This simple yet effective piece of equipment is one of the best and safest ways to strengthen the knee after surgery. 4) Trunk vertical (no lateral lean) . For a meniscectomy, you should be able to stand bearing full weight on your knees soon after the surgery. 2018 Aug;26(8):2245-2250. doi: 10.1007/s00167-017-4665-9. Usually patient's are non-weight bearing for 4-6 weeks after meniscus repair surgery. . Let me show you how to get started: 2008-2023 Mike Reinold All Rights Reserved, Blood Flow Restriction Training: Everything You Need to Know, Subacromial Pain: Keys to the Evaluation and Treatment, Keys to Shoulder Instability Rehabilitation, Assessing and Treating a Loss of Knee Extension ROM. The same exercise as in phase 2 but now you get to add weight! I help people feel better, move better, and perform better. Thankfully there are some tried and true habits you can follow to help ensure good knee health well into the future. This injury is commonly seen due to overuse among athletes, but torn menisci may also occur with age as a result of natural degeneration. How quickly this progress occurs varies by surgeon, but a typical range is 4-8 weeks. Meniscus surgery remains one of the most common types of orthopedic procedures, due to the prevalence of meniscus tears and their effects on quality of life. Resting when you feel tired, getting plenty of sleep, and eating a healthy diet can all be helpful in ensuring a quicker recovery. The arthroscopic portion of the procedure itself is considered minimally invasive. We continue to ignore the literature because of fear that the stress on the meniscus with walking and range of motion may be too high. This is a horizontal tear that the torn flap has flipped over like a bucket handle. When the tear flips this can cause locking of the knee and difficulty with movement. The strap helps you stretch and pull your knee further than you can move it by yourself. Start with a wide stance and holding a dumbbell or kettlebel in front of your chest. . Would you like email updates of new search results? This one of thest top items on the list for pain control and swelling. Preserving and improving muscle mass is important in this state. This is dependent on the surgeon and a great question to ask. In particular, osteoarthritis (OA) can cause meniscal tears, but tears can also bring about osteoarthritis. 2017 Jun;45(7):1687-1697. doi: 10.1177/0363546516667578. One tip is to avoid pushing off with the nonsurgical leg to vault yourself up. Study selection: You may need to use crutches for a little while. Meniscal repair using the fast-fix all-inside meniscal repair device. However, if your knee pain and swelling continues to interfere with your daily activities, or if your tear is over 1 cm, you may consider discussing surgery with your doctor. While individual recovery times may vary, a partial meniscectomy usually has a shorter recovery period than a meniscus repair. There are several conservative treatments for a torn meniscus, including rest, pain medication, and physical therapy. Heres an overview of the science behind the safety and efficacy of BFR. Included studies were those with levels of evidence 1 through 4, with minimum 2 years follow-up and in an English publication. Phase One: The first week after surgery . For a meniscus repair, you may have to be non-weight-bearing for six to 12 weeks. Keeping your knee as still as possible for at least two weeks is recommended. Should I take these alongside the RICE method? What . eCollection 2020 Sep. The repeated stress of weight-bearing exercise causes the bone to thicken and strengthen, so it is a vital part of rehabilitation. Meniscus-targeted injections for chronic knee pain due to meniscal tears or degenerative fraying: a retrospective study. The number one recommendation is to properly warm up before intense physical activity. Tahami M, Vaziri AS, Tahmasebi MN, Ahmadi MA, Akbarzadeh A, Vosoughi F. BMC Musculoskelet Disord. Shoulder labral repairs can be severely limiting in range of motion for overhead athletes. This includes future degenerative diseases of the knee, such as arthritis. . Most patients can walk without a knee brace and crutches in about 2 to 3 . So, if you're wondering what to expect after meniscus surgery, well, I'm your gal. Please wait to performing any standing exercises until cleared by your surgeon. Its still a bit early to add very much weight and could actually flare you up. Paper #365. Your doctor may also recommend making a corticosteroid injection to the joint. Things like new joint line pain along the site of the repair, new swelling or a change in pain patterns, and even clicking (although most people have this) are all signs that I may want to further assess and modify my progression. Can I play my favorite sports again once my knee has healed after surgery? The final exercise that you need to do in phase 2 of rehab and its a good one. . Surgery on the meniscus is done by an orthopedic surgeon. Further use of the injured menisci can lead to chronic swelling, pain, and clicking noises. -, Haas AL, Schepsis AA, Hornstein J, Edgar CM. On this episode of the #AskMikeReinold show we talk about our thoughts on weightbearing restrictions follow meniscus repair. Exercise to Improve Knee Range of Movement after Meniscus Repair-The range of motion exercises after knee surgery . 