4 259 recog- 4 osthetic. Ertl History and Development nized thatamputations patients were with havingfunctional substantial transtibial difficulties andthe were using amputatedattachment stump as for a a passive pr of the Ertlwas technique, performed the osteoplasty withosteoperiosteal elevation sleeve of fromtibia an the and fibula distal that was suturedend at the of these two bones to seal the As early as 1920, Janos Ertl believed thatamputation provided traditional a nonphysiologic transtibial environment that was worsened by the often discordant motions ofand the fibula tibia articulations. after In the loss initial of description the distal the use of a vascularizedthe fibular presence strut, or lackosteal of sleeve, an and osteoperi- fixation the constructs use and of postoperative regimens; various these variations are major confounding influences onoutcomes patient andinvestigation. warrant further The impact of a 2 Although somewhat 3 Advances in patient care 1 espite considerable advances in limb salvage and revasculariza- Much of the current evidence Abstract Amputation may be required for managementtrauma of and lower medical extremity conditions, such asvascular neoplasm, compromise. infection, The and Ertl technique, anprocedure osteomyoplastic for transtibial amputation, can befunctional residual used limb. to Creation create of a a tibiofibular highly bonea bridge stable, provides broad tibiofibular articulation thatdistal may weight be bearing. capable Several of different some modifiedfibular techniques bridge and fixation methods have beenevidence used; exists however, regarding no comparison current of theAdditional different research techniques. is needed to elucidatepopulation, the technique, optimal and patient postoperative protocol forosteomyoplastic the transtibial Ertl amputation technique. Review Article tion techniques, amputationperformed because is the still pain-free, creation functional of residual a extrem- ity may not beclinical possible scenario owing to or the nique the used. salvage tech- lower-extremity amputationpatients should not on behowever. minimized, Thesecontinued patients will dysfunction have their throughout lifetime. and prosthetic design havepatient increased functionand after a large amputation, return number to of many, patientspreinjury activities. can if not all, of their regarding the Ertlflicting, technique and is theprocedure con- remain indications somewhat for debated. Many this different variations of thenique tech- have been described, including controversial, the Ertl techniqueosteomyoplastic amputation has for been proposed as a reconstructive method that can furthercomes of improve transtibial amputation. the out- D Osteomyoplastic Transtibial Amputation: The Ertl Technique 2016;24: the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited. ª bureau or has made paid bureau or has made paid ’ ’ Copyright Academy of Orthopaedic Surgeons. Biomet. J Am Acad Orthop Surg 259-265 http://dx.doi.org/10.5435/ JAAOS-D-15-00026 Copyright 2016 by the American presentations on behalf ofBiomet Zimmer and Depuy Synthes;serves and as a paid consultant toBiomet. Zimmer Dr. Poka orfamily an member immediate is aspeakers member of a presentations on behalf of Stryker and serves as a paid consultant to Zimmer From the Department ofSurgery, Orthopaedic Grant Medical Center, Columbus, OH. Dr. Taylor or anmember immediate has family received royaltiesZimmer from Biomet; is aspeakers member of a April 2016, Vol 24, No 4 Benjamin C. Taylor, MD Attila Poka, MD

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11-13 Figure 1 (Arthrex). To date, no clinical studies have compared the use of various fixation constructs for the synostosis in transtibial amputation.

