Changes in Contact Area in Meniscus Horizontal
Cleavage Tears Subjected to Repair and Resection
Brandon S. Beamer, M.D., Kempland C. Walley, B.Sc., Stephen Okajima, B.Sc.,
Ohan S. Manoukian, B.Sc., Miguel Perez-Viloria, M.D., Joseph P. DeAngelis, M.D.,
Arun J. Ramappa, M.D., and Ara Nazarian, Ph.D.
Purpose: To assess the changes in tibiofemoral contact pressure and contact area in human knees with a horizontal
cleavage tear before and after treatment. Methods: Ten human cadaveric knees were tested. Pressure sensors were
placed under the medial meniscus and the knees were loaded at twice the body weight for 20 cycles at 0,10
, and 20of
ﬂexion. Contact area and pressure were recorded for the intact meniscus, the meniscus with a horizontal cleavage tear,
after meniscal repair, after partial meniscectomy (single leaﬂet), and after subtotal meniscectomy (double leaﬂet).
Results: The presence of a horizontal cleavage tear signiﬁcantly increased average peak contact pressure and reduced
effective average tibiofemoral contact area at all ﬂexion angles tested compared with the intact state (P<.03). There was
approximately a 70% increase in contact pressure after creation of the horizontal cleavage tear. Repairing the horizontal
cleavage tear restored peak contact pressures and areas to within 15% of baseline, statistically similar to the intact state
at all angles tested (P<.05). Partial meniscectomy and subtotal meniscectomy signiﬁcantly increased average peak
contact pressure and reduced average contact area at all degrees of ﬂexion compared with the intact state (P<.05).
Conclusions: The presence of a horizontal cleavage tear in the medial meniscus causes a signiﬁcant reduction in contact
area and a signiﬁcant elevation in contact pressure. These changes may accelerate joint degeneration. A suture-based
repair of these horizontal cleavage tears returns the contact area and contact pressure to nearly normal, whereas both
partial and subtotal meniscectomy lead to signiﬁcant reductions in contact area and signiﬁcant elevations in contact
pressure within the knee. Repairing horizontal cleavage tears may lead to improved clinical outcomes by preserving
meniscal tissue and the meniscal function. Clinical Relevance: Understanding contact area and peak contact pressure
resulting from differing strategies for treating horizontal cleavage tears will allow the surgeon to evaluate the best strategy
for treating his or her patients who present with this meniscal pathology.
The meniscus serves to dissipate force across the
articular surface by increasing the contact area
between the concave distal femoral condyle and the
relatively ﬂat tibial plateau.
Multiple studies have
shown that removal of meniscal tissue lowers the
contact area and increases contact pressure.
thought that the resulting elevated tibiofemoral contact
pressure leads to degenerative changes of the articular
Tears in the meniscus compromise the load distribu-
tion function of the meniscus. In the clinical setting, the
torn tissue often is removed to alleviate immediate
symptoms; however, tissue removal predisposes the
knee to arthritis.
Studies also show that greater
amounts of tissue removal are associated with worse
long-term outcomes in patients.
For this reason, ap-
proaches that preserve meniscal tissue and potentially
prevent future degeneration have been growing.
Most biomechanical studies have concentrated on
vertical or radial tears, with little in the literature pub-
lished on horizontal cleavage tears (HCTs) until
recently. HCTs divide the meniscus into an upper and
lower lamina, relatively parallel to the tibial plateau.
They are among the most common meniscal tears
From the Center for Advanced Orthopaedic Studies (B.S.B., K.C.W., S.O.,
O.S.M., M.P-V., A.N.) and Department of Orthopaedic Surgery (B.S.B.,
K.C.W., S.O., O.S.M., M.P-V., J.P.D., A.J.R., A.N.), Beth Israel Deaconess
Medical Center, Harvard Medical School, Boston, Massachusetts, U.S.A.
J.P.D., A.J.R., and A.N. contributed equally to this work and should be
considered coesenior authors.
The authors report the following potential conﬂicts of interest or sources of
funding: The Orthopaedic Research and Education Foundation (OREF) in
conjunction with the Dr. Dane and Mary Miller Endowment Fund funded
this study. Ceterix provided devices for the study.
Received March 2, 2016; accepted September 12, 2016.
