Osteoporosis complete discussion orthopaedic postgraduate drArshac

Dr.Arshac
DNB Pgt 1st year orthopaedics
HWH Orthopaedics hospital

DEFINITION
 Osteoporosis is a systemic skeletal disease
characterized –
 1. low bone density
 2. a micro- architecture deterioration of bone
tissue
 3. that enhances bone fragility
 4. increases the risk of fracture

World Health Organization (WHO) definition for
osteoporosis is more objective and stresses solely on
the bone mineral density (BMD)
BMD 2.5 SD or more below the mean for young healthy
adult of same gender(T-score at or below -2.5).

Epidemiology
 Osteoporosis is pandemic in prevalence
 1 in 3 women over 50 years suffer from osteoporosis.
 1 in 5 men over 50 years suffer from osteoporosis.
 15% - 30% men and 30%- 50% women suffer fractures
related to osteoporosis in their life time.
 Peak incidence-
western – 70 – 80 years
india – 50 – 60 years

 In women it isThree times more common than
men
1.low peak bone mass (PBM)
2.hormonal changes at menopause
3.live longer than men
• Osteoporosis and consequent fragility # are major
public health concerns and pose immense economic
burden

 fragility # mc sites - vertebral (spine), proximal femur
(hip), distal forearm (wrist) and proximal humerus
 Prior fragility # increases the risk of new fracture by 2-
5 fold

Risk factors
 Advancing age
 Gender F > M.
 Sedentary lifestyle
 Nutrition
 Low BMI
 Smoking / Alcohol
 Oral/systemic glucocorticoids
 Prolonged immobilisation

1.PEAK BONE MASS
2.BONE REMODELLING

1.Peak bone mass & Osteoporosis
 Peak bone mass is the maximum mass of bone achieved
by an individual at skeletal maturity, typically between
ages 25 and 35
 After peak bone mass is attained, both men and
women lose bone mass over the remainder of their
lifetimes
 Because of the subsequent bone loss, peak bone
mass is an important factor in the development of
osteoporosis 10

Determinants Of Peak Bone Mass
Peak Bone Mass
Physical activity Gonadal status
Nutritional
status
Genetic
factors

Peak Bone Mass in Women
10 20 30 40 50 60
•Women achieve lesser peak bone mass than men
12

 Increased bone loss occurs in women after menopause
since osteoclast activity is increased due to absence of
estrogen.
 So increased bone resorption and osteoblast cannot
replace the resorbed bone at same rate, net results is
bone loss .

BONE MODELLING AND
REMODELLING
 MODELLING- during growth, skeleton increases in
size by apposition of new bone tissue on outer surface
of cortex.
 REMODELLING- It is a cellular process of bone
activity by which both cortical and cancellous bone are
maintained.

 Bone modelling
 begins early in skeletal development, modifies the size
and shape of a bone
 bone is removed from one anatomical site and new
bone is formed at another distinct skeletal sites to
bring about major changes in bone architecture

 Bone remodelling is a continuous process taking place
in BMU
 Bone resorption and formation are coupled together
this ensures that structural integrity is maintained
while allowing up to 10% of the skeleton to be replaced
each year
 Bone remodelling is important for repair of micro
fractures in bone due to Normal activities ,mineral
homeostasis (Ca2+,Po4)
 In osteoporosis there is imbalance in bone
remodelling process (bone resorption > bone
formation)
Bone remodelling

 M-CSF- expressed by osteoblast/cyte stimulates RANK
expression in osteoclast via CSF1 receptor
 RANK(receptor activated nuclear kappa factor)
receptor in osteoclast precursor cells
 RANK L – produced by osteoblast/cyte.
 OPG(osteoprotegrin)- soluble decoy receptor for
RANK L, source – osteoblast/cyte
RANK/RANK L/ OPG SIGNALLING
PATHWAY

Hormones & Growth factors regulating bone formation &
resorption
Factor Target cells Effect
Parathyroid Hormone
(PTH)
Kidney
Bone
Helps in active VIT d formation.
Ca2+ absorption and PO4 diuresis
Continuous- bone resorption
Intermittent - bone formation
Net effect : ⬆️ Ca2+ & PO4 ⬇️
Calcitonin Bone osteoclasts Inhibits resorptive action of
osteoclasts: lowers circulating
Calcium.
Calcitriol
(1.25-dihydroxy vit-D3)
Bone Osteoblasts
Bone Osteoclasts,
Kidney,
Intestine
-Stimulates collagen, osteopontin
synthesis
-⬆️ bone resorption
-⬆️ Calcium and PO4 retention
-⬆️calcium and Po4 absorption
Net effect : ⬆️ Ca2+ & ⬆️PO4

