In the MRI evaluation of patients with suspected ACL injury the following results were obtained for both acute and chronic complete disruption on orthogonal (sagittal) and nonorthogonal (oblique sagittal) imaging, respectively: sensitivity, 61 (16/26) versus 100%; specificity, 70 (21/34) versus 100%; positive predictive value, 61 (16/26) versus 100%; negative predictive value 70 (24/34) versus 100%; and accuracy, 66 (40/60) versus 100%. In 12 of the 18 normal controls the ACL appeared convex toward the posterior side when the knee was extended and gradually became straight when the knee was flexed. Many imagers can perform oblique sagittal imaging, but the operator must set the proper degree of obliquity for the examination. Orthogonal imaging failed to correctly identify any of the partial ACL injuries. In 13 intact ligaments, the average number of images clearly demonstrating the entire length of the ACL was 1.77 on the coronally prescribed sequence and 1.31 on the axially prescribed images. To read the full-text of this research, you can request a copy directly from the authors. Only two patients (0.9%) were recalled for additional sequences by the radiologist, and one ACL was normal and one had a full thickness tear at arthroscopy. The anatomical and clinical aspects are also discussed so that the contribution of MRI to the diagnosis and therapeutic management of an ACL tear can be better understood. The reciprocal of T2⁎ value was correlated with that of T2 value (r = 0.886, P < 0.001). Two patients in the control population demonstrated evidence of chronic ACL tears. Side-to-side ACL volume was also well correlated (correlation=0.91, p<0.0001). The filmed ACL evaluation for complete tears and a normal ACL had a sensitivity of 100%, specificity of 97.1% and accuracy of 97.3%, slightly higher than evaluating on the monitor. An additional volume sequence was beneficial when filmed. En cas de lésion … Auteur : Docteur Philippe LORIAUT - Chirurgien Orthopédiste Paris Lilas Thirty-one patients underwent two sets of oblique sagittal T2-weighted fast spin-echo sequences to evaluate the ACL. Despite a well‐established role of ACL anatomy on its biomechanics, little is known on how ACL anatomy develops and changes during skeletal growth. The three-dimensional orientation was determined by placing paths through the ligaments and by measuring the angles between corresponding tangents and the three main imaging planes. There was no statistically significant difference in the notch width index between the sexes. However, after a typical acute ACL rupture it is not possible to measure the dimensions of the ACL itself due to concomitant or subsequent degeneration of the remaining ligamentous tissue. Greater participation has increased awareness of health and medical issues specific to the female athlete. These angles were used for oblique T2-weighted (T2w) MRI of the knees of the remaining five volunteers, and the number of slices that depicted the entire ACL was calculated. l. Stabler A, Glaser C, Reiser M. Musculoskeletal MR: lmee. Beyond the basic principles of imaging knee injuries great impact was made on the understanding of indirect or collateral findings, even in rare diseases. Dans cette vidéo, nous abordons le test de Muller, également appelé "Quadriceps active test", dans le cadre des atteintes du ligament croisé postérieur. The limited oblique T1 sequence had sensitivities and negative predictive value of over 90%, but low specificity and positive predictive values and slight interobserver reliability (Kappa 0.42, 95% CI 0.2–0.6).Conclusions AimsTo compare different supplementary MRI sequences of the ACL to arthroscopy and determine the diagnostic performance of each sequence. Experienced radiographers identified most cases requiring supplementary MRI ACL sequences. Results showed significantly higher anterior cruciate ligament injury rates in both female sports compared with the male sports. Magnetic resonance imaging (MRI) has proven to be an excellent tool in the evaluation of meniscal tears and associated pathology. Thirty patients with acute hemarthroses underwent MRI within 12 days of injury, followed by arthroscopy within 24 h of the MRI. While the knee may normally assume this amount of obliquity in the relaxed position, the orientation of the imaging plane is not guaranteed. Des séquences additionnelles suivant l'orientation spatiale théorique du LCA ont été proposées : plan coronal oblique en densité protonique, ... La distinction entre une rupture partielle et une rupture totale est importante à établir puisque elle modifie la prise en charge thérapeutique : la rupture partielle peut cicatriser avec un traitement fonctionnel, ce qui n'est pas le cas des ruptures complètes [1,42]. Diagnostic efficacy of oblique coronal magnetic resonance