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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 13  |  Issue : 2  |  Page : 122-128

A comparative study of cross pinning versus lateral pinning technique in the management of completely displaced type-III supra condylar humerus fracture in the rural India children: A prospective study


1 Deparment of Orthopaedics, UPUMS, Saifai, Etawah, Uttar Pradesh, India
2 Deparment of Orthopaedics, AIIMS, Raebareli, Uttar Pradesh, India
3 Deparment of Orthopaedics, BRD Medical College, Gorakhpur, Uttar Pradesh, India
4 Deparment of Orthopaedics, Dr. RMLIMS, Lucknow, Uttar Pradesh, India

Date of Submission05-Mar-2021
Date of Acceptance11-Jul-2021
Date of Web Publication27-Dec-2021

Correspondence Address:
Dr. Santosh Kumar Singh
New SR Hostel-203, UPUMS, Saifai, Etawah - 206 130, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jotr.jotr_13_21

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  Abstract 


Context: Supracondylar fractures of the humerus (SCFH) are the most common type of pediatric fracture and related to significant morbidity with the complication of nerve injury and loss of reduction. Closed reduction and percutaneous Kirchner wires pinning either by lateral pin fixation or cross pin fixation for the displaced fractures are the mainstay treatment. Aims: This study has purpose to compare the construct stability, functional, and radiological results between the two methods of fracture fixation. Subjects and Methods: A total of 61 children with Gartland III SCFH were placed randomly into two groups, Group A (n = 30) managed by lateral pinning technique and Group B (n = 31) were managed by cross pinning techniques. Both groups were quite comparable with regard to age, gender, duration of injury, and degree of displacement of the fracture. The results were analyzed in terms of clinical and radiological outcome, Flynn functional scoring system, and complications. Fisher's exact test and unpaired t-tests were used. The results were expressed as mean, and the P < 0.05 was considered statistically significant using the SPSS software (version 22). Results: Statistically, there was no significant difference in clinical or radiological results between the two groups at 6 months after operation (P > 0.05). There was no significant loss of reduction found in either of the groups. There was one (6.6%) case of the lateral pinning group that had a minimal loss of reduction and two (6.4%) cases of the iatrogenic ulnar nerve neuropraxia in the cross pinning group. Neuropraxia recovered fully. Superficial pin tract infection was seen in two (6.67%) cases of the lateral pinning group. Conclusions: Although it appears that cross spinning is a more stable construct, the lateral pin fixation provides the same result without risk of iatrogenic nerve injury with comparable results.

Keywords: Displaced supracondylar fracture humerus, fracture fixation, Kirschner wires


How to cite this article:
Singh SK, Singh P, Gill SP, Mishra L, Arora J. A comparative study of cross pinning versus lateral pinning technique in the management of completely displaced type-III supra condylar humerus fracture in the rural India children: A prospective study. J Orthop Traumatol Rehabil 2021;13:122-8

How to cite this URL:
Singh SK, Singh P, Gill SP, Mishra L, Arora J. A comparative study of cross pinning versus lateral pinning technique in the management of completely displaced type-III supra condylar humerus fracture in the rural India children: A prospective study. J Orthop Traumatol Rehabil [serial online] 2021 [cited 2022 Aug 10];13:122-8. Available from: https://www.jotr.in/text.asp?2021/13/2/122/333553




  Introduction Top


Supracondylar fractures of the humerus (SCFH) are the most common fracture in children around the elbow and constitutes 60%–65% of all elbow injuries having peak incidence between 4 and 7 years of age.[1],[2] Up to 2/3rd of pediatric elbow injuries require hospitalization and requires surgical treatment. The main immediate and late complications associated with supracondylar humerus fractures are compartment syndrome, neurovascular involvement, Volkman's ischemic contracture, myositis ossificans, and angular deformities.[2],[3],[4],[5] Extension type supracondylar fractures are most common (97%–99%) with a small remainder being flexion type.[6] The most common classification system used for these types of fracture is Gartland's classification. The fractures are classified as Type I (none displaced), Type II (displaced in extension with a fracture of the anterior cortex and intact posterior cortex), and Type III (completely displaced fracture).[6] Gartland's Type I fractures can be managed with close reduction and above elbow Plaster of Paris cast application. Most Type II and Type III fractures usually need closed reduction and percutaneous pinning with Kirchner wires.[5] The conservative treatment may be complicated with loss of reduction, closed compartment syndrome, and with angular deformity.[2] Type III fractures are commonly managed with closed reduction and retrograde percutaneous pinning with Kirschner wires.[2],[3],[4] K-wires have the advantage of easy to use, less cost, and limited hospitalization stay.[3],[4] The configuration of these wires may be different-a medial pin and a lateral pin in the cross manner or two pins inserted in the lateral pinning fashion.[3] Medial and lateral pinning pins purchase the lateral and medial pillars at the fracture site with center crossing point ideally, whereas lateral pinning pins purchase the lateral and central pillars at the fracture site. However, the controversy persists between the two techniques for the superiority. The main advantage of the cross spinning technique is probably increased stability of the fracture segments, although iatrogenic injury of the ulnar nerve may result with medial pin placement.[7],[8] The treatment aims to prevent the complications and achieve normal functioning.[2]