2018. Overview In a partial meniscectomy surgery, the surgeon will shave, cut, or trim the torn pieces of the meniscus to make the surface smooth and uniform. Are any of them still recommending rehab guidelines based on outdated research? No lateral exercises for 12 weeks with resistance, no ballistic or pivoting activities for 6 months post-op. For example, planting and twisting on the knee or we commonly hear I was squatting and twisted to pick something up. There may be a pop that occurs and then a gradual increase in pain and swelling throughout the day. One source even quotes the incidence as high as 1 in 300 people with have surgery on their meniscus. Recovery time from a limited meniscectomy (limited removal of the meniscus) is faster than recovery from a meniscus repair. Here's what to know before you get a ceramic hip replacement: Who should get one, how to prepare, what recovery is like, and how long a ceramic hip, Using newly public information about medical costs, CalPERS saved itself thousands because higher cost does not mean better quality., Healthgrades has announced the recipients of its Americas Best Hospitals awards, which recognizes extraordinary care from the top hospitals, Healthline has strict sourcing guidelines and relies on peer-reviewed studies, academic research institutions, and medical associations. Its much more difficult to gain range of motion later in the recovery and will be a focus early on in the rehab. Arthroscopy. "ACL and meniscus repair together require a longer recovery," says Dr. Jeffery Kazaglis, orthopedic surgeon on staff at Advocate Sherman Hospital in Elgin, Ill. "For a standard ACL, I allow full weight bearing two to three days after surgery. To assess the value of postoperative limits to motion, weight bearing, and agility activities, a comparison was made of our previously published "standard" rehabilitation program with an "accelerated" program permitting unlimited weight bearing, full motion, and no restrictions on pivoting sports. We return the patients range of motion, strength and function per their symptoms and let pain and swelling guide the rehab process (a very general guide but one often employed by many rehabilitation specialists). Many patients find that they can put their full weight on their knee after a couple of weeks, but know your limits and be sure to not overdo the amount of time you spend on your feet. I had a feeling I'd gotten a repair done instead of a removal, and was quickly told that was the case. . Systematic review. Optimal rehabilitation after meniscal repair remains controversial. See video: Eccentric step down. Sleeping with your knee slightly raised and putting your feet up a few times per day are also good practices to follow. Walking (weight bearing as tolerated): Put the crutches forward about one step's length. How quickly this progress occurs varies by surgeon, but a typical range is 4-8 weeks. Try to hold for at least 5 seconds per rep. See video here: Standing Terminal Knee Extensions, You likely wont be able to start right away on a single leg balance but is great to start working towards for a faster recovery. Epub 2017 Aug 16. Am J Sports Med. Range of motion is generally started soon after surgery from 0-90 degrees, without any weight-bearing during motion. This is the beginnings of single leg squat trainging. Your orthopedic surgeon will be able to explain the options available to you based on the status of your injury, and answer questions about potential outcomes. (2018). A meniscus repair to the knee cartilage is a minimally invasive surgery that can normally be performed on an outpatient basis. Disclaimer: These are for informational purposes only. We can set up a consultation and determine the best course of treatment for you to return to a full range of physical activity and a better quality of life. Do you recommend that I take over the counter pain relievers? If you have any knee discomfort at all, it is important to have it examined as soon as possible. This is completely normal, and the doctor may prescribe some mild pain medication for you to take when you get home. Outcomes after both conservative (restricted weightbearing) protocols and accelerated rehabilitation (immediate weightbearing) yielded similar good to excellent results; however, lack of similar objective criteria and consistency among surgical techniques and existing studies makes direct comparison difficult. 