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ORIGINAL ARTICLE

Heterotopic Ossification And Functional Status Of The Hip Joint Following Total Hip Arthroplasty And Postoperative Prophylactic Irradiation

Dalia AM Ahmad, Chie-Hee Cho, Boris Pantchechnikov, Wolfgang Noack*, Volker Budach, Peter Wust, Reinhold Graf

Department of Radiation Oncology, Campus Virchow-Klinikum, Charité Universitätsmedizin Berlin, Berlin, Germany.

*Department of Orthopedics and Traumatology, Ev. Waldkrankenhaus Spandau, Berlin, Germany.

Address for Correspondence:
Dalia Abdel-Moaty Ahmad Khalil
Department of Radiation Oncology
Campus Virchow Klinikum
,
Charité Universitätsmedizin Berlin
,
Augustenburger Platz 1
,
13353 Berlin
, Germany.

Phone : +49-30-450-527-052, -021, +49-17687204998
Fax     :
+49-30-450-7527052
E-mail :
dalia.ahmad-khalil@charite.de

Abstract:

Background and purpose: Heterotopic ossification (HO) is one of the major complications following total hip arthroplasty (THA). The aim of this study is to evaluate HO and functional status (FS) of the hip joint 5 years after THA and prophylactic postoperative irradiation with a single dose of 7 Gy.

Methods: We analyzed a random sample of 100 patients 5 years after THA and postoperative radiotherapy with a single dose of 7 Gy. Brooker score (BS) was used to classify the radiographic signs of HO and Harris-Hip Score (HHS) to assess the FS of the hip joint. The range of motion was assessed in all directions and was measured in degrees.

Results: 51% of patients had radiographic evidence of HO; mean HHS 84.8 ± 16.5 points. Height (p = 0.025) and weight (p = 0.008) correlated positively with the extent of HO. Men developed significantly higher BS than women (p = 0.009). Duration of surgery correlated with HHS (p = 0.026).  In the category BS 0 vs. BS 1 for the range of motion in degrees, there were significant correlations for flexion (p = 0.05), adduction (p = 0.03) and sum of motions (p = 0.04) in favour of BS 0. In the category BS 0 vs. BS 1,2,3,4, there were significant correlations for flexion (p = 0.07), adduction (p = 0.05), and sum of motions (p = 0.05) in favour of BS 0. For the range of motion in points (HHS), no significant correlations with all categories of HO were found.

Conclusion: Mild HO of BS 1 can deteriorate the range of motion after THA significantly. The sum of motion in degrees has been proved a more sensitive tool for assessing the clinical outcome than the range of motion in points according to HHS or the total HHS.

J.Orthopaedics 2010;7(4)e12

Keywords:

 

Heterotopic Ossification; Total Hip Arthroplasty; Postoperative Prophylactic Irradiation.

Introduction:

Heterotopic ossification (HO) after total hip arthroplasty (THA) is a relatively common complication and can have an impact on the functional outcome, occurring in up to 60 to 90% of patients. The exact mechanism for heterotopic bone formation has not been thoroughly elucidated; however, it appears to involve pluripotent mesenchymal cell differentiation into osteoprogenitor cells after tissue injury or dissection. This process begins as soon as sixteen hours after injury and is maximal at thirty-six to forty-eight hours (1).

There are two primary methods of preventing HO: Radiotherapy, and pharmacotherapy with both selective COX-2 inhibitors and nonselective COX-1 and COX-2 inhibitors of non steroid anti-inflammatory drugs (NSAIDs) (2). Perioperative NSAIDs, apart from low dose aspirin, appear to produce between a one half and two thirds reduction in the risk of HO. With routine use, such agents may be able to prevent 15-20 cases of HO among every 100 THA performed (3).

More recently, a metaanalysis of 9 randomized controlled trials including 1295 patients reported no statistically significant or clinically important difference between NSAIDs or radiation in preventing HO (4).

There has been no randomized study comparing total hip replacement alone with or without irradiation. Nevertheless, the available data support the current standards including single-fraction treatment of 7 Gy given <4 h preoperatively or <72 h postoperatively for prophylaxis (5). Both RT concepts achieved a similar low radiologic and functional failure rate of about 10.9 % and 5%, respectively (6).

