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- Indian J Orthop
- v.57(2); 2023 Feb
- PMC9880122
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Indian J Orthop. 2023 Feb; 57(2): 253–261.
Published online 2022 Dec 13. doi:10.1007/s43465-022-00792-4
PMCID: PMC9880122
PMID: 36777116
Koichi Yano,
1 Makoto f*ckuda,2 Takuya Uemura,3 Yasunori Kaneshiro,1 Kiyotaka Yamanaka,4 Hidetoshi Teraura,5 Ken Yamamoto,6 Ryo Sasaki,1 and Takeshi Matsuura1
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Abstract
Background
We surgically treated comminuted radial head and neck fractures using headless compression screws, including multiple screws for the radial head and a single oblique screw for the radial neck. This study aimed to compare the clinical and radiological results for comminuted radial head and neck fractures between surgery using headless compression screws with a single oblique screw for the radial neck, our new procedure, and a plate system precontoured to the proximal radius.
Methods
This retrospective study included 23 patients (11 and 12 in the screw and plate groups, respectively). The fractures were type 3 according to the Mason–Johnston classification modified by Broberg and Morrey. Clinical outcomes analyzed included the motion range of the elbow and forearm, Mayo Elbow Performance Score, and radiological assessments. In addition, postoperative complications were also investigated. The average follow-up was 18months.
Results
The bone union was achieved in all the patients, and there were no significant differences in clinical outcomes and radiological assessments except forearm supination (p = 0.02). Furthermore, additional surgical procedures were performed in one and five patients in the screw and plate groups, respectively (p = 0.16). Posterior nerve palsy was observed in two patients in the plate group. Complications were observed in one and six patients in the screw and plate groups, respectively (p = 0.07).
Conclusion
Both surgical procedures achieved good clinical and radiological outcomes with bone and ligament injury repair. The screw group had a greater range of forearm supination than the plate group.
Keywords: Radial head fracture, Radial neck fracture, Headless compression screw, Plate, Open reduction and internal fixation, Comminuted fracture
Introduction
The radial head is essential for elbow stabilization secondary to the primary stabilizers, medial and lateral collateral ligaments, and up to 60% of axial load transmission from the forearm to the distal humerus [1, 2]. Therefore, properly treating radial head fractures is necessary because unfavorable results can restrict daily activities due to pain, limited range of motion, and instability.
Generally, the Mason–Johnston classification, modified by Broberg and Morrey, is used for grading radial head fractures and treatment planning [3, 4]. For Mason type 3 fractures (comminuted fracture of the radial head), surgery with open reduction and internal fixation (ORIF) using plate and screws or radial head arthroplasty (RHA) has been indicated. After obtaining unsatisfactory results in patients with over three articular fragments (failure of fixation, painful non-union, and limited forearm rotation), RHA has been limited to patients with severe, comminuted, unreconstructable fractures with concomitant ligamentous injury [5, 6]. However, its long-term clinical results, especially in young patients, have not been elucidated [7, 8].
Plate and screw fixation methods are conventionally used for displaced radial neck fracture; however, less invasive methods using two cross-screw fixations or the three-tripod technique are also used. Recently, headless compression screws have been used to obtain longitudinal stability between the radial head and neck [9, 10]. However, it is challenging to place a few oblique screws for a radial head and neck fracture when there are multiple articular fragments due to limited space. Therefore, we treat patients with comminuted radial head and neck fractures using headless compression screws with a single oblique screw between the radial head and neck. This technique and clinical results have not been published before.
The study aimed to evaluate the clinical and radiological outcomes of the new techniques at our institution and compare these with plate and screw treatments performed at other institutions.
Materials and Methods
Patients
A retrospective chart review was performed at five trauma center hospitals. The study included skeletally mature patients who were surgically treated between 2014 and 2020 for radial head and neck fractures and followed up for > 1year postoperatively. The fractures included type 3 comminuted fractures involving the entire radial head according to the Mason–Johnston classification, modified by Broberg and Morrey [3, 4].
Surgery was performed using headless compression screws only (S group) or plate and screws (P group). The former was performed at a single hospital by one author (KY), and the latter was performed by the other five surgeons.
