#radiologycpd #medicalimaging #imaging #radcme #rheumatology #arthritis #rheumatologist #orthopaedic #painphysician #physiotherapy #sportsmed #orthopaedic #mskmri. [5]. The pathogenesis of mucoid degeneration is unclear, but injury, ganglion cysts, and degenerative process have been implicated as the most likely etiologic factors in the production of this change. PubMed A systematic literature search in the databases MEDLINE, Embase, Google Scholar, Cochrane, ISI web of science and Scopus was performed through July 2020 by three independent . EMMY NOMINATIONS 2022: Outstanding Limited Or Anthology Series, EMMY NOMINATIONS 2022: Outstanding Lead Actress In A Comedy Series, EMMY NOMINATIONS 2022: Outstanding Supporting Actor In A Comedy Series, EMMY NOMINATIONS 2022: Outstanding Lead Actress In A Limited Or Anthology Series Or Movie, EMMY NOMINATIONS 2022: Outstanding Lead Actor In A Limited Or Anthology Series Or Movie. Your knee may become more and more unstable and may give out more often. Although a few studies such as the one by Lee etal. . Details on the top journals, universities, and authors on t. Anyone else have this and how was it treated if at all? Most older patients with meniscus tears can obtain relief from symptoms such as pain, swelling and decreased range of motion, and improve function, without surgery. 3 Do-Dai DD, Youngberg RA, Lanchbury FD, et al: Intraligamentous ganglion cysts of the anterior cruciate ligament: MR findings with clinical and arthroscopic correlations. Rehabilitation, speech therapy, crenotherapy. Mucoid degeneration (MD) of the anterior cruciate ligament (ACL) is a well-recognized pathology characterized by the degradation of collagen fibers and infiltration of a mucoidlike substance, [1,2 . c 24.5months post-operative radiograph showing no posterior translation of femur compared with pre-operative and immediate post-operative radiograph. Health. Finally, the patients who underwent debulking had a better mean subjective patient satisfaction (9.830.37 versus 8.680.71) at the final follow-up at 2years (p<0.05) (Table 2). We offer latest arthroscopic and minimally invasive single and double row rotator cuff repair in cases of rotator cuff tear. Plain radiographs of all the patients taken in anteroposterior and lateral views (in standing) at 2years follow-up showed no signs of implant failure in any patient. Very minor tears (sprains) may heal with non-surgical treatments and regenerative medicine therapy. [6] and Lintz etal. Contact us. Platelet-rich plasma (PRP) is known to influence musculoskeletal healing through multiple growth factors. This study holds clinical significance in terms of the very limited literature available on the role of MD-ACL in outcomes of patients undergoing UKA. Follow us on social media for the latest updates, Future Medicine Ltd, Unitec House, 2 Albert Place, London, N3 1QB, UK, We use cookies to improve your experience. If left untreated, a small ACL tear will increase in size, causing more pain and increasing the laxity in the knee. After surgery patient is allowed to walk from the next day. Sun H, Gill TJ. 1998 Oct;53(10):771-3. was responsible for physiotherapy, writing review, editing and project administration. cystic degeneration degeneration with formation of cysts. . https://doi.org/10.1007/s00167-011-1433-0, Article Despite integrity and status of cruciates being paramount in a UKA, no study has evaluated the effect of debulking MD-ACL in this procedure. the degree of laxity, and the patient's age and willingness to pursue vigorous postoperative physical therapy are other major determinants. Once considered a rare disease, it is probably a less diagnosed condition of knee pain. Accessed Nov. 13, 2018. Su Chan Lee, Kyung Won . I have persistent pain in the back of that knee that is exacerbated by walking and bending it. The cause is not really known, but patients usually do not complain of instability. Modalities such as icing, joint mobilization, and massage can provide short-term pain relief and reduce swelling. interval progression at C5-6. Unicompartmental knee arthroplasty (UKA) has rapidly emerged as a superior surgical option to total knee arthroplasty for bone-on-bone osteoarthritis owing to less trauma to the surrounding soft tissue, more conservative bone cuts, minimal bleeding, smaller incision, a better range of motion (ROM), faster recovery, preserved kinematics, higher rate of implant survival and decreased chances of major complications such as thromboembolism, cardiac arrest and stroke [9]. Sagittal T1-weighted (1a) and fat-suppressed proton density-weighted (1b) images. mucoid degeneration acl symptoms. . 