Original Contribution

Obere Extremität 2019 · 14:53–59https://doi.org/10.1007/s11678-018-0485-xReceived: 11 May 2018Accepted: 12 September 2018Published online: 10 October 2018© The Author(s) 2018

J. Schmalzl · N. Sadler · M. Feucht · C. Gerhardt · L. J. LehmannDepartment of Traumatology and Hand Surgery, St. Vincentius Clinic, ViDia Clinics, Karlsruhe, Germany

Monteggia-like lesionsA case series

Monteggia-like lesions represent a rarebut complex injury of the elbow joint[25] accounting for 2–5% of proximalforearm fractures [17]. The Italian sur-geon Giovanni Battista Monteggia firstdescribed this lesion in 1814 as a frac-ture of the ulna shaft combined with ananterior dislocation of the radial head.However, the anterior dislocation of theradial head occurs in only about 25% ofthese complex elbow joint injuries.

Jose Luis Bado elaborated the path-omechanismanddefined the term“Mon-teggia-like lesion” in 1957 as a complexinjury to the elbow joint including aprox-imal ulna fracture and dislocation of theradial head [1, 2]. However, additionallesions such as radiohumeral dislocation,ulnohumeral dislocation, proximal ra-dioulnar dislocation, radial head frac-ture, and lesion of the distal radioulnarjoint can occur [18].

Even for experienced surgeons, Mon-teggia-like lesions are a challenge. Accu-rate preoperative diagnostics are essen-tial to determine the extent of the injuryand plan further therapeutic steps. Thedetection of osseous injuries as well asof lesions affecting the capsule or liga-ments is crucial. With surgical therapy,anatomic reductionof the joint should bestrived for and instability should be ad-dressed, in order to achieve normal jointfunction and allow early rehabilitation ofrange of motion (ROM).

There are only few publications ontreatment of this injury. Probably due tothe broad variety of Monteggia-like le-sions, notreatmentalgorithmis currentlyavailable, and both treatment techniqueand results are variable. Therefore, theaim of this study was to retrospectivelyinvestigate our patients with Monteggia-like lesions between 2014 and 2016, in

order to analyze postoperative outcomeand identify possible pitfalls.

Methods

Institutional review board approval wasgranted, and informed consent was ob-tained from each patient.

Searching our trauma database fromJanuary2014 toDecember2016, we iden-tified 14 patients who were admitted andsurgically treateddue to aMonteggia-likelesion. We defined a Monteggia-like le-sion as a proximal ulna fracture togetherwith dislocation of the radial head andin combination with additional lesionssuch as radiohumeral dislocation, ulno-humeral dislocation, proximal radioul-nar dislocation, and radial head fracture.

In all patients, preoperative CT scansof the injured elbow joint were obtainedto rule out associated injuries and toimprove preoperative classification andplanning. According to the Bado clas-sification, all 14 patients had a type IIinjury. Only 1 patient (7%) presentedwith an open fracture, which was classi-fied according to Gustilo and Andersonas a type I injury [11]. Bado type IIlesions were subclassified according toJupiter et al. [15]. There were fourtype IIa, one type IIb, four type IIc, andfive type IId injuries. Noassociatednerveor vascular injuries were observed. Os-teosynthesis of the ulna was performedwithavariableangle lockingcompressionplate (VA-LCP; Synthes, West Chester,PA, USA) in nine cases, with a doubleplate (Aptus, Medartis, Basel, Switzer-land) in four cases, and with a tensionplate (Aptus, Medartis, Basel, Switzer-land) in one case. Use of the differentplating systems depended on the sur-geon’s preference; the tension plate wasused in case of a very proximal small

