CHA P T E R 54

Osteonecrosis of the Knee

Michael B. Boyd, DO
William D. Bugbee, MD

Osteonecrosis of the knee is a difficult clinical entity. Three
general categories include idiopathic or spontaneous
osteonecrosis (also known as Ahlbäck disease), secondary
or atraumatic osteonecrosis, and traumatic osteonecrosis.
The diagnosis of osteonecrosis can be arduous. A common
error is to misdiagnose degenerative subchondral bone
Signs and Symptoms
Spontaneous Osteonecrosis
● Sudden pain usually over the medial aspect of the
knee (may be initiated by a minor injury)
● Increased pain at night and with activity

cysts of osteoarthritis as spontaneous osteonecrosis. There Atraumatic Osteonecrosis

are several theories of the etiology of spontaneous osteo-
necrosis and atraumatic osteonecrosis, but in general,
these premises are not well understood. Traumatic osteo-
necrosis hypothetically occurs after fracture or surgery.
● Long-standing insidious pain (note: some patients
may be asymptomatic)
● Pain may be difficult to localize

This chapter focuses on the unique presentations and

various treatment options of spontaneous osteonecrosis Physical Examination
and atraumatic osteonecrosis.
Typical Findings
Spontaneous Osteonecrosis
Preoperative Considerations ● Range of motion may be decreased secondary to pain,

muscle spasm, or subchondral collapse

History ● High sensitivity to touch over the lesion (usually, the

medial femoral condyle)

A thorough history may simplify the diagnosis of osteone- ● Swelling (±), effusion (±)
crosis. Risk factors for atraumatic osteonecrosis include
● Ligaments: stable
corticosteroid use, alcohol consumption, Gaucher disease,
sickle cell disease, caisson disease, coagulopathy, and sys- Atraumatic Osteonecrosis
temic lupus erythematosus. The typical patient with spon- ● Range of motion may be decreased secondary to pain,
taneous osteonecrosis is an obese woman older than 55 muscle spasm, or subchondral collapse
years. Spontaneous osteonecrosis is usually unilateral and
● Nonspecific knee pain (especially with multiple
typically affects just one condyle. Atraumatic osteonecrosis
lesions)
often presents bilaterally and can affect multiple condyles
or plateaus. In addition, it is frequently seen in other ● No swelling, no effusion

joints. ● Ligaments: stable

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 Surgical Techniques of the Articular Cartilage

Imaging Optional
● Merchant view of patellofemoral joint

Radiography ● Long-leg anteroposterior mechanical axis view to

● Weight-bearing anteroposterior radiograph of knee in evaluate for malalignment

full extension with a radiopaque magnification marker
(Fig. 54-1A)
● Non–weight-bearing 90-degree-flexion lateral view of
knee (Fig. 54-1B)
● Notch (Fig. 54-1C) or Rosenberg view of knee
Other Modalities
Magnetic resonance imaging can help confirm the diagno-
sis and the extent of the lesion (Fig. 54-2)
Technetium Tc 99 m bone scan is generally unreli-
able but may assist in diagnosis when radiographs are

Figure 54-1 A, Anteroposterior standing radiograph of a knee with a

radiopaque magnification marker (the arrow demonstrates the tibial width
dimension used for allograft sizing). B, Non–weight-bearing 90-degree flexion
lateral view of a knee demonstrating atraumatic osteonecrosis. C, Notch
view of a knee depicting atraumatic osteonecrosis.
C

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 Osteonecrosis of the Knee

Box 54-1 Aglietti Classification for Spontaneous Osteonecrosis

(Modified Koshino)

Stage I Normal radiographs; magnetic resonance imaging

abnormalities

Stage II Some flattening of the weight-bearing portion of the

condyle

Stage III Subchondral radiolucency with surrounding sclerosis

without sequestration

Stage IV ↑ Sclerosis with subchondral collapse and

sequestration; visible as a calcium plate
54
Stage V Secondary degenerative changes (narrowing of joint
space, osteophyte formation, subchondral sclerosis)
associated with some erosions

Box 54-2 Mont and Hungerford Classification for Atraumatic Osteonecrosis

(Modified Ficat-Arlet)

Stage I Normal radiographs, magnetic resonance imaging

A abnormalities

Stage II Cysts and sclerosis present

Stage III Subchondral collapse is seen as the crescent sign

Stage IV Secondary degenerative changes (narrowing of joint

space, osteophyte formation) on both sides of joint

Staging

The Aglietti classification for spontaneous osteonecrosis

(modified Koshino) and the Mont and Hungerford classi-
fication for atraumatic osteonecrosis (modified Ficat-
Arlet) are described in Boxes 54-1 and 54-2.