Exclusion criteria were treatment with another procedure, including RHA; radial head excision; neurovascular deficits; elbow arthritis, including rheumatoid arthritis; pathological fracture; and dementia.
Informed consent was obtained from each patient, and ethical approval was obtained from the institutional review board.
Surgical Technique
The operative procedure was performed in the supine position under general anesthesia using an air tourniquet. In cases with/without elbow dislocation associated with proximal ulnar fracture, the ulna was repaired using plate fixation to achieve the original forearm length using a universal or posterior approach at first. In other cases, a lateral approach (Kocher or extensor digitorum communis splitting approach) was used to repair a radial head and neck fracture and lateral collateral ligament injury. For proximal radial fractures, all articular fragments of the radial head without soft tissue continuity were retrieved from the surgical field to the outside (Fig.1a–c). On the surgical table, fragments were reduced through “on-table reconstruction”[11]. In the S group, fragments were fixed using guide pins of headless compression screws and then screws (Fig.1d). Screws were selected by the size of the fragments (DTJ mini, Herbert type screw, standard screw, MEIRA Co., Nagoya, Japan; Acutrak2 Micro, Mini, Acutwist, Japan Medicalnext Co., Ltd., Osaka, Japan). After fixing, the entire fragment was reduced to the surgical site and matched to the fracture line of the radial neck or the remaining fragment with a minimal incision of the annular ligament. When the fracture void was large and there was instability and risk of loss of reduction, a bone graft was harvested from the proximal ulna and placed in the void. Thereafter, the radial head and neck was fixed obliquely using a single Acturak2 Mini screw from the largest articular fragment to the distal radius while the screw tip was placed distal to the fracture line (Fig.1e, f). Fixation stability was confirmed by rotation of the forearm and flexion–extension of the elbow. In the P group, fragment reduction and bone graft were performed in the same manner as in the S group. The radial head and neck were fixed using a plate specifically contoured to the proximal radius with an entire cut of the annular ligament. For patients with large articular fragments, temporary pin fixation was performed, and the fragments were fixed using the proximal screw of the plate. After fixation of the proximal radius, the annular ligament was repaired, and the injured LCL was repaired using suture anchors. When ulnar instability or re-dislocation using a hanging arm test remained, the MCL was repaired via a medial approach using suture anchors [12]. When elbow instability remained, the coronoid fracture was repaired.
Fig. 1
Images using headless compression screws only. a Anteroposterior and b lateral plain radiography preoperatively. c Computed tomography image. d On-table reduction. e Anteroposterior and f lateral plain radiography immediately after surgery. g Anteroposterior and h lateral plain radiography at 18months postoperatively
Postoperative Therapy
For all the patients, pushing up on their injured hands and heavy lifting were prohibited until the bone union was achieved. In patients with radial head and neck fracture without ligament injury, active forearm rotation and elbow flexion–extension commenced the day after splint removal at two weeks postoperatively. In patients with elbow ligament injury, a longarm splint was changed to a hinged brace at two weeks postoperatively. The elbow was limited to a 30° extension for four weeks postoperatively. At six weeks postoperatively, the extension limitation was reduced to 0°. Furthermore, after the bone union, free activity was allowed (Fig.1g, h).
Clinical Outcomes
All the patients were assessed at the last follow-up. Elbow and forearm motion was evaluated using a standard goniometer. The Mayo Elbow Performance Score (MEPS) measured the clinical outcome [13]. We classified MEPS as excellent (> 90), good (75–89), fair (60–74), and poor (< 60).
Radiological Assessments
All the patients were assessed with plain radiography immediately after surgery and at the last follow-up. Bone union was defined as bony bridging across the fracture site and time to obtain union was also assessed. Post-traumatic arthrosis on plain radiography was analyzed using the Knirk and Jupiter scale.[14] Heterotopic ossification was assessed using the Hastings and Graham classification [15]. The radial head shaft (RHS) angle (double dagger) as an index for angular stability and radial head–neck diameter (RHND) ratio as an index for the morphology of the radial head were measured on lateral plain radiography of the elbow in both groups (Fig.2). Measurement was taken by one of the authors (RS) independent to the surgery using ImageJ (Wayne Rasband, National Institutes of Health, Bethesda, MD).