The mostly used radiographic classification for HO is the Brooker classification (7), based on radiographic findings of HO at the hip after THA, and includes four classes. According to Brooker Score (BS) the incidence of HO after THA and no prophylactic treatment is 43 % for any score and 9% for score III and IV, depending on risk factors (8). HO is typically asymptomatic and detected as an incidental finding on radiographs. BS I and II are considered clinically insignificant because symptoms rarely manifest with this extent of HO. BS III and IV are considered to be clinically significant because symptoms are typically present. In total, only a minority of patients with HO (10–30%) develop functional impairment (9). The large number of hip operations, however, leads to a significant number of patients with clinically significant symptoms (10). Higher grades of HO can result in significant limitation of function and can vitiate the benefits of joint replacement (11). The role of lower grades with respect to impairment of the range of motion is a matter of debate.

Materials and Methods:

Of all the patients who underwent THA in the Department of Orthopedics and Traumatology of Evangelical Waldkrankenhaus Spandau, Berlin, during a period of 12 months, 30% of patients received postoperative prophylactic hip irradiation. Out of these patients, and after 5 years from treatment, a random selection of 100 patients was done for evaluation of radiographic evidence of HO and FS of the hip joint. THA was performed in 34 males and 66 females, the mean age at time of surgery was 65.1± 8.1 years (range 47-82 years), and at time of evaluation 70.7± 8.2 years (range 55-88 years). Mean height was 167.8±8.8 cm (range 147-194 cm), mean weight 76.0±13.6 Kg (range 49-112 kg) (Table 1).

Surgery:

All patients were operated with THA in the Department of Orthopedics and Traumatology of the Evangelisches Waldkrankenhaus Spandau, Berlin, by the same team of surgeons. All prostheses were implanted for the first time; there was no replacement of preexisting prosthesis in any patient. The right joint was treated in 49% of patients and the left joint in 51% of patients. There was no previous surgery on the ipsilateral side in any patient. The femoral component of the prosthesis was cementless in 93% of patients and cemented in 7% of patients. The mean duration of surgery was 75.9±26.6 minutes (range 29-162 minutes) (Table 1).

Radiotherapy:

All the patients received radiotherapy in Department of Radiation Oncology, Campus Virchow Klinikum, Charite Universitätsmedizin Berlin. Radiotherapy was delivered in a single dose of 7 Gy delivered to the reference point International Commission on Radiation Units and Measurements Report 50 (12), with 18-20 MeV maximum photon energy by linear accelerators MevatronTM or Mevatron KD2TM (Siemens Medical Solutions, Erlangen, Germany). All patients underwent simulation, and two parallel-opposed fields (anteroposterior and posteroanterior) were used. According to patient body size, a portal of about 12 x 13 cm (± 1cm) using a curved block in the upper medial part for the inner pelvic region was chosen to enclose the periarticular soft tissue area, the acetabulum, and the proximal femur. Timing of radiotherapy after surgery varied among the patients with an average of 51±19.2 hours (range 3.5-82 hours) (Table 1).

Table 1: Patients’ characteristics.

Patients

Number = %

Mean ±SD

Range

Number of patients

Male
Female

Height (cm)

Weight (kg)

Age at surgery (years)

Age at evaluation (years)

100

34
66

 



 

167.8 (± 8.8)

76.0 (± 13.6)

65.1 (± 8.1)

 

70.7 (± 8.2)

 



 

147 – 194

49 – 112

47 - 82

 

53 - 88

Number of hips

Right hip
Left hip

100

49
51

 

 

The prosthesis:

Cementless
Cemented

 

93
7

 

 

Duration of surgery (minutes)

 

75.9 (± 26.6)

29 - 162

Interval radiation – surgery (hours)

 

51.0 (± 19.2)

3.5 - 82

 

Patient Evaluation:

All the patients were evaluated clinically and radiographically 5 years after treatment. The evaluation was done after patient’s informed consent. Both the investigators who evaluated the patients clinically and the investigators who made the radiographic evaluation were blinded to the results of each other’s evaluations.

Radiographic Assessment (Brooker Score):

Comparison of radiographs of the pelvis (anterior-posterior) and hip (anterior-posterior) after 5 years with those radiographs performed preoperatively and direct postoperatively was done. Analysis of radiographs was performed by three experts (two radiotherapists, one radiologist). The presence of HO was evaluated according to the four-grade classification described by Brooker et al. (7) (Table 2).