Treatment
B
Figure 54-2 Magnetic resonance images of a knee exhibiting spontaneous Nonoperative
osteonecrosis (A) and atraumatic osteonecrosis (B).
● Anti-inflammatory medicines (? benefit)

● Analgesics

● Pharmacologic treatment based on underlying disease

process
● Activity modifications, protective weight bearing

● Closed-chain quadriceps exercises

normal. Bipolar uptake is more indicative of osteoarthritis, ● Unloader knee brace

except in the late stages of osteonecrosis. Conversely,

Operative
simultaneous atraumatic osteonecrosis of the ipsilateral
tibial plateau and femoral condyle is certainly possible ● Arthroscopy ± débridement

during any stage and usually presents with more intense ● Core decompression by extra-articular drilling ± bone
uptake than with osteoarthritis. grafting

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 Surgical Techniques of the Articular Cartilage

● Osteochondral allograft for large lesions versus

osteochondral autograft for small lesions
● Realignment procedure: high tibial osteotomy for genu
varum versus distal femoral osteotomy for genu
valgum
● Unicompartmental knee arthroplasty versus total knee
arthroplasty
Because of the heterogeneous nature of osteonecrosis of
the knee in both etiology and stage, no single technique is
always preferred. Treatment should be individualized.
Core decompression and allografting with or without
realignment are our preferred treatments for the younger
population of patients and are further discussed in this
chapter. Our general treatment algorithm is presented in
Figure 54-3.
Core Decompression
Brief Description
Extra-articular drilling is recommended in the treatment of
symptomatic osteonecrosis of the knee in pre–subchondral
collapse stages. Core decompression can be done in con-
junction with knee arthroscopy. A small incision is made
just proximal to the metaphyseal flare for femoral lesions
and adjacent to the tubercle for tibial lesions. With fluoro-
scopic guidance, a 3- to 6-mm trephine is advanced to within
3 mm of the subchondral bone. The surgeon may elect to
lightly pack autologous iliac crest bone graft inside the
lesion. Postoperatively, the patient is restricted to 50%
partial weight bearing for 4 to 6 weeks.

SONK I, II, or III SONK IV SONK V

AONK I or II AONK III AONK IV

Nonoperative treatment - Fresh OCA

- OATS
(+/– Realignment procedure)

YES - Core decompression

Persistent
- Bone grafting
symptoms?
- Realignment procedure Persistent
symptoms?

NO YES
Persistent
symptoms?
Success TKA vs UKA
NO YES

NO
Radiographic
progression? YES TKA vs UKA
(consider fresh OCA +/–
NO realignment in pt younger
Bone Joint than 55 years old)
symptoms? symptoms?
Success
YES YES

Repeat core Arthroscopic débridement

decompression (consider fresh OCA vs OATS)

Figure 54-3 Treatment algorithm for osteonecrosis of the knee (modified Mont algorithm). SONK, spontaneous osteonecrosis; AONK, atraumatic osteonecrosis;
OATS, osteochondral autograft; OCA, osteochondral allograft; TKA, total knee arthroplasty; UKA, unicompartmental knee arthroplasty.

