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Shoulder& Elbow. ISSN 1758-5732
E R E V I E W A R T I C L E
Primary elbow osteoarthritis: an updated reviewDeepthi Nandan Adla & David Stanley
Department of Orthopaedics, Northern General Hospital, Sheffield, UKDepartment of Orthopaedics, STH Foundation Trust, Sheffield, UK
Received
Received 30 April 2010;
accepted 16 July 2010
KeywordsPrimary osteoarthritis, elbow, aetiology, natural
history, management, open surgery and
arthroscopy, arthroplasty
Conflicts of Interest
None declared
Correspondence
David Stanley, Department of Orthopaedics,
Northern General Hospital, Sheffield, South
Yorkshire, S5 7AU, UK.
Tel.:+44 (0)114 2714025.Fax:+44 (0)114 2266796.
E-mail: [email protected]
DOI:10.1111/j.1758-5740.2010.00089.x
ABSTRACT
Primary elbow arthritis predominantly affects middle aged men undertaking heavy manual work. Patients
present with pain and limited movement butmay also complain of ulnar nerve sensory or motor symptoms.
Radiographic features include osteophytes at the tip of the olecranon and coronoid processes, loose bodies,
narrowing of the radiocapitellar joint space and thickening of the olecranon fossa membrane.
Treatment options range from conservative management using oral analgaesics and non-steroidal anti-
inflammatory drugs through to open debridement procedures, arthroscopy and occasionaly in selected
patients total elbow arthroplasty.
INTRODUCTION
Primary osteoarthritis (OA) of the elbow is a relatively uncommon
condition mainly affecting middle aged men. It accounts for 1% to
2% of patients presenting with all types of elbow arthritis [1]. In a
specialistrheumatologypractice,DohertyandPrestonidentified16
patients (7%)withelbow osteoarthritis from225 referrals withnon-nodal large joint osteoarthritis [2]. Previous reports on elbow OA
have notcommented on associated involvement at other sites but,
in this series, 71% of men had associated metacarpophalangeal
joint OA. As with the elbow, the metacarpophalangeal joint is
often considered an uncommon site for OA. It has been suggested
that this association occurs principally in those undertaking heavy
manual work (Missouri metacarpal syndrome) [2,3]. In a study
assessing 1000 consecutive fracture clinic patients, the prevalence
of symptomatic elbow osteoarthritis was noted to be 2%. The
condition was rarely seen in patients below 40 years of age and
was very uncommon in women [4].
AETIOLOGY
The aetiology of primary elbow OA is still unclear, although
combinations of environmental and genetic factors have been
implicated. In particular, there are a number of studies that have
suggested heavy and repetitive work to be important factors.
Elbow osteoarthritis was noted in 32.8% of 744 German coal
miners who used pneumatic boring hammers on a regular
basis [5]. A later study by Hunteret al. assessed 286pneumatic tool
workers, and noted elbow OA in 10.5%. The authors concluded,
however, that there was no convincing evidence for this being
caused by pneumatic tools. They also noted that there was
no increase in frequency of OA in patients using tools with
higher vibration frequencies [6]. Lawrence showed no statistical
significant difference in the incidence of elbow OA in coal miners
who used pneumatic drills for 1 year (31%) compared to those
who did not use this equipment (16%). He concluded that thedevelopmentof elbowarthritis wasa feature ofmosttypesof heavy
manual work that he investigated [7]. More recently, a significant
doseeffect relationship to the range of flexion and radiographic
changes in the dominant elbow, which was independent of age,
wasnotedinastudyof74malestonequarryworkerswhooperated
chipping hammers and rock drills [8].
Heavy nondrilling work has also been reported to be associated
with elbow OA. It has not been reported in light manual office
based workers, although it was noticed more commonly in
heavy coalmine workers [7,9]. A study from Sheffield showed the
prevalence of elbow OA to be 10.5% in heavy workers compared
to 2.2% in nonheavy workers, with the dominant arm more
frequently affected. The condition is also recognized in patients
with ambulatory problems, requiring the use of crutches. In this
group, the dominant extremity is involved in approximately 80%
to 90% of patients [10]. All these findings suggest that excessive
loading of the elbow is an important predisposing factor.
