|Year : 2015 | Volume
| Issue : 3 | Page : 231-237
Comparative analysis of functional outcomes of different modalities of hemiarthroplasty in the treatment of fracture neck of femur in an elderly population of rural Bengal
Samares Naiya1, Pradip Kumar Ghosh1, Arunima Chaudhuri2, Sudipta Dasgupta1, Abhijit Ghosh1, Anindita De3
1 Department of Orthopedics, BMCH, Burdwan, West Bengal, India
2 Department of Physiology, BMCH, Burdwan, West Bengal, India
3 Department of Community Medicine, BMCH, Burdwan, West Bengal, India
|Date of Web Publication||2-Sep-2015|
Department of Physiology, BMCH, Burdwan, West Bengal
Background: Arthroplasty of one form or another is an appropriate treatment for many patients with a displaced femoral neck fracture; there is an ongoing controversy about the relative merits of different types of arthroplasty among specific groups of patients. Aims: This study was conducted to compare functional outcomes of different modalities of hemiarthroplasty (HA) in the treatment of fracture neck of femur in an elderly population of rural Bengal. Materials and Methods: This study was conducted in a time span of 3 years after taking Institutional ethical clearance and informed consent of the subjects. In the study 20 patients in each modality of HA (Austin Moore [AM] prosthesis, cemented Thompson prosthesis and cemented bipolar prosthesis) were taken into consideration. First generation cementing technique was applied. The cases were assessed on the basis of Harris Hip Score (HHS). Results: At 6 months follow-up satisfactory results of AM was −56%, Thompson was 80% and bipolar was 85%. At 12 months of follow-up satisfactory results of AM prosthesis was 60.5%, Thompson was 87% and bipolar was 91%. After 2 years average HHS of AM prosthesis was about 60%, Thompson prosthesis was 86% and the bipolar prosthesis was 91%. Conclusions: The functional outcome was relatively better in cemented bipolar and cemented Thompson group. Most of the unsatisfactory result (unipolar) group was due to shortening, acetabular erosion, and anterior thigh pain. Therefore, it should not be recommended in all cases of intracapsular fracture neck of the femur with poor bone quality relatively less physiological age. Bipolar and Thompson almost equal clinical and radiological outcome in clinical practice in such cases. Cemented Thompson may provide equally effective satisfactory outcome in comparison to nonmodular bipolar prosthesis.
تحليل مقارن لنتائج الوظيفية لطرائق مختلفة لرأب المفصل النصفي في علاج كسر عنق عظم الفخذ في المسنين البنغال الريفيين
خلفية البحث: تقويم مفاصل باى طريقة هو العلاج المناسب للكثير من المرضى
الذين يعانون من كسر عنق الفخذ النازح. هناك جدل قائم حول المزايا النسبية للاأنواع المختلفة من العلاج بين فئات معينة من المرضى. الأهداف: أجريت هذه الدراسة لمقارنة النتائج الفنية لطرائق مختلفة من رأب المفصل النصفي (HA) في علاج كسر عنق عظم الفخذ في المسنين البنغال الريفيين. المواد والطرق: أجريت هذه الدراسة في الفترة الزمنية من 3 سنوات وبعد أخذ الموافقة الأخلاقية المؤسسية والموافقة المسبقة من المرضى في 20 مريضا في كل طريقة HA (الاعضاء الاصطناعية لأوستن مور [AM]، والاعضاء الاصطناعية لطومسون والاعضاء الاصطناعية ثنائية القطب) مع تطبيق أول تقنية الجيل للترسيخ. تم تقييم الحالات على أساس نقاط هاريس لكسر عنق عظم الفخذ (HHS). النتائج: بعد 6 أشهر من المتابعة كانت النتائج المرضية لAM -56٪، وفى مجموعة طومسون 80٪ وفى مجموعة ثنائي القطب 85٪ . بعد 12 شهرا من المتابعة كانت نتائج AM مرضية فى 60.5٪، وفى طومسون 87٪ وفى ثنائي القطب91 ٪ وبعد عامين من المتابعة كان متوسط HHS فى مجموعة AM حوالي 60٪، وفى مجموعة طومسون 86٪ وفى مجموعة بين القطبين كان 91٪ . الاستنتاجات: إن النتائج الوظيفية كانت أفضل نسبيا في مجموعة ثنائى القطبين ومجموعة طومسون. معظم النتائج الغير مرضية كانت فى مجموعة القطب الواحد نظرا لما حدث من تقصير، وتآكل العظم الحقي، وآلام في الفخذ الأمامي وبالتالي، فإنه لا ينبغي أن يكون الموصى بها في جميع الحالات كسر عنق الفخذ النازح خاصة اذا كانت نوعية العظام رديئة. وثبت ان طريقتى ثنائي القطب وتومسون يتتاويان تقريبا فى نتائجهم السريرية والشعاعية في مثل هذه الحالات. المرضية. وقد توفرطريقة طومسون نفس القدر من الفعالية
نتيجة مرضية بالمقارنة مع طريقة ثنائي القطب.
