微创治疗儿童桡骨颈骨折的基础与临床研究

发布时间：2018-05-31 06:16

本文选题：桡骨颈骨折 + 微创治疗　；参考：《苏州大学》2016年博士论文

【摘要】：儿童桡骨颈骨折病例数量约占儿童肘部骨折病例数的5%-10%。桡骨颈的血供可能被外伤当时所受的暴力破坏,或者(和)被切开复位的手术创伤或者暴力的手法复位所影响,医源性加重损伤桡骨颈的血供,导致儿童桡骨颈骨折的不愈合及桡骨小头坏死等等并发症。肘关节及前臂存在复杂的解剖,桡骨小头与骨间后神经(posterior interosseous nerve,PIN)关系密切,所以至今以来儿童桡骨颈骨折还是一个比较难以处理的问题。虽然治疗方法各种各样,但经皮闭合复位固定的微创理念得到认可。本文比较了儿童桡骨颈骨折行Metaizeau治疗法、经皮克氏针撬拨复位法(percutaneous Kirschner’s wire leverage,PKWL)及两种微创方法的结合,分析该微创治疗方法的手术时间、术中注意事项及手术效果等。微创治疗儿童桡骨颈骨折创伤小,效果佳,但骨间后神经和桡骨颈关系密切,骨间后神经的损伤成为儿童桡骨颈骨折手术治疗多见的并发症。通过对儿童桡骨颈的解剖研究,尤其是与骨间后神经关系的研究,来减少甚至避免骨间后神经的损伤,达到儿童桡骨颈骨折的最佳治疗效果。第一部分骨间后神经在桡骨近端后外侧的解剖目的:骨间后神经对上肢的功能有非常重要的作用,它营养并支配着前臂后部肌肉。桡神经穿过肘关节囊前部,并分成桡神经浅支和深支,桡神经浅支在肱桡肌深面走行,桡神经深支延续为骨间后神经并穿过旋后肌管,环绕桡骨近端走行,到达前臂伸肌,发散开支配各肌。[1]虽然报道桡骨头及桡骨颈骨折可导致骨间后神经损伤,但骨间后神经也可以为医源性损伤,尤其是通过前路、侧方及后外侧入路显露桡骨近端,甚至肘关节镜检查也可损伤骨间后神经。可通过骨间后神经相关解剖学的详细学习而避免其损伤,至少可降低损伤发生率。Diliberti等称旋前位可增加桡骨近端的安全区范围,但骨间后神经的定位没有可靠的解剖学结构来做参照,特别是儿童桡骨颈骨折病例,没有既定的数据及结构来参照。因此,本研究依据前臂的旋转,分析骨间后神经与桡骨近端的位置关系的变化,定位骨间后神经的走行,在微创治疗儿童桡骨颈骨折时,特别是在撬拨复位过程中避免骨间后神经的医源性损伤。方法:解剖6具儿童尸体的上肢,年龄介于7-12岁。对每个标本,打开旋后肌浅层,保留骨间后神经下方的旋后肌深层,显露骨间后神经。旋前状态下,测量自肱骨小头远端关节面至骨间后神经越过桡骨干后侧骨皮质中轴线交点的距离,测量自肱骨小头远端关节面至骨间后神经越过桡骨外侧骨皮质中轴线交点的距离。旋后状态下,测量自肱骨小头远端关节面至骨间后神经越过桡骨干后侧骨皮质中轴线交点的距离,测量自肱骨小头远端关节面至骨间后神经越过桡骨外侧骨皮质中轴线交点的距离。金属线定位标记骨间后神经,对标本进行摄片检查和三维ct检查。结果:前臂于完全旋后位时,从肱骨小头远端关节面至骨间后神经越过桡骨干后侧骨皮质中轴线交点的距离平均(32±5.9)mm,肱骨小头远端关节面至骨间后神经越过桡骨外侧骨皮质中轴线交点的距离平均(19.5±3.0)mm。前臂位于完全旋前位,从肱骨小头远端关节面至骨间后神经越过桡骨干后侧骨皮质中轴线交点的距离平均(39±8.3)mm,肱骨小头远端关节面至骨间后神经越过桡骨外侧骨皮质中轴线交点的距离平均(22±3.3)mm。肘关节屈伸对这一距离没有影响。桡骨长度平均(205.2±13.6)mm。前臂旋后位时,后侧骨皮质中轴线可在近端被安全暴露的范围,占平均桡骨长度的(15.5±2.1)%;外侧骨皮质中轴线可在近端被安全暴露的范围,占平均桡骨长度的(9.4±1.0)%。前臂旋前位时,该长度比例增至(18.8±3.1)%和(10.7±1.0)%。结论:旋前位有效地增加了骨间后神经近端的安全区域范围。因此,手术显露桡骨头时,前臂应当置于旋前位,把骨间后神经的损伤风险降到最低。且在旋前位撬拨复位时,后侧进针点到肱骨小头关节面的距离尽量不超过桡骨总长的15%,外侧进针点到肱骨小头关节面的距离尽量不超过桡骨总长的9%。第二部分metaizeau法治疗儿童桡骨颈骨折疗效分析目的:在微创治疗儿童桡骨颈骨折方法出现以前,对严重移位的儿童桡骨颈骨折绝大部分以手术切开复位克氏针固定方法为主。经多年的临床随访观察,治疗效果较差,特别是手术后患儿易出现桡骨头骺缺血坏死改变、骺早闭、肘外翻、肘关节屈伸和前臂旋转功能受限等。1980年metaizeau报道经桡骨远端骨皮质置入髓内钉,对桡骨颈骨折进行复位和固定,效果良好。分析我院采用metaizeau法治疗倾斜移位30°以上的儿童桡骨颈骨折病例,结合治疗效果及体会,研究metaizeau法治疗倾斜移位30°以上的儿童桡骨颈骨折的临床疗效。方法:回顾性分析2008年8月至2010年2月采用metaizeau法治疗倾斜移位30°以上的儿童桡骨颈骨折12例的临床资料。取桡骨远侧生长板以上1~2.5cm处桡侧背侧纵切口,长1.5~2cm。逐层显露桡骨远侧干骺端背侧骨皮质,注意避开头静脉及桡神经背侧感觉支。骨皮质开孔角度约30°,开孔不可过大,孔过大髓内钉有松动可能,置入髓内钉,注意髓内钉头端朝向桡侧。逐渐推进髓内钉至骨折断端,一般髓内钉到达骨折断端会遇到阻力,术中透视髓内钉位置。当髓内钉到达骨折断端后,稍后退髓内钉,术者左手在皮外向内上方挤压骨折近端,可适当旋转前臂,有助复位,固定桡骨小头,继续推进髓内钉,使髓内钉头端穿入桡骨小头,并将桡骨头顶起复位。如果桡骨颈骨折仍有水平移位或不明显的成角移位,适当旋转髓内钉,纠正桡骨头的成角畸形与侧方移位。术后屈肘90°,前臂中立位或旋后位石膏外固定,三角巾悬吊于胸前。约4周后解除外固定,进行功能锻炼。术后3个月左右拔除髓内钉。结果:10例metaizeau法成功复位患儿均在3月内骨愈合。按metaizeau的整复标准,本组10例中,良好7例,较好2例,一般1例。经适当功能锻炼后,患肢外观无畸形,肘关节活动范围基本正常。术后随访3~12个月,平均9个月。根据tibone和stoltz的患肢临床功能标准来评定,10例metaizeau法成功复位患儿优8例,良2例。2例metaizeau法复位失败患儿,1例患儿功能恢复优,1例患儿肘关节功能恢复可,x线复查示此患儿出现桡骨颈骨折断端延迟愈合。结论:metaizeau法是一种微创的、行之有效的儿童桡骨颈骨折治疗方法,但对于严重移位的桡骨颈骨折成功率不高。对于桡骨颈骨折成角移位60°以上者,metaizeau法复位失败率较高,需切开复位,但切开复位桡骨颈骨折,易损伤桡骨头颈的血液供应,造成桡骨头的缺血坏死和骨折的不愈合,随着儿童的成长,出现肘外翻并加重。此外,切开复位对肘关节周围组织的干扰,可引起肘关节的功能受限。因此,对于儿童桡骨颈骨折的治疗,除了metaizeau法,急需开创另外的微创方法来治疗移位严重的儿童桡骨颈骨折。第三部分经皮克氏针撬拨复位结合弹性髓内钉固定技术治疗儿童难复桡骨颈骨折目的:桡骨颈的血供比较脆弱,桡骨颈的血供可能被外伤当时所受的暴力破坏,可能被暴力的手法复位所影响,也有可能被切开复位的手术创伤所破坏,医源性加重损伤桡骨颈的血供,导致儿童桡骨颈骨折的不愈合及桡骨小头坏死等等并发症。治疗方案主要取决于桡骨颈骨折近端的成角和水平移位情况。目前整复的方式包括手法整复,弹性髓内钉复位固定技术(closeintramedullarypinning,cimp),经皮克氏针撬拨技术(percutaneouskirschner’swireleverage,pkwl)等。在微创治疗儿童桡骨颈骨折方法出现以前,对移位明显的儿童桡骨颈骨折多以手术切开复位和/或克氏针固定为主,容易发生桡骨头骺缺血坏死,骺板损伤早闭,关节内钙化等并发症,疗效优良率仅在20%-50%之间,因此现在主张尽可能避免采用切开复位。