Fig. 2
Measurements on lateral plain radiography. a The radial head shaft angle (double dagger) is made by a line through the articular surface of the radial head (asterisk) and a perpendicular line to the midline of the proximal radial shaft (dagger). b Radial head–neck diameter ratio. The largest diameter of the radial head (section mark) is divided by the smallest diameter of the radial neck (parallel rules)
Complications
All postoperative patient records were reviewed. Complications requiring surgical proximal radius treatment were major complications, with all others being minor.
Statistical Analysis
Numerical variables are presented as average and standard deviation, and the distribution was assessed using the Kolmogorov–Smirnov test. Most variables demonstrated a skewed distribution; therefore, the Mann–Whitney U test was performed. Differences between groups were assessed using the Wilcoxon rank-sum test. The Chi-square or Fisher exact tests were performed for categorical variables. Significance was set at p values of < 0.05. All statistical analyses were performed with EZR (Saitama Medical Center, Jichi Medical University, Saitama, Japan), a graphical user interface for R (The R Foundation for Statistical Computing, Vienna, Austria) [16]. More precisely, it is a modified version of R Commander designed to add statistical functions frequently used in biostatistics.
Results
The study included 23 elbows in 23 patients (14 males and 9 females). Demographic data of the patients are presented in Table Table1.1. Low-energy trauma was defined as a fall from a standing height (5 patients) and high-energy trauma as any other type of trauma (18 patients). Sports injury and elbow dislocation were observed in two and six patients, respectively. Accompanying injuries were ipsilateral wrist fracture in four patients, contralateral wrist fracture in three, and pelvic fracture in one patient.
Table 1
Demographic data of the patients
| Total | S group | P group | p | |
|---|---|---|---|---|
| Total number | 23 | 11 | 12 | |
| Age (years) | 43.2 ± 20.3 (18–87) | 42.8 ± 17.3 (19–71) | 43.5 ± 23.5 (18–87) | 0.88 |
| Sex (M/F) | 14/9 | 6/5 | 8/4 | 0.68 |
| Injured side (R/L) | 9/14 | 5/6 | 4/8 | 0.68 |
| Trauma energy (L/H) | 5/18 | 3/8 | 2/10 | 0.64 |
| Dislocation ( ±) | 6/17 | 1/10 | 5/7 | 0.16 |
| Injury to OP (D) | 7.6 ± 2.7 (4–13) | 5.9 ± 2.1 (4–10) | 8.8 ± 2.3 (6–13) | 0.01 |
| FU period (M) | 18.4 ± 8.3 (12–42) | 19.0 ± 9.5 (12–42) | 17.9 ± 7.5 (12–37) | 1 |
| Articular fragment | 2.8 ± 0.9 (2–5) | 3.0 ± 1.1 (2–5) | 2.7 ± 0.7 (2–4) | 0.58 |
| Olecranon ( ±) | 4/19 | 3/8 | 1/11 | 0.32 |
| MCL ( ±) | 9/14 | 0/11 | 9/3 | < 0.01 |
| LCL ( ±) | 5/18 | 2/9 | 3/9 | 1 |
| Bone graft ( ±) | 6/17 | 3/8 | 3/9 | 1 |
Open in a separate window
Data are shown as average ± standard deviation (range)
S group screw group, P group plate group, pp value, M male, F female, R right, L left, L low, H high, Dislocation dislocation of the elbow joint, Injury to OP the days from injury to operation, D day, FU follow-up, M month, Articular fragment the number of articular fragments of radial head, Olecranon the number of surgical fixation for olecranon fracture, MCL the number of patients with the surgical repair of the medial collateral ligament of the elbow, LCL the number of patients with the surgical repair of the lateral collateral ligament of the elbow, Bone graft the number of patients with usage of bone graft
The S and P groups included 11 and 12 patients, respectively. There were significant differences in the duration from injury to surgery (5.9 and 8.8days in the S and P groups, respectively, p = 0.01) and the number of patients with MCL repair (0/11 and 9/12 in the S and P groups, respectively, p < 0.01). Regarding dislocations, the S group had one patient with olecranon fracture dislocation, whereas the P group had one patient with Monteggia elbow fracture dislocation (type 1) [17], and group P had four patients with terrible triad injury.