58th ed. 6 Antonacci VP, Foster T, Fenlon H, Harper K, Eustace S: Technical report: CT-guided aspiration of anterior cruciate ligament ganglion cysts. Close. Instrumental treatment. Sequential intra-operative pictures (left to right): a Surgeon unable to pass the arthroscopy hook between the medial cortex of lateral femoral condyle and lateral border of mucoid ACL. The severity of the ACL injury is graded from 1 to 3. (Table 2). Ever since mucoid degeneration of the anterior cruciate ligament (MD-ACL) was named by Kumar etal. et al. . The most common mechanism is that of a sudden pivoting or cutting maneuver during sporting activity, which is commonly seen in football, basketball and soccer. Mucoid degeneration of the ACL is a rare cause of knee pain in the middle-aged patient group, without knee instability. fatty degeneration deposit of fat globules in a tissue. If present in a patient undergoing unicompartmental knee arthroplasty, it can deteriorate the final outcome. (7a) Intra-articular extension of a cruciate ligament ganglion. Being a multicentric study involving five different surgeons, surgeon factors could potentially affect surgical procedure and clinical outcome, despite a predetermined endpoint for the debulking. When the arthroscopy hook was attempted to be passed between the lateral femoral condyle and the lateral aspect of the ACL, it was noticed that the impinging fibers of the mucoid ACL blocked its passage, thereby not allowing the hook to be passed between the lateral femoral condyle and the lateral aspect of the ACL, which is otherwise possible in cases with normal ACL. Treatment of ACL mucoid degeneration by arthroscopic resection is effective for posterior pain and flexion limitation. After surgery you'll resume another course of rehabilitative therapy. CAS They cross each other to form an X with the anterior cruciate ligament in front and the posterior cruciate ligament in back. Any use of this site constitutes your agreement to the Terms of Use and Privacy Policy and Conditions of Use linked below. A few studies have shown direct correlation between the presence of meniscus tear in patients with MD-ACL. The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. Mayo Clinic on Incontinence - Mayo Clinic Press, NEW The Essential Diabetes Book - Mayo Clinic Press, NEW Ending the Opioid Crisis - Mayo Clinic Press, FREE Mayo Clinic Diet Assessment - Mayo Clinic Press, Mayo Clinic Health Letter - FREE book - Mayo Clinic Press, Mayo Clinic Graduate School of Biomedical Sciences, Mayo Clinic School of Continuous Professional Development, Mayo Clinic School of Graduate Medical Education, Setback to comeback: Twin sisters return to the basketball court after ACL tears, Book: Mayo Clinic Family Health Book, 5th Edition, Newsletter: Mayo Clinic Health Letter Digital Edition, NSF Certified for Sport Nutritional Supplements. The patients clinical history and symptoms do not support an ACL injury. Mucoid Degeneration of Posterior Cruciate Ligament Leads to Roof Impingement with Anterior Cruciate Ligament: Case Report. An anterior cruciate ligament (ACL) mucoid degeneration, along with tears and anterior cruciate ligament ganglion cysts, is a relatively common cause of incr. How long does it take an ACL to heal without surgery? 2). Score: 4.7/5 (45 votes) . This denoted adequate release of the impinging fibers against the lateral femoral condyle, femoral notch and PCL. Mucoid degeneration of ACL is a disease affecting ACL in which mucoid like substance (glycosaminoglycans) gets interspersed within the substance of ACL and as a result ACL gets thickened. However, all of these debridements were done under arthroscopy, whereas the surgeons in this study progressively debulked the ACL by open method using a 15-number blade, under direct vision. Patients were followed up post-surgery for rehabilitation. ACL ganglion cyst occurs more frequently among relatively younger patients compared to mucoid degeneration. Discussion: Treatment of ACL mucoid degeneration by arthroscopic resection is effective for . Role of debulking mucoid ACL in unicompartmental knee arthroplasty: a prospective multicentric