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Posterolateral Corner Injuries

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Posterolateral Corner Injuries

Comprehensive exam-ready guide to PLC injuries - dial test, arcuate sign, reconstruction techniques

complete
Updated: 2025-12-17
High Yield Overview

POSTEROLATERAL CORNER INJURIES

Dial Test | Arcuate Sign | Combined PCL | Reconstruction

16%Of knee ligament injuries
60-70%Associated with cruciates
DialKey diagnostic test
ReconstructDo not repair isolated

PLC STRUCTURES

FCL
PatternFibular collateral ligament
TreatmentPrimary varus restraint
Popliteus
PatternMuscle-tendon unit
TreatmentExternal rotation restraint
Popliteofibular
PatternLigament
TreatmentConnects popliteus to fibula
Arcuate Complex
PatternPosterolateral capsule
TreatmentStatic stabilizer

Critical Must-Knows

  • PLC = primary restraint to EXTERNAL ROTATION and VARUS
  • Dial test at 30 degrees only = isolated PLC. At 30 AND 90 degrees = combined PCL
  • Arcuate sign on X-ray = avulsion of PLC attachment to fibula
  • Missing PLC injury = ACL/PCL graft failure
  • Reconstruct rather than repair for best outcomes

Examiner's Pearls

  • "
    Varus thrust gait = chronic PLC deficiency
  • "
    Common peroneal nerve at risk (20%+ injuries)
  • "
    LaPrade anatomic reconstruction = gold standard
  • "
    Address varus alignment with osteotomy before/with PLC

Clinical Imaging

Imaging Gallery

(a) Magnetic resonance imaging (MRI; T2 weighted coronal image) showing the absence of the biceps femoris tendon (arrow head). (b) MRI (T2 weighted coronal image) showing the popliteus muscle tendon r
Click to expand
(a) Magnetic resonance imaging (MRI; T2 weighted coronal image) showing the absence of the biceps femoris tendon (arrow head). (b) MRI (T2 weighted coCredit: Oshima T et al. via Case Rep Orthop via Open-i (NIH) (Open Access (CC BY))
(a) There was evidence of contusion of the common peroneal nerve, and the patient underwent neurolysis (arrow head). (b) There were complete avulsions of the lateral collateral ligament (arrow), popli
Click to expand
(a) There was evidence of contusion of the common peroneal nerve, and the patient underwent neurolysis (arrow head). (b) There were complete avulsionsCredit: Oshima T et al. via Case Rep Orthop via Open-i (NIH) (Open Access (CC BY))
Anatomical single bundle anterior cruciate ligament reconstruction with the ipsilateral semitendinosus tendon was performed.
Click to expand
Anatomical single bundle anterior cruciate ligament reconstruction with the ipsilateral semitendinosus tendon was performed.Credit: Oshima T et al. via Case Rep Orthop via Open-i (NIH) (Open Access (CC BY))
At the final follow-up, 31 months after the injury, there was excellent knee range of motion (5°–0°–145°), stability of the knee, and muscle strength.
Click to expand
At the final follow-up, 31 months after the injury, there was excellent knee range of motion (5°–0°–145°), stability of the knee, and muscle strength.Credit: Oshima T et al. via Case Rep Orthop via Open-i (NIH) (Open Access (CC BY))

Critical Exam Concepts

Dial Test is KEY

Dial test at 30 and 90 degrees distinguishes isolated PLC (30 only) from combined PCL/PLC (30 and 90). Critical for surgical planning.

Commonly Missed

PLC injuries often missed. Always check with PCL and ACL injuries. Missing PLC leads to cruciate graft failure.

Peroneal Nerve

Common peroneal nerve injury in 20%+ of PLC injuries. Check foot drop, lateral leg sensation. Document preoperatively.

Reconstruct Not Repair

Reconstruction superior to repair. Isolated repairs have high failure rates. LaPrade anatomic reconstruction is gold standard.

Dial Test Interpretation

Finding30 Degrees90 DegreesDiagnosis
NormalSymmetricSymmetricNo injury
Isolated PLCGreater than 10 degree increaseSymmetricPLC injury only
Combined PCL/PLCGreater than 10 degree increaseGreater than 10 degree increasePCL + PLC injury
Mnemonic

FAPPLC Structures

F
FCL
Fibular collateral ligament (primary varus)
A
Arcuate complex
Posterolateral capsule
P
Popliteus complex
Popliteus tendon, popliteofibular ligament

Memory Hook:FAP structures form the PLC!