The part played by genetic factors in elbow OA is less clear,
although demographic studies have shown differences in the
incidence of the condition in different races. A positive family
history was not noted in patients with symptomatic elbow
OA [4].
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Table 1 Classification of primary elbow osteoarthritis
Symptoms Signs Radiographic findings
Mild Intermittent acute pain. Pain mostly onextension
Posterior tenderness,Pain on passive elbow extension sign of posterior
impingementROM: near normal, but may have fixed flexion
deformity of less than 30 . Flexion is usually normal
Small osteophytes on tip ofolecranon and orcoranoid
Moderate Pain worse with activitiesLocking of jointDeteriorating ROM
Tender posteriorly and sometimes anteriorly.Crepitus on gripping and forearm rotationROM: 30 to 120
Obvious osteophytesJoint line preservedOlecranon and coronoid
fossae thickened
Severe Constant pain requiring regular analgesiaPain throughout ROMStiffness and crepitus
Generalized joint tendernessCrepitus and pain throughout ROMROM: 50 to 110
Obvious osteophytesJoint line narrowedLoss of the outline of
olecranon and Coranoidfossae
ROM, range of motion.
NATURAL HISTORYANDCHANGES INELBOW
OSTEOARTHRITIS
Goodfellow and Bullough studied the age related changes in
the elbow joint in 28 cadavers. They noticed a certain pattern
of degeneration and wear in the radiohumeral joint which was
considered to be the result of a combination of rotation and hinge
movements. By contrast, the ulnohumeral articulation, which has
hingemovementonly, showed onlyminorlinearwear changes [11].
Age-related changes appear to start on the radial aspect of the
elbow and gradually progress to the ulnohumeral joint, as a
result of excessive load concentrations occurring at the centre
of the joint. These findings were confirmed in another cadavericstudy [12] and similar intra-operative observations have been
recorded [13,14].
More recently, a casecontrol study comparing radiographic
changes at the elbow joint in patients with elbow osteoarthritis
with age- and sex-matched individuals showed that joint nar
rowing at the radiocapitellar joint was the third most common
findinginOApatients.Thechangesintheosteoarthritisgroupwere
predominantly of osteophyte formation, involving the olecranon,
coronoid and radial head in descending order. The classic features
of osteoarthritis with joint space narrowing and cyst formation
are late and uncommon findings in the elbow. Loose bodies and
thickening of the olecrenon fossa membrane were also frequentlynoted [15].
A histopathological study of the elbow confirmed thickening
of all components of olecranon fossa membrane (anterior cortical
bone, medullary cavity, posterior cortical bone, and anterior and
posterior fibrous tissue) in patients with osteoarthritis of theelbow
compared to a control group [16].
The histological and radiographic changes in the osteoarthritic
elbow help to explain the pattern of presentation, which is
predominantly related to impingement and loose body formation,
causing mechanical symptoms.
Clinicalpresentation
The usual mode of presentation is pain, reduced movement
and locking. The clinical presentation can be broadly classified
as mechanical, which may be in mild, moderate, severe stages
(Table 1), or neurological from ulnar neuropathy.
Mild
Patients withmild disease mostfrequentlypresent withdull aching
pain in theelbowwithintermittent episodes of acute pain. Patients
frequently have a near normal range of motion (ROM), although,
when a deficit is present, it is usually a fixed flexion deformity of
less than 30. There may be early ulnohumeral impingement as a
result of osteophytes at thetip of theolecranonand coranoid,with
pain on terminal extension and tenderness in the paraolecranon
fossae (Fig. 1).
Moderate
In this stage, there is a progressive deterioration of ROM, with
episodes of locking andacutepain.The pain is worse with activities
that require heavy lifting or extension of the elbow. Patients often
describe, locking of the joint, which requires trick movements to
unlock the elbow, and usually indicating the presence of a loose
body [17]. On clinical examination,the elbow maybe swollen, with
tenderness over the posterior and anterior aspects. A reduction
in ROM to less than 30 of full extension to 120 flexion is
often present. Crepitus may be palpable on gripping and forearm
rotation, indicating degeneration of the radiocapitellar joint. The
symptoms at this stage are a result of osteophytes and loose
bodies, which can be confirmed by plain radiographs (Fig. 2).
