When bone tissue dies as a result of a lack of blood supply, the condition is referred to as avascular necrosis, also known as osteonecrosis. This may result in minor bone cracks and eventual bone collapse. AVN of the shoulder, although less common than AVN of the hip, is a significant concern due to its debilitating effects on shoulder function. Affected individuals can experience pain and limited mobility, making daily tasks challenging and affecting overall well-being.

The orthopedic field continuously researches new methods and techniques to address AVN, making it a constantly evolving and critical area of study.

This introduction aims to provide readers with a clear understanding of AVN’s nature and its specific manifestation in the shoulder joint. By emphasizing its significance in orthopedics, it sets the stage for the subsequent sections that delve deeper into the condition’s intricacies.

Causes of shoulder AVN

Causes of shoulder AVN

1. Trauma

Fractures or Dislocations of the Shoulder: The shoulder joint is primarily supplied by the anterior and posterior circumflex humeral arteries. A traumatic event, like a fracture or dislocation, can cause a direct disruption to these blood vessels. Additionally, the subsequent swelling from the trauma can compress vessels, further reducing blood flow. This disruption can lead to a decrease in oxygen and essential nutrients needed for bone cells, initiating the process of necrosis resulting in AVN of humeral head (1).

2. Steroids

Long-term or High-dose Use of Corticosteroids: Corticosteroids, when used in large doses or for extended periods, can have several effects that culminate in AVN. They can:

Alter Fat Metabolism: This leads to fat deposits in and around blood vessels, including those supplying the humeral head. These deposits can narrow the vessels, reducing blood flow to the bone (2).

Affect Blood Clotting: Corticosteroids can increase the risk of thrombus (blood clot) formation. If a clot forms in a vessel supplying the shoulder joint, it can lead to an interruption in blood flow (4).

Directly Impact Bone Cells: Prolonged exposure to steroids can reduce the viability and function of osteoblasts (bone-forming cells) and increase the activity of osteoclasts (bone-resorbing cells), making bones more fragile.

Read More: Why Do Some Lung Cancer Patients Experience Shoulder Pain

3. Alcohol

Excessive Alcohol Consumption: Chronic heavy drinking can lead to multiple problems associated with AVN:

  • Bone Metabolism Alteration: It also has a toxic effect on bone marrow, leading to decreased bone production and increased bone resorption (5).
  • Impact on Blood Clotting: Alcohol can change the balance of clotting factors, potentially leading to clot formation.
  • Fatty Deposits in Blood Vessels: Chronic alcohol use can disrupt fat metabolism, causing fatty streaks or plaques in arteries, which can narrow or occlude them.

4. Other Conditions

Diseases and conditions that impact blood circulation, clotting, or the immune response can contribute to AVN. For example:

  • Sickle Cell Anemia: This condition involves misshapen red blood cells that can block vessels, including those supplying the shoulder leading to AVN (6).
  • Lupus: An autoimmune disease, lupus can cause inflammation in blood vessels, compromising blood flow to the bone (7).
  • Gaucher’s Disease: A genetic disorder where fatty substances accumulate in cells and certain organs, leading to bone lesions and possibly AVN (8).
  • Pancreatitis: Inflammation of the pancreas can lead to increased fat in the bloodstream, which might deposit in blood vessels.
  • Decompression Sickness: Commonly known as “the bends”, this condition occurs when divers ascend too quickly. Nitrogen bubbles can form and block blood vessels, potentially leading to AVN if they block vessels supplying the humeral head.

Process of bone death and repair

Process of bone death and repair

Ischemia: The first step in the progression towards avascular necrosis (AVN) is the reduced blood flow or ischemia to the bone. Reduced blood flow may be caused by a number of factors, including trauma, thrombosis, or vasculitis (5).

Necrosis: As the bone is deprived of essential nutrients and oxygen, it begins to die, a process called necrosis. Dead bone doesn’t function properly and can collapse over time, leading to joint deformity (2).

Bone Remodeling: The body reacts to the dead bone by trying to remove and replace it, a process called bone remodeling. New bone is formed by cells called osteoblasts, while old bone is reabsorbed by cells called osteoclasts (#reference33).

Joint Dysfunction: If the avascular necrosis is near a joint, the collapsing bone can lead to arthritis in that joint, resulting in pain, reduced range of motion, and dysfunction (4).