The average number of headless compression screws used in surgery was 2.9 (range 2–5) in the S group and 1.3 (range 0–4) in the P group. Fixation plates were: LCP proximal radius plates 2.4 (DePuy Synthes, Tokyo, Japan) in five, A.L.P.S. proximal radius plates (Zimmer Biomet G. K., Tokyo, Japan) in two, n-radial plate in four (Teijin Nakashima Medical Co., Ltd., Okayama, Japan), and radial head and neck locking plate (Meira Co., Ltd., Nagoya, Japan) in one patient. Only the n-radial plate had no locking system. Regarding proximal ulnar fracture, the A.L.P.S. olecranon plate (Zimmer Biomet G. K.) was used for three patients in the S group, and the LCP plate (DePuy Synthes) for one patient in the P group.
A coronoid fragment (Reagan and Morrey classification type 3) was fixed using a headless compression screw in one patient with an olecranon fracture in the S group [18].
Bone grafts were harvested from the ulna in three S and one P group patients and the ilium in one P group patient. In addition, an artificial bone graft (OSferion, beta-tricalcium phosphate, Olympus Terumo Biomaterials Co., Ltd., Tokyo, Japan) was used in one P group patient.
Regarding the range of elbow and forearm motion, there was a significant difference in supination between the groups (p = 0.02) but not in elbow flexion–extension and forearm pronation. Furthermore, MEPS was not significantly different between the groups (p = 0.50) (Tab. (Tab.2).2). The result was excellent in eight and seven patients and good in three and five patients in the S and P groups, respectively.
Table 2
Postoperative assessments and complications
| Total | S group | P group | p | |
|---|---|---|---|---|
| Flexion (°) | 137.4 ± 7.8 (120–150) | 137.7 ± 7.5 (125–150) | 137.1 ± 8.4 (120–150) | 0.95 |
| Extension (°) | −4.3 ± 9.5 (−25–15) | −0.9 ± 7.7 (−15–15) | −7.5 ± 10.1 (−25–5) | 0.16 |
| Pronation (°) | 79.3 ± 9.6 (65–95) | 82.3 ± 8.2 (70–90) | 76.7 ± 10.3 (65–95) | 0.16 |
| Supination (°) | 83.9 ± 6.7 (70–90) | 87.3 ± 5.2 (75–90) | 80.8 ± 6.7 (70–80) | 0.02 |
| MEPS | 94.8 ± 7.3 (85–100) | 95.9 ± 7.0 (85–100) | 93.8 ± 7.7 (85–100) | 0.50 |
| Time to union (month) | 5.2 ± 3.2 (2–14) | 5.1 ± 2.9 (3–12) | 5.3 ± 3.5 (2–14) | 0.95 |
| Minor complications ( ±) | 2/21 | 0/11 | 2/10 | 0.48 |
| Major complications ( ±) | 5/18 | 1/10 | 5/7 | 0.16 |
| Total complications ( ±) | 7/16 | 1/10 | 6/6 | 0.07 |
Open in a separate window
Data are shown average ± standard deviation (range)
S group screw group, P group plate group, pp value, MEPS mayo elbow performance score
Bone union was found in all the patients at the last follow-up. The average time to union was 5.2months (standard deviation 3.2; range 2–14). There were no patients with elbow instability. Post-traumatic arthrosis grade 1 was observed in one and two patients in the S and P groups, respectively. Heterotopic ossification grade 1 was observed in three and six patients in the S and P groups, respectively. Two patients in the P group displayed posterior interosseous nerve (PIN) palsy postoperatively, which resolved completely with conservative treatment. Additional surgical procedures for the proximal radius included one screw removal in the S group due to re-fracture and five plate removals with surgical mobilization in the P group due to painful crepitus and limitation of motion in forearm rotation. There were no significant differences between post-surgery and last follow-up in RHS angle and RHND ratio in either group (Table (Table33).