Severe
In severe disease, there is significant reduction in the ROM and the
pain is more constant. Patients usually require regular analgesia
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Fig. 1 Patient initially underwent a tennis elbow release, but represented
withpainonextendingtheelbowandwithsignsofposteriorimpingement(mild osteoarthritis). Plain radiographs show heterotropic bone formation
at the surgical site but a computed tomography scan with elbow in
extension shows posterior impingement.
and significant night pain may be a feature. On examination, there
is reduction in the ROM to 50 to 110 of flexion, and crepitus
throughout the ROM is frequently noted. Reduction in joint space
and osteophytes are seen on plain radiographs (Fig. 3).
Ulnarneuropathy
Ulnar nerve irritation is commonly observed in patients with
elbow OA. Reduced sensation in the ulnar nerve distributionand weakness may be the sole presenting symptoms. Kashiwagi
reported an incidence of 40.3% in patients with elbow OA [18] and
a Japanese study on cubital tunnel syndrome noted evidence of
elbow OA > 30% of patients [19]. A recent case series of elbow
arthritisreportedulnarnerveirritationtobeashighas84% [20].The
irritation/entrapment is considered to be a result of osteophytes
or other space occupying lesions such as ganglions arising from
the elbow joint. A prevalence of 3% to 8% of medial elbow
ganglia as a cause of ulnar nerve compression has been reported
in patients presenting with cubital tunnel syndrome. This was the
third most common cause of ulnar nerve compression [21,22].
A rapid onset of ulnar nerve symptoms should raise the
suspicion of a ganglion and further imaging is appropriate before
surgery [22].
Investigations
Imaging modalities are used to confirm the diagnosis of elbow OA
and electrophysiological tests for assessing ulnar nerve function.
A standard plain radiograph of the elbow (anteroposterior and
lateral views) is sufficient to diagnose most cases of elbow OA. The
anteroposterior radiograph helps to assess the overall alignment
of the joint, ulnohumeral joint line, radiocapitellar joint line and
Fig. 2 Patient withmoderateelbow osteoarthritis. Plainradiographsshow
the osteophytes and the computed tomography scan shows a thickened
olecranon membrane.
radial head osteophytes. It also shows the loss of outline of
the olecranon fossa (indicating thickening of the membrane).Kashiwagi advocated a special radiographic view to assess the
fossa. This is performed with the elbow flexed to 60 and the
distal arm placed flat over the X-ray plate [18] (Fig. 4). The lateral
radiograph is useful in assessing osteophytes at the tip of the
olecranon and coronoid process, the ulnohumeral articulation and
loose bodies. A recent radiographic study showed that the most
common features in elbow OA were olecranon osteophytes (96%),
followed by osteophytes of the coronoid process (90%), radial
head (86%) and coronoid and radial fossae (64%) [15]. A more
recent three-dimensional computed tomography (CT) scan study
of 22 patients with elbow OA, to map the osteophyte distribution
confirmed that, in 95% of patients, the osteophytes involved theulnohumeral joint, whereas radiohumeral osteophytes were only
foundin 59%. Although cadaveric and biomechanical studies show
that theradiohumeral joint ismore proneto wear, theulnohumeral
joint is more markedly affected by osteophytes [23].
Loose bodies are a common cause for locking and they can
mostly be identified on a plain radiograph. Ward et al. reported a
sensitivity of 79%, a specificity of 69% and a diagnostic accuracy
of 75% for plain radiography of loose bodies in the elbow [24].
A more recent comparison of plain radiography with arthroscopy
yielded a sensitivity of 84% and a specificity of 71%. Plain
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Fig. 3 Patientwith severeelbowosteoarthritis,with jointspacenarrowing.
radiography had a similar sensitivity and specificity to CT
arthrography and magnetic resonance imaging (MRI) (overall
sensitivity for the detection of loose bodies in either compartment
was 88% to 100% with a specificity 20% to 70%) [25].