Read More: Is Your Shoulder Pain Related to Ankylosing Spondylitis?

Stages of AVN progression

Stages of AVN progression
  • Stage I: Early stage where the bone may appear normal on X-rays, but MRI and other scans can detect changes. The bone is still intact.
  • Stage II: Bone softening starts. X-rays may now show some abnormalities.
  • Stage III: The bone’s surface begins to break down, leading to the formation of small cracks. Cartilage overlying the bone also starts to deteriorate.
  • Stage IV: The affected bone and surrounding joint surfaces collapse.
  • Stage V: The joint’s deterioration spreads to encompass more of the joint, leading to advanced arthritis.
  • Stage VI: The end stage where severe osteoarthritis is evident. The joint space is reduced or obliterated, and there’s extensive damage to the joint and bone.

Read More: How Thyroid Disease Can Lead to Frozen Shoulder Symptoms

Clinical Presentation

Symptoms

Shoulder Pain

Nature and Localization: The pain experienced due to AVN of the shoulder often originates from the affected humeral head, where the bone tissue has begun to deteriorate. It can be a deep, throbbing ache within the shoulder joint or a sharper pain that intensifies with certain movements.

Aggravating Factors: Activities that place increased pressure or load on the shoulder, such as lifting heavy objects or pushing against resistance, may exacerbate the pain.

Night Pain: Night pain or increased discomfort while lying down can occur. This might be because of the increased contact between the humeral head and the socket of the shoulder joint in certain lying positions. It can disrupt sleep and affect overall quality of life.

Radiating Pain: In some cases, the pain might radiate down the arm, towards the elbow, or even towards the chest. This can sometimes be mistaken for cardiac pain or other conditions.

Limited Range of Motion

Stiffness: As AVN progresses, the shoulder joint may become increasingly stiff. This can be due to joint capsule tightening, protective muscle spasms, or structural changes within the bone and cartilage.

Activities Affected: Everyday tasks such as reaching overhead, putting on clothes, or combing one’s hair might become challenging. This limited mobility can significantly impact daily activities and overall function.

Crepitus

Origin: Crepitus, or the grinding sound in the shoulder, often results from the irregular surface of the humeral head (due to dead bone tissue) rubbing against other joint surfaces. It can also arise from the joint capsule or tendons gliding over these irregularities.

Associated Sensations: Alongside the sound, individuals might feel a gritty or rough sensation when moving the shoulder. This can be both unsettling and a sign of advancing joint damage.

Weakness

Muscle Atrophy: Muscles around the shoulder may become smaller and weaker from disuse, as individuals tend to move an aching shoulder less to avoid pain. With prolonged inactivity, muscles can lose their mass and strength.

Nerve Compression: In some advanced cases of AVN, the altered joint structures might put pressure on nearby nerves, leading to weakness in the muscles they innervate. This can compound the functional challenges already presented by the condition.

Compensatory Actions: To cope with the weakness and pain, individuals might develop compensatory movement patterns, using other muscle groups more intensively. Over time, this can lead to imbalances and other orthopedic issues.

Duration and onset of symptoms

Sudden vs. Gradual Onset: Some patients may experience a sudden onset of pain, especially if AVN is related to a traumatic event. In other cases, especially non-traumatic AVN, the symptoms may emerge slowly over weeks to months.

Duration: Early in the disease, pain might be intermittent or activity-dependent. As the condition advances, symptoms may become chronic and persistent.

Progression: If untreated, AVN symptoms generally worsen over time. This can range from months to years, depending on the underlying cause and the effectiveness of any treatments employed.

Differential diagnoses

Osteoarthritis: Degenerative joint disease can also cause pain, stiffness, and limited motion, similar to AVN.

Rotator cuff tear or tendinitis: In the shoulder, a rotator cuff injury can cause pain and limited movement.

Frozen shoulder (Adhesive Capsulitis): This condition results in pain and a significant restriction in the shoulder’s movement.

Bursitis: Inflammation of the bursa, a fluid-filled sac in the shoulder, can lead to pain and discomfort.

Rheumatoid arthritis: An autoimmune condition that can affect the shoulder and mimic symptoms of AVN.

Infections: Osteomyelitis or septic arthritis can present with pain, swelling, and fever, which might be confused with AVN.

