CFB OT01 Introduction To Orthopaedic Surgery
An introductory overview of orthopaedic surgery covering the fundamental principles of diagnosis, prevention, and treatment of disorders affecting the musculoskeletal system, including bones, joints, ligaments, tendons, and muscles.
This introductory CFB lecture by Professor Peter K Y Chiu provides the conceptual scaffolding for all of orthopaedic surgery. It answers three fundamental questions:
- What is orthopaedic surgery? — Etymology, scope, subspecialties, and defining philosophy.
- What diseases does it deal with? — A systematic disease classification (the "orthopaedic sieve") applied to the musculoskeletal system.
- What are the principles of management? — Aims of treatment, conservative vs operative strategies, and the "5 Rs" framework (Remove, Release, Repair, Reconstruct, Rehabilitate).
Think of this lecture as the table of contents for every subsequent orthopaedic GC lecture. Every topic you encounter later (knee OA, hip arthritis, sports injuries, spine pathology, paediatric orthopaedics, bone tumours, musculoskeletal infection, high-energy trauma) slots into the framework taught here. The exam tests whether you can organise orthopaedic thinking — not just recall isolated facts.
Learning Objectives (Inferred from Slides)
- Define orthopaedic surgery and explain its etymology [1]
- List orthopaedic subspecialties [1]
- Enumerate the components of the musculoskeletal system [1]
- Distinguish form vs function and common deformity terminology [1]
- List the chief complaints in orthopaedics [1]
- Classify musculoskeletal diseases using a systematic sieve [1]
- State the three aims of management [1]
- Differentiate conservative vs operative management [1]
- Explain the "5 Rs" of operative management with clinical examples [1]
- Understand orthopaedics as a multidisciplinary specialty [1]
1. What Is Orthopaedic Surgery?
"Ortho = straightening; Pedics = child." The term was coined by Nicholas Andry, a French physician, in 1741. The original concept was correcting ("straightening") deformities in children. [1]
- Hippocrates (Greek physician, ~480 BC) is credited as the father of medicine and made early contributions to the treatment of fractures and dislocations. The lecture opens with him to root orthopaedics in its ancient surgical heritage. [1]
- The specialty has since expanded far beyond paediatric deformity correction — it now encompasses the entire musculoskeletal system across all ages.
| Region | Preferred Name |
|---|---|
| UK / HK | Orthopaedics; Orthopaedic Surgery |
| USA / HK official | Orthopedics & Traumatology |
The HK department name uses "Orthopaedics & Traumatology" — reflecting trauma as a core part of the specialty. [1]
The orthopaedic subspecialties are: General, Trauma, Spine, Joint Replacement, Hand & Foot, Paediatrics, Sports, Oncology, and Rehabilitation. [1]
| Subspecialty | What It Covers (brief) |
|---|---|
| General | Common conditions not fitting neatly into other subspecialties |
| Trauma | Fractures, dislocations, polytrauma |
| Spine | Cervical/thoracic/lumbar pathology including degenerative disease, deformity, infection |
| Joint Replacement | Arthroplasty (hip, knee, shoulder, etc.) for end-stage arthritis |
| Hand & Foot | Peripheral extremity surgery (including microsurgery, nerve repair) |
| Paediatrics | DDH, clubfoot, scoliosis, Perthes disease, SCFE |
| Sports | Ligament injuries (ACL), meniscal tears, cartilage lesions |
| Oncology | Benign/malignant bone tumours, metastatic disease |
| Rehabilitation | Splints, orthotics, prosthetics, exoskeleton technology |
Exam Tip
If asked to "list subspecialties of orthopaedics," remember the mnemonic G-T-S-J-H-P-S-O-R (nine subspecialties). The lecture slide lists exactly these nine — reproducing them earns full marks.
2. The Musculoskeletal System
The musculoskeletal system consists of: Bone, Joint, and Soft Tissues (muscles, tendons, ligaments, nerves, …). [1]
Why does this matter? Because orthopaedic pathology can arise in any of these components. When you see a patient, you must systematically consider which structure is responsible for their complaint.
| Component | Role | Pathology Examples |
|---|---|---|
| Bone | Structural support, mineral reservoir, haematopoiesis | Fractures, tumours, metabolic bone disease, infection (osteomyelitis) |
| Joint | Articulation, movement | OA, RA, septic arthritis, dislocation |
| Muscles | Movement generation, shock absorption | Strains, myopathy, compartment syndrome |
| Tendons | Connect muscle to bone, transmit force | Rupture, tendinopathy, trigger finger |
| Ligaments | Connect bone to bone, joint stability | Sprains, ACL tears |
| Nerves | Sensation, motor control | Carpal tunnel syndrome, nerve injuries |
| Blood vessels | Perfusion | AVN, diabetic foot, vascular injury |
2.2 Form and Function
The lecture emphasises that the musculoskeletal system serves two purposes: form (structure/appearance) and function (what the body can do). [1]
- Normal form — anatomically correct alignment
- Abnormal form = Deformity [1]
Key deformity terminology from the slides:
- Genu valgum = "Knock knee" (knees angle inward)
- Genu varum = "Bow leg" (knees angle outward)
- Scoliosis = lateral curvature of the spine
- Kyphosis = excessive forward curvature of the thoracic spine [1]
How to Remember Valgum vs Varum
Valgum — the "L" in vaLgum looks like the legs going toward each other (knock knees). Varum — think "V-A-R" → "aRound" → bowing outward. Alternatively: in valgus deformity, the distal part angles AWAY from the midline; in varus, it angles TOWARD the midline.
