Ankle fractures by tD7C8TF



Instructions for authors
One or two sentences that describes the injury. Try to say something beyond the obvious.
An apt comment might be “Geriatric hip fractures are low energy injuries typically
associated with osteoporosis, and a (perhaps shockingly high) one year mortality rate of
20% or more” or “Tears of the anterior cruciate ligament of the knee are often sustained
while playing sports and often require surgical intervention to give the patient sufficient
anterior tibial stability to return to high levels of play”)

Acetabular fractures are complex injuries associated with intricate, often
confusing anatomy, with a recognized potential for long-term disability and
progressive joint degeneration. They occur in isolated fashion, or in
combination with pelvic ring disruption and/or ipsilateral extremity injuries,
including hip dislocations.

Native hip dislocations require an inherently massive force secondary to the
intrinsic stability of the hip joint. Timely reduction, assessment of stability,
and detection of associated injuries are paramount to achieving an enduring
functional result.

Structure and function

Instructions for authors
Please include a brief review of the relevant anatomy, enough to make clear what is
disturbed by the injury and why such a disturbance is clinically important. It is possible that
there may not be much to say (a femoral shaft fracture is clinically important for obvious
reasons) but even in such cases there probably is something to say (eg the femur is the
largest bone in the body and therefore associated blood loss can be significant, or that
because of its size the amount of intravascular debris and accompanying risk of fat
embolism is higher)

The acetabulum is formed from the ilium, ischium, and pubis. Its structure is
generally described via a two-column concept, which intrinsically resembles
an inverted-Y position. The anterior column consists of iliac and pubic
components, while the posterior column incorporates the ischium. The
acetabular dome, considered the weight-bearing portion, is formed by the
junction of both columns.

The hip is an extremely stable joint, conferred via bony, ligamentous,
muscular, and soft tissue constraints. Much force is required to cause hip
Fractures of the acetabulum and/or hip dislocations can lead to an
incongruent hip joint and altered weight-bearing characteristics that
contribute to pain and dysfunction. This may be manifested through post-
traumatic arthritis, avascular necrosis, and associated gait abnormalities.
Treatment options for young adults with hip pathology are still evolving, but
at present, remain quite limited.

Instructions for authors
Who gets this? How rare is it? What is the disease burden in various populations of interest?
The goal here is not to inundate with facts (who cares that back pain causes
$6,476,400,000 in lost work productivity) but to give a general sense of importance (lost
time from work is very costly!). Is this rare or common? If it is rare, what is its impact

Acetabular fractures are relatively uncommon injuries, generally affecting
the young adult population following motor vehicle collisions. Significant
psychosocial and economic burden may incur, with great potential for long-
term functional deficits. In consideration of diminished bone quality and less
traumatic mechanisms in the older population, damaging consequences can
still be quite significant.

Despite a strong association with acetabular fractures, the disease burden of
hip dislocations can be quite similar, or in fact, drastically different. Simple
dislocations without fracture generally enjoy good long-term results if
reduction is concentric and timely, while future consequences can be
destructive despite any/all accepted treatment measures, with or without
fracture. Results tend to be individualized.

Clinical presentation

Instructions for authors
Here include mechanism of injury and how the patient presents. Describe how this injury is
sustained, especially the points that may be relevant to differential diagnosis, treatment,
outcome etc. Examples: Geriatric hip fractures are from falls – so maybe a syncope work up
is needed; Geriatric hip fractures patients may have altered mental state from dehydration
and pain and may “perk up” when these are addressed. Or, ACL tears are from twisting
injuries, so the meniscus may be damaged then too. There may be a lot of pain from
bleeding into the knee or from a bone bruise (the former gets better with aspiration, the
latter will resolve over time. We don’t fix ACLs because of pain)

Common mechanisms causing acetabular fractures include motor vehicle
collisions, pedestrian versus auto, falls from height, and industrial accidents.
Full trauma evaluation is required, with many patients arriving unconscious
or obtunded in consideration of associated injuries.

The proximal femur is excessively loaded, with the precise fracture pattern
determined by the position of the hip at time of impact, the magnitude of
the force, and the quality of bone. Anterior column disruption generally
results from the hip contacted in an externally rotated and abducted
position, while posterior column injury follows an internally rotated and
adducted position. Moreover, if force transmission continues, the femoral
head can also be displaced, resulting in dislocation.

