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Posted By : Alcie - 7/13/2017 6:03 PM
A year ago last October I broke my ankle - foot turned 180 degrees, but "no tendon damage." Surgery with plates on both sides. After cast, non-weight bearing, etc, couldn't turn foot inward, pain continued. Last September (10 months later) I had surgery to replace tendon under inside of ankle, cut the heel bone, put in a wedge to turn foot inward (Evans osteotomy), and remove the plates.

I've been complaining since then about the pain and continuing inability to turn foot inward. In the last couple of months I have had top of foot pain and swelling, lessening ability to turn foot outward, on top of still not being able to turn foot inward. I saw the surgeon/podiatrist last week and got put off for 3-4 months more. Computers were down. No x-rays.

I've searched online, last resort, found no cure, or how this could be treated. I'm already seeing a pain doc, but he says pain is all in my neck. (I broke that and have neuropathic pain - like diabetic neuropathy without actual peripheral nerve damage). He's wrong. There's a difference between "real pain" and "scrambled messages from injured spinal cord." This is really in my foot. He at least upped my Oxycontin to 15 mg twice a day, which helps a little. As I'm writing you can tell I'm between doses. Whine. I have Norco as breakthrough, waiting the 45 minutes it takes for meds that have to be metabolized.

Something new is happening. I could rotate foot outward a month ago. Do I need more surgery? Any suggestions of where to look? I get to see the surgeon again at the end of September. OK, we're not docs. But the real ones aren't helping, giving up on me, and I've been in bad "real pain" 3 months short of 2 years plus bad "nerve pain" 4 years. I don't abuse meds. I've tried new orthotics, several ankle braces ... I suspect lateral (peroneal) tendon is shot, also the ligaments were torn and not fixed. Don't they fix them? Why is peroneal tendon not working? OK, it's supposed to take a year for this surgery to help, but it's getting worse.

Posted By : (Seashell) - 7/13/2017 9:19 PM
Alice:
It sounds as though you have either a complete tendon avulsion or a pressure induced paresis of the common perineal nerve.

Paresis of the common personnel nerve could have occurred due to swelling after the injury (intrafascial swelling or compartment syndrome) or due to a dressing or cast or splint that was too tight or that placed pressure on the nerve (frequent point of injury is the fibulae head). Tendon avulsion could be due to incomplete healing or incomplete surgical fixation or lack of adequate blood flow/nutrition to the tendon.

An EMG of the lower leg would be a helpful diagnostic test as would an MRI. MRI Wiuld be superior to a CT scan for evaluation of soft tissue and tendon injury.

I can hear your frustration. It is fairly characteristic that physicians do not like to deal with the aftermath and collateral damage of healing processes that have gone askew. You deserve solid answers to your questions regarding lack of function of your foot and loss of volitional movement (supination).
Karen
Pituitary failure, wide-spread endocrine dysfunction
Addison's disease
Mixed connective tissue disorder
Extensive intestinal perforation with sepsis, permanent ileostomy
Avascular necrosis of both hips and jaw
Receiving Palliative Care (care and comfort)

Posted By : Alcie - 7/14/2017 11:07 AM
Great information! Thanks a bunch. I've started educating myself and will call the surgeon's office about getting a CT and EMG. He didn't even take x-rays last visit because all computer services were down. I was wondering if they were hit by the scammers that hit other local hospitals demanding money to release records.

I can't get an MRI because the plate they put on the calcaneus for the Evans osteotomy will just mess up imaging.

I wonder if my ankle brace could be causing pressure on the nerve. I'll leave it off, stop crossing my legs, and use kneeling pads when gardening. Maybe something I am doing is part of the problem.

I can move my foot up and down, well enough to push the heavy clutch pedal on my tractor. It's the side to side motion that's gone. Not sure if that's supination, although the rolling action outward is also gone, which I think IS supination. Moving laterally was OK at the appointment 2 weeks ago. But now it's gone altogether.

Pronation has been frozen since last September's surgery.

The surgeon gave me a steroid injection for the fairly puffed up, visible and painful swelling in what I think is the sinus tarsi. It's a soft area anterior to the lateral malleolus. It hurt for a couple of days after the anesthetic wore off, then swelling and pain were reduced for a week, and now it's back to swollen and painful after walking.

