 6, 12 and 24 months; and at a final follow-up (FFU) of at least 5 years. Covariants included age, gender, BMI, tibial slope (TS) and the number of operated ligaments. Two blinded observers reviewed all radiographs, evaluating the TS and the posterior tibial translation. RESULTS All patients were evaluated at a mean final follow-up of 102 (range 65-187) months. Mean side-to-side difference of the PTT significantly improved from preoperative to 3-month postoperative values (10.9 ± 3.1 vs. 3.6 ± 3.8 mm; P < 0.0001). The PTT increased to 4.6 ± 3.7 mm at 6 months, to 4.8 ± 3.3 mm at 12 months, to 4.8 ± 3.2 mm at 24 months, to 5.4 ± 3.4 mm at FFU. Consequently, there was a significant increase of PTT between 3-month and final follow-up (3.6 ± 3.8 vs. 5.4 ± 3.4 mm; P = 0.02). Flattening of the TS resulted in a significantly higher PTT compared to subjects with a high TS at 24 months and FFU. There was no significant influence by BMI, age, gender and the number of operated ligaments. CONCLUSIONS Early results after PCL reconstruction seem promising as posterior tibial translation is significantly improved. However, there is a significant increase in PTT from early postoperative values to the final follow-up of at least 5 years. This is particularly notable in patients with flattening of the TS. As a consequence, surgeons and patients need to be aware that initial posterior stability should not be equated with the final outcome. LEVEL OF EVIDENCE Cohort study, Level III.
Collapse
Affiliation(s)
- Clemens Gwinner
- Center for Musculoskeletal Surgery, Charité-University Medicine Berlin, Augustenburger Platz 1, 13353, Berlin, Germany.
| | - Tobias M Jung
- Center for Musculoskeletal Surgery, Charité-University Medicine Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Imke Schatka
- Center for Diagnostic and Interventional Radiology and Nuclear Medicine, Charité-University Medicine Berlin, Berlin, Germany
| | | |
Collapse
|
4
|
Schatka I, Weiler A, Jung TM, Walter TC, Gwinner C. High tibial slope correlates with increased posterior tibial translation in healthy knees. Knee Surg Sports Traumatol Arthrosc 2018; 26:2697-2703. [PMID: 28889191 DOI: 10.1007/s00167-017-4706-4] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2017] [Accepted: 09/04/2017] [Indexed: 11/30/2022]
Abstract
PURPOSE Notwithstanding the importance of the tibial slope (TS) for anterior tibial translation, little information is available regarding the implications on posterior laxity, particularly in healthy subjects. It was hypothesized that increased TS is associated with decreased posterior tibial translation (PTT) in healthy knees. METHODS A total of 124 stress radiographs of healthy knees were enrolled in this study. Tibial slope and the posterior tibial translation were evaluated using a Telos device with a 150-N force at 90° of knee flexion. Two blinded observers reviewed independently on two different occasions. RESULTS One hundred and twenty-four patients [35 females and 89 males; 41 (range 18-75) years] were enrolled in this study, with a mean PTT of 2.8 mm (±1.9 mm; range 0-8 mm) and a mean TS of 8.6° (±2.6°; range 1°-14°). Pearson correlation showed a significant correlation between the PTT and TS in the overall patient cohort (P < 0.0001) with r = 0.76 and R 2 = 0.58. There was no statistical difference between female and male patients regarding the PTT or the TS. Subgrouping of the patient cohort (four groups with n = 31) according to their TS (groups I < 7°; II = 7°-8.5°; III = 9°-10.5°; IV ≥ 11°) revealed significant differences between each subgroup, respectively. Furthermore, there was a weak but significant correlation between age and PTT (P = 0.004, r = 0.26). CONCLUSION In addition to the substantial variance in tibial slope and posterior laxity among healthy knees, high tibial slope significantly correlates with increased posterior tibial translation. Increasing age is further associated with a greater magnitude of posterior tibial translation. Consequently, knowledge of the tibial slope facilitates simple estimation of posterior knee laxity, which is mandatory for PCL reconstruction and knee arthroplasty.
