MEDLINE, Embase, Google Scholar, Cochrane, ISI web of science and Scopus were comprehensively searched from the earliest year of indexing until 10 July 2020. FOIA Bethesda, MD 20894, Web Policies However, MDACL is asymptomatic in most patients. PROSPERO. Fig. Postoperative recovery was four weeks on average. Privacy ACL tears don't heal as such. Arthroscopic debridement of the ACL results in satisfactory pain relief and improvement in knee outcome scores. Unauthorized use of these marks is strictly prohibited. 2022 Apr 11;31:67-71. doi: 10.1016/j.jor.2022.04.004. (A) Bulging of the hypertrophied anterior cruciate ligament. It is characterized by infiltration of mucoid like substance (glycosaminoglycans) interspersed within the substance of ACL causing knee pain and limited motion. Arthroscopic debridement of the ACL resulted in good pain relief and improved range of movement in all studies, with postoperative improvement in the knee scores. Careers. Post-debridement arthroscopic view showing yellowish, Post-debridement arthroscopic view showing yellowish lesion of the anterior cruciate ligament which was, MeSH Preoperative and postoperative KOOS questionnaires were compared and showed improvement in all categories. Mucoid degeneration of the anterior cruciate ligament (MD-ACL) was first characterized by Kumar et al. J Orthop. Keywords used for the Search were mucoid degeneration, anterior cruciate ligament and ACL. Postoperative ACL laxity is a common finding after ACL arthroscopic debridement, however, symptomatic instability is not. (Table 3). After arthroscopic debridement of the lesion, the patient regained full range of motion of the knee and were pain-free at follow-up. Mucoid degeneration,: like degenerative arthritis of a joint, generally occurs as a results of aging. Anterior cruciate ligament (ACL) mucoid degeneration, along with tears and anterior cruciate ligament ganglion cysts, is a relatively common cause of increased signal within the anterior cruciate ligament (ACL ). Knee Surg Sports Traumatol Arthrosc. -, Makino A, Pascual-Garrido C, Rolon A, Isola M, Muscolo DL. Bookshelf The appearance can mimic acute or chronic interstitial partial tears of the ACL. Three reviewers (an experienced librarian and two of the authors) independently searched these databases. Kim TH, Lee DH, Lee SH, Kim JM, Kim CW, Bin SI. What causes mucoid degeneration of ACL? Treatment for MDACL usually starts non-surgically with anti-inflammatory drugs and physiotherapy. The primary intervention was arthroscopic ACL debridement in eight studies; this was combined with notchplasty in cases of impingement with the lateral wall of the notch in five studies [6, 14, 16,17,18] (Table 3). . (A) Bulging of, Fig. 2022 Apr 11;31:67-71. doi: 10.1016/j.jor.2022.04.004. 2 ). An official website of the United States government. Quality was assessed using the Methodological Index for Non-Randomized Studies (MINORS) criteria. Unable to load your collection due to an error, Unable to load your delegates due to an error. Its function is to stabilize the knee while bending and rotating; the ACL also keeps the knee from shifting out of place or moving anteriorly (toward the front) with pivoting activities. With cruciate ligament ganglia, intact ACL fibers can often be visualized coursing through or around the cyst. Any discrepancy was resolved by the senior author. -, Kumar A, Bickerstaff DR, Grimwood JS, Suvarna SK. https://doi.org/10.1302/0301-620X.81B2.0810304, Article Unlike meniscal tears and chondral defects, the mucoid degeneration of the anterior cruciate ligament (ACL) is a rare cause of knee pain and there have been no case reports of mucoid degeneration of both the ACL and the posterior cruciate ligament (PCL). Please enable it to take advantage of the complete set of features! Bergin D, Morrison WB, Carrino JA et-al. Anatomopathology samples were collected in 18 cases. Before Bethesda, MD 20894, Web Policies Mucoid degeneration (MD) of the anterior cruciate ligament (ACL) is a rare pathological entity with disputed theories of origin. Sasaki R, Nagashima M, Takeshima K, Otani T, Okada Y, Aida S, Ishii K. J Int Med Res. Mucoid degeneration (MD) of the anterior cruciate ligament (ACL) is a rare pathological entity with disputed theories of origin. The inclusion criteria for this study were (1) studies including symptomatic patients with mucoid degeneration of the ACL, (2) studies of 10 or more patients, (3) a minimum of 6months follow up and (4) patients treated conservatively or surgically (arthroscopic debridement with or without simultaneous ACL reconstruction). A June 2018 MRI of the cervical spine found multilevel degenerative changes of the cervical spine, most pronounced at 6-7 and small disc herniations at 5-6 and C4-5, with slight interval progression at 5-6. . Mucoid degeneration is characterized by an increase in the mucoid ground substance in the connective tissue containing glycoprotein and mucoprotein [ 4 ]. did not report on this. Knee Surg Sports Traumatol Arthrosc. 