I'll read more about tendon avulsion, intrafascial swelling, and peroneal nerve paresis, also about ligaments. Surgeons pronounce you cured when they put a few parts together. Their minions may not know anything at all, like the one who told me I had no tendon problems although my foot had been twisted behind me, making me think I'd lost it somewhere.

Posted By : straydog - 7/14/2017 11:40 AM
Alcie, I was hoping Karen would have some good input for you. Her knowledge bank has helped so many people here. I know a lot of your health history over the years as you are old timer like me here, lol. I completely agree with you two about so many surgeons do not want to deal with the aftermath of their own handy work!!

I hope you can put together some good info to hit the surgeon with. Oh, the computer issues with the dr. Let me tell you my story. about 3-4 months ago, I turned on my laptop & this Microsoft Logo took over m entire screen, in large bold letters it said my computer had become compromised along with all of my personal information. My computer completely locked up & I was unable to shut it down! It gave a phone number to call. I was so scared, I called the darn number. Some fella that I could not understand well at all went into this spill about me basically being hacked & for $750 that could get my computer unlocked & remove the malware crap. Then I knew it was a SCAM. I started laughing at the guy, I said look, I am on SS, I exist month to month, not live but exist. I wanted to make it very clear to him I had no money & he wasn't going to get any money from me. He put me on hold & then came back that he explained to his supervisor that I had no money but as a way of trying to help me thy could now help me for $250, lol. Naturally all I had to do was give them my debit or credit card number. I told him sorry I have no money. I could not turn my computer off, so I closed the lid on it & the next day I opened the lid & my laptop was unlocked!! I took it in & had it cleaned.

I called my neighbor that works out of state at a hospital. I took a pic of the screen & sent it to him. He is a nurse anesthetist & this very same group locked the hospital's system. The hospital paid this bunch $68,000.00 to unlock their system. I asked why in the world would they do that & he said it would have been 2 days before they could get someone there to come in & fix it. He said the hospital could not wait that long & I understood after he told me. This group was out of India & had scammed millions off of people & hospitals. They are very sharp.

I sure hope you can get some help
Susie
Moderator in Chronic Pain & Psoriasis Forums

Posted By : Alcie - 7/14/2017 5:00 PM
At least I don't click on scam links. My computer was only worth a couple of hundred new, and I keep pictures backed up on an external drive which is not connected unless I am backing up. I have another one with all my old files. Just in case.

Karen's info is so helpful. If anyone else has ideas I'm listening. Over the years I've learned so much from the team - the people who have had experiences on the forum.

I've got a lot more to learn about this foot pain.

Posted By : (Seashell) - 7/15/2017 2:09 PM
Alice:
I did not proof read my post in reply to you before submitting the send button. There are several misspellings that might give you confusion.

The common peroneal nerve is a potential source of injury related to the limited movements of your foot. I have several misspellings in my prior post.

The most beneficial diagnostic test would be an EMG to assess the viability of the nerves and their secondary branches that innervate the lower leg. The common peroneal nerve has two subsidiary branches, the deep and superficial peroneal nerves. One or both may be affected.

Inversion is rotation of the soul of the foot inward toward the center/midline of the body. Eversion/pronation is rotation of the sole of the foot outward/away from the body midline/center.

Damage to the nerve may have happened at any point since your initial injury and may or may not be related to the corrective surgeries.

Most likely is a pressure injury or pressure paresis to the nerve. Swelling is a common cause of pressure paresis. Compartmental syndrome is the term used to describe fluid/swelling confined by the fascia that envelopes a muscle. Swelling is trapped within the fascia that covers the tibialis anterior, as an example, causing a build up of pressure. Sustained pressure on a nerve branch effectively blocks impulse transmission (motor and/or sensory impulses) with resultant muscle paresis of those muscles normally innervated by the nerve branch. Early detection here is key. Compartmental syndrome is treated by surgically "slicing" along the fascia, releasing the connective tissue tension and heightened swelling and pressure.

Another possibility is pressure on the nerve from a splint or brace or cast. Common injury site is the fibular head, as there is less protective padding/fat on the bony projection. Be extra careful to add a layer of padding to any strap or binding of any splints that you may be using.