study, https://doi.org/10.1186/s43019-022-00169-9, https://doi.org/10.1302/0301-620X.81B2.0810304, https://doi.org/10.2214/ajr.182.5.18212835, https://doi.org/10.1007/s00167-011-1433-0, https://doi.org/10.1007/s00167-012-1991-9, https://doi.org/10.1186/s43019-021-00110-6, https://doi.org/10.1016/j.knee.2020.06.004, https://doi.org/10.1302/0301-620X.73B4.2071640, https://doi.org/10.1016/j.knee.2010.05.003, https://doi.org/10.3109/17453679209154722, https://doi.org/10.1302/0301-620X.93B4.25562, https://doi.org/10.1186/s10195-020-00551-x, https://doi.org/10.1177/03635465010290051301, https://doi.org/10.1016/j.eats.2017.11.006, https://doi.org/10.20546/ijcrar.2016.411.003, https://doi.org/10.4055/cios.2018.10.3.307, http://creativecommons.org/licenses/by/4.0/, http://creativecommons.org/publicdomain/zero/1.0/. Interested in more discussions like this? what causes mucoid degeneration of acl. 4 McIntyre J, Moelleken S, Tirman P: Mucoid degeneration of the anterior cruciate ligament mistaken for ligamentous tears. Proton density-weighted sagittal demonstrates a diffusely increased size of the ACL with ill-defined increased signal and interspersed intact ACL fibers. On longitudinal, intra-group comparison of the individual groups, it was noted that there was statistically significant (p<0.05) improvement in the ROM of patients who underwent debulking (Z-value: 13.047; p-value: 0.00) as well as no debulking group (Z-value: 9.990; p-value: 0.00) at 2years follow-up, compared with their individual pre-operative ROM. (2a) T1-weighted sagittal image demonstrates an enlarged, club-shaped anterior cruciate ligament (arrows). Mucoid degeneration of anterior cruciate ligament (ACL). Recent studies have reported that the prevalence of ACL mucoid degeneration is approximately 2-14% [20, 23, 24, 25]. CAS A surgical procedure that involves replacing a damaged, worn or diseased knee with an artificial joint to restore knees movement. https://doi.org/10.3109/17453679209154722, Gibson PH, Goodfellow JW (1986) Stress radiography in degenerative arthritis of the knee. : any of various mucoproteins that occur especially in secretions of mucous membranes. Stability of the joint is not compromised on controlled debulking. How common is mucoid degeneration of the ACL? Love. The samples collected from the five hospitals were 122 (group A: 58; group B: 64), 68 (group A: 35; group B: 33), 94 (group A: 46; group B: 48), 83 (group A: 41; group B: 42) and 75 (group A: 36; group B: 39), respectively. My MRI done in June states that I have very severe mucoid degeneration/partial thickness tearing of the ACL with the tibial spine tractional marrow edema. I know what the words mean. . S Banerjee: Substantial contributions to the conception, drafting the work interpretation of data for the work, agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The MR-findings of mucoid degeneration of the ACL include: an ill-defined ACL; an increased ligamentous girth The authors presume that this objective end point suggests adequate debulking, just enough to remove the impingement factor from the lateral femoral condyle, femoral notch and PCL, and consequently the symptoms associated with the impingement. Mucoid degeneration of the anterior cruciate ligament (ACL) of the knee can cause knee pain and other symptoms. Our study provides further evidence that arthroscopic total or partial excision of anterior cruciate ligament is a safe and effective treatment for mucoid degeneration of the anterior cruciate ligament, improving patient satisfaction and function without causing clinical instability in daily activities. Anterior cruciate ganglion cysts are probably more prevalent than stated in the literature. J Sports Med Phys Fit 48(4):483487, CAS They were however, supplemented by other objective methods such as comparison of pre-operative, post-operative and follow-up status of lateral view of plain radiograph in standing position, to look for any posterior translation of the femur which would suggest instability. If your activities do not involve making pivoting movements on the knee, physical therapy rehabilitation may be all you need. Both the groups were matched in terms of age, body mass index, pre-operative ROM, pre-operative International Knee Documentation Committee (IKDC) score [17] and pre-operative Knee Society score (KSS) [18]. Signs and symptoms: It usually affects middle aged and elderly people. J Bone Jt Surg Br 73(4):582586. This is a 79-year old woman with recently found asymptomatic left hydronephrosis. ACL mucoid degeneration is present on ~10% (range 9-12%) of 3 T MRI examinations and 2% of 1.5 T MRI examinations 6. https://doi.org/10.1177/03635465010290051301, Insall JN, Dorr LD, Scott RD, Scott WN (1989) Rationale of the Knee Society clinical rating system. 