scholarly journals Medial collateral ligament reconstruction graft isometry is effected by femoral position more than tibial position

2021 ◽  
Author(s):  
Christoph Kittl ◽  
James Robinson ◽  
Michael J. Raschke ◽  
Arne Olbrich ◽  
Andre Frank ◽  
...  
Keyword(s):  
Medial Collateral Ligament ◽  
Knee Flexion ◽  
Length Change ◽  
Collateral Ligament ◽  
Complex Behaviour ◽  
Femoral Attachment ◽  
Attachment Sites ◽  
Custom Made ◽  
Length Changes ◽  
Graft Length

Abstract Purpose The purpose of this study was to examine the length change patterns of the native medial structures of the knee and determine the effect on graft length change patterns for different tibial and femoral attachment points for previously described medial reconstructions. Methods Eight cadaveric knee specimens were prepared by removing the skin and subcutaneous fat. The sartorius fascia was divided to allow clear identification of the medial ligamentous structures. Knees were then mounted in a custom-made rig and the quadriceps muscle and the iliotibial tract were loaded, using cables and hanging weights. Threads were mounted between tibial and femoral pins positioned in the anterior, middle, and posterior parts of the attachment sites of the native superficial medial collateral ligament (sMCL) and posterior oblique ligament (POL). Pins were also placed at the attachment sites relating to two commonly used medial reconstructions (Bosworth/Lind and LaPrade). Length changes between the tibiofemoral pin combinations were measured using a rotary encoder as the knee was flexed through an arc of 0–120°. Results With knee flexion, the anterior fibres of the sMCL tightened (increased in length 7.4% ± 2.9%) whilst the posterior fibres slackened (decreased in length 8.3% ± 3.1%). All fibre regions of the POL displayed a uniform lengthening of approximately 25% between 0 and 120° knee flexion. The most isometric tibiofemoral combination was between pins placed representing the middle fibres of the sMCL (Length change = 5.4% ± 2.1% with knee flexion). The simulated sMCL reconstruction that produced the least length change was the Lind/Bosworth reconstruction with the tibial attachment at the insertion of the semitendinosus and the femoral attachment in the posterior part of the native sMCL attachment side (5.4 ± 2.2%). This appeared more isometric than using the attachment positions described for the LaPrade reconstruction (10.0 ± 4.8%). Conclusion The complex behaviour of the native MCL could not be imitated by a single point-to-point combination and surgeons should be aware that small changes in the femoral MCL graft attachment position will significantly effect graft length change patterns. Reconstructing the sMCL with a semitendinosus autograft, left attached distally to its tibial insertion, would appear to have a minimal effect on length change compared to detaching it and using the native tibial attachment site. A POL graft must always be tensioned near extension to avoid capturing the knee or graft failure.

scholarly journals Length change pattern of the medial structures of the knee and related reconstructions

2020 ◽  
Vol 8 (9_suppl7) ◽  
pp. 2325967120S0053
Author(s):  
Arne Olbrich ◽  
Elmar Herbst ◽  
Christoph Domnick ◽  
Johannes Glasbrenner ◽  
Michael J. Raschke ◽  
...  
Keyword(s):  
Medial Collateral Ligament ◽  
Knee Flexion ◽  
Insertion Site ◽  
Length Change ◽  
Collateral Ligament ◽  
Femoral Insertion ◽  
Superficial Medial Collateral Ligament ◽  
Custom Made ◽  
Length Changes ◽  
Length Reduction