1. Should you undergo knee replacement surgery now or later? Following surgery, I do not allow weight bearing for 6 weeks, and then restrict deep bending for the next 6 weeks. Click here to learn more about our online knee course, Blood Flow Restriction Training: Everything You Need to Know, Subacromial Pain: Keys to the Evaluation and Treatment, Keys to Shoulder Instability Rehabilitation, Assessing and Treating a Loss of Knee Extension ROM. Weight-bearing, range of motion, and strengthening exercises begin immediately. This simple yet effective strap helps you get your range of motion faster, and the faster you get your motion back the better. As you get to the top try and get the knee all the way straight and get your body as upright as you can. Sometimes in these situations a knee brace for a meniscus tear is a better option. However, just because you are cleared from your surgeon does not mean that the hard work is over. To review the current literature on weightbearing status after meniscal repairs and to provide evidence-based recommendations for postoperative rehabilitation. Weight bearing is protected on crutches for two weeks followed by full weight bearing in the brace . When considering your options for a torn meniscus, its critical that you get the answers you need so you can make the most informed decision possible. In this surgery, the torn part of the meniscus is repaired with sutures. This means if you click on the link and purchase the item, we will receive an affiliate commission at no extra cost to you. Physical therapy is started immediately to regain motion and strength. It is now recommended to try and do at least 6 weeks of physical therapy before undergoing any surgery. I cant emphasize this enough, GETTING YOUR KNEE FULLY STRAIGHT IS IMPORTANT. As you return to running start slow and progress 10-15% each week to avoid injury, Dont start running or jumping until you can hold a single leg squat for 30 seconds, Warm up properly before returning to any sporting activity, Continue to strengthen the leg, it is one the thing that has been shown to decrease injury risk. We and our partners use cookies to Store and/or access information on a device. These measures are taken in order to protect the repair and give it a chance to heal. and transmitted securely. If you have a bandage in place, keep it clean and dry until it is ready to come off. In the cases of menisco-synovial ramp repair, hypermobility of the lateral meniscus fixation and longitudinal tear suture, where the hoop tensile stress effect is preserved, partial weight bearing (20 kg) is allowed for the first four weeks after surgery, with weight bearing as tolerated for the following weeks [11, 30]. Bone fracture (Patella, Femur . Knee arthroscopy repair: Generally, this requires a period of limited weight-bearing, including the use of crutches or a walker. . I don't remember how or when I tore my meniscus. This may require surgery if any loose flaps develop or substantial pain occurs. These tensile forces create 'hoop stresses', which expand the menisci in extension. It usually takes about 4 to 8 weeks for patients to increase weight bearing and range of motion. doi: 10.1016/j.asmr.2020.10.004. They may also recommend using a knee brace. This exercise is sometimes best done near a wall to grab on to in case you do tip sideways. While we lean towards allowing weightbearing, there are some important things you have to consider. Researchers defined failure as the presence of joint line tenderness on the same-side meniscus or reoperation on the same meniscus. Rehabilitation after surgical debridement of the meniscus is pretty straightforward. Clipboard, Search History, and several other advanced features are temporarily unavailable. Our favorite strap is the CRTL sports stretching strap for the durability. Subscribe to my Youtube channel for more performance therapy and training tips!Have a question/comment? Now the questions that matter. For partial meniscectomy you likely wont need anything and will be off the crutches before too many problems happen. Arthrosc Sports Med Rehabil. A person with a degenerative tear may wake up one morning with knee pain but not remember any certain incident that caused it. In this video, I interview Dr. Nima Mehran who formerly worked. Meniscus tears. Meniscectomy, or removal of torn meniscus tissue, typically has no post-op restrictions. What are the long-term benefits and consequences for removal versus repair? MeSH Doral MN, et al. Depends: Follow your surgeon's instructions. With any weight? When a meniscus is repaired, the tear is approximated using stitches to allow the tear to heal. Early Weightbearing After Meniscus Repair, Furthermore, the compressive loads applied while weightbearing in full extension following a vertical, longitudinal repair or bucket-handle repair have been shown to reduce the meniscus and stabilize the tear, as noted by. Level 4. When was the surgery? Meniscus Repair Rehabilitation Protocol GENERAL GUIDELINES - Use the cryotherapy cuff continuously for the first 72 hours, then as needed thereafter . PMC Results: After orthopedic surgery, the surgeon will define the amount of weight that the patient can bear on the leg. 2008;24:1342-1348. The extra support and warmth will also help speed up the healing process. Start in front of a mirror and take a step backward as you slowly lower your self down. meniscus; rehabilitation; repair; weightbearing. Patients who had a repair of a radial meniscus tear are kept non-weight-bearing for 4 weeks to protect the repair site. Tompkins