3 Do-Dai DD, Youngberg RA, Lanchbury FD, et al: Intraligamentous ganglion cysts of the anterior cruciate ligament: MR findings with clinical and arthroscopic correlations. Some patient may also complain of pain with full knee extension. . ), or their login data. Feb 17, 2023 7:27 AM. This study aims to compare functional and clinical outcomes of debulking the mucoid ACL in patients undergoing mobile-bearing unicompartmental knee . Histopathological confirmation of mucoid degeneration was obtained in all 442 patients. The rest of the surgery remained the same and all patients underwent mobile-bearing Oxford UKA. Breast cancer is one of the most common cancers in women, with more than 2 million new diagnoses last year alone. Clin Orthop Relat Res 248:1314, Hotchen AJ, Melton JTK (2018) Radiofrequency ablation for mucoid degeneration of the anterior cruciate ligament. Physiotherapy. Terms and Conditions, Get your query answered 24*7 only on | Practo Consult . Here are the search results of the thread mucoid degeneration of acl treatment from Bing. They assessed the stability of the joint with the Lachman test intra-operatively, confirming it to be either grade zero or one, with firm end point, before commencing with the UKA [16]. Surgery is typically not needed. : tissue degeneration marked by conversion of cell substance into a glutinous substance like mucus. It's important to ensure that strength, stability and movement patterns are optimized before you return to an activity with a risk of ACL injury. A physical therapist will teach you exercises that you will perform either with continued supervision or at home. 3, 2018 www.ecios.org Mucoid degeneration (MD . Patients with mucoid ACL undergoing mobile-bearing UKA at five different centres by five different arthroplasty surgeons were included. Int J Sports Phys Ther 10(1):5261, PubMed Rehabilitation, orthophony, crenotherapy. A: ACL (anterior cruciate ligament) mucoid degeneration means the lesion of the ACL. Grade 1: The ligament is intact, and the joint is stable, but there is minimal stretching and some microscopic tearing of the ACL. What is the meaning of mucoid degeneration? Surgery is typically not needed. The results found improved functional scores and pain scores compared with preoperative levels. The portal can access those files and use them to remember the user's data, such as their chosen settings (screen view, interface language, etc. Most surgeons recommend a program of physical therapy post-operatively to reduce pain and swelling, promote full range-of-motion, and improve knee function. 18 Apr 2021. Pre-operative and follow-up lateral radiographs of the patients who underwent debulking were analysed by a blinded radiologist and no posterior translation of the femur was noted, thereby confirming no instability caused by the debulking (Fig. What is your diagnosis? The soft-tissue thickening and increased signal intensity along the course of the ligament with either form of cyst may be confused with the appearance of an ACL tear. 5 Stoller DW: Magnetic Resonance Imaging in Orthopaedics and Sports Medicine . Intraosseous increased signal is present within the tibial spine deep to the posterior extent of the ACL insertion (arrowhead). All Rights Reserved. Connect with thousands of patients and caregivers for support and answers. He did total knee replacement on both side and now my mother is walking without aid. To provide the highest quality clinical and technology services to customers and patients, in the spirit of continuous improvement and innovation. J Bone Jt Surg [Br] 68-B:608609, Kang SN, Smith TO, De Rover WBS, Walton NP (2011) Pre-operative patellofemoral degenerative changes do not affect the outcome after medial Oxford unicompartmental knee replacement: a report from an independent centre. What are the findings? Mucoid degeneration of the anterior cruciate ligament is a rare pathological entity with disputed theories of origin [1,2,3,4]. It can trap and damage the menisci in the knee and can also lead to early osteoarthritis. [22]. However, the terminal ROM achieved after debulking MD-ACL was significantly better (p<0.05) at 2years of follow-up as compared with the group that did not undergo debulking. Among other conditions - osteoarthritis, osteopenia, spondylolisthesis- an MRI report showed "severe mucoid degeneration of the ACL" in my left knee. The abnormal sliding within the knee also can hurt cartilage. Questions just answered: mucoid degeneration of acl physiotherapy. Correlations between degree of knee instability and SIR were assessed for each bundle, each time point, and each sequence. These patients who underwent UKA with debulking of MD-ACL were included in group B (nb=226). Hence, the improvement