Indications and Contraindications

The osteoplastic component of the Ertl technique adds surgical time to the procedure; however, we consider this component to be indicated for active patients who are able to regain mobility postoperatively. Patients who have had a traditional transtibial amputation may also benefit from a A, AP radiograph of the lower extremity obtained immediately postoperatively revision surgery with the Ertl tech- demonstrating an osteomyoplastic transtibial amputation. Note the placement of nique to treat symptomatic instability an autogenous fibular strut across the distal aspect of the amputated tibia and of the residual tibia and fibula, also fibula. AP (B) and lateral (C) radiographs of the extremity obtained 36 months “ ” postoperatively. known as chopsticking. Contraindications for the procedure include inadequate distal margins medullary canal and form a solid bony attention to appropriate, tension-free from an infection or neoplasm because synostosis at the distal amputation skin closure is crucial to minimize harvest of the fibula and/or periosteal stump.4 wound healing complications. sleeve requires a longer healthy limb The bone bridging (ie, osteoplastic) Later investigation on the effect of than that typically required for a tra- component remains the most recog- sealing the medullary canal revealed ditional transtibial amputation. In nizable aspect of the Ertl technique, that this closure led to a prompt early reports, the procedure was con- but descriptions of the procedure recovery of the intramedullary pressure traindicated in patients with diabetes focus equally on the evaluation and of the tibia, which was shown in several mellitus or vascular insufficiency; treatment of the soft tissues. Individ- angiographic evaluations to improve however, larger case series that ual ligation of each component of the medullary blood flow such that it included these patients revealed that neurovascular bundles is required to was comparable to that of uninjured they can undergo the procedure suc- recreate a residual limb that is as limbs.10 In addition, this closure has cessfully but may not achieve the same physiologically similar to the native been shown to increase blood flow to level of function as do patients without 9,12,14 limb as possible, with transection of the residual limb, which may have these comorbidities. all nerves done while under tension to important implications in healing.7,10 allow for proximal retraction. A The Ertl technique has continued to ’ meticulous myoplasty also is essential evolve, with the most notable alteration Authors Preferred to create a well-balanced, stable limb of the original procedure described by Technique with minimal muscle-related com- Pinto and Harris.8 Theyreportedona plaints; in fact, the myoplastic com- series of patients who underwent the Preoperative Evaluation ponent of the procedure may be just procedure with the addition of an Multimodal evaluation and treat- as important as the bony aspects. The autogenous fibular strut placed across ment is often critical for patients who myoplasty or myodesis recreates the the distal aspect of the remaining tibia are candidates for the Ertl technique, tension of muscles of normal length, and fibula (Figure 1). Pinto and Har- and the involvement of a psychologist, increases and stabilizes the surface area ris8 used heavy, nonabsorbable suture physical therapist, social worker, available for prosthetic fitting, normal- for fixation of the synostosis, but prosthetist, vascular surgeon, and izes muscle function as viewed on elec- several different fixation methods have family physician may be necessary. tromyographic testing, and improves since been described, including small Preoperative workup may also include both the arterial and venous circulation fragment screws, headless com- laboratory or vascular perfusion stud- of the residual stump.5-9 Careful pression screws, and the TightRope ies; wound healing potential can be