Introduction: Aim of the study was to investigate the length changes of the medial structures and related reconstructions. It was assumed that the three fibre sections (anterior/middle/posterior) of the superficial medial collateral ligament (sMCL) have different length change patterns, which cannot be imitated by current reconstructions. Hypotheses: The three fibre sections (anterior/middle/posterior) of the superficial medial collateral ligament (sMCL) cannot be imitated by current reconstructions. Methods: Measurements were made on eight cadaveric knees. The knee joints were clamped in a custom-made open chain extension structure. For this purpose, the portions of the quadriceps and the iliotibial tract were aligned according to their fibre direction and statically loaded using hanging weights. The respective tibial and femoral insertion points of the sMCL anterior/middle/posterior fibres were marked by small pins. Similarly, pins were inserted at the tibial and femoral attachment sites of the posterior oblique ligament (POL). In order to imitate the Lind reconstruction, a pin was additionally inserted on the tibial semitendinosus insertion site. Pin combinations accounting for the anterior/middle/posterior sMCL, the POL, and the Lind reconstruction were connected using a high resistant suture. Then the length change patterns were measured using a rotary encoder from 0-120° knee flexion. Statistical analysis was performed using 2-way repeated-measures ANOVA and a post-hoc Bonferroni correction (p <0.05). Results: The anterior and posterior fibres of the sMCL showed a reciprocal behaviour (p< 0.001). The anterior fibres showed a length reduction (2%) up to a flexion of 20°, followed by an elongation of 5% at 120° flexion, which means that the anterior fibres are tight in knee flexion. Conversely, the posterior fibres of the MCL showed an initial length reduction of 4% at 20° flexion. This was followed by an isometric range (20° - 80°) and a further length reduction of 8% in deep flexion (120°). Thus, the posterior fibres of the MCL were tight in extension. The three parts of the POL showed a constant reduction of 25% between 0° and 120°. The Lind reconstruction with the tibial pin at the semitendinosus insertion site showed similar length changes compared to the sMCL (n.s.). Furthermore, the Lind reconstruction was dependent on the femoral placement of the pins (p <.001). The tibial placement had no significant influence. Conclusion: The anterior portion of the sMCL was tight in flexion, whereas the posterior portion was tight in extension. This reciprocal behavior could not be imitated by a single point to point reconstruction. When surgically applying these reconstructions, special attention should be paid to the femoral insertion.

scholarly journals Length-change patterns of the medial collateral ligament and posterior oblique ligament in relation to their function and surgery

2020 ◽  
Vol 28 (12) ◽  
pp. 3720-3732 ◽  
Author(s):  
Lukas Willinger ◽  
Shun Shinohara ◽  
Kiron K. Athwal ◽  
Simon Ball ◽  
Andy Williams ◽  
...  
Keyword(s):  
Internal Rotation ◽  
Medial Collateral Ligament ◽  
Knee Flexion ◽  
External Rotation ◽  
Length Change ◽  
Linear Displacement ◽  
Collateral Ligament ◽  
Posterior Oblique Ligament ◽  
Draw Force ◽  
Length Changes

Abstract Purpose To define the length-change patterns of the superficial medial collateral ligament (sMCL), deep MCL (dMCL), and posterior oblique ligament (POL) across knee flexion and with applied anterior and rotational loads, and to relate these findings to their functions in knee stability and to surgical repair or reconstruction. Methods Ten cadaveric knees were mounted in a kinematics rig with loaded quadriceps, ITB, and hamstrings. Length changes of the anterior and posterior fibres of the sMCL, dMCL, and POL were recorded from 0° to 100° flexion by use of a linear displacement transducer and normalised to lengths at 0° flexion. Measurements were repeated with no external load, 90 N anterior draw force, and 5 Nm internal and 5 Nm external rotation torque applied. Results The anterior sMCL lengthened with flexion (p < 0.01) and further lengthened by external rotation (p < 0.001). The posterior sMCL slackened with flexion (p < 0.001), but was lengthened by internal rotation (p < 0.05). External rotation lengthened the anterior dMCL fibres by 10% throughout flexion (p < 0.001). sMCL release allowed the dMCL to become taut with valgus rotation (p < 0.001). The anterior and posterior POL fibres slackened with flexion (p < 0.001), but were elongated by internal rotation (p < 0.001). Conclusion The structures of the medial ligament complex react differently to knee flexion and applied loads. Structures attaching posterior to the medial epicondyle are taut in extension, whereas the anterior sMCL, attaching anterior to the epicondyle, is tensioned during flexion. The anterior dMCL is elongated by external rotation. These data offer the basis for MCL repair and reconstruction techniques regarding graft positioning and tensioning.

scholarly journals Simulation of varying femoral attachment sites of medial patellofemoral ligament using a musculoskeletal multi-body model

2015 ◽  
Vol 1 (1) ◽  
pp. 547-551 ◽  
Author(s):  
A. Geier ◽  
T. Tischer ◽  
R. Bader
Keyword(s):  
Knee Flexion ◽  
Medial Patellofemoral Ligament ◽  
Numerical Study ◽  
Patellofemoral Instability ◽  
Length Change ◽  
Systematic Evaluation ◽  
Parameter Study ◽  
Femoral Attachment ◽  
Attachment Sites ◽  
Length Changes