Factor Target cells Effect
Estrogen Osteocytes
Osteoblast
Osteoclast
⬇️Apoptosis⬇️ bone remodelling
activation
⬇️Apoptosis , maintenance of bone
formation
⬆️apoptosis,⬇️RankL/ Rank
⬇️Bone resorption
Testosterone Muscle, Bone Muscle growth, placing stress on
bone to stimulate bone formation
Prostaglandins Osteoclasts Stimulate resorption and bone
formation

CLASSIFICATION-
1.NORDIN – 1. generalized
2. localized
2. RIGGS AND MELTON-
a.Primary osteoporosis –type 1 post menopausal
type 2 senile
b.Secondary osteoporosis

CLINICAL FEATURES
 A/K SILENT DISEASE.
 No spf clinical signs and symptoms – generally
nonspecific,non localised,mild bone bains
 Low back ache- usually mild.
 Loss of height
 KYPHOSIS
 Fractures- mc vertebral and hip.

DIFFERENTIAL DIAGNOSIS
 HYPERPARATHYROIDISM
 PAGETS DISEASE
 OSTEOMALACIA
 OSTEOGENESIS IMPERFECTA
 MULTIPLE MYELOMA
 SECONDARY TUMOURS

WORK UP FOR SECONDARY
OSTEOPOROSIS

X-ray
 Not a sensitive modality, as more than 30-50% bone
loss is required to appreciate decreased bone density
on a radiograph
 Post menopausal osteoporosis :Trabecular resorption
and cortical resorption
 Senile osteoporosis: Endosteal resorption

 LS spine X-ray
 Generalized osteopenia
 Thinning and accentuation of cortex
 Accentuation of primary trabeculae and thinning of
secondary trabeculae .
 Vertically striated appearance vertebral body.

HIP X RAY
loss of trabeculae in the proximal femur area, which is explained by Singh index
(Grade 3 and below indicate definite osteoporosis)

 In tubular bones (especially metacarpals), there will
be thinning of the cortex ,cortical thickness <25% of
the whole thickness of the metacarpal signifies
osteoporosis (normally 25-33%)

Sites of measurement are the spine, the hip, calcaneum
and the wrists.

DEXA SCAN
 Gold std for BMD measurement
 Principle – 2 x ray of 70Kv and 140kv are fired on site of
measurement with lag time 0f 4ms.
 Detector detects accentuation of 2 beams.
 Data is fed into computer powered with complex
algorithm and calculates BMD.
 SITES-
 Central dexa- lumbar spine, hip, whole body.
 Peripheral dexa- forearm , calcaneum.
 Regular follow-up with serial DEXA scan to monitor
therapy is controversial.

 CONTRAINDICATIONS-
 PREGNANCY.
 RECENT ADMINISTRATION OF CONTRAST.
AGENT,NUCLEAR MEDICINE SCAN.
 RADIOPAQUE IMPLANT IN MEASUREMENT AREA.
 EXTREME HIGH OR LOW BMI

WHO FRAX SORING TOOL
 A web based algorithm designed to calculate the 10
year probability of hip fracture/major osteoporosis
related fracture based on clinical risk factors and
BMD(optional)
 Results evaluated are given in % of risk of patient
developing fracture in next 10 years.

 https://frax.shef.ac.uk/FRAX/tool.aspx
 Since Indian data is not completely available, the
usage of FRAX for uniform guidance on intervention
threshold is to be applied cautiously
 But given the heterogeneity of Indian scenario, it is
difficult to develop a universally acceptable FRAX
model for India.