Correlating theclinical symptoms and signs with theradigraphic
features is helpful in planning treatment because mild andmoderate stage disease can be managed by debridement
procedures. In early stage OA, the radiographs may show small
osteophytes on the tip of olecranon or coranoid with thickening of
the olecranon fossa membrane (Fig. 1). In moderate stage OA, the
osteophytes aremore obvious, although thejointline remains well
preserved (Fig. 2). In severe stages of OA, there is a clear reduction
in the joint space, which initially affects the radiocapitellar joint
and, subsequently, the ulnohumeral articulations (Fig. 3).
CT scans of the elbow with three-dimensional reconstructions
help visualize shelf osteophytes, in the olecranon, radial and
Fig. 4 Kashiwagi view: anteroposterior view of elbow taken with theelbow flexed to 60 and arm resting flat on the plate. The olecranon fossa
is clearly demonstrated.
the coronoid fossae. CT scanning with the elbow in maximal
extension identifies impingement of the tip of the olecranon on
the membrane of the fossa. The relationship of osteophytes to the
ulnar nerve is important with respect to surgical planning [26].
Both MRI and CT arthrography have excellent sensitivity (92%to 100%) but low to moderate specificity (15% to 77%) for
identifying posteriorly-based loose bodies. Neither MRI, nor CT
arthrography is consistently sensitive (46% to 91%) or specific
(13% to 73%) in predicting thepresenceor absence of loose bodies
anteriorly. In view of the invasive nature of CT arthrography, MRI
is preferable [25]. In addition, MRI is of help in diagnosing non-
calcified loose bodies and assessing the articular carilage [27].
Ultrasound examination of the ulnar nerve is a well recognized
technique for assessing the thickness of the nerve, site of
compression and presence of other lesions such as ganglions.
TREATMENTNon-operative
Once thediagnosis is made, patients shouldreceive an explanation
as to the cause of the symptoms and adviced on the natural
history. Symptomatic treatment, aiming to control pain, is the
first line of management. This is more appropriate for patients
with mild stage disease, who have no significant limitation of
activities of daily living or work. The main stay of initial treatment
is analgesics and anti-inflammatory medication. In the event of
failure of this approach, consideration may be given to the use
of steroid/viscosupplement injections. This is based solely on the
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practice of using this technique in other joints. We are unaware
of any studies showing it to be of benefit in the elbow joint. A
recent case series of 19 patients with post-traumatic elbow OA,
who received three intra-articular sodium hyaluronate injections
at regular intervals over 4 weeks, showed minimal improvement
in pain at 3 months, and no improvement at 6 months [28].
Operative treatmentSeveral surgical treatmentscan be consideredwhen non-operative
measures fail to control symptoms.Thesecan be divided into open
or arthroscopic techniques, all of which aim to reduce pain and
achieve some improvement in ROM. The decision on the choice of
method depends on the stage of presentation and the surgeons
skill and the familiarity with the different techniques.
Open techniques
Posterior approach (ulnohumeral arthroplasty). The Outer-
bridgeKashiwagi procedure was first described by Kashiwagi
in 1978 [18,29]. The procedure is performed through a posterior
triceps splitting approach with fenestration of the olecranon fossa(1 cm to 1.5 cm) being performed to gain access to the anterior
aspect of the elbow. The osteophytes on the olecranon and the
coronoid process are excised (Minami and Ishii, 1986). Morrey
modified the procedure and described the use of a trephine to
fenestrate the olecranon fossa. He followed up 15 patients over
a mean of 33 months and reported excellent results in 87% [30].
Theresults of ulnohumeral arthroplastyhave been reported in sev-
eral studies and are summarized in Table 2. Some of the patients
reported by Antuna et al. also had an anterior capsular release
through the fenestration or by a column procedure [14].
Long-term results of ulnohumeral arthroplasty have remained
encouraging. Minami et al. reviewed the results of this arthroplasty
in 44 elbows followed for 8 years to 16 years. They reported 61%patients had slight or no pain at final review but noted 10%
deterioration in ROM, when the same group was compared at
5 years and 12 years after initial surgery [36].
Complications. Complications that have been reported following
open ulnohumeral arthroplasty include ulnar nerve entrapment,
ulna nerve neuropraxia/irritation [14,37], anterior interosseous
nerve palsy [35], superficial wound infection, hematoma [37],
myositis ossificans and triceps rupture [35]. A reoperation rate
of 8% has also been reported [37].