Mnemonic

VERSEPLC Function

V
Varus restraint
FCL is primary varus restraint
E
External rotation restraint
Popliteus controls ER
R
Recurvatum restraint
PLC resists hyperextension
S
Secondary ACL backup
Helps control anterior translation
E
Extension tightening
PLC tightens in extension

Memory Hook:The PLC controls VERSE directions of instability!

Mnemonic

DRIVEPLC Examination

D
Dial test
At 30 and 90 degrees
R
Reverse pivot shift
PLC-specific test
I
Instability varus
Test at 0 and 30 degrees
V
Varus thrust gait
Observe walking
E
External rotation recurvatum
Supine, lift great toe

Memory Hook:DRIVE through PLC examination!

Overview and Epidemiology

Commonly Missed Injury

PLC injuries are frequently missed on initial presentation. Have high index of suspicion with PCL and ACL injuries. Missing PLC leads to cruciate graft failure - must address all injured structures.

Epidemiology

  • 16% of knee ligament injuries
  • 60-70% with cruciate injury
  • Usually high-energy trauma
  • Sports: football, soccer, skiing
  • MVCs common cause

Mechanism

  • Varus force: Direct blow to medial knee
  • Hyperextension: With varus component
  • External rotation: On planted foot
  • Knee dislocation: Multiligament pattern
  • Contact sports: Direct lateral blow

Pathophysiology and Mechanisms

PLC Anatomy (LaPrade)

Fibular Collateral Ligament (FCL):

  • Origin: Lateral femoral epicondyle
  • Insertion: Lateral fibular head
  • Primary varus restraint

Popliteus Complex:

  • Popliteus tendon: Femoral origin, inserts on tibia
  • Popliteofibular ligament: Connects popliteus to fibula
  • Primary external rotation restraint

Posterolateral Capsule: Static stabilizer, arcuate ligament.

PLC Function

Primary restraints:

  • Varus angulation (FCL primary)
  • External rotation (popliteus primary)

Secondary restraints:

  • Posterior translation (at full extension)
  • Hyperextension (recurvatum)

PLC and PCL work together - PCL resists posterior translation, PLC resists rotation. Loss of one stresses the other.

Common Peroneal Nerve

Anatomy: Wraps around fibular neck. Very vulnerable.

Injury rate: 20%+ with PLC injuries.

Symptoms: Foot drop, numbness lateral leg/dorsum foot.

Always document neurological status preoperatively - medicolegal importance and affects prognosis.

Always Check Peroneal Nerve

Common peroneal nerve injury occurs in 20%+ of PLC injuries. Check ankle dorsiflexion and toe extension. Document sensation. Nerve injury affects rehabilitation and prognosis.

Classification Systems

PLC Injury Grading

GradeExternal RotationVarusImplication
ILess than 5 degree increaseMinimalSprain, intact structures
II5-10 degree increaseModeratePartial tear
IIIGreater than 10 degree increaseSignificantComplete rupture, surgery indicated

Grade based on dial test asymmetry compared to contralateral side.

Injury Pattern

Isolated PLC:

  • Dial test positive at 30 degrees only
  • Rare (under 30%)
  • Still usually needs reconstruction

Combined PCL/PLC:

  • Most common (50%+)
  • Dial test positive at 30 AND 90 degrees
  • Both need reconstruction

Combined ACL/PLC:

  • Also common
  • Must address PLC or ACL graft fails

Multiligament (dislocation): Check vascular injury, all ligaments.

Anatomic Classification

FCL injury: Primary varus laxity at 30 degrees.

Popliteus injury: External rotation laxity (dial test).

Combined: Usually both involved.

Avulsion: May be femoral or fibular. Arcuate sign = fibular.

MRI determines specific structures injured.