我院采用经皮克氏针撬拨复位结合弹性髓内钉固定技术治疗judetiii、iv型儿童桡骨颈骨折,现结合治疗结果,来评估经皮克氏针撬拨复位结合弹性髓内钉固定技术治疗judetiii、iv型儿童桡骨颈骨折的疗效。方法:2010年6月至2013年12月共收治50例judetiii、iv型的桡骨颈骨折手术病例,平均年龄8.4岁,其中男31例,女19例;左侧26例,右侧24例。术中先行手法闭合复位,如闭合复位成功或使成角小于45°,使用桡骨髓内钉固定及cimp技术复位固定。手法闭合复位失败,行pkwl技术,透视见移位的桡骨颈骨折尚未解剖复位,但成角小于45°,可使用弹性髓内钉cimp技术帮助复位。术后长臂石膏固定于上肢功能位4-6周,拆除石膏后功能锻炼。结果:50例judetiii、iv型桡骨颈骨折患儿中,11例桡骨颈骨折病人手法闭合复位成功,直接行弹性髓内钉固定,5例通过cimp技术协助复位及固定,平均手术时间58分钟;30例桡骨颈骨折病人,行经pkwl技术复位成功行弹性髓内钉固定,平均手术时间50分钟;4例手法闭合复位失败直接行切开复位弹性髓内钉固定术,平均手术时间80分钟。8例合并尺骨近端骨折中2例同时行尺骨骨折切开复位内固定,1例术前合并桡神经损伤病例术后经保守治疗3月恢复正常。pkwl组与闭合复位髓内钉及cimp组比较,手术时间无显著性差异,pkwl组病例桡骨颈骨折成角度数较大,骨折移位程度较大,骨折成角度数与移位程度的比值较大。切开复位组与PKWL组、闭合复位髓内钉、CIMP组比较,骨折的成角度数、移位程度及其比值无显著性差异,但切开复位组手术时间较长。45例获得随访,平均随访时间2年。所有病例骨折均愈合,平均愈合时间4.1个月,取内固定平均时间为4.3个月。根据Tibone和Stoltz的临床功能评价标准,3例切开复位者肘关节活动受限10°-20°不等,其余治疗效果均优。无其他并发症发生。结论:至今儿童桡骨颈骨折一直是一个比较难以处理的疾病。单纯手法整复及石膏固定治疗儿童桡骨颈骨折的能力有限,可试用于治疗骨折倾斜小于45°的桡骨颈骨折,或是配合其他复位方法使用。本组病例中桡骨颈骨折超过60°,或严重骨折嵌插,成角度数/移位程度90,通过CIMP技术行桡骨颈骨折复位失败率高,可直接行PKWL技术复位骨折,再行CIMP技术辅助复位及固定复位的骨折。PKWL能整复大部分儿童桡骨颈骨折,包括那些经CIMP复位失败的病例,并可选择顺势穿针固定儿童桡骨颈骨折。但这种经皮克氏针贯穿桡骨颈骨折远近端的固定限制了肘关节的早期活动及功能锻炼,易引起肘关节僵硬。CIMP通过髓腔内的弹性髓内钉顶起桡骨头,解除骨折嵌插,扶持骨折倾斜,实现儿童桡骨颈骨折的复位固定。CIMP术后拆除外固定后不限制肘关节的活动,这样固定有利于肘关节的早期锻炼。对于那些倾斜移位程度较大或嵌插较紧的桡骨颈骨折,建议先行PKWL技术复位桡骨颈骨折,再行CIMP技术固定桡骨颈骨折,PKWL配合CIMP技术可提高难复性桡骨颈骨折疗效。近年来,我院根据既往的儿童桡骨颈骨折治疗经验,对桡骨颈骨折成角移位超过60°,甚至嵌插严重的病例超过45°时,PKWL代替CIMP作为主要的复位方法。
[Abstract]:The blood supply of 5%-10%. radial neck in children's radius neck fracture cases, which accounts for the number of cases of children's elbow fractures, may be damaged by the violence at that time, or (and) the surgical trauma or violent manipulation of the open reduction. The iatrogenic aggravation of the blood supply of the radius and neck causes the nonunion of the fracture of the radius and neck of the children and the nonunion of the fracture of the radius and neck of the children. The complex anatomy of the elbow and forearms, the small head of the radius and the posterior interosseous nerve (posterior interosseous nerve, PIN) are closely related. So far, the fracture of the radius and neck of the children is a difficult problem to be dealt with. In this paper, the Metaizeau treatment of radial neck fracture in children was compared with the combination of percutaneous Kirschner 's wire leverage, PKWL and two minimally invasive methods. The operation time of the minimally invasive treatment, the items of attention and the effect of operation were analyzed. The minimally invasive treatment of the fracture of the radius and neck of children was made. Small trauma and good effect, but the posterior interosseous nerve and the radial neck are closely related, and the injury of the posterior interosseous nerve becomes a common complication in the operation of the radial neck fracture in children. Through the study of the radial neck of children, especially the study of the relationship between the posterior interosseous nerve, to reduce or even avoid the injury of the posterior interosseous nerve, to reach the radius neck bone of children. The first part of the posterior interosseous nerve at the proximal end of the radius: the posterior interosseous nerve has a very important role in the function of the upper limb. It nourishes and dominates the posterior muscles of the forearm. The radial nerve passes through the anterior part of the elbow capsule and divides into the superficial and deep branches of the radial nerve, and the superficial branch of the radial nerve travels in the deep face of the brachial and radial muscles. The deep branch of the radial nerve extends into the posterior interosseous nerve and passes through the posterior circumflex canal to reach the proximal end of the radius, reaching the extensor of the forearm and diverting the muscle.