in ROM, attenuation of rest pain and better long term functional outcome measures supported the hypothesis regarding the positive effect of debulking a MD-ACL in patients undergoing UKA. Anterior knee pain is the more common complaint. It can be secondary to trauma, or simply degeneration caused by meniscal injury, osteoarthritis or chondral damage [2]. Follow the R.I.C.E. Knee Surg Relat Res 33(1):26. https://doi.org/10.1186/s43019-021-00110-6, Kennedy JA, Mohammad HR, Mellon SJ, Dodd CAF, Murray DW (2020) Age stratified, matched comparison of unicompartmental and total knee replacement. Methods From January 2012 to August 2013, 32 knees (24 females and 8 males with left knee of 14 and 18 of right) were diagnosed with mucoid degeneration of the ACL and underwent arthroscopic treatment, all of whom with a mean age of 58.817.97 years (42-74 years). Anterior cruciate ligament (ACL) injuries. (Tr. Treatment options include non-operative management, arthroscopic debridement with a biceps tenotomy or tenodesis, complete or partial repair, patch augmentation, superior capsular reconstruction, muscle/tendon transfer and reverse total shoulder arthroplasty. 1). Grade 1: The ligament is intact, and the joint is stable, but there is minimal stretching and some microscopic tearing of the ACL. Freedom from war and natural disaster. TimesMojo is a social question-and-answer website where you can get all the answers to your questions. On exposure of the joint, ACL was looked for in terms of integrity and any degenerative changes. 1st ed. Clinical History: 37 year-old male with no known injury, complaining of diffuse knee pain and stiffness, worsening over the last 3 months. 21 yrs old Male asked about Mucoid degeneration of ACL, 2 doctors answered this and 92 people found it useful. Our study provides further evidence that arthroscopic total or partial excision of anterior cruciate ligament is a safe and effective treatment for mucoid degeneration of the anterior cruciate ligament, improving patient satisfaction and function without causing clinical instability in daily activities. Despite maximising the factors involved between the two groups, as the sample size collection was done during two separate time periods and consecutive sampling was done instead of randomisation, there is a possibility of sampling bias. However, upon following-up with these patients, and gauging their clinical and functional parameters, complaints of rest pain and restriction of terminal flexion seemed to persist. The demographic distribution of study population with respect to the mean age, gender distribution and the side affected was similar to the recent studies done on the MD-ACL as a standalone entity [2, 3, 5, 8]. 1998-2023 Mayo Foundation for Medical Education and Research (MFMER). A proton density-weighted coronal view from the same patient as seen in (A) and (B) reveals intraosseous ganglia (arrows) communicating with the ACL ganglion cyst (short arrow). One MRI was reported as a possible ganglion cyst or mucoid degeneration of the ACL, whereas all others were reported as either partial or complete tears of the ACL. Friedberg RP. Instrumental treatment. Extraligamentous extension into the joint and intercondylar notch produces a higher incidence of mechanical symptoms (7a). Remote ligamentous trauma as well as mucinous degeneration associated with aging likely play a role in the development of cruciate cysts. All the demographic and biostatistical data was compiled and computed on the SPSS-24 software. K Kunal: Substantial contributions to the conception, drafting the work, interpretation of data for the work, agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work. Do you ever feel that your knee is unstable or unable to support your weight? Laskowski ER (expert opinion). Papadakis MA, et al., eds. Non-traumatic thickening of the ACL was associated with osteoarthritis and meniscal tears in almost all cases and showed increased signal intensity and ill-defined borders simulating acute ligamentous tears. https://orthoinfo.aaos.org/en/diseases--conditions/anterior-cruciate-ligament-acl-injuries/. Functional assessment was done by the same clinician using patient-related outcome measures (PROMs) using the self-questionnaire-based International Knee Documentation Committee (IKDC) score, Knee Society score (KSS), VAS score (for rest pain) and subjective satisfaction level. In: Current Medical Diagnosis & Treatment 2019. The authors state that they have obtained verbal and written informed consent from the patient/patients for the inclusion of their medical