Tumors: Both benign and malignant bone tumors can lead to pain and changes in bone structure, sometimes mimicking AVN.

Read More: Varicella Zoster Infection and Its Role in Frozen Shoulder Onset

Diagnostic Procedures

Medical History

  • Detailed Inquiry: A comprehensive understanding of the patient’s symptoms is crucial. The physician will ascertain:
    • Onset: Was it sudden or gradual?
    • Intensity: Is the pain sharp, dull, or throbbing?
    • Aggravating and Relieving Factors: What makes the pain better or worse?
  • Risk Factor Identification: History of trauma (e.g., shoulder dislocation or fracture), prolonged corticosteroid use, excessive alcohol consumption, and certain medical conditions can predispose an individual to AVN. Establishing a link between these factors and symptoms can hint at the diagnosis.
  • Previous Interventions: It’s essential to understand any treatments the patient might have tried, whether medications, physiotherapy, or alternative therapies, and their effects.

Physical Examination

Physical Examination
  • Inspection: The physician looks for any visible abnormalities such as swelling, muscle atrophy, or postural changes.
  • Palpation: By pressing and feeling the shoulder, the doctor assesses tenderness, warmth, and any palpable crepitus.
  • Range of Motion (ROM) Assessment: Active and passive ROM can be tested to understand movement limitations. Reduced ROM may indicate joint damage or muscular inhibition.
  • Strength Testing: Muscle strength around the shoulder is evaluated to determine if there’s weakness or nerve involvement.
  • Special Tests: There are specific orthopedic tests to assess shoulder stability, impingement, and other pathologies. Examples include the Neer’s test, Hawkins-Kennedy test, and the apprehension test.

Imaging Tests

X-rays: Early Stages: AVN might not be visible on standard X-rays during its early stages.

Later Stages: As the disease progresses, X-rays can show decreased bone density, a flattened or misshapen humeral head, and joint space narrowing if arthritis sets in.

Magnetic Resonance Imaging (MRI):

Sensitivity: MRI is highly sensitive for AVN and can detect early changes in the bone marrow, even before any structural changes occur.

Details: It can also visualize edema, bone marrow changes, and the exact extent and location of necrotic bone.

Computed Tomography (CT) Scan:

This provides a detailed cross-sectional view of the bone and can be useful to visualize subtle changes and guide surgical planning.

Bone Scan:

Using radioactive tracers, this scan can detect areas of altered bone metabolism. While not as specific as an MRI, it can indicate areas of increased bone turnover.

Angiography:

Although not commonly used for AVN diagnosis, angiography can visualize blood flow in the arteries supplying the shoulder. It might be utilized if vascular occlusion is suspected.

Importance of early detection

Preventing Progression: Early detection and intervention can potentially slow or halt the disease’s progression.

Better Outcomes: Initiating treatment before the bone collapses or significant joint damage occurs can lead to better functional outcomes and may reduce the need for more invasive procedures like joint replacement.

Economic Implications: Early and appropriate treatment can reduce the long-term healthcare costs associated with managing advanced AVN and its complications.

Quality of Life: Detecting and addressing AVN early can help preserve joint function, reduce pain, and maintain a patient’s quality of life.

Treatment Approaches

Nonsurgical Treatment Options

1. Medications:

NSAIDs: These drugs, like ibuprofen or naproxen, not only help alleviate pain but also combat inflammation at the joint. Long-term use, however, needs monitoring due to potential side effects like gastrointestinal issues or kidney problems.

Bisphosphonates: Originally designed for osteoporosis, these drugs may slow the progression of AVN by reducing the rate at which bone is resorbed and remodeled (9).

Statins: While primarily used to lower cholesterol, there’s emerging evidence suggesting statins may help in AVN due to their effect on bone blood flow and metabolism.

Blood Thinners: Drugs like aspirin or warfarin may be used to improve blood circulation, especially if clotting disorders are identified as contributing factors.

2. Activity Modification:

Patients are educated about the importance of avoiding joint stress. A balanced approach of resting and engaging in approved activities is key to maintaining joint health without exacerbating the condition.

3. Physical Therapy:

Targeted Exercises: Therapists curate exercise routines tailored to each patient, aiming to strengthen supporting musculature, enhance joint stability, and maintain flexibility.