single-fragment ulna fracture in a Bado/Jupiter type IIa lesion. Althoughall radialhead fractures were dislocation fracturesper definition, we classified radial headfractures according to theMason classifi-cation depending on the actual fragmentdislocation in the preoperative imaging.These consisted of three Mason type II,four Mason type III, and seven Masontype IV fractures [5, 14, 20]. Depend-ing on fracture pattern, fragment dislo-cation, and patient age, osteosynthesis,radial head replacement, or radial headresection was performed. Radial headfractures were either addressed “throughthe ulna” or bydissecting subcutaneouslyfrom theulna to theposterolateral borderandopening the radiocapitellar jointwiththeBoydapproach. A fractured coronoidprocess could be observed in nine cases.These fractures were classified accordingto O’Driscoll [21] and consisted of twoO’Driscoll type 1 (one1.1 and one1.2),two O’Driscoll type 2 (two2.2), and fiveO’Driscoll type 3 (five3.2) lesions. Incase of intraoperative ulnohumeral insta-bility, these lesions were addressed eitherwith indirect transosseous refixation ac-cording to the so called lasso techniquedescribed by Garrigues et al. [9], or withretrogradescrewfixationthroughtheole-cranon plate. Intraoperative testing re-vealed 5 patients with lateral instabilitydue to rupture of the lateral collateral lig-ament. In these patients, refixation of thelateral ligament complex was performedusing suture anchors.

In all cases, surgical treatment wasperformed within the first 24h afterinjury. Surgical therapy was providedby three different surgeons specializedin upper extremity and trauma surgery.Patients received standardized postop-erative treatment with early immediatecontinuous active and passive motion.

Obere Extremität 1 · 2019 53

Original Contribution

Table 1 Main characteristics of the 14 includedpatients and outcomeparameters

Number Percent

Number of patients 14 100

Gender

Male 2 14

Female 12 86

Injured side

Dominant arm 8 57

Non-dominant arm 6 43

Bado classification

Type I 0 0

Type II 14 100

Type III 0 0

Type IV 0 0

Bado/Jupiter classification

Type IIa 4 29

Type IIb 1 7

Type IIc 4 29

Type IId 5 36

Radius fracture

Radial head fracture Mason I 0 0

Radial head fracture Mason II 3 21

Radial head fracture Mason III 4 29

Radial head fracture Mason IV 7 50

Coronoid fracture

O’Driscoll Type 1 2 14

O’Driscoll Type 2 2 14

O’Driscoll Type 3 5 36

Lateral instability 5 36

Open fracture 1 7

Available for follow-up 13 93

Mean age in years [range] 63 [24–89] –

Mean follow-up inmonths [range] 21.9 [7–40] –

Mean ulnohumeralmotion injured side in ˚ [range] 116 [70–155] –

Mean ulnohumeralmotion contralateral side in ˚ [range] 146 [110–165] –

Mean forearm rotation inured side in ˚ [range] 138 [70–180] –

Mean forearm rotation contralateral side in ˚ [range] 164 [140–180] –

Mean Broberg andMorrey score [range] 79 [23–100] –

Mean Quick DASH score [range] 23.6 [0–61] –

MeanMayo Elbow Performance Score [range] 82 [35–100] –

Mean subjective elbow value [range] 66 [20–90] –

Mean visual analogue scale [range] 2.6 [0–8] –

Cases requiring revision surgery other than implant removal 3 (23%) –

DASH Disabilities of the Arm, Shoulder and Hand

Therefore, 2 to 5 days after surgery, anelbow orthosis for mobilization withan extension and flexion limitation of0°–30°–120° was adjusted and worn for6 weeks after surgery [12].

For follow-up examination, patientswere asked to grade pain on a visual ana-logue scale (VAS). Moreover, elbow flex-ion, extension, pronation, andsupinationwere measured with a goniometer andcompared to the contralateral side. In

addition, the distal radioulnar joint wasexamined for tenderness, and valgus andvarus instability of the elbow joint weretested in full extension, if possible, aswellas at 30° of flexion. Theoverall functionaloutcome was assessed using the Brobergand Morrey Score (BMS) and the MayoElbow Performance Score (MEPS) as el-bow-specific scores. Furthermore, theDisabilities of the Arm, Shoulder andHand (DASH) questionnaire as well asthe subjective elbow value (SEV) wereused as patient-focused outcome tools.Additionally, a neurologic examinationof the operated side was performed todetect sensory or motoric deficits. Post-operative radiographs of the elbow wereroutinely obtained 2 days after surgery.If medically indicated (pain/loss of func-tion), additional radiographsof theelbowwere performed during follow-up.

Due to the low case number, onlya descriptive statistical analysis wasperformed using Excel (Microsoft, Red-mond, WA, USA).