AbstractThe medial patellofemoral ligament (MPFL) is a key structure in the treatment of habitual and traumatic patellofemoral instability. However, there exists little knowledge about its behaviour during deep knee flexion after femoral refixation. Since improper femoral attachment sites may lead to unnatural length change patterns in the ligament and consequently to osteoarthritis due to pathological femoro-patellar contact pressure, the understanding of the patella kinematics and MPFL behaviour is crucial.The purpose of this numerical study was to compute the six-degree-of-freedom motion pattern of the human patella during deep knee flexion for systematic analysis of varying landmarks for the femoral attachment in medial patellofemoral ligament reconstruction surgery by means of multibody simulation.Therefore, based on a previously presented musculoskeletal model [1] the dynamic pathways of the patella were computed. Then, the spatial motion was approximated by rheonomic polynomials and exploited for systematic evaluation of the MPFL length change patterns. Hence, 16 femoral attachment points at a radius of 5 mm and 10 mm around the radiographic centre point [2] were defined and the absolute length changes were recorded during deep knee flexion to 120 degree.This approach allows for a systematic evaluation of numerous MPFL attachment sites while exploiting the physiological patella kinematics. The patella kinematics including shift, flexion, tilt and rotation as well as the MPFL length change patterns were consistent to in vitro and in vivo data in the literature [3–7] and therefore indicate validity of the numerical approach. The parameter study on the femoral attachment site should enable to determine the most isometric point and non-isometric variations corresponding to patellofemoral instability, arthritis or high graft load.

scholarly journals Length Change Pattern of the Medial Structures of the Knee and Related Reconstructions

2020 ◽  
Vol 8 (5_suppl4) ◽  
pp. 2325967120S0031
Author(s):  
Christoph Kittl ◽  
Arne Olbrich ◽  
Michael J. Raschke ◽  
Christoph Domnick ◽  
Johannes Glasbrenner ◽  
...  
Keyword(s):  
Medial Collateral Ligament ◽  
Strain Range ◽  
Length Change ◽  
Total Strain ◽  
Collateral Ligament ◽  
Total Strain Range ◽  
Severe Problem ◽  
Posterior Portion ◽  
Deep Flexion ◽  
Length Changes

Aims and Objectives: Chronic medial instability presents a severe problem both for the patient and the surgeon, and may result into anterior cruciate ligament graft failure in a combined anteromedial instability. Thus, reconstructions have been developed to conquer this problem. However, these are not capable of mimicking the flat anatomy of the medial structures of the knee. The goal of the present study was to examine the length change patterns of the native medial structures of the knee and their related reconstructions. It was hypothesised that the different portions of the medial collateral ligament present different length change patterns, which cannot be imitated by current reconstructions. Materials and Methods: Eight cadaveric knees were dissected of skin and subcutaneous fat. The satorius fascia was removed to get a clear vision of the medial structures. The knee was then mounted in a rig and the quadriceps muscle and the iliotibial tract were loaded, using cables and hanging weights, according to its fiber orientations and cross-sections. Threads attached to three tibial pins at the anterior/middle/posterior portion of the medial collateral ligament (MCL) were then guided to three femoral eyelets at the anterior/middle/posterior portion of the femoral MCL insertion and analogous with the tibial/femoral posterior oblique ligament (POL) insertion. A tibial pin was also put at the semitendinosus insertion to imitate the Lind reconstruction. Between 0-120 degree knee flexion, the distances between each possible tibiofemoral combination were measured using a linea variable differential transformer (LVDT). Statistical analysis was performed using two way repeated measurements ANOVA. Results: The anterior MCL showed an initial slackening (2%) until 20° flexion, followed by a tightening (5%) towards deep flexion (120°), meaning that it is tight in flexion. The posterior MCL also showed an initial slackening (4%) until 20° of flexion. However, then followed by an isometric area (20-80°) and a further slackening (8%) towards deep flexion (120°), meaning that it is tight in extension. The three portions of the POL showed a linear slackening between 0-120° (25%). The middle MCL showed a sine wave behaviour, slackening from 0- 60° (3%) and tightening between 60-100° (1%). This behaviour was similar in the Lind and Robinson reconstruction, which were the most isometric tibiofemoral combinations (total strain range: 5,3 ± 2,1). The native POL length changes showed the most non-isometric behaviour resulting into a total strain range of 28,8 ± 6,2, which was significantly different from the native MCL and MCL reconstructions (p< .001) Conclusion: The anterior, middle, and posterior parts of the MCL showed different length change patterns. The anterior part tightened in flexion, whereas the posterior part tightened in extension. This behavior could not be reproduced by the current reconstructions, such as the Lind and Robinson procedure, which only could imitate the middle portion of the native MCL.