Address correspondence to Ara Nazarian, Ph.D., Center for Advanced
Orthopaedic Studies, Beth Israel Deaconess Medical Center, 330 Brookline
Avenue, RN115, Boston, MA 02215, U.S.A. E-mail: anazaria@bidmc.
Ó2016 by the Arthroscopy Association of North America
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol -,No-(Month), 2016: pp 1-8 1
have been associated with degradation of knee carti-
The presence of a horizontal tear may cause
symptoms leading to arthroscopic intervention. HCTs
frequently are treated with partial meniscectomy
(single leaﬂet resection), subtotal meniscectomy
(resection of both leaﬂets), or conservative treatment.
Haemer et al.
studied the impact of partial and subtotal
meniscectomy for small and large horizontal tears in a
goat model and showed that both partial and subtotal
meniscectomy led to signiﬁcant elevations in contact
pressure for large tears. A recent systematic review
examined all reported outcomes after HCT repair
attempts and showed a success rate similar to that
reported for other tear types that are repaired more
Subsequently, 2 additional clinical studies
reported success rates of more than 90% for HCT
repair, raising the question related to the biomechanical
rationale for such repairs.
The speciﬁc aim of this study was to assess the
changes in tibiofemoral contact pressure and contact
area in human knees with a HCT before and after
treatment. We hypothesized that resection of one or
both lamina of a large HCT in the medial meniscus leads
to elevation in contact pressures in the knee, which
may be mitigated through repair.
Preparation, Repair, and Loading
Ten intact fresh frozen human cadaveric knees
(donor weight 66 11 kg, donor height 169 8.1 cm,
donor age 67 7 years, 5 male and 5 female) were
acquired (Medcure, Providence, RI) and evaluated by
an orthopaedic surgeon (B.S.B.) to exclude those with
grade 3 or 4 cartilage lesions (no specimens were
excluded). The skin and subcutaneous fat were
removed from the specimens, followed by the under-
lying muscle and extensor mechanism. Care was taken
to preserve the integrity of the joint capsule, collateral
ligaments, and cruciate ligaments. On gross examina-
tion, each showed no evidence of signiﬁcant arthritis or
meniscal tearing. The femur and tibia were cut 10 cm
from the joint line.
To gain access to the medial compartment, an
osteotomy was performed at the femoral origin of the
medial collateral ligament (MCL) so that the superﬁcial
and deep ﬁbers could be taken down as a continuous
sleeve. The bone was then repaired in situ with a
50-mm 3.5-mm cortical screw and washer. This
technique was chosen because it does not affect tibio-
femoral contact pressures.
To allow the testing ﬁlm to
lie ﬂat on the tibial plateau, an incision was made
beneath the anterior and posterior horns of the
meniscus along the joint line, and approximately 1 cm
of the coronary ligaments was resected without
disrupting the meniscal root, meniscofemoral liga-
ments, or the remaining capsular attachments.
A calibrated pressure sensor (4010N; 44 mm
68 mm 0.2 mm, 422 sensels, 25 sensels/cm
Tekscan, South Boston, MA) was wrapped in adhesive
ﬁlm (Tegaderm, Nexcare; 3M, Saint Paul, MN) and
was inserted under the medial meniscus ﬂush with
the tibial plateau. Sensors were calibrated for repeat-
ability according to manufacturer’sprotocol.The
sensor was secured with 2 #1 PDS sutures (Poly-
diaxone suture; Ethicon, Somerville, NJ) placed
through the periphery of the sensor and the perios-
teum of the tibia.
Before insertion, the pressure sensor was calibrated
with a loading frame (Instron 8511; Instron, Norwood,
MA) with its native load cell (2500 N limit). Three
calibration pressures within the expected minimum
and maximum tibiofemoral contact pressure ranges of
the study were applied, and the entire matrix area of
the sensor was loaded to ensure precise calibration.
