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Shoulder Arthroscopy:Shoulder Arthroscopy:
Where we are where weWhere we are where we
are heading for?are heading for?
Man...
The Shoulder
 Greatest Range of Motion in the Body
 Motion in all 3 planes of movement
 Prone to injuries
 8-20% of al...
HistoryHistory
1931 First Cadaver Shoulder Arthroscopy1931 First Cadaver Shoulder Arthroscopy BurmanBurman
1974 First Shou...
Diagnostic arthroscopyDiagnostic arthroscopy
The way everything began!!The way everything began!!
Arthroscopy in its infancyArthroscopy in its infancy
Diagnostic ArthroscopyDiagnostic Arthroscopy
Distinguish Normal AnatomyDistinguish Normal Anatomy
Anatomic VariantsAnatomi...
Glenohumeral LigamentGlenohumeral Ligament
VariationsVariations
 66% - Well defined SGHL, MGHL & IGHL66% - Well defined S...
Diagnostic ToolDiagnostic Tool
Bufford ComplexBufford Complex
www.shoulder.gr
Diagnostic ToolDiagnostic Tool
Sublabral holeSublabral hole
www.shoulder.gr
Diagnostic ToolDiagnostic Tool
Os acrmialeOs acrmiale
www.shoulder.gr
Diagnostic ToolDiagnostic Tool
SLAP LesionsSLAP Lesions
www.shoulder.gr
Diagnostic ToolDiagnostic Tool
Internal ImpingementInternal Impingement
www.shoulder.gr
Shoulder ArthroscopyShoulder Arthroscopy
the evolution of the techniquethe evolution of the technique
Diagnostic
Tool
Fina...
Therapeutic ArthroscopyTherapeutic Arthroscopy
Rotator Cuff diseaseRotator Cuff disease
Tears (Full, Partial, Intratendoni...
Therapeutic ArthroscopyTherapeutic Arthroscopy
SLAP lesionsSLAP lesions
Frozen ShoulderFrozen Shoulder
AC jointAC joint
Ar...
Arthroscopic EvolutionArthroscopic Evolution
Metal Anchors
Absorbable
Anchors
Peek Anchors
Single suture
Double sutures
ww...
Cuff repairCuff repair
Tendon to bone repairTendon to bone repair
www.shoulder.gr
Rotator CuffRotator Cuff
Single Row
Double Row
Triple Row
Different
Suture
Passing
techniques
www.shoulder.gr
RC Arthroscopic RepairRC Arthroscopic Repair
1.1. Recognition, of the type of the tearRecognition, of the type of the tear...
Risk to Benefit RatioRisk to Benefit Ratio
• Rot cuff tears DO NOT heal spontaneously
• Tear repairability
• Think of Size...
Act early try to avoid irreversibleAct early try to avoid irreversible
bad tissue qualitybad tissue quality
What is Bad Tissue Quality?What is Bad Tissue Quality?
Large or massive tears,Large or massive tears,
Retracted tears,Retr...
ANY TYPE OF RECONSTRUCTIONANY TYPE OF RECONSTRUCTION
MUST AVOID TENSION OVER-LOADMUST AVOID TENSION OVER-LOAD
OF THE REPAI...
Recognize the Tear PatternRecognize the Tear Pattern
Tears must be repaired in the directionTears must be repaired in the ...
L-Shaped & U-Shaped TearsL-Shaped & U-Shaped Tears
Side to side sutures from medial to lateralSide to side sutures from me...
Side to Side Repair
Cuff repair
www.shoulder.gr
Double Row Fixation
Restoration of the footprint
www.shoulder.gr
1st
Anchor Insertion – Medial Row
www.shoulder.gr
1st
suture passage- Medial row - mattress
www.shoulder.gr
suture passage- Medial row – post. anchor
www.shoulder.gr
Lateral Row 1st
Anchor Insertion
www.shoulder.gr
Inspection of Suture Position
www.shoulder.gr
Final Repair
Double row fixationDouble row fixation
Stronger repair biologically
attractive but
Time consuming and of
rais...
Massive Contracted ImmobileMassive Contracted Immobile
TearsTears
No mobility from medial to lateral or fromNo mobility fr...
Massive Contractive TearsMassive Contractive Tears
better mobilization techniquesbetter mobilization techniques
Anterior I...