Approximately 85-90% of hip dislocations are posterior, and occur secondary
to axial loading of a flexed and adducted hip. This leads to a shortened,
adducted, and internally rotated extremity. Associated sciatic nerve palsy is
present in about 10% of cases, with the peroneal division (ankle
dorsiflexion) preferentially affected. It can be pierced by displaced
acetabular fragments, or stretched over a posteriorly dislocated femoral

In contrast, anterior hip dislocations result from loading a flexed, abducted,
and externally rotated extremity. This leads to a flexed, abducted, and
externally rotated limb. The degree of hip flexion will determine whether the
dislocation is inferior or superior.

Following initial trauma management, the position of the affected limb, a
complete neurovascular exam, and an assessment of skin integrity should be
documented. Once hemodynamic stability is assured, specific imaging may
then be obtained.

RIGHT POSTERIOR HIP DISLOCATION                                 (Ext
Shortened, Add, & IR)

Red flags
Instructions for authors
Make special note, please, of “don’t miss this!” things that deserve particular
mental attention or prompt referral to a specialist . This section is, in a way, a
subsection of “clinical presentation” but should be listed distinctly.

“Classic” presentations of injuries can be dramatically altered with
accompanying pathology, thus a high level of suspicion must exist in
patients unable to provide a detailed history of injury events. Time is of the
essence in native hip dislocation, with the risk of avascular necrosis
increased with a delay in management. Also, up to 50% of patients with hip
dislocations incur associated fractures.

Any patient presenting with an acetabular fracture and/or hip dislocation
must be evaluated for a femoral neck fracture. It is imperative to visualize
an undisturbed femoral neck before attempted reduction and/or traction pin
placement. The long-term consequences of missing this injury may
dramatically alter treatment, heighten the risk of AVN and/or cause life-
altering consequences.

AVN is commonly associated with hip dislocations, as the dominant blood
supply to the femoral head, the medial femoral circumflex artery, can be
stretched or occluded. The risk of AVN increases the longer the hip remains
dislocated, and the rate is slightly higher when there is an associated
femoral head fracture. This is indicative of the higher energy required to
cause a fracture. The overall rate of AVN following hip dislocation is
approximately 15%, but increases to 20% with an associated femoral head

Sciatic nerve palsy is also a common complication of acetabular fractures
and/or hip dislocations. Documentation of function should proceed any
attempts at treatment. Prior to attempts at closed reduction, appropriate
consent including the risks of sedation, femoral head/neck fracture, loss or
diminished sciatic nerve function, and the potential of an unsuccessful result
with the need for open reduction must be performed.

The patient should receive conscious sedation, analgesia, and adequate
muscle paralysis. Patient reluctance can inevitably hinder reduction
attempts, leading to greater potential for fracture risk, articular injury, and
unnecessary temporal delays related to the development of AVN. Loss of
function following attempted closed reduction generally necessitates surgical

Pelvic angiography and/or embolization may be required in acetabular
fracture patients that are hemodynamically unstable and unresponsive to
resuscitative techniques.

There is an increased risk of venous thrombolembolism and associated
pulmonary embolism (PE) with acetabular fractures and related pelvic
injuries, thus anti-coagulation methods (pharmacologic and/or mechanical)
should be considered. For those individuals that fall outside this therapeutic
recommendation based upon allergic and/or extremity contraindications,
placement of a venal caval filter can decrease the risk of PE, but does not
prevent or treat existing venous thrombi.

Differential diagnosis

Instructions for authors
For many injuries, the question is not ‘do you have it?’ (for the x-rays show it) but rather
‘what else do you have?’ So this section is really a review of the associated injuries, but also
take the opportunity here to briefly discuss how “your’ condition is unique.

Based upon loading mechanism, associated ipsilateral injuries can involve
the entire extremity. Isolated posterior wall fractures, the most common
acetabular fracture pattern, are frequently associated with posterior hip
dislocations and/or ipsilateral knee injuries. This can include patellar
fractures and rupture of the cruciate ligaments, specifically the posterior
cruciate ligament (PCL). These structures comprise the so-called “dashboard
injury,” whereby a flexed knee contacts the dashboard as force is
transmitted to the hip joint.

Pelvic ring and spinal injuries are also frequent associated injuries, with
disruption of adjacent organ systems a regular consequence.