imaging of the knee, Magnetic resonance imaging of anterior cruciate ligament tears: Reevaluation of quantitative parameters and imaging findings including a simplified method for measuring the anterior cruciate ligament angle, Cruciate and Posterolateral Corner Injuries in the Athlete: Clinical and Magnetic Resonance Imaging Features, Side-to-side differences in anterior cruciate ligament volume in healthy subjects. The entire ACL and the meniscus were imaged by oblique sagittal and midsagittal PD-FS, respectively, with the following parameters: TR/TE = 3000/33 ms, field of view (FOV) = 150 × 150 mm, slice thickness = 4 mm, matrix = 320 × 240, pixel size = 0.6 × 0.5 × 4.0 mm, number of excitations = 1, flip angle = 150 degrees, bandwidth = 240 Hz/pixel, and scan time = 2:32 min, ... MRI has a high diagnostic performance for complete ACL ruptures 4 . The results of this study show that the volume of the contralateral ACL is a valid surrogate measure for a missing ACL on the injured side. The study had ethical approval and two hundred and thirty one consecutive prospective MRI patients with mechanical knee symptoms (77 females, 154 males, of mean age 43.5, range 18–82 years) gave written informed consent. The anterior cruciate ligament (ACL) and posterior cruciate ligament (PCL) are important stabilizers of the knee. Il chemine vers le haut, l'avant et le côté pour s'insérer dans la partie antérieure latérale du condyle médial du fémur. The early degeneration could occur in various knee cartilage compartments after acute ACL rupture, especially in the superficial layer of LT. T2⁎-mapping might be more sensitive in detecting deep layer of cartilage than T2-mapping. The male players were taller and heavier than their female counterparts, although they had 11% less body fat. Particular emphasis is put on the evaluation of three different quantitative parameters, including a simplified method for measuring the ACL angle. Eur White LM, Miniaci A. Cmciate and posterolateral corner injuries ln MR imaging has the potential to accurately identify these ligamentous injuries, as well as other potential associated combined injuries of the knee, with information from MR imaging examination assisting in decision-making and planning with regard to potential clinical and/or surgical patient management. Results With a threshold value of 45 degrees the ACL angle reached a sensitivity and specificity of 100% for detecting ACL tears. Improvements in the quality of MRI images (1.5 and 3 Tesla, multichannel knee coils) with thin slice acquisitions in the plane of the ACL (coronal oblique or sagittal oblique, or water sensitive 3D sequences), ... Each participant was required to rest for 30 min prior to the knee scan to ensure that the cartilage is at resting condition. You can request the full-text of this article directly from the authors on ResearchGate. Elle est particulièrement incontournable pour le bilan du pivot central et des lésions méniscales éventuellement associées. Oblique sagittal images parallel to the ACL were obtained at various flexed angles of the knee joint. The template can be reproduced by photocopying the diagram provided onto a transparency. We performed a 5-year evaluation of anterior cruciate ligament injuries in collegiate men's and women's soccer and basketball programs using the National College Athletic Association Injury Surveillance System. The elevated percentages of T2 and T2⁎ value in superficial LT were most significant (20.738%, 17.525%). Magnetic resonance imaging (MRI) can diagnose cruciate ligament injuries with high accuracy. Magnetic resonance images of 269 unique knees (3‐18 years old; 51% female) were used to measure ACL length, cross‐sectional area, length‐to‐cross‐sectional area ratio, and elevation angles. This pictorial essay reviews the MRI appearance of normal and injured cruciate ligaments. The anterior cruciate ligament, when adjustments have been made for body weight, is smaller in female athletes, and therefore, probably does not compensate for the lack of stiffness and strength. Methods: MRI enables the exact determination of the three-dimensional orientation of the lateral ankle ligaments. The contralateral ACL may be an appropriate surrogate for measuring, Access scientific knowledge from anywhere. The angles deviating from the axial imaging plane were 18.0 degrees for the anterior talofibular ligament, 52.3 degrees for the calcaneofibular ligament and 28.2 degrees for the posterior talofibular ligament. Twenty healthy volunteers without previous injury to the ankle were included in the study. One hundred matched high school basketball players, 50 male and 50 female, were evaluated with anthropometric measurements, body fat analysis, muscle strength evaluation, and magnetic resonance imaging measurements of the