Non-Surgical Triangular fibrocartilage complex tear and distal radioulnar instability
Ross Hauser, MD
You have a lot of pain on the outside of your wrist. After a few weeks or months of anti-inflammatories and other over-the-counter painkillers, you go online or to the nearest pharmacy and buy yourself a wrist brace. After continued self-managed care and the fact that your wrist is still painful and nothing you are doing are helping, you go to your doctor.
A common injury from falling on an outstretched hand, or in athletes who put a lot of pressure on their wrists, such as gymnasts, is a tear of the triangular fibrocartilage complex. This small piece of cartilage and ligaments on the ulnar side of the wrist (the same side as the little finger) acts as a cushion for the joint. Ligament injury in the front, back, and ulnar side of the wrist cause wrist instability. This is the most common cause of pain and cartilage degeneration in this area. Most patients with wrist instability and damage to the TFCC have a characteristic clicking sound in the wrist. Many have also been diagnosed via x-ray or MRI.
The doctor’s visit and diagnosis
After an examination, your doctor refers you to the orthopedist. An eventual MRI reveals that you have a Triangular fibrocartilage complex tear or a TFCC. What you probably hear is something like you have some type of tear in your wrist. You ask the doctor, “will it require surgery?” “Maybe not,” is the reply. “But you will need to rest your wrist to allow it to heal.”
Your orthopedist will probably ask you if you have been putting ice on your wrist? Most people do.
Then you may be asked, “Do you keep your hand elevated on a pillow when you are trying to sleep?” Because of the wrist pain, you may tell the doctor that you are having difficulty in getting a good night’s sleep. You may be one of the people who wraps their hand up in a pillow and makes a soft cast out of it with the help of an ace bandage. This is usually not effective.
At this time a cortisone injection may be recommended to you. For many people, this will work fine. For others, the wrist pain will continue and more options will need to be considered. You may be reading this page because you are on the hunt for more options.
- Now I have to wait another 2 months, maybe more for the TFCC surgery and then it could be a 2 to 6 months TFCC surgery recovery beyond that.
- Wrist braces, ice, and cortisone. Then after years of trying to figure out what was causing my wrist pain – surgery should be considered
- Some people need to work now and their job is physically demanding. TFCC surgery may not be the desired treatment option.
- 11o patients with ulnar side wrist pain had 17 different diagnoses.
- The path to TFCC surgery and what surgery may look like when you get there.
- A note about the youth athlete and TFCC tear.
- MRI suggested surgery may not be the best treatment in adolescent athletes.
- Triangular fibrocartilage complex tear – more than a cartilage tear – is a problem of the hypermobile wrist and grinding instability.
- Distal radioulnar instability
- The ligament complex is really important.
- The question among many did the triangular fibrocartilage complex (TFCC) tear caused the degenerative condition by creating instability or did the triangular fibrocartilage complex (TFCC) tear develop as a result of the wrist instability.
- Removing cartilage? Shaving down bone? How much does triangular fibrocartilage surgery help an athlete return to sport? A worker back to the job?
- TFCC Surgery made it worse.
- Non-Surgical TFCC tear treatment options.
- Corticosteroid injections.
- Focus on strengthening the wrist ligaments and stabilizing the grinding wrist
- Prolotherapy treatment demonstrated and described
Now I have to wait another 2 months, maybe more for the TFCC surgery and then it could be a 2 to 6 months TFCC surgery recovery beyond that.
Some people will wind up here at Caring Medical. When we first meet them they are sitting at our examination table. They will usually be grasping their “bad” wrist with their other hand and rubbing the pinky side area. They will say things like this:
Chronic wrist pain
My wrist has been bothering me for a long time now. I play a lot of tennis, it has been getting worse and worse. I went to my doctor, and he referred me to the orthopedist, I had a nerve test and an MRI and everything came back pointing to a Triangular fibrocartilage complex tear. If I have the surgery it will be months before I can do anything with that hand.
Wrist braces, ice, and cortisone. Then after years of trying to figure out what was causing my wrist pain – surgery should be considered
I am thinking about getting the surgery now, I have been icing and bracing and resting for months now. I had cortisone, but nothing helps. Now I have to wait another 2 months maybe more for the surgery and then it could be a 2 to 6 months recovery beyond that. I am frustrated and would like to get something done now.