Keywords: Austin Moore prosthesis, cemented bipolar prosthesis, cemented Thompson prosthesis, hemiarthroplasty
|How to cite this article:|
Naiya S, Ghosh PK, Chaudhuri A, Dasgupta S, Ghosh A, De A. Comparative analysis of functional outcomes of different modalities of hemiarthroplasty in the treatment of fracture neck of femur in an elderly population of rural Bengal. Saudi J Sports Med 2015;15:231-7
|How to cite this URL:|
Naiya S, Ghosh PK, Chaudhuri A, Dasgupta S, Ghosh A, De A. Comparative analysis of functional outcomes of different modalities of hemiarthroplasty in the treatment of fracture neck of femur in an elderly population of rural Bengal. Saudi J Sports Med [serial online] 2015 [cited 2019 Nov 13];15:231-7. Available from: http://www.sjosm.org/text.asp?2015/15/3/231/164290
| Introduction|| |
The femur is the main weight-bearing bone of human body and intracapsular fractures of the proximal femur account for a major share of fractures in the elderly. The primary goal of treatment is to return the patient to prefracture functional status. There are multiple internal fixation options (screws dynamic hip screw plate or blade plates) and hemi and total hip arthroplasty (THA). Open reduction and internal fixation have been shown to have a high rate of revision surgery due to nonunion and avascular necrosis. Hip replacement arthroplasty (hemi or total) is a viable treatment option. Hip replacement (hemi or total) is a successful procedure for the elderly population over 70 years with femoral neck fractures. Return to the premorbid level of activity and independent functions occur very swiftly avoiding the hazards of prolonged incumbency. ,,
Reconstruction options using hip arthroplasty include unipolar or bipolar hemiarthroplasty (HA), and THA. THA yields the best functional results in patients with displaced femoral neck fractures with complication rates comparable to HA. THA is beneficially implanted using an anterior approach exploiting the internervous plane between the tensor fasciae latae and the sartorius muscles allowing for immediate full weight-bearing. THA is the treatment of choice for femoral neck fractures in patients older than 60 years. HA should only be implanted in patients with limited life expectancy. ,
Although there is little doubt that arthroplasty of one form or another is appropriate treatment for many patients with a displaced femoral neck fracture, there is ongoing controversy about the relative merits of different types of arthroplasty among specific groups of patients. In particular, THA is infrequently recommended because of concerns about the perceived high initial cost, increased risk of dislocation, and the anticipated low functional demands and life expectancy of the typical hip fracture patient. When viewed in this traditional context, the merits of THA are not believed to outweigh the risks, except in the rare instance of a patient with preexisting symptomatic hip arthritis that sustains a hip fracture. Accumulating evidence suggests that a reevaluation of the role of THA in patients with hip fracture is warranted. Recent comparative follow-up studies have documented superior and more durable function in a subset of patients with displaced femoral neck fractures after total hip replacement when compared to HA or uncomplicated osteosynthesis. Economic analyses have suggested that the long-term cost of treatment favors total hip replacement because of the additional cost of treating failures of internal fixation and HA in patients who survive 2 years or longer after their initial hip fracture. Finally, recent advances in the design of THA components such as the introduction of improved bearing surfaces allowing the use of larger femoral heads, combined with improved surgical techniques, may be making THA safer and less prone to dislocation and other mechanical complications. 
The treatment options for displaced femoral neck fracture in elderly are screw fixation, HA and THA based primarily on the age of the patient. The issues in screw fixation are ideal patient selection, optimal number of screws, optimal screw configuration and positioning inside the head and neck of femur. The problems of screw fixation may be loss of fixation, joint penetration, avascular necrosis of femoral head, nonunion, prolonged rehabilitation period and the need for second surgery in failed cases. 