260 Journal of the American Academy of Orthopaedic Surgeons

Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited. Benjamin C. Taylor, MD, and Attila Poka, MD predicted with an ankle-brachial procedure. We recommend the use of and division of the neurovascular index .0.5, transcutaneous oxygen general anesthesia and a well-padded bundle in the lateral compartment. levels .20 mm Hg, a serum albumin tourniquet on the ipsilateral thigh. The deep posterior compartment is level .2.5g/dL,andanabsolute A long posterior flap is created unless transected at the level of the tibial cut, lymphocyte count .1,500/mL.15 previous scars, wounds, or other fac- and the superficial posterior com- Finally, the surgeon should have an tors require an alteration of the flap partment is then sharply beveled honest and candid discussion with the design. In these cases, vascular-based from the tibial cut to the level of the patient and his or her family regarding skew flaps, fish mouth flaps, long skin incision for the posterior flap. the procedure, its inherent limitations, medial flaps, or sagittal flaps may be The posterior neurovascular bundle and the inability to eliminate all pain; used. To create a long posterior flap, the is identified and carefully separated, the value of fostering realistic patient anterior incision is drawn at the level of ligated, and divided. The tibial nerve expectations regarding such a pro- the intended tibial resection, with the should be cut as proximally as pos- cedure has been well documented.16 posterior incision drawn approxi- sible, whereas the posterior tibial As with any surgery, a successful mately 1 cm distal than the diameter of artery and vein should be divided as outcome is built on the foundation of thelegatthelevelofthetibialcut17 distally as possible to protect the a carefully constructed preoperative (Figure 2). The apex of the incision vascularity of the posterior muscu- plan. High-quality biplanar radio- is ,90° to minimize creation of locutaneous flap. The amputated graphs of the knee, tibia, and ankle protruding skin, or “dog ears.” The portion of the limb is then removed should be obtained, and additional anterior incision is carried through the from the operating table; bone graft advanced imaging studies (eg, MRI, anterior fascia, and the musculature of often can be harvested from the distal CT, white blood cell–tagged studies) the anterior compartment is sharply tibia or calcaneus to augment the should be reviewed in developing the transected inline with the incision. The bone bridge of the amputation or for surgical plan. The surgeon should anterior neurovascular bundle is then other concurrent orthopaedic proce- have information on any retained separated and ligated; we minimize dures.9 The sural nerve is identified orthopaedic implants should intra- formation of symptomatic neuroma by in the subcutaneous posterior flap, operative removal become necessary. ligating each nerve as proximal as and the nerve is transected via a Previous incisions, scars, and mus- possible to decrease vascularity of the limited anterior approach.18 cular flaps must be examined to end of the transected nerve and by A second fibular osteotomy is then ensure that the tissue is adequate for sharply cutting the nerve while it is made at the level of the tibial cut, and use. At the end of the procedure, under tension to allow it to retract the intact fibula and distal tibia are a minimum of 10 to 15 cm of proximally. After division of the notched with a high-speed burr to cre- residual tibial length is necessary for anterior compartment is complete, the ate a tight-fitting space for placement of an optimal prosthetic fit; if this saphenous nerve is identified and the fibular autograft (Figure 2). Once length is not available, other surgical treated in the same fashion. the distal tibia is shaped appropriately, options may be necessary. Con- The site for the tibial incision is eight 2.0-mm holes are drilled for versely, excessive residual tibial identified and, provided that the con- suture passage: two in the medial length can lead to delayed stump ditions of the distal bone and soft tissue distal tibia, two in the medial edge of breakdown from decreased muscle allow, an osteoperiosteal sleeve is ele- the transverse fibular strut, two in the and soft-tissue mass in the distal vated from the tibia in a distal-to- lateral edge of the transverse fibular third of the leg. In general, the dis- proximal direction for approximately strut, and two in the distal aspect of tance between the end of the stump 8 cm to a level just above the intended the intact fibula. Heavy nonabsorb- and the ground should be at least 17 level of transection. The osteoperi- able suture is used to attach the fibular cm for most integrated foot and osteal sleeve is then tagged and allowed strut at this time, and the osteoperi- pylon shock-absorbing systems. to retract proximally for protection osteal flap is carried distally around during tibial transection. Finally, soft thebonebridgeasavascularized tissue is elevated from the posterior sleeve and sutured into position. Surgical Procedure tibia and the tibial cut is made with an Autogenous bone graft can be placed The patient is positioned supine, with a oscillating saw. The distance between on the proximal surface of the bone small bump placed under the ipsilateral the tibia and fibula at the level of the bridge or placed within the osteo- hip to help control the limb’stendency tibial cut is then measured, and the periosteal flap at this time. The tour- to rotate externally. A radiolucent bed peroneal musculature and fibula are niquet is then released and all bleeding can be used when fluoroscopy is to be transected at this distance distal to the points are clamped and ligated or used for the osteoplastic portion of the level of tibial transection after ligation treated via electrocautery. Once