This study aimed to compare the clinical and radiological outcome of cross pinning and lateral pinning technique in the children with completely displaced type-III SCFH.[9],[10]


  Subjects and Methods Top


This is a prospective study was done in orthopedics department, at rural tertiary care center in North India for the period of 2 years from July 2016 to July 2018. A total 138 patients had come to the outpatient department (OPD) and emergency department with SCFH.

Inclusion criteria

We have included the patients between the age group of 3 and 10 years, Gartland's Type III supracondylar humerus fracture within 6 days of injury with intact neurovascular status of the affected extremity.

Exclusion criteria

We have excluded the patients of age <3 years or more than 10 years, nondisplaced supracondylar humerus fracture, duration of injury more than 6 days, open fractures, fracture requiring neurovascular exploration, fracture requiring open reduction, floating elbow injuries, bilateral supracondylar humerus fracture, and previous ipsilateral elbow fractures.

Open fractures, multiple fracture ipsilateral extremity, the patients managed conservatively for Gartland I and Gartland II fractures and the patients who refused to operate were excluded from the study (n = 60). The remaining 78 patients were found suitable to include in the study. Patients were allocated randomly in two groups, Group A – lateral pinning group and Group B – cross pinning group with the help of computer-generated randomization table. Seven patients from the lateral pinning group and ten patients from the cross pinning group were lost to follow-up, and the remaining 30 were in Group A and 31 in Group B.

Finally, this study comprises 61 cases of Type III supracondylar fracture. Ethical committee approval was obtained. A written informed consent was obtained from the parents/legal guardian before participating in the study [Figure 1].
Figure 1: Methodology of study

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Thorough neurovascular assessment of affected limb was done in each patient. Standard anteroposterior and lateral X-ray were obtained in the injured elbow. All the patients included in the study were admitted to the emergency room, preliminary reduction with immobilization by the pop slab in 30°–40° flexion of the elbow with strict limb elevation was done to control pain, minimize the risk of compartment syndrome and avoid neurovascular injuries. A preoperative anesthesia checkup was done. We performed the surgery as soon as possible; usually, this duration was within 24 h of admission.

Surgical techniques

A team of senior trained orthopedic surgeons performed all the surgeries. General anesthesia was used in all the patients. We performed the surgery with all the patients in the supine position. The injured affected limb was placed on a radiolucent table in abduction. The long gentle traction was applied along the axis of the limb with the elbow in a hyperextended and supinated position. One assistant provided the counter traction by holding the patient arm. While maintaining the traction medial and lateral displacement in the coronal plane was corrected by applying valgus or varus forces. Milkman's maneuver was used in the condition where the skin puckering was present to deliver the proximal fragment. Later by pronating or supinating the distal limb corrects the rotational deformity of the distal fragment. A force over olecranon is applied while the elbow was flexed gentle to correct the posterior displacement of distal fragment. The reduction was confirmed with an image intensifier keeping the elbow in the flexed position. The pin size of 1.5 mm in the patient of <20 kg and the pin size of 2.0 mm in the patients with weight more than 20 kg.

Lateral pinning technique

The lateral pin was placed percutaneously directly at the center of the lateral epicondyle. Two K-wires inserted from the lateral epicondyle with bicortical purchas engaging the medial cortex either in parallel or divergent fashion with adequate separation at fracture site maintaining the elbow in hyper flexed position [Figure 2].
Figure 2: (a) Preoperative radiograph, (b) immediate postoperative radiograph with lateral pinning fixation of 4-year-old male patient, (c) follow-up at 12 months, (d and e) at final follow-up

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For the cross spinning technique

At first the lateral k-wire was placed followed by medial k-wire. With the help of opposite thumb, the ulnar nerve was rolled back to avoid the iatrogenic injury, the medial pin was placed percutaneously anterior to ulnar nerve groove, directly through the tip of the medial epicondyle keeping the elbow at 45–60 short of extension. A small stab incision was given over medial epicondyle in those cases where intense swelling is present around the elbow, and medial epicondyle is not palpable [Figure 3].
Figure 3: (a) Preoperative radiograph, (b) immediate postoperative radiograph with cross-pinning configuration of 4-year-old female patient, (c and d) at final follow-up

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Satisfactory reduction achieved and confirmed by the image intensifier. The pins were bent cut, and the ends were buried under the skin. After the placement of the pins, the elbow was examined, and the carrying angle was measured. The aseptic dressing was done the elbow was kept in posterior slab/splint in the 90° of flexion. Immediate postoperative status of the ulnar and radial pulse was checked and secured. At the time of induction, a single dose of cefuroxime was given intravenously and postoperatively oral cefuroxime was given for 3 days.