Collapse
Affiliation(s)
- Imke Schatka
- Center for Diagnostic and Interventional Radiology and Nuclear Medicine, Charité-University Medicine Berlin, Berlin, Germany
| | | | - Tobias M Jung
- Center for Musculoskeletal Surgery, Charité-University Medicine Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Thula C Walter
- Center for Diagnostic and Interventional Radiology and Nuclear Medicine, Charité-University Medicine Berlin, Berlin, Germany
| | - Clemens Gwinner
- Center for Musculoskeletal Surgery, Charité-University Medicine Berlin, Augustenburger Platz 1, 13353, Berlin, Germany.
| |
Collapse
|
5
|
Abstract
PURPOSE OF REVIEW The purposes of this review are to (1) describe the anatomic and biomechanical rationale for high tibial osteotomy (HTO) in the setting of posterior cruciate ligament (PCL) deficiency, (2) review the indications for concomitant HTO and PCL reconstruction, (3) provide guidance for the clinical assessment of the patient with suspected PCL deficiency, and (4) summarize the key surgical steps necessary to attain the appropriate sagittal and coronal plane corrections. RECENT FINDINGS The preponderance of available biomechanical data pertaining to the PCL-deficient knee suggests that an increased proximal tibial slope limits posterior tibial translation under axial compressive loads. Moreover, recent clinical data has demonstrated that decreased proximal tibial slope may exacerbate residual anterior-posterior laxity and jeopardize the durability of PCL reconstruction. Thus, in the setting of PCL deficiency, an HTO that increases the posterior tibial slope may be advisable. HTO may be an important treatment adjunct in the surgical management of PCL deficiency. In the setting of chronic injuries and varus malalignment, HTO should be considered in order to ensure a durable ligamentous reconstruction and forestall the progression of secondary osteoarthritis.
Collapse
Affiliation(s)
- João V Novaretti
- Department of Orthopaedic Surgery, University of Pittsburgh, 3471 Fifth Avenue, Pittsburgh, PA, 15213, USA.,Orthopaedics and Traumatology Sports Center (CETE), Department of Orthopaedics and Traumatology, Paulista School of Medicine (EPM), Federal University of São Paulo, São Paulo, Brazil
| | - Andrew J Sheean
- Department of Orthopaedic Surgery, University of Pittsburgh, 3471 Fifth Avenue, Pittsburgh, PA, 15213, USA
| | - Jayson Lian
- Department of Orthopaedic Surgery, University of Pittsburgh, 3471 Fifth Avenue, Pittsburgh, PA, 15213, USA.,Albert Einstein College of Medicine, Bronx, New York, New York, USA
| | - Joseph De Groot
- Department of Orthopaedic Surgery, University of Pittsburgh, 3471 Fifth Avenue, Pittsburgh, PA, 15213, USA
| | - Volker Musahl
- Department of Orthopaedic Surgery, University of Pittsburgh, 3471 Fifth Avenue, Pittsburgh, PA, 15213, USA.
| |
Collapse
|
6
|
Heinrichs CH, Schmoelz W, Mayr R, Keiler A, Schöttle PB, Attal R. Biomechanical evaluation of a novel dynamic posterior cruciate ligament brace. Clin Biomech (Bristol, Avon) 2016; 33:20-25. [PMID: 26896691 DOI: 10.1016/j.clinbiomech.2016.02.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2015] [Revised: 01/29/2016] [Accepted: 02/01/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND Use of a rigid brace or cast immobilization is recommended in conservative treatment or postoperative rehabilitation after a posterior cruciate ligament injury. To prevent the loss of knee joint function and muscle activity often associated with this, a flexible knee brace has been developed that allows an adjustable anteriorly directed force to be applied to the calf in order to prevent posterior tibial translation. The purpose of this biomechanical study was to evaluate the impact of this novel dynamic brace on posterior tibial translation after posterior cruciate ligament injury and reconstruction. METHODS A Telos stress device was used to provoke posterior tibial translation in seven human lower limb specimens, and stress radiographs were taken at 90° of knee flexion. Posterior tibial translation was measured in the native knees with an intact posterior cruciate ligament; after arthroscopic posterior cruciate ligament dissection with and without a brace; and after posterior cruciate ligament reconstruction with and without a brace. The force applied with the brace was measured using a pressure sensor. FINDINGS Posterior tibial translation was significantly reduced (P=0.032) after application of the brace with an anteriorly directed force of 50N to the knees with the dissected posterior cruciate ligament. The brace also significantly reduced posterior tibial translation after posterior cruciate ligament reconstruction in comparison with reconstructed knees without a brace (P=0.005). INTERPRETATION Posterior tibial translation was reduced to physiological values using this dynamic brace system that allows an anteriorly directed force to be applied to the calf.