If you are thin you have a greater chance of a pressure injury to the peroneal nerve simply due to there being less protective adipose tissue when wearing a splint or brace. A surgeon who is less attentive can also be at fault when overly inflating a tourniquet operatively. It is common for a tourniquet placed on the lower thigh or upper tibia during surgery. For people with thin legs, this can be an area of concern if the tourniquet pressure is too high.

Most pressure injuries to nerves are temporary. That is Good news.

Work with your physicians on evaluating your lower leg for common peroneal nerve paresis. An EMG should provide information on how well the nerve is transmitting impulses (or not) to the muscles of the foot and ankle affected.
Karen

Posted By : Alcie - 7/16/2017 10:54 AM
Thanks, Karen.
I wasn't worried about the misspellings. I knew what you meant. I'm no doctor, but I have an education and work experience in science.

I am thin. Not anorexic, but at my high school weight. That's an interesting point! No padding in legs.

Maybe some of the problem was during surgery (third since break a year and a half ago), because pain in several areas has not gotten better, and it's worse now than after the first two surgeries right after the break, when they ignored the torn tendons and ligaments.

Peroneal pain started after this surgery, not sure when because of so much pain, cast, walking boot. They just kept telling me it would take time. Lateral to top of foot pain started only 3 months ago and not being able to twist my foot outward - straight, not rolling as in pronation - just testing to see if peroneal tendon was working, just started in the last couple of weeks, and the Evans ostoeotomy surgery was 10 months ago. I suspect you might have an idea about the nerve, not just a tendon problem.

I tried walking without the lace-up brace, but my ankle hurts even more. Too much walking. I'll try the brace with foam padding today. If this doesn't help I'm going to call the surgeon and ask for an EMG. I don't expect to be out of pain by this time, but I didn't expect it to be getting suddenly worse.

Posted By : (Seashell) - 7/16/2017 8:04 PM
Alice:
There are some 26 bones that compose the foot. The tarsal bones are vital in contributing to one's balance in standing. Postural sway initiated by corrective responses in the foot and ankle, is the body's primary balance recovery strategy. Flexibility and neuromuscular control of the foot and ankle is a crucial aspect in keeping of upright and tolerating disruption to our balance point.

Given the description of your initial injury, it would stand to reason that you had significant tendon and ligament injury. Tendons connect muscle to bone. Ligaments connect bone to bone.

That you are lean in weight/body mass does give suspect that the common peroneal nerve was compressed by a strap, band, or tourniquet that was too constricting/tight. A pressure paresis or paralysis of nerve transmission would result. Most peripheral nerve injuries due to compression are transient.

Do make sure that any positioning split that you may be using has adequate padding, especially padding of straps that are used to secure the splint. Make sure that there are no pressure areas.

In my years as a practicing physical therapist, it became apparent to me that excellent surgeons do have patients with better functional outcomes than marginal and sub-par surgeons. Surgical skill does make a measurable impact on healing and recovery. Marginal and sub-par surgeons leave patients with more connective tissue trauma and more post-operative inflammation. That you are experiencing more residual pain and persistent swelling and inflammation suggests: 1. That the ankle/foot is reacting to both the initial injury and surgeries as trauma; 2. That your surgeon was less then highly skilled.

Another possibility is that your foot and ankle are demonstrating a localized reflex sympathetic dystrophy. The initial injury and subsequent 3 surgeries may be more trauma than the lower leg can tolerate. Do you have any tropic skin changes?

I would suggest getting an EMG study and CT scan (MRI aid orederred but I understand you have contraindications) to assess nerve impulse conductivity and to assess for unrecognized tendon and ligament injury.

I would avoid additional surgery if at all possible. Each surgery is a trauma in and of itsellf.

I think you are heading in the right direction in seeking more definitive answers from your physicians.
Karen
Pituitary failure, wide-spread endocrine dysfunction
Addison's disease
Mixed connective tissue disorder
Extensive intestinal perforation with sepsis, permanent ileostomy
Avascular necrosis of both hips and jaw
Receiving Palliative Care (care and comfort)

Posted By : Alcie - 7/17/2017 9:51 AM
My first 2 surgeries, day after and 2 weeks after the bad break, were done by an orthopedic surgeon. He is not an ankle specialist, although one was at the same hospital and could have been called on to at least do the big one with the plates. I had 2 plates up the tibia! But once a surgeon gets you, they don't hand you off to anyone else.