Massive TearsMassive Tears
Easily repairedEasily repaired
Difficult repair (anterior & posterior Slide)Difficult repair (a...
Rotator CuffRotator Cuff
Rot cuff tears that can be repaired withRot cuff tears that can be repaired with
open techniques ...
Rotator CuffRotator Cuff
Massive Tears
www.shoulder.gr
Rotator CuffRotator Cuff
Massive Tears
www.shoulder.gr
Rotator CuffRotator Cuff
Graft Jacket
www.shoulder.gr
Rotator CuffRotator Cuff
Subscapularis Tear
www.shoulder.gr
Rotator CuffRotator Cuff
Subscapularis
Tear
www.shoulder.gr
Rotator CuffRotator Cuff
Calcifying TendonitisCalcifying Tendonitis
www.shoulder.gr
Rotator CuffRotator Cuff
Calcifying TendonitisCalcifying Tendonitis
www.shoulder.gr
Frozen ShoulderFrozen Shoulder
www.shoulder.gr
AC JointAC Joint
Distal Clavicle ExcisionDistal Clavicle Excision
www.shoulder.gr
AC JointAC Joint
Distal Clavicle ExcisionDistal Clavicle Excision
www.shoulder.gr
AC JointAC Joint
DislocationDislocation
www.shoulder.gr
Shoulder InstabilityShoulder Instability
www.shoulder.gr
The Spectrum of Instability Lesions

Minor instability withMinor instability with
activity related painactivity related p...
Bankart Lesion
Bankart Lesion
the essential lesion
 Avulsion of the IGHL from the glenoid rim
from 2 o’clock to 6 o’clock
 Primary rest...
ALPSA lesion
humerus
Bankart lesion
glenoid
1. Identify and Define Pathology
Our findings in first shoulderOur findings in first shoulder
dislocationdislocation
Hemarthrosis 100%Hemarthrosis 100%
Ban...
Arthroscopic Shoulder
Reconstruction
Goal of the Operation: Define the pathology
Restoration of the Labrum to its anatomic...
 Patients of all ages and all activity levels with
recurrent anterior instability who are impaired
functionally and in wh...
InstabilityInstability
Anterior Instability – Bankart LesionAnterior Instability – Bankart Lesion
www.shoulder.gr
humerus
labrum
completed repair
6. Assessment of the Final Repair
SLAP repair
InstabilityInstability
Posterior InstabilityPosterior Instability
www.shoulder.gr
InstabilityInstability
Posterior InstabilityPosterior Instability
www.shoulder.gr
Posterior capsule reefing
Posterior Instability
Posterior Instability
InstabilityInstability
MultidirectionalMultidirectional
InstabilityInstability
www.shoulder.gr
Multidirection instability
Plication of the posterior capsule
InstabilityInstability
Anterior Instability. Bony defects – HillAnterior Instability. Bony defects – Hill
SachsSachs
www.s...
InstabilityInstability
Anterior Instability –Hill Sachs -RemplisageAnterior Instability –Hill Sachs -Remplisage
www.should...
InstabilityInstability
Anterior Instability – Hill Sachs -RemplisageAnterior Instability – Hill Sachs -Remplisage
www.shou...
InstabilityInstability
Anterior Instability. Bony defectsAnterior Instability. Bony defects
Glenoid bone lossGlenoid bone ...
Normal Glenoid
inverted
pear
Bony Bankart
pear
Compression
Bankart
loss of
anterior rim
The normal glenoid shape
Inverted pear glenoid
 Glenoid Bone Loss > 30%
 Engaging Hill-Sachs
 HAGL lesions
Limitations of the
Arthroscopic Techniques
Future of instability repairFuture of instability repair
HAGL lesions can be repaired withHAGL lesions can be repaired wit...
Future of instability repairFuture of instability repair
Glenoid bone loss:Glenoid bone loss:
arthroscopic bone grafting d...
Arthroscopic success rateArthroscopic success rate
Savoie 1997 93%Savoie 1997 93%
Burchart, De Bear 2000 96%Burchart, De B...
Trends in arthroscopic surgeryTrends in arthroscopic surgery
•Mechanically stronger repair
techniques
•Arthroscopic techni...