Despite clinical success, radiographic signs of recurrence in the
fenestrated area at the olecranon and coronoid fossae are know to
occur. The rate of this recurrence increases with time. Wada et al.
found recurrence of osteophytes in both the olecranon and the
coronoid fossae in 100% of patients followed for 10 years or more.A correlation between radiographic signs of recurrence and func-
tional outcome has not been firmly established. However, theslow
reformationoftheolecranonfossamembraneandosteophytesthat
hasbeennotedmayexplainthedelayinrecurrenceofimpingement
symptoms despite obvious radiographic changes [20,36,38].
Prognostic factors to predict the outcomes of ulnohumeral
debridement have been suggested. Duration of symptoms of less
than 2 years, pain scores of 2 or 3 (no pain, 0; occasional or mild
pain, 1; regular pain requiring analgesia, 2; severepain notrelieved
by analgesia, 3), and the presence of cubital tunnel syndrome
were associated with an increased chance of a good outcome. The
absence of pre-operative locking was associated with an increased
chance of a poor outcome, although a history of trauma, the
pre-operative ROM and number of loose bodies did not affect the
outcome [37].
Posteromedial approach. Wada et al. described a posteromedial
approach for debridement of the arthritic elbow. They reported
the results in 32 patients, with a mean duration of follow-up of
121 months, of which 19 elbows were followed for more than
10 years. Twenty-eight (85%) patients reported no pain and five
had mild pain. The mean arc of movement improved by 24. The
mean Japanese Orthopaedic Association elbow score improved by
23 points. Of 25 patients who had performed heavy manual work,76% returned to their previous job or an equivalent job. In the
elbows followed formore than 10 years,the limitationof extension
hadincreased by 7 with nochange in flexion.The lossof extension
was attributed to the recurrence of osteophytes at the olecranon
process (47%) and the olecranon fossa (47%). Wada advocated
this approach for patients with degenerativearthritis whoalso had
ulnar nerve symptoms requiring decompression [20].
Table 2 Open ulnohumerl arthroplasty
Reference Year Numberof elbows PrimaryOA% Meanage Follow-up(months) Improvementin ROM Satisfaction(subjective) MEPS (good-excellent) Complicationrate Reoperationrate
Forster et al. [38] 2001 36 65 57 39 25 81% 17% 8%Antuna et al. [14] 2002 46 100 48 80 20 74% 74% Phillips et al. [32] 2003 20 100 51.4 75 20 65% Sarris et al. [33] 2004 17 95 52 36 32 Allen et al. [34] 2004 9 89 45 26 21 11% Vingerhoeds
et al. [35]2004 16 20 20 86.6% 87.5%
Hearnden et al. [36] 2009 59 67 63 92 18 63% 60% 24% 3.3%
OA, osteoarthritis; MEPS, Mayo Elbow Performance Score; ROM, range of motion.
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Posterolateral approach. Tsuge and Mizuseki described an
extensive debridement arthroplasty though a posterolateral
approach in 29 elbows, with an average follow-up of 5 years. The
ulnar nerve was decompressed, the triceps and periosteum of the
olecranonreflected, and thejoint dislocated by dividing the lateral
collateral ligament. Pain was relieved in all cases, although some
patients complained of dullaching on firm gripping.Impingement
in flexion and extension was noted at 5 years and most patients
returned to their former occupation [13].
Oka et al. compared patients who had a lateral (20 patients),
medial(10patients)andacombinedmedialandlateralapproaches
(eight patients) over a mean of 5.9 years. No significant differences
in the outcomes were noted between the groups [39].
Arthroscopic techniques. Arthroscopy of the elbow has evolved
with the advances in arthroscopic equipment and surgical
techniques. It has become a more popular, safer and more
effective treatment option for many elbow problems. Arthroscopic
debridement of osteophytes and removal of loose bodies alone
has shown promising results [40]. Arthroscopic modification of the
OuterbridgeKashiwagi procedure has also been described. Thisprocedure involves arthroscopic excision of the osteophytes and
fenestration of the olecranon fossa. A study of 12 patients who
underwent this procedure reported improvement in symptoms in
all patients, although significant improvements in ROM was not
noted [41]. Inclusion of anterior and posterior capsular releases
has been suggested to improve the ROM in the elbow [42]. Some
studies have also included excision of the radial head [43,44].
