Outcome of desmoplasty and fasciotomy for desmitis involving the origin of the suspensory ligament in horses: 27 cases (1995–2004)

Christina A. Hewes Marion DuPont Scott Equine Medical Center, Virginia-Maryland Regional College of Veterinary Medicine, Virginia Tech, Leesburg, VA 20177.

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Nathaniel A. White II Marion DuPont Scott Equine Medical Center, Virginia-Maryland Regional College of Veterinary Medicine, Virginia Tech, Leesburg, VA 20177

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Abstract

Objective—To determine outcome of percutaneous ultrasound-guided desmoplasty with simultaneous fasciotomy for proximal suspensory desmitis (ie, desmitis of the origin of the suspensory ligament) in horses that have not responded to stall rest.

Design—Retrospective case series.

Animals—27 horses.

Procedures—Medical records of horses with proximal suspensory desmitis treated by means of desmoplasty with fasciotomy were reviewed. Follow-up information was obtained through telephone conversations with owners and trainers of the horses or by examination of horses at the hospital.

Results—23 of the 27 (85%) horses, including 3 of 4 horses with forelimb lesions and 20 of 23 horses with hind limb lesions, were able to return to full work after surgery and rehabilitation. All horses had ultrasonographic evidence of healing of suspensory ligament lesions.

Conclusions and Clinical Relevance—Results suggest that desmoplasty with fasciotomy is a viable treatment option in horses with proximal suspensory desmitis that have not responded to stall rest.

Abstract

Objective—To determine outcome of percutaneous ultrasound-guided desmoplasty with simultaneous fasciotomy for proximal suspensory desmitis (ie, desmitis of the origin of the suspensory ligament) in horses that have not responded to stall rest.

Design—Retrospective case series.

Animals—27 horses.

Procedures—Medical records of horses with proximal suspensory desmitis treated by means of desmoplasty with fasciotomy were reviewed. Follow-up information was obtained through telephone conversations with owners and trainers of the horses or by examination of horses at the hospital.

Results—23 of the 27 (85%) horses, including 3 of 4 horses with forelimb lesions and 20 of 23 horses with hind limb lesions, were able to return to full work after surgery and rehabilitation. All horses had ultrasonographic evidence of healing of suspensory ligament lesions.

Conclusions and Clinical Relevance—Results suggest that desmoplasty with fasciotomy is a viable treatment option in horses with proximal suspensory desmitis that have not responded to stall rest.

Inflammation of the interosseous muscle (ie, suspensory ligament) is recognized as a potential cause of lameness in horses used in a variety of athletic sports, although it appears to be more common in Thoroughbred racehorses and in horses used as hunters or jumpers or for dressage than in horses used for western performance activities or 3-day eventing.1,2 The suspensory ligament can be divided into 3 regions of interest: the proximal portion, the body, and the branches. The proximal portion of the ligament extends from 4 to 12 cm distal to the accessory carpal bone in the forelimb and 2 to 10 cm distal to the tarsometatarsal joint in the hind limb.3 The body of the ligament is located between the proximal portion and the site where the ligament divides into 2 branches in the midmetacarpal or metatarsal region.3 The branches extend from the division of the ligament into 2 separate structures to their insertion on the proximal sesamoid bones.3 The proximal portion of the suspensory ligament is often injured in athletic horses,3 whereas in Thoroughbred and Standardbred racehorses, such injuries most often involve the body of the suspensory ligament or its branches.3

Traditionally, treatment for suspensory desmitis has involved application of support bandages and rest, with a slow return to exercise.4,5 Although commonly successful for treatment of horses with proximal suspensory desmitis of the forelimbs, conservative treatment is generally unsuccessful in horses with proximal suspensory desmitis of the hind limbs.1,4 Conservative treatment is often successful in horses with desmitis involving the body and branches of the ligament,3 although horses with injuries to the branches of the ligament can have a poor prognosis if the insertion on the proximal sesamoid bone is affected.3 Unlike injuries to the body and branches of the ligament, injuries to the proximal portion of the ligament more commonly are chronic, resulting in recurrent lameness. Various ancillary treatments have been recommended for horses with suspensory desmitis, including local or systemic administration of glucosaminoglycans, local administration of corticosteroids, injection of bone marrow or bioscaffold material, shock wave therapy of the lesion, fasciotomy with neurectomy of the deep branch of the lateral plantar nerve, and desmoplasty (ie, surgical splitting) of the injured portion of the ligament.3,4,6–9