In a developing country like India, Austin Moore (AM) prosthesis replacement is still widely used. AM prosthesis has served as a good implant over the years in the management of femoral neck fracture in elderly. The disadvantages of AM prosthesis are relatively poor outcomes in active patients secondary to poor femoral fixation and a marked potential for acetabular erosion. Therefore, at this time, the indication for a Moore's arthroplasty should be reserved for very limited or nonambulatory, low-demand patients. However, because of less cost and good short-term results, its widespread use in improperly selected patients leads to large number of failures with this type of prosthesis. ,
A good number of people sustaining fracture neck femur in their sixties or later have their bone osteoporotic, which does not have enough strength to support the prosthesis. Hence, in the course of time, there is progressive sinking of the prosthesis, which makes it loose. The loosening and gradual displacement from its initial position cause anterior thigh pain. Application of cement provides a strong support on which the prosthesis on the rest. Hence, there is a few chance of sinking and loosening of the prosthesis less incidence of thigh pain. Early weight-bearing can be advised to the patients. ,,
This study was conducted to compare functional outcomes of different modalities of HA in the treatment of fracture neck of femur in an elderly population of rural Bengal.
| Materials and Methods|| |
This study was conducted in Burdwan Medical College in a time span of 3 years after taking Institutional Ethical Clearance and informed consent of the subjects. In the study 20 patients in each modality of HAs (AM prosthesis, cemented Thompson prosthesis and cemented bipolar prosthesis) were taken into consideration. First generation cementing technique was applied. Forty patients were treated within the tertiary care hospital cemented Thompson prosthesis and cemented bipolar prosthesis while twenty received AM prosthesis in a rural hospital (with the lack of modern operative facilities). All patients had osteoporotic, and displaced intracapsular fracture. There was no significant difference in age, sex and type of fracture between the three groups. HA was not be used in physically active patients, even in elderly individuals. Careful patient selection for HA versus THA is vital and may decrease the incidence of complications and ameliorate the outcomes in the treatment of intracapsular femoral neck fractures. ,,,,,, Among the patients retired government employees were 10%, unemployed laborer were 35% and female housewives are 55%.
Patients above 65 years of age admitted with recent and old displaced intracapsular fracture neck of the femur without preexisting minimal degenerative changes of the hip.
Associated life threatening injuries and medical condition like diabetes mellitus, tuberculosis, significant arthritis of the hip joint and disease of the acetabulum.
Seventy-nine percent of the patients had Garden type 4 and 21% of the cases had Garden type 3. In female, 39 and 41 no. prosthesis were commonly used and in male, 47 and 49 no. The prosthesis was commonly used.
On admission to the ward, a detailed history of the case was taken and age, sex, occupation, socioeconomic status, mode and date of injury were determined, and any concurrent illness, relevant past illness and previous muscular skeletal injury or surgery were recorded.
A thorough clinical examination of the major system of the affected part was done. Then patient were put on surface/skeletal traction and encouraged to exercise the hip and knee muscles. Radiograph of the fracture was taken in antero-posterior and lateral views of the pelvis and femur. Appropriate preoperative investigations (routine blood, chest X-ray, electrocardiography etc.) were done. Preoperative anesthetic assessment and counseling of patient were done and then the patient was put up for operation. Preoperative antibiotic (ceftriaxone + sulbactum 1.5 g) intravenous was usually given 1-h before operation.
Surgical approach and procedure
The hip joint was opened through posterior approach under spinal anesthesia in all cases. A fracture table was not used in any case.
Patient is placed in a lateral position with affected side facing upwards. After proper antiseptic dressing and draping, the affected hip joint was exposed by a posterior approach. Then the femoral head was dislocated and removed. The acetabular fossa was cleaned of ligamentum teres and other soft tissue and packed with roller gauze. Preparation of femoral canal was started. The proximal femur was exposed, and lesser trochanter was visualized and 1-2 cm neck was retained. Then entry point was made into the femoral medullary canal by box chisel. Then reaming of medullary cavity was started from lateral most aspect of the cut surface of the neck with small size to maximum size that goes easily maintaining 10°-15° anteversion in relation to axis of the fixed tibia. Head size was measured from the trial set.