ConclusionConclusion
Today, apart from Shoulder ReplacementToday, apart from Shoulder Replacement
and major Shoulder Fract...
ConclusionConclusion
Literature suggests equal or betterLiterature suggests equal or better
results than Open Surgeryresul...
ConclusionConclusion
Combined withCombined with
Lower MorbidityLower Morbidity
Day Case surgeryDay Case surgery
Smalls Inc...
You are all WelcomeYou are all Welcome
www.esskacourse.grwww.esskacourse.gr
Thank YouThank You
Shoulder arthroscopy general
Shoulder arthroscopy general
Shoulder arthroscopy general
Shoulder arthroscopy general
Shoulder arthroscopy general
Shoulder arthroscopy general
Shoulder arthroscopy general
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Shoulder arthroscopy general

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Shoulder arthroscopy general

  1. 1. Shoulder Arthroscopy:Shoulder Arthroscopy: Where we are where weWhere we are where we are heading for?are heading for? Manos AntonogiannakisManos Antonogiannakis Director of Center for ShoulderDirector of Center for Shoulder ArthroscopyArthroscopy IASO General HospitalIASO General Hospital AthensAthenswww.shoulder.gr
  2. 2. The Shoulder  Greatest Range of Motion in the Body  Motion in all 3 planes of movement  Prone to injuries  8-20% of all sports injuries
  3. 3. HistoryHistory 1931 First Cadaver Shoulder Arthroscopy1931 First Cadaver Shoulder Arthroscopy BurmanBurman 1974 First Shoulder Arthroscopy in vivo1974 First Shoulder Arthroscopy in vivo Johnson LLJohnson LL 1982 First Arthroscopic repair1982 First Arthroscopic repair Johnson LLJohnson LL of Shoulder Instabilityof Shoulder Instability www.shoulder.gr
  4. 4. Diagnostic arthroscopyDiagnostic arthroscopy The way everything began!!The way everything began!!
  5. 5. Arthroscopy in its infancyArthroscopy in its infancy
  6. 6. Diagnostic ArthroscopyDiagnostic Arthroscopy Distinguish Normal AnatomyDistinguish Normal Anatomy Anatomic VariantsAnatomic Variants Variation of GHLsVariation of GHLs Sublaral HoleSublaral Hole Cord-like middle GHLCord-like middle GHL Buford ComplexBuford Complex Rotator Crescent Sign (cuff “ridge”)Rotator Crescent Sign (cuff “ridge”) SLAP lesionsSLAP lesions Bursal side RC tearsBursal side RC tears Internal ImpingementInternal Impingement www.shoulder.gr
  7. 7. Glenohumeral LigamentGlenohumeral Ligament VariationsVariations  66% - Well defined SGHL, MGHL & IGHL66% - Well defined SGHL, MGHL & IGHL  7% - Confluent MGHL & IGHL7% - Confluent MGHL & IGHL  19% - Cordlike MGHL with a high riding19% - Cordlike MGHL with a high riding attachmentattachment  8% - No discernable MGHL – IGHL but one8% - No discernable MGHL – IGHL but one confluent anterior capsular sheathconfluent anterior capsular sheath
  8. 8. Diagnostic ToolDiagnostic Tool Bufford ComplexBufford Complex www.shoulder.gr
  9. 9. Diagnostic ToolDiagnostic Tool Sublabral holeSublabral hole www.shoulder.gr
  10. 10. Diagnostic ToolDiagnostic Tool Os acrmialeOs acrmiale www.shoulder.gr
  11. 11. Diagnostic ToolDiagnostic Tool SLAP LesionsSLAP Lesions www.shoulder.gr
  12. 12. Diagnostic ToolDiagnostic Tool Internal ImpingementInternal Impingement www.shoulder.gr
  13. 13. Shoulder ArthroscopyShoulder Arthroscopy the evolution of the techniquethe evolution of the technique Diagnostic Tool Final Treatment www.shoulder.gr From tool of the devil the treatment of choice of most shoulder pathologies
  14. 14. Therapeutic ArthroscopyTherapeutic Arthroscopy Rotator Cuff diseaseRotator Cuff disease Tears (Full, Partial, Intratendonious)Tears (Full, Partial, Intratendonious) Calcifying TendonitisCalcifying Tendonitis InstabilityInstability Anterior, Posterior, MultidirectionalAnterior, Posterior, Multidirectional Bony Bankart lesionsBony Bankart lesions Glenoid defectsGlenoid defects HAGL and reverse HAGL lesionsHAGL and reverse HAGL lesions www.shoulder.gr