[1], although it is reported that the fracture of the radial head and the radial neck can lead to the injury of the posterior interosseous nerve, but the posterior interosseous nerve can also be a iatrogenic injury, especially through the anterior, lateral and posterolateral approaches. The proximal and even elbow arthroscopy can also damage the posterior interosseous nerve. It can avoid the injury by detailed study of the posterior interosseous nerve related anatomy. At least the incidence of.Diliberti, such as the incidence of injury, can be reduced to a safe area of the proximal end of the radius. However, the location of the posterior interosseous divine meridian has no reliable anatomical structure for reference. In this study, the changes in the position of the posterior interosseous nerve and the proximal radius of the bone were analyzed, and the posterior interosseous nerve was located. In the minimally invasive treatment of the fracture of the radius and neck of the children, especially in the process of prying reduction, the interosseous post was avoided. Methods: to dissect the upper limbs of 6 children's cadavers, the age of the upper limbs of 7-12 years old. For each specimen, open the superficial layer of the posterior pronation muscle, retain the deep posterior pronation muscles below the interosseous nerve and expose the posterior interosseous nerve. Distance from the distal joint of the humerus to the intersection of the interosseous posterior interosseous nerve across the medial axis of the lateral radius. The distance from the distal articular surface of the humerus to the interosseous axis of the radial diaphysis, measured from the distal joint of the humerus to the posterior interosseous God, measured the distance from the distal joint of the humerus to the posterior axis of the radial diaphysis. The distance between the interosseous points of the medial axis of the lateral bone of the radius was crossed. The posterior interosseous nerve was labeled with metal lines, and the specimens were examined and the three-dimensional CT examination. Results: the distance between the distal part of the humerus and the posterior interosseous nerve crossing the medial axis of the radial diaphysis (32 + 5.9) mm, the humerus The distance between the distal articular surface of the small head and the interosseous posterior nerve across the medial axis of the lateral radius of the radius is (19.5 + 3) mm. forearm at the complete pronation. The distance between the distal part of the humerus and the posterior interosseous nerve across the medial axis of the distal radius is (39 + 8.3) mm, and the distal joint of the humerus head to the posterior interosseous. The average distance (22 + 3.3) mm. elbow flexion and extension did not affect the distance between the nerve and the lateral cortical axis of the radial