Then we assembled trial components and inserted it to assess stability, limb length, and range of motion and adjusted as necessary. After that trial component was removed, if the reamer went into the canal easily or trial component was loose in the canal then, the decision of cement introduction was taken. Subsequently, the canal was thoroughly irrigated with normal saline.
We used CMW1 bone cement elements, which are self-curing cement like a compound for sitting and securing the prosthesis in the femoral medullary canal. It has two components: Liquid component - It is a colorless flammable liquid with a distinctive odor containing the methyl methacrylate in monomer form. Hydroquinone and ascorbic acid are also present as a stabilizer to prevent premature polymerization. N, N-Dimethyl P-toluidine is present as an activator to promote polymerization when the powder and liquid components are mixed. Ethyl alcohol is present as a vehicle to enhance the solubilization of the ascorbic acid. Powder component - It is a white finely divided powder. Its major component is polymethyl methacrylate, which also has benzoil peroxide for initiation of polymerization when the powder and liquid components mixed. Except one variety of CMW bone cement, all contain, barium sulfate as a radio-opaque agent.
Application of bone cement
After thorough mixing of liquid and powder part of bone cement, removal of packing from the femoral canal was done and bone cement was introduced in doughy state into the medullary cavity digitally (first generation cementation technique) and by a rush nail, few holes were made in doughy cement for passage of air from the canal to outside. Then, Thompson or bipolar prosthesis was introduced. Determination of amount of anteversion and mediolateral position was done before stem insertion. The stem was held by the head and inserted first manually and then by plastic tipped impactor, and maintained in the position until the cement was set. Excess bone cement was removed before the cement has completely hardened. After that prosthesis was reduced, movement of the hip joint was checked. Then, repair of the capsule, and short external rotators was done, and wound closed in layers with a negative suction drain.
Postoperatively patient was kept in bed without any immobilization. Only a pillow was kept between two thighs during 1 st week. Muscle tone up exercises were started from 2 nd day, like straight leg raise, breathing exercises, isometric quadriceps exercises, etc., suction drain was removed after 48 h of surgery and patients were allowed to sit in bed. Assisted walking (partial weight-bearing) using walker started after 4-5 days as tolerated by the patient in case of cemented prosthesis and after 14 days in case of AM prosthesis. Stitch was removed on 14 th postoperative day. The full set of precautions and exercise programs were explained to the patient before discharge. Then, patients were discharged to attend follow-up clinic at 6 weeks, 12 weeks, 6 months, 1-year, 2 years for follow-up.
Patients were followed up regularly and were put up for clinical and radiological examination and functional assessment. Functional assessment was done by Harris Hip Score (HHS), that is, pain, limp, waling ability, aids, sitting ability without squatting, range of motion, limb length discrepancy, fixed deformity, etc.
Radiological assessment was done by an antero-posterior view of both hip joint and lateral view including proximal half of the femur to see the distal end of the prosthesis. Following points were recorded from radiograph, that is, prosthesis alignment, proximal migration (acetabular erosion), distal migration, periarticular calcification, peri-prosthetic fracture, metal reaction, signs of infection, etc., All these data were recorded in a proforma for each patient.
| Results|| |
In the study 20 patients in each modality of HAs (AM prosthesis, cemented Thompson prosthesis and cemented bipolar prosthesis) were taken into consideration. There was no death. First generation cementing technique was applied. The cases were assessed on the basis of HHS. All patients in the study were operated through posterior (Moore) approach. There was female predominance in our study similar to other study. The cause of female predominance may be due to postmenopausal osteoporosis. The decrease in female preponderance in our Indian series in comparison to western series may be due to confinement of our women to indoors only. In our series, in 20% cases, there is no uniformity in the width of the cement mantle. This may be due to first generation cementation technique (digital method). Partial weight-bearing was allowed in almost half of the patient of Thompson and bipolar within 1-week and most of the AM patient within 2 weeks.
Operative time was between 1 h and 30 min. To 1 h 45 min in AM prosthesis-patient, and between 1 h 40 min and 2 h 30 min in cases of cemented Thompson and bipolar prosthesis.