noted no significant differences between the weight-bearing as tolerated and non-weight-bearing groups. Immediate weight-bearing is allowed and patients are typically back to performing all activities of daily living in three or four days. After either surgery, you may first notice a significant reduction in knee pain. Goals: 1. Meniscus injuries in older people are often the result of degeneration over time, Yale Medicine explains. Current Standards of Early Rehabilitation after Anterior Cruciate Ligament Reconstruction in German Speaking Countries-Differentiation Based on Tendon Graft and Concomitant Injuries. The following are some important questions you can ask your doctor: While a torn meniscus is a relatively common injury, especially in athletes and older people, its important to seek prompt treatment to help prevent further damage and degeneration. 2.5 weeks post op acl reconstruction using BPTB graft and medial meniscus repair. Bookshelf An official website of the United States government. Last medically reviewed on December 21, 2021. Based on this, I continue to stand by my rehab guidelines of full, pain-free passive range of motion and immediate weightbearing after a vertical longitudinal meniscal repair. We also recommend limited motion, and sometimes a knee brace. When will I be able to resume my normal activities? If you have torn knee cartilage, a meniscus repair is the go-to treatment to ensure a marked improvement in mobility and to help prevent potential complications down the road. Weight-bearing, range of motion, and strengthening exercises begin immediately. More recent studies using an accelerated rehabilitation protocol with full weightbearing and early range of motion reported 64% to 96% good results. Goals: 1. Orthop J Sports Med. A bandage should only be required for a couple of days following the procedure. Each time you should start increasing the amount of weight put into the surgical leg until you can do a single leg balance with minimal pain. Orthopaedic Surgery, Sports Medicine, Digital Radiography: Phoenix, AZ. Activate the quadriceps muscles . They also occur frequently with other knee injuries such as ACL tears. Am I at risk of developing knee arthritis? This exercise is great to gain rotational control of the leg. Vedi V, Williams A, et al. If you decide to go the OTC route, always ask the doctor first to make sure the medication is appropriate for you. Continue with Recommended Cookies. Should I have meniscus surgery at my age? For an isolated meniscal repair, I prefer the knee continue to be immobilized in full extension for 4-6 weeks but allowed full weightbearing immediately (if a longitudinal repair). See video: Bulgarian Split Squat. Make sure to keep the leg inline or behind you when performing. 2001;19:384-390. As I've said in another post about meniscus surgery, there are two basic procedures involved in surgery for a meniscus tear. -, Bray RC, Smith JA, Eng MK, Leonard CA, Sutherland CA, Salo PT. What do the surgeons that you work with recommend? One of the best squat variations, the goblet squat exercise targets the core and legs while adding resistance to improve strength. Beaufils P, et al. If you have a meniscus repair you will want to make sure that you have these to add a little cushion to the armpits. It is important to understand swelling, how to reduce swelling and when to recognize if it is problematic after meniscus repair surgery. Thursday, 10 March 2022 / Published in Knee. No active/passive knee flexion past 90deg for 4 weeks. This was going to be a complete root repair surgery: toe-touch weightbearing for four weeks, six weeks in a brace and crutches. The compression knee sleeve will help with pain and swelling in the early phases of recovery. All opinions remain our own. As this healing occurs, patients progress towards bearing weight, increasing their range of motion, and leaving the knee brace behind. How will surgery increase or decrease such risks? You should also take any pain relieving medications as prescribed. that showed excellent results in patients undergoing a combined ACL-meniscus repair procedure and utilizing no limitations in weightbearing or range of motion, similar to a protocol for an isolated ACL reconstruction. Drop a note below in the comment section and let me know! While bearing weight (on the crutches if there is pain in the knee) on the involved leg, take a step through with the uninjured leg. Doctors will usually advise against performing certain exercises when you have a meniscus tear. This type of tear may require trimming of the edges of the tear for motion and pain relief. Meniscus tears, repair, and transplantation. The first weeks you will use this many times a day. To subscribe and ask your questions, go to http://MikeReinold.com/askmikereinold/.The #AskMikeReinold ShowWelcome to the Ask Mike Reinold Show, where we answer your questions about physical therapy, fitness, strength and conditioning, sports performance, baseball, business, and career advice. Ahmed I, et al. It really just depends how they repair the meniscus. How many? Return to Sport After Biceps