 Following assessment of fracture risk using FRAX, the
patient can be classified according to the NOGG
intervention thresholds: -
 Low risk – only reassurance
 Intermediate risk - measure BMD
 High risk – intervention needed

 International Osteoporosis Foundation (IOF) and
International Federation of Clinical Chemistry and
Laboratory Medicine has proposed
 serum CTX-1 (sCTX) – bone Resorption
 serum P1NP – bone formation
 Classify osteoporosis into:
 Low turn over osteoporosis— BTM⬆️- anabolic
therapy
 High turn over osteoporosis –BTM⬇️- antiresorptive
therapy

Uses
 Untreated patients- Predicts the risk of Fractures and
rapidity of bone loss
 Treated patients - for follow up, #risk reduction,
increase in BMD

Limitations
 Lack of standardisation of BTM assays
 Ethnic variations of BTM and lack of reference interval
 No data on response of BTM to different osteoporosis
Rx and comparison between them

1.NON
PHARMACOLOGICAL –
PREVENTION OF
OSTEOPOROSIS AND
OSTEOPOROTIC
FARCTURE.
A.NUTRITION
B.LIFE STYLE
MODIFICATIONS
C.PREVENTION OF
FALL
D.HIP PROTECTORS
2. BASIC THERAUPETIC
MEASURES
A. VIT D AND
CALCIUM
SUPPLEMENTATIO
N
B. ESTEROGEN AND
HRT
3.ANTI RESORBTIVE
AGENTS
A.CALCITONIN
B.BISPHOSPHONATES
C.SERM
D.DONESUMAB
4. DRUGS STIMULATE
BONE FORMATION
EXOGENOUS PTH
5. DRUGS WITH DUAL
ACTION
A.STRONTIUM
RANELATE
B.ROMOSOZUMAB

 Men (50-70) – 1000mg/day calcium
 Women >50 & Men >70 - 1200 mg/day of calcium.
 Intakes in excess of 1200 to 1500 mg/day may increase
the risk of developing kidney stones, cardiovascular
disease, and stroke.
Calcium

VIT D
 ADULTS > 50years — 800-1000IU of Vitamin D/daily
 Treatment of vitamin D deficiency-
Adults should be treated with 60,000 IU once a week or the
equivalent daily dose
for8–12 weeks to achieve a 25(OH)D blood level of
approximately 30 ng/ml.
This regimen should be followed by
maintenance therapy of 1500–2000 IU/day.

2.LIFESTYLE MODIFICATIONS-
a.Physical activity-weight bearing and muscle
strengthing exercises.
Exercise improves bone strength by 30%to 50%.
Exercise should be life long.
b.Cessation of smoking,alcohol,high caffeine intake.
c.Adequate sunexposure

Prevention of falls
 a. Exercises like balance training, lower limb
strengthing exercises
 b. Correction of sensory impairment like
correction of low vision and hearing impairments
 c. Reduce environmental hazards
 d. Appropriate reduction of medications
 e. Education of individual in behavior strategies
 f.Management of other medical conditions

HIP PROTECTORS-PREVENT DIRECT IMPACT ON
PELVIS.
1.Energy absorption type
2.Energy shunting types
3.Crash helmet type
4.Airbag type

Pharmacologic therapy
 Proper counselling – imporatance of life style changes
,nutrition, calcium and vitamin d supplementation
 Rule out all secondary causes
 Measure pre op BMD by Dexa if available
 Preop BTM if planing to follow up & if available

Who should be considered for
treatment?
Postmenopausal women/ men age ≥50years
presenting with
 A hip or vertebral fracture (clinically apparent or found
on imaging).
 T-score ≤−2.5 (after ruling out secondary cause)
 T-score between −1.0 to −2.5 with prior h/o fractures &
Secondary causes ass with high risk of #
(glucocorticoids use& immobilization)
 FRAX score for hip # ≥3% and major osteoporotic #
≥20%

Bisphosphonates
 Are analogues of pyrophosphates.
 1st line drugs in osteoporosis
 Fracture reduction is commonly seen after 1 year of
treatment. ⬇️ vertebral and non-vertebral # risk by
approximately 40%.

 plasma t1/2 is 30-180mins , but once incorporated into
bone can remain bound up to 10 years

 Bisphosphonates can be classified into two groups
 oral (alendronate, risedronate and tiludronate)
 intravenous (pamidronate and zoledronic acid)
 both (ibandronate and clodronate).
 Based on the presence or absence of nitrogen.
 Non Nitrogen containing-clodronate, etidronate and
tiludronate
 Nitrogen -alendronate, neridronate, olpadronate,
pamidronate, risedronate, ibandronate and zoledronate

