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Injury to the Tarsometatarsal Joint Complex

Thompson, Michael C. MD; Mormino, Matthew A. MD

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Journal of the American Academy of Orthopaedic Surgeons: July 2003 - Volume 11 - Issue 4 - p 260-267
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Abstract

Lisfranc described amputations through the tarsometatarsal (TMT) joint for the treatment of severe, gangrenous midfoot injuries, and his name has been associated with many different injuries to this region.1 Myerson2 described such injuries as involving the tarsometatarsal complex (TMC), which includes the metatarsals and TMT joints, the cuneiforms, the cuboid, and the navicular.2 The spectrum of TMC injury ranges from low-energy trauma, such as a misstep, to high-energy crush injuries characterized by extensive osseous comminution and soft-tissue compromise. Accordingly, the pattern of TMC injury is highly variable and may involve purely ligamentous disruptions without fracture, associated metatarsal fractures, or fractures of the cuneiforms, cuboid, or navicular.

Accurate diagnosis of these injuries is paramount. Although only minimal displacement may be present on initial radiographs, severe ligamentous disruption might still exist. Left untreated, such disruption may result in marked disability characterized by painful posttraumatic arthritis and planovalgus deformity.3,4 A high index of suspicion should be maintained when examining a patient with an injured foot because delayed or missed diagnosis occurs in up to 20% of cases.5-7

The goal of treating TMC injury is to obtain a plantigrade, stable, painless foot. Successful outcome largely is related to obtaining and maintaining an anatomic reduction.5,6,8,9 Early studies documented the failure of closed reduction to maintain an anatomic reduction.10-12 In 1982, Hardcastle et al13 reported that open techniques with temporary, nonrigid fixation occasionally resulted in late displacement. Rigid screw fixation, the technique reported by Arntz et al6 in 1988, has become the preferred method for stabilization of these injuries.5

Anatomy and Biomechanics

Understanding the anatomy of the TMC is imperative for accurate assessment and treatment of injuries. Stability of the complex is achieved by a combination of bony architecture and ligamentous support. The medial, middle, and lateral cuneiforms articulate distally with the first, second, and third metatarsals, respectively14 (Fig. 1, A). The cuboid articulates distally with the fourth and fifth metatarsals. The middle cuneiform is recessed proximally relative to the medial and lateral cuneiforms. This mortise configuration accommodates the base of the second metatarsal and lends additional osseous stability at this articulation. In the coronal plane, stability is further enhanced by the so-called Roman arch configuration of the metatarsal bases, with the second metatarsal base acting as the keystone (Fig. 1, B).

Figure 1 A,
Figure 1 A,:
Anteroposterior view of the bony and ligamentous anatomy of tarsometatarsal joint complex. I through V = metatarsal bones. (Adapted with permission from Myerson MS: Fractures of the midfoot and forefoot, in Myerson MS: Foot and Ankle Disorders. Philadelphia, PA: WB Saunders, 2000, vol 2, pp 1265-1296.) B, Coronal section through the metatarsal bases illustrating the Roman arch configuration. (Adapted with permission from Lenczner EM, Waddell JP, Graham JD: Tarsal-metatarsal [Lisfranc] dislocation. J Trauma 1974;14:1012-1020.)

Ligaments supporting the TMC are grouped according to anatomic location (dorsal, plantar, and interosseous). The lesser metatarsals are bound together by dorsal and plantar intermetatarsal ligaments (Fig. 1, A). Similarly, dorsal and plantar intertarsal ligaments hold the cuneiforms and cuboid together. There are no ligamentous connections between the first and second metatarsal bases. The largest and strongest interosseous ligament in the TMC is the socalled Lisfranc ligament, which arises from the lateral surface of the medial cuneiform and inserts onto the medial aspect of the second metatarsal base near the plantar surface.14 The first metatarsal base is anchored to the dorsal and plantar aspects of the medial cuneiform by two longitudinal ligaments. The peroneus longus and tibialis anterior tendon insertions further stabilize the first TMT joint. A variable network of longitudinal and oblique ligaments secures the remainder of the metatarsals to the cuneiforms and cuboid on the dorsal and plantar aspects of the complex. In general, the dorsal ligaments are weaker than their plantar counterparts. To a lesser extent, the plantar fascia and intrinsic musculature of the foot add stability to the TMC.