Table 2: Brooker grading system of heterotopic ossification

Score

Ossification visible on radiogram

0

No soft-tissue ossification

1

Separate small foci of ossification about the hip

2

Ossification projecting from the proximal femur or pelvis with ≥ 1 cm between opposing bone surfaces

3

Ossification projecting from the proximal femur or pelvis with < 1 cm between opposing bone surfaces

4

Ossification completely bridging the proximal femur and pelvis

Functional Outcome Assessment (Harris Hip Score):

Functional outcome was assessed with the modified Harris Hip Score (13) (Table 4). Assessment of this score based on 2 parts, a patient-based part (the subjective categories, pain and function), and an investigator-based part (physical examination categories, deformity and range of motions). Based on a total of 100 points possible, each of these four categories was awarded a certain number of points. Pain with a maximum of 44 points, function with 47 points, deformity with 4 points, and range of motions with 5 points were awarded. The score of 90-100 was reported as excellent functional results, 80-89 good, 70-79 fair, 60-69 poor, and below 60 failed.

Functional treatment results were defined as passive ROM of hip joint measured with a standard goniometer as described by Pohl (14).

Calculation of the Range of Motion:

We measured the range of motion in degrees in the four directions (hip flexion, extension, adduction, and abduction) and for the 2 rotations (internal rotation, external rotation), and then calculated the sum of the ranges of motions in degrees.

Correlation between radiographic finding (BS) and Functional outcome (HHS):

In order to find if the radiographic evidence of HO has an impact on functional outcome of the hip joint, we correlated the radiographic evidence of HO scored according to Brooker system with each category of functional outcome measured in points according to Harris Hip Score, and also with the range of motion measured in degrees.

Statistical Analysis:

The categorical variables were described with their absolute and relative values, and the continuous variables were defined with their mean ± standard deviation (SD), and range (minimum and maximum). Comparisons of frequencies of categorical variables were tested using Fisher’s exact test and chi-square analysis. Because of small sample size, the non-parametric Wilcoxon-Mann Whitney test was used for comparisons of the means of continuous variables. The confidence interval was set to 95% and the p-value to 0.05. The calculations were performed by using Statistical Package for Social Sciences (SPSS, Chicago, IL).

Results :

Radiographic outcome (Brooker Classification):

Fifty one patients (51%) had radiographic evidence of HO at 5 years. Thirty three patients (33%) had HO of Brooker’s grade 1, 9 patients (9%) grade 2, nine patients (9%) grade 3, while no patient developed grade 4 (Table 3).

Table 3: Distribution of Patients according to Brooker grading system.

Brooker Score

Number = %

(100)

Brooker score 0

49

Brooker score 1

33

Brooker score 2

9

Brooker score 3

9

Brooker score 4

0

Evaluating prognostic factors for HO development, patients with a body height >168 cm developed significantly more HO than patients ≤168cm (p = 0.025). Weight in the categories >75 kg and ≤75 kg also showed a positive correlation with HO of higher degree (p = 0.008). Men developed significantly more HO than women (p = 0.009). Duration of surgery in the categories >71 minutes and ≤71 minutes also showed a positive correlation with HO of higher degree (p = 0.02). The following factors were found not to correlate significantly with HO: Age, and interval between radiotherapy and surgery.

Functional outcome (HHS):

The clinical score according to modified HHS at 5 years was almost excellent for the vast majority of patients with an overall mean score of 84.8 ± 16.5 points (range 24.7-100 points). The subjective category of HHS pain was appraised as 36.2 ± 8.8 points (range 10-44 points), the subjective category function 39.7 ± 9.2 (range 6-47 points). The physical examination results of the range of motion component of HHS were rated as 4.9 ± 0.25 (range 2.6-5) (Table 4).

Table 4: Harris-Hip-Score of hip function. For comparison the results of our study are added. The postoperative values including mean (±SD) and range of values are given.