The sensors were instructed to collect pressure data at
a sampling rate of 100 Hz during cyclic loading
experiments and at a sampling rate of 4 Hz during the
ramped loading tests to ensure a consistent peak
pressure measurement. The ramped loading tests also
acquired pressure data at 4 Hz for 10 seconds once the
maximum load was achieved. Data acquisition for
each specimen was ﬁnished after the ramped loading
The tibiofemoral loading protocol was based on the
work of Bedi et al.,
in which the authors analyzed
tibiofemoral contact pressures for radial tears in
cadaveric lateral menisci. The ﬂexion angles were
chosen to recreate the tibiofemoral contact pressure
proﬁle transitioning from stance
to normal walking
gait before execution of the swing mechanism, where
load on the meniscus is minimal. Although a mea-
surement at 0best resembles a well-established
loading scheme, load bearing occurs at various ﬂexion
angles; thus, additional testing at ﬂexion angles of 10
and 20was investigated for potential variations in
loading behaviors surrounding the meniscus.
A simpliﬁed testing jig was designed to apply axial
load to the knee joint at varying ﬂexion angles. The jig
consisted of 2 boxes to mount the embedded ends of
the proximal femur and the distal tibia. The distal tibia
box was mounted on a 6-degree of freedom (DoF) load
cell (Omega 160; ATI Industrial Automation, Apex,
NC) and a sliding mechanism to allow for the selection
of different ﬂexion angles. The testing jig was mounted
on the load cell (2500 N limit) of the load frame
(Instron 8511; Instron). The proximal femoral box was
attached to a ball joint before being connected to the
hydraulic actuator of the load frame (Fig 1). The knee
was placed in the testing jig by potting the tibial and
femoral diaphyses into a block mold with the use of
2B. S. BEAMER ET AL.
polymethylmethacrylate. The polymethylmethacrylate
blocks were placed and secured into the jig, ensuring
the joint line was perpendicular to the mechanical axis
of the mechanical testing system at 0ﬂexion angle via
a laser guide (Fig 2). Knees were loaded axially at twice
the body weight and 0ﬂexion angle (1310-2437 N),
simulating the average joint reactive force the knee
experiences during normal gait.
Axial loads for 10
and 20ﬂexion angles were calculated and applied for
the said angles (1290-2400 and 1231-2290 N, respec-
tively). For each testing condition and ﬂexion angle,
the knees were loaded axially for 20 cycles at a rate of
1 Hz. The native load cell of the load frame was used to
control the load frame, and the 6DoF load cell was used
to record loads and torques along X (anterior-posterior,
posterior þdirection), Y (medial-lateral, lateral þdi-
rection), and Z (superior-inferior, superior þdirection)
axes. Under these conditions, data were recorded for
average and peak tibiofemoral contact pressures and
contact area in the intact medial meniscus (group 1)
with the jig placed in 0,10
respectively (Fig 2), for 20 cycles each, to simulate
various phases of the gait cycle.
After the MCL was then taken down, an HCT was
made in the medial meniscus under direct visualization
with a #11 surgical blade just superior to the apex. The
tear extended to within 1 mm of the joint capsule and
extended from the anterior horn to the posterior horn
(Fig 3A) at the approximate midpoint of the meniscus.
Fig 1. An outline of the testing jig with key components and a
left knee mounted onto the jig. (DoF, degree of freedom.)
Fig 2. The tibiofemoral axial loading apparatus employed in this study at 0,10
, and 20settings with a left knee.
HORIZONTAL TEARS AND JOINT CONTACT PRESSURE 3
The location and size of tear were conﬁrmed by visual
inspections. The MCL osteotomy was repaired and the
loading regimen was repeated, and we analyzed
tibiofemoral contact area and pressure for the torn
meniscus and recorded for the varying degrees of
ﬂexion (group 2).
Fig 3. The experimental testing states (torn [A], repaired [B], partially resected [C], and fully resected [D]) presented in this
study with a left knee.
4B. S. BEAMER ET AL.
The meniscus was then repaired in an open fashion
with an all-inside, vertical loop technique. Four vertical
loops of 2-0 UHMWPE suture (Teleﬂex, Morrisville,
NC) were spaced evenly along the length of the torn
meniscus (Fig 3B) and tied with surgeon’s knots. The
sutures were placed via the use of a suture passing
device (NovoStitch; Ceterix Orthopaedics, Menlo Park,
CA). The loading regimen was repeated for the repair
group (group 3). The repair sutures were removed and
the upper leaﬂet resected to within 2 mm of the
meniscal periphery to simulate a partial meniscectomy
and the sample was loaded (group 4) (Fig 3C). Lastly,
the remaining lower meniscal leaﬂet was resected back
to a stable rim (2 mm from capsular attachment) to
complete a subtotal meniscectomy. The loading process
was repeated (group 5) (Fig 3D).