Clinical Assessment

History

  • Mechanism: Varus blow, hyperextension, MVA
  • Pain: Lateral and posterolateral knee
  • Instability: Varus, giving way
  • Gait: Varus thrust (chronic)
  • Nerve symptoms: Foot drop, numbness

Examination

  • Dial test: 30 and 90 degrees (KEY)
  • Varus stress: 0 and 30 degrees
  • External rotation recurvatum: Lift toe
  • Reverse pivot shift: Clunk on extension
  • Peroneal nerve: Motor and sensory

Dial Test Technique

Patient prone, knees flexed 30 degrees (then 90). Externally rotate both feet simultaneously. Compare tibial thigh angle. Greater than 10 degree asymmetry = positive. At 30 degrees only = isolated PLC. At 30 AND 90 = combined PCL.

Key Clinical Pearls

Varus thrust gait: Lateral thrust during stance phase. Indicates chronic PLC deficiency and significant laxity.

External rotation recurvatum test: Patient supine, lift great toe. Positive = tibia drops into hyperextension and external rotation.

Investigations

MRI Assessment

Sensitivity: Good for PLC but structures can be subtle.

Key structures:

  • FCL: Coronal images
  • Popliteus: Sagittal and coronal
  • Popliteofibular ligament: Often difficult to see
  • Arcuate complex: Posterolateral capsule

Associated injuries: Peroneal nerve edema, bone bruise, cruciate tears.

Plain Radiographs

Arcuate sign: Avulsion fracture of fibular styloid/head.

Pathognomonic for PLC injury.

Other findings:

  • Segond fracture (lateral tibial plateau)
  • Widened lateral joint space (varus stress)
  • Osteophytes (chronic)

Alignment: Assess for varus malalignment.

Stress Radiography

Varus stress views: Quantify lateral joint opening.

Useful for: Chronic cases, monitoring, research.

Compare to contralateral side for meaningful interpretation.

Arcuate Sign

Arcuate sign = avulsion fracture of fibular head/styloid on plain X-ray. Pathognomonic for PLC injury. Indicates avulsion of FCL and/or biceps femoris. Suspect multiligament injury.

Management Algorithm

📊 Management Algorithm
posterolateral corner injuries management algorithm
Click to expand
Management algorithm for posterolateral corner injuriesCredit: OrthoVellum

PLC Injury Management

Treatment Pathway

AcuteInitial Assessment

Document neurovascular status. MRI for full injury pattern. Assess alignment.

Grade I-IIMay Trial Conservative

Limited evidence. Bracing, rehabilitation. Monitor for progressive laxity.

Grade IIISurgical Reconstruction

Anatomic reconstruction preferred. Address all injured structures. Early surgery (within 3 weeks) if combined.

ChronicReconstruction with Alignment

Assess for varus thrust. May need HTO before or with PLC reconstruction.

LaPrade Anatomic Reconstruction

Gold standard technique.

Reconstructs:

  • FCL (allograft)
  • Popliteus tendon
  • Popliteofibular ligament

Key principles:

  • Anatomic tunnel placement
  • Appropriate tensioning
  • Address all structures

Superior outcomes to isolated repairs.

Combined PLC/Cruciate

With PCL:

  • Reconstruct both
  • Single or staged surgery
  • Acute (within 3 weeks) is preferred

With ACL:

  • Reconstruct both
  • PLC essential or ACL will fail

Timing: Early surgery prevents PLC contracture and improves outcomes.

Surgical Technique

Anatomic PLC Reconstruction

Graft: Achilles allograft with bone block, or split semitendinosus.

Tunnels:

  • Femoral: At FCL and popliteus origins (separate tunnels)
  • Fibular: At FCL insertion

Technique:

  • Reconstruct FCL from femur to fibula
  • Reconstruct popliteus and popliteofibular ligament
  • Graft crosses from fibula to tibial sulcus

Anatomic reconstruction restores both varus and rotational stability.

Why Reconstruction Preferred

Repair has high failure rate for isolated PLC injuries.

Reconstruction advantages:

  • More reliable outcomes
  • Addresses chronic attenuation
  • Anatomic restoration

Exception: Acute avulsion with good bone (can fix fragment).

Address Varus Alignment

Varus malalignment increases stress on PLC.

If significant varus present:

  • Opening wedge HTO (proximal tibia)
  • Correct to neutral or slight valgus
  • May stage before or perform with PLC

Without alignment correction, PLC reconstruction will fail.

Peroneal Nerve Protection

Common peroneal nerve at risk during PLC reconstruction. Meticulous dissection required. Identify and protect nerve throughout. May be scarred/displaced in chronic cases.