intercondylar notch and cross-sectional area of the anterior cruciate ligament at the outlet. An accurate diagnosis of cruciate ligament injuries is vital in patient care. However, ACL abnormalities and secondary findings, alone or combined, failed to surpass the diagnostic value of the ACL angle for predicting ACL tears. Secondly, either volume sequence (DESS or FLASH) could be used as the supplementary sequence, to evaluate the ACL, but a limited oblique T1 sequence of the intercondylar notch cannot be recommended. Son rôle est de maintenir le tibia sous le fémur : - il contrôle le "TIROIR POSTERIEUR" Ses attaches sont derrière le tibia et sur le condyle interne du fémur. Objectives This study was undertaken to evaluate the diagnostic efficacy of additional oblique coronal magnetic resonance (MR) imaging of the knee for the grading of anterior cruciate ligament (ACL) injury. All rights reserved. ... Les séquences habituelles pour les IRM de genou sont : le T1 sagittal [3], la densité protonique avec saturation de la graisse (DP FS) dans les trois plans axial, coronal et sagittal [28]. They then had a knee arthroscopy within seven days of the MRI. This article discusses the MR imaging and clinical features of sports-related injuries of the cruciate ligaments and posterolateral corner of the knee, highlighting the implications of such injuries on joint function. In 15 of the 22 ACL graft patients the grafts appeared straight when the knee was extended and became convex toward the anterior side when the knee was flexed. The arthroscopy was normal and the radiographers correctly did not scan the extra sequence in 140 patients (72%) who then had normal arthroscopies. Of these, 10 patients had a partial and 12 complete ACL tears. Les aspects anatomiques et cliniques sont également exposés afin de mieux comprendre l’apport de l’IRM dans la conduite diagnostique et dans la prise en charge thérapeutique de la rupture du LCA. The MR examinations included routine sequences and oblique coronal T2-weighted images, which oriented in parallel to the course of the femoral intercondylar roof. With the right ankle in the normal anatomic position stabilized in a splint, coronal T2-weighted spin-echo sequences (TSE) were obtained. In this article the spectrum of disorders of the knee are reviewed and an overview of the current literature is given. In the evaluation of partial ACL injury, four partial tears were correctly diagnosed on nonorthogonal MRI, with one false-positive diagnosis. II-Biomécanique du compartiment interne On distingue, sur la face interne du genou, un plan superficiel, le ligament collatéral médial proprement dit, et un plan profond capsulaire avec trois chefs : § Le chef moyen : renforcement profond du ligament collatéral médial § Le chef postérieur : le ligament postérieur oblique du Hughston. Use of the monitor can offer some benefits. The usual MRI sequences for the knee are sagittal T1 [6], and proton density-weighting with fat saturation (PD fat-sat) in the three axial, coronal and sagittal planes. Meanwhile, patients exhibited higher T2⁎ values in deep layers of lateral tibiofemoral joint. The extent and severity of such injuries may have important implications with regard to potential return to athletic pursuits as well as impacting upon activities of daily life. The knee cartilage was segmented into six compartments, including lateral femur (LF), lateral tibia (LT), medial femur (MF), medial tibia (MT), trochlea (Tr), and patella (Pa). Women's participation in intercollegiate athletics has increased dramatically in recent years. Methods Le LIGAMENT CROISE POSTERIEUR (LCP) est un des ligaments croisés du genou. A normal ACL was found in 16.6% (5/30) of patients. Some reports have noted a higher susceptibility to knee injury, specifically injuries to the anterior cruciate ligament, in female athletes as compared with their male counterparts. We performed a prospective study based on the hypothesis that physiologic differences exist between men and women in strength after adjustments for body weight; that the size of the anterior cruciate ligament is proportionate to the strength of its antagonists, the quadriceps muscles; and that women have a relatively small anterior cruciate ligament, thus predisposing them to a disproportionate number of anterior cruciate ligament injuries. To ascertain whether radiographers could identify patients requiring supplementary MRI sequences of anterior cruciate ligament (ACL) tears, without a supervising radiologist.Methods Twenty-three patients and 23 healthy controls were enrolled and underwent quantitative MRI examination. Les entorses du Ligament Croisé Postérieur. Full-length visualization of the ACL was demonstrated by 1.4 slices using the sagittal oblique plane prescribed for RFL-1, 2.4 slices using