On the 1st postoperative day, X-ray was done, and a check dressing was done. On day 3, the patient was discharged. K-wires and slab were removed after the 3–4 weeks when the evidence of callus is present and the fracture line blurs on radiograph. Moreover, the full elbow range of motion exercise started. Follow-up of all the patients was done at the 1st, 3rd, 6th week, 3 months, 6 months, and 1 year on OPD basis. The orthopedic surgeon did the clinical and radiological examination. Assessment of carrying angle, measurement of passive elbow range of motion, neurovascular examination of the extremity, complication such as superficial or deep infection, loosening of pins, and condition of skin were included in the clinical examination. Radiographic examination of elbow joint was done with the standard anteroposterior view and the lateral view by measuring the metaphyseal-diaphyseal (MD) angle, Baumann angle. We used Flynn criteria [Table 1] for the clinical examination which is based on the elbow range of motion and the carrying angle.[11] The final outcome was divided into excellent, good, fair, and poor based on the range of motion in the sagittal plane and measurement of carrying angle in the coronal plane. Unsatisfactory range of motion and difference in carrying angle are the indicators of poorer outcome.
Table 1: Flynn's criteria for grading of functional and cosmetic results

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Loss of reduction was defined according to the criteria of Skaggs et al. which is based on the change in Baumann angle (I) no displacement (loss <6°), (2) moderate displacement (loss 6°–12°), and (3) large displacement (loss >12°).[12]

Statistical analysis

Data were summarized as mean and standard deviation. We used the Fisher's exact test and unpaired t-test to evaluate for the presence of significant difference in the outcome variable between the two groups. The results were expressed as mean, and the P < 0.05 was considered statistically significant. Analysis of the data was done using the SPSS software (version 22) (IBM SPSS Statistics for Windows, Version 22.0. Armonk, NY).


  Results Top


A total of 61 patients with completely displaced Type III supracondylar fracture were available for the follow-up and were included in this study. The mean age of all the patients was 8.3 years, in the lateral pinning group, it was 8.26 years, whereas it was 8.54 years in the cross pinning group. The male-to-female ratio in the lateral pinning group was 22:8, and it was 23:8 in the cross pinning group. The right side was involved in 16.67% in the lateral pinning group and 25.81% in the cross pinning group. The most common cause of injury was fall from height 63.9 3%, followed by fall during playing 29.5 1% and due to road traffic accidents 6.56%. The posteromedial fracture type was present in 49 (80.3 2%) cases and the posterolateral fracture type was present in 12 (19.6 8%) cases. In the lateral pinning group, their frequency was 25 (83.33%) and 5 (16.67%), respectively, and 24 (77.41%) and 7 (22.59%) in the cross pinning group, respectively. Radial pulse was weak in 55.5 4%, normal in 14.1 6%, and was absent with a viable hand in 6.56%. The presence of a vascular surgeon was assured at the time of surgery but in all patients, the radial pulse appeared after close reduction and k-wire fixation. We do not need brachial artery exploration in any cases. A total of seven patients presented with median nerve injury, of which 4 from lateral pinning group and 3 from cross pinning group, associated with a fracture at the time of admission. All the median nerve palsies resolved spontaneously postoperatively. The average delay from the date of injury to the day of surgery was 2.24 days in the lateral pinning group and 2.36 day in the medial entry group. The overall average delay was 2.25 days. The average hospital stay was 2.33 days in the lateral pinning group and 2.5 days in the cross pin group with an overall hospital stay was 2.41 days with a mean of 2 days–4 days. The average duration of follow-up was 35.28 week in the lateral pinning group and 33.53 weeks in the cross pinning group with an overall mean follow-up was 35.33 weeks with a minimum of 25 weeks and a maximum duration was 61 weeks. There was no statistical significance difference (P > 0.05) present between the groups concerning any of these variables [Table 2]. Postoperative complication such as superficial pin tract infection was present in two (6.67%) cases of lateral pinning group and 1 (3.22%) cases in cross pinning technique group. All the infections were subsided during the follow-up. Iatrogenic ulnar nerve neuropraxia was present in 6.4% cases of the cross winning group, and it recovered fully within 3 weeks [Table 3]. There was no significant loss of reduction, only one case which was found with mild loss of reduction of lateral pinning group although the fracture healing occurred within a similar time period without any residual deformity. There was no significant difference (P > 0.05) regarding the change in Baumann angle, MD angle, carrying angle, or elbow range of motion [Table 4]. The final result was excellent in 49 (80.3 2%) cases and was good in 12 (19.6 7%) cases. Excellent outcome was found in 23 (76.67%) cases of lateral pinning group and 26 (83.87%) cases of cross pinning group. The outcome of seven cases (23.33%) in the lateral pinning group and five (16.1 2%) cases in the cross pinning group was found good [Table 5].
Table 2: Demographic data and P value between two groups