Desmoplasty has been used for several decades in horses with suspensory desmitis that did not improve following conservative treatment.7 The goals of the procedure are to decompress the suspensory ligament in horses with acute lesions and promote development of new blood supply in horses with chronic lesions.7,10 Experimentally created defects in the superficial digital flexor tendon in horses initially heal with fibrovascular tissue and after 24 weeks have the appearance of normal tendon,11 suggesting that healing can be stimulated by incision of the tendon to stimulate vascular ingrowth. But whether the same is true for the suspensory ligament is unclear.

A previous report11 described the use of a fanlike incision for desmoplasty of the branches of the suspensory ligament in Standardbred trotters. To our knowledge, however, the efficacy of desmoplasty in horses with proximal suspensory desmitis has not been determined. The purpose of the study reported here, therefore, was to determine results of percutaneous ultrasound-guided desmoplasty with simultaneous fasciotomy in horses with proximal suspensory desmitis. We hypothesized that desmoplasty would be associated with resolution of the lameness and improvement in the ultrasonographic appearance of the lesion.

Criteria for Case Selection

Medical records of all horses admitted to the Marion duPont Scott Equine Medical Center between January 1995 and December 2004 because of proximal suspensory desmitis were reviewed. Horses were included in the study only if a core lesion was identified ultrasonographically in the proximal third of the suspensory ligament, treatment consisted of desmoplasty with fasciotomy of the deep palmar metacarpal or plantar metatarsal fascia at the site of the core lesion, and information on outcome > 1 year after surgery was available.

Procedures

Information recorded from medical records of horses included in the study consisted of history, physical examination findings, results of lameness examinations, ultrasonographic findings, previous treatments (including duration of stall rest), surgical procedure, and outcome. In horses in which a diagnosis of suspensory desmitis had been made by the referring veterinarian, efforts were made to determine whether the severity of the lameness or the ultrasonographic appearance of the lesion had changed since the last examination by the referring veterinarian. If lameness severity or ultrasonographic appearance of the lesion had changed or if the owner requested additional diagnostic testing, a complete lameness examination was performed. Similarly, in horses referred for examination because of lameness in which suspensory desmitis had not previously been diagnosed, a complete lameness examination was also performed.

The complete lameness examination included evaluation of the gait at a walk, at a trot, and while circling in both directions at a trot on hard ground. Severity of the lameness was graded on a scale from 0 to 5.12 Underlying cause of the lameness was localized by palpation of the suspensory ligament and local infiltration of mepivacaine hydrochloride at the origin of the suspensory ligament; no other diagnostic anesthesia procedures were performed. Because of the possibility that infiltration of local anesthetic at the origin of the suspensory ligament could result in anesthesia of the carpometacarpal or tarsometatarsal joint, if the response to diagnostic anesthesia did not correlate with ultrasonographic changes in the suspensory ligament or if the horse had clinical signs of carpal or tarsal joint abnormalities, diagnostic anesthesia was repeated at a later time.

Transverse and longitudinal ultrasonography of the suspensory ligament was performed with a 7.5- to 10-MHz linear array probe; fiber pattern, fiber echogenicity, and thickness of the suspensory ligament were evaluated. The diagnosis of proximal suspensory desmitis was confirmed if a core lesion was identified at the origin of the suspensory ligament or in the proximal third of the ligament.

Radiography was performed if an irregularity of the third metatarsal or third metacarpal bone was seen during ultrasonography of the suspensory ligament. In some instances, nuclear scintigraphy was used to localize the underlying cause of lameness to the proximal metacarpal or metatarsal region of the affected limb.

All horses in which a diagnosis of proximal suspensory desmitis had been made prior to referral had been treated with a period of rest prior to referral. In horses in which the diagnosis was made after referral to the Equine Medical Center, treatment consisted of stall rest for 1 month. If, after this time, there was subjective improvement in fiber density and at least partial filling of the core lesion evident during a follow-up ultrasonographic examination, then stall rest was continued as the only treatment. Horses underwent desmoplasty and fasciotomy only if there was no response following a minimum of 1 month of complete stall rest without hand walking or turnout.