Modalities: Techniques such as TENS (transcutaneous electrical nerve stimulation), therapeutic ultrasound, or cryotherapy can be employed to manage pain and reduce inflammation.

4. Assistive Devices:

The use of these devices can be temporary or long-term, depending on the progression of AVN. They serve to offload stress from the affected joint and provide stability during movement.

Surgical Treatment Options

1. Core Decompression:

  • By drilling into the humeral head, pressure within the bone is relieved. This can stimulate new vascular growth, potentially reversing or halting the progression of AVN.
  • Bone Grafts/Stem Cells: These are sometimes introduced into the drilled holes to enhance bone regeneration and repair.

2. Resurfacing Arthroplasty: A conservative approach preserving much of the native bone. The metal cap ensures the joint surface remains smooth and functional, reducing pain and improving mobility.

3. Hemiarthroplasty: Especially beneficial for those with a good glenoid surface and intact rotator cuff, this procedure replaces the humeral head, allowing natural movement and functionality.

4. Total Shoulder Arthroplasty: Both joint surfaces are replaced. This comprehensive solution is for cases where the rotator cuff may be compromised, or the glenoid surface is severely damaged.

5. Reverse Total Shoulder Arthroplasty: Revolutionizing treatment for those with severe rotator cuff damage, this procedure allows individuals to use their deltoid muscle instead of the compromised rotator cuff for arm elevation. This is particularly advantageous for patients who previously struggled to raise their arm due to muscle deficiencies.

New Diagnostic Tools and Techniques

Biomarkers: Biomarkers are specific molecules present in blood, tissue, or other bodily fluids that can provide valuable insights into the presence and progression of diseases. In the case of avascular necrosis (AVN), researchers are focusing on identifying biomarkers that could indicate the early stages of the condition even before significant changes appear on imaging. Detecting these biomarkers could lead to earlier diagnosis and intervention, potentially preventing the progression of AVN to more severe stages (10).

Functional Imaging: While traditional imaging techniques like MRI are effective, advanced methods such as Diffusion Tensor Imaging (DTI) offer enhanced visualization of tissue microstructure and connectivity. In the context of AVN, DTI could provide better insights into the early changes occurring in bone and surrounding tissues, allowing for more accurate diagnosis and monitoring of the disease’s progression.

3D Imaging: Advanced 3D imaging technologies are being developed to provide a more comprehensive understanding of the structural changes within bones affected by AVN (11). These techniques offer detailed views of bone morphology and can help guide surgical interventions with greater precision. By visualizing the three-dimensional aspects of bone deterioration, doctors can make informed decisions about treatment strategies.

Advances in Treatment Modalities

Stem Cell Therapy: Stem cell therapy involves introducing stem cells, which have the potential to develop into various cell types, into the affected area. In the context of AVN, stem cells could promote bone regeneration by differentiating into bone-forming cells and stimulating the healing process. Ongoing research aims to optimize this approach to enhance its effectiveness in treating AVN and restoring bone health.

Gene Therapy: Understanding the genetic factors that contribute to the development of AVN opens the door to potential gene therapies. Researchers are exploring ways to modify or repair faulty genes associated with AVN, which could mitigate the underlying causes of the condition and prevent its progression.

Biological Modifiers: Growth factors and other biologically active molecules play crucial roles in tissue repair and regeneration. By harnessing these natural processes, researchers are investigating ways to enhance bone healing and regeneration in AVN patients. These biological modifiers could be administered directly to the affected area to accelerate healing and improve outcomes.

Personalized Treatment: The concept of personalized medicine involves tailoring treatments to individual patients based on their unique characteristics. In the context of AVN, this could involve considering a patient’s genetic makeup, lifestyle factors, disease stage, and other relevant factors to develop a treatment plan that is most likely to be effective for that specific individual.

3D Printed Bone Scaffolds: Bioengineering techniques, including 3D printing, are being utilized to create custom-made bone scaffolds. These scaffolds can be implanted into areas of bone loss caused by AVN, providing a framework for new bone growth. This approach holds promise for reconstructing damaged bone tissue and restoring its function.

Predicting and Monitoring AVN Progression

Machine Learning & AI: The vast amount of patient data available, including medical records, imaging results, and treatment outcomes, can be analyzed using machine learning and artificial intelligence algorithms. These technologies can help predict the progression of AVN in individual patients by identifying patterns and risk factors. This enables healthcare providers to intervene earlier and tailor treatments based on predicted outcomes.