Complications

ComplicationCausePreventionManagement
Peroneal nerve injuryTraction, directIdentify and protectObservation, EMG, may recover
Residual laxityTechnical error, missed structureAnatomic reconstructionRevision
StiffnessScarring, immobilizationEarly ROMPhysiotherapy, MUA
FailureMissed varus alignmentCorrect alignmentHTO then revision

Peroneal Nerve Outcomes

Peroneal nerve injury occurs in 20%+ of PLC injuries. Complete lesions have poor recovery. Incomplete lesions may recover over 6-12 months. Consider nerve exploration/grafting if no recovery at 3-6 months.

Postoperative Care

PLC Reconstruction Rehabilitation

Week 0-2Protection

Brace locked in extension. Non-weight bearing. Avoid external rotation.

Week 2-6Early ROM

Progressive flexion. Partial weight bearing. Quad strengthening.

Week 6-12Progressive

Full ROM. Weight bearing progression. Closed chain exercises.

Month 3-6Strengthening

Sport-specific preparation. Pool running. Proprioception.

Month 6-9Return to Sport

Functional testing. Full sport when strength and stability restored.

Rehabilitation Cautions

Avoid external rotation stress early - this stresses the PLC reconstruction. Avoid varus stress. Progress slower if combined with other reconstructions.

Outcomes and Prognosis

Outcome Factors

Good outcomes: Anatomic reconstruction, early surgery, all structures addressed, alignment corrected.

Poor outcomes: Isolated repair, delayed surgery, missed varus alignment, incomplete reconstruction, peroneal nerve injury.

Long-Term

If untreated or undertreated: Progressive varus deformity, lateral compartment OA, cruciate graft failure.

If addressed appropriately: Good return to activity, stable knee, preserved function.

Evidence Base and Key Studies

LaPrade Anatomic Reconstruction

4
LaPrade RF et al. • JBJS Am (2004)
Key Findings:
  • Described anatomic reconstruction technique
  • Addresses FCL, popliteus, popliteofibular ligament
  • Biomechanically restores stability
  • Became gold standard technique
Clinical Implication: LaPrade reconstruction is the reference standard technique.
Limitation: Technique description, no long-term outcomes initially.

Repair vs Reconstruction

4
Stannard JP et al. • JBJS Am (2005)
Key Findings:
  • Compared repair vs reconstruction for PLC
  • Repair failure rate 37%
  • Reconstruction failure rate 9%
  • Reconstruction significantly superior
Clinical Implication: Reconstruction preferred over repair for PLC injuries.
Limitation: Retrospective comparison.

PLC with Cruciate Injuries

4
Levy BA et al. • JBJS Am (2010)
Key Findings:
  • PLC injuries commonly combined with cruciates
  • Missing PLC leads to cruciate graft failure
  • Must address all injured structures
  • Early surgery improves outcomes
Clinical Implication: Always assess for PLC with cruciate injuries.
Limitation: Observational study.

Timing of PLC Surgery

4
Geeslin AG, LaPrade RF • AJSM (2011)
Key Findings:
  • Early surgery (within 3 weeks) better outcomes
  • Delayed surgery = PLC contracture
  • Acute reconstruction superior to delayed
  • Combined injuries should be addressed early
Clinical Implication: Early surgery for acute PLC injuries is preferred.
Limitation: Retrospective, single center.

Varus Alignment and PLC

4
Arthur A et al. • AJSM (2007)
Key Findings:
  • Varus alignment predisposes to PLC failure
  • HTO before or with PLC reconstruction
  • Failure high without alignment correction
  • Assess mechanical axis in all PLC injuries
Clinical Implication: Address varus malalignment with PLC reconstruction.
Limitation: Small numbers.

Exam Viva Scenarios

Practice these scenarios to excel in your viva examination

VIVA SCENARIOStandard

Scenario 1: Acute Combined Injury

EXAMINER

"A 25-year-old motorcyclist presents after an MVC. He has a swollen knee. Posterior drawer shows Grade III laxity. Dial test shows 20 degrees increased external rotation at both 30 and 90 degrees compared to the opposite side. He has ankle dorsiflexion weakness. What is your assessment and management?"