Table 3
Radiological assessments of proximal radius
| RHS angle (°) | p | ||
|---|---|---|---|
| Immediately after surgery | At last FU | ||
| S group | 8.8 ± 3.9 (3–15) | 8.9 ± 7.7 (3–19) | 0.40 |
| P group | 10.5 ± 4.8 (1–23) | 8.6 ± 7.5 (1–24) | 0.40 |
Open in a separate window
| RHND ratio | |||
|---|---|---|---|
| Immediately after surgery | At last FU | ||
| S group | 1.8 ± 0.1 (1.6–2.1) | 1.8 ± 0.1 (1.6–2.0) | 0.55 |
Open in a separate window
Data are shown as average ± standard deviation (range)
S group screw group, P group plate group, RHS angle radial head shaft angle, FU follow-up, pp value, RHND ratio radial head neck distance ratio
Case Presentations
Case 1
A 19-years-old woman fell on her left hand during a karate competition. Plain radiography and computed tomography image presented a comminuted radial head and neck fracture (Fig.1a–c). The four articular fragments (Fig.1d) were fixed using two, and radial neck fracture was fixed using one headless compression screw, respectively (Acutrak2 Mini, one; Micro, one; and Acutwist, one) (Fig.1e, f). At 18months postoperatively, bone union was achieved without post-traumatic arthrosis (Fig.1g, h). Her elbow was stable and asymptomatic without limitation to daily and karate activities. MEPS was 100, and the range of motion was as follows: elbow flexion, 140°; extension, 0°: forearm pronation, 90°; and supination, 90°.
Case 2
A 21-years-old woman fell on her left hand while riding a bicycle. Plain radiography and computed tomography image displayed a comminuted radial head and neck fracture (Fig.3a–d). The articular fragments were fixed using headless compression screws (Acutrak2 Micro, one), the radial neck was fixed using an LCP proximal radius plate 2.4 (DePuy Synthes), and the MCL was repaired using suture anchors (Fig.3e, f). She displayed PIN palsy postoperatively but recovered fully. At one year and three months postoperatively, she presented with painful forearm arc and limitation of the motion (forearm pronation, 60°; supination, 30°), and plate removal and surgical mobilization were performed (Fig.3g, h). Five months after the second surgery, her elbow was asymptomatic, without daily activity disturbance. MEPS was 100, and the range of motion was: elbow flexion, 145°; extension, 5°; forearm pronation, 70°; and supination, 90° (Fig.3i, j).
Fig. 3
Images using a plate system. a Anteroposterior and b lateral plain radiography preoperatively. c, d Preoperative computed tomography images. e Anteroposterior and f lateral plain radiography immediately after surgery. g Anteroposterior and f lateral plain radiography at 20months postoperatively
Discussion
Traditionally, a reconstructable comminuted proximal radial fracture is treated using plate systems. Ring et al. reported that ORIF for Mason type 3 radial head fractures using a 2.0mm plate or screws in patients with over three articular fragments was more likely to result in unsatisfactory outcomes due to hardware failure or non-union, with 10 of 26 patients requiring resection of the radial head [6]. Ring et al. drew conclusions based on the fracture type and the number of fragments, not fixation methods. ORIF for comminuted fractures of the radial head using two low-profile T-shaped mini plates (profile height, 0.55mm; screw diameter, 1.7mm) resulted in plate removal in 9 of 10 patients, bone union in all the patients, and a favorable motion range (flexion arc, 7°–134°; supination–pronation arc, 74°–85°) [19]. The clinical results using locking plates (screw thickness 1.4 and 2.0mm) in 34 patients revealed that 11 patients required plate removal, and the flexion and the supination–pronation arc were 6°–134° and 64°–70°, respectively [20]. For comminuted proximal radius fractures, plate fixation displayed good final results using recently developed ones; therefore, we believe that plate fixation is a good option, including plate removal and surgical mobilization.
In contrast to the plate system, radial neck fixation using oblique screws was introduced as a less invasive method based on the comparative surgical results of patients with displaced radial head and neck fractures using a plate or oblique screws (2.0mm cannulated screw, minimum of two screws) [21]. Their results revealed that the supination–pronation arc was 53°–70° in the plate group and 80°–80° in the screw group and concluded that their screw technique was useful in axially stable fractures. Clinical outcomes for radial head and neck fracture, including Mason types 2, 3, and 4, using the tripod technique, which were obliquely inserted into the radial neck using three 3.5mm cannulated headless compression screws, were bone union with a supination–pronation arc of 75.4°–79.7° [10, 22].