the sagittal oblique plane prescribed for RFL-2, and 1.4 slices using the coronal oblique plane prescribed for RFL-3. This study examined whether the ACL volume is significantly different between the left and right knees of uninjured subjects. If they identified no ACL, then two 3D volume sequences (Dual Echo Steady State and Fast Low Angle Shot) and 2D limited sagittal oblique T1 sequences were also performed. Between 10 degrees and 20 degrees of external rotation of the knee is considered ideal. This was a pragmatic study to see if the six general MRI radiographers, each with over four years experience, could evaluate the ACL on routine orthogonal sequences (sagittal T1, Gradient Echo T2, Coronal STIR and axial fat suppressed dual echo). Results: anatomical dimensions, but it remains unknown whether side-to-side differences preclude using the contralateral as a valid surrogate for the ruptured ACL. Despite similar ACL size between males and females at early ages, adolescent males had significantly longer and thicker ACLs compared to the age‐matched females (P<0.05). One oblique was prescribed from a coronal localizing sequence, while the other was prescribed off an axial series. The ACL angle may be confidently measured in a single MRI section and can be considered to be the most reliable quantitative parameter for detecting ACL tears. The trends seen in normalized ACL size measurements suggest that unlike ACL cross‐sectional area, ACL length is primarily controlled by body size. The radiographers did perform additional ACL sequences in 63 patients (27%). The mean ACL volume was not significantly different (p=0.2331) between the two sides in this population. The imaging diagnosis should be based on primary signs, although the secondary signs are sometimes useful, particularly in chronic cases. Using the calculated angles, full-length visualization of the lateral ligaments of the ankle was achieved. To investigate the three-dimensional (3D) course of the anterior cruciate ligament (ACL) and determine the optimum planes for oblique full-length MRI of the ligament. The objective of this review is to present the various direct and indirect MRI signs of tearing of the anterior cruciate ligament (ACL) and then describe the lesions associated with it. Objective (average number of images to demonstrate ACL) and subjective (radiologist's confidence level) evaluations of both sequences were performed independently of the other and then comparatively by two radiologists. When faced with a clinical suspicion of knee ligament injury, MRI nowadays has a central role in the diagnostic strategy. It is concluded that the morphological changes seen on MR images of ACL grafts from when the knee is extended to when the knee is flexed are different from those in the normal ACL. This article is protected by copyright. To determine the three-dimensional orientation of the lateral ankle ligaments with MRI. A controlled, prospective study of 30 patients with suspected acute internal derangement of the knee was undertaken to evaluate the sensitivity, specificity, predictive value, and accuracy of nonorthogonal (oblique) sagittal magnetic resonance imaging (MRI) in the assessment of anterior cruciate ligament (ACL) injuries. The C-shaped fibrocartilaginous menisci aid in joint stabilization and load transmission. Volume sequences had specificities and accuracies over 95%, with good intraobserver reliability (Kappa 0.859, 95% CI 0.705-1.0). The weighted kappa scores (kappaws) were 0.752 (reader 1) and 0.784 (reader 2) by routine knee MR imaging only; with additional oblique coronal imaging, the kappaws increased to 0.809 (reader 1) and 0.843 (reader 2). Firstly, we have shown pragmatically that experienced radiographers identified almost all cases requiring supplementary MRI ACL sequences, without over scanning or needing supervision. Further investigations are required to identify the intrinsic and extrinsic factors responsible for these discrepancies. Magnetic resonance imaging is the most sensitive, specific, and accurate noninvasive method for diagnosing internal derangement of the knee. Male players had statistically greater quadriceps and hamstring muscle strength than female players, even when adjustments were made for body weight. Angles between these tangents and reference lines RFL-1 (the line connecting the posterior edges of the femoral condyles), RFL-2 (the line through the intercondylar joint space), and RFL-3 (the line connecting the anterior and posterior edge of the medial tibial condyle) were measured. Smaller ACLs and lower cross‐sectional growth rate observed in females may be contributing factors to the higher risk of ACL injuries in females. With a threshold value of 0 degrees the Blumensaat angle had a sensitivity of 90% and a specificity of 98%. All