Objective evidence
Instructions for authors
Don’t assume that the correct x-rays are always obtained. So first, describe what films are
needed (the view, the extent, etc: 3 views of the shoulder (why?), getting a ‘joint above
and joint below’ on the picture, etc) Next describe for what one should scrutinize the films-
what exactly are we looking for? Example: for ankle fractures, the status of the
syndesmosis is key; for tibial plateau fractures, depression is important; for clavicular
fractures, the location relative to the CC ligaments is important.
Then discuss need for supplemental imaging (CT, MRI, etc) with some parameters, ie, who
needs one, and what question does this test answer?
Are any other tests needed? Metabolic work up? (distal radius fractures) Blood tests of any
sort (hemoglobin after femur fracture?)

Secondary to its high energy mechanism, a full trauma imaging evaluation
should be obtained. This includes an AP chest, AP pelvis, and lateral cervical
spine films. Judet views are required if an acetabular fracture is discovered,
while an AP/cross-table lateral view of the hip, and a full-length femur film
that includes the knee should be considered depending upon associated
pathology and/or treatment expectations. Likewise, if a pelvic ring injury is
suspected, inlet and outlet views should be obtained.

There are six radiographic landmarks that should be identified on an AP
Pelvic x-ray:

1)Anterior column-delineated by the iliopectineal line.

2)Posterior column-delineated by the ilioischial line.

3)Anterior wall-located medially relative to the convex posterior wall.
4)Posterior wall-larger and more lateral than the anterior wall.

5)Acetabular roof-also referred to as the “sourcil” (eyebrow) and found
cranial to the femoral head

6)Teardrop-radiographic structure created by confluence of medial
obturator neurovascular sulcus, the quadrilateral surface of the pelvis, and
the lateral cortical boundary of the acetabular fossa.


Acetabular fracture classification is divided into five elementary patterns with
a single fracture plane and five associated fracture patterns that combines
elementary patterns.


1) Anterior Column       1)Posterior Column/Posterior Wall

2)Posterior Column      2)Transverse/Posterior Wall

3)Anterior Wall         3)Ant Column/Post HemiTransverse**

4)Posterior Wall        4)T-Type***

5)Transverse*           5)Both Column
*Splits articular surface through dome, at junction of dome/acetabular
fossa, or through fossa (Transtectal, Juxtatectal, Infractectal)

**Referred to as “hemitransverse” because the transverse component only
involves one column.

***Involves a transverse fracture plane with additional vertical fracture line
splitting the ischiopubic component, creating the appearance of the letter


   1) Anterior Column-AP Pelvis-Iliopectineal line disruptedfurther
      identify on Obturator Oblique Judet view

   2) Posterior Column-AP Pelvis-ilioischial line disruptedfurther identify
      on Iliac Oblique Judet view.

   3) Anterior wall-best seen on Iliac Oblique Judet view. The “teardrop” is
      usually displaced medially with respect to the ilioischial line.

   4) Posterior wall-(PW) best seen on Obturator Oblique Judet view. Most
      common isolated acetabular fracture.

   5) Transverse-AP Pelvis-iliopectineal and ilioischial lines disrupted.
      Ilioischial line and teardrop maintain normal relationship.

   6) Posterior column/Posterior wall-AP Pelvis-PC-ilioischial line
      disrupted, also seen on Iliac Oblique view. PW best seen on Obturator
      Oblique view.

   7) Transverse/Posterior wall-AP Pelvis-Iliopectineal and ilioischial line
      disrupted, PW best seen on Obturator Oblique view.

   8) Anterior Column/Posterior HemiTransverse-AP Pelvis-iliopectineal
      and ilioischial lines disrupted. Ant column fracture also seen on
      Obturator Oblique view.

   9) T-Type-AP Pelvis-iliopectineal and ilioischial lines disrupted.

   10)BOTH Column-AP Pelvis-iliopectineal and ilioischial lines disrupted.
   “Spur sign” on Obturator Oblique-created by intact, non-displaced ilium
   Acetabular Fx Classification System Elementary fxs
   (top row), Assoc fxs (bottom row)

JUDET VIEWS: The Obturator Oblique radiograph is obtained by rotating
the patient 45 degrees onto the unaffected side. It better delineates anterior
column and posterior wall fractures, while also scrutinizing the posterior
acetabular surface to assess for posterior subluxation of the hip joint.