scholarly journals Effect of Patella Alta on the Native Anatomometricity of the Medial Patellofemoral Complex: A Cadaveric Study

2020 ◽  
Vol 8 (7_suppl6) ◽  
pp. 2325967120S0045
Author(s):  
Hailey Huddleston ◽  
Kevin Campbell ◽  
Michael Redondo ◽  
Alejandro Espinoza ◽  
Jorge Chahla ◽  
...  
Keyword(s):  
Quadriceps Tendon ◽  
Length Change ◽  
Patella Alta ◽  
Constant Length ◽  
Cadaveric Specimen ◽  
Inferior Aspect ◽  
Attachment Sites ◽  
Custom Made ◽  
Length Changes ◽  
Medial Patellofemoral Complex

Objectives: Patella alta has been identified as an important risk factor for lateral patellar instability and medial patellofemoral complex (MPFC) reconstruction failure. To our knowledge, no prior study has analyzed the anisometry of the MPFC in the setting of patella alta as this may play a role in the postoperative outcomes and could affect surgical technique. Methods: Eight (n=8) fresh frozen cadaveric knees were used in this study. No IRB approval was needed at our institution due to the use of cadaveric specimen. The MPFC was identified and dissected along with the patellar tendon, and quadriceps tendon. A custom-made jig was utilized to evaluate MPFC lengths from 0-90° of flexion. Length was measured at four possible reconstruction locations (midpoint patella [MP], MPFC osseous center [FC], superior medial pole of the patella [SM], and quadriceps tendon [Q]) along the extensor mechanism using a 3D robotic arm. These measurements were repeated at 0, 20, 40, 60 and 90° degrees of flexion. Degrees of increasing severity of patella alta at Caton-Deschamps index (CDI) ratios of 1.0, 1.2, 1.4, and 1.6, were then investigated. Results: CDI and attachment sites significantly affect changes in MPFC length from 0-90° of flexion (p < 0.0005). Proximal attachment points had more robust length changes than distal ones and increases in CDI enhanced these differences. Point Q at CDI 1 was similar to SM at 1.2 (p = 0.234), SM and FC at 1.4 (p = 0.89 and p = 0.073) and FC at 1.6 (p = 0.928). SM at CDI of 1 was similar to FC at 1.2 and 1.4 (p = 0.414 and p = 0.503) and MP at 1.6 (p = 0.473), while FC at CDI 1 was similar to the FC at 1.2 (p = 0.157) and MP at 1.4 and 1.6 (p = 0.068 and p = 0.519). Finally, the MP was similar at CDI 1.2 (p = 0.888) and 1.4 (p = 0.385) compared to at CDI of 1. At the quadriceps points, MPFC length and flexion degrees showed a moderate negative linear correlation at a CDI of 1 (r = -0.484, p = 0.002) and 1.6 (r = -0.692, p < 0.0005) (Fig 1). At the MP location at a CDI ratio of 1.6, significant differences were seen at 0° vs 90° (p = 0.027), 0° vs 60° (p = 0.044), 0° vs 40° (p = 0.016), and 0° vs 20° (p = 0.044), suggesting differing length change properties between the Q and MP attachment sites. Conclusions: Anisometry varies with location of the patellar attachment and with patellar height within the MPFC. The superior aspect of the MPFC demonstrated the most isometric behavior, increasing linearly with increasing flexion. The inferior aspect of the MPFC retains a relatively constant length at 20 to 90° of flexion. Increasing CDI amplified these results. These findings demonstrate that proximal based grafts loosen significantly before engaging in the trochlea and this effect is exaggerated in the setting of patella alta. Furthermore, this data suggests that soft tissue surgical reconstructions may be modified to correct for patella alta in place of performing distalization, which carries significant morbidity.