rights reserved. With adjustments for body weight, the size of the anterior cruciate ligament in girls was found to be statistically smaller than in boys. Of the secondary findings anterior tibial displacement was the best predictor of ligamentous injury. ACL-ruptured patients showed higher T2 and T2⁎ values in full-thickness and superficial layers of medial and lateral tibiofemoral joint. During the past 15 years knowledge of pathologic conditions of the knee had evolved significantly. Discontinuity was found to be the most useful of the ACL abnormalities. Oblique sagittal images prescribed off a coronal localizer are both subjectively and objectively more effective than axially prescribed sagittal obliques in evaluating the ACL. Il est mis sous tension maximale lors de la flexion de 90-120° du genou et se trouve plus relâché en … These ligaments are commonly injured in sports and motor vehicle accidents. 3D paths along the course of the ACL and corresponding tangents were constructed. L'amélioration de la qualité des images IRM (1,5 et 3 Tesla, antenne genou ... excellent MR imaging of the entire length of the anterior cruciate ligament in its oblique sagittal plane. This includes considerations about how to achieve a high-standard MR imaging study of the knee, and principles of imaging anterior cruciate ligament and meniscal tears. Two hundred and thirty-one consecutive patients (77 females; 154 males; average age 43.5, range 18 to 82 years; 205 with chronic, 20 acute, and 6 acute on chronic symptoms) underwent knee arthroscopy for mechanical symptoms within a week of MRI. Examination of anterior cruciate ligament (ACL) anatomy is of great interest both in studying injury mechanisms and surgical reconstruction. Accurate interpretation of the MRI examination requires a meticulous MRI technique, knowledge of the imaging anatomy, and understanding of the lesion appearance. © 2008-2020 ResearchGate GmbH. The study data support our hypothesis that sex differences in anterior cruciate ligament tear rates are caused primarily by several interrelated intrinsic factors. With an increasing number of people participating in recreational and competitive sporting activities, sports-related injuries of the knee and knee ligaments have increased in incidence. Se connecter avec Facebook Ligament croisé postérieur - Ligamentum cruciatum posterius Structures anatomiques The severity of the ACL injury was graded using a 4-point system from MR images, namely, intact, low-grade partial tear, high-grade partial tear, and complete tear, and results were compared with arthroscopic findings. Volume sequences including partial tears, had specificities and accuracies over 94%, with substantial interobserver agreement (Kappa 0.86, 95% CI 0.71–1.0). Observed changes in ACL cross‐sectional area‐to‐length ratio indicate that age‐ and sex‐dependent changes in ACL size are not homogenous. Patients requiring extra sequences, missed by the radiographers, were recalled. The mean angles to the ACL were 74.0 degrees for RFL-1, 79.9 degrees for RFL-2, and 70.4 degrees for RFL-3. Meniscal tears are among the most common etiologies of knee pain and suspected meniscal tears are the most common indication for MRI of the knee. tl'e athlete: clinical and magnetic resonance irnaging features. T2 and T2⁎ values were measured in full-thickness as well as superficial and deep layers of each cartilage compartment. Eighteen normal controls and 22 ACL graft patients were studied. Differences of T2 and T2⁎ values between patients and controls were compared using unpaired Student's t-test, and the correlation between their reciprocals was analyzed using Pearson's correlation coefficient. The ACL evaluation for complete tears and a normal ACL on the volume sequences had a sensitivity of 100%, specificity of 97% and accuracy of 97%, excluding partial tears. In particular, it is essential for assessing the cruciate ligaments and any associated meniscal tears. A focus is put on distinct diseases including intra-articular and intraosseous ganglion cysts, iliotibial band friction syndrome, transient osteoporosis, osteonecrosis, osteochondritis dissecans, and imaging of the articular cartilage. There were no sex differences in ACL elevation angles (P >0.2) except for larger coronal elevation in 7‐10 years old females compared to age‐matched males (P = 0.012). The ACL is best depicted using a sagittal oblique imaging plane angled at 80 degrees from a line through the intercondylar joint space. Apport de l’IRM dans le diagnostic des ruptures traumatiques du ligament croisé antérieur, The contribution of MRI to the diagnosis of traumatic tears of the anterior cruciate ligament, Quantitative T2-Mapping and T2 ⁎ -Mapping Evaluation of Changes in Cartilage Matrix after Acute Anterior Cruciate Ligament Rupture