Desmoplasty procedure—For desmoplasty, horses were sedated with xylazine hydrochloride (0.3 to 0.4 mg/kg [0.14 to 0.18 mg/lb], IV), and anesthesia was induced with a combination of ketamine hydrochloride (2.2 mg/kg [1.0 mg/lb], IV) and guaifenesin (15 to 25 g, IV, to effect) or a combination of ketamine hydrochloride (2.2 mg/kg, IV) and diazepam (0.1 mg/kg [0.045 mg/lb], IV). Horses were positioned in lateral recumbency with the affected limb up or, if both limbs were affected, in dorsal recumbency. Anesthesia was maintained with a continuous IV infusion of guaifenesin, xylazine hydrochloride, and ketamine hydrochloride in horses positioned in lateral recumbency and with halothane or isoflurane in oxygen in horses positioned in dorsal recumbency. Skin at the surgical site was prepared for aseptic surgery.

For the desmoplasty procedure, an ultrasound probe was placed on the mediopalmar or medioplantar aspect of the limb to obtain a transverse view of the suspensory ligament, and a number 11 scalpel blade or ligament knife was used, as described,7 to make stab incisions in the skin just lateral to the superficial digital flexor tendon. The scalpel blade or ligament knife was advanced under ultrasound guidance to the core lesion (Figure 1), and the blade was moved in a proximal-to-distal direction, keeping the blade parallel to the fibers of the suspensory ligament, for approximately 2 to 3 cm to open the core lesion and overlying fascia without disrupting unaffected portions of the ligament surrounding the core lesion. This was accomplished by moving the blade in an arc while maintaining the position of the shaft of the instrument at the stab incision. Additional stab incisions were made at 2-cm intervals as necessary to allow desmoplasty of the entire length of the core lesion. Ultrasound guidance was used to ensure that the blade was placed in the same plane in the suspensory ligament and fascia each time, so that the opening into the core lesion was continuous. At the origin of the suspensory ligament, the blade was advanced through the core lesion to the bone surface, which was scored with the blade.

Figure 1—
Figure 1—

Ultrasonograms of a desmoplasty procedure for treatment of suspensory desmitis in a horse (A) and illustration of the gross anatomy involved (B). In the ultrasonograms, a ligament knife (arrows) has been positioned in a core lesion in the origin of the suspensory ligament. In the gross anatomic specimen, which consists of a cross section of the limb, the anatomic relationships of the suspensory ligament (SL); superficial digital flexor tendon (SFDT); deep digital flexor tendon (DDFT); and metatarsal bones (MT) 2, 3, and 4 can be seen.

Citation: Journal of the American Veterinary Medical Association 229, 3; 10.2460/javma.229.3.407

Skin incisions were not sutured following desmoplasty. The limb was bandaged with sterile gauze covered by a support wrap.

Postoperative care—Horses were treated with phenylbutazone (2.2 mg/kg, PO, q 12 h) for 5 days after surgery. The bandage was maintained for 7 to 10 days after surgery, after which time a support wrap was maintained for an additional 3 weeks. Horses were confined to a stall for 30 days after surgery, followed by confinement to the stall for an additional 30 days except for 5 to 10 minutes of hand walking daily.

Recheck ultrasound examinations were performed 60 days after surgery. If the ultrasonographic appearance of the suspensory ligament had improved and no lameness was detected, the amount of daily exercise was gradually increased. Once the horse was walking for 15 to 20 minutes daily, recheck examinations, which included a lameness examination, were performed every 4 to 6 weeks. Turnout for exercise was not allowed until there was ultrasonographic evidence of increased core lesion echogenicity indicative of ligament healing.

Follow-up evaluation—Owner, trainers, and referring veterinarians were contacted 1 to 5 years after surgery to determine whether the lameness had resolved and the horse's current level of activity. A horse was considered to have returned to full work if it had returned to its original level of activity or had achieved the level of activity desired by the owner.

Data analysis—When possible, measurements of the cross-sectional thickness of the suspensory ligament (ie, distance from the dorsal to the palmar or plantar aspect of the suspensory ligament) at the site of the core lesion obtained prior to desmoplasty and at the time of the final follow-up ultrasound examination were recorded. Ultrasonograms from all horses were digitized, and relative cross-sectional areas of the ligament prior to desmoplasty and at the time of the final follow-up ultrasound examination were calculated with image software.a A paired Student t test was then used to determine whether mean cross-sectional areas before and after surgery were significantly different.