  15. 15. Therapeutic ArthroscopyTherapeutic Arthroscopy SLAP lesionsSLAP lesions Frozen ShoulderFrozen Shoulder AC jointAC joint ArthritisArthritis DislocationDislocation Biceps PathologyBiceps Pathology www.shoulder.gr
  16. 16. Arthroscopic EvolutionArthroscopic Evolution Metal Anchors Absorbable Anchors Peek Anchors Single suture Double sutures www.shoulder.gr
  17. 17. Cuff repairCuff repair Tendon to bone repairTendon to bone repair www.shoulder.gr
  18. 18. Rotator CuffRotator Cuff Single Row Double Row Triple Row Different Suture Passing techniques www.shoulder.gr
  19. 19. RC Arthroscopic RepairRC Arthroscopic Repair 1.1. Recognition, of the type of the tearRecognition, of the type of the tear 2.2. Retraction and releasesRetraction and releases 3.3. Repair Options:Repair Options: AnchorsAnchors:: metallic or absorbablemetallic or absorbable Type of stitchType of stitch:: Mason-Allen,Mason-Allen, Mc Stitch,Mc Stitch, Mattress sutures,Mattress sutures, Horizontal mattress,Horizontal mattress, Simple suturesSimple sutures Restoration of footprintRestoration of footprint:: Double row orDouble row or Single rowSingle row www.shoulder.gr
  20. 20. Risk to Benefit RatioRisk to Benefit Ratio • Rot cuff tears DO NOT heal spontaneously • Tear repairability • Think of Size, Elasticity and Chronicity • Fatty infiltration is not fully reversible www.shoulder.gr Operative TreatmentOperative Treatment Act aggressive and early
  21. 21. Act early try to avoid irreversibleAct early try to avoid irreversible bad tissue qualitybad tissue quality
  22. 22. What is Bad Tissue Quality?What is Bad Tissue Quality? Large or massive tears,Large or massive tears, Retracted tears,Retracted tears, Coutallier three or four fatty infiltrationCoutallier three or four fatty infiltration www.shoulder.gr
  23. 23. ANY TYPE OF RECONSTRUCTIONANY TYPE OF RECONSTRUCTION MUST AVOID TENSION OVER-LOADMUST AVOID TENSION OVER-LOAD OF THE REPAIROF THE REPAIR www.shoulder.gr
  24. 24. Recognize the Tear PatternRecognize the Tear Pattern Tears must be repaired in the directionTears must be repaired in the direction of greatest mobility -> minimal strainof greatest mobility -> minimal strain
  25. 25. L-Shaped & U-Shaped TearsL-Shaped & U-Shaped Tears Side to side sutures from medial to lateralSide to side sutures from medial to lateral Progressively converge the margin of theProgressively converge the margin of the tear lateral to bone bedtear lateral to bone bed Closing 50% of a U-Shaped tear ->Closing 50% of a U-Shaped tear -> reduces strain at converge margin by areduces strain at converge margin by a factor of 6factor of 6 [Burkhart S][Burkhart S]
  26. 26. Side to Side Repair Cuff repair www.shoulder.gr
  27. 27. Double Row Fixation Restoration of the footprint www.shoulder.gr
  28. 28. 1st Anchor Insertion – Medial Row www.shoulder.gr
  29. 29. 1st suture passage- Medial row - mattress www.shoulder.gr
  30. 30. suture passage- Medial row – post. anchor www.shoulder.gr
  31. 31. Lateral Row 1st Anchor Insertion www.shoulder.gr
  32. 32. Inspection of Suture Position www.shoulder.gr
  33. 33. Final Repair Double row fixationDouble row fixation Stronger repair biologically attractive but Time consuming and of raised difficulty www.shoulder.gr
  34. 34. Massive Contracted ImmobileMassive Contracted Immobile TearsTears No mobility from medial to lateral or fromNo mobility from medial to lateral or from anterior to posterioranterior to posterior Subcategories:Subcategories:  Massive Contracted Longitudinal TearsMassive Contracted Longitudinal Tears  Massive Contracted Crescent TearsMassive Contracted Crescent Tears Represent 9.6% of massive tearsRepresent 9.6% of massive tears [Burkhart][Burkhart]