Wearable Tech: Wearable devices equipped with sensors can monitor joint movement, detect pain levels, and track other relevant metrics. For AVN patients, these devices can provide real-time data that helps both patients and healthcare providers monitor the disease’s progression and response to treatment. This continuous monitoring contributes to a more comprehensive understanding of the condition.

Longitudinal Studies: Long-term studies that follow a large group of AVN patients over extended periods provide valuable insights into the natural course of the disease. By observing how AVN progresses in different individuals, researchers can identify factors that influence disease development and outcomes. These studies contribute to a deeper understanding of AVN and inform treatment strategies.

Conclusion

Recent advances, particularly in diagnostic tools and treatment modalities, are emblematic of the rapid pace of medical innovation. The introduction of biomarkers, advanced imaging techniques, and the promising realms of stem cell and gene therapy offer renewed hope to patients. Moreover, the embrace of technologies such as machine learning and wearable tech emphasizes a shift towards precision medicine and patient-centric care.

While much has been achieved, the study of avascular necrosis remains a dynamic field. The importance of early detection and intervention cannot be overstated, as they often determine the quality of life for affected individuals. It’s also imperative that we continue to champion research, understanding that each discovery not only contributes to our knowledge of AVN but to the broader landscape of orthopedic and degenerative diseases.

In sum, avascular necrosis of the shoulder underscores the essential interconnectedness of anatomy, technology, and therapeutic strategy. As we move forward, it remains our collective responsibility clinicians, researchers, and patients alike to foster a collaborative approach, ensuring that every individual facing this condition is met with the most informed and compassionate care available.

FAQ’s

1. What is avascular necrosis (AVN)?

Answer: Avascular necrosis (AVN), also known as osteonecrosis, refers to the death of bone tissue due to a lack of blood supply. This can lead to tiny breaks in the bone and eventually cause the bone to collapse.

2. How is avascular necrosis of the shoulder different from other types of shoulder pain?

Answer: AVN in the shoulder typically presents as a deep, aching pain that may or may not be associated with movement. It’s caused by an interruption in the blood supply to the bone, whereas other types of shoulder pain might arise from inflammation, muscle strains, or injury.

3. What are the common symptoms of avascular necrosis in the shoulder?

Answer: Common symptoms include deep, persistent pain in the shoulder, limited range of motion, and increased pain during the night or when lying on the affected shoulder.

4. What causes avascular necrosis of the shoulder?

Answer: Causes can include trauma to the shoulder, long-term use of high-dose steroid medications, excessive alcohol consumption, certain autoimmune diseases, and other conditions that can interrupt the blood flow to the bone.

5. How is avascular necrosis diagnosed?

Answer: Diagnosis usually involves a physical examination, patient’s medical history, and imaging tests like X-rays, MRI, or CT scans.

6. Is there a connection between steroid use and avascular necrosis?

Answer: Yes, long-term use of high-dose corticosteroids has been identified as a risk factor for AVN. The exact reason is not fully understood but may be related to increased fat deposits in blood vessels, reducing blood flow.

7. What are the risk factors for developing avascular necrosis in the shoulder?

Answer: Risk factors include trauma or injury, long-term corticosteroid use, excessive alcohol intake, certain diseases like lupus and sickle cell anemia, and certain medical treatments like radiation.

8. What treatment options are available for avascular necrosis of the shoulder?

Answer: Treatment options vary depending on the severity and stage of the disease. They can range from medications and physical therapy to surgical interventions such as bone grafts or joint replacement.

9. Can physical therapy help with avascular necrosis of the shoulder?

Answer: Yes, physical therapy can help maintain joint mobility and strengthen surrounding muscles, which may alleviate some symptoms and delay disease progression.

10. How does avascular necrosis progress? What stages are there?

Answer: AVN progresses in stages, starting with a minor pain and limited range of motion and potentially leading to bone collapse. Early stages involve small areas of bone death, while advanced stages might include larger bone collapses and arthritis.

11. What complications can arise from untreated avascular necrosis in the shoulder?

Answer: Untreated AVN can lead to the collapse of the affected bone, increased pain, decreased joint function, and development of osteoarthritis?