Results

A total of 13 patients were availablefor follow-up (93%) at an average of21.9 months (range 7–40 months) aftersurgery, while 1 patient had died ofunrelated causes. Patients’ main charac-teristics and the outcome parameters arereported in . Table 1. In . Table 2, theindividual results of each patient can beseen. According to the BMS [4], 2 (15%)patients had excellent, 7 (54%) good,2 (15%) fair, and 2 (15%) poor results.Mean BMS was 79 (23 to 100), meanMEPS was 82 (35 to 100), mean DASHScore was 23.6 (0 to 61), and mean SEVwas 66% (20 to 90). Average pain levelon the VAS was 2.6 out of 10 points (0 to8). Ulnohumeral ROM was 116° (70 to155°) on the injured side and 146° (110to 160°) on the contralateral side. Meanforearm rotationwas 138° (70 to 180°) onthe fractured side and 164° (140–180°)on the contralateral side. At follow-up, none of the patients demonstratedinstability of the distal radioulnar jointor medial or lateral instability of theelbow.

In total, 3 patients underwent revi-sion surgery other than implant removal

54 Obere Extremität 1 · 2019

Abstract · Zusammenfassung

Obere Extremität 2019 · 14:53–59 https://doi.org/10.1007/s11678-018-0485-x© The Author(s) 2018

J. Schmalzl · N. Sadler · M. Feucht · C. Gerhardt · L. J. Lehmann

Monteggia-like lesions. A case series

AbstractIntroduction.Monteggia-like fractures arerare but complex injuries to the elbow joint,accounting for 2–5% of proximal forearmfractures. Even for experienced surgeons, theirtreatment can be challenging. The objectiveof this retrospective study was to analyze theshort-term results after surgical treatment ofMonteggia-like fractures in adults.Methods. All patients who sustaineda Monteggia-like fracture over a period of3 years (2014–2016) and underwent surgicaltreatment in the authors’ institution werefollowed-up. Pain level (visual analogue scale,VAS), range of motion (ROM), Broberg andMorrey Score (BMS), Mayo Elbow PerformanceScore (MEPS), Disabilities of the Arm, Shoulder

and Hand (DASH) Score, and subjective elbowscore (SEV) were recorded.Results. Of 14 adult patients who sustaineda Monteggia-like lesion during a 3-yearperiod, 13 were available for follow-up aftera mean time of 21.9 months (7 to 44 months).According to the BMS, 3 patients (15%)showed excellent, 7 (54%) good, 2 (15%) fair,and 2 (15%) poor results. A total of 3 patients(23%) needed revision surgery other thanimplant removal. Mean BMS was 79 (23 to100), mean MEPS was 82 (35 to 100), meanDASH score was 23.6 (0 to 61), mean SEV was66% (20 to 90), and mean VAS was 2.6 (0–8).Conclusion. Good short-term results can beachieved if the injury is classified correctly

and a standardized surgical treatment of allinjury components is performed. The resultsare comparablewith data from the literature.Patients with Monteggia-like fractures shouldbe informed about the risk of potentialfunctional deficits and the possible need offurther surgery.Level of evidence. This study is evidencelevel IV.

KeywordsMonteggia-like lesion · Radial head fracture ·Coronoid fracture · Elbow luxation · Surgicaltreatment

Monteggia-ähnliche Verletzungen. Eine Fallserie

ZusammenfassungHintergrund.Monteggia-ähnliche Frakturenstellen seltene, aber komplexe Verletzungendes Ellbogengelenks dar, sie machen 2–5%der proximalen Unterarmfrakturen aus.Selbst für erfahrene Chirurgen kann ihreBehandlung eine Herausforderung sein.Ziel der vorliegenden retrospektiven Studiewar die Auswertung der Kurzzeitergebnissenach chirurgischer Behandlung Monteggia-ähnlicher Frakturen bei Erwachsenen.Methoden. Alle Patienten, die eine Monteg-gia-ähnliche Fraktur in einem Zeitraum von3 Jahren (2014–2016) erlitten und bei denenin der Klinik der Autoren eine chirurgischeTherapie erfolgte, wurden diesbezüglichnachbeobachtet. Schmerzniveau (visuelleAnalogskala, VAS), Bewegungsumfang („rangeof motion“, ROM), Broberg-Morrey-Score(BMS), Mayo ElbowPerformance Score (MEPS),