 

 

Points

Postoperative values

 

 

 

Mean ±SD (Range)

A. Pain

 

44

36.2 ± 8.8 (10-44)

 

None

44

 

 

Slight pain

40

 

 

Mild pain

30

 

 

Moderate pain

20

 

 

Marked pain

10

 

 

Totally disabled

0

 

B. Function

 

47

39.7 ± 9.2 (6-47)

 Limp

 

11

9.5 ± 2.8 (0-11)

 

None

11

 

 

Slight

8

 

 

Moderate

5

 

 

Severe

0

 

 Support

 

11

9.6 ± 2.8 (0-11)

 

None

11

 

 

Cane for long walks

7

 

 

Cane most of time

5

 

 

One crutch

3

 

 

Two canes

2

 

 

Two crutches

1

 

 Walking

 

11

8.8 ± 2.3 (2-11)

 

Unlimited

11

 

 

Six blocks

8

 

 

2-3 blocks

5

 

 

Indoors only

2

 

 

Bed and chair only

0

 

 Sitting

 

5

4.7 ± 1.1 (0-5)

 

Ordinary chair

5

 

 

High chair

3

 

 

Unable

0

 

 Transportation

 

1

0.9 ± 0.3 (0-1)

 

Yes

1

 

 

No

0

 

 Walking stairs

 

4

2.8 ± 1.2 (0-4)

 

Normally without using a railing

4

 

 

Normally using a railing

2

 

 

In any manner

1

 

 

Unable to do stairs

0

 

 Put on Shoes and Socks

 

4

3.2 ± 1.1 (0-4)

 

With ease

4

 

 

With difficulty

2

 

 

Unable

0

 

C. Absence of Deformity

 

4

n.e.††

 

Less than 30° fixed flexion contracture

1

 

 

Less than 10° fixed abduction

1

 

 

Less than 10° fixed internal rotation in extension

1

 

 

Limb length discrepancy less than 3.2 cm

1

 

D. Range of Motion

 

5

4.9 ± 0.3 (2.6-5)

 

Flexion (140°*)

1

 

 

Abduction (40°*)

1

 

 

Adduction (40°*)

1

 

 

External Rotation (40°*)

1

 

 

Internal Rotation (40°*)

1

 

Total hip score

 

100

84.8 ± 16.5 (24.7-100)

total points possible for category

††not evaluated

*normal

SD= standard deviation

Regarding prognostic factors for the postoperative functional outcome, patients with a duration of surgery of >71 minutes performed significantly worse in comparison to patients with a duration of ≤71 minutes (HHS 80.8 vs. 88.6, p = 0.026). The following factors were found not to correlate significantly with HHS: Age, gender, weight, height and interval between radiotherapy and surgery.

 

A prognostic factor for the range of motion component of HHS was weight: Those in the categories ≤75 kg and >75 kg showed a strong negative correlation with higher score (Score 4.95 for lower weight vs. 4.93 for higher weight, p = 0.001). Patients with a duration of surgery >71 minutes performed significantly worse in comparison to patients with a duration of ≤71 minutes (Score 4.89 vs. 4.99, p = 0.007). Male patients performed worse than female patients (p = 0.013). The following factors were found not to correlate significantly: Age, height and interval between radiotherapy and surgery.

 

Correlation between radiographic signs of HO (BS) and postoperative functional outcome (HHS):

The radiographic signs of HO graded with Brooker score was found not to be correlated with the functional outcome evaluated with HHS (p = 0.946).

Also for the range of motion in points (according HHS), there were no significant differences between all categories of HO graded with BS evaluated. For the subjective component of function as evaluated by HHS and subjective component pain according to HHS, there were no differences between all categories examined, nor could be found significant correlations for the total HHS score (Table 5).

Table 5: Correlation of mean range of motion and grade of heterotopic ossification (BS) in the categories 0 vs. 1 and 0 vs.1,2,3,4.

Category

BS 0 vs. BS 1

BS 0 vs. BS 1,2,3,4

 

BS 0

BS 1

p

BS 0

BS 1,2,3,4

p

Flexion

119.4

112.8

0.05

119.4

114.0

0.07

Extension

0.41

0.0

n.s.

0.41

0.0

n.s.

Internal rotation

24.0

22.0

n.s.

24.0

22.5

n.s.

Erternal rotation

29.2

29.7

n.s.

29.2

29.5

n.s.

Abduction

36.2

35.0

n.s.

36.2

35.2

n.s.