– or –
I had hyperextending my wrist two years ago. My doctor recommended that for hyperextension injuries, rest and ice are suggested. I rested my hand and wrist for months. No improvement. When I tried to do anything, like a push-up, I had no strength in my hand and a lot of pain. My wrist cracks and pops all the time, somedays I notice a little more puffiness or swelling than usual. I went to an orthopedic surgeon who did an MRI and said I probably have a TFCC tear. I went on to visit a hand specialist for a surgical consult. Now I am being recommended for surgery. I was told I was misdiagnosed as a simple sprain (hyperextension).
Some people need to work now and their job is physically demanding. TFCC surgery may not be the desired treatment option.
Not everyone is a weekend warrior, a sports enthusiast who goes all out on the weekend. Some people are in our office because they need to work and their job is physically demanding. They find that their wrist is catching, and getting stuck, and they are not only in pain but they are losing hand function. Some of these people are close to making a surgical decision.
“My MRI came back that I had a triangular fibrocartilage tear. My orthopedist gave me a very sound opinion based on his experiences. Since I had a lot of inflammation, we can try to put my wrist in a cast for 4 weeks and see if the forced inactivity and rest would calm everything down, or, I could have the surgery. It would be 2 or 3 or 4 months of recovery, AND, there is no guarantee that the surgery would help me.”
– or –
I have had chronic wrist pain for years now. I fell and tore my TFCC ligament. At the time my doctors told me the tear was not that bad. I do work that is physically demanding making long-term resting of my wrist next to impossible so all I can do is buy wrist braces. I bought a few, some better than others. I had a cortisone injection which helped for a while but I was not able to regain the grip strength I need for work.
My wrist continued to cause me pain and continued to lose strength. When the pain became even worse I went in for an MRI and examination which revealed that I now had chronic tendinitis and “likely” carpal tunnel syndrome. Immediately after this evaluation, I was given another cortisone shot which did help relieve the pain. I am now concerned that the continued recommendations for cortisone injections are causing more damage to my wrist. I am looking for something to repair my ligaments without surgery.
For some people, surgery may be beneficial. Some surgeons, as we will discuss below in new research, do not think surgery is a “sure thing.”
11o patients with ulnar side wrist pain had 17 different diagnoses.
Doctors in Australia writing in the Australian and New Zealand Journal of Surgery (10) offered outlooks and suggestions in tackling the challenging identification of the causes of ulnar side wrist pain. Making an accurate diagnosis, according to the researchers, will tackle another problem, that being the problem of “outcome and recovery following surgery (which) can be unpredictable.”
In this study, the charts of 110 patients with pain on the ulnar side of the wrist were analyzed. Within this analysis were a medical history and MRI reports.
- Results: There were 17 different diagnoses.
- Eighty-five percent of the diagnoses were triangular fibrocartilage complex (TFCC) injuries, ulnocarpal abutment syndrome (wrist instability causing the bones to grind against each other leading to wrist osteoarthritis), pisotriquetral arthritis (wear and tear among the wrist’s pinky side outer bones), triquetral fracture or non-union, distal radioulnar joint arthritis, and extensor carpi ulnaris (ECU) wear and tear damage.
Conclusion: Diagnosis of TFCC injuries, ulnocarpal abutment syndrome, distal radioulnar joint arthritis, and extensor carpi ulnaris (ECU) injuries are challenging as the clinical symptoms and signs for the four diagnoses were similar and required either magnetic resonance imaging or computed tomography for diagnostic confirmation after clinical examination.
The path to TFCC surgery and what surgery may look like when you get there
A February 2020 paper (1) sought to offer surgeons a less complicated surgical option that may work. In the introduction to this paper, the research surgeons looked at the familiar path people take to surgery and some of the problems they may encounter when they get there.
“Nowadays, arthroscopy plays an important role in providing treatment as well as in establishing the diagnosis. (of Triangular fibrocartilage complex tear). Arthroscopic repair of a TFCC tear is indicated after the failure of non-surgical treatments such as cast immobilization, splinting, and administration of nonsteroidal anti-inﬂammatory drugs for more than 3 months. Several arthroscopic therapeutic methods have been described, including the inside-out, outside-in, and all-arthroscopic techniques. However, these arthroscopic procedures are time-consuming and technically demanding.”
That is the patient journey to TFCC surgery.