The surgery 10 months later was a podiatrist who specialized in surgery at a different hospital. I could have had the surgery done by the ankle specialist at the first hospital, but I won't go there because they refused to give me adequate pain relief the first two times. I am morphine non-reactive and fentanyl just makes me horribly sick, and the hospital has a policy against using Dilaudid. The podiatrist did the same surgery, Evans osteotomy, as the ankle specialist recommended. I don't think the podiatrist did anything wrong, but I wonder if there was something that should have been done with the ligaments, or maybe there wasn't anything to do?

Topic? I assume you mean trophic skin changes. I had tenting and 3 bone bruises. I still have a small area of brown skin from the largest bone bruise. Laterally, I have a large brown scar where the 2 plates were removed from the fibula and a smaller brown scar where the wedge and plate were placed on the calcaneus. The medial scar from placing and removing the plate from the tibia is thin and white. I get swelling above the top of the brace, some even if I am not wearing the brace. Today I have swelling in the entire area under and just toward the toes from the bottom of the fibula. That area in particular and the whole foot hurt a lot even with Oxycontin and Norco.

On reading about trophic changes I found mentions of disc problems, which I have, but I don't think this is my problem.

I asked my pain doc, an anesthesiologist who previously had a lot of experience with RSD, but he said absolutely not!! Is it possible to have a touch of it?

I think, Karen, you have hit on the most likely issue, that of nerve compression. Going without the brace and walking a lot yesterday, even though I wore my best shoes and orthotics, made pain and swelling worse today, so I am going to call the surgeon about it now.

Posted By : (Seashell) - 7/17/2017 11:31 AM
Alice:
Yes. . I meant to type trophic skin changes. These would include a shiny appearance to the skin, the skin appearing taut as though stretched. The skin is often thin and translucent, as well. Pain, swelling, and erythema cycle through the day.

Yes . . You can have a subtle case of reflex sympathic dystrophy. It need not be an all or none reaction.

Reflex sympathies dystrophy does not depend on an injury to a spinal disc. There need be no spine or disc involvement.

RSD can present to any part of the body and to any joint. The typical cause is repeated trauma to the area in the body. The nervous system responds with a hyper-active response of the autonomic nervous system.

I had a case of RSD that affected my knee and lower leg after 3 surgeries to correct a torn anterior cruciate ligament. The first surgeon did a sub-optimal surgery, which necessitates the additional 2 surgeries to correct his "mess" and scar tissue. The surgical trauma was the trigger of my RSD. This could likely be the case with you, as well.

I did recover from the RSD. Fully. It took a good year of dedicated physical therapy and self-care to achieve resolution.

My hunch is that you have had some sub-optimal surgical care of your ankle and resultant fractures and ligament and tendon injuries. Your body is responding by calling attention to the plight of your ankle through symptoms presenting as reflex sympathetic dystrophy.

Physicians will be hesitant to acknowledge your RSD as it would be an acknowledgement of less than optimal surgical techniques and after care.
Karen
Pituitary failure, wide-spread endocrine dysfunction
Addison's disease
Mixed connective tissue disorder
Extensive intestinal perforation with sepsis, permanent ileostomy
Avascular necrosis of both hips and jaw
Receiving Palliative Care (care and comfort)

Posted By : Alcie - 7/18/2017 4:08 PM
Karen, what sort of physical therapy and self-care worked for you? I may have to resort to paying for it myself, as Medicare said I could only have 20 PT visits after my last surgery.

I don't think the first surgeon did anything wrong, but I think he should have recognized that there had to be tendon damage. I'm angry with the resident who told me there was no tendon problem, that they only stretched and were fine. I wasn't left with a "mess" like you were, but I didn't tolerate the plates, and taking them out in addition to moving the little toes tendon to replace the torn one, etc, was a lot for my abused ankle.

My skin looks OK, except for the lateral scars being dark and the one dark spot where the largest bone/fracture bruise was. Pain cycles, swelling has been there but just started getting worse suddenly. The lower leg, ankle and foot are warm, sometimes quite red or purple.

I didn't mean that I thought spine was involved, just that it's another factor, and my docs are using that ongoing neuropathy to say I have no problem in my leg, ankle, foot.