During the entire
testing process, the Tekscan sensors were monitored for
Tibiofemoral contact pressures average 6 1.5 MPa
in the medial compartment of normal knees and
7.4 1.5 MPa in knees with the medial meniscus
When these values are used as a guide, a
sample size of 10 was calculated to result in 80%
power to detect a 20% change in contact pressure
based on analysis of variance (nQuery Advisor ver. 7.0;
Statistical Solutions, Saugus, MA). The Shapiro-Wilk
test for normality was used to evaluate the distribu-
tion of the data. When a normal distribution was
assumed, 2-way analysis of variance with the esti-
mated marginal means method and Tukey post-hoc
analysis was performed with group (intact, full-
thickness tear, repair, partial meniscectomy, and sub-
total meniscectomy) and ﬂexion angle (0,10
ﬁxed factors and contact pressure and contact area as
dependent variables. SPSS software (version 21.0,
Chicago, IL) was used for data analysis. All reported
Pvalues are 2-tailed, and P<.05 was considered
The presence of a HCT signiﬁcantly increased average
peak contact pressure and reduced effective average
tibiofemoral contact area at 0,10
compared with the intact state (P<.03) (Fig 4). The
increase in contact pressure was approximately 70%
after creation of the HCT. Repairing the HCT resulted in
peak contact pressures and areas that were restored to
within 15% of baseline, statistically similar to the intact
state at all angles tested (P<.05). Partial meniscec-
tomy, through the removal of the superior leaﬂet,
signiﬁcantly increased average peak contact pressure
and reduced average contact area at all degrees of
ﬂexion compared with the intact state (P<.05), with
pressures approximating the unresected HCT status.
Although partial meniscectomy decreased the average
contact area and increased the average peak contact
pressure from baseline by a greater amount than the
torn state, the difference between the torn and partial
meniscectomy conditions was not statistically signiﬁ-
cant. Compared with the intact and repaired states,
Fig 4. Tibiofemoral contact area (A) along with average
(B) and peak (C) contact pressures for each of the 5 test
states (intact, torn, repaired, partial, and total resection).
Single asterisk (*) denotes difference between intact state
with other states; double asterisk (**) denotes difference
between tear state and other states; and diamond symbol
denotes difference between repaired state and other states.
HORIZONTAL TEARS AND JOINT CONTACT PRESSURE 5
subtotal meniscectomy increased the average peak
contact pressure by more than 100% and decreased the
average tibiofemoral contact area by approximately
50% at all degrees of ﬂexion (P<.0001).
Increasing ﬂexion angle was associated with
decreased average contact areas by 10% to 15% in the
presence of a tear, repair or meniscectomy, with 20
ﬂexion resulting in larger reductions in contact areas. In
the intact state, little difference in average contact area
was observed between 0and 10ﬂexion, and a small
difference was observed at 20ﬂexion. Moreover,
increasing ﬂexion angle resulted in some differences in
contact pressure, predominantly in the partial and full
resection states. Contact pressure values in the intact,
torn, and repaired states were very similar between all
Review of the data found that they were normally
distributed. Measurable pressures were observed both
under the meniscus and between the femoral condyle
and tibial plateau, with maximum pressures observed
between the femoral condyle and tibial plateau in all
conditions. Results from the 6DoF load cell revealed no
differences in forces and torques in the anterior-
posterior and medial-lateral directions among groups
(intact, tear, repair, partial meniscectomy, and subtotal
meniscectomy) across all ﬂexion angles (Pvalues
greater than .05 for all cases) (Table 1).
A large HCT in the medial meniscus decreased tibio-
femoral contact area, leading to increased contact
pressures when the knee was at or near full extension.
When the tear was repaired with a vertical suture
conﬁguration, the contact area and pressure improved
and returned almost to baseline. With resection of the
superior leaﬂet and subtotal meniscectomy, the contact
area was reduced and contact pressure increased pro-
portionally to the amount of meniscus removed.
This behavior was consistent throughout knee ﬂexion
, and 20).
Historically, symptomatic HCTs have been treated
with the use of benign neglect or subtotal resection of
the inferior or superior lamina of the meniscus.
previous studies, the presence of a HCT has been
associated with joint degeneration.
tomy has been performed to alleviate pain and prevent
the progression of tears.