bone. When the length of the radius was (205.2 + 13.6) mm. forearm, the posterior axis of the cortical axis could be safely exposed at the proximal end, accounting for (15.5 + 2.1)% of the average radius and the axis of the lateral cortical bone. The near end was exposed to a safe range of radius (9.4 + 1)% of the average radius. The length of the forearm was increased to (18.8 + 3.1)% and (10.7 + 1)% when the forearm pronation was (10.7 + 1)%. Conclusion: the pronation effectively increases the safety area of the proximal interosseous nerve. Therefore, the forearm should be placed in the pronation position and the posterior interosseous nerve injury when the radial head is exposed. 9%. second part of the lateral needle point to the joint surface of the small head of the humerus is not more than the total length of the radius as far as possible for the treatment of the radial neck fracture in children: a minimally invasive treatment for the treatment of radial neck fracture: a minimally invasive treatment for the treatment of the radial neck fracture in children. In children with radial neck fracture, most of the fractures of the radius and neck in children were mainly treated with surgical open reduction and Kirschner fixation. After years of clinical follow-up observation, the treatment effect was poor, especially after the operation, the changes of the epiphysis ischemic necrosis, epiphyseal early closure, elbow valgus, elbow flexion extension and forearm were easy to occur in the children after the operation. .1980 year Metaizeau reported that the distal radius bone cortex was inserted into the intramedullary nail for the reduction and fixation of the fracture of the radius and neck in.1980 years. The results were analyzed in our hospital by using the Metaizeau method for the treatment of radial neck fracture in children with tilted displacement more than 30 degrees, and combined with the therapeutic effect and experience, the Metaizeau method was used to treat the tilted displacement of 30 degrees. Methods: a retrospective analysis of the clinical data of 12 cases of radial neck fracture in children with inclined displacement more than 30 degrees from August 2008 to February 2010 by Metaizeau method. The longitudinal incision of the radial lateral dorsal side of the distal growth plate above the radius and the long 1.5~ 2cm. to the distal metaphyseal bone skin of the distal radius were revealed. Quality, pay attention to avoiding the sensory branch of the opening vein and the dorsal radial nerve. The angle of the opening of the bone cortex is about 30 degrees, the opening of the perforated hole is not too large. The intramedullary nail is loosened and the intramedullary nail is inserted, and the intramedullary nail head is pointed to the radial side. The intramedullary nail is gradually pushed to the fracture end, and the intramedullary nail will encounter resistance at the fracture end. When the intramedullary nail reaches the broken end of the fracture, the intramedullary nail is retreated later, and the left hand squeezing the proximal end of the fracture in the upper part of the skin. It can properly rotate the forearm, assist the reduction, fix the small head of the radius, continue to push the intramedullary nail, make the head end of the intramedullary