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Figure 2

A, Preoperative clinical photograph of the distal tibia demonstrating the desired incision level. The apex of the intended incision is ,90°. Intraoperative photographs demonstrating the elevation of the osteoperiosteal flap from the tibia with a sharp osteotome (B) and the remaining limb with the long fibula after amputation (C). Intraoperative photographs demonstrating fixation of the fibular bone bridge with heavy, nonabsorbable suture (D) and closure of the peroneal musculature over the distal bone bridge (E). Careful attention to closure and soft-tissue balancing is crucial. careful hemostasis is obtained, the by a licensed prosthetist, if available, stability; however, full bony union is peroneal musculature is brought over to allow for earlier mobilization, to not always achievable with the flap the end of the strut medially and improve psychological function, and alone.21 The modified procedure sutured into place. The fascia of the to reduce surgical site complications involves placement of an autograft posterior musculature is then attached (eg, dehiscence).19,20 Patients are al- fibular segment in the bridging to the anterior tibial periosteum and lowed to ambulate immediately, but region as an alternative to the osteo- the anterior compartment fascia. full weight bearing is precluded until periosteal flap. In several studies, Subcutaneous tissue is closed in a 6 to 8 weeks after surgery to allow successful union has been reported in layered fashion, and the skin edges are for bony and soft-tissue healing. 86% to 100% of patients who finally brought together in a tension- Initial true prosthetic socket fitting is underwent amputation with the free manner with interrupted non- begun as early as 4 weeks post- modified Ertl technique.8,9,22 In these absorbable sutures. Any dog ears operatively but can be delayed in reports, the authors note that fibular should be trimmed sparingly instances of delayed incisional heal- periosteal and soft-tissue attachments to minimize additional vascular insult ing or persistent wound drainage. were maintained whenever possible to the surrounding skin edges. to maximize the healing potential of Clinical Experiences and the bony bridge. Time to union of the Postoperative Rehabilitation Outcomes fibular strut was an average of 16 Protocol weeks (range, 8 to 20 weeks). At the conclusion of the procedure, In the initial description of the Ertl As mentioned earlier, there are the residual limb is placed into an technique, the osteoperiosteal flap several different fixation methods for immediate postoperative prosthesis was used to obtain distal tibiofibular the fibular strut and/or osteoperiosteal

262 Journal of the American Academy of Orthopaedic Surgeons

Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited. Benjamin C. Taylor, MD, and Attila Poka, MD sleeve, and consensus regarding the Figure 3 optimal construct is lacking at this time. In the traditional Ertl technique, the osteoperiosteal sleeve and the myoplasty are fixed with heavy non- absorbable suture. This construct allows for a stable platform, but other authors have suggested the use of a single small-fragment screw for fixa- tion of the fibular segment, which presumably results in increased initial stability.22-26 The screw is placed in a retrograde fashion from the fibular strut into the intact tibia or in a transverse fashion from the intact fibula, through the fibular strut, and into the intact medial tibial cortex. Several authors have reported on the AP radiographs of a lower extremity after transtibial amputation and fixation of use of the TightRope to stabilize the the fibular strut with heavy nonabsorbable suture (A), fixation with a 3.5- 22,27 millimeter screw (B), and fixation with the TightRope (Arthrex) (C). At this time, fibular strut. Proponents of this no comparative evidence is available to evaluate the differences among these device note that suture breakage over fixation constructs. the sharp edges of bone tunnels is less frequent and that the development of symptomatic implant prominence is although one recent study noted a either technique is not substantially 22,28 less likely with the TightRope device considerable increase in the rate of different, two civilian studies did than with screws. However, no revision with the modified Ertl tech- report a considerably increased rate 22 comparative evidence exists to cor- nique, other studies have found no of ambulation with the Ertl osteo- roborate these claims (Figure 3). marked difference between osteomyo- myoplastic technique, which cor- Several studies have compared os- plastic and traditional amputation responds with our clinical 9,23 teomyoplastic amputation tech- techniques with regard to the rate of experience. Civilian patient- 9,23,28 niques with the traditional transtibial revision. reported outcomes have been inves- amputation technique. Surgical time Controversy exists regarding the tigated as well, with reports of the for the Ertl technique is generally optimal transtibial amputation tech- Ertl osteomyoplastic technique hav- 29,30 9,14 longer and has been reported to be as nique, with data supporting both the ing equivalent or better scores much as twice that of the non–bone- traditional transtibial and Ertl tech- in terms of function and quality of life bridging technique, with correspond- niques. One study found no difference compared with the scores in patients ing increases in tourniquet time.9,28 between the techniques with regard to who underwent traditional transtibial Despite the increased surgical time, the limb-socket kinematics,26 although the amputation. However, many of these risk of deep infection or wound com- analysis was limited to vertical dis- studies have been completed using plications does not appear to be ele- placement of the stump with loading, different questionnaires, and critical vated.9,22,23,28 However, the addition which is likely an oversimplification of comparisons of groups cannot be of the bone bridge does add another a complex biomechanical interaction. made. surgical variable that has been shown Advocates of the Ertl technique report to increase the incidence of complica- that the stump better tolerates direct Future Directions tions. In fact, nonunion of the bone end bearing in a prosthesis because the bridge is reported in 0% to 14% of increased surface area of the stump is Much of the evidence supporting the cases in two studies, although revision better able to dissipate forces, resulting Ertl technique is limited and primarily is not always necessary.8,9 Device irri- in less pain from the unstable patho- consists of level III to V evidence, with a tation is the most common complica- logic motion of the remaining fib- lack of high-quality level I evidence. The tion associated with the Ertl technique, ula.8,9,12,17,21,23,24,27,29 In addition, US Department of Defense has and with screw fixation, implant although the rate of ambulation in acknowledged this knowledge deficit removalratesashighas27% armed forces service members who and supports the completion of a ran- have been reported.22 Interestingly, have undergone amputation with domized, prospective study by the