Several attempts have been made to understand the
clinical impact of a horizontal tear and its treatment
with meniscectomy. Arno et al.
Table 1. Load and Torque Data From the 6-Degree of Freedom Load Cell for All Axes
Angle, Condition Fx, N Fy, N Fz, N Mx My Mz
0 Intact 53.73 104.89 1702.46 0.97 5.61 0.20
SD 43.86 47.61 189.35 7.18 4.13 0.68
0 Tear 50.22 102.80 1693.77 1.20 5.37 0.42
SD 50.62 31.16 193.63 5.10 5.18 0.61
0 Repair 47.72 105.64 1696.22 1.15 5.60 0.14
SD 56.37 47.75 186.21 8.26 7.07 0.74
0 Part res 50.26 102.90 1719.32 1.42 5.36 0.48
SD 55.28 44.58 190.70 7.65 6.40 0.52
0 Full res 67.28 104.88 1729.79 0.87 4.61 0.44
SD 63.63 41.86 191.23 7.49 7.94 0.73
10 Intact 213.08 204.14 1664.48 21.94 32.69 1.14
SD 58.28 43.99 190.84 5.90 5.58 1.49
10 Tear 219.20 212.74 1676.55 24.82 36.86 1.08
SD 47.50 45.08 188.10 7.78 5.25 1.26
10 Repair 190.37 212.69 1672.86 31.20 27.00 1.54
SD 44.51 56.01 178.37 9.99 7.59 1.33
10 Part res 191.63 202.32 1683.35 27.60 28.07 1.52
SD 49.64 54.90 185.29 8.96 7.49 1.36
10 Full res 210.35 208.12 1680.01 26.09 30.27 1.82
SD 66.40 52.19 180.09 8.38 7.90 1.32
20 Intact 350.06 298.44 1620.92 47.57 58.45 2.22
SD 52.30 51.86 148.91 5.66 7.75 1.82
20 Tear 370.73 303.64 1634.72 47.56 62.86 2.17
SD 59.26 60.46 153.96 8.54 8.98 1.99
20 Repair 343.26 301.31 1610.24 56.45 56.31 2.24
SD 45.50 69.02 163.22 8.09 8.93 1.96
20 Part res 331.37 289.63 1628.28 44.48 59.25 2.16
SD 56.69 71.65 153.81 9.75 8.75 2.06
20 Full res 367.04 303.52 1622.47 51.93 61.06 1.96
SD 55.24 59.98 155.04 7.20 7.56 2.15
NOTE. F denotes force in x, y and z axes (Fx, Fy, and Fz), while M denotes moment in x, y and z directions (Mx, My, and Mz).
res, resection; SD, standard deviation.
6B. S. BEAMER ET AL.
contact area decreases and contact pressure increases in
knees with a HCT during simulated walking, stair
climbing/descending, rising from a chair, and squatting.
They concluded that the presence of an untreated HCT
may lead to cartilage degradation. It is noteworthy that
the horizontal tears created in this study were longer
than those in the study of Arno et al.
Brown et al.
explored the difference in contact area and pressure
after partial meniscectomy and total resection for a
small horizontal tear during axial loading at full
extension. These authors created a tear near the pos-
terior horn of the medial meniscus and the resection
was of the inferior leaﬂet rather than the superior
leaﬂet resected in the present study. Their work, in
contrast to other published investigations and the pre-
sent study, suggested no signiﬁcant change in contact
area for any condition other than the total resection.
Although this study found no signiﬁcant detrimental
effects from removing the inferior leaﬂet of HCTs, our
study found signiﬁcant increases in contact pressure
when the superior leaﬂet was removed
Haemer et al.
tested small and large tears and found that both partial
meniscectomy and total resection of large tears caused a
signiﬁcant increase in contact pressure. None of these
investigations explored the effect of suturing the tear
together to simulate a repair.
HCTs of the meniscus can present a clinical dilemma
for orthopaedic surgeons. Leaving the tear alone may
result in tear progression, resulting in increased contact
pressures and degeneration of the articular cartilage
(Arno et al.,
Haemer et al.