Images obtained before and after surgery were examined by a single individual (CAH) who assigned an echogenicity score13 from 0 to 3 for each image (0 = isoechoic; 1 = slightly hypoechoic but mostly isoechoic; 2 = mixed echogenicity; 3 = mostly or completely anechoic). A fiber alignment score13 from 0 to 3 was also assigned (0 = target path ≥ 75% parallel; 1 = target path ≥ 50% but < 75% parallel; 2 = target path ≥ 25% but < 50% parallel; 3 = target path < 25% parallel; where target path is the proportion of longitudinal fibers in the ligament that are parallel on the long-axis ultrasonographic image). These scores were assigned after review of the images without reviewing the history of the horses or the time the examination was performed, whether it was before or after surgery. These scores did not affect the clinical outcome of the cases but were provided as a quantitative measure to assess ligament healing for the present study.

Results

During the study period, 167 horses were evaluated because of proximal suspensory desmitis of the forelimb or hind limb. Thirty-eight of these horses underwent desmoplasty with fasciotomy (8 with forelimb lesions and 30 with hind limb lesions), but follow-up information on outcome > 1 year after surgery was not available for 11 of the 38. The remaining 27 horses were included in the study (4 with forelimb lesions and 23 with hind limb lesions).

The 27 horses included in the study consisted of 22 geldings and 5 mares. There were 14 warmbloods, 7 Thoroughbreds, 2 Quarter Horses, 1 Morgan, 1 Cleveland Bay, 1 Paint Horse, and 1 mixed-breed horse.

Mean age was 10.2 years (range, 5 to 17 years). Horses were used as show hunters or jumpers or for dressage, eventing, steeplechase, team roping, or pleasure riding. Most of the horses were used for jumping or dressage, with only 1 horse used for steeplechase racing. Mean time from injury to desmoplasty was 3.5 months (range, 1 to 12 months). Ten horses had a history of chronic suspensory desmitis without any indication in the medical record of the specific duration of lameness. However, all 10 had been lame, even with rest, for at least 3 months prior to undergoing desmoplasty. Three horses did not have any history of a specific injury recorded in their medical record.

All horses were recorded as lame at the trot, but a lameness grade was recorded for only 14 horses. For these horses, lameness grade ranged from 1 to 2.5 on a scale from 0 to 5 (mean grade, 2.2). All horses had ultrasonographic evidence of a core lesion involving the origin of the suspensory ligament consisting of an anechoic region of fiber disruption. Ligament enlargement was apparent in all cases.

All 4 horses with forelimb suspensory desmitis had lesions involving the origin of the suspensory ligament. Three had unilateral lesions (2 with lesions of the right forelimb and 1 with a lesion of the left forelimb) and 1 had bilateral lesions. In all horses, stall rest had resulted in ultrasonographic evidence of healing of the lesion. However, once work was initiated, lameness recurred, and new lesions were identified ultrasonographically. In 2 of the 4 horses, radiographs of the third metacarpal bone had been obtained; no abnormalities were seen.

After surgery and rehabilitation, 2 of the 4 horses with forelimb suspensory desmitis had increased echogenicity and normal fiber alignment on ultrasonograms obtained at the time of the final follow-up examination. The other 2 horses had mildly decreased echogenicity and slightly abnormal fiber alignment at the time of the final follow-up examination. Three of the 4 horses were able to return to full work (lower-level dressage, midlevel dressage, and advanced eventing) without evidence of lameness. One horse returned to full work (midlevel dressage) but subsequently reinjured the suspensory ligament. In this horse, magnetic resonance imaging of the region revealed a bone exostosis pushing into the suspensory ligament from the palmar surface of the third metacarpal bone at its junction with the second metacarpal bone. This exostosis, which was not seen on previous ultrasonographic or radiographic examinations, interrupted the attachment of the suspensory ligament. The horse was retired without further treatment.