Column Fx- Iliopectineal line disrupted/”Spur sign”)
In contrast, the iliac oblique film rotates the patient 45 degrees onto the side
of the fracture, with the beam directed perpendicular to the iliac wing. It
provides detailed imaging of the posterior column and anterior wall.


(Both Column Fx-Ilioischial line disrupted/Intact Ant Wall)

With evidence of an acetabular fracture, roof arc angles are commonly
obtained to assist in determining stability. They describe the location of
column fracture lines with respect to the roof of the acetabulum. However,
they cannot be used with posterior wall fractures (out of plane) and both
column fracture patterns (less predictive).

They are measured on the AP Pelvis (medial arc) and Judet views (Obturator
Oblique-anterior arc/Iliac Oblique-posterior arc) respectively. A vertical line
is drawn through the geometric center of the acetabulum and a second line
drawn where the fracture line enters the joint. If the fracture line does not
enter the joint on any views, then it does not involve the weight-bearing
dome, and is considered a stable fracture. Likewise, if a fracture does enter
the joint, a measurement of at least 45 degrees generally entails an intact
weight-bearing dome, thus no operative intervention is indicated. As the roof
arc angle increases, acetabular dome coverage also increases, usually
intimating heightened hip congruity and stability.

Inlet and outlet views demonstrate anterior/posterior and vertical
displacement of the pelvis respectively.

CT can provide further information regarding size and position of column
fractures, impacted patterns, incarcerated bony fragments, and level
of comminution. It is also usually substituted for lateral C-spine
radiographs, and can help to better identify associated traumatic and
occult injuries.

Ct may also be used to determine subchondral arc measurements to
provide an estimate of acetabular fracture stability. The subchondral ring of
the acetabulum is defined as 10mm inferior to the subchondral bone of the
roof, thus if this ring is not interrupted, then roof arc measurements
obtained from plain films must also be greater than 45 degrees. As stated
previously, this usually indicates non-operative management.

Hip dislocations follow a similar pattern of required imaging, with a cross-
table lateral key to defining an anterior or posterior location of the femoral
head with respect to the acetabulum. The femoral heads will appear of
different size if there is a dislocation, with the femoral head smaller in a
posterior dislocation and larger if displaced anteriorly. This reflects the
distance of the femoral head from the x-ray beam.



Risk factors and prevention

Instructions for authors
List here risk factors for this injury
Example: geriatric hip fracture = Propensity for falling (eg due to alcoholism or
neuromuscular disease) What can be done to prevent this? Is this cost effective? Does it
In younger individuals, risk factors that are preventable include wearing a
seatbelt and any associated safety precautions with respect to potential for
high energy/velocity injuries. Regarding older individuals and/or those
persons with propensity for falling and/or gait abnormalities, individual fall
precautions, visual/auditory testing, and monitoring of medication effects
may help to decrease number of events.

If a sciatic nerve palsy is present following acetabular fracture and/or
posterior hip dislocation, prevention of skin breakdown and ankle equinus
contracture are paramount. An ankle-foot orthosis (AFO) can help maintain a
plantigrade foot while monitoring for recovery.

Treatment options
Instructions for authors
Note the treatment options. Offhand, injuries can be treated with benign neglect; casual
immobilization; rigorous immobilization; functional rehabilitation; surgical repair; surgical
replacement; or some combination.
For each treatment, describe the rationale/method for each treatment, and whether it is
evidence based.

Non-operative management of an acetabular fracture requires a congruent,
stable hip joint, with an intact weight-bearing dome as measured by “roof
arc” or “subchondral arc” measurements. In addition, the orthopaedic
surgeon must take into account associated injuries, the functional demands
and expectations of the patient, consider his or her own experience treating
the injury pattern, as well the capability of the participating institution to
accommodate the patient. Elderly, non-ambulatory patients with multiple co-
morbidities may be considered for non-operative management regardless of
fracture pattern-patient treatment should always be individualized.

The goals of surgical treatment of an acetabular fracture should be to
maintain a painless and functional hip joint, restore the articular surface to
prevent post-traumatic arthritis, and help diminish the risk of development
of future complications (AVN, HO). Early referral to an appropriate institution
with an experienced acetabular surgeon can positively affect outcomes. It
diminishes the need for more extensile exposures and allows for
manipulation of more mobile fracture fragments. This can lead to a more
accurate reduction, improving chances for better long-term results.