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Major Extremity Trauma Research 3. MacKenzie EJ, Bosse MJ, Castillo RC, et al: pain after dysvascular lower extremity Functional outcomes following trauma- amputation. Rehabil Psychol 2014;59(4): Consortium to compare the traditional related lower-extremity amputation. J Bone 459-463. and Ertl types of transtibial amputa- Joint Surg Am 2004;86(8):1636-1645. 31 17. Taylor BC, Poka A: Osteomyoplastic tions. The knowledge gained from 4. Ertl J: Uber Amputationstumpfe. Chirurg transtibial amputation: Technique and tips. this investigation has the potential to 1949;20:218-224. J Orthop Surg Res 2011;6:13. be of considerable benefit to future 5. Mongon ML, Piva FA, Mistro Neto S, 18. Tintle SM, Donohue MA, Shawen S, amputees and may provide further Carvalho JA, Belangero WD, Livani B: Forsberg JA, Potter BK: Proximal sural insight into the specific indications, Cortical tibial osteoperiosteal flap traction neurectomy during transtibial technique to achieve bony bridge in amputations. J Orthop Trauma 2012;26 techniques, and protocols that would transtibial amputation: Experience in nine (2):123-126. maximize function in this patient adult patients. Strategies Trauma Limb Reconstr 2013;8(1):37-42. 19. Ali MM, Loretz L, Shea A, et al: A population. contemporary comparative analysis of 6. Condie DN: Electromyography of the immediate postoperative prosthesis lower limb amputee, in Cerquiglini S, placement following below-knee Venerando A, Wartenweiler J, eds: amputation. Ann Vasc Surg 2013;27(8): Summary Medicine and Sport Biomechanics III. 1146-1153. Basel, Switzerland, Karger, 1973, vol 8, pp 65-72. 20. Folsom D, King T, Rubin JR: Lower- We strongly believe in the concepts of extremity amputation with immediate a biologic amputation surgery, with 7. Hansen-Leth C, Reimann I: Amputations postoperative prosthetic placement. Am J preservation of as much anatomy as with and without myoplasty on rabbits Surg 1992;164(4):320-322. with special reference to the possible and restoration of the phys- vascularization. Acta Orthop Scand 1972; 21. Okamoto AM, Guarniero R, Coelho RF, iology and structure in an attempt to 43(1):68-77. Coelho FF, Pedrinelli A: The use of bone bridges in transtibial amputations. Rev limit the postoperative dysfunction 8. Pinto MA, Harris WW: Fibular segment Hosp Clin Fac Med Sao Paulo 2000;55(4): that is common in many amputees. bone bridging in trans-tibial amputation. 121-128. Prosthet Orthot Int 2004;28(3):220-224. The Ertl transtibial amputation 22. Tintle SM, Keeling JJ, Forsberg JA, technique was originally developed 9. Taylor BC, French B, Poka A, Blint A, Shawen SB, Andersen RC, Potter BK: Operative complications of combat- and subsequently modified to achieve Mehta S: Osteomyoplastic and traditional transtibial amputations in the trauma related transtibial amputations: A these goals, and despite the limited patient: Perioperative comparisons and comparison of the modified burgess and and often conflicting evidence on the outcomes. Orthopedics 2010;33(6):390. modified Ertl tibiofibular synostosis techniques. J Bone Joint Surg Am 2011;93 technique, we believe that it remains a 10. Hansen-Leth C: Muscle blood flow after (11):1016-1021. safe and viable option for patients amputation with special reference to the influence of osseous plugging of the 23. Brown BJ, Iorio ML, Hill L, et al: Ertl requiring a transtibial amputation. medullary cavity: Assessed by 133 xenon below-knee amputation using a and histamine. An