All 23 horses with hind limb suspensory desmitis had lesions involving the origin of the suspensory ligament. Eight had unilateral lesions (3 with lesions of the right hind limb and 5 with lesions of the left hind limb) and 15 had bilateral lesions. Radiographs of the third metatarsal bone were obtained in 6 of the horses. Two had mild sclerosis at the origin of the suspensory ligament; the other 4 did not have any radiographic abnormalities. Magnetic resonance imaging of the suspensory ligaments was performed in 1 horse; no abnormalities of the third metatarsal bone were seen.

Desmoplasty was performed on 38 ligaments. Lesions resolved or improved ultrasonographically in 22 of the 23 horses (36 of 38 ligaments), but only 20 of the 23 (85%) horses returned to full work. The 1 horse in which lesions did not resolve or improve had abnormal extension of both metatarsophalangeal joints before and after surgery; this horse did not return to full work after surgery. Owners of 2 horses did not want to stress the suspensory ligaments after the rehabilitation period, and these 2 horses were limited to light riding, which was not the horses' original career. One horse with a unilateral lesion underwent desmoplasty twice because of reinjury of the ligament during the rehabilitation period; the horse eventually returned to steeplechase racing. Because of excess extension of the metatarsophalangeal joint, 1 horse was treated after surgery with a brace attached to the shoe, which supported the joint during the period of stall rest. This horse returned to its previous use of intermittent light pleasure riding 12 months after undergoing desmoplasty.

In all 27 horses, fiber echogenicity and alignment scores were improved at the time of the final follow-up examination, compared with scores obtained prior to surgery (Figure 2). For all 43 ligaments, echogenicity score prior to surgery was grade 3 and score at the time of final follow-up examination was grade 1 (23 ligaments) or 0 (20 ligaments). Similarly, for all 43 ligaments, fiber alignment score prior to surgery was grade 2 (13 ligaments) or 3 (30 ligaments) and fiber align ment score at the time of final follow-up examination was grade 1 (10 ligaments) or 0 (33 ligaments).

Figure 2—
Figure 2—

Ultrasonograms of a horse with desmitis of the proximal portion of the suspensory ligament; images were obtained before (A) and 75 days after (B) desmoplasty. A core lesion (arrows) can be seen on images obtained before surgery. On images obtained after surgery, increased fiber density and partial resolution of the core lesion are evident.

Citation: Journal of the American Veterinary Medical Association 229, 3; 10.2460/javma.229.3.407

Cross-sectional thickness of the suspensory ligament at the site of the core lesion could be determined before and after surgery in 19 horses (3 with forelimb lesions and 16 with hind limb lesions). For horses with forelimb lesions, mean cross-sectional thickness was 1.17 cm (range, 1.05 to 1.27 cm) prior to surgery and 0.93 cm (range, 0.96 cm to 1.04 cm) at the time of final follow-up examination. For horses with hind limb lesions, mean cross-sectional thickness was 1.65 cm (range, 1.22 to 2.36 cm) prior to surgery and 1.46 cm (range, 1.12 to 2 cm) at the time of final follow-up examination. Mean relative cross-sectional area at the time of the final follow-up examination (55,000 pixels2; range, 23,000 to 82,200 pixels2) was significantly (P = 0.04) lower than mean relative cross-sectional area prior to surgery (83,400 pixels2; range, 30,200 to 118,000 pixels2).

Overall, 23 of the 27 (85%) horses returned to full work after undergoing desmoplasty. Time from surgery to return to full work was available for 2 horses with forelimb lesions and was 7 months in 1 horse and 12 months in the other. Time from surgery to return to full work was available for 8 horses with hind limb lesions and ranged from 5 to 18 months (mean, 7.5 months). Time to return to full work was not available for the other horses because owners were unable to accurately remember when the horse returned to full work. Desmitis recurred in only 2 horses. One horse returned to steeplechase racing after treatment of the recurrent injury; the other horse was retired by the owner.

Discussion

Results of the present study suggest that desmoplasty with fasciotomy is a viable treatment option in horses with proximal suspensory desmitis that have not responded to stall rest. All horses in the present study continued to be lame despite enforced stall rest for at least 1 month. Nevertheless, 23 of the 27 (85%) were able to return to full work after surgery and rehabilitation, and all had ultrasonographic evidence of healing of suspensory ligament lesions.