and the Correlation between the Results of Both Methods, Diagnostic performance of volume and limited oblique MRI of the anterior cruciate ligament compared to knee arthroscopy, Age‐Related Changes in ACL Morphology During Skeletal Growth and Maturation Are Different Between Females and Males, Radiographer led supplementary anterior cruciate ligament MRI sequences: Technical report, Magnetic Resonance Imaging of Cruciate Ligament Injuries of the Knee, MRI of the lateral ankle ligaments: Value of three-dimensional orientation, Anterior cruciate ligament: Oblique sagittal MR imaging, Accuracy of nonorthogonal magnetic resonance imaging in acute disruption of the anterior cruciate ligament, Oblique Sagittal MRI of Anterior Cruciate Ligament, Knee Injury Patterns Among Men and Women in Collegiate Basketball and Soccer: NCAA Data and Review of Literature, MRI of normal anterior cruciate ligament (ACL) and reconstructed ACL: Comparison of when the knee is extended with when the knee is flexed, Correlation of Anthropometric Measurements, Strength, Anterior Cruciate Ligament Size, and Intercondylar Notch Characteristics to Sex Differences in Anterior Cruciate Ligament Tear Rates, Oblique sagittal view of the anterior cruciate ligament: Comparison of coronal vs. axial planes as localizing sequences, Grading of anterior cruciate ligament injury. Interobserver agreements for routine knee MR imaging and additional coronal imaging were considered to be "very good" (kappaw = 0.851, 0.868, respectively). In the acute hemarthrosis patient population, the incidence at arthroscopy of acute complete ACL tears was 60% (18/30); of partial ACL tears, 13.3% (4/30); and of chronic tears, 10% (3/30). Weighted kappa statistics were used to analyze the diagnostic accuracy of routine knee MR imaging with and without additional oblique coronal imaging. The purpose of this study was to evaluate, using MRI, the morphology of normal anterior cruciate ligament (ACL) and ACL grafts when the knee was extended compared with when the knee was flexed. Elles sont rares et souvent traumatiques pour ne pas dire qu'elles font suite à un accident de la circulation comme le tibia du motard qui bute contre un pare choc...anecdotiquement une chute sur les genoux pliés qui va faire fortement reculer le tibia sous le femur. Nevertheless, the ACL may not always be visualised. We retrospectively reviewed MR images of the knee in 169 patients. The MRI sequences were evaluated in a blinded fashion by three radiologists, and compared to the knee arthroscopy findings, with the normal ACL acting as internal controls. We believe that we have demonstrated the superiority of T2-weighted nonorthogonal sagittal over conventional orthogonal sagittal ACL MRI in the evaluation of ACL injury. We hypothesized that ACL size and orientation will change by age during skeletal growth and maturation with different trends in males versus females. Semin Musculoskel Radiol 2OO4;8: I I l-131. The purpose of this study was to determine whether oblique sagittal T2-weighted images of the anterior cruciate ligament (ACL) are better prescribed off axial or coronal localizing images. Spin-echo (SE) T1-weighted images (TR 330 ms/TE 15 ms, NEX 1) were obtained with a slice thickness of 3 mm. To quantitatively assess changes in cartilage matrix after acute anterior cruciate ligament (ACL) rupture using T2- and T2⁎-mapping and analyze the correlation between the results of both methods. The detection of associated injuries of other structures of the knee, including menisci, collateral ligaments, cartilage, and bone, are also important. This non-invasive, in vivo technique for measuring ACL volume may prove useful in future large-scale comprehensive studies of potential risk factors for ACL rupture, in quantifying potential loading effects on ACL size as a prophylactic measure against ACL rupture, and in the use of ACL volume as a screening tool for assessing risk of injury. We describe a simple technique that consistently produces excellent MR imaging of the entire length of the anterior cruciate ligament in its oblique sagittal plane. Possible causative factors for this increase in anterior cruciate ligament injuries among women may be extrinsic (body movement, muscular strength, shoe-surface interface, and skill level) or intrinsic (joint laxity, limb alignment, notch dimensions, and ligament size). Axial proton density-weighted (PDw) images of the knees of 20 volunteers were obtained. Many strategies have been used to improve the visualisation of the ACL including sagittal, coronal oblique sequences, and 3D volume imaging. Most importantly, stiffness and muscular strength increase stress on the anterior cruciate ligament in female athletes.

ligament oblique postérieur genou

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