Disabilities of the Arm, Shoulder and HandScore (DASH) sowie subjektiver Ellbogen-Score („subjective ellbow value“, SEV) wurdendokumentiert.Ergebnisse. Von 14 erwachsenen Patienten,die innerhalb eines 3-Jahres-Zeitraumseine Monteggia-ähnliche Fraktur erlitten,waren 13 für eine Nachuntersuchung nachim Mittel 21,9 Monaten (7–44 Monate)verfügbar. Gemäß BMS wiesen 3 Patienten(15%) ausgezeichnete, 7 (54%) gute,2 (15%) ausreichende und 2 (15%) schlechteErgebnisse auf. Insgesamt war bei 3 Patienten(23%) eine Revisionsoperation, abgesehenvon der Metallentfernung, erforderlich.Durchschnittlich betrug der BMS 79 (23–100),der MEPS 82 (35–100), der DASH-Score 23,6(0–61), der SEV 66% (20–90) und der Wert aufder VAS 2,6 (0–8).

Schlussfolgerung. Gute Kurzzeitergebnissekönnen erzielt werden, wenn die Verletzungkorrekt klassifiziert und eine standardisiertechirurgische Behandlung aller Verletzungs-komponenten durchgeführt wird. DieErgebnisse sind den Daten aus der Literaturvergleichbar. Patienten mit Monteggia-ähnlichen Frakturen sollten über das Risikomöglicher funktioneller Defizite und ggf.erforderliche weitere Operationen informiertwerden.Evidenzniveau. Diese Studie weist dasEvidenzniveau IV auf.

SchlüsselwörterMonteggia-ähnliche Fraktur · Radiuskopf-fraktur · Processus Coronoideusfraktur ·Ellenbogen Luxation · Operative Therapie

(overall revision rate 23%). In one case,postoperative redislocationoccurred dueto persisting instability after failed tran-sosseouscoronoidrefixationandprimaryradial head resection. Therefore, in thefirst revision, direct screw fixation of thecoronoid process and implantation ofa radial head prosthesis was performed;however, re-redislocation occurred. Be-cause of extreme noncompliance and re-duced general health, re-refixation of thecoronoid process as well as a temporarytransfixation of the elbow joint with an

external fixator was realized in order tostabilize the joint. After removing the ex-ternal fixator, joint stabilitywas achieved;nevertheless, elbowfunctionwas severelylimited. Theprosthesishadtoberemovedafter 1.5 years due to chronic subluxationcausing severe elbow pain and a limitedROM. In another case, failure of radialhead osteosynthesis was observed; thus,a secondary radial head prosthesis wasimplanted. In the third case, postop-eratively persistent sensory irritation ofthe ulnar nerve occurred; consequently,

revision surgery with neurolysis of theulnar nerve was realized.

Implant removal was not counted asrevision surgery. In total, 3 patients un-derwent elective implant removal—twicedue to the young patient age (24 and32 years) and in one case because of cos-metic demands.

Postoperatively, 3 patients (23%) pre-sentedanassociatedneurologicalsensorydeficit of the ulnar nerve. Two cases re-solvedwithout surgical interventionuntil

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Original Contribution

Table 2 Individual results

Patient Bado/Jupiter Mason O’Driscoll Lateralinstability

Revisionsurgery

UlnohumeralROM

VAS QuickDASH

MEPS SEV

1 2D 2 – – – 115 5 25 85 70

2 2A 2 3.2 Yes Yes 105 1 25 95 80

3 2A 4 2.2 – – 120 6 50 70 60

4 2A 4 3.2 Yes Yes 110 2 9 85 70

5 2D 4 3.2 – Yes 70 8 61 35 20

6 2D 3 3.2 Yes – 80 5 59 55 50

7 2A 4 3.2 Yes – 90 2 32 80 70

8 2B 4 1.1 – – 145 1 2 85 70

9 2C 4 – – – 150 0 0 100 90

10 2D 3 – – – 120 0 5 100 80

11 2D 3 1.2 – – 120 5 34 70 40

12 2C 3 – – – 125 0 5 100 60

13 2C 2 – – – 155 0 0 100 95

ROM range of motion, VAS visual analog scale, DASH Disabilities of the Arm, Shoulder and Hand, MEPS Mayo Elbow Performance Score, SEV subjectiveelbow value

follow-up; however, in one case, neuroly-sisof theulnarnervehadtobeperformed.

Nopostoperativewound infectionoc-curred in this case series.