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 Osteonecrosis of the Knee

Fresh Osteochondral Allografting Surgical Technique: Fresh

for Osteonecrosis of the Knee Osteochondral Allografting
Indications and Contraindications Anesthesia and Positioning

Fresh osteochondral allografting can be used as a salvage Anesthesia

procedure in patients for whom other treatments of osteo-
● General
necrosis have failed, including nonoperative care, arthros-
● Epidural
copy, and core decompression. Allografts are used as an
alternative to arthroplasty in the young population. Typi- ● Spinal

cally, the lesions should be more than 2 cm (approximately) ● Regional (±) 54

in diameter. Osteochondral autografting is an excellent
alternative for smaller lesions with compromised articular
Positioning
cartilage.
Relative contraindications to fresh osteochondral ● Supine on a standard operating room table

allografting include uncorrected limb malalignment and ● Padded thigh tourniquet

joint instability. The senior author has not found steroid ● Leg holder to position knee between 70 and 100
dependency to be a contraindication to fresh osteochon- degrees of flexion for access to the lesion
dral allografts, as previously reported in the literature.7a
Allografting should not be considered an alternative to
total knee arthroplasty or unicompartmental knee arthro-
plasty in a patient with symptoms, age, and activity level Surgical Landmarks, Incisions,
appropriate for prosthetic replacement. Finally, fresh and Portals
osteochondral allografting should not be performed in
the individual with advanced multicompartmental knee Landmarks
arthrosis.
Patella
Patellar tendon
Joint line
Tibial tubercle
Surgical Planning
Approaches
Concomitant Procedures ● Mini medial parapatellar arthrotomy

● Mini lateral parapatellar arthrotomy

Significant limb malalignment, ligamentous instability, or
meniscal disease can be addressed either before or con-
comitant with fresh osteochondral allograft transplanta-
tion. Concomitant distal femoral osteotomy or femoral
condyle osteochondral allografting is not recommended
and should be staged because of the increased fear of
● Standard medial parapatellar arthrotomy for
bicondylar lesions
Structures at Risk
● Medial parapatellar approach: anterior horn of medial

nonunion. meniscus, patellar tendon

● Lateral parapatellar approach: anterior horn of lateral

meniscus, patellar tendon

Allograft Sizing
A measurement of the width of the tibia, a few millimeters
inferior to the plateau, is made from a standing anteropos-
terior knee radiograph with a radiopaque magnification
marker (see Fig. 54-1A). The measurement is corrected for
magnification and sent to the tissue bank for a matched
donor.
Examination Under Anesthesia
and Diagnostic Arthroscopy
Examine the knee’s range of motion and stability under
anesthesia. Perform a diagnostic arthroscopy before the
allografting procedure if questions about the meniscus or
articular cartilage exist.

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 Surgical Techniques of the Articular Cartilage
Specific Steps (Box 54-3)
1. Exposure
A standard midline incision is made from approximately
the center of the patella to the tip of the tibial tubercle
(Fig. 54-4). A medial or lateral parapatellar arthrotomy is
then made extending from the superomedial or superolat-
eral aspect of the patella down to the distal end of the
incision. The incision can be extended for bicondylar
lesions. Care is taken to preserve the anterior horn of the
meniscus after incision through the infrapatellar fat pad.
For access to deep posterior femoral condyle lesions, the
meniscus may need to be taken down, leaving a cuff of
tissue for later repair. Retractors are placed medially and
laterally to better expose the condyle. One of these retrac-
tors is carefully placed in the notch, retracting the patella
and protecting the cruciate ligaments. The knee is then
flexed to the appropriate level to deliver the lesion to the
arthrotomy. If additional mobilization of the patella is nec-
essary, the fat pad can be released further, staying anterior
to the anterior horn of the opposite meniscus.
2. Recipient Site Preparation
Two techniques are used for osteochondral allografting,
the dowel and the shell techniques. When possible, a dowel
Box 54-3 Surgical Steps
1. Exposure
2. Recipient site preparation
3. Fresh osteochondral allograft preparation
4. Graft insertion and fixation
5. Closure
Figure 54-4 Standard midline incision, medial parapatellar approach.
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ch054-X3447.indd 532
or plug (generally 20 mm or larger) is the preferred tech-
nique as the instrumentation facilitates the procedure
(Fig. 54-5). This is the typical scenario for spontaneous
osteonecrosis. Often, however, the disease is too extensive
for a dowel or multiple dowels, and a freehand shell tech-
nique is performed (typical for atraumatic osteonecrosis
lesions).
With the dowel technique, the lesion is inspected
and probed to assess its margins. A guide wire is then
drilled perpendicular to the curvature of the articular
surface into the center of the lesion. The graft is sized with
cannulated dowels. A cannulated cutting reamer is used to
penetrate the remaining articular cartilage. Next, 3 to
4 mm of subchondral bone is removed with the appropri-
ately sized cannulated bone reamer. If it is indicated, more
necrotic bone can be reamed down to bleeding margins,
not to exceed 6 to 10 mm. The guide wire is then removed
(Fig. 54-6). The depth of the lesion is measured in four
Figure 54-5 Dowel technique instrumentation and fresh hemicondylar
femoral allograft.
Figure 54-6 Dowel technique—lesion reamed down to bleeding bone.
10/17/2007 2:49:09 PM