EXCEPTIONAL ANSWER
This is a combined PCL and posterolateral corner injury based on the examination findings. The Grade III posterior drawer indicates complete PCL rupture. The dial test positive at both 30 and 90 degrees confirms combined PCL and PLC injury - if it were isolated PLC, the dial test would only be positive at 30 degrees because the intact PCL would prevent rotation at 90 degrees. The ankle dorsiflexion weakness indicates peroneal nerve injury, which occurs in 20%+ of PLC injuries. I would document a complete neurological examination. For imaging, I would obtain X-rays (looking for arcuate sign) and MRI to define all injured structures. Management would be surgical reconstruction of both PCL and PLC. I would aim for early surgery within 2-3 weeks to prevent PLC contracture. I would use the LaPrade anatomic reconstruction for the PLC (addressing FCL, popliteus, popliteofibular ligament) and PCL reconstruction. Both must be addressed or the other will fail. Postoperatively, structured rehabilitation protecting both reconstructions. I would counsel him about the peroneal nerve - incomplete injuries may recover over 6-12 months, but complete injuries have poor prognosis. I would consider EMG at 3-6 months if no recovery.
KEY POINTS TO SCORE
Combined PCL + PLC injury
Dial test interpretation critical
Peroneal nerve injury common
Early surgical reconstruction of both
LaPrade technique for PLC
COMMON TRAPS
✗Missing the PLC injury
✗Operating on PCL alone
✗Not documenting nerve status
✗Delaying surgery past 3 weeks
LIKELY FOLLOW-UPS
"What is the dial test interpretation?"
"What is the LaPrade technique?"
"What is the peroneal nerve prognosis?"
VIVA SCENARIOChallenging

Scenario 2: Chronic PLC with Varus Thrust

EXAMINER

"A 35-year-old presents with lateral knee instability for 2 years after a rugby injury. He walks with a noticeable varus thrust. Dial test shows 15 degrees increased external rotation at 30 degrees, symmetric at 90 degrees. X-rays show varus alignment (mechanical axis 5 degrees varus). What is your approach?"

EXCEPTIONAL ANSWER
This is chronic isolated PLC deficiency with varus malalignment. The dial test positive at 30 degrees only confirms isolated PLC injury (no PCL involvement). The varus thrust gait indicates significant functional disability from lateral instability. The 5-degree varus mechanical axis is an important finding. Management of chronic PLC deficiency with varus malalignment requires addressing both problems. If I reconstruct the PLC without correcting alignment, the reconstruction will fail due to increased lateral compartment loading. My surgical plan would be a two-stage or single-stage procedure depending on severity. For significant varus (5 degrees), I would perform an opening wedge high tibial osteotomy to correct alignment to neutral or slight valgus, then proceed with anatomic PLC reconstruction (LaPrade technique). This can be staged (HTO first, PLC 3-6 months later) or combined in a single surgery depending on preference and cartilage status. Without alignment correction, PLC reconstruction has a high failure rate. Postoperatively, he would need protected weight bearing for HTO healing, then progressive rehabilitation similar to isolated PLC reconstruction.
KEY POINTS TO SCORE
Chronic isolated PLC deficiency
Varus alignment must be corrected
HTO before or with PLC reconstruction
Failure without alignment correction
LaPrade technique for reconstruction
COMMON TRAPS
✗Reconstructing PLC without addressing varus
✗Missing the varus thrust significance
✗Attempting isolated repair
✗Not checking mechanical axis
LIKELY FOLLOW-UPS
"What HTO technique would you use?"
"Single-stage or staged approach?"
"What are outcomes of chronic PLC reconstruction?"
VIVA SCENARIOCritical

Scenario 3: Arcuate Sign

EXAMINER

"A 22-year-old presents after a knee hyperextension injury during soccer. X-ray shows a small avulsion fracture of the fibular head. He has tenderness posterolaterally. Dial test is positive at 30 degrees only. What is your management?"