Because of the unique bony and ligamentous anatomy of the TMC, normal motion of the individual components varies. Having articular contact with all three cuneiforms, the base of the second metatarsal demonstrates very little motion under normal circumstances, with an average dorsiflexion-plantarflexion arc of 0.6°.15 In comparison, dorsiflexion-plantarflexion at the third TMT joint is approximately 1.6°, and, at the first joint, 3.5°. The fourth and fifth TMT joints are the most mobile, demonstrating an average of 9.6° and 10.2° of dorsiflexion-plantarflexion, respectively.15

Injury to the Tarsometatarsal Joint Complex

The overall annual incidence of TMC injuries is approximately 1 per 60,000 persons,13,16 and the injury is two to three times more common in males (Table 1). Motor vehicle accidents are the most frequently cited mechanism, accounting for about 40% to 45% of injuries. Low-energy mechanisms account for approximately 30%. Falls from a height and crush injuries are also commonly reported causes.

Table 1
Table 1:
Tarsometatarsal Joint Complex: Mechanisms of Injury

The mechanism of TMC injury may be either direct or, more commonly, indirect trauma. The direct mechanism involves high-energy blunt trauma, usually applied to the dorsum of the foot. Crush injuries constitute most of these injuries, and many are associated with notable soft-tissue trauma. Associated compartment syndromes and open fracture-dislocations are more often present with direct injury mechanisms. In part as a result of the associated soft-tissue trauma and greater degree of articular injury, direct injuries often result in a worse clinical outcome compared with indirect injuries.8,9

The indirect mechanism of injury usually involves axial loading of the plantarflexed foot. An example is a football player falling onto the heel of another player whose foot is planted and plantarflexed. This type of injury also can occur with soccer, basketball, and gymnastics.17 Falls from a height may result in forefoot plantarflexion at the time of impact. In automobile accidents, injury to the plantarflexed foot occurs with a combination of deceleration and floorboard intrusion. Less commonly, violent abduction or twisting of the forefoot may result in fracture-dislocation around the TMC.

The fracture pattern and direction of dislocation in direct injuries are highly variable and depend on the force vector applied. In contrast, the most frequent pattern seen in indirect injuries involves failure of the weaker dorsal TMT ligaments in tension, with subsequent dorsal or dorsolateral dislocation of the metatarsals. Minor displacement at the TMT joint level results in a marked reduction in articular contact. Dorsolateral displacement of the second metatarsal base of 1 or 2 mm results in the reduction of the TMT articular contact area by 13.1% and 25.3%, respectively.18 Although fractures of the cuneiforms are relatively common, the most frequent fracture in TMC injuries involves the second metatarsal base.16 Less common are associated fractures of the cuboid, navicular, or other metatarsals.

Diagnosis

The diagnosis of high-energy or crush injuries to the TMC is relatively straightforward. Examination typically reveals moderate to severe swelling of the forefoot and, in open injuries, disruption of the skin and subcutaneous tissue. Inspection of the foot may reveal gross morphologic abnormalities such as widening or flattening. A gap between the first and second toes is suggestive of intercuneiform disruption as well as TMT joint injury.19,20 Palpation of the dorsalis pedis artery may not be possible, depending on the extent of swelling and deformity. Although disruption of the dorsalis pedis artery has been reported, the incidence of vascular injury appears to be rare.7,21,22 Significant pain on passive dorsiflexion of the toes in a tensely swollen foot is suggestive of a compartment syndrome; however, evaluation may be hampered by pain associated with the osseous injury.23,24 When there is uncertainty about the presence of a compartment syndrome, pressures should be measured. An absolute pressure >40 mm Hg is diagnostic and an indication for emergent compartment release. Particularly in the hypotensive patient, a compartment pressure within 30 mm Hg of the diastolic pressure also is an indication for release.

