Injury, Int. J. Care Injured 44 S3 (2013) S26–S32

Introduction

Shoulder instability represents a common condition primarily

affecting young active people and especially athletes. It occurs

when the humeral head is forced out of the glenoid fossa. This

can be the result of a sudden injury or from overuse activities

of the shoulder joint. Once the soft tissues (ligaments, tendons,

and muscles) supporting the shoulder become loose or torn, the

shoulder joint becomes prone to dislocations. Chronic shoulder

instability is defined as the persistent inability of the soft tissues

to keep the humeral head congruent into the glenoid fossa.1–4

The stability of the glenohumeral joint depends on the

stabilizing musculotendinous structures of the rotator cuff and

most of the muscles of the shoulder girdle. The glenoid labrum

also plays an important role in shoulder stability by providing

the fibrous attachment of the glenohumeral ligaments and

capsule to the glenoid rim.5

According to the injured anatomical structures, several

distinct pathological conditions have been described. Because of

the complexity of the anatomy of the shoulder joint, the diagnosis

and management of these conditions can be challenging.

SLAP lesion represents an injury of the superior labrum, at

the point where the tendon of the biceps muscle inserts on the

K E Y W O R D S

Musculoskeletal ultrasound

Acute and chronic shoulder instability

Magnetic resonance arthrography of shoulder

Capsulolabral complex lesion

Rotator cuff rupture

A B S T R A C T

Introduction: The aim of our study was to compare US, conventional MRI and MR arthrography

findings in patients with anterior shoulder instability and with a clinical diagnosis of labral capsular

ligamentous complex lesion. At the same time we evaluated the accuracy of MR arthrography in the

diagnosis of this lesion.

Methods: After approval of the local Ethics Committee, our department’s Trauma Registry from July

2008 up to February 2012 was retrospectively reviewed to identify all eligible patients. Eligibility

criteria included: 1) history of acute or chronic shoulder instability (more than three dislocations over

a period of more than two months); 2) diagnosis of labroligamentous lesion.

All patients were investigated with plain radiographs, Ultrasound Scans (US), Magnetic Resonance

Imaging (MRI) and MR arthrography. Finally, all patients underwent an arthroscopy that confirmed

the diagnosis.

Results: A total of 200 consecutive patients who met the inclusion criteria were included in this study.

The mean age was 39 years (range 15 to 83); 147 were male and 133 involved the right shoulder. Chronic

instability was documented in 133 patients, whereas acute instability was documented in 67 patients.

We detected a statistically significant difference between US and MR arthrography in SLAP (Superior

Labrum Anterior to Posterior) lesions (Type II, III and IV), in Bankart lesions, in glenohumeral ligament

lesions (superior, middle, anterior-inferior and anterior inferior glenohumeral ligament) in Hill-Sachs

lesions, in diagnosing internal subacromial impingement and in normal findings. MR arthrography was

superior to the US.

A statistically significant difference was evident between MRI and MR arthrography findings in

SLAP lesions (III and IV Type lesions), in glenohumeral ligament lesions (anterior inferior and

posterior inferior glenohumeral ligament), in partial rotator cuff ruptures and in normal findings. MR

arthrography diagnosed this lesion better than MRI without contrast.

We also found a statistically significant difference between US and MRI findings in SLAP Type II

lesions, in partial rotator cuff ruptures, in Hill-Sachs lesions and in diagnosing internal subacromial

impingement.

Conclusion: The US scan is a valuable diagnostic technique for rotator cuff complete or incomplete

ruptures. For evaluating Hill-Sachs lesions or bony Bankart lesions, MRI is more accurate. In the case of

labral capsular ligamentous complex lesions, MR arthrography is superior.

© 2013 Elsevier Ltd. All rights reserved.

Diagnostic value of US, MR and MR arthrography in shoulder instability

Roman Pavica,b,*, Petra Margeticb, Mirta Bensicc, Renata Letica Brnadicb

aSchool of Medicine, J.J.Strossmayer University, Osijek, CroatiabUniversity Hospital “Sisters of Mercy”, Clinic for Traumatology, Zagreb, CroatiacDepartment of Mathematics ,J.J.Strossmayer University, Osijek, Croatia

* Corresponding author at: Clinic of Traumatology Zagreb, Draskoviceva 19,

10 000 Zagreb, Croatia. Tel. 00385 98 9330 746

E-mail address: roman.pavic@os.t-com.hr (R. Pavic).