Harris Hip Score
Cases were evaluated on the basis of HHS at 6 months, 12 months and 2 years. At 6 months follow-up satisfactory (excellent + good) results of AM was − 56%, Thompson was 80% and bipolar was 85%. At 12 months of follow-up satisfactory (excellent + good) results of AM prosthesis was 60.5%, Thompson was 87% and bipolar was 91%. After 2 years average HHS of AM prosthesis was about 60%, Thompson prosthesis was 86% and the bipolar prosthesis was about 91%.
All the patients were able to sit on a chair for 1 h. At 12 months, ROM was 211-300° in 45% and 161-210° in 55% in case of Thompson prosthesis. ROM was 211-300° in 52% and 161-210° in 48% in case of bipolar prosthesis. ROM was 211-300° in 40% and 161-210° in 40%, 101-160° in 15% and 61-100° in 5% cases in AM prosthesis.
At 6 months follow-up in AM series 3 (18%) patients, in cemented Thompson series 1 (7%) patient and in bipolar series 1 (6%) patient experienced anterior thigh pain. Average pain score (HHS) of AM was 30, Thompson and bipolar was also 30 (mild pain).
At 12 months follow-up in AM series 2 (12%) patients, in cemented Thompson series 1 (6%) patient and in bipolar series 1 (6%) patient experienced anterior thigh pain. Average pain score (HHS) of AM was 30, Thompson and bipolar was also 30 (mild pain). Thirty-five percent patient were able to walk unlimited, 52% 6 block, 3% patient 2-3 block and 4% were able to walk indoor only in case of Thompson prosthesis after 12 months. Forty percent patient were able to walk unlimited, 55% pt 6 block, 3% pt only 2-3 block and 2% patient were able to walk indoor only in case of bipolar prosthesis.
Ten percent patient were able to walk unlimited, 20% pt 6 block, 60% pt 2-3 block and 10% pt were able to walk indoor only in case of AM prosthesis.
In our study, 80% patients of Thompson prosthesis had occasional pain and 85% of the bipolar prosthesis after 6 months. However, in AM prosthesis 60% patient had occasional pain after 6 months. After 2 years, pain gradually increased in case of AM prosthesis. Limb length discrepancy: In the present series, 20% of the patients had shortening in AM prosthesis, and 10% had shortening in bipolar prosthesis after 1-year. Common shortening was 0-1 cm and according to HHS, these were not significant. Regarding postoperative complication, we had found only three cases of superficial infection, which went off with antibiotics and dressing.
As regards of breakage of prosthesis and metal reaction, there were no such cases in our series. We have not found any case of peri-prosthetic calcification in our series. There was not a single case of distal migration of prosthesis. It was measured by comparing the distance between the collar of the prosthesis and the superior margin of the lesser trochanter on the first and last radiographs. There was a single case of protrusio acetabuli in our study. Proximal migration was seen as loss of joint space, irregular subarticular bone with selerosis and was measured as the difference in distance between the head of the prosthesis and the ilio ischial line between the initial and last radiographs. Migration beyond the line was taken as protrusion acetabuli.
| Discussion|| |
Austin Moore replacement prosthesis has fairly good short term results for intracapsular femoral neck fractures in the elderly; it still is a compromised option and has a high failure rate in the long run.  The present study was conducted to compare functional outcomes of different modalities of HAs in the treatment of fracture neck of femur in an elderly population of rural Bengal. Cementation in HA of the hip is a new procedure to this part of the country especially in the conventional centers like ours. Our case series is too small and too short to make a comment or conclusion. We offered three modalities of HAs randomly in the aged patient between 65 and 90 years and compared their outcome by clinicoradiologically. Operation time was double in cemented group than the uncemented group, but the short outcome is relatively poor in the unipolar uncemented group.
Sabnis and Brenkel in 2011  conducted a study to compare outcomes of unipolar versus bipolar uncemented HA and determine factors affecting outcomes. Four hundred and thirty-three and 274 elderly patients with displaced intracapsular femoral neck fractures underwent uncemented unipolar HA and uncemented bipolar hydroxyapatite-coated HA, respectively. Surgical options were based on the patient's general condition and preinjury mobility status. In the respective groups, the mortality of 377 and 242 patients and the mobility of 270 and 217 patients were reviewed at the 4-month follow-up. Patients who underwent unipolar HA were significantly older, less fit, and less mobile (P < 0.001). Patients who underwent bipolar HA achieved better outcomes for mortality and mobility (P < 0.001). Among patients who were able to walk unaided before injury, more of those having bipolar HA were able to do so at month 4 than those having unipolar HA (13% vs. 33%, P < 0.001). When patients were stratified according to age groups, mortality within 4 months was lower in patients having bipolar HA.