Many people do have very successful TFCC surgeries. These are not the people that we see at our center. We see the people for whom surgery, is not an option for them various reasons including the inability to take off prolonged periods of work or not being able to use one hand for months.
A note about the youth athlete and TFCC tear
A review study was published in the Journal of Clinical Medicine (2) sought to determine if the overall good results of wrist arthroscopic surgery seen in adults, were also seen in youth athletes. A review of current published studies revealed that a total of 254 patients with verified TFCC tears and an average age of 16 years (youngest patient was 7, oldest 19) received:
- Arthroscopic repair (162 patients, 67.1% of total).
- An arthroscopic repair usually consists of suture repair of tears and partial ruptures. More complicated cases require screws and wires.
- or debridement, removal of dead tissue (77 patients, 29.7% of total).
- Arthroscopic treatment resulted in low pain levels, high patient satisfaction, and a fast return to sport.
Note: As mentioned many people have very successful surgeries for TFCC tear and repair. How many? Returning to this same study let’s see how many people did not.
- Complications overall were sparse and consisted mainly of persistent wrist pain (31 patients) and temporary paresthesia (6 patients) of the dorsal sensory branch of the ulnar nerve.
- About one in eight patients continued to have wrist pain
- About one in 45 had temporary paresthesia or numbness.
- About one in 60 tore the TFCC again in the sport.
We do typically see one in eight types of patients who had continued pain after the surgery.
MRI suggested surgery may not be the best treatment for adolescent athletes
A November 2021 paper from the University of Amsterdam published in the journal Skeletal Radiology (12) suggested that TFCC can be seen in asymptomatic adolescents and that caution should be taken when suggesting these asymptomatic adolescents to surgery. These are the summary highlights of this paper:
The study group consisted of 23 asymptomatic adolescents (12 girls and 11 boys). The average age was 13.5 years (range youngest 12.0-17.0 oldest). With the goal of offering a better diagnostic interpretation of MRI, the researchers found: that “MRI findings, whether normal variation or asymptomatic abnormality, can be observed in TFCC and TFCC-related features of asymptomatic adolescents. The rather low inter-observer agreement (the MRI interpretation among four different readers) underscores the challenges in interpreting these small (wrist) structures on MRI. This should be taken into consideration when interpreting clinical MRIs and deciding upon arthroscopy. ”
Triangular fibrocartilage complex tear – more than a cartilage tear – is a problem of the hypermobile wrist and grinding instability
In our experience, patients/athletes with triangular fibrocartilage complex (TFCC) injury suffer from complex ligament degenerative problems that are contributing to the grinding wrist instability, and carpal instability. Using the term “grinding instability,” is probably something that you can relate to because your wrist is grinding, making cracking, popping noises, and it feels like things in your wrist are being rubbed the wrong way.
Some of you with a more advanced problem may have suggested an ulnar shortening osteotomy because of this grinding. This is a surgery to shave down the ulna, the pinky side forearm bone that forms the ulnocarpal complex or triangular fibrocartilage complex. Simply, where the forearm and wrist meet. A simple surgical answer to if the bones are rubbing against each other is to shave down the bone so they don’t.
Distal radioulnar instability
It was not until recently that surgeons discovered the vast complexity and interaction between the distal radioulnar joint, the wrist’s outer joint where the ulnar and radius bones meet, and triangular fibrocartilage complex tears.
This was acknowledged in the surgical journal Hand Clinics. (3) here surgeons offered guidance on understanding the relationship between distal radioulnar joint instability and TFCC ligaments.
“During the last two decades, increased knowledge of functional anatomy and pathophysiology of the triangular fibrocartilage complex (TFCC) have contributed to a change in surgeons’ perspective toward it. The earlier concept of the TFCC as the “hammock” structure of the ulnar carpus has been updated to the “iceberg” concept, whereby the much larger “submerged” part represents the foveal (the ligament complex) insertions of the TFCC and functions as the stabilizer of the distal radioulnar joint and the ulnar carpus, thus lending it greater functional importance.”
The ligament complex is really important.
In the journal Geriatric Orthopaedic Surgery & Rehabilitation, (4) surgeons described distal radioulnar instability, this way, with emphasis on the ligament structure.