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Table 3: Postoperative complications (P>0.05)

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Table 4: Analysis of Baumann angle loss, metaphyseal - diaphyseal angle loss, carrying angle loss and range of motion loss at 6 months' follow-up

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Table 5: Flynn functional outcome grading (P=0.479)

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  Discussion Top


Closed reduction and percutaneous k-wire fixation is the most appropriate treatment for the completely displaced (Type-III) SCFH in the children, with the two primary treatment techniques involving the use of either two lateral pinning pins or crossed medial and lateral pinning pins. The advantage of cross entry pin fixation is probably greater biomechanical stability at the fracture site, although there is a chance of iatrogenic injury of ulnar nerve from the placement of the medial pin. Although the construct of lateral pinning is biomechanically less stable, there is an advantage of evading iatrogenic injury of ulnar nerve.[5],[13],[14],[15]

Biomechanical studies of synthetic pediatric bone models and adult cadavers have suggested that cross entry pin fixation provides greater torsional rigidity than does lateral pin fixation. The overall strength of these constructs also relates to the divergence of the pins in different columns of the distal humerus and the overall number of pins. Provide the torsional rigidity as well as varus and valgus loading similar to cross pins can be achieved by three lateral pins or two lateral pins that are divergent and are located in both the lateral and the central column.[5],[8],[16]

The risk of iatrogenic injury of the ulnar nerve is determined by the different techniques of insertion of pins from medial side.[17],[18] In a systematic review study, Kocher et al. reported that the rate of iatrogenic injury of the ulnar nerve from cross entry pin fixation was 3.3% and cross entry pin fixation method has 4.86 times higher risk for developing iatrogenic nerve injury than lateral pinning fixation method.[19] In different studies, it has been observed that the risk of iatrogenic nerve injury can be minimized with small incision over the medial aspect of the elbow and putting the elbow in extension at the time of medial pin.[20],[21],[22] The majority of iatrogenic injury of the ulnar nerve due to placement of medial pin resolves spontaneously.[21],[22]

In this study, there were two cases (6.4%) in the cross pinning group, who had ulnar nerve neuropraxia which recovered completely within 3 weeks of the surgery.

The reported risk of loss of reduction following lateral pinning fixation has also varied widely. Lateral pinning fixation is biomechanically less stable construct than cross entry pin fixation method.[10],[16] In our study, it may be the cause of average loss of the carrying angle, Baumann angle, M–D angle and range of motion in the lateral pinning cases [Table 4]. Only one patient of lateral pinning group had mild loss of reduction, but there was no residual deformity and both radiological and clinical union occurred in a same time period. The loss of both the range of motion and the carrying angle was greater in these patients, compared to those without loss of reduction. Davis et al. reported displacement of two of seven Type III fractures treated with two lateral pins.[10] Kallio et al. found a loss of reduction in 14% (eleven) of 80 cases in which two lateral pins had been used.[9] However, Skaggs et al. reported no loss of reduction after fixation of 55 Type III fractures with two or three lateral pinning pins.[12] In a quantitative synthesis that pooled data from 1680 patients from 33 studies that met a priori eligibility criteria, the rate of displacement following lateral pinning pin fixation was 2.1%.[19] The risk of displacement after lateral pinning fixation can be reduced by emphasizing proper pin-placement technique, with divergent pins, pins that engage the lateral and central columns, and the use of a third lateral pin if needed.[9],[12]

In our study, we did not find any statistically insignificant difference (P = 0.49) between the two groups considering the loss of range of movement. Excellent and good elbow range of movements was observed in both the groups. The functional outcome following cross pinning was excellent in 84% and good in 16% of cases with no poor results. While cases treated with lateral pinning showed 77% excellent and 23% good results with no poor results [Table 5]. The results of our study were similar results shown by Kocher et al., Gordon et al., Pavone et al., and Aronson and Prager[3],[7],[23],[24] [Table 6]. The difference in functional outcome between the two groups in our study was not statistically significant (P = 0.479).
Table 6: Comparison of final functional results with different studies

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Randomization of the patients was done very close to the time of surgery. Both the techniques were standardized in terms of pin size, pin location, the use of a medial incision, and the position of the elbow for medial pin placement. Through clinical and radiographic evaluation was done by the same orthopedic surgeon at standardized regular time intervals.