and treatment history within this case series. These ganglia consist of myxoid material. Accessed Nov. 21, 2018. There was a statistically significant improvement in the mean IKDC and mean KSS of both the groups at 2years of follow-up as compared with their pre-operative scores (p<0.05). Arthroscopic debridement may help relieve the anterior knee pain. Knee 18(3):168171. https://doi.org/10.1302/0301-620X.73B4.2071640, Pandit H, Gulati A, Jenkins C (2011) Unicompartmental knee replacement for patients with partial thickness cartilage loss in the affected compartment. It can cause pain and to a meniscal tear. [4]showed high percentages of laxity post debulking of MD-ACL, a finding which would not allow a surgeon to carry out a UKA after the debulking. Google Scholar, White SH, Ludkowski PF, Goodfellow JW (1991) Anteromedial osteoarthritis of the knee. American Journal of Sports Medicine. Mucoid degeneration of ACL is a disease affecting ACL in which mucoid like substance (glycosaminoglycans) gets interspersed within the substance of ACL and as a result ACL gets thickened. This allows the doctor to see the knee structures more clearly. Informed written consent was obtained from all individual participants included in the study. Little is known about this condition that affects 1.85.3% of the population as per magnetic resonance imaging (MRI) diagnosis [2, 3]. Treatment: For symptomatic knees surgical debulking /debridement in which thickened part of the ACL is shaved off, is the treatment of choice. California Privacy Statement, Flag this answer. Patient having mucoid degeneration of ACL seeks multiple orthopedic consultation and most of the time treating orthopedican miss its diagnosis either because of lack of experience or rare cause of pain unless doctor sought magnetic resonance imaging (MRI) of knee. Mucoid degeneration of the anterior cruciate ligament (ACL) is mostly observed in middle-aged patients with knee pain and limited range of motion. Correspondence to Physiotherapy and yoga based exercises will help you. just over two decades ago [1], the interest in this condition has quickly gathered pace in the orthopaedic community. This study showed that the patients who underwent debulking had statistically superior knee function, lesser rest pain and greater satisfaction rates at 2years of follow-up compared with those in whom MD-ACL was not debulked. The ACL appears on MRI to be enlarged with cystic changes throughout, however it is intact. Usually there is no history of any significant trauma. Why Do Cross Country Runners Have Skinny Legs? DOI: 10.1016/J.JAJS.2015.12.001 Corpus ID: 74774556; Mucoid degeneration of the anterior cruciate ligament: Partial arthroscopic debridement and outcomes @article{Khanna2016MucoidDO, title={Mucoid degeneration of the anterior cruciate ligament: Partial arthroscopic debridement and outcomes}, author={Gagan Khanna and Rajan Sharma and Aditya Bhardwaj and Harjot S. Gurdutta and Deepak Agrawal and . Role of debulking mucoid ACL in unicompartmental knee arthroplasty: a prospective multicentric study. https://doi.org/10.1186/s10195-020-00551-x, Mulligan EP, McGuffie DQ, Coyner K, Khazzam M (2015) The reliability and diagnostic accuracy of assessing the translation endpoint during the lachman test. Journal of the American Academy of Orthopaedic Surgeons. With an increasing trend of UKA being performed worldwide, the role of addressing concomitant MD-ACL is vital in improving the overall outcome of the patient without causing any instability or implant failure, as shown in this study. The Infona portal uses cookies, i.e. "Mayo," "Mayo Clinic," "MayoClinic.org," "Mayo Clinic Healthy Living," and the triple-shield Mayo Clinic logo are trademarks of Mayo Foundation for Medical Education and Research. Home | About | Contact | Copyright | Report Content | Privacy | Cookie Policy | Terms & Conditions | Sitemap. MD-ACL lies in the grey area of a stable, yet functionally limiting condition that has the propensity to become relatively unstable after undergoing debulking. https://doi.org/10.1302/0301-620X.81B2.0810304, Article Go to the Bones, Joints & Muscles Support Group. The first resembles ganglia in other periarticular locations, presenting as a discrete fluid signal cystic structure within the substance or on the surface of the ACL(5a).3 The second form has been likened to a celery stalk in appearance.4 The ACL demonstrates diffuse thickening containing ill-defined intraligamentous T2-hyperintensity, which splays the intact ACL fibers (6a).
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