quadrants (Fig. 54-7). If necessary, multiple small drill
holes can be made to decompress the lesion. Curettage and
autologous bone grafting (i.e., iliac crest bone graft) can be
performed for extensive bone deficiency. At times, a second
graft is necessary to cover the entire lesion. In this case,
the dowel technique is repeated, overlapping the grafts
(Fig. 54-8).
Alternatively, the entire condyle might be involved,
rendering it difficult to graft with simple dowels (Fig. 54-
9A). In this situation, the recipient site is prepared by a
freehand technique with osteotomes and burs. The goal is
to produce a simple geometric pattern (Fig. 54-9B). This
often incorporates the entire hemicondyle. The dimen-
sions and position of the prepared site are measured and
transferred to the allograft.
3. Fresh Osteochondral Allograft Preparation
With the dowel technique, the matching anatomic loca-
tion on the donor graft is identified. The graft is held
Figure 54-7 Depth measurements of a dowel in four quadrants.
Figure 54-8 Overlapping dowel technique.
ch054-X3447.indd 533
Osteonecrosis of the Knee
securely by an assistant with a large tenaculum bone clamp.
A saw guide is placed perpendicular to the articular surface.
The appropriately sized tube saw is placed over the guide
and used to core the graft (Fig. 54-10). The graft is then
amputated from the condyle with a cut at its base by an
oscillating saw. The previously measured recipient site
depths are marked at the four corresponding quadrants of
the graft. The graft is placed in a special bone holder, and
the oscillating saw is used to make the final cut at the
marks. Fine adjustments can be made with a bone rasp.
To reduce its immunogenicity, the graft is then copiously
irrigated with bacitracin solution by the jet lavage system 54
to remove any remaining bone marrow elements
(Fig. 54-11).
With the shell technique, the cuts are made free-
hand, forming a geometric match of the recipient site (Fig.
54-12). Repeated trial fittings are performed. The graft is
A
B
Figure 54-9 A, Severe atraumatic osteonecrosis lesion of the lateral femoral
hemicondyle requiring a shell technique. B, Lesion after débridement into
simple geometric configuration.
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 Surgical Techniques of the Articular Cartilage

A A

B B
Figure 54-10 A, Preparation of dowel allograft with a reamer. B, View of Figure 54-12 A, Example of shell allograft. B, Shell allograft implanted in
dowel allograft before amputation. lesion seen in Figure 54-9.

modified accordingly until the articular geometry is

restored.

4. Graft Insertion and Fixation

With the appropriate orientation, the allograft dowel is
manually inserted and gently tapped in place until flush. If
necessary, the recipient site can be opened up farther with
an oversized dilator. Fine adjustments to the allograft are
made. An excellent press fit is typically noted (Fig. 54-13);
however, the graft can be secured further with bioabsorb-
able pins. With a shell graft, fixation is obtained with a
combination of bioabsorbable pins and small titanium
screws. The knee is then put through a range of motion to
assess for graft stability and possible impingement, espe-
cially at the notch.

5. Closure
Figure 54-11 The allograft is washed thoroughly with a jet lavage system to Standard layered closure of the arthrotomy is performed
remove bone marrow elements.
over a 1/8-inch drain.