animal experiment. Acta vascularized fibular strut in a nontrauma Orthop Scand 1976;47(6):613-618. elderly population: A case series. Ann Plast Surg 2014;73(2):196-201. References 11. Malloy JP, Dalling JG, El Dafrawy MH, Bustillo JS, Reid JS: Tibiofibular bone- 24. Mongon ML, Piva FA, Mistro Neto S, Evidence-based Medicine: Levels of bridging osteoplasty in transtibial Carvalho JA, Belangero WD, Livani B: amputation: Case report and description of Cortical tibial osteoperiosteal flap evidence are described in the table of technique. J Surg Orthop Adv 2012;21(4): technique to achieve bony bridge in contents. In this article, references 1 270-274. transtibial amputation: Experience in nine adult patients. Strategies Trauma Limb and 3 are level I studies. References 2 12. DeCoster TA, Homedan S: Amputation Reconstr 2013;8(1):37-42. and 30 are level II studies. References osteoplasty. Iowa Orthop J 2006;26:54-59. 25. Malloy JP, Dalling JG, El Dafrawy MH, 9, 14, 19, 22, and 28 are level III 13. Berlet GC, Pokabla C, Serynek P: An Bustillo JS, Reid JS: Tibiofibular bone- studies. References 4, 5, 8, 11-13, alternative technique for the Ertl bridging osteoplasty in transtibial 15-18, 20, 21, 23-27, and 29 are osteomyoplasty. Foot Ankle Int 2009;30 amputation: Case report and description of (5):443-446. technique. J Surg Orthop Adv 2012;21(4): level IV studies. References 7 and 10 270-274. 14. Pinzur MS, Pinto MA, Saltzman M, are level V expert opinion. Batista F, Gottschalk F, Juknelis D: Health- 26. Tucker CJ, Wilken JM, Stinner PD, References printed in bold type are related quality of life in patients with Kirk KL: A comparison of limb-socket transtibial amputation and reconstruction kinematics of bone-bridging and non-bone- those published within the past 5 years with bone bridging of the distal tibia and bridging wartime transtibial amputations. fibula. Foot Ankle Int 2006;27(11): J Bone Joint Surg Am 2012;94(10): 1. Bosse MJ, MacKenzie EJ, Kellam JF, et al: 907-912. 924-930. An analysis of outcomes of reconstruction or amputation after leg-threatening 15. Pinzur MS, Stuck RM, Sage R, Hunt N, 27. Ng VY, Berlet GC: Improving function in injuries. NEnglJMed2002;347(24): Rabinovich Z: Syme ankle disarticulation transtibial amputation: The distal 1924-1931. in patients with diabetes. J Bone Joint Surg tibiofibular bone-bridge with Arthrex Am 2003;85(9):1667-1672. Tightrope fixation. Am J Orthop (Belle 2. Penn-Barwell JG: Outcomes in lower limb Mead NJ) 2011;40(4):E57-E60. amputation following trauma: A systematic 16. Williams RM, Turner AP, Norvell DC, review and meta-analysis. Injury 2011;42 Henderson AW, Hakimi KN, 28. Gwinn DE, Keeling J, Froehner JW, (12):1474-1479. Czerniecki JM: The role of expectations in McGuigan FX, Andersen R: Perioperative

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differences between bone bridging and non- transtibial amputation. J Bone Joint Surg amputations. J Bone Joint Surg Am 2013; bone bridging transtibial amputations for Am 2008;90(12):2682-2687. 95(10):888-893. wartime lower extremity trauma. Foot Ankle Int 2008;29(8):787-793. 30. Keeling JJ, Shawen SB, Forsberg JA, et al: 31. Major Extremity Trauma Research Comparison of functional outcomes Consortium: TAOS/Ertl study. 29. Pinzur MS, Beck J, Himes R, Callaci J: following bridge synostosis with non-bone- https://metrc.org. Accessed January 11, Distal tibiofibular bone-bridging in bridging transtibial combat-related 2016.

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