“Distal radioulnar joint instability is a common clinical condition but a frequently missed diagnosis. Both surgical and nonsurgical treatments are possible for chronic cases of Distal radioulnar instability. Nonsurgical treatment can be considered as the primary therapy in less active patients, while surgery should be considered to recover bone and ligament injuries if nonsurgical treatment fails to restore forearm stability and function. The appropriate choice of treatment depends on the individual patient and specific derangement of the Distal radioulnar joint instability.”
The question among many was, did the triangular fibrocartilage complex (TFCC) tear cause the degenerative condition by creating instability, or did the triangular fibrocartilage complex (TFCC) tear develop as a result of the wrist instability.
A paper from Massachusetts General Hospital and the University of Amsterdam published in July 2020 in the medical journal Hand (11) showed how significant the wrist degenerative process was in patients with triangular fibrocartilage complex tear who underwent surgical repair.
In this paper, the problem of diagnosis was highlighted: “The clinical picture of ulnar-sided wrist pain is oftentimes confusing because various pathologies may be coexistent.” Then the next question the researchers wanted to answer was why did some patients have inferior surgical results: “In this study, we aimed: (1) to compare the prevalence of potential causes of ulnar-sided wrist pain on magnetic resonance imaging (MRI) in patients who underwent triangular fibrocartilage complex (TFCC) repair and control subjects: and (2) to evaluate whether inferior clinical results were associated with specific patient characteristics or other potential causes of ulnar-sided wrist pain.”
- The researchers included 67 patients who underwent a TFCC repair and 67 control subjects.
- The MRI scans were examined for sources of ulnar-sided wrist pain.
- After TFCC repair, 42 patients (63%) completed surveys, including Quick Disabilities of the Arm, Shoulder, and Hand, and pain scores.
Results: The researchers found significantly higher rates of distal radioulnar joint arthritis, extensor carpi ulnaris (ECU) pathology, and ulnar styloid fractures in patients with TFCC repairs. This signaled ulnar-sided wrist joint instability lead to a progressive degenerative disorder. The question among many was did the triangular fibrocartilage complex (TFCC) tear cause the degenerative condition by creating instability or did the triangular fibrocartilage complex (TFCC) tear develop as a result of the wrist instability. The next question was if wrist instability exists and caused the triangular fibrocartilage complex (TFCC) tear, wouldn’t that same instability cause another tear in the triangular fibrocartilage complex (TFCC) repaired wrist? The researchers noted this: “We observed higher rates of distal radioulnar joint arthritis and ECU pathology in patients with TFCC tears undergoing repair compared with age- and sex-matched controls. This may be due to damage to the TFCC itself altering relationships of the distal radioulnar joint arthritis and the ECU subsheath, or it may reflect various pathologies that cause ulnar-sided wrist pain and drive patients toward surgery.”
In this video, Ross Hauser, MD discusses distal radioulnar instability. Summary learning points are:
- Distal radioulnar joint instability is often overlooked even though the patient will have loud clicking and popping noises coming from the wrist.
- In this video at 0:48, Dr. Hauser demonstrates wrist rotation and how radioulnar joint instability can cause pain, reduced strength, and popping and clicking in the wrist.
- The radius bone and the ulnar bone are supposed to stay together with wrist rotation, the two bones are not supposed to move apart.
- At 1:10 of the video, under Digital Motion X-ray, a patient’s radius bone and ulnar bone are seen to clearly move apart
- The patient in the video was treated with Prolotherapy injections to strengthen the ligaments of the wrist. This is discussed below.
What are we seeing in this image?
In this image from the video, Dr. Hauser demonstrates a case of severe distal radioulnar instability, a condition that is routinely overlooked in wrist pain examinations. Here the ulnar and radius, the two forearm bones that meet at the wrist are seen to be greatly separated at the wrist when they are supposed to stay together. This is a tell-tale sign of ligament damage-causing wrist instability.
Removing cartilage? Shaving down bone? How much does triangular fibrocartilage surgery help an athlete return to sport? A worker back to the job?
Above, research is given to support the general use of surgery for TFCC tears. Let’s stress again that many people have very successful surgeries. Not everyone does, however.
In June 2019, researchers in Scotland looked to provide information on return rates and times to return to sport following surgical management of triangular fibrocartilage tears. They published their paper in the British Medical Bulletin (5) in which they examined 10 previously conducted studies where the patient followed conservative management for 6 weeks to 6 months as the first-line treatment. If symptoms persisted following this period, surgical management was advised. Arthroscopic debridement was recommended for central tears, and arthroscopic repair was recommended for peripheral tears.