nail into the radial head, and reposition the radial head. If the radial neck fracture is still displaced horizontally or not, there is still horizontal displacement or insignificant fracture of the radial neck. Angle displacement and proper rotation of intramedullary nail to correct the angular deformity of the radial head and lateral displacement. After operation, the flexion of the elbow was 90 degrees, the forearm neutral or the supination plaster was fixed outside the chest. The trigonometric towel was suspended on the chest. After about 4 weeks, the external fixation was relieved and the intramedullary nails were removed about 3 months after the operation. Results: 10 cases of the successful reduction of Metaizeau method were 3. In the 10 cases of this group, 7 cases were good, 2 cases were good, 1 cases were good. After proper functional exercise, the limb appearance was no deformity and the range of elbow joint was basically normal. The postoperative follow-up was 3~12 months, averaging 9 months. According to the clinical functional criteria of the affected limbs of TiBone and Stoltz, 10 cases of Metaizeau method were successfully reset. The children were excellent in 8 cases, good in 2 cases of.2 cases with Metaizeau failure, 1 cases of good function recovery and 1 cases of elbow joint function recovery. X-ray examination showed that the broken end of radial neck fracture was delayed union. Conclusion: Metaizeau method is a minimally invasive, effective treatment for radial fracture of the neck of children, but for the severely displaced radius. The success rate of neck fracture is not high. For those with radial neck fracture more than 60 degrees, the failure rate of Metaizeau method is high and need open reduction, but open reduction and reduction of radial neck fracture, damage to the blood supply of the radial head and neck, cause the necrosis of the radial head and the nonunion of the fracture, with the growth of the children, the elbow eversion and aggravation. In addition, cut off. The interference of the open reduction on the surrounding tissue of the elbow can cause the function limitation of the elbow joint. Therefore, for the treatment of radial neck fractures in children, in addition to the Metaizeau method, another minimally invasive method is urgently needed to treat the displaced radial neck fracture in children. The third part is treated with a prying reduction combined with elastic intramedullary nail fixation. The blood supply of the radial neck is fragile. The blood supply of the radial neck is relatively fragile. The blood supply of the radial neck may be destroyed by the violence at that time. It may be affected by the manipulative reduction of violence. It may also be damaged by the surgical trauma of open reduction. The iatrogenic aggravation of the blood supply of the radius and neck causes the nonunion of the fracture of the radius and neck of the children. The treatment scheme mainly depends on the angle and horizontal displacement of the proximal end of the radius and neck fracture. The methods currently included include manipulation, closeintramedullarypinning, CIMP, percutaneouskirschner 'swireleverage, pkwl, and so on. Before the emergence of minimally invasive treatment of radial neck fractures in children, open