0020-1383/$ – see front matter © 2013 Elsevier Ltd. All rights reserved.

Contents lists available at SciVerse ScienceDirect

Injury

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R. Pavic et al. / Injury, Int. J. Care Injured 44 S3 (2013) S26–S32 S27

labrum and extends anteriorly and posteriorly. It is diagnosed

when contrast media interposed between superior and anterior

glenoid labrum oriented laterally towards the biceps brachii

tendon insertion.4 Type  I is characterized by marked fraying of

the free edge of the superior labrum. Type  II occurs when the

labral-bicipital complex is avulsed from the glenoid. Type  III is

a displaced bucket handle tear of the superior labrum with an

intact biceps anchor and Type  IV is a bucket handle tear of the

superior labrum, with extension into the fibers of the biceps

tendon.

The classic Bankart lesion is defined as a defect of the

capsulolabral complex at the site of the inferior glenohumeral

ligament (Figure 1). Its variants include: Perthes lesion (Figure 2),

anterior labral periosteal sleeve avulsion (ALPSA) (Figure  3),

humeral avulsion of the glenohumeral ligament (GLAD)

(Figure 4), bony humeral avulsion of the glenohumeral ligament

and the floating anteroinferior glenohumeral ligament (HAGL).

Any of these lesions can be associated with glenolabral articular

disruption.6

In Perthes lesions, the scapular periosteum remains intact

but is stripped medially resulting in incomplete avulsion of the

labrum from the glenoid margin, whereas in Bankart lesions,

the scapular periosteum is torn. In ALPSA lesions, the labrum,

capsule and ligaments are medially displaced, inferiorly rotated

and fibrosed. In GLAD lesions the anterior glenoid labrum is

partially torn with an adjacent articular cartilage chondral defect

in clinically stable patient. Hill-Sachs lesion is an impacted

fracture of dorsolateral aspect of the humeral head with/without

changes in intensity of adjacent bone (Figure  5). The criteria

for defining a ligamentous lesion are: rupture, thickness and

changing of intensity of the ligament.

Many methods have been described in the literature

for diagnosing shoulder pathology. These include standard

radiograms, conventional arthrotomography, ultrasound, CT

arthrography and MR imaging.7

For the evaluation of rotator cuff injuries, ultrasound (US) and

magnetic resonance imaging (MRI) are considered to be the most

accurate. MRI however, is more universally accepted although it

can be limited in evaluating partial tears of the rotator cuff.8,9

On the other hand, labral capsular ligamentous complex lesions

can be diagnosed by MRI but subtle lesions are better visualised

after intra-articular injection of contrast media and subsequent

distension of capsule.10–16

The aim of our study was to compare US, conventional MRI

and MR arthrography findings in patients with anterior shoulder

instability and with a clinical diagnosis of labral capsular

ligamentous complex lesion. At the same time we evaluated the

accuracy of MR arthrography in the diagnosis of this lesion.

Materials and methods

After approval of the local Ethics Committee, our department’s

Trauma Registry from July 2008 up to February 2012 was

retrospectively reviewed to identify all eligible patients.

Eligibility criteria included: 1)  history of acute or chronic

shoulder instability (more than three dislocations over a period

Fig. 1. MR arthrography, left shoulder, coronal plane, fibrous Bankart lesion with

loose intraarticular chondral body.

Fig. 2. MR arthrography, left shoulder, transversal plane, intact scapular is

stripped medially resulting in incomplete avulsion of the labrum from the glenoid

margin - Perthes lesion.

Fig. 3. MR arthrography, left shoulder, transversal plane, ALPSA lesion where

labrum, capsule and ligaments are medially displaced, Hill-Sachs lesion.

S28 R. Pavic et al. / Injury, Int. J. Care Injured 44 S3 (2013) S26–S32

of more than two months); 2)  diagnosis of labroligamentous

lesion.

Details including patient age, gender, mechanism of injury,

clinical examination, finding of imaging modalities (standard

radiograms, US, conventional MRI and MR arthrography), were

recorded and analysed.