Findings after a low-energy TMC injury may be relatively subtle. A high index of suspicion should be maintained in the patient with forefoot pain after even a minor traumatic event. Patients usually have notable pain on weight bearing or are unable to bear weight on the affected foot. Swelling is present to a variable extent, and ecchymosis occasionally is found along the plantar aspect of the midfoot.25 Palpation of the affected TMT joints usually reveals tenderness. Notable pain on passive abduction and pronation of the forefoot also is suggestive of TMC injury.17

The initial radiographic examination should include anteroposterior, lateral, and 30° oblique views of the foot. To visualize the Lisfranc joint in the tangential plane, the anteroposterior radiograph should be taken with the beam approximately 15° off vertical. Standing radiographs are ideal but may be difficult to obtain secondary to pain (Fig. 2, A and B). If weight-bearing views are not possible, a stress view with the forefoot in abduction often will reveal subtle instability, especially at the first TMT joint.17,26 All radiographs should be evaluated for signs of instability. On the anteroposterior view, the distance between the first and second metatarsal bases varies among uninjured individuals, with up to 3 mm considered normal.26,27 In subtle cases, radiographs of the contralateral foot should be obtained for comparison.

Figure 2 A,
Figure 2 A,:
Anteroposterior non-weight-bearing radiograph of a patient with forefoot pain after an axial load injury. Note the subtle widening (arrow) between the bases of the first and second metatarsals. B, Anteroposterior standing view of the same patient as in Panel A demonstrating subluxation (arrow) at the base of the second metatarsal. C, Anteroposterior view of a patient with avulsion of the Lisfranc ligament, or fleck sign (arrow), at the base of the second metatarsal.

Stein28 reviewed 100 radiographs of normal feet and noted several constant anatomic relationships. On the anteroposterior view, the medial border of the second metatarsal is in line with the medial border of the middle cuneiform, the first metatarsal aligns with the medial and lateral borders of the medial cuneiform, and the first and second intermetatarsal space is continuous with the intertarsal space of the medial and middle cuneiforms (Fig. 1, A). On the 30° oblique view, the medial border of the fourth metatarsal is in line with the medial border of the cuboid, the lateral border of the third metatarsal is aligned with the lateral border of the lateral cuneiform, and the third and fourth intermetatarsal space is continuous with the intertarsal space of the lateral cuneiform and the cuboid.28

Other radiographic findings may assist with diagnosis. The fleck sign, or avulsion of Lisfranc's ligament at the base of the second metatarsal, is diagnostic of TMC injury9 (Fig. 2, C). Analysis of the medial column line on an anteroposterior abduction stress view may reveal subtle injury26 (Fig. 3). Flattening of the longitudinal arch may suggest injury to the TMC and can be evaluated by comparing the weight-bearing lateral view to that of the uninjured foot.29

Figure 3
Figure 3:
Medial column line. On an anteroposterior radiograph with the forefoot stressed in abduction (dashed outline of first metatarsal), a line is drawn tangential to the medial borders of the navicular and medial cuneiform (heavy dashed line). Failure of this line to intersect the base of the first metatarsal is strongly suggestive of TMC injury. A, Normal foot. B, First, second, and third TMT joint disruption (heavy dark line). Arrows indicate direction of forces. (Adapted with permission from Coss HS, Manos RE, Buoncristiani A, Mills WJ: Abduction stress and AP weightbearing radiography of purely ligamentous injury in the tarsometatarsal joint. Foot Ankle Int 1998;19:537-541.)

Computed tomography (CT) has proved to be a valuable tool in the diagnosis of injuries to the TMC. It is more sensitive than plain radiographs in detecting minor displacement and small fractures.30-32 Displacement of up to 2 mm may not be detectable on plain radiographs but is visible on CT.31 Axial and coronal views of both feet should be made for comparison. Subtle widening or dorsal subluxation of the metatarsals are CT findings suggestive of TMC disruptions, and avulsion fracture of the second metatarsal base is diagnostic of injury33 (Fig. 4). In high-energy fracture-dislocations, a preoperative CT may facilitate surgical planning by delineating the extent of osseous injury.

Figure 4 A,
Figure 4 A,:
Coronal CT scan demonstrating subtle widening (arrow) of the first and second metatarsal bases. B, Coronal CT scan showing an avulsion fracture (arrow) of the second metatarsal base.

The role of magnetic resonance imaging (MRI) in evaluating TMC injuries has yet to be defined. MRI is more sensitive than plain radiographs in detecting small fractures and joint malalignment and in assessing ligamentous structures around the TMC.33,34 However, with regard to diagnosis and decision-making, CT is superior to MRI.30 Therefore, MRI is not routinely recommended in the assessment of these injuries.