In the present study, examination of serial ultrasonograms confirmed healing of suspensory ligament lesions, as illustrated by increased echogenicity of core lesions, decreased ligament size, and a return to the normal longitudinal arrangement of ligament fibers. These ultrasonographic changes corresponded with resolution of the lameness by the time of the final follow-up examination. Although suspensory ligament size or fiber pattern did not always return to normal, this did not appear to affect the horses' ability to return to full work.

Results of the present study are different from results reported in previous studies,1,4,9 in which only 14% to 17% of horses with hind limb proximal suspensory desmitis returned to work after a 1-year rest-and-rehabilitation program and only 41% of horses with hind limb proximal suspensory desmitis returned to work after 3 shock wave treatments. Previous reports4,9 have described better results for horses with forelimb proximal suspensory desmitis, with resolution of lameness in 90% of horses with forelimb proximal suspensory desmitis that are provided adequate rest. A previous report11 describing desmoplasty of the suspensory ligament in Standardbred trotters with lesions involving a branch of the suspensory ligament indicated that 168 of the 285 (59%) horses raced > 10 times after surgery and 82 of 285 (29%) raced 1 to 10 times, with most horses returning to racing between 6 and 7 months after surgery. Although only 59% of the horses raced > 10 times after surgery, concurrent involvement of the proximal sesamoid bone was thought to have possibly limited performance in some horses. Thus, although results of the present study can-not be directly compared with results of these previous reports, our findings suggest that desmoplasty may be useful in horses with proximal suspensory desmitis that have not responded to conservative treatment.

Fasciotomy releases compartment pressure, allowing ingrowth of blood vessels needed for healing.14 A previous studyb found that fasciotomy combined with lateral plantar neurectomy resulted in resolution of lameness in 19 of 20 (95%) horses with proximal suspensory desmitis involving a hind limb. Thus, fasciotomy may have played an important role in the success of surgery in horses described in the present report, even though it was unlikely that neurectomy was performed because the incision was directed parallel to the nerve and suspensory ligament fibers.

Results of the present study also cannot be directly compared with results of studies involving intralesional injection for treatment of suspensory desmitis in horses. In 1 study,15 31 of 38 (82%) horses with proximal suspensory desmitis and 4 of 6 (67%) horses with suspensory branch desmitis treated with intralesional injection of a bioscaffold material became sound and were able to return to work. In that study, however, fasciotomy was performed in 36 of the 38 horses with hind limb suspensory desmitis, making it difficult to determine results of intralesional injection alone. Similarly, a study8 involving injection of bone marrow into the suspensory ligament in 100 horses with suspensory desmitis (81 with forelimb lesions and 19 with hind limb lesions) reported that 84 returned to full work and an additional 8 had only mild residual lameness. However, 15 of these horses had a fasciotomy because the proximal portion of the suspensory ligament was greatly enlarged.

In the present study, all horses were treated with a similar rest-and-rehabilitation program following surgery. Most of the horses were sound when reexamined 4 months after surgery, but all required additional time for complete ligament healing, as determined on the basis of a qualitative evaluation of fiber density seen ultrasonographically. One horse that required a total of 18 months to heal underwent desmoplasty a second time because of reinjury during the rehabilitation period, but this horse was eventually able to return to steeplechase racing.

Four horses in the present study had undergone radial pressure wave therapy prior to undergoing desmoplasty. Radial pressure wave therapy can cause a reduction in lameness severity, possibly because of analgesia, without exacerbating the desmitis.9 However, it does not result in resolution of core lesions. Because horses in the present study that underwent radial pressure wave therapy still had evidence of lameness and a core lesion in the proximal portion of the suspensory ligament 4 months after treatment, it was concluded that radial pressure wave therapy was not successful in healing the desmitis in these cases.

Because the present study was retrospective in nature, a control group was not included. Therefore, our results must be interpreted with caution. Nevertheless, horses in the study had not responded to an appropriate period of rest prior to undergoing desmoplasty, and 23 of 27 (85%) were able, after surgery and rehabilitation, to return to full work, which included dressage, eventing, jumping, and steeplechase racing.

a.

Scion Image, Scion Corp, Frederick, Md.

b.

Bathe A. Plantar metatarsal neurectomy and fasciotomy for treatment of hindlimb proximal suspensory desmitis (abstr), in Proceedings. Annu Meet Am Coll Vet Surg 2004;2.

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