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A
B
Figure 54-13 A, Example of dowel graft adjacent to recipient site.
B, Excellent press fit of dowel graft.
Postoperative Considerations
Hospital Course
● Hospital admission for 23 to 48 hours
● Intravenous antibiotics for 24 hours
● Drain removed on postoperative day 1
Rehabilitation
● Immediate touch-down weight bearing is permitted
with unlimited range of motion and quadriceps
strengthening for 6 to 12 weeks.
● Stationary bicycling is started at 4 weeks.
ch054-X3447.indd 535
Osteonecrosis of the Knee
● With meniscal detachment or repair and large
posterior grafts, flexion is limited to 60 degrees for
4 to 6 weeks.
● Progressive weight-bearing begins at 6 to 12 weeks.
● Sports and recreation are resumed at 6 months.
Complications
● Delayed union or nonunion of the allograft
Infection
●
54
● Arthrofibrosis
PEARLS AND PITFALLS
General
● Degenerative subchondral bone cysts (usually large, isolated defects
about the medial femoral condyle) are commonly misdiagnosed as
osteonecrosis but are rather a variant presentation of early
osteoarthritis.
● Defining the stage and lesion size (volume and surface area) is key
to sound application of our treatment algorithm.
● Subchondral fracture or collapse drastically alters prognosis and
limits treatment options.
Surgical
● Concomitant distal femoral osteotomy or femoral condyle
osteochondral allografting is not recommended and should be staged
because of fear of nonunion.
● For access to deep posterior femoral condyle lesions, the meniscus
may need to be taken down, leaving a cuff of tissue for later repair.
● If mobilization of the patella is necessary, the fat pad can be
released, staying anterior to the anterior horn of the opposite
meniscus.
Results
Core decompression can be an effective way to treat osteo-
necrosis of the knee, especially before the development of
subchondral collapse. Recent data have shown a 94%
success rate with fresh osteochondral allografting with or
without realignment in steroid-induced osteonecrosis of
the knee in the young patient. Unicompartmental knee
arthroplasty has been shown to be successful for the treat-
ment of end-stage spontaneous osteonecrosis. Total knee
arthroplasty is an excellent treatment for all end-stage
osteonecroses. The use of cemented stems during total
knee arthroplasty improves the long-term results in
patients with mutifocal osteonecrosis. Uncemented total
knee arthroplasty is no longer recommended in the treat-
ment of osteonecrosis. These results are summarized in
Table 54-1.
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 Surgical Techniques of the Articular Cartilage

Table 54-1 Clinical Results of Various Treatment Options of Osteonecrosis

Procedure Osteonecrosis Author Mean Miscellaneous Notes Outcome

Type Follow-up

High tibial osteotomy Spontaneous Koshino9 (1982) 5.1 years 23 knees with concomitant core 35 of 37 (95%)
decompression or bone grafting successful

Unicompartmental knee Spontaneous Aglietti et al1 4.4 years 35 total, 2 unicompartmental; all 35 of 37 (95%)
arthroplasty, total knee (1983) stages included successful
arthroplasty

Fresh osteochondral Atraumatic, Bayne et al2 4.8 years 3 of 3 patients with steroid- 6 of 13 (46%)
allograft, débridement, spontaneous, (1985) induced osteonecrosis treated spontaneous
high tibial osteotomy, traumatic with only fresh osteochondral successful; 4 of 7
core decompression allograft failed after 18 months (57%) atraumatic
successful

Core decompression Atraumatic Jacobs et al8 4.5 years 16 of 18 patients with steroid- 7 of 7 (100%) stage
(1989) induced osteonecrotic lesions I-II successful; 11 of
21 (52%) stage III
successful

Total knee arthroplasty Atraumatic, Bergman and 4 years Only a 68% 5-year predicted 33 of 38 (87%)
spontaneous Rand3 (1991) implant survivorship by revision successful
due to pain as end point

Unicompartmental knee Spontaneous Marmor10 5.5 years 2 of 4 failures due to subsequent 30 of 34 (88%)
arthroplasty (1993) osteonecrosis of opposite femoral successful
condyle

Fresh-frozen Atraumatic, Flynn et al5 4.2 years Young patient group, 2 patients 12 of 17 (71%)
osteochondral allograft spontaneous, (1994) with steroid-induced osteonecrosis successful
traumatic converted to total knee
arthroplasty