). Alternatively, resection
of one leaﬂet of the horizontal tear may be palliative
but result in a permanent loss of meniscal tissue. In
their study, Brown et al.
showed minimal detrimental
effects if the inferior leaﬂet is resected. The present
study showed signiﬁcant changes in contact area and
contact pressure when the superior leaﬂet was resected.
Both studies agree that resecting both leaﬂets will lower
contact area and increase contact pressures, similar to a
subtotal resection. As a third option, the horizontal tear
could be repaired. If the tissue heals, a patient’s symp-
toms may resolve. By preserving their meniscus and its
function, further degeneration may be avoided by
restoring the contact area and contact pressure to near
At present, there are few studies describing the clin-
ical results after a repair of horizontal cleavage
meniscus tears. In recent systematic review, Kurzweil
found only 9 studies in the literature dating back
to 1980 that included at least one clinical outcome.
These studies included repairs of 98 HCTs and noted
success with freedom from reoperation in approxi-
More recently, Pujol et al.
studied open repairs of
HCTs with and without the use of platelet-rich plasma.
At a mean follow-up of 34 months, only 3 of 34
patients did not respond (91% success). The study
noted no signiﬁcant differences in failure rate between
patients treated with and without platelet-rich plasma.
Likewise, Ahn et al.
followed 32 patients after a
symptomatic HCT repair. The tears were treated with
all-inside suture technique and marrow stimulation.
At an average of 45.6 months, only 3 repairs had
failed, resulting in a 91% success rate. Second-look
arthroscopy in 11 patients revealed 1 repair that had
failed to heal. Lastly, Salle de Chou et al.
2 groups of patients receiving open repairs of HCTs.
One group of 18 patients was followed for more than
2 years, whereas the other group of 9 patients was
followed for more than10 years. Both groups showed
positive clinical results on their Lysholm and Interna-
tional Knee Documentation Committee scores as well
as decreased magnetic resonance imaging signal in
all patients. Most importantly, the positive results
achieved obtained in the short term were maintained
in the long term.
As for limitations, this investigation was a controlled
laboratory experiment, not an in vivo clinical trial. As
such, it would be inappropriate to extrapolate our data
to clinical outcomes. The tears studied were large by
design and may not be applicable to smaller HCTs.
Moreover, an open repair technique was used in this
study because pressure sensor placement required a
wide dissection. All-inside arthroscopic techniques may
not produce the same results.
In this investigation, each specimen was subjected to
an axial load at varying degrees of knee ﬂexion. We did
not recreate the complex mixture of axial loading,
translation, rotation, and shear that is present in vivo.
Similarly, the effects of a torn, resected, or HCT on the
knee’s ligamentous stability was not investigated. The
coronary ligaments were resected partially to allow the
pressure ﬁlm to lie ﬂat on the tibial plateau. This partial
resection of this tissue may have increased the meniscal
motion. For comparison, the same methodology was
used in the controls and subsequent torn specimens. As
a relative change, our approach may or may not
recreate the natural state.
Each specimen was loaded for 20 cycles. They were
not tested to failure. As such, the durability of the repair
was not tested. Similarly, the impact of the suture on
the articular cartilage was not considered. Because the
NovoStitch device is relatively new, there is little clin-
ical experience with this repair technique. A recent
publication by Saliman
provides one perspective
regarding the feasibility of placing all-inside circumfer-
ential compression stitches to repair meniscus tears
HORIZONTAL TEARS AND JOINT CONTACT PRESSURE 7
The presence of a HCT in the medial meniscus causes
a signiﬁcant reduction in contact area and a signiﬁcant
elevation in contact pressure. These changes may
accelerate joint degeneration. A suture-based repair
of these HCTs returns the contact area and contact
pressure to nearly normal, whereas both partial and
subtotal meniscectomy lead to signiﬁcant reductions
in contact area and signiﬁcant elevations in contact
pressure within the knee. Repairing HCTs may lead to
improved clinical outcomes by preserving meniscal
tissue and the meniscal function.
The authors acknowledge Ceterix, Inc., for providing
repair devices used in this study and the staff at the
Scientiﬁc Instrumentation Facility at Boston Uni-
versity’s Department of Physics for manufacturing the
biomechanical testing apparatus. The authors also
acknowledge Dr. Peter Kurzweil for providing
thoughtful feedback on the manuscript.
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