Our surgical technique, using a single oblique screw for fixation of the radial neck, was first performed for a young patient to maintain the original radial head instead of RHA (Fig.1). We subsequently performed this technique for consecutive patients because the clinical result was excellent. An increase in the number of articular fragments leads to an increased number of screws. However, we must ensure that the oblique screw does not interfere with articular screws. The advantage of the procedure was less surgical exposure to the annular ligament and potentially less scar formation than those in the P group. In the S group, no patients had postoperative PIN palsy. In addition, the proximal side of the headless compression screw is buried in the radial head; therefore, the screw head does not interfere with the surrounding tissue, including the capsule and proximal radioulnar joint (PRUJ). Moreover, screws can be inserted from a 360° angle around the radial head, whereas plates have a setting limitation due to the need for a safe zone that does not interfere with PRUJ [23]. Therefore, the S group achieved a better forearm motion range, statistically significant in supination, than the P group (supination–pronation arc 87.3°–82.3° versus 80.8°–76.7°). The anatomical morphology of the radial head and the neck and head–neck angle vary across individuals and between the sexes; hence, anatomical precontoured plates might not fit the radial neck [24, 25]. Plate bending and reference to the uninjured proximal radius were recommended for plate systems; however, these are unnecessary when only using screws. We assumed that plates had stronger angular stability than single oblique screws before this study; nonetheless, two radiological measurements revealed that both groups maintained fracture reduction until the last follow-up. To our knowledge, there are no biomechanical studies comparing single oblique screw fixation with plate fixation for radial neck fracture, and we would like to assess the strength of fixation in a future study. From the radiological assessments, we assumed that a single oblique screw might be stable enough for the range of motion exercise of the elbow and forearm until bone union. Plate fixation could be a better procedure in cases with severely comminuted radial neck fracture (neck to radial tuberosity), which may be difficult to fix using an oblique screw. Oblique screw fixation is also challenging when the largest fragment is smaller than the diameter of the screw, and plate fixation is also indicated in that case.
There were several limitations to our study. First, it was a retrospective study. The frequency of comminuted fractures of the proximal radius is low; therefore, P group patients were enrolled from several institutions [26, 27]. The number of complications was higher in the P group; nevertheless, there was no significant difference. This is probably related to the few patients in both groups. Furthermore, the P group had several surgeons, and varying plates were used. Therefore, there might be a difference in postoperative treatment depending on the surgeon and ORIF indication. There was also a bias regarding the new procedure, one oblique screw technique, which one surgeon performed. There were significant differences in group backgrounds (duration from injury to operation and number of patients undergoing MCL repair). The P group might include patients with more soft tissue damage than the S group. Additionally, the RHND ratio could not be assessed in the P group because plates covered the radial head and neck. Therefore, reconstructed CT images might provide more accurate measurements due to radius rotation. Lastly, the follow-up was short for evaluating post-traumatic arthrosis of the elbow.
In conclusion, this study revealed satisfactory clinical and radiological outcomes of surgery for proximal radial fracture involving multiple head and neck fragments with headless compression screws or a plate system and ligament injury repair in both groups. There was no significant difference in motion range except forearm supination and MEPS between the groups.
Acknowledgements
We would like to thank Honyaku Center Inc. for English language editing.
Funding
Nothing to declare.
Data availability
The data that support the findings of this study are available on request fromthe corresponding author. The data are not publicly available due to ethical restrictions.
Declarations
Conflict of Interest
The authors received no financial or material support for the research.
Ethical Approval
Ethical approval was obtained from the institutional review board.
Informed Consent
Informed consent was obtained from each patient.
Footnotes
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Contributor Information
Koichi Yano, Email: moc.liamtoh@onayihciok.
Makoto f*ckuda, Email: pj.oc.oohay@7796adukufm.
Takuya Uemura, Email: pj.ca.uc-akaso.dem@arumeu-t.
Yasunori Kaneshiro, Email: moc.liamg@orihsenakironusay.
Kiyotaka Yamanaka, Email: moc.liamtoh@akattoyik.
Hidetoshi Teraura, Email: pj.en.tenoe.aiam@aret-ih.
Ken Yamamoto, Email: pj.ca.uc-akaso.dem@215-nek.
Ryo Sasaki, Email: moc.liamg@347egovb.
Takeshi Matsuura, Email: moc.duolci@2003ihcttamt.
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