Limitations

Weaknesses of this study include small numbers of the case in each group because the power of study not done, lack of blinding of the clinical and radiographic observers to the pinning technique, and follow-up for the shorter period.


  Conclusions Top


Both pin-fixation techniques appear to be safe and effective, economically viable, and quite comparable in clinical and radiographic outcomes. Properly placed medial pin is safe with respect to the iatrogenic injury of the ulnar nerve. Either types of pin configuration did not appear to affect the change in the final Baumann angle, functional outcome, and stability, fracture union and postoperative complications. However, these results are contingent on the specific surgical techniques used in this study.

Acknowledgments

All authors have participated sufficiently in this work concerning conception and design of this study, drafting the article, critical revision for important intellectual content, and final approval.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Kocher MS, Kasser JR, Waters PM, Bae D, Snyder BD, Hresko MT, et al. Lateral entry compared with medial and lateral entry pin fixation for completely displaced supracondylar humeral fractures in children. A randomized clinical trial. J Bone Joint Surg Am 2007;89:706-12.  Back to cited text no. 3
    
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Ramachandran M, Skaggs DL, Crawford HA, Eastwood DM, Lalonde FD, Vitale MG, et al. Delaying treatment of supracondylar fractures in children: Has the pendulum swung too far? J Bone Joint Surg Br 2008;90:1228-33.  Back to cited text no. 4
    
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Skaggs DL, Hale JM, Bassett J, Kaminsky C, Kay RM, Tolo VT. Operative treatment of supracondylar fractures of the humerus in children. The consequences of pin placement. J Bone Joint Surg Am 2001;83:735-40.  Back to cited text no. 5
    
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Gordon JE, Patton CM, Luhmann SJ, Bassett GS, Schoenecker PL. Fracture stability after pinning of displaced supracondylar distal humerus fractures in children. J Pediatr Orthop 2001;21:313-8.  Back to cited text no. 7
    
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Skaggs DL, Cluck MW, Mostofi A, Flynn JM, Kay RM. Lateral-entry pin fixation in the management of supracondylar fractures in children. J Bone Joint Surg Am 2004;86:702-7.  Back to cited text no. 12
    
13.
Topping RE, Blanco JS, Davis TJ. Clinical evaluation of crossed-pin versus lateral-pin fixation in displaced supracondylar humerus fractures. J Pediatr Orthop 1995;15:435-9.  Back to cited text no. 13
    
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Lee SS, Mahar AT, Miesen D, Newton PO. Displaced pediatric supracondylar humerus fractures: Biomechanical analysis of percutaneous pinning techniques. J Pediatr Orthop 2002;22:440-3.  Back to cited text no. 16
    
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Kalenderer O, Reisoglu A, Surer L, Agus H. How should one treat iatrogenic ulnar injury after closed reduction and percutaneous pinning of paediatric supracondylar humeral fractures? Injury 2008;39:463-6.  Back to cited text no. 17
    
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Rasool MN. Ulnar nerve injury after K-wire fixation of supracondylar humerus fractures in children. J Pediatr Orthop 1998;18:686-90.  Back to cited text no. 18
    
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Shim JS, Lee YS. Treatment of completely displaced supracondylar fracture of the humerus in children by cross-fixation with three Kirschner wires. J Pediatr Orthop 2002;22:12-6.  Back to cited text no. 20
    
21.
Green DW, Widmann RF, Frank JS, Gardner MJ. Low incidence of ulnar nerve injury with crossed pin placement for pediatric supracondylar humerus fractures using a mini-open technique. J Orthop Trauma 2005;19:158-63.  Back to cited text no. 21
    
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Barlas K, Baga T. Medial approach for fixation of displaced supracondylar fractures of the humerus in children. Acta Orthop Belg 2005;71:149-53.  Back to cited text no. 22
    
23.
Pavone V, Riccioli M, Testa G, Lucenti L, De Cristo C, Condorelli G, et al. Surgical treatment of displaced supracondylar pediatric humerus fractures: Comparison of two pinning techniques. J Funct Morphol Kinesiol 2016;1:39-47.  Back to cited text no. 23
    
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    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]



 

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