reduction and / or Kirschner fixation are most important for the displaced radial neck fractures in children with obvious displacement. It is easy to have complications such as epiphyseal necrosis of the radial head, early closure of epiphyseal plate injury and intra-articular calcification. The effective rate is only between 20%-50%. Therefore, it is now advocated to avoid as much as possible. The treatment of radial and cervical fractures of type judetiii and IV children was treated with percutaneous reduction and elastic intramedullary nail fixation in our hospital. Combined with the results of treatment, the therapeutic effect of percutaneous Kirschner pin reduction and elastic intramedullary nail fixation for the treatment of judetiii and IV type children's radial neck fracture was evaluated. Methods: June 2010 to 201 In December 3 years, 50 cases of judetiii, IV type of radial neck fracture were treated with an average age of 8.4 years old, including 31 men, 19 women, 26 left cases and 24 right sides. The operation was closed reduction, such as closed reduction success or making angle less than 45 degrees, using radial bone marrow nail fixation and CIMP technique reduction and fixation. Closed reduction failure, pkwl technique Surgery, perspective displaced radial neck fracture has not been anatomic reduction, but the angle is less than 45 degrees, the elastic intramedullary nail CIMP technique can be used to help the reduction. After the operation, the long arm plaster is fixed to the functional position of the upper limb for 4-6 weeks. The result: 50 cases of judetiii, IV type radius neck fracture, 11 cases of radial neck fracture patients closed reduction Work, direct elastic intramedullary nail was fixed, 5 cases were assisted by CIMP technology to help the reduction and fixation, the average operation time was 58 minutes. 30 cases of radial neck fracture were treated with pkwl technique, and the average operation time was 50 minutes. 4 cases were treated by open reduction and elastic intramedullary nail fixation, and the average operation was performed. After 80 minutes, 2 cases of ulna proximal fracture were combined with open reduction and internal fixation, and 1 cases with radial nerve injury were treated by conservative treatment in March, and in March, the normal.Pkwl group was restored to the normal group and the closed reduction intramedullary nail and CIMP group. There was no significant difference between the operation time and the pkwl group. There was a greater degree of fracture displacement and the ratio of the angle degree of fracture to the degree of displacement. There was no significant difference between the open reduction group and the PKWL group, the closed reduction intramedullary nail, the CIMP group, the degree of angle of fracture, the degree of displacement and the ratio of the fracture, but the open reduction group was followed up for a longer operation time and the average follow-up time was 2 years. All cases were fractured. The average healing time was 4.1 months, and the average time for internal fixation was 4.3 months. According to the clinical evaluation criteria of Tibone and Stoltz, 3 cases were cut.
【学位授予单位】：苏州大学
【学位级别】：博士
【学位授予年份】：2016
【分类号】：R726.8

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