Effect of Patella Alta on the Native Anatomometricity of the Medial Patellofemoral Complex: A Cadaveric Study

2020 ◽  
Vol 48 (6) ◽  
pp. 1398-1405
Author(s):  
Adam B. Yanke ◽  
Hailey P. Huddleston ◽  
Kevin Campbell ◽  
Michael L. Redondo ◽  
Alejandro Espinoza ◽  
...  
Keyword(s):  
Attachment Site ◽  
Quadriceps Tendon ◽  
Length Change ◽  
Patellar Height ◽  
Extensor Mechanism ◽  
Patella Alta ◽  
Similar Length ◽  
Custom Made ◽  
Length Changes ◽  
Medial Patellofemoral Complex

Background: Patella alta has been identified as an important risk factor for lateral patellar instability and medial patellofemoral complex (MPFC) reconstruction failure. Purpose: To evaluate the length changes of the MPFC at multiple possible reconstruction locations along the extensor mechanism in varying degrees of patella alta throughout knee motion. Study Design: Controlled laboratory study. Methods: Eight fresh-frozen cadaveric knees were used in this study. The MPFC was identified and dissected with the patellar tendon and quadriceps tendon. A custom-made jig was utilized to evaluate lengths from 0° to 90° of flexion with physiological quadriceps loading. Length was measured with a 3-dimensional robotic arm at 4 possible reconstruction locations along the extensor mechanism: the midpoint patella (MP), the MPFC osseous center (FC), the superior medial pole of the patella (SM) at the level of the quadriceps insertion, and 1 cm proximal to the SM point along the quadriceps tendon (QT). These measurements were repeated at 0°, 20°, 40°, 60° and 90° of flexion. Degrees of increasing severity of patella alta at Caton-Deschamps index (CDI) ratios of 1.0, 1.2, 1.4, and 1.6 were then investigated. Results: Patella alta and MPFC attachment site location significantly affected changes in MPFC length from 0° to 90° of flexion ( P< .0005). Length changes at attachment MP showed no difference when CDI 1.0 was compared with all patella alta values (CDI 1.2, 1.4, 1.6; P > .05). Similarly, FC showed no difference in length change from 0° to 90° until CDI 1.6, in contrast to proximal attachments (SM, QT), which demonstrated significant changes at CDI 1.4 and 1.6. When length changes were analyzed at each degree of flexion (0°, 20°, 40°, 60°, 90°), Spearman correlation analysis showed a moderate negative linear correlation for QT at CDI 1.0 ( r= −0.484; P = .002) and 1.6 ( r = −0.692; P < .0005), demonstrating constant loosening at the QT point at normal and elevated patellar height. In contrast, no differences in length were observed for MP at CDI 1.0 throughout flexion, and at CDI 1.6, there was a difference only at 0° ( P < .05). Points FC and MP at CDI 1.6 had similar length change properties to points SM and QT at CDI 1.0 ( P > .05), suggesting that distal attachments in the setting of patella alta may provide similar length changes to proximal attachmentswith normal height. Conclusion: Anisometry of the MPFC varies not only with attachment location on the extensor mechanism but also with patellar height. Increased patellar height leads to more significant changes in anisometry in the proximal MPFC attachment point as compared with the distal component. In the setting of patella alta, including a CD ratio of 1.6, the osseous attachments of the MPFC remain nearly isometric wheras the proximal half length changes increase significantly. Clinical Significance: The results of this study support the idea that the MPFC should be considered as 2 separate entities (proximal medial quadriceps tendon femoral ligament and distal medial patellofemoral ligament) owing to their unique length change properties.

Can isolated removal of osteophytes achieve correction of varus deformity and gap-balance in computer-assisted total knee arthroplasty?