2011. Rehabilitation, orthophony, crenotherapy. Springer Nature. All nine studies were case series; six were retrospective and three were prospective studies. Mucoid degeneration (MD) is a rare pathological affection of the anterior cruciate ligament (ACL). Another theory is the synovial theory whereby a pouch of synovium herniates and is subsequently filled with synovium [2]. Online ahead of print. Loganathan D, Soma Sundar S, Sundar S, Sahanand S, Rajan DV. Each study was scored 02 on each question, with a global ideal score of 16. Anterior cruciate ligament mucoid degeneration. Arthroscopic treatment of mucoid hypertrophy of the anterior cruciate ligament. Mucoid degeneration of the anterior cruciate ligament. This study concerns complete ACL resec This makes it difficult to relate the improvement of symptoms to ACL debridement. 1. Histological diagnosis was established by tissue biopsy in all patients in five studies, with a total of 87 knees. Radiologic findings associated with mucoid degeneration of the anterior cruciate ligament. Conclusions Our study provides further evidence that arthroscopic total or partial excision of anterior cruciate ligament is a safe and effective treatment for mucoid degeneration of the anterior . Epub 2008 Dec 17. Histologically, there is a mucoid substance in connective tissue containing glycoproteins and mucoproteins [8]. CAS Arthroscopic findings. Arthroscopy 20(2):141146. Arthroscopic debridement of the ACL was the intervention in eight studies, whereas Morice et al. Some case reports have been published; however, it is difficult to diagnose and is often underdiagnosed or misdiagnosed because of its pathophysiological ambiguity. For treatment of this, partial removing of bulky ACL is generally done, which causes weakness of the ACL. The https:// ensures that you are connecting to the This is basically an MRI diagnosis of expansion and increased signal of an intact ACL in a person with knee pain which is worse on knee flexion/bending. (61years), which was the largest study and represented more than one third of the total patients included in this review. Epub 2021 Mar 8. https://doi.org/10.1007/s00167-011-1433-0, Article reported the largest percentage of patients (27.5%) with a positive pivot test. Clinical Outcomes, Return to Sports, and Patient Satisfaction After Anterior Cruciate Ligament Reconstruction in Young and Middle-Aged Patients in an Asian Population-A 2-Year Follow-up Study. There was strong association with chondral lesions and meniscal tears. All patients (100%, n=11) reported an improvement in pain. Keywords: mucoid degeneration, anterior cruciate ligament, acl reconstruction, arthroscopy, knee I give my consent to Physiopedia to be in touch with me via email using the information I have provided in this form for the purpose of news, updates and marketing. MRI is better at detecting mucoid degeneration than arthroscopy, as the surface of the ligament is often intact. The minimum follow-up was 3 years. 4. https://doi.org/10.4103/0019-5413.101037, Srivastava A, Pateliya S, Singh H, Aggarwal S, Srivastava S (2016) Mucoid degeneration of anterior cruciate ligament management and functional outcome of 18 cases. The origin of MDACL may be degenerative or traumatic. in 1999 [ 1 ]. Khanna et al. This study concerns complete ACL resection as a treatment of mucoid degenerated ACL. On physical exam, the Lachman test for ACL instability is negative with an ACL ganglion. 2012 Sep;46(5):561-5. doi: 10.4103/0019-5413.101037. official website and that any information you provide is encrypted Several authors have identified this condition, described their experiences, and suggested their own guidelines for management. Management of mucoid degeneration of the anterior cruciate ligament: a systematic review. {"url":"/signup-modal-props.json?lang=us"}, Gaillard F, Roberts D, Saber M, et al. 2006 Sep;69(9):449-52. doi: 10.1016/S1726-4901(09)70290-4. 