Nonoperative treatment Atraumatic Mont et al11 11 years Mean asymptomatic period, 11 26 of 32 (81%)
(1997) months; all but 6 required total unsuccessful
knee arthroplasty by 6 years

Core decompression Spontaneous Forst et al6 3 years No late stages 16 of 16 (100%)

(1998) successful

Total knee arthroplasty Atraumatic Seldes et al14 5.3 years 5 patients required revision (3, 26 of 31 (84%)
(1999) aseptic loosening; 2, sepsis) successful

Core decompression Atraumatic Mont et al12 7 years No late stages; 15 successful 72 of 91 (79%)
(2000) knees needed repeated surgery successful

Total knee arthroplasty Atraumatic, Mont et al13 9 years Improved results attributed to use 31 of 32 (97%)
spontaneous (2002) of cement in all patients and successful
stems as warranted

Iliac crest autograft Atraumatic Fukui et al7 6.6 years Young patient group with large 9 of 10 (90%)
with periosteum (2002) steroid-induced osteonecrotic successful
lesions

Fresh osteochondral Atraumatic Bugbee et al4 5.3 years Young patient group with large 17 of 18 (94%)
allograft (2004) steroid-induced osteonecrotic successful
lesions

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References
1. Aglietti P, Insall JN, Buzzi R. Idiopathic osteonecrosis of the knee.
Aetiology, prognosis and treatment. J Bone Joint Surg Br
1983;65:588-597.
2. Bayne O, Langer F, Pritzker KP, et al. Osteochondral allografts in the
treatment of osteonecrosis of the knee. Orthop Clin North Am
1985;16:727-740.
3. Bergman NR, Rand JA. Total knee arthroplasty in osteonecrosis.
Clin Orthop 1991;273:77-82.
4. Bugbee WD, Khadivi B, Jamali A. Fresh osteochondral allografting
in the treatment of osteonecrosis of the knee [paper No. 108]. Amer-
ican Academy of Orthopaedic Surgeons annual meeting; San Fran-
cisco, Calif; 2004.
5. Flynn JM, Springfield DS, Mankin HJ. Osteoarticular allografts to
treat distal femoral osteonecrosis. Clin Orthop 1994;303:38-43.
6. Forst J, Forst R, Heller KD, Adam G. Spontaneous osteonecrosis of
the femoral condyle: casual treatment by early core decompression.
Arch Orthop Trauma Surg 1998;117:18-22.
7. Fukui N, Kurosawa H, Kawakami A, et al. Iliac bone graft for
steroid-associated osteonecrosis of the femoral condyle. Clin Orthop
2002;401:185-193.
ch054-X3447.indd 537
Osteonecrosis of the Knee
7a. Gross AF, McKee NH, Pritzker KP, et al. Reconstruction of skeletal
deficits of the knee: a comprehensive osteochondral transplant
program. Clin Orthop 1983;174:96-106.
8. Jacobs MA, Loeb PE, Hungerford DS. Core decompression of the
distal femur for avascular necrosis of the knee. J Bone Joint Surg Br
1989;71:583-587.
9. Koshino T. The treatment of spontaneous osteonecrosis of the knee
by high tibial osteotomy with and without bone-grafting or drilling
of the lesion. J Bone Joint Surg Am 1982;64:47-58.
10. Marmor L. Unicompartmental arthroplasty for osteonecrosis of the
knee joint. Clin Orthop 1993;294:247-253.
11. Mont MA, Tomek IM, Hungerford DS. Core decompression for 54
avascular necrosis of the distal femur—long term followup. Clin
Orthop 1997;334:124-130.
12. Mont MA, Baumgarten KM, Rifai A, et al. Atraumatic osteonecrosis
of the knee. J Bone Joint Surg Am 2000;82:1279-1290.
13. Mont MA, Rifai A, Baumgarten KM, et al. Total knee arthroplasty
for osteonecrosis. J Bone Joint Surg Am 2002;84:599-603.
14. Seldes RM, Tan V, Duffy G, et al. Total knee arthroplasty for steroid-
induced osteonecrosis. J Arthroplasty 1999;14:533-537.
537
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