Posterior hip pathology is approached through a Kocher-Langenbeck
exposure, while anterior injuries are treated through a Smith-Peterson
approach. Hip arthroscopy is an alternative to open arthrotomy, and is
indicated in select circumstances including removal of residual joint debris
and incarcerated fragments. Its less invasive nature however is generally
offset by its heightened skill level requirement.

The most important parameter regarding treatment of a native hip
dislocation involves time to reduction. Likewise, assessment of
neurovascular function, specifically the sciatic nerve, must be evaluated
before and after attempted reduction.

Reduction of a posterior dislocation involves traction/counter-traction,
stabilizing the patients’ pelvis, along with gentle rotation motions, and
sometimes slight adduction. Successful reduction is usually signalled by an
palpable/audible “clunk”, with the return of appropriate leg length and
rotation. Stability should then be assessed regarding the likelihood of
maintaining concentric reduction. If it is determined stable, a knee-
immobilizer should be protect against excessive flexion, adduction, and
internal rotation.

Post-reduction radiographs should confirm concentric reduction and a pelvic
CT can evaluate for residual bony fragments and/or marginal impaction.
Otherwise, protected weight bearing is implemented, and is continued until
there is evidence of healing on x-ray if there is an associated fracture.

If the hip is irreducible, or dislocates upon dynamic testing (70-90 degrees
of flexion, neutral rotation, posterior-directed force), there may be a soft-
tissue or bony block to reduction. Likewise, it may be too unstable with
respect to associated injuries (PW fx). In the former case, surgical
intervention is required, while in the latter case, traction pin placement to
temporarily maintain reduction may be entertained with the patient re-
evaluated at a later date. However, this modality must be considered with
respect to patient age (contraindicated in pediatric population/questionable
in elderly osteoporotic patients), as well as in patients with associated
injuries (ipsilateral extremity fractures).

A CT scan should then also be obtained to check for subtle joint incongruity,
residual bony fragments in the joint that can lead to articular degeneration,
and “marginal impaction. Likewise, if the hip joint is determined non-
concentric, bony fragments remain, or any other new pathology is
uncovered, the CT scan can aid in pre-operative planning for open reduction.


Instructions for authors
This should list the expected outcomes of treatment if all goes well; the possible
complications of treatment; the presentation of untreated disease; and the long term
consequences of the injury.

Outcome of patients with acetabular fractures are based upon numerous
factors including fracture pattern, bone quality, extent of articular injury,
associated injuries (hip dislocation, proximal femur fracture, neurovascular
complications, etc.), presence/absence of surgical complications, and co-
morbid conditions.

Post-traumatic arthritis following acetabular fractures and/or hip dislocation
can result from an incongruent hip joint, alterations in femoral head
sphericity, bony defects of the acetabulum, and articular defects. These
conditions can all lead to alterations in contact stress and weight-bearing
biomechanics manifested by pain, stiffness, gait abnormalities, and overall
decreased function.

Heterotopic Ossification (HO), ectopic bone formation, can disrupt joint
motion/function, and can develop following operative or non-operative
intervention. However, the highest risk for its development can be found
following a posterior approach. Male patients and/or those with a traumatic
brain injury carry the highest risk. Prophylaxis should be considered
following acetabular surgery, with a choice of two recommended protocols:

1)Indomethacin 25mg three times daily for 4-6 weeks

2)LOW-DOSE LOCAL RADIATION THERAPY: 700-1000cGY within 24-48hrs
following the surgical procedure

Regarding hip dislocations, the time to relocation is an extremely important
parameter, directly affecting outcome. Every effort should be made to
minimize temporal issues that can lead to AVN because there is no good
treatment for its consequences, most notably in the younger population.

Simple posterior dislocations enjoy 70-80% excellent outcomes with early
concentric reduction versus those with an associated fracture or if reduction
was delayed >12 hours. In the latter case, the associated fractures
dominate the outcome parameters. Likewise, the incidence of post-traumatic
arthritis is much lower in simple hip dislocations versus injuries that involve
associated fractures.