Collapse
Affiliation(s)
- Christian H Heinrichs
- Department of Trauma Surgery, Medical University of Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria.
| | - Werner Schmoelz
- Department of Trauma Surgery, Medical University of Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria.
| | - Raul Mayr
- Department of Trauma Surgery, Medical University of Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria.
| | - Alexander Keiler
- Department of Trauma Surgery, Medical University of Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria.
| | - Philip B Schöttle
- Department of Orthopaedic and Trauma Surgery, Isar Medical Center, Sonnenstrasse 24, 80331 Munich, Germany.
| | - René Attal
- Department of Trauma Surgery, Medical University of Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria.
| |
Collapse
|
7
|
LaPrade RF, Smith SD, Wilson KJ, Wijdicks CA. Quantification of functional brace forces for posterior cruciate ligament injuries on the knee joint: an in vivo investigation. Knee Surg Sports Traumatol Arthrosc 2015; 23:3070-6. [PMID: 25145947 DOI: 10.1007/s00167-014-3238-4] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2014] [Accepted: 08/11/2014] [Indexed: 12/01/2022]
Abstract
PURPOSE Counteracting posterior translation of the tibia with an anterior force on the posterior proximal tibia has been demonstrated clinically to improve posterior knee laxity following posterior cruciate ligament (PCL) injury. This study quantified forces applied to the posterior proximal tibia by two knee braces designed for treatment of PCL injuries. METHODS The forces applied by two knee braces to the posterior proximal tibia and in vivo three-dimensional knee kinematics of six adult, male, healthy volunteer subjects (mean ± standard deviation: height, 182.5 ± 5.2 cm; body mass, 83.2 ± 9.3 kg; body mass index, 24.9 ± 1.5 kg/m(2); age, 25.8 ± 2.9 years) were measured using a custom pressure mapping technique and traditional surface marker motion capture techniques, while subjects performed three functional activities. The activities included seated unloaded knee flexion, squatting, and stair descent in a new generation dynamic force (DF) PCL brace and a static force (SF) PCL brace. RESULTS During unloaded flexion at the lowest force level setting, the force applied by the DF brace increased as a function of flexion angle (slope = 0.7 N/°; p < 0.001) compared to the SF brace effect. Force applied by the SF brace did not significantly change as a function of flexion angle (slope = 0.0 N/°; n.s.). By 45° of flexion, the average force applied by the DF brace (48.1 N) was significantly larger (p < 0.001) than the average force applied by the SF brace (25.0 N). The difference in force continued to increase as flexion angle increased. During stair descent, average force (mean ± standard deviation) at toe off was significantly higher (p = 0.013) for the DF brace (78.7 ± 21.6 N) than the SF brace (37.3 ± 7.2 N). Similar trends were observed for squatting and for the higher force level settings. CONCLUSIONS The DF brace applied forces to the posterior proximal tibia that dynamically increased with increased flexion angle. Additionally, the DF brace applied significantly larger forces at higher flexion angles compared to the SF brace where the PCL is known to experience larger in situ forces. Clinical studies are necessary to determine whether the loading characteristics of the DF brace, which more closely replicated the in situ loading profile of the native PCL, results in long-term improved posterior knee laxity following PCL injury. LEVEL OF EVIDENCE II.
Collapse
Affiliation(s)
- Robert F LaPrade
- Steadman Philippon Research Institute, 181 W. Meadow Drive, Suite 1000, Vail, CO, 81657, USA. .,The Steadman Clinic, Vail, CO, USA.
| | - Sean D Smith
- Steadman Philippon Research Institute, 181 W. Meadow Drive, Suite 1000, Vail, CO, 81657, USA
| | - Katharine J Wilson
- Steadman Philippon Research Institute, 181 W. Meadow Drive, Suite 1000, Vail, CO, 81657, USA
| | - Coen A Wijdicks
- Steadman Philippon Research Institute, 181 W. Meadow Drive, Suite 1000, Vail, CO, 81657, USA
| |
Collapse
|