Adduction

24.0

21.5

0.03

24.0

22.1

0.05

Sum of motionsand rotations

233.2

221.0

0.04

233.2

223.1

0.05

Range of Motiont††

4.94

4.94

n.s.

4.94

4.95

n.s.

Function††

39.2

39.5

n.s.

39.2

40.1

n.s.

Pain††

35.8

35.7

n.s.

35.8

36.6

n.s.

Total††

83.9

83.9

n.s.

83.9

85.5

n.s.

degrees

†† points according HHS

n.s = no significance

 

Correlation between radiographic signs of HO (BS) and range of motion (in degrees):

By evaluating the postoperative results for the range of motion (in degrees) in the four directions and two rotations (flexion, extension, abduction, adduction, external rotation, internal rotation), there were significant correlations between radiographic signs of HO in categories BS 0 vs. BS 1, and flexion (119.4 vs. 112.8, respectively, p = 0.05), and also adduction (24 vs. 21.5, respectively, p = 0.03).

Furthermore we found significant correlations between radiographic signs of HO in categories BS 0 vs. BS 1,2,3,4 and flexion (119.4 vs. 114, respectively, p = 0.07), and also adduction (24 vs. 22.1, respectively, p = 0.05).

For the total sum of motions (in degrees) in the four directions and for rotations there were significant correlations with BS 0 vs. BS 1 (233.2 vs. 221.0, respectively, p = 0.04), and with BS 0 vs. 1,2,3,4 (233.2 vs. 223.1, respectively, p = 0.05) (Table 5).

Discussion :

Coventry and Scanlon (15) demonstrated that fractionated RT given postoperatively could successfully be used in the prevention of HO. As illuminated in a review by Balboni et al. (5), there was a substantial evolvement of irradiation for prevention of HO after THA since then. Pellegrini et al. (16) proved in a prospective randomized trial the efficacy of single-fraction irradiation (8 Gy vs. 5x2 Gy). Healy et al. (17) established the currently accepted dose of 7 Gy demonstrating significant worse results with 5.5 Gy. Seegenschmiedt et al. (18), in a randomized trial (with doses of different biological effectivness) and Gregoritch et al. (19), in a (small sample sized) randomized trial of 7-8 Gy launched the use of preoperative irradiation.

At present, doses of approximately 7 Gy are given, for prophylaxis of HO, mostly in one fraction and often preoperatively. Yet, there is some evidence that the application of preoperative application of RT for prevention of HO does not result in the same low overall incidence of HO according to BS of all grades. Koelbl et al. (20) found for preoperative irradiation, in comparison to a historical control group, a higher rate of mild (BS 1) HO. Gregoritch et al. (19) observed for preoperative (vs. postoperative) irradiation an increase percentage of mild and moderate HO. Seegenschmiedt et al. (18) observed in the preoperative (vs. postoperative) irradiated group more cases of mild HO and a higher rate of change of BS by (merely) one category towards a higher score.

The clinical significance of HO of mild (BS 1) or moderate (BS 2) grade is not established yet nor does a consensus exist in the literature. The knowledge of the correlation between HO of lower or medium grade with clinical outcome would facilitate the decision for or against the (risk-adapted) indication for prophylactic treatment and clinical parameters could support morphologic criteria to define the significance of HO in the context of controversial matters like pre- vs. post-operative application of irradiation, higher or lower doses or irradiation vs. NSAIDs. A number of studies have reported possible associations of even mild or moderate HO with decreased range of motion at the hip, an important observation considering the large number of patients treated annually.

In our study, the clinical examination measuring the range of motion (in degrees, for four directions and two rotations) and the sum of motions (in degrees) has proved helpful, clarifying the significance of differences, more than the range of motion in points (according HHS), the subjective component of motion or pain, or the range of motion in points (according to HHS). Neal outlined in a comprehensive review, that the clearest associations were the effects of HO on range of motion in degrees reflecting the greater sensitivity and precision than when compared to the cruder measures for overall function (21). For the postoperative range of motion in degrees, we found significant correlations in the categories BS 0 vs. BS 1 for flexion (p = 0.05) and for adduction (p = 0.03), in the categories BS 0 vs. BS 1,2,3,4 for flexion (p = 0.07) and for adduction (p = 0.05). There were no correlations in all other categories evaluated against another. For the sum of motions (in the four directions and two rotations) there were significant correlations for HO of BS 0 vs. 1 (p = 0.04) and BS 0 vs. 1,2,3,4 (p = 0.05) (Table 5).