12. Are there any preventative measures for avascular necrosis?

Answer: While not all cases are preventable, reducing risk factors such as excessive alcohol intake, properly managing underlying health conditions, and avoiding prolonged high-dose corticosteroid use can decrease the risk.

13. How common is avascular necrosis in the shoulder compared to other joints?

Answer: The hip is the most common joint affected by AVN. However, the shoulder is also a commonly affected site, though less frequently than the hip.

14. Is surgery always necessary for avascular necrosis in the shoulder?

Answer: No, surgery is not always necessary. Early stages of AVN may be managed with medications, lifestyle changes, and physical therapy. Surgical interventions are often considered for advanced stages or when conservative treatments fail to provide relief.

References

1. Catto, M., 1965. A histological study of avascular necrosis of the femoral head after transcervical fracture. The Journal of Bone & Joint Surgery British Volume, 47(4), pp.749-776. https://boneandjoint.org.uk/article/10.1302/0301-620x.47b4.749

2. Weinstein, R.S., Nicholas, R.W. and Manolagas, S.C., 2000. Apoptosis of osteocytes in glucocorticoid-induced osteonecrosis of the hip. The Journal of Clinical Endocrinology & Metabolism, 85(8), pp.2907-2912. https://academic.oup.com/jcem/article-abstract/85/8/2907/2853970

3. Manolagas, S.C., 2000. Birth and death of bone cells: basic regulatory mechanisms and implications for the pathogenesis and treatment of osteoporosis. Endocrine reviews, 21(2), pp.115-137. https://academic.oup.com/edrv/article-abstract/21/2/115/2423739

4. Zalavras, C.G. and Lieberman, J.R., 2014. Osteonecrosis of the femoral head: evaluation and treatment. JAAOS-Journal of the American Academy of Orthopaedic Surgeons, 22(7), pp.455-464. https://journals.lww.com/jaaos/Fulltext/2014/07000/Osteonecrosis_of_the_Femoral_Head__Evaluation_and.7.aspx

5. Jones, L.C., Mont, M.A., Le, T.B., Petri, M., Hungerford, D.S., Wang, P. and Glueck, C.J., 2003. Procoagulants and osteonecrosis. The Journal of rheumatology, 30(4), pp.783-791. https://www.jrheum.org/content/30/4/783.short

6. Hernigou, P., Flouzat Lachaniette, C.H., Delambre, J., Zilber, S., Duffiet, P., Chevallier, N. and Rouard, H., 2014. Biologic augmentation of rotator cuff repair with mesenchymal stem cells during arthroscopy improves healing and prevents further tears: a case-controlled study. International orthopaedics, 38, pp.1811-1818. https://link.springer.com/article/10.1007/s00264-014-2391-1

7. Mok, C.C., 2006, October. Therapeutic options for resistant lupus nephritis. In Seminars in arthritis and rheumatism (Vol. 36, No. 2, pp. 71-81). WB Saunders. https://www.sciencedirect.com/science/article/pii/S0049017206000655

8. Charrow, J., Andersson, H.C., Kaplan, P., Kolodny, E.H., Mistry, P., Pastores, G., Rosenbloom, B.E., Scott, C.R., Wappner, R.S., Weinreb, N.J. and Zimran, A., 2000. The Gaucher registry: demographics and disease characteristics of 1698 patients with Gaucher disease. Archives of internal medicine, 160(18), pp.2835-2843. https://jamanetwork.com/journals/jamainternalmedicine/article-abstract/485470

9. Agarwala, S., Jain, D., Joshi, V.R. and Sule, A., 2005. Efficacy of alendronate, a bisphosphonate, in the treatment of AVN of the hip. A prospective open-label study. Rheumatology, 44(3), pp.352-359. https://academic.oup.com/rheumatology/article-abstract/44/3/352/2899274

10. Kubo, T., Ueshima, K., Saito, M., Ishida, M., Arai, Y. and Fujiwara, H., 2016. Clinical and basic research on steroid-induced osteonecrosis of the femoral head in Japan. Journal of Orthopaedic Science, 21(4), pp.407-413. https://www.sciencedirect.com/science/article/pii/S0949265816300069

11. Karantanas, A.H., 2007. Acute bone marrow edema of the hip: role of MR imaging. European Radiology, 17, pp.2225-2236. https://link.springer.com/article/10.1007/s00330-007-0591-4

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