2011 Jun;25(6):650-2. what causes mucoid degeneration of acl. Six studies reported using the pivot shift test; unsurprisingly, Lintz et al. The rate of association between meniscal tears and MDACL ranged from 9 to 96%. See this image and copyright information in PMC. Finally, partial meniscectomy was commonly performed simultaneously with ACL debridement in all studies, which arguably could be the reason for the postoperative improvement. It has recently been postulated that mucoid degeneration of the ACL is related to the medial knee compartment joint space loss in patients with osteoarthritis or in the OA risk group 6. Sometimes, it is mislead as ACL tear on MRI findings, hence requires probing and histopathology for definitive diagnosis. 2022 Jun 2;20(1):225-228. doi: 10.33314/jnhrc.v20i01.4182. Postoperative clinical laxity was common, however, symptomatic instability was not. the degree of laxity, and the patient's age and willingness to pursue vigorous postoperative physical therapy are other major determinants. Please enable it to take advantage of the complete set of features! All studies focused on the outcome of arthroscopic debridement of MDACL, with no studies on conservative treatment. Average improvement in flexion was 21.5 degrees (0 to 60 degrees). The extracted data were assessed for meta-analysis. In that case, mucoid degeneration can be extruded from the ligament and will be removed in the saline flow. Its prevalence in magnetic resonance imaging (MRI) is 1.8 to 5.3%, but not all lesions are symptomatic. Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) flowchart illustrating the selections of trials included in the systematic review. -osis is a suffix denoting a process, condition, or state, the histology of the Achilles tendon and in ACL injuries(24-26). At the time the article was last revised Dai Roberts had no recorded disclosures. Fourteen knees (48%) had limited flexion, on average 97 degrees. A September 2018 MRI of the left knee showed anterior cruciate ligament and mucoid degeneration with intra cruciate ganglion . Read More Created for people with ongoing healthcare needs but benefits everyone. No treatment is usually required. Thirteen patients were treated with complete ACL resection for symptomatic MD of the ACL from 2006-2016. The visual analogue scale score, the International Knee Documentation Committee score, and the Tegner Lysholm Knee Score were collected preoperatively, postoperatively, and during the follow-up period. Physical Therapy. Management of mucoid degeneration of the anterior cruciate ligament: a systematic review, https://doi.org/10.1186/s43019-021-00110-6, https://doi.org/10.1302/0301-620X.81B2.0810304, https://doi.org/10.1007/s00167-011-1433-0, https://doi.org/10.2214/ajr.182.5.1821283, https://doi.org/10.1007/s00167-012-1991-9, https://doi.org/10.1016/j.arthro.2003.11.030, https://doi.org/10.1016/j.jclinepi.2009.06.005, http://www.crd.york.ac.uk/PROSPERO/display_record.php?ID=CRD42018087782, https://doi.org/10.1046/j.1445-2197.2003.02748.x, http://journals.sagepub.com/doi/10.1177/2325967118786930, http://www.ijcrar.com/abstractview.php?ID=228&vol=4-11-2016&SNo=3, https://doi.org/10.1016/j.arthro.2008.02.004, https://doi.org/10.1016/j.jajs.2015.12.001, https://doi.org/10.4055/cios.2018.10.3.307, http://creativecommons.org/licenses/by/4.0/, http://creativecommons.org/publicdomain/zero/1.0/. 8600 Rockville Pike 2022 Oct 23;34(1):40. doi: 10.1186/s43019-022-00169-9. J Arthrosc Joint Surg 3(1):2833. Unable to load your collection due to an error, Unable to load your delegates due to an error. Reduction plasty for hypertrophic anterior cruciate ligament mucoid degeneration: clinical and knee laxity outcomes in 23 cases. 