Holistic medicine
Instructions for authors
Nutritional factors, Psychosocial impact of disease and Economic effects

The long-term psychosocial and economic impact faced by the young
population with hip pathology can be overwhelming. Unfortunately, there are
no good treatment options at present. Conservative treatment (non-narcotic
analgesics, physical therapy, weight loss, etc.) generally only provides
transient relief, while surgical intervention is a highly questionable long-term
solution. Hip arthroscopy, associated resurfacing, and/or replacement may
initially be beneficial, but will all likely require revision/alternative
intervention at some later date.


Instructions for authors
In this section include everything a professor can mumble, without necessarily having
evidence to support the assertions

      Random factoids to help students remember important stuff. E.g.: Why are sailors
       called “limey”? Sailors at sea where prone to scurvy from Vit C deficiency (imagine
       the toothless deck hand). Once that was known, they were issued limes to eat---to
       help the collagen cross link
      Clinical pearls
      Favorite facts for exam writers. It would be great if you can compose a question or
       two for students to ponder.
      Frontier of science - what is coming down the pike from our basic science friends
      What we don’t know

-Mnemonic to remember what each Judet view emphasizes: “PIC and POW”

PICIliac oblique-Posterior Column/Anterior wall

POWObturator Oblique-Anterior Column/Posterior Wall

-Posterior wall fractures involve separation of the posterior articular
surface, and are often combined with “marginal impaction.” This refers to
articular cartilage being impacted into the underlying cancellous bone. It is
best assessed on CT scan and requires surgical management.

-In Both Column fracture patterns (“floating acetabulum”), the articular
surface does not have any connection to the intact hemipelvis. However,
based upon the principle of “secondary congruency,” it can be considered
stable and potentially treated non-operatively. The “spur sign” on the
obturator oblique view is pathognomonic for this injury, with the caudal
extent of the intact ilium appearing more prominent as the acetabular
articular fragments displace medially.

-Corona Mortis-vascular communication between the external iliac artery
or inferior epigastric artery and the obturator artery. Found in approximately
85% of the population, with a large potential for bleeding complications if

-Morel-Lavalle lesion: classic skin degloving injury associated with
acetabular fractures that requires extensive debridement prior to fracture
repair. Infected in up to one-third of cases.


-Anterior wall fractures are the least common of all fracture types based
upon biomechanical loading properties.

-Anterior hip dislocations have a high risk of associated femoral head
fractures, thus the examiner should be fully aware of the potential for
associated pathology when assessing this injury. The combination injury
heightens the risk for AVN.

-Commonly there is a residual avulsed bony fragment off the femoral head
(ligamentum teres) following hip dislocations. It is generally not an
indication for open reduction as it does not affect the weight-bearing surface
and can effectively be ignored.

-Isolated posterior wall fractures are the most common acetabular fracture
pattern. The hip is generally considered stable and be treated with protected
weight bearing if there is less than 20% wall disruption. It is considered
unstable if >40% is involved. A gray area exists between these endpoints,
with cases assessed on an individual basis.

**The surgical approach to hip reduction generally proceeds from the
direction of dislocation to avoid further damage to the blood supply.


1) What is the most common direction for a hip dislocation?

2) What are the six radiographic markers examined on an AP Pelvic

Key terms
Instructions for authors
For learning and indexing purposes, suggest the key terms associated with this condition.

Acetabulum, Hip, Hip Dislocation, Elementary Fracture pattern, Associated
fracture pattern, Sciatic Nerve, Avascular Necrosis (AVN), Post-Traumatic
Arthritis, Heterotopic Ossification (HO), Roof Arc Angle, Subchondral Arc,
Marginal Impaction, Kocher-Langenbeck approach, Smith-Peterson approach


Instructions for authors
Students, according to the Association of American Medical Colleges, must acquire the
necessary “knowledge, skills and attitudes” to practice medicine. Obviously, a book
concentrates on “knowledge”. Attitudes are perhaps more nebulous and taught implicitly.
Skills, on the other hand, can be taught----but perhaps not in a book. Therefore, please list
here the skills related to the knowledge presented above for which students must seek
bedside instruction.
This section should also prove useful to for those who want to map this text to a
competency based curriculum.

Radiographic Analysis, Recognition/Treatment of Emergent Orthopaedic
Conditions (Hip Dislocation/Open fractures), Extremity Neurovascular
Examination (sciatic nerve)

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