Classification

The earliest classification system was published in 1909 by Quenu and Kuss12 and subsequently modified by Hardcastle et al13 in 1982 and Myerson et al9 in 1986. The most recently published classification system, published by the Orthopaedic Trauma Association,35 is similar to the original Quenu and Kuss classification. These classification systems are all based on the congruency of the TMT joints and the direction of displacement of the metatarsal bases. Common to all classification systems is that none appears to be helpful in terms of management or prognosis.9

Management

Nonsurgical management of TMC injuries should be limited to those that are without fracture, nondisplaced, and stable under radiographic stress examination. As little as 2 mm of displacement or the presence of a fracture within the TMC warrants fixation. Nondisplaced, stable ligamentous injuries may be treated in a non-weight-bearing short leg cast for a minimum of 6 weeks. Radiographic examination should be done 1 to 2 weeks after injury to ensure that alignment and stability are maintained. Gradual weight bearing in a protective brace may begin at 6 weeks. Permission for unrestricted activity, such as running and jumping, should be withheld for 3 to 4 months.

Although displaced or unstable TMC injuries have been treated by closed reduction and casting, loss of reduction was common and outcomes were variable, with a high incidence of poor results. Currently accepted surgical techniques involve either closed reduction with percutaneous Kirschner wire (K-wire) or screw fixation2 or open reduction with screw and/or K-wire fixation.4-6 For fixation of the medial three TMT joints, screw fixation may be preferable to K-wires because ligamentous healing may require as much as 12 to 16 weeks of immobilization to occur, and K-wires can become loose, necessitating removal as early as 6 weeks. Regardless of the technique used, the goal should be anatomic reduction of the affected joints because numerous studies have documented that clinical outcome correlates with accuracy of reduction.1,5-9,12,21,36,37

Ideally, surgical management of closed injuries is undertaken when soft-tissue swelling is at a minimum, either immediately or after swelling has abated. This delay may take up to 2 weeks and can be identified by the return of wrinkles to the skin. The initial incision is made dorsally between the first and second web space. The extensor hallucis longus tendon, deep peroneal nerve, and dorsalis pedis artery are identified and retracted as a unit, allowing deep, sharp dissection to expose the first and second TMT joints. Small, irreducible bone fragments are débrided from the joints. The reduction should begin medially and progress laterally. Aligning the medial aspect of the first metatarsal and the medial cuneiform reduces the first TMT joint. The entire medial aspect of this joint is exposed to ensure that plantar gapping is not present. The reduction is provisionally held with a K-wire, and the joint is stabilized with a countersunk 3.5- or 2.7-mm screw placed from the base of the first metatarsal into the medial cuneiform. Using fully threaded cortical screws placed for positioning, rather than compression, is preferable. Screws crossing otherwise normal joints result in little, if any, long-term morbidity. If rotational instability of the first TMT joint persists after placement of the first screw, a second screw or K-wire may be placed from the medial cuneiform into the base of the first metatarsal.

The second metatarsal is then reduced to the medial border of the middle cuneiform and temporarily held with a K-wire. Definitive fixation follows with a 3.5- or 2.7-mm countersunk screw directed from the base of the second metatarsal into the middle cuneiform. A 3.5-mm screw is usually appropriate for most patients; a 2.7-mm screw may be used for patients of small stature or when there is concern about the size of the 3.5-mm screw relative to the diameter of the second metatarsal. Medial column fixation is then completed by placing a 3.5- or 2.7-mm screw from the medial cuneiform into the base of the second metatarsal.

If the third TMT joint is disrupted and remains unstable after fixation of the first and second TMT joints, a second dorsal incision is made between the third and fourth metatarsals to expose the third TMT joint. This joint is similarly reduced and fixed with a 3.5- or 2.7-mm screw directed from the base of the third metatarsal into the lateral cuneiform. Reduction of the fourth and fifth TMT joints usually occurs with reduction of the medial three TMT joints and is secured with percutaneous K-wire fixation (Fig. 5). Alternative fixation, although typically unnecessary, is done with screw fixation.

Figure 5
Figure 5:
Typical fixation scheme for a TMC disruption.