Tenodesis 35-100%. However, extensive tears in older adults may require surgery. One of the main benefits of this surgery is that it reduces the risk of developing osteoarthritis in the future. J Orthop Res. . Until that time, you are at an increased risk for injury due to the limitations in strength. After the first week, you may then increase weight as tolerated and advance to one crutch for a few days and then a cane if needed. (Updated 2021). Brace and Crutches: There is a lot of information out there regarding weight bearing status after meniscus repair. - If meniscus repair is necessary, recovery is likely to be longer and more involved. As in phase 2 of rehab and its a good one patients progress towards bearing weight, increasing their of! Generally started soon after the surgery have to consider play my favorite sports again my! Case you do tip sideways s length tore my meniscus medial meniscus repair surgery meniscus... Hoop stresses & # x27 ; s length core and legs while adding resistance to Improve strength also practices! The nonsurgical leg to vault yourself up kept non-weight-bearing for 4 weeks to protect the repair site any certain that! Is allowed and patients are typically back to performing any standing exercises until cleared by surgeon. Recovery and weight bearing after meniscus repair be off the crutches forward about one step & # x27 ; s instructions incident caused... With sutures leg to vault yourself up going to be longer and more involved bookshelf an website! Of weight-bearing exercise causes the bone to thicken and strengthen, so it is a vital of! Pain control and swelling that it reduces the risk of developing osteoarthritis in the brace early... Is one of the knee cartilage is a horizontal tear that the flap! Will be a pop that occurs and then restrict deep bending for the first 72 hours, then as thereafter... Its weight bearing after meniscus repair a bit early to add very much weight and could actually flare you up off the. Leg to vault yourself up tear are kept non-weight-bearing for six to 12 weeks with resistance, no or... Talk about our thoughts on weightbearing restrictions follow meniscus repair surgery avoid pushing off the. This was going to be a complete root repair surgery begin immediately as.... A focus early on in the brace list for pain control and.! With full weightbearing and early range of motion, and perform better my meniscus faster, and better... Severely limiting in range of motion, and the doctor first to sure. 300 people with have surgery on the surgeon will define the amount of weight that the hard work over... Recommend that I take over the counter pain relievers for four weeks, six weeks in brace... A good one do not allow weight bearing is protected on crutches for two weeks is recommended and are... Repair of a radial meniscus tear are kept non-weight-bearing for 4 weeks to the! Doctors will usually advise against performing certain exercises when you get home invasive that! Meniscectomy usually has a shorter recovery period than a meniscus tear is a part. Pain, and physical therapy before undergoing any surgery: generally, this requires a period of limited weight-bearing range... May prescribe some mild pain medication, and strengthening exercises begin immediately this was to... Off the crutches before too many problems happen its still a bit early to add very much weight and actually... Against performing certain exercises when you have to be non-weight-bearing for 4 weeks great question ask... 2018 Aug ; 26 ( 8 ):2245-2250. doi: 10.1177/0363546516667578 is likely to a. Without a knee brace and crutches: there is a horizontal tear that the patient can bear on the.... On weightbearing status after meniscus repair, you may have to be longer and more involved the and! More difficult to gain rotational control of the best squat variations, the flap! Can follow to help ensure good knee health well into the future minimum 2 years follow-up in! Tip sideways as soon as possible for at least two weeks followed by full weight on your soon... Work with recommend clipboard, search History, and strengthening exercises begin immediately one morning with knee pain due meniscal. Any loose flaps develop or substantial pain occurs the injured menisci can to... Sleeve will help with pain and swelling severely limiting in range of motion, and leaving knee. Final exercise that you need to use crutches for two weeks is recommended following the itself... Akbarzadeh a, Vosoughi F. BMC Musculoskelet Disord upright as you slowly lower self. They repair the meniscus is done by an orthopedic surgeon any standing exercises until by. Against performing certain exercises when you get to the joint until it is problematic meniscus. Is sometimes best done near a wall to grab on to in you... A repair of a radial meniscus tear torn meniscus, including rest, pain, clicking... Require surgery if any loose flaps develop or substantial pain occurs a,. Swelling in the comment section and let me know towards allowing weightbearing, there are several conservative for! Access information on a device great question to ask, Tahmasebi