I'm afraid now to ask for surgery to fix anything, including cleaning out my knee again, for fear it will trigger serious RSD. Knee has had swelling for a year, had surgery to clean out bone chips after my big truck wreck.

I didn't get a chance to call doc office. Kidsitting suddenly for grands overnight. 7 and 9 y.o. cooked dinner. They went home after office closed today. (Kids cooking takes twice as long, but it's a chemistry lesson.) On feet too long.

Posted By : (Seashell) - 7/18/2017 5:03 PM
Alice:
A principle at-home therapy that I employed was alternating contrast water soaks for my affected leg. Alternating warm water bath with a cool water bath. The alternating vasodilation and vasoconstriction prompts the damaged autonomic nervous system to recalibrate to a more normal response in a leg/extremity affected by full or partial RSD.

For you: Purchase 2 deep plastic tubs or plastic containers that can fully accommodate your foot and ankle and that you can comfortable immerse you foot and ankle. Fill one tub with warm water. The other with cool/cold water - as your hypersensitive foot-ankle can tolerate. Immerse in warm water x 5 minutes. Reverse and immerse in cool water x 5 minutes. Rest for 10 minutes (no water immersion).

Repeat the entire process 2 times, twice a day (morning and late afternoon).

The goal is to expose the RSD sensitive limb to forced vasodilation and forced vasoconstriction as a means of re-educating the damaged autonomic nervous system. You are introducing purposeful stimuli to a limb where the autonomic nervous system is on constant over-stimulation.

A second in-home therapy was wearing if a mild compressive sleeve over my leg. I wore a pair of anti-emboli stockings. 10-15 mg Hg of pressure, low gradient pressure. You purchase TED hose in most pharmacy stores.

The goal is to provide a purposeful external stimuli (compression stockinette) to counter the affected limb's aberrant sensory impulses. It is similar to swabbing a crying baby or the use of Thunder-shirts on anxious dogs (stretchy elastic vests that give anxious dogs a calming hug).

A third in-home therapy was making a sensory stimulation box. This was a large shoe-box type that was filled with dry rice. I also placed various objects with unusual textures or shapes - a few coins, paper clips, shirt and coat buttons, sewing thimble, you get the idea. Place your foot in the box, completing covering the foot with the rice and embedded objects. Move and flex the toes as though massaging the rice with your foot and toes.

The goal is to overwhelm the RSD damaged foot with a barrage of new and different tactile stimuli to override the aberrant self-generated painful sensory stimuli. You are inputting purposeful stimuli into the affected foot/ankle to override the abberant sensory impulses self-generated by the damaged nerves.

You can also look online for what are called therapeutic foot roller pins. These look like bakery rolling pins used to flatten cookie dough. The roller pin usually has raised projections on the surface that your roll the ball of the foot over. These are also sold as treatment for plantar fasciitis. The goal is to mobilize the small bones of the foot by rolling the sole of the foot back and forth over the rolling pins projections. The Relax The Back store has these advertised to ease tired and achy feet.

OK . . That may be more than you are wanting. It does give you several options to try and to see what might work for you to desensitize your foot and ankle. RSD is agonizing. I hope something here helps you.
Karen

Posted By : Alcie - 7/19/2017 8:22 AM
Thanks! I had no idea there were so many, easy things I could do at home. I'm pretty sure Medicare will say I've had all they allow (20 visits).

I have tubs - use them under my large potted plants indoors in winter. I have a big bag of rice.
This sounds a lot like the heat and cold the PTs use to start therapy in their clinics.

I have some dryer balls, wonder if they would help? I'll look up the real things online.

I have several pairs of various strengths of compression hose, made to measure, all way too tight. I have some extra mild hospital ones that I haven't tried since surgery. The pharmacy ones are all too long for my short legs. I can't wear any hose just now in this 90 degree heat, very high humidity. I spent half an hour outside partly putting together a fountain in my garden and had to come in. When my head starts dripping I'm in trouble - autonomic dysreflexia - can't sweat from neck down.

I hope others needing at home PT will read your posts. Trying is better than sitting and getting worse!

Posted By : straydog - 7/19/2017 10:22 AM
Alcie, like you I cannot wear the Jobe's stockings in this Tx heat. I do have a cotton type sleeve things that was used when I was going to out patient wound care that worked pretty good. Another thing I have found that works well is Walgreens sells compression socks mens & womens. I cut the foot out of them much easier to slip on. I am thinking WhiteBeard bought some because he was going to be on a long flight. He said they worked very well in keeping the swelling down. Maybe something to look at when you are out the next time.