Discussion

In our case series from January 2014 toDecember 2016, exclusively Monteggia-like lesions Bado type II were registered.Several other authors also observed thepredominance of Bado type II fracturesin adults [8, 16, 22, 23, 29], while in chil-dren and in cases of high-energy trauma,Bado type I injuries are more common[28, 32]. Bado type I lesions show ex-cellent or good functional outcomes inmost cases, probably due to a low in-cidence of concomitant fractures of theradial head or the coronoid process [16,28, 32]. In contrast, Bado type II le-sions are reported to show significantlypoorer outcomes [16, 26, 28]. Fracturesof the radial head or the coronoid pro-cess have been reported to correlate withpoor functional outcome scores and oc-curmore frequently inolderpatientswithassociated bone weakness [16, 32]. Kon-rad et al. described Bado type IIa andIId lesions as negative prognostic factors[16]. In this context, our case series re-vealed similar results.

Our case series is too small to en-able establishment of a data-based treat-ment algorithm. However, several pit-

falls could be identified retrospectively,andthe followingtreatmentstrategiescanthus be recommended. In addition, twoexemplarycases are illustrated in. Figs. 1and 2.

First, in patients with concomitantradial head fractures, open reductionand internal fixation (ORIF) should bestrived for, as patients undergoing radialhead replacement showed worse clinicalresults in various studies examining thetreatment of comminuted isolated radialheadfractures [3, 27, 31, 33]. Inourexpe-rience, these findings can be transferredto Monteggia-like lesions. Minimallydisplaced radial head fractures (Masontype I/II) should be treated with screwfixation, plating represents a valid treat-ment option for radial neck fractures orcomminuted fractures (Mason type III).Lindenhovius et al. reported that openreduction and internal fixation of unsta-ble displaced fractures of the radial headoccasionally fail, but could reduce therisk of subsequent elbow dislocation andprotect against long-term arthrosis [19].In severely comminuted and displacedfractures (Mason type IV) or in case ofbad bone quality, ORIF becomes impos-sible and a radial head prosthesis shouldbe implanted [27]. Ring et al. reportedthat ORIF of displaced fractures withmore than three fragments is associatedwith early failure, nonunion, and lossof forearm rotation [27]. Therefore,

a radial head prosthesis should be avail-able when operating on a Monteggia-like lesion with a comminuted radialhead fracture. The literature shows thatradial head excision is linked to inferiorclinical results compared to ORIF andradial head prosthesis, as radiocapitellarcontact is important for elbow and fore-arm stability [27]. Due to a subsequentloss of stability, radial head excision iscontraindicated in acute situations andshould only be considered as a salvageprocedure or for elderly patientswith lowfunctional demands in order minimizeoperating time [3, 13, 19, 27]. However,to date, this has only been examined forisolated radial head fractures and not inMonteggia-like lesions. As mentionedabove, in our cohort, 1 patient under-went primary radial head resection dueto severe intraoperative problems causedby morbid obesity. Postoperatively, thispatient presented with persistent in-stability; however, it remains unclearwhether this was caused by radial headresection or failed osteosynthesis of thecoronoid fracture.

Second, olecranon fractures can beaddressed with different techniques, aslong as exact anatomical reposition andfixation is achieved. To date, it remainsunclear whether any one of the availableplating systems (VA-LCPvs. doubleplatevs. tensionplate) is superior to theothers;

56 Obere Extremität 1 · 2019

Fig. 18 A66-year-oldpatientwith aMonteggia-like lesionBado/Jupiter type IIb anda concomitant radial head fractureMa-son type IV (preoperative imagesa–c).Open reductionandfixationof theulnawithaVA-LCPOlecranon (3.5/2.7mm;Synthes,West Chester, PA, USA) and radial head osteosynthesis with three screwswere performed.Postoperative images are shownind and e. At 44months follow-up, the patient had achieved good clinical resultswith 92points in the Broberg andMorreyScore and 2 points in the Disabilities of the Arm, Shoulder andHand Score.L left

thus, we recommendusing the systemthesurgeon is most familiar with.