- The researchers noted that surgery and conservative care treatments remain controversial because of limited success. They write: “The optimal treatment modalities for triangular fibrocartilage tears remain to be defined.”
The researchers did find that Traumatic central tears can be treated with arthroscopic debridement alone. Arthroscopic repair with an all-inside repair can improve return rates to sport over an outside-in technique for ulna-sided tears. But these were not conclusive, writing: “Future prospective studies should aim to establish the optimal treatment modalities for triangular fibrocartilage tears.
As with any medical treatment, some people will benefit, and some people will not. The controversy surrounding surgery for triangular fibrocartilage tears comes from papers like that published in the medical journal Arthroscopy (6) (November 2018). This is from Wake Forest University School of Medicine.
“After ruling out additional potential pain generators for ulnar-sided wrist pain, arthroscopic debridement for triangular fibrocartilage complex pathology can be an effective means for decreasing pain and improving function in the short term. Arthroscopic skills aside, this procedure will not work for all comers, and establishing realistic patient expectations is essential for optimal outcomes.”
- In other words, even if you get the triangular cartilage removed or the bone shaved down, there remains the possibility of continuing grinding wrist instability. Don’t take our word for it. Listen to the surgeons.
TFCC Surgery made it worse
We would like to stress again that surgery for Triangular fibrocartilage complex tear can help many people. These are typically not the people we see in our office. We see the people after surgery or those whose surgeon evaluated their situation and could not give a confident expectation that surgery would provide the hoped-for pain relief and increase in function.
This is a February 2019 study that appeared in the Journal of Wrist Surgery (7). It comes from the Department of Orthopaedic Surgery, St. Vincent’s Hospital, Catholic University of Korea. Here are some of the findings.
- The relationship between a triangular fibrocartilage complex (TFCC) tear and ulnar impaction syndrome has not been fully understood.
- Ulnar impaction syndrome is when the ulna bone is longer than its companion forearm bone, the radius, and this creates an unnatural impact on the triangular fibrocartilage complex. The idea of surgery of course, as mentioned above, is to correct this problem and alleviate pain and restricted motion of the wrist at the triangular fibrocartilage complex.
- The researchers of this study hypothesized that a triangular fibrocartilage complex tear could change the ulnar variance, which may be the cause of ulnar impaction syndrome.
- The ulnar variance is the length differential between the ulnar and the radius bones of the forearm.
- The researchers examined 72 patients who underwent TFCC foveal repair (ligament and soft tissue repair) between January 2011 and June 2016. Among them, 44 patients diagnosed with TFCC foveal tear with distal (pinky side) radioulnar joint instability and no ulnar impaction syndrome underwent TFCC foveal repair only (group A) and 28 patients diagnosed with TFCC foveal tear with ulnar impaction syndrome underwent TFCC foveal repair and ulnar shortening osteotomy simultaneously (group B).
- The researchers measured their ulnar variances in preoperative, postoperative, and last follow-up plain radiography.
- Once the TFCC was repaired, ulnar variance decreased. (The problem got better). However, it was increased on the last follow-up radiograph. (The problem returned).
- Conclusion: “Ulnar variance may be changed after a TFCC tear. In our study, it decreased after TFCC foveal repair. However, as time went on, the ulnar variance increased again, which could be one of the causes of ulnar impaction syndrome and ulnar-sided wrist pain.”
Non-Surgical TFCC tear treatment options
For a general explanation of non-surgical treatment options and when surgery should be considered, let’s turn to the online publication Triangular Fibrocartilage Complex in the US National Library of Medicine’s STATPEARLS Updated April 2021. (8)
Learning points and summary highlights:
- Initial treatment includes rest, physical therapy, and corticosteroid injections. The length of time to attempt conservative treatment before advancing to surgical options varies.
- Six months of conservative treatment is reasonable if there is no Distal Radioulnar Joint Instability.
- There is limited evidence to support the use of bracing as a treatment option for TFCC tears. weeks.
- Treating athletes can vary from treatment for non-athletes.
- A high school athlete who will not compete beyond high school should begin with four weeks of rest, ice, and anti-inflammatories.