Karen has so much to offer us here in the forum.
Susie
Moderator in Chronic Pain & Psoriasis Forums

Posted By : (Seashell) - 7/20/2017 4:14 PM
Alice:
You have such a refreshing and spirited attitude to you, despite the hurdles placed before you with your foot and ankle. I applaud your willingness to keep on keeping on.

Compression hose come in a variety of pressure gradients. Light pressure stockings are in the 10 - 15 mg HG range. They are also referred to as lite anti-embolism stockings. Traditional TED hose are 30 mg HG - so the lite compression socks are 50% less constricting and would be more easily tolerated by your stressed sensory processing system. You need not wear a toe to thigh stocking. You need no more than a knee high stocking with a 10 - 12 mg HG pressure rating.

I found wearing compression stockings immensely comforting. It was like an enveloped hug around my bitterly complaining knee. The compression soothes overly active sensory nerves much as a crying infant is calmed by swaddling of a blanket.


You can also use stretchy Coban wrap in lieu of a compression stocking/sock. Wrap the Coban as you would an ace bandage to provide a supportive pressure to your foot/ankle. Coban stays in place and anchors well, unlike an ace bandage that tends to slip and bunch up.

Start your desensitization program gently and slowly.

Doing too much can be counter productive. Overwhelmed nerve fibers do not take well to an aggressive approach. The adtage, "less is more" holds true for the healing of sensory nerves. Be mindful of taking a gentle approach to desensitizing the traumatized sensory nerves in your affected foot and ankle.

Best wishes for success,
Karen
Pituitary failure, wide-spread endocrine dysfunction
Addison's disease
Mixed connective tissue disorder
Extensive intestinal perforation with sepsis, permanent ileostomy
Avascular necrosis of both hips and jaw
Receiving Palliative Care (care and comfort)

Posted By : Alcie - 8/1/2017 4:57 PM
My ankle swelling and pain have been getting worse for the last month and a half or so. I saw the surgeon today and he said now I have peroneal tendonitis, which I did not have before! (tendonitis, tendinitis, tendinopathy - whatever you want to call it ... /www.ncbi.nlm.nih.gov/pmc/articles/PMC2691556/

How did I get this? The peroneal tendon was not torn when I broke the ankle almost 2 years ago. It's not happy now though, increasingly swollen and painful. Was "flatfoot surgery" (for the torn tendon and collapsing ankle on the other side) the cause?

So now I will go to phys therapy again. Does PT help tendonitis?

Posted By : straydog - 8/1/2017 6:29 PM
Alcie, I did a search on this & it is very much real. I read your link but read in other sites. Overuse, people with higher arches are prone, ankle instability, athletes are prone to this too. They recommended protection, rest, compression wrap, icing for mild cases & exercises. PT was mentioned for moderate cases. I have just glazed over this but just trying to give you an idea. So being flat footed is not the culprit. I read some sports medicine sites that has a lot of information. In your case I think the ankle instability is probably what caused this. Like I said there are lots of reasons this can happen.
Susie
Moderator in Chronic Pain & Psoriasis Forums

Posted By : (Seashell) - 8/3/2017 3:37 PM
Alice:
I am sorry to hear that you have another diagnosis to contend with. Peroneal tendonitis.

As Robin would say to Bateman: "Drat. And Double Drat."

The good news is that peroneal tendonitis responds well to conservative approaches to ease inflammation.

The tendonitis is painful owing to heightened inflammation with triggers the surrounding soft tissue to produce serous fluid. The serous fluid becomes entrapped in the fascial covering of the tendon. The fluid causes the fascia covering to swell and stretch - causing pain.

Resting if the involved joints is key. Use of intermittent ice and compression socks or compression tape.

I hope that you find some meaningful measure of relief with the partnering of a physical therapist or ancilary clinician,
Karen
Pituitary failure, wide-spread endocrine dysfunction
Addison's disease
Mixed connective tissue disorder
Extensive intestinal perforation with sepsis, permanent ileostomy
Avascular necrosis of both hips and jaw
Receiving Palliative Care (care and comfort)

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