Third, fractures of the coronoid pro-cess can result in ulnohumeral instabil-ity [7, 24]. For better evaluation of thecoronoid fracture, the O’Driscoll clas-sification should be used [21]. In thiscontext, all O’Driscoll type 2 and 3 le-sions must be addressed, as they poten-tially result in an unstable ulnohumeraljoint. Special care should be taken in caseof O’Driscoll type 2.3 lesions, which in-clude fracture of the sublime tubercle,the ulnar insertion of the medial collat-eral ligament (MCL). Therefore, in anunstable posterior Monteggia-like lesionwith fractureof the coronoidprocess, sta-ble reduction of the coronoid fracture isnecessary to restore ulnohumeral articu-lation, thereby providing elbow stabilityand minimizing the risk of future ulno-humeral arthritis due to chronic instabil-

ity [10, 28]. Depending on the fracturepattern, repair of the coronoid fracturecan be realized either directly by ORIFwith screws, volar plating, or suture an-chors [6, 30], or with the lasso techniqueby passing a suture through the anteriorcapsular attachment, shuttling it throughthe ulna, and tying it down on the sub-cutaneous posterior border of the ulna[9, 30]. Another possible technique isindirect osteosynthesis from the poste-rior ulna through the olecranon plate.In most O’Driscoll type I lesions the ul-nohumeral joint remains stable and it isnot necessary to address these fracturesof the coronoid process; however, ulno-humeral joint stability has to be testedintraoperatively [7, 30].

Forth, our case series revealed thatMonteggia-like lesions can be associatedwith concomitant lateral elbow instabil-ity. This has not yet been reported in the

literature, although several case series ofMonteggia-like lesions can be found [16,18, 32]. Inour study, four cases presentedlateral elbow instability intraoperatively;therefore, refixation of the lateral liga-ment complex with suture anchors wasperformed. During the operation, lat-eral stability should be checked and incase of instability, refixation of the lat-eral capsule–ligament complex should beperformed with a suture anchor.

Our study has strengths and weak-nesses. Among the strengths is the rela-tively large population of adult patientshaving this uncommon injurywith a verylow loss to follow-up. Our study has theinherent limitations of a retrospective se-ries. Moreover, the study cohort is quiteinhomogeneous due to many influenc-ing factors and the average follow-up of21 months is rather short.

Obere Extremität 1 · 2019 57

Original Contribution

Fig. 28 A75-year-old femalewith aMonteggia-like lesionBado/Jupiter type IIa and concomitant ra-dialheadfractureMasontype IV,coronoid fractureO’Driscoll type3.2, and lateral instability (preopera-tive imagesa–d). Open reductionwasperformedwithaVA-LCPOlecranon (3.5/2.7mm;Synthes,WestChester,PA,USA), implantationofa radialheadprosthesis (Mopyc;WrightMedical,Memphis,TN,USA),and refixationof the lateral collateral and the annular ligamentwith suture anchors.At 36months fol-low-up, the patient had achieved good clinical results with 81points in the Broberg andMorrey Scoreand 9 points in the Disabilities of the Arm, Shoulder andHand Score

Conclusion

Our findings demonstrate that goodshort-term results can be achieved if theinjury is classified correctly and a stan-dardized surgical treatment of all injurycomponents is performed. The resultsare comparable with the data in the lit-erature. Patients with Monteggia-likefractures should be informed about the

risk of potential functional deficits andpossible need for further surgery. Addi-tional studies with larger patient popu-lations and longer follow-up are neededto establish a treatment algorithm.

Corresponding address

J. Schmalzl, MDDepartment of Traumatologyand Hand Surgery, St.Vincentius Clinic, ViDia ClinicsSuedendstraße 32,76137 Karlsruhe, Germanyjonas.schmalzl@vincentius-ka.de

Compliance with ethicalguidelines

Conflict of interest. J. Schmalzl, N. Sadler,M. Feucht,C. Gerhardt, and L.J. Lehmanndeclare that theyhaveno competing interests.

All procedures performed in studies involvinghumanparticipantswere in accordancewith the ethical stan-dards of the institutional and/or national researchcommittee andwith the 1964Helsinki declaration andits later amendmentsor comparable ethical standards.The local ethics committee approved this study (Reg.Nr.: 2017-663N-MA).Written consentwas givenby allparticipants.

OpenAccess. Thisarticle isdistributedunderthetermsof the Creative CommonsAttribution 4.0 InternationalLicense (http://creativecommons.org/licenses/by/4.0/), which permits unrestricteduse, distribution,and reproduction in anymedium, provided yougiveappropriate credit to the original author(s) and thesource, providea link totheCreativeCommons license,and indicate if changesweremade.

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