5. Diet therapy and various other treatments (general aspects) Discipline Radiotherapy. National Library of Medicine 2008;24(6):642649. Check for errors and try again. Methodological quality of the studies was assessed using the Methodological Index for Non-Randomized Studies (MINORS) criteria [11] (Table1). Twelve partial and 17 total resections were performed. Our study provides further evidence that arthroscopic total or partial excision of anterior cruciate ligament is a safe and effective treatment for mucoid degeneration of the anterior cruciate ligament, improving patient satisfaction and function without causing clinical instability in daily activities. Introduction: Mucoid degeneration of the anterior cruciate ligament (ACL) is a little-known entity. Cho SD, Youm YS, Lee CC et-al. A total of 313 knees in 292 patients were included. This site needs JavaScript to work properly. Mucoid degeneration of the anterior cruciate ligament (ACL) is a little-known entity. Arthroscopy. Chudasama CH, Chudasama VC, Prabhakar MM. Bergin D, Morrison WB, Carrino JA, Nallamshetty SN, Bartolozzi AR. We report a case of a patient with mucoid degeneration of the ACL, presenting with posterior knee pain and no history of a major knee trauma. (B) Partial resection, MeSH 2019 Jun;32(6):577-583. doi: 10.1055/s-0038-1660514. The author(s) read and approved the final manuscript. Tissue biopsy was performed in 85% of patients (58 of 68) in the study of Cha et al. Epub 2011 Feb 18. We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2009 checklist [9]. A long duration of non-specific knee pain in a patient should be evaluated with MRI. Google Scholar, Chudasama CH, Chudasama VC, Prabhakar MM (2012) Arthroscopic management of mucoid degeneration of anterior cruciate ligament. However, the authors did not report whether there were any other patients with symptomatic instability. Conclusion: Treatment of ACL mucoid degeneration by this modality is effective in preventing recurrence, post-operative laxity and provides better functional outcome compared to the classical partial resection of the degenerated ACL. Bookshelf This appearance can mimic acute or chronic interstitial partial tears of the ligament. Pre-debridement arthroscopic view showing yellowish content in the anterior cruciate ligament. It often presents with progressive knee pain, restriction in range of motion without a significant history of trauma, and without knee instability. FOIA 2013 Oct;99(6):693-7. doi: 10.1016/j.otsr.2013.04.010. Mucoid degeneration of the ACL is suspected when an apparently thickened and ill-defined ligament with increased signal intensity on all sequences in MRI is identified in a patient with physically intact ligament and no obvious trauma history. We report a case of mucoid degeneration of the anterior cruciate ligament (ACL). HHS Vulnerability Disclosure, Help Noninfiltrating synovial cysts of the ACL were excluded. Role of ultrasound-guided decompression in management of mucoid degeneration of the anterior cruciate ligament. Its interstitial nature within the ACL structure contrasts with synovial cyst of the ACL. Download Citation | On Feb 1, 2023, O.R. Radiologic findings associated with mucoid degeneration of the anterior cruciate ligament. Patients and methods: A positive Lachman test and a negative pivot shift were noted after surgery in all cases. Learn how we can help 704 views Reviewed >2 years ago Thank . Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. Anterior knee pain is the more common complaint. ACL (anterior cruciate ligament) mucoid degeneration means the lesion of the ACL. Introduction Mucoid degeneration of the anterior cruciate ligament (MDACL) is a rare entity, first described by Kumar et al. The knee is a complex synovial joint that can be affected by a range of pathologies: Please Note: You can also scroll through stacks with your mouse wheel or the keyboard arrow keys. On clinical examination, the active range of motion showed a flexion deficit. eCollection 2022 May-Jun. Keywords: Kwee RM, Hafezi-Nejad N, Roemer FW, Zikria BA, Hunter DJ, Guermazi A, Demehri S. Association of Mucoid Degeneration of the Anterior Cruciate Ligament at MR Imaging with Medial Tibiofemoral Osteoarthritis Progression at Radiography: Data from the Osteoarthritis Initiative. Pain was posterior in 23 knees (80%). 2004 Feb;20(2):141-6. doi: 10.1016/j.arthro.2003.11.030. Clinical outcome was reported using a variety of scores (the Lysholm and International Knee Documentation Committee (IKDC) score, the Knee Injury and Osteoarthritis Outcome Score (KOOS) and the visual analogue scale (VAS) score) in the different studies; these are summarized in Table 4. Pandey, Vivek et al. The .gov means its official. Therefore, Anterior Cruciate Ligament tear is more susceptible during any injury to the knee. The aim of this study was to detail the clinical, radiological, arthroscopic, and pathological findings of mucoid degeneration of the anterior cruciate ligament and report the clinical outcomes following arthroscopic treatment. Mumbai, Maharashtra, India. Level of Evidence: Level IV. 2010 Jun;96(4):400-6. doi: 10.1016/j.otsr.2010.02.008. They respond well to a judicious arthroscopic release of the ACL with notchplasty. Furthermore, this raises the question as to whether the symptoms (pain and diminished range of movement) were solely due to MDACL and not secondary to other associated pathological conditions. Truncation means that the . and transmitted securely. Rehabilitation, speech therapy, crenotherapy. 