  35. 35. Massive Contractive TearsMassive Contractive Tears better mobilization techniquesbetter mobilization techniques Anterior Interval SlideAnterior Interval Slide and/orand/or Posterior Interval SlidePosterior Interval Slide
  36. 36. Massive TearsMassive Tears Easily repairedEasily repaired Difficult repair (anterior & posterior Slide)Difficult repair (anterior & posterior Slide) Medialized repairMedialized repair Impossible repairImpossible repair Incomplete RepairIncomplete Repair Graft JacketsGraft Jackets Tendon transfersTendon transfers
  37. 37. Rotator CuffRotator Cuff Rot cuff tears that can be repaired withRot cuff tears that can be repaired with open techniques can be repaired withopen techniques can be repaired with arthroscopic techniques alsoarthroscopic techniques also Irreparable Tears:Irreparable Tears: Partial repairPartial repair Medialized repairMedialized repair Grafts and substitutesGrafts and substitutes Tendon transfersTendon transfers www.shoulder.gr
  38. 38. Rotator CuffRotator Cuff Massive Tears www.shoulder.gr
  39. 39. Rotator CuffRotator Cuff Massive Tears www.shoulder.gr
  40. 40. Rotator CuffRotator Cuff Graft Jacket www.shoulder.gr
  41. 41. Rotator CuffRotator Cuff Subscapularis Tear www.shoulder.gr
  42. 42. Rotator CuffRotator Cuff Subscapularis Tear www.shoulder.gr
  43. 43. Rotator CuffRotator Cuff Calcifying TendonitisCalcifying Tendonitis www.shoulder.gr
  44. 44. Rotator CuffRotator Cuff Calcifying TendonitisCalcifying Tendonitis www.shoulder.gr
  45. 45. Frozen ShoulderFrozen Shoulder www.shoulder.gr
  46. 46. AC JointAC Joint Distal Clavicle ExcisionDistal Clavicle Excision www.shoulder.gr
  47. 47. AC JointAC Joint Distal Clavicle ExcisionDistal Clavicle Excision www.shoulder.gr
  48. 48. AC JointAC Joint DislocationDislocation www.shoulder.gr
  49. 49. Shoulder InstabilityShoulder Instability www.shoulder.gr
  50. 50. The Spectrum of Instability Lesions  Minor instability withMinor instability with activity related painactivity related pain  Recurrent subluxationRecurrent subluxation  Recurrent dislocationRecurrent dislocation  Locked dislocation withLocked dislocation with loss of motionloss of motion
  51. 51. Bankart Lesion
  52. 52. Bankart Lesion the essential lesion  Avulsion of the IGHL from the glenoid rim from 2 o’clock to 6 o’clock  Primary restraint to anterior translation at 90o of abduction  85% in traumatic anterior dislocations  Not enough to induce symptomatic instability
  53. 53. ALPSA lesion
  54. 54. humerus Bankart lesion glenoid 1. Identify and Define Pathology
  55. 55. Our findings in first shoulderOur findings in first shoulder dislocationdislocation Hemarthrosis 100%Hemarthrosis 100% Bankart 78.2%Bankart 78.2% Bony Bankart 13.04%Bony Bankart 13.04% Hill-Sachs 65.21%Hill-Sachs 65.21% capsular laxity 8.69%capsular laxity 8.69% SLAP lesions 21.73%SLAP lesions 21.73% C. Yiannakopulos E Mataragas E.Antonogiannakis Arthroscopy Sep 2007
  56. 56. Arthroscopic Shoulder Reconstruction Goal of the Operation: Define the pathology Restoration of the Labrum to its anatomic attachment Reestablishment of the appropriate tension in the IGHL complex and capsule Repair bony Bankart and large Hill-Sachs lesions Repair SLAP lesions Repair rot cuff tears
  57. 57.  Patients of all ages and all activity levels with recurrent anterior instability who are impaired functionally and in whom nonoperative treatment has failed  Revision stabilization  First-time, acute shoulder dislocations Arthroscopic Shoulder Stabilization Patient Selection