Imaging

US were performed on a SHIMADZU 2200 using a 7-15 MHz

linear probe. Patients were examined according to the accepted

standard Musculoskeletal Ultrasound Technical Guidelines

published by the European Society of Musculoskeletal

Radiology.17

Conventional MRI and MR arthrography were performed by

a 1.0-T system (Magnetom Expert; Siemens, Erlangen, Germany)

and a dedicated phased-array shoulder coil (Siemens). Patients

underwent imaging with the humerus in neutral position.

Conventional MRI was done using a dedicated shoulder coil,

3  mm slice thickness, 12-16  cm FOV and 512  x  512 matrix; the

following sequences were used: oblique coronal proton density,

axial proton density, oblique coronal T2 with fat saturation and

oblique sagittal T2 with fat saturation. Injection of contrast

media for MR arthrography was performed with a posterior

approach by radiologists with at least 2  years of experience in

arthrography. Intra-articular positioning of the needle (22-gauge

needle) was confirmed by means of injection of 5 ml of iodinated

contrast media (iopromide, Ultravist 300; Schering Berlin,

Germany). Once the needle is in position 0.1 ml of gadopentetate

dimeglumine (Magnevist; Schering) diluted with 20  ml saline

was injected. After injection of contrast material, the patient was

escorted to the MR imaging room. MR imaging was performed

within 45  minutes after contrast agent injection. Coronal

oblique, sagittal oblique and transverse T1-weighted, spin-echo

sequences and a coronal oblique T2-weighted fast spin-echo

pulse sequence were performed. For the image analysis of the MR

arthrograms and the classification of labroligamentous lesions,

pre-established criteria were applied (Figures 6 and 7).18–21

All patients were consented before undergoing the procedure

and all images were evaluated by a single experienced

musculoskeletal radiologist (>12  years’ experience in

musculoskeletal radiology).

A shoulder arthroscopy was finally performed to all patients,

where the definitive diagnosis was made.

Statistical Analysis

To test for marginal homogeneity, the exact McNemar test

was used (small sample size). A p-value of less than 0.05 was

considered as statistically significant.

Results

A total of 200 consecutive patients who met the inclusion

criteria were included in our study. The mean age was 39 years

(range 15 to 83 years); 147 were male and 133 involved the right

Fig. 4. MR arthrography, left shoulder, tranversal plane, humeral avulsion of the

glenohumeral ligament - GLAD lesion.Fig. 5. MR arthrography, left shoulder, transversal plane, impacted fracture of

dorsolateral aspect of the humeral head without changes in intensity of adjacent

bone - Hill-Sachs lesion.

Fig. 6. MR arthrography, right shoulder, coronal plane, SLAP lesion Type III -

displaced bucket handle tear of the superior labrum with an intact biceps anchor.

Partial rotator cuff rupture.

R. Pavic et al. / Injury, Int. J. Care Injured 44 S3 (2013) S26–S32 S29

shoulder. Chronic instability was documented in 133 patients,

whereas acute instability was documented in 67 patients.

All patients had plain radiographs, US scans and conventional

MRIs.

Plain radiographs were reported as normal in all patients,

whereas the US scans revealed rotator cuff ruptures in

80  patients (complete in 27  patients and partial in 54  patients)

(Table  1). MRI scans identified 20 patients with SLAP lesions

(Type  II: 16  patients; Type  II: 4  patients), while for 67  patients

the report was unremarkable. The MR arthrograms revealed

a labroligamentous lesion in 159  patients and an isolated Hill-

Sachs lesion in 4 patients (Table 2).

We then compared each the treatment modalities using the

exact McNemar test (Tables 3, 4 and 5).

Discussion

For the evaluation of the rotator cuff tears, both MRI and

ultrasound are regularly used in clinical practice. Kelly et al.

reported that US and MRI are both useful in diagnosis of rotator

cuff tears, although no method was considered superior.22 In

our study we didn’t find any statistically significant difference

between these techniques in diagnosing incomplete rotator cuff

rupture; however, there was a statistically significant difference

with regards to partial rotator cuff rupture. When we analysed

the detection of labrum and ligamentous defects (SLAP Type

II lesion and in Hill-Sachs lesion), we found a statistically

significant difference between the two techniques (Table 5).