EXCEPTIONAL ANSWER
The avulsion fracture from the fibular head is the arcuate sign, which is pathognomonic for posterolateral corner injury. This is an avulsion of the FCL and/or biceps femoris attachment. Given the mechanism (hyperextension) and arcuate sign, I must carefully exclude multiligament injury. I would perform a thorough examination for cruciate injuries (Lachman, pivot shift, posterior drawer). The dial test positive at 30 degrees only suggests isolated PLC injury, which is reassuring. I would obtain MRI to fully characterize the PLC injury and confirm no cruciate involvement. For management, this is an acute bony avulsion injury. If the bone fragment is adequate, I have the option of open reduction and internal fixation of the avulsion to restore the PLC attachment anatomically. This has potential advantages in the acute setting with healing bone. However, if the fragment is small or comminuted, I would proceed with anatomic reconstruction (LaPrade technique) rather than attempting repair of inadequate tissue. The evidence shows reconstruction is superior to soft tissue repair for PLC injuries. I would aim for surgery within 2-3 weeks to optimize outcomes. Postoperatively, standard PLC rehabilitation protocol.
KEY POINTS TO SCORE
Arcuate sign = pathognomonic PLC injury
Rule out multiligament injury
Acute avulsion may be fixed
Reconstruction if inadequate bone
Surgery within 2-3 weeks optimal
COMMON TRAPS
✗Missing the significance of arcuate sign
✗Not looking for associated injuries
✗Treating conservatively when surgery indicated
✗Attempting repair of inadequate tissue
LIKELY FOLLOW-UPS
"What is the arcuate sign anatomically?"
"When would you fix vs reconstruct?"
"What other injuries commonly associated?"

MCQ Practice Points

Dial Test Interpretation

Q: Dial test positive at 30 degrees only vs 30 and 90 degrees? A: 30 degrees only = isolated PLC. 30 and 90 degrees = combined PCL + PLC. At 90 degrees, intact PCL prevents external rotation.

Primary Function

Q: What are the primary functions of the PLC? A: Varus restraint (FCL primary) and external rotation restraint (popliteus primary). Also resists hyperextension.

Arcuate Sign

Q: What is the arcuate sign? A: Avulsion fracture of fibular head on X-ray. Pathognomonic for PLC injury. Indicates avulsion of FCL/biceps attachment.

Repair vs Reconstruction

Q: Why is reconstruction preferred over repair for PLC? A: Repair has 37% failure rate vs 9% for reconstruction. Reconstruction anatomically restores all structures.

Peroneal Nerve

Q: What nerve is at risk with PLC injuries? A: Common peroneal nerve - 20%+ injury rate. Check ankle dorsiflexion and lateral leg sensation. Document preoperatively.

Varus Alignment

Q: Why is varus alignment important in PLC injuries? A: Varus increases load on PLC. Must correct with HTO before or with reconstruction, or reconstruction will fail.

Australian Context

Clinical Practice

  • LaPrade technique widely adopted
  • Allograft availability variable
  • Sports medicine specialists manage
  • MRI readily available
  • Recognition improving

Funding and Access

  • Private insurance covers
  • Variable public wait times
  • Rehabilitation accessible
  • May need tertiary referral

Orthopaedic Exam Relevance

PLC injuries are high-yield viva topics. Know the dial test interpretation, arcuate sign significance, and why reconstruction is preferred. Be prepared to discuss combined injuries and the importance of addressing alignment.

POSTEROLATERAL CORNER INJURIES

High-Yield Exam Summary

PLC Structures (FAP)

  • •FCL: Primary varus restraint
  • •Arcuate complex: Posterolateral capsule
  • •Popliteus complex: External rotation restraint
  • •Popliteofibular ligament connects them

Dial Test Critical

  • •Test at 30 AND 90 degrees
  • •Positive at 30 only = isolated PLC
  • •Positive at 30 AND 90 = combined PCL + PLC
  • •Greater than 10 degree asymmetry = positive

Key Findings

  • •Arcuate sign: Fibular head avulsion = PLC
  • •Varus thrust gait: Chronic PLC deficiency
  • •Peroneal nerve injury: 20%+ cases
  • •Combined injuries most common

Treatment Principles

  • •Reconstruction superior to repair (37% vs 9% failure)
  • •LaPrade anatomic technique gold standard
  • •Early surgery (within 3 weeks) preferred
  • •Address varus alignment or reconstruction fails

Exam Pearls

  • •Commonly missed injury - high suspicion
  • •Always check with PCL and ACL injuries
  • •Document peroneal nerve status
  • •Early surgery prevents contracture
Quick Stats
Reading Time68 min
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