Eighty-four elderly patients (age > 70 years) with a femoral neck fracture were treated over a 5-year period (January 2001 to December 2006) Marya et al.  Eighty of the 84 patients underwent some form of hip replacement after appropriate medical and anesthetic fitness. Good results were seen in all the patients in terms of return to the prefracture level of activity, independent ambulation and satisfaction with the procedure. Patients over the age of 80 years who underwent bipolar HA all progressed well without any complication. Patients in their seventies underwent some form of total hip replacement and barring one case of deep infection, two cases of deep vein thrombosis and three cases of dislocation (which were managed conservatively), there were no real complications.
Patients ≥50 years of age (range: 50-73 years) who sustained displaced femoral neck fracture and fulfilled the inclusion criteria were enrolled in a prospective study. By Satish et al.  They were treated with closed reduction under image intensifier control and cannulated cancellous screw fixation. The accurate anatomical reduction was not aimed, and a cross-sectional contact area of >75% without varus was accepted as good reduction. Four screws were positioned in four quadrants of femoral head and neck, as parallel and as peripheral as possible. Radiological and functional results were evaluated periodically. Sixty-four patients who could complete a minimum follow-up of 2 years were analyzed. Radiologically, all fractures healed after a mean duration of 10 weeks (range: 8-12 weeks). There was no avascular necrosis. Nonanatomical healing was observed in 45 cases (70%). All patients except one had an excellent functional outcome and could do cross-legged sitting and squatting. Chondrolysis with progressive head resorption was seen in one case, which was converted to THA. They concluded that closed reduction and cannulated cancellous screw fixation gave satisfactory functional results in a large group of elderly patients. The four quadrant parallel peripheral screw fixation technique gives good stability, allows controlled collapse, avoids fixation failure and achieves predictable bone healing in displaced femoral neck fracture in patients ≥ 50 years of age.
Eighty-nine cemented THA surgeries for failed AM prosthesis were performed between 1986 and 2005 by Bhosale et al.  AM failures were classified into seven groups on the basis of mode of failure. Infected failures were excluded from the study. There were 35 men and 54 women in the study group. The mean age was 68 years (range: 57-91 years). Mean follow-up was 8 years (range: 5-13 years). Average HHS improved from 65 preoperatively (range: 42-73) to 87 (range: 76-90) at 1-year postoperatively and to 86 (range: 75-89) at the last follow-up. The overall complication rate was 4.5%. Conversion THA is an excellent treatment strategy for symptomatic failed AM HA in terms of pain relief and restoration of function and mobility as near as possible to the preinjury level.
Functional outcome was relatively worse with AM when compared with cemented Bipolar and cemented Thompson group in the present study. Most of the unsatisfactory result (unipolar) group was due to leg length discrepancy (LLD) (shortening), acetabular erosion, and anterior thigh pain. Therefore, it should not be recommended in all cases of intracapsular fracture neck of the femur with poor bone quality relatively less physiological age. Bipolar and Thompson almost equal clinical and radiological outcome in clinical practice in such cases. Cemented Thompson may provide equally effective satisfactory outcome in comparison to the nonmodular bipolar prosthesis.
| Conclusions|| |
Cementation in HA of the hip is a new procedure to this part of the country especially in the conventional centers like ours. We offered three modalities of HA randomly in the aged patient between 65 and 90 years and compared their outcome by clinicoradiologically. Operation time was double in cemented group than the uncemented group, but the short outcome is relatively poor in the unipolar uncemented group. Functional outcome was relatively better in cemented bipolar and cemented Thompson group. Most of the unsatisfactory result (unipolar) group was due to LLD (shortening), acetabular erosion, and anterior thigh pain. Therefore, it should not be recommended in all cases of intracapsular fracture neck of the femur with poor bone quality relatively less physiological age. Bipolar and Thompson almost equal clinical and radiological outcome in clinical practice in such cases. Cemented Thompson may provide equally effective satisfactory outcome in comparison to the nonmodular bipolar prosthesis.
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