 Non nitrogen containing-gets incorporated directly
into ATP, produces toxic analogs of ATP- promotes
apoptosis in osteoclast (apoptosis is the primary
effect)
 N2 containing- inhibit farnesyl pyrophosphate
synthase (FPPS) in osteoclasts. FPPS is a rate-limiting
enzyme in the HMG CoA reductase pathway/
cholesterol metabolism (Osteoclast dysregulation is
primary effect)
MOA

 Main effect is to ⬇️ bone resorption and bone turn over
 Other effects-⬇️angiogenesis and ⬇️VEGF
 The net effect of these actions is reduced healing
capacity and the bone sort of becomes metabolically
inactive (metabolic freeze)

DRUG DOSAGE ROUTE SPL REMARKS
Alendronate Prevention
5mg/day
35mg/ weekly
Treatment
10mg/day
70mg/week
ORAL Preferred in
glucocorticoids
induced
osteoporosis
Max upto 3-5 years
Risedronate 5mg/ day
35mg/week
150mg/ monthly
ORAL Safe up to 7 years
Ibandronate 150mg/ month
3mg/3ml every 3
monthly once
Oral
IV ( over 15-30secs)
Check serum
creatinine
Zoledronic acid 5mg
Prevention every 2
years once
Treatment every
year once
IV( over 15 mins)

 Drug administration method
 the pills should be swallowed with 250 mL of water on
an empty stomach,
 remaining upright for 30 min (60 min for
ibandronate)
 after swallowing the tablet, and having nothing to eat
or drink for 30 min (60 min for monthly ibandronate)
after ingesting each pill.

 Patients should be well hydrated and may be pre-treated
with acetaminophen to reduce the risk of an acute phase
reaction (arthralgia, headache, myalgia, fever).
 Despite wide usage of the drug there is still uncertainty
about the optimum duration of treatment of BPs therapy
and treatment holidays
 Other indications- Paget disease,hypercalcemia of
malignancy,osteolytic bone mets,osteogenesis imperfecta

Drug safety
 Side effects for all oral bisphosphonates gastrointestinal
problems ,oesophagitis and gastritis.
 Approximately 30% of the patients experience influenza
like illness
 Ocular inflammation- conjunctivitis,uveitis etc
 All bisphosphonates are contraindicated in patients with
estimated GFR below 30–35 ml/min,Achalasia cardia and
esophageal strictures
 osteonecrosis of the jaw (ONJ) can occur with long-term
use of bisphosphonates (>5year).
 Although rare, low-trauma atypical femur fractures may be
associated with the long-term use of bisphosphonates (e.g.,
>5 years of use).

Calcitonin
 Treatment of osteoporosis in women who are at least
5 years postmenopausal when alternative treatments are
not suitable.
 200 IU delivered as a single dose daily intranasal spray on
alternate nostrils
 100IU SC/IM alternate day
 Supplemented with calcium 1g/day and vitamin d
400Iu/day
 Intranasal calcitonin can cause rhinitis, epistaxis, and
allergic reactions.
 Very small increase in the risk of certain cancers.
 Has analgesic effect for acute pain relief in osteoporosis
related fractures

Estrogen replacement therapy ERT
 Now only historical value ,FDA has withdrawn approval of ERT
for osteoporosis prevention
 Estrogen has pleitropics effects on bone

Esterogen with or without progestin is used.
Also relieves symptoms of postmenopausal
symptoms, vulvovaginal atrophy.
Dose-0.625mg daily.
Routes –oral,transdermal
Side effects – CAD, venous thromboembolic
events,endometrial hyperplasia ,Risk of breast
cancer⬆️

SERM
Used for Rx & prevention
RALOXIFENE-60mg/day.
Advantages- decreases CAD , decreases breast cancer,
⬇️ vertebral # risk
Side effects-DVT ( same as ERT)
Limitations – no # risk reduction at non vertebral sites,
effects on BMD dissipate after withdrawal
Can be combined with Alendronate to have greater
increase in BMD

DENOSUMAB[RANKL INHIBITOR]-
Dose-60mg/6months S.C
Used in postmenopausal women.
Side effects-hypocalcemia , cellulitis ,skin
rash,osteonecrosis of jaw ,pancreatitis
Reduces both vertebral and non vertebral # risk
significantly by end of 3 years
Effect wane of immediately after stopping the drug