Shahabpour et al. compared the different diagnostic imaging

methods for assessing the soft tissues and articular pathology

of the shoulder23. He concluded that all the imaging modalities

were less accurate for partial-thickness tears. Nevertheless,

when comparing them he found that MR arthrography and US

are more accurate in detecting these defects, compared to MRI.

Conversely, for SLAP lesions (Type II, III and IV), Bankart lesions,

glenohumeral ligament lesions (superior, middle, anterior-

inferior and posterior-inferior glenohumeral ligaments) and Hill-

Sachs lesions, the MR arthrography was superior to US (Table 3).

MRI represents a more universally accepted imaging modality,

because it is easier to perform and can be evaluated by more

than one radiologist. On the other hand, US is more challenging

Fig. 7. MR arthrography, right shoulder, transversal plane, SLAP lesion Type IV -

bucket handle tear of the superior labrum, with extension into the fibers of the

biceps tendon.

Table 1Results of ultrasound findings

Diagnosis Ultrasound (number of participants)

Complete rotator cuff rupture 27

Partial rotator cuff rupture 54

Hill-Sachs lesion 17

Osseous Bankart lesion 1

Degenerative changes 36

Negative 65

Total 200

Bankart lesion: injury of the anterior (inferior) glenoid labrum of the shoulder

due to repeated (anterior) shoulder dislocation; Hill-Sachs lesion: cortical

depression in the posterolateral head of the humerus bone.

Table 2Results of conventional MR and MR arthrography findings

Diagnosis Conventional MR (number of participants) MR arthrography (number of participants)

SLAP lesion 16 - Type II

4 - Type III

2 - Type I

21- Type II

45 - Type III

43 - Type IV

ALPSA lesion 1 4

GLAD lesion 0 1

Bankart lesion 5 -bony lesion

15 - fibrous lesion

Perthes lesion 0 6

Glenohumeral lesion (GHL) 1 - superior GHL

2 - middle GHL

5 - anterior inferior GH

2 - posterior inferior GHL

11 - superior GHL

13 - middle GHL

40 - anterior inferior GHL

21 - posterior inferior GHL

Rotator cuff rupture 27 - complete rupture

58 - partial rupture

27 - complete rupture

61 - partial rupture

Hill-Sachs lesion 40 4

Degenerative changes 85 86

Negative findings 67 5

ALPSA: anterior labral periosteal sleeve avulsion; Bankart lesion: injury of the anterior (inferior) glenoid labrum of the shoulder due to repeated (anterior)

shoulder dislocation; GLAD: anterior-inferior labral tear associated with an injury to the glenoid articular cartilage; Hill-Sachs lesion: cortical depression in the

posterolateral head of the humerus bone; MR, magnetic resonance; Perthes lesion: anterior glenohumeral injury in which the anterior labrum is lifted from the

edge of the glenoid along with a sleeve periosteum which is displaced medially, off the underlying bone; SLAP: superior, anterior-posterior labral lesion.

S30 R. Pavic et al. / Injury, Int. J. Care Injured 44 S3 (2013) S26–S32

to perform and is operator dependent. For assessing the glenoid

labrum, the origin and course of glenohumeral ligaments, tears

of the glenoid labrum, the relationship of the labrum with the

bicipital tendon and glenohumeral ligaments, MR arthrography

is superior to conventional MR imaging.

Jin et al. described the findings of Type II SLAP lesions in MR

arthrography.24 They assessed 57  patients, of which 34  patients

had SLAP Type II lesions and 23 patients had a sub-labral recess.

They concluded that anteroposterior (AP) extension of high signal

intensity on axial images was a helpful finding in diagnosing

type II SLAP lesions. This confirms our findings, where all of the

21 patients with SLAP lesions had an AP extension of high signal

intensity on axial images (Table 6).

Waldt et al. evaluated the accuracy of MR arthrography in

classifying the anteroinferior labroligamentous injuries.6 He

reported that MR arthrography was accurate both for acute

and chronic anteroinferior labroligamentous injuries, a finding

similar to ours (Table  6).