2020 ◽  
Vol 102-B (6_Supple_A) ◽  
pp. 49-58
Author(s):  
Arun Mullaji
Keyword(s):  
Total Knee Arthroplasty ◽  
Soft Tissue ◽  
Knee Arthroplasty ◽  
Medial Collateral Ligament ◽  
Knee Flexion ◽  
Deformity Correction ◽  
Computer Assisted ◽  
Cruciate Ligaments ◽  
Collateral Ligament ◽  
Total Knee

Aims The aims of this study were to determine the effect of osteophyte excision on deformity correction and soft tissue gap balance in varus knees undergoing computer-assisted total knee arthroplasty (TKA). Methods A total of 492 consecutive, cemented, cruciate-substituting TKAs performed for varus osteoarthritis were studied. After exposure and excision of both cruciates and menisci, it was noted from operative records the corrective interventions performed in each case. Knees in which no releases after the initial exposure, those which had only osteophyte excision, and those in which further interventions were performed were identified. From recorded navigation data, coronal and sagittal limb alignment, knee flexion range, and medial and lateral gap distances in maximum knee extension and 90° knee flexion with maximal varus and valgus stresses, were established, initially after exposure and excision of both cruciate ligaments, and then also at trialling. Knees were defined as ‘aligned’ if the hip-knee-ankle axis was between 177° and 180°, (0° to 3° varus) and ‘balanced’ if medial and lateral gaps in extension and at 90° flexion were within 2 mm of each other. Results Of 50 knees (10%) with no soft tissue releases (other than cruciate ligaments), 90% were aligned, 81% were balanced, and 73% were aligned and balanced. In 288 knees (59%) only osteophyte excision was performed by subperiosteally releasing the deep medial collateral ligament. Of these, 98% were aligned, 80% were balanced, and 79% were aligned and balanced. In 154 knees (31%), additional procedures were performed (reduction osteotomy, posterior capsular release, and semimembranosus release). Of these, 89% were aligned, 68% were balanced, and 66% were aligned and balanced. The superficial medial collateral ligament was not released in any case. Conclusion Two-thirds of all knees could be aligned and balanced with release of the cruciate ligaments alone and excision of osteophytes. Excision of osteophytes can be a useful step towards achieving deformity correction and gap balance without having to resort to soft tissue release in varus knees while maintaining classical coronal and sagittal alignment of components. Cite this article: Bone Joint J 2020;102-B(6 Supple A):49–58.

In Vivo Strain Ultrasound Elastographic Assessment of the Stiffness of the Medial Collateral Ligament at Varying Knee Flexion Angles

2019 ◽  
Vol 2019 (0) ◽  
pp. J02513
Author(s):  
Makoto SAKAMOTO ◽  
Surangika WADUGODAPITIYAI ◽  
Yusuke MORISE ◽  
Masaei TANAKA ◽  
Koichi KOBAYASHI
Keyword(s):  
Medial Collateral Ligament ◽  
Knee Flexion ◽  
Collateral Ligament

scholarly journals In vivo length change of ligaments of normal knees during dynamic high flexion

2020 ◽  
Author(s):  
Kenichi Kono ◽  
Shoji Konda ◽  
Takaharu Yamazaki ◽  
Sakae Tanaka ◽  
Kazuomi Sugamoto ◽  
...  
Keyword(s):  
Medial Collateral Ligament ◽  
Sagittal Plane ◽  
Cruciate Ligament ◽  
Lateral Collateral Ligament ◽  
Length Change ◽  
3D Registration ◽  
Collateral Ligament ◽  
High Flexion ◽  
Leg Motion

Abstract Background Few studies compared the length change of ligaments of normal knees during dynamic activities of daily living. The aim of this study was to investigate in vivo length change of ligaments of the normal knees during high flexion. Methods Eight normal knees were investigated. Each volunteer performed squatting, kneeling, and cross-leg motions. Each sequential motion was performed under fluoroscopic surveillance in the sagittal plane. The femoral, tibial, and fibular attachment areas of the anterior cruciate ligament (ACL), posterior cruciate ligament (PCL), deep medial collateral ligament (dMCL), superficial medial collateral ligament (sMCL), and lateral collateral ligament (LCL) were determined according to osseous landmarks. After 2D/3D registration, the direct distance from the femoral attachment to the tibial or fibular attachment was measured as the ligament length. Results From 20° to 90° with flexion, the ACL was significantly shorter during cross-leg motion than during squatting. For the PCL, dMCL, sMCL, and LCL, there were no significant differences among the 3 motions. Conclusion The ACL was shorter during cross-leg motion than during squatting in mid-flexion. This suggests that the ACL is looser during cross-leg motion than during squatting. On the other hand, the length change of the PCL, MCL, and LCL did not change even though the high flexion motions were different.

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