For the postoperative range of motion (in points according to HHS), there we found no significant differences in all categories evaluated against another. The sum of the motions (in degrees) proved as valuable in different studies too, even if comparatively sparse data are available about BS grade 1 or 1,2 compared to no HO. Burd et al. (22) correlated in 166 patients with fracture of the acetabulum, the grade of HO with hip motion. HO of BS 1-3 did not decrease the range of motion of the hip except in flexion, where they found a significant relationship (p = 0.011) with the grade of HO, and even HO grade 1 was associated with a decreased amount of flexion. In the study by Effenberger et al. (23) the range of flexion was reduced in patients with HO of BS 2.

In our study, as well for the postoperative range of motion (according HHS in points, as evaluated by clinical examination) and the subjective components of function and pain according to HHS there were no differences between all categories of BS examined. Several studies approved that the HHS for BS 0, 1, 2 did not differ significantly from that for grades 3 and 4. Kienapfel et al. (24) showed in a study of 154 patients evaluated for correlation of radiologic and clinical failure, that there was no correlation between the BS and the clinically evaluated range of motions (according to HHS). The category of pain in HHS correlated significantly only with the range of motion parameters (p = 0.025), not with BS. Ashton et al. compared HHS with BS to give a functional assessment of overall hip function. The distribution of the several BS grades in the groups with HHS of >80 and <80 were not significantly different (25). Effenberger et al. (23) found in a review of 143 revision arthroplasties no correlation between pain score and BS (p = 0.755) (22). Grohs et al. (26) also found no correlation between the HHS and the BS. Fransen et al. (27) showed that patients with BS 3 and 4 had higher pain and disability scores than those with less severe grades of ectopic bone formation, though this trend was not significant. Yet, there are other studies claiming a correlation between BS and HHS. Seegenschmiedt et al. (6) published within the results of German patterns of care study that patients who developed a radiologic failure (especially with a high BS of 3–4), a higher functional failure rate was experienced.

In summary, the applied treatment scheme of irradiation with 7 Gy within 72 hours (3 days) after total hip joint replacement surgery proved successful with respect to the endpoints HO, functional status and range of motion. The overall incidence of any grade HO was low, both radiologically and clinically. We could confirm the significance of even mild HO (BS 1) with respect to deterioration of the range of motion of the hip. The sum of motion (in degrees) has been proved a more sensitive tool for assessing the clinical outcome than the range of motion (in points according HHS) or the total HHS.

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  24. Kienapfel H, Koller M, Wüst A, Sprey C, Merte H, Engenhart-Cabillic R, Griss P. Prevention of heterotopic bone formation after total hip arthroplasty: a prospective randomised study comparing postoperative radiation therapy with indomethacin medication. Arch Orthop Trauma Surg 1999;119:296-302.

  25. Ashton LA, Bruce W, Goldberg J, Walsh W. Prevention of heterotopic bone formation in high risk patients post-total hip arthroplasty. J Orthop Surg (Hong Kong) 2000;8:53-57.

  26. Grohs JG, Schmidt M, Wanivenhaus A. Selective COX-2 inhibitor versus indomethacin for the prevention of heterotopic ossification after hip replacement: a double-blind randomized trial of 100 patients with 1-year follow-up. Acta Orthop 2007;78:95-8.

  27. Fransen M, Anderson C, Douglas J, MacMahon S, Neal B, Norton R, Woodward M, Cameron ID, Crawford R, Lo SK, Tregonning G, Windolf M; HIPAID Collaborative Group. Safety and efficacy of routine postoperative ibuprofen for pain and disability related to ectopic bone formation after hip replacement surgery (HIPAID): randomized controlled trial. BMJ 2006;333:519.

This is a peer reviewed paper 

Please cite as: Dalia Abdel-Moaty Ahmad Khalil: Heterotopic Ossification And Functional Status Of The Hip Joint Following Total Hip Arthroplasty And Postoperative Prophylactic Irradiation.

J.Orthopaedics 2010;7(4)e12

URL: http://www.jortho.org/2010/7/4/e12

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