Occasionally, an associated impacted (nutcracker) fracture of the cuboid may require treatment. The technique described by Sangeorzan and Swiontkowski38 involves restoration of cuboid length by distraction bone grafting and plating. Failure to restore length results in lateral column shortening and a persistently abducted and pronated forefoot. A distractor or external fixator may be used intraoperatively to facilitate distraction before plating (Fig. 6). Associated fractures of the navicular may be exposed and stabilized by extending the dorsal medial incision proximally. In most cases, fragments are large enough to accommodate 3.5- or 2.7-mm screws placed using a lag technique.

Figure 6
Figure 6:
Restoration of cuboid length with bone graft and a plate. An external fixator or distractor may be used intraoperatively to facilitate distraction. (Adapted with permission from Hansen ST Jr: Acute fractures in the foot, in Hansen ST Jr: Functional Reconstruction of the Foot and Ankle. Philadelphia, PA: Lippincott Williams & Wilkins, 2000, pp 65-103.)

Rarely, severely comminuted or contaminated injuries of the TMC may not be amenable to internal fixation using standard techniques. Temporary or definitive spanning external fixation is an option for these difficult cases. Limited percutaneous fixation with K-wires or screws may augment stabilization but should be used with caution in contaminated cases.

Wound closure should be accomplished with meticulous soft-tissue handling and closure. A short leg, non-weight-bearing cast is maintained for 6 weeks. Any percutaneous pins are then removed, and the patient is advanced to full weight bearing in a walking boot for an additional 4 to 6 weeks. The indication for screw removal remains controversial.2,5 Most authors recommend routine removal of the screws either on weight bearing or approximately 16 weeks after fixation.2 We prefer to remove screws only if patients are symptomatic but no sooner than 16 weeks postoperatively. Broken screws seem to occur in only a minority of patients. Furthermore, affected patients are often asymptomatic, although broken screws may be problematic if salvage by fusion is necessary.

When a compartment syndrome is diagnosed at the initial evaluation, emergent fasciotomy should be done.23 Using the two dorsal incisions described, the interosseous compartments are each released. Dissection between the metatarsals is done to achieve release of the medial, central, and lateral compartments (Fig. 7). Rarely, associated hindfoot injuries such as a calcaneus fracture may be present and may require release of the calcaneal compartment. This may be achieved through a longitudinal medial incision over the compartment. After fasciotomy, definitive fixation should be done. Fascial compartments and wounds should be left open, and the patient may undergo redébridement and attempted wound closure within 48 to 72 hours. Delayed primary wound closure may not be possible, and coverage with splitthickness skin graft may be necessary.23,24

Figure 7
Figure 7:
Release of compartment syndrome through dorsal incisions. (Adapted with permission from Myerson MS: Experimental decompression of the fascial compartments of the foot: The basis for fasciotomy in acute compartment syndromes. Foot Ankle 1988;8:308-314.)

Open TMC fracture-dislocations should be treated as surgical emergencies. Débridement and irrigation should be done within 6 hours of injury, if possible. In addition to tetanus prophylaxis, Gustilo and Anderson type I and II open injuries should receive a first-generation cephalosporin, with an aminoglycoside added for type III injuries. Severe contamination or vascular compromise requires adding penicillin G to the antibiotic regimen. Wounds are left open and covered with saline gauze or an equivalent dressing. Repeat débridement and irrigation are done every 48 hours until a clean, viable wound bed is achieved. Ideally, wound closure is achieved by delayed primary closure. In the foot, however, this is often not possible. Coverage may be achieved by splitthickness skin graft, free tissue transfer, or local rotation flaps, according to surgeon preference and institution capabilities.

Results

In 1986, Myerson et al9 published a retrospective study of 76 TMT joint injuries treated over a 10-year period. Six open injuries were included. Treatment methods comprised immobilization alone, closed reduction and casting, closed reduction and percutaneous K-wire fixation, and open reduction followed by K-wire fixation. Fifty-five injuries were followed up at a mean of 4.2 years (range, 1.6 to 11 years). Immobilization alone or closed reduction and casting resulted in 0 of 5 and 3 of 15 (20%) good and excellent results, respectively. In contrast, good to excellent clinical results were documented in 9 of 17 patients (53%) who underwent closed reduction and percutaneous pinning as well as in 14 of 18 patients (78%) treated with open reduction and K-wire fixation. Seven of the eight direct crush injuries had fair to poor functional outcomes (88%). Overall, the quality of reduction, which was a subjective assessment of TMT joint alignment, correlated with the clinical result. Good to excellent results were achieved in 22 of 26 patients (85%) with an acceptable reduction and in only 5 of 29 patients (17%) with an unacceptable reduction. The authors concluded that the major determinants of unacceptable results are the damage to the articular surface at the time of injury and the quality of the initial reduction.9