PTH, teriparatide
 Teriparatide is approved for the treatment of osteoporosis
in postmenopausal women and men at high risk for
fracture , systemic steroid induced osteoporosis
 High risk for fractures criteria
 Preexisting osteoporotic fractures.
 (T-score < –3.5)
 Above and/or an unsatisfactory response to antiresorptive
therapy
 DOSE-20 μg daily subcutaneous injection.
 Duration not to exceed 18 to 24 months.

 significant vertebral and non vertebral # risk reduction
 Maximum ⬆️ BMD is seen with teriparatide than
Bisphosphonates
 When treatment is stopped, bone loss can be rapid and
alternative agents ( bisphosphonates) should be considered
to maintain BMD.
 SIDE EFFECTS- leg cramps, nausea, dizziness &
osteosarcoma ( not reported in humans),hypercalcemia
and hypercalciuria
 CONTRA INDICATIONS- Paget’s disease, prior radiation
therapy of the skeleton , unexplained ⬆️ ALP

Romosozumab
 FDA approved – PM women with high risk of #
 Both antiresorptive and anabolic action
 Monoclonal antibody against Sclerostin
 Sclerostin produced by osteocyte is a negative regulator of
bone formation and also ⬆️ RANK L and ⬇️OPG —
osteoclast activation.
 Early studies suggest greater ⬆️in BMD than teriparatide
 Dose-210mg SC/monthly for 1year
 Along with calcium and vitamin d supplement
 BMD ⬇️ when Rx stops –follow up with antiresorptives
 Disadvantages- ⬆️CVA & high cost

Strontium ranelate
 2gm sachet OD/ day
 Both antiresorptive and bone formation
 Nephrotoxic
 ODANACATIB- Cathepsin K is a lysosomal enzyme is
produced by the osteoclast during resorption process,
and odanacatib (ODN) is a specific inhibitor of this
enzyme

Tibolone
 Synthetic steroid with –estrogen+ progestogenic+
androgenic property
 Dose 2.5 mg OD oral dose
 Uses- treat menopausal symptoms and osteoporosis

PREVENTION TREATMENT COST
Calcium 500mg to 1500
mg
1000 to 1500
Vit – D 400IU 400IU – 800IU
Bi phosphonates
1. Alendronate 5mg/day 10mg/day Rs200-300
2. Ibandronate - 150mg/month
3. Risedronate - 5mg/day Rs 200-300
4. Zolendronic acid 5mg/2 year 5mg/ 1 year
Raloxifene 60mg/ day
Calcitonin 200 IU 200IU
Parathyroid harmone 20ug/day SC 20-40ug/day SC Rs 3000-6000/
month
Denosumab - 60mg/6
months
Rs 20-30k/
6monthly

Combination therapy
 combining osteoanabolic therapy with antiresorptive
agents is unclear , studies are underway
 Antiresorptive agents acting via different mechanisms
can be used in combination to have an additive effect
on ⬆️ in BMD
 Current recommendation is to start antiresorptive
drugs, such as bisphosphonates as first line agents
 Pts with severe osteoporosis (that have enhanced risk
of fracture) start Anabolics – teriparatide then follow
up with antiresorptive drugs

Thin cortices: choose screw diameter as large as
possible
When a screw is inserted, only two threads of the
screw engaged. Normally, 4–5 threads engaged.
Slide 95
FAILURE WITH UNICORTICAL SCREWS

OSTEOPOROTIC TRABECULAR BONE:
CLINICAL CONSEQUENCES
 Cut out
 Loss of screw fixation
 Spontaneous fractures
Slide 97

Role of Orthopaedicians &surgical
management
 The goals of surgical treatment of osteoporotic
fractures include
 rapid mobilization and return to normal function
and activities
 Avoid too much manipulations
 Progressive physio therapy

 Early definitive # treatment
 Surgery ASAP
 Surgery –simple,minimise operative time
 Intraarticular # —anatomical reduction
 Metaphysical & diaphyseal # — relative stability
 Multidisciplinary team approach to manage other
medical conditions

Principles of Internal Fixation of
Osteoporotic Bone
1. Use of load sharing implants
2. Biologic fixation
3. Impaction and compression
4. Wide buttress
5. Long splintage ILIM nailing
6. Augmentation
7. Replacement
8. Shortening of communited areas of #
9. Fibulae strut grafting & bone grafting
10. Locking screw plate