Table 3Comparison of US and MR arthrography findings in 200 patients

US findings

Yes, US found No, US found

Type of lesion MR arthrography findings lesion no lesion McNemar exact test p-value

SLAP Type II (n) Yes, MRA found lesion

No, MRA found no lesion

0

0

21

179

<0.001

SLAP type III (n) Yes, MRA found lesion

No, MRA found no lesion

0

0

45

155

<0.001

SLAP type IV (n) Yes, MRA found lesion

No, MRA found no lesion

0

0

43

157

<0.001

Bankart lesion (n) Yes, MRA found lesion

No, MRA found no lesion

0

0

20

180

<0.001

Superior glenohumeral ligament lesion (n) Yes, MRA found lesion

No, MRA found no lesion

0

0

11

189

<0.001

Middle glenohumeral ligament lesion (n) Yes, MRA found lesion

No, MRA found no lesion

0

0

13

187

<0.001

Anterior inferior glenohumeral ligament lesion (n) Yes, MRA found lesion

No, MRA found no lesion

0

0

40

160

<0.001

Posterior inferior glenohumeral ligament lesion (n) Yes, MRA found lesion

No, MRA found no lesion

0

0

21

189

<0.001

Number of participants 200

Bankart lesion: injury of the anterior (inferior) glenoid labrum of the shoulder due to repeated (anterior) shoulder dislocation; MR, magnetic resonance;

n, number of participants; SLAP: superior, anterior-posterior labral lesion; US, ultrasonography.

Table 4Comparison of MR and MR arthrography findings in 200 patients

US findings

Yes, US found No, US found

Type of lesion MR arthrography findings lesion no lesion McNemar exact test p-value

SLAP type III (n) Yes, MRA found lesion

No, MRA found no lesion

4

0

21

179

<0.001

SLAP type IV (n) Yes, MRA found lesion

No, MRA found no lesion

0

0

45

155

<0.001

Anterior inferior glenohumeral ligament lesion (n) Yes, MRA found lesion

No, MRA found no lesion

5

0

35

160

<0.001

Posterior inferior glenohumeral ligament lesion (n) Yes, MRA found lesion

No, MRA found no lesion

2

0

19

179

<0.001

Partial rotator cuff rupture (n) Yes, MRA found lesion

No, MRA found no lesion

58

0

13

129

<0.001

Number of participants 200

MR, magnetic resonance; n, number of participants; SLAP: superior, anterior-posterior labral lesion; US, ultrasonography.

Table 5Comparison of US and MR findings in 200 patients

US findings

Yes, US found No, US found

Type of lesion MR arthrography findings lesion no lesion McNemar exact test p-value

SLAP type II (n) Yes, MR found lesion

No, MR found no lesion

0

0

16

184

<0.001

Partial rotator cuff rupture (n) Yes, MR found lesion

No, MR found no lesion

54

0

4

142

<0.001

Hill-Sachs lesion (n) Yes, MR found lesion

No, MR found no lesion

17

0

23

160

<0.001

Number of participants 200

Hill-Sachs lesion: cortical depression in the posterolateral head of the humerus bone; MR, magnetic resonance; n, number of participants; SLAP: superior,

anterior-posterior labral lesion; US, ultrasonography.

R. Pavic et al. / Injury, Int. J. Care Injured 44 S3 (2013) S26–S32 S31

Bencardino et al. concluded in their study that MR arthro-

graphy is a useful and accurate technique in the diagnosis of SLAP

lesions of the shoulder. More specifically, it provided pertinent

pre-operative information with regards to the exact location

of tears and grade of involvement of the biceps tendon.25 Out

of 52 patients involved in their, 19 SLAP lesions were reported.

Our study agrees with their results with regards to the accuracy

of the MR arthrography, whereas out of 200 patients, 111 were

diagnosed with a SLAP lesion.

Amin et al. investigated the MR arthrography sensitivity and

concluded that it is a sensitive, minimally invasive technique

that can be utilised for the diagnosis and grading of SLAP lesions,

reducing the need for diagnostic arthroscopy.26 Out of 59 patients

included in their study, 22 were diagnosed with a SLAP lesion

and 1 with a Bankart lesion. In our study, out of 200 patients

included, 111 were diagnosed with a SLAP lesion and 15 with

Bankart lesions (Table 6).

Li et al. suggested that MR arthrography has a higher

sensitivity, specificity and accuracy when compared to MRI,

for the detection of anterior labrum lesions27, a finding similar

to our results. However, we detected no statistically significant

difference in diagnosing SLAP Type I and Type II with MRI, with or

without contrast media. Moreover, MR arthrography was found

to be more accurate in diagnosing SLAP Type II and III lesions.