  58. 58. InstabilityInstability Anterior Instability – Bankart LesionAnterior Instability – Bankart Lesion www.shoulder.gr
  59. 59. humerus labrum completed repair 6. Assessment of the Final Repair
  60. 60. SLAP repair
  61. 61. InstabilityInstability Posterior InstabilityPosterior Instability www.shoulder.gr
  62. 62. InstabilityInstability Posterior InstabilityPosterior Instability www.shoulder.gr
  63. 63. Posterior capsule reefing
  64. 64. Posterior Instability
  65. 65. Posterior Instability
  66. 66. InstabilityInstability MultidirectionalMultidirectional InstabilityInstability www.shoulder.gr
  67. 67. Multidirection instability Plication of the posterior capsule
  68. 68. InstabilityInstability Anterior Instability. Bony defects – HillAnterior Instability. Bony defects – Hill SachsSachs www.shoulder.gr
  69. 69. InstabilityInstability Anterior Instability –Hill Sachs -RemplisageAnterior Instability –Hill Sachs -Remplisage www.shoulder.gr
  70. 70. InstabilityInstability Anterior Instability – Hill Sachs -RemplisageAnterior Instability – Hill Sachs -Remplisage www.shoulder.gr
  71. 71. InstabilityInstability Anterior Instability. Bony defectsAnterior Instability. Bony defects Glenoid bone lossGlenoid bone loss
  72. 72. Normal Glenoid inverted pear Bony Bankart pear Compression Bankart loss of anterior rim
  73. 73. The normal glenoid shape
  74. 74. Inverted pear glenoid
  75. 75.  Glenoid Bone Loss > 30%  Engaging Hill-Sachs  HAGL lesions Limitations of the Arthroscopic Techniques
  76. 76. Future of instability repairFuture of instability repair HAGL lesions can be repaired withHAGL lesions can be repaired with arthroscopic techniquesarthroscopic techniques Engaging Hill-Sachs. The remplisageEngaging Hill-Sachs. The remplisage technique of Eugene Wolftechnique of Eugene Wolf
  77. 77. Future of instability repairFuture of instability repair Glenoid bone loss:Glenoid bone loss: arthroscopic bone grafting describedarthroscopic bone grafting described by E. Tavernaby E. Taverna Arthroscopic coracoid transferArthroscopic coracoid transfer described by L. Laffossedescribed by L. Laffosse
  78. 78. Arthroscopic success rateArthroscopic success rate Savoie 1997 93%Savoie 1997 93% Burchart, De Bear 2000 96%Burchart, De Bear 2000 96% J Tauro 2000 93%J Tauro 2000 93% Kim 2003 96%Kim 2003 96% Snyder 2006 93%Snyder 2006 93% Fabbriciani 2004 100%Fabbriciani 2004 100%
  79. 79. Trends in arthroscopic surgeryTrends in arthroscopic surgery •Mechanically stronger repair techniques •Arthroscopic techniques for tendon substitutes •Better tendon mobilization techniques • Arthroscopic repair of Bone defects in instability surgery www.shoulder.gr
  80. 80. ConclusionConclusion Today, apart from Shoulder ReplacementToday, apart from Shoulder Replacement and major Shoulder Fractures,and major Shoulder Fractures, nearly all Shoulder Pathologynearly all Shoulder Pathology can be treatedcan be treated With arthroscopic techniquesWith arthroscopic techniques www.shoulder.gr
  81. 81. ConclusionConclusion Literature suggests equal or betterLiterature suggests equal or better results than Open Surgeryresults than Open Surgery www.shoulder.gr
  82. 82. ConclusionConclusion Combined withCombined with Lower MorbidityLower Morbidity Day Case surgeryDay Case surgery Smalls IncisionsSmalls Incisions No Deltoid injuryNo Deltoid injury Earlier MobilizationEarlier Mobilization Less PainLess Pain Earlier Return to Daily ActivitiesEarlier Return to Daily Activities Better Understanding of Shoulder PathologyBetter Understanding of Shoulder Pathology www.shoulder.gr
  83. 83. You are all WelcomeYou are all Welcome www.esskacourse.grwww.esskacourse.gr
  84. 84. Thank YouThank You

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