Load sharing implants
 IF with load sharing device(IMN) >> load bearing
(plate) whenever possible. Diaphyseal # - IMN Nail
 Failure of IF is usually due to bone failure rather than
implant failure. Osteoporotic bones have poor holding
power of screws & severe comminution
 IMN is the gold standard for diaphyseal fractures of
the tibia and femur. IMNs are less susceptible to
implant failure compared with plate fixation. Central
location of nail is biomechanically superior to plating

 Advantages of Intramedullary Nail
 As the nail is centrally placed, it distributes load more
uniformally than plates.
 Fixation is stable
 It is a load sharing device, bone shares the load, this
helps in early healing
 Interlocking has improved the strength of the bone
and rotational stability.
 It is a biological fixation, fracture site is not opened at
all.
 currently used IM nail has options to use 4 or 5 screws
in a multidirectional, multilevel and multiplanner
fashion, which gives excellent stability.

 One important complication with IM nails is
splitting/crack of the bone during insertion. In the
femur, for example, the nail must travel along a
curved path during insertion, due to the natural
anterior bow of the femur.
 If the starting point for the nail is incorrectly placed it
results in further fractures intraoperatively

Internal fixation using plates
 spacing of screws is more important than the number
of screw used for fixation.
 Screws should be placed as close to and as far away
from the fracture site as possible.
 long plate with relatively few screws gives greater
stability than a shorter plate with the same number of
screws

 The screws next to fracture zone on either side are
crucial screws, which determine the fate of fracture
healing
 Longest possible plate should be used as it is more
stable. Longer plates have been shown to significantly
improve bending strength
 Toggling of screw which occurs in osteoporotic bone
is prevented by LCP.

 Locking plates are too stiff, resulting in failure. Various
stress modulation techniques have been developed to
reduce stress,they are
 ⬆️working length
 Use longer plate
 Hybrid fixation with conventional &locking screws
 Far cortical screws
 Use titanium plate
 Conventional screw in the outermost hole

Biological fixation
 Biological fixation must be done ,avoid opening # site
 Less soft tissue trauma @ time of surgery
 Preservation of blood supply to bone
 Can be achieved with wide buttress plate, LISS,LCP
 # fixation with load sharing device + biological
fixation better healing

Impaction & compression
 Impaction is the key factor in stability, achieved by
compression or inserting one fragment into other or
shortening the comminuted segment.
 Useful in – NOF,pertrochanteric, Valgus impacted prox
humerus
 Achieved with help of DHS, sliding screw,IMN, ilizarov

Wide buttress
 Wide buttress concept applicable for epiphyseal and
metaphyseal fractures
 One of the way to achieve biological fixation
 Ex- buttress plate for prox tibia &distal radius,TBW for
medial and lateral Malleolus #

Long splintage
 long plate with relatively few screws gives greater
stability than a shorter plate with the same number of
screws. Long plates may compensate for the reduced
holding power of screws in osteoporotic bone
 Intramedullary nailing represents a very efficient form
of long splintage.

Augmentation
 (1) polymethyl methacrylate (PMMA) cement,
 (2) tricalcium phosphate (TCP),
 (3) hydroxyapatite (HA). Cement injected around
screw increases the screw purchase in the porotic
bone
 Screws coated with HA or bisphosphonates have also
been designed as a means of improving implant
fixation.

Augmentation to Improve Screw Fixation
Enlarges the bone implant surface area
Slide 113

Bone grafting
 Rapid healing
 Useful in fracture gaps,non union, comminuted
fractures

If bone is very poor, consider
prosthetic replacement
Slide 115

VERTEBRAL FRACTURES
 Vertebroplasty to reduce vertebral fracture–associated
pain, percutaneous injection of PMMA,S/E – cement
extravasation
 Kyphoplasty to restore height or to treat the deformity
associated with osteoporotic vertebral fractures,here a
balloon tamp is inflated in the vertebral body to
compress the cancellous bone and create a cavity then
cement injected
 Progressive vertebral collapse or
deformity-pedicle screw fixation

Osteoporosis complete discussion orthopaedic postgraduate drArshac

Osteoporosis complete discussion orthopaedic postgraduate drArshac

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