Jana et al. analysed 52 patients with acute shoulder instability

and detected 30  labroligamentous lesions.28 They reported that

MR arthrography yields a good correlation with arthroscopy. In

our study only 35 patients underwent arthroscopy, but there still

was a good correlation with MR arthrography findings (Table 6).

MRI represents a sensitive method for the prompt assessment

of both bony and ligamentous injuries of the shoulder joint

when the initial radiographs are normal. The interpretation of

the results however depends on the reporting radiologist and

his experience.11 Generally, ample experience is required to

distinguish between a labral lesion and a normal anatomical

variant, small partial rupture of rotator cuff or ligamentus lesion.

In our case series, a single experienced radiologist reported all

the MRIs.

US scans were performed in all of our patients. Our results

correspond to results in literature.6,7 The topography and extend

of the lesion could be clearly visualised as well, which represents

critical information in planning the arthroscopic treatment. In

detail, detail pre-operative assessment of the extension of the

labral tear assists with planning the suture anchor placements

and saves time during arthroscopy. ALPSA lesions are also

important to be diagnosed on arthrograms since they can be

missed during arthroscopy, particularly after chronic injuries.8

ALPSA is indicative of a more severe trauma and recurrent

dislocation, which causes displacement of the labrocapsular

complex medially along the scapular neck.

Our study has some limitations. Because our cases were

collected from a non-selected patient population with a history

of chronic shoulder pain and instability, no specific images were

obtained. In only 35 cases arthroscopy followed MR arthrography

and confirmed MRI findings. In other cases patients went on

rehabilitation or they are still waiting for arthroscopy. Also, inter

observer variation was not assessed in our study because all MR

images were evaluated by only one musculoskeletal radiologist.

Conclusion

The US scan is a valuable diagnostic technique for rotator

cuff complete or incomplete ruptures. For evaluating Hill-Sachs

lesions or bony Bankart lesions, MRI is more accurate. In the case

of labral capsular ligamentous complex lesions, MR arthrography

is superior.

Table 6Comparison of MR arthrography findings in various studies

MR arthrography findings US findings

SLAP GLAD ALPSA Bankart Perthes rotator cuff Hill-Sachs

Author lesion lesion lesion lesion lesion rupture lesion Other findings

Bencardino, 200035

52 participants

19

T I - 16

T II - 9

T III -1

T IV - 3

3 B 1 3 inferior gleno-humeral

ligament lesion – 8

chondral lesion – 5

posterior labral tear -1

normal findings - 12

Jin, 200533

57 participants

T II - 34 superior labral recesus - 23

Waldt, 200534

104 participants

3 22 44 F 12 Non-classifiable. lesions

(injuries could not be

assigned to any categories)

- 23

Amin, 201236

34 participants

22 1 F 1 normal findings – 10

Li, 201237

78 participants

8 32 39 F 7 67

Jana, 201238

30 participants

T I - 1 29 F

Pavic, 2012

200 participants

111

T I – 2

T II – 21

T III – 45

T IV – 43

1 4 15 F

5 B

6 27 - complete

71- partial

41 27 complete and

54 partial

rotator cuff rupture

17 Hill-Sachs lesion

1 bony Bankart lesion

ALPSA: anterior labral periosteal sleeve avulsion; Bankart lesion: injury of the anterior (inferior) glenoid labrum of the shoulder due to repeated (anterior)

shoulder dislocation; Bony Bankart: Bankart lesion that includes a fracture of the anterior-inferior glenoid cavity of the scapula bone; B: bony lesion; F: fibrous

lesion; GLAD: anterior-inferior labral tear associated with an injury to the glenoid articular cartilage; Hill-Sachs lesion: cortical depression in the posterolateral

head of the humerus bone; Perthes lesion: anterior glenohumeral injury in which the anterior labrum is lifted from the edge of the glenoid along with a sleeve

periosteum which is displaced medially, off the underlying bone; MR, magntic resonance; SLAP: superior, anterior-posterior labral lesion; T I: Type I; T II:Type II;

T III: Type III; T IV: Type IV; US, ultrasonography.

S32 R. Pavic et al. / Injury, Int. J. Care Injured 44 S3 (2013) S26–S32

Conflict of interest

All authors declare they have no conflicts of interest.

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