- For elite athletes, if there is no distal radioulnar joint instability, one week of rest with splinting and re-examination after one week is reasonable.
- If there is a tear of the TFCC with the instability of the distal radioulnar joint, this is potentially career-threatening.
- If there is a chronic tear, the athlete can receive counsel that the risk of further damage is minimal. Therefore, the athlete can choose to try to play through the injury until the season is over, or the athlete could elect surgery immediately.
- Corticosteroid injections are also an option, especially in elite athletes who elect to delay surgical intervention in an attempt to finish the season.
In the research cited in this article, Corticosteroid injections are seen favorably as a short-term option. Let’s be clear, for some people corticosteroid injections may help short-term. However, the overall success of corticosteroid injections is seen in a diminished light when you consider many corticosteroid patients move on to surgery.
There is little by way of research that focuses on TFCC tear and cortisone effectiveness. There is a recently recruited study being conducted by the William Beaumont Army Medical Center titled: A Prospective Randomized Double-Blinded Controlled Trial of Non-Operative Management of TFCC Injuries (TFCC) with an estimated study date of completion in 2022-2023. (9)
In this study, Platelet-Rich Plasma (PRP) is being studied in a side-by-side comparison with cortisone. Injections. Our website is filled with articles containing PRP vs. Cortisone studies.
- PRP treatment takes your blood, like going for a blood test, and re-introduces the concentrated blood platelets from your blood into problem areas of the wrist.
- Your blood platelets contain growth and healing factors. When concentrated through simple centrifuging, your blood plasma becomes “rich” in healing factors, thus the name Platelet RICH plasma. Platelets play a central role in blood clotting and wound/injury healing.
- The procedure and preparation of therapeutic doses of growth factors consist of an autologous blood collection (blood from the patient), plasma separation (blood is centrifuged), and application of the plasma rich in growth factors (injecting the plasma into the area.) In our office, patients are generally seen every 4-6 weeks. Typically three to six visits are necessary per area.
Simple key points about PRP treatments:
- PRP injections may help prevent the need for surgery while improving wrist function.
- In other research, PRP was found to provide more long-lasting pain relief than cortisone injections for wrist-related pain.
- PRP therapy can repair damaged tendons and ligaments.
Focus on strengthening the wrist ligaments and stabilizing the grinding wrist
We are going to briefly summarize Triangular fibrocartilage complex tear symptoms and treatment with Prolotherapy. This is a non-surgical injection technique designed to stabilize the wrist, reduce or eliminate pain, and restore range of motion. Dozens of research studies have documented Prolotherapy’s effectiveness in treating chronic joint pain. The treatment of TFCC injuries includes splinting or casting, ice, rest, and anti-inflammatory medications. In some cases, surgery to remove the cartilage may be recommended. These treatments are pain management techniques that typically do not prompt repair, only suppression of symptoms. We utilize Prolotherapy injections (simple dextrose) to repair damage to the cartilage and the ligaments of the wrist, and hand TFCC tear areas.
Prolotherapy treatment demonstrated and described
In the video below, Prolotherapy treatment is being demonstrated on a wrist. A summary of the video is below.
As you can see the outer part, pinky-side, of the wrist is being treated.
- The patient in the video is a personal fitness trainer. She is very physically fit. She does many exercises that put a lot of pressure on her wrists – push-ups, Zumba, yoga.
- The pain in her wrist is making it very difficult for her to demonstrate the various exercises to her classes.
- We are injecting both rows of the carpal bones. The wrist is comprised of 8 bones and 27 ligaments. It is easy to see why a treatment that focuses on strengthening and repairing the wrist ligaments would be so important to someone with significant wrist pain.
- We see many people with wrist pain on the ulnar side where Triangular fibrocartilage complex injuries occur.
- The video shows treatment around the navicular bone and the scaphoid lunate and surrounding ligaments. We see a lot of injuries there.
- The average person requires 3 to 6 treatments.
- Prolotherapy injections can be very effective for wrist instability. When we treat the wrist, we treat the entire wrist not only the ulnar side.
Summary and contact us. Can we help you?
We hope you found this article informative and it helped answer many of the questions you may have surrounding wrist pain issues. If you would like to get more information specific to your challenges please email us: Get help and information from our Caring Medical staff
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This article was updated on April 12, 2022