Cohen et al. compared the results of arthroscopic (20) and open
(15) debridement for primary OA of the elbow. Both procedures
were surgically effective but no difference was noted in the
patient perceived benefit between the two groups, although the
range of flexion was slightly better in the open group at mean
follow-up of 35.3 months [45]. More recent studies of arthroscopic
debridement have shown some improvement in the ROM
(Table 3). One study by Krishnan et al. has reported far greater
improvement in ROM than the other arthroscopic studies and the
published data from open procedures [46]. This study is of interest
because the mean age of the patients was younger (36 years as
opposed to>50 years) and therefore may not reflect the outcome
that canbe expected in themore usual older aged patient with this
condition.
Debate remains as to whether radial head excision should be
combined with the arthroscopic procedure. Kelly advised against
it even in the presence of radiocapitellar arthritis [47], whereas
McLaughlinet al.feltthiswasanimportantaspectoftheprocedure.
They reported the results of arthroscopic radial head excision with
or without ulnohumeral arthroplasty in 36 patients with elbow
arthritis (10 primary, 26 secondary). Twenty-eight patients had an
ulnohumeral arthroplasty andradial head excision andthe rest had
only a radial head excision. They noted better outcome scores and
arc of motion in those who had radial head excision alone (62)
compared to patients who had a combined procedure (46) [44].
Complications after elbow arthroscopy are more common than
other joint arthroscopies as a result of the close proximity of
the neurovascular structures. The most common complication is
transient nerve palsy, which occurs in up to 14% of reported
series [42 48]. Various techniques have been suggested to
reduce neurological complications after elbow arthroscopy [42].
Other complications include deep infection (0.8%) in patients
who had steroid injections postoperatively [47] and myositis
ossificans [48,49].
Ulnar nerve symptoms. Most authors recommend simple
decompression of the ulnar nerve, although anterior transposition
is advisable in patients with a fixed flexion deformity of>60, andwhen there is a space occupying lesion such as a ganglion in
the cubtal tunnel [22]. Cubital tunnel reconstruction by excision
of the medial osteophytes and deepening the cubital tunnel
has been advocated and reported to produce encouraging
results [50].
Arthroplasty. Totalelbow arthroplastyhas been successfully used
to treatlow demand patients with inflammatoryarthritis, although
is not routinely recommended for primary OA. There is a paucity
of literature regarding prosthetic replacement for this condition.
One report of linked prosthesis used in five patients (mean age
68 months), with a minimum assessment of 3 months (range
37 monthsto 125 months) reported complicationsin four patients.
These included subluxation, fractureof a humeral componentwith
particulatesynovitis, heterotopic ossification, recurrent osteophyte
formation, and transient ulnar neuropathy [51]. Another series
using unlinked SouterStrathclyde total elbow arthroplasties in
nineelbowsreportedasymptomaticradiologicallooseninginthree
humeral and twoulnar components. One patient required revision
for loosening and failure at a mean follow-up of 68 months (range
15 months to 117 months) [52].
Other procedures. Other procedures, to reduce elbow pain have
been described, although these have not been widely adopted.
Table 3 Arthroscopic procedures
Reference YearNumber
of elbowsPrimary
OA%Meanage
Follow-up(months)
Improvementin ROM
Satisfaction(subjective)
MEPS (good-excellent)
Complicationrate
Krishnan et al. [47] 2007 11 100 36 26 73 100% 100% Kelly et al. [48] 2007 25 51 67 21 90% nilAdams et al. [49] 2008 42 100 52.8 40.6 35 78.6% 81% 4.7% (one hetrotopic)
OA, osteoarthritis; MEPS, Mayo Elbow Performance Score; ROM, range of motion.
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Bateman described denervation of the elbow in a small group of
patients with elbow pain and reported improvement in pain in
most patients [53].
Distraction interposition arthroplasty has also been used for
young patients with post-traumatic elbow OA, although there are
no published data available on this technique in primary OA [26].
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