In 1988, Arntz et al6 published their results of 41 TMC injuries in 40 patients treated with open reduction and screw fixation. Seven of the injuries were open fracture-dislocations. At surgery, intra-articular fracture or periarticular comminution was noted in 54% of injuries (22/41). Anatomic reduction (within 2 mm) was achieved in 97% of the closed injuries (33/34) and in 88% overall (36/41). Hardware was removed from all patients at a minimum of 12 weeks. Thirty-four patients (35 injuries) were followed up at a mean of 3.4 years after injury. Good or excellent functional results were reported for 93% of closed injuries (27/29). In contrast, four of the six patients with open fractures had a fair or poor functional result. In all patients, the presence of degenerative changes on follow-up radiographs negatively correlated with functional outcome. Radiographic evidence of posttraumatic degenerative changes was absent or minimal in 26 of the 30 injuries with an anatomic reduction (87%). Conversely, all five injuries with nonanatomic reduction after surgery developed moderate or severe posttraumatic arthritis. In general, patients who sustained open injuries were more likely to have periarticular comminution noted intraoperatively, more advanced posttraumatic degenerative changes at follow-up, and a worse functional outcome. The authors concluded that injury to the articular cartilage and failure to achieve an anatomic reduction were the most important determinants in the development of posttraumatic arthritis. Furthermore, they stressed the importance of open anatomic reduction followed by rigid screw fixation in optimizing outcome.6

More recently, Kuo et al5 reported on 92 TMC injuries treated over a 7-year period. Six open injuries were included in the study. All patients were treated surgically with the medial three joints stabilized with screws and the fourth and fifth joints, with Kirschner wires. Postoperatively, screws were removed only when painful. Forty-eight patients were examined at a mean of 4.3 years after injury (range, 1.1 to 9.5 years), for a follow-up rate of 52%. The prevalence of radiographic posttraumatic arthritis was significantly (P = 0.004) lower in patients with an anatomic reduction within 2 mm (6/38 [16%]) compared with those with nonanatomic reduction (6/10 [60%]). In addition, patients with anatomic reduction had a statistically significant (P = 0.05) better average functional score, as measured by the American Orthopaedic Foot and Ankle Society score for the midfoot. Purely ligamentous injuries tended to have a higher prevalence of osteoarthritis, but without statistical significance. The authors concluded that the overall outcomes after surgical treatment of these injuries are good and that anatomic reduction is important for long-term outcome.5

Complications

Posttraumatic arthritis remains the most common complication after TMC injury. Not all patients who develop degenerative radiographic changes are symptomatic.9 In the series by Kuo et al,5 12 of 48 patients (25%) had symptomatic arthritis at final follow-up. Of these, six underwent arthrodesis. Arntz et al6 reported moderate to severe degenerative changes on follow-up radiographs in 9 of 35 patients (26%). Cushioned inserts, shoe modifications, and nonsteroidal anti-inflammatory medications are the mainstay of nonsurgical treatment for posttraumatic arthritis after TMC injury. If these modalities fail, arthrodesis of the affected joints is the treatment of choice.

Other complications occur with less frequency. Arntz et al6 and Kuo et al5 reported an incidence of broken screws of 2% and 25%, respectively. Superficial infection, residual dysesthesias, late displacement, and deep vein thrombosis have been reported in <4% of cases.5,6,9

Summary

Injuries to the tarsometatarsal joint complex are often overlooked and can be misunderstood. An appreciation of the complex bony and ligamentous anatomy is necessary to make an accurate diagnosis from the appropriate radiographic studies. Open anatomic reduction and rigid internal fixation is the preferred method of management. The keys to maximizing outcome are maintaining anatomic reduction (<2 mm) and avoiding complications with safe soft-tissue handling.

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