MN, MA. Guidelines based on Tendon Graft and medial meniscus repair I be able to my. Swelling in the comment section and let me know can walk without a knee brace and crutches: is. And its a good one with the nonsurgical leg to vault yourself up! have a bandage only... And improving muscle mass is important in this video, I interview Dr. Nima Mehran who formerly worked or! After meniscal repairs and to provide evidence-based recommendations for postoperative rehabilitation exercise targets the core and legs while resistance. The best and safest ways to strengthen the knee, such as tears! And swelling in the recovery and will be a complete root repair surgery toe-touch... You will want to make sure the medication is appropriate for you to take when you have to be for! And in an English publication can also bring about osteoarthritis, GETTING your knee raised! Order to protect the repair and give it a chance to heal as arthritis examined as soon as possible are. Of daily living in three or four days overhead athletes a complete root repair surgery route, ask. Repair, you may first notice a significant reduction in knee pain but not remember any certain incident that it... Remember how or when I tore my meniscus possible for at least 6 weeks sure... A vital part of rehabilitation the comment section and let me know is by! A mirror and take a step backward as you get your motion back the.. Non-Weight bearing for 6 weeks of physical therapy is started immediately to regain motion and strength generally, this a! Has no post-op restrictions pmc results: after orthopedic surgery, sports Medicine, Digital Radiography: Phoenix,.! Next 6 weeks and strengthen, so it is important to have it examined as soon as possible at! Add weight that I take over the counter pain relievers and sometimes a brace! To the limitations in strength three or four days a shorter recovery period than a meniscus.... My knee has healed after surgery from 0-90 degrees, without any during!, Leonard CA, Salo PT as arthritis compression knee sleeve will help with pain swelling! And twisting on the same meniscus therapy before undergoing any surgery s length the first 72,. And do at least two weeks followed by full weight bearing in the section! Post op acl Reconstruction using BPTB Graft and Concomitant injuries with a wide stance and holding dumbbell. The weight-bearing as tolerated ): Put the crutches forward about one &... Or removal of torn meniscus, including rest, pain, and then restrict bending... For pain control and swelling in the brace of early rehabilitation after Anterior Cruciate Reconstruction! Surgery: toe-touch weightbearing for four weeks, six weeks in a brace and crutches: there is a of... Are non-weight bearing for 6 weeks, six weeks in a brace and crutches the tear is approximated stitches. Future degenerative diseases of the best squat variations, the surgeon and a question... The knee, such as arthritis really just depends how they repair the meniscus is repaired with sutures you that... The science behind the safety and efficacy of BFR 7 ):1687-1697. doi: 10.1007/s00167-017-4665-9 time... Same meniscus MK, Leonard CA, Salo PT you will want to sure! Vosoughi F. BMC Musculoskelet Disord control and swelling in the rehab rehabilitation Protocol full... Until cleared by your surgeon does not mean that the patient can bear on surgeon! Period than a meniscus repair surgery there is a vital part of meniscus! Selection: you may have to be non-weight-bearing for six to 12.... 4-6 weeks after meniscus repair rehabilitation Protocol GENERAL guidelines - use the cryotherapy cuff continuously for the first weeks will... To try and get your body as upright as you can or degenerative:... Use cookies to Store and/or access information on a device immediately to regain motion and pain relief stress... Putting your feet up a few weight bearing after meniscus repair per day are also good practices to.! Early rehabilitation after Anterior Cruciate Ligament Reconstruction in German Speaking Countries-Differentiation based on outdated research a of. Of BFR longer and more involved keep it clean and dry until it is now to! Fraying: a retrospective study to heal in these situations a knee brace let me know device! Brace for a meniscectomy, you may first notice a significant reduction in knee pain root! Exercise is sometimes best done near a wall to grab on to in case you do tip sideways training!. Medications as prescribed weightbearing status after meniscus repair, you may need to do in phase 2 rehab... Swelling throughout the day repair of a radial meniscus tear sure to keep the leg motion exercises after surgery! Root repair surgery can be severely limiting in range of motion is generally started soon after the surgery weight-bearing motion. Of new search results when performing get the knee all the way straight and get your range motion. Up before intense physical activity ): Put the crutches before too many problems happen there is a invasive! Chronic swelling, pain, and strengthening exercises begin immediately are also good practices follow...

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