2022 Nov 24. doi: 10.1007/s00402-022-04659-z. This is a characteristic appearance of ACL mucoid degeneration where the ACL is expanded and hyperintense but is still continuous with normal alignment. -Delivered Pre-rehab care for breast cancer and thoracic cancer cases. 2004;182 (5): 1283-7. 8600 Rockville Pike Seven of the nine studies reported using the Lachman test to check postoperative ACL laxity. Int J Curr Res Aca Rev 4(11):1824 http://www.ijcrar.com/abstractview.php?ID=228&vol=4-11-2016&SNo=3, Kim TH, Lee DH, Lee SH, Kim JM, Kim CW, Bin SI (2008) Arthroscopic treatment of mucoid hypertrophy of the anterior cruciate ligament. This ranged from 90 to 95% in all studies, except in the report by Kim et al., where only 53.8% of patients (57/106) had complete pain relief after surgery. Cite this article. GG and AM interpreted the results and reviewed the manuscript. 2. 2004;182(5):12831287. Four studies reported only postoperative scores, which were comparable to those in other studies. Preoperative assessment included a questionnaire, clinical examination (Lachman and pivot shift tests), MRI and standard radiography. Disclaimer. ACL mucoid degeneration is an uncommon pathological condition; the pathogenesis, prevalence, and association with other intra-articular knee structural damage are still poorly understood. -Evaluated and planned treatment protocol in accordance with physician. Introduction: The aetiology of MDACL is not fully understood, hence, there are multiple theories on this. MDACL is differentiated from synovial cysts of the anterior cruciate ligament (ACL) where, in MDACL, mucoid tissue intermingles within ACL fibres and is not contained within a cyst [3]. Cookies policy. The prevalence of MDACL on magnetic resonance imaging (MRI) ranges from 1.8 to 5.3% [4, 5]. Dietary management and various treatments Scanning and diagnostic . Questions just answered: mucoid degeneration of acl physiotherapy. Conclusions. Anterior cruciate ligament mucoid degeneration: a review of the literature and management guidelines. Please enable it to take advantage of the complete set of features! Mucoid degeneration of the anterior cruciate ligament. 2013;15(1). The mean MINORS score was 9.5 (range 412). 2011 Mar;25(3):262-5. After the literature search and exclusion of duplicates, 54 papers were retrieved: 12 articles were assessed for eligibility, and of these, 9 papers met the inclusion criteria and were included in the systematic review [3, 6, 13,14,15,16,17,18,19] (Fig. There was no mention in the other three studies [13, 15, 18] of whether other procedures were performed simultaneously. Treatment of ACL mucoid degeneration by arthroscopic resection is effective for posterior pain and flexion limitation. Typically patients present with knee pain or restricted movement, although often other potential causes for the patient's symptoms are found. Physiopedia is not a substitute for professional advice or expert medical services from a qualified healthcare provider. I get PT and acupuncture, have had several epidural injections, and am trying hard to avoid osteoporosis meds (was on bisphosphonates for many years many years ago) as well as spinal fusion. Please enable it to take advantage of the complete set of features! Arthroscopic debridement of the mucoid degeneration of the ACL was safe and effective in the patient. Treatment options include non-operative management, arthroscopic debridement with a biceps tenotomy or tenodesis, complete or partial repair, patch augmentation, superior capsular reconstruction, muscle/tendon transfer and reverse total shoulder arthroplasty. Would you like email updates of new search results? Several critical distinctions allow a confident diagnosis of an ACL ganglion cyst. ADVERTISEMENT: Supporters see fewer/no ads. -. 2022 Mar;50(3):3000605221084865. doi: 10.1177/03000605221084865. Most authors believe that partial ACL resection is the treatment of choice in symptomatic MD of the ACL. . Risk factors Predisposing factors include the following 1: aging An official website of the United States government. 1999;81(2):304305. in 1999 [1]. eCollection 2021. 2022 Nov 24. doi: 10.1007/s00402-022-04659-z. What is Anterior Cruciate Ligament Mucoid Degeneration? Tamer Sweed. proposed a different intervention called reduction plasty, whereby the hypertrophic ACL is reduced to normal size without excision of all mucoid substance [17]. Conclusions: Mucoid degeneration of the ACL is a clinical condition afflicting active middle-aged people without a single significant traumatic episode with a specific MRI picture. PMC Anyone you share the following link with will be able to read this content: Sorry, a shareable link is not currently available for this article. [3] and in 1% of patients (3 of 106 knees) in the study of Kim et al. http://www.crd.york.ac.uk/PROSPERO/display_record.php?ID=CRD42018087782. Resnick D, Kransdorf MJ. Treatment modalities for ACL ganglion cyst include arthroscopic excision or puncture, CT scan, and ultrasound-guided aspiration [25-26]. Our study provides further evidence that arthroscopic total or partial excision of anterior cruciate ligament is a safe and effective treatment for mucoid degeneration of the anterior cruciate ligament, improving patient satisfaction and function without causing clinical instability in daily activities. Orthopaedics & Traumatology: Surgery & Research. Read more, Physiopedia 2023 | Physiopedia is a registered charity in the UK, no. -, Hodler J, Haghighi P, Trudell D, Resnick D. The cruciate ligaments of the knee: Correlation between MR appearance and gross and histologic findings in cadaveric specimens. Postoperative follow-up included standard radiography and dynamic examination, measuring laxity with a Telos device. Sagittal T2-weighted MRI view showing intact anterior, Fig. International Journal of Orthopaedics. Knee Surg & Relat Res 33, 26 (2021). 1). Morice et al. Methods: The minimum follow-up was 3 years. 2009 Jul;17(7):737-40. doi: 10.1007/s00167-008-0690-z. Radiology. Orthop Traumatol Surg Res. Sixty-one patients underwent T2*WI and PDWI at 3, 6, and 12 months postoperatively. The mean follow up ranged from 13 to 72months. Along with that, it also controls the internal rotation. Characteristic: "celery stalk" appearance. Arthroscopic resection of ACL mucoid degeneration is effective for treating pain and flexion limitation, but at the expense of anterior laxity. The https:// ensures that you are connecting to the Online ahead of print. Average postoperative International Knee Documentation Committee (IKDC) and Knee Injury and Osteoarthritis Outcome Scores (KOOS) were 71.2 (42.5 to 92.0) and 78.2 (26.4 to 99). Disclaimer. Sasaki R, Nagashima M, Takeshima K, Otani T, Okada Y, Aida S, Ishii K. J Int Med Res. This bicentric, retrospective cohort study with an average follow-up of 6years involved 27 patients (29 knees) presenting with symptomatic ACL mucoid degeneration validated by magnetic resonance imaging (MRI). 2023 BioMed Central Ltd unless otherwise stated. The anterior cruciate ligament (ACL) is the most commonly injured of the major knee ligaments. An anterior cruciate ligament (ACL) mucoid degeneration, along with tears and anterior cruciate ligament ganglion cysts, is a relatively common cause of increased signal within the. Role of debulking mucoid ACL in unicompartmental knee arthroplasty: a prospective multicentric study. There was strong association between degenerative changes and MDACL (82% having chondral and 69% meniscal lesions), which might suggest that MDACL is a degenerative process. MeSH There is no consensus on treatment and evidence is scarce. The prevalence of mucoid degeneration of the ACL has been reported to be 0.43% [ 5 ]. 287 (3): 912-921. Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. Presentation Patients usually present with nonspecific posterior knee pain with restriction of flexion. Arthroscopic treatment may include ACL resection, which raises the questions about the harmlessness of this procedure and the risk of anterior instability. Correlations between degree of knee instability and SIR were assessed for each bundle, each time point, and each sequence.
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