- Activities of Daily Living (ADL) — the functional benchmark in orthopaedics [1]
- ADLs include: dressing, eating, bathing, toileting, transferring, walking
- A patient may have normal anatomy but poor function (e.g., stiff knee after fracture), or abnormal anatomy but preserved function (e.g., mild scoliosis without symptoms)
- Why this matters: Management decisions hinge on whether the problem is primarily one of form (cosmesis, deformity correction) or function (restoring independence)
Chief complaints include: Pain, Deformity, Stiffness, Instability, Weakness, Numbness, … [1]
| Complaint | Think About… | Why |
|---|---|---|
| Pain | Most common presenting complaint in ortho; characterise by site, severity, onset, aggravating/relieving factors, night pain (red flag for tumour/infection) | Guides differential — mechanical vs inflammatory vs sinister |
| Deformity | Congenital or acquired? Progressive? | Determines urgency and intervention |
| Stiffness | Morning stiffness > 30 min = inflammatory arthritis; < 30 min = OA | Discriminates inflammatory from degenerative |
| Instability | Joint giving way? Recurrent dislocation? | Suggests ligamentous insufficiency |
| Weakness | Myopathic? Neurogenic? Tendon rupture? | Level of pathology changes management entirely |
| Numbness | Peripheral nerve? Radiculopathy? Myelopathy? | Distribution tells you the lesion level |
Diseases of the musculoskeletal system can be classified as:
- Congenital / Developmental
- Trauma
- Infection
- Neoplasm
- Inflammation
- Metabolic
- Neurovascular
- Degeneration
- Idiopathic [1]
This is the surgical sieve adapted for orthopaedics. Every orthopaedic condition you will ever encounter fits into one of these categories. The lecture illustrates each with a specific clinical example:
| Category | Lecture Example | Key Points |
|---|---|---|
| Congenital/Developmental | Congenital Talipes Equinovarus (CTEV / "Club foot") | Foot is in equinus (plantarflexion), varus (inversion), adductus, and cavus. Treated with Ponseti method (serial casting → tenotomy → bracing) [1] |
| Congenital/Developmental | Congenital Dislocation of Hip (CDH) / Developmental Dysplasia of Hip (DDH) | Spectrum from instability to frank dislocation. Screened by Barlow and Ortolani tests. Early Pavlik harness. [1] |
| Trauma | Fractures of radius and ulna; Shoulder dislocation | Most common reason for orthopaedic presentation. Management principles: reduce, hold, rehabilitate [1] |
| Infection | Tuberculosis of the spine | Professor Arthur Hodgson (HKU, 1915–1993) pioneered the "Hong Kong Operation" — anterior radical debridement and bone grafting for spinal TB [1] |
| Infection | Necrotising fasciitis | Life-threatening deep soft tissue infection. Emergency surgical debridement is mandatory [1] |
| Neoplasm (Benign) | Osteochondroma ("Exostosis") | Most common benign bone tumour. Cartilage-capped bony outgrowth. [1] |
| Neoplasm (Malignant) | Osteosarcoma | Most common primary malignant bone tumour in adolescents. Treated by neoadjuvant chemo + wide excision + adjuvant chemo [1] [4] |
| Inflammation | Rheumatoid arthritis (RA) | Autoimmune synovitis → joint destruction. Symmetrical small joint involvement [1] |
| Inflammation | Ankylosing spondylitis (AS) | HLA-B27 associated. Bamboo spine. Axial skeleton predominant [1] |
| Metabolic | Gouty arthritis | Monosodium urate crystal deposition. Negatively birefringent under polarised microscopy [1] |
| Metabolic | Diabetic foot | Neuropathy + vasculopathy → ulceration, infection, Charcot arthropathy [1] |
| Neurovascular | Carpal tunnel syndrome | Compression of median nerve at wrist under transverse carpal ligament. Thenar wasting, numbness in radial 3.5 digits [1] |
| Neurovascular | Avascular necrosis (AVN) of the femoral head | Disruption of blood supply → bone cell death → collapse. Risk factors: steroids, alcohol, SLE, trauma (femoral neck fracture) [1] |
| Degeneration | Osteoarthritis of the knee | Wear-and-tear of articular cartilage. Most common joint disease worldwide. [1] |
| Degeneration | Lumbar spondylosis | Degenerative disc disease and facet arthropathy → back pain, possible radiculopathy/stenosis [1] |
| Idiopathic | Idiopathic Adolescent Scoliosis (AIS) | By definition, cause unknown. Screened by Adam's forward bend test. Cobb angle determines management [1] |
High Yield: The Hong Kong Operation
Professor Arthur Hodgson (HKU, 1915–1993) pioneered the "Hong Kong Operation" for tuberculosis of the spine — anterior radical debridement and bone grafting. This is a classic HKU orthopaedic history fact and has appeared in local exam settings. It is the lecture's way of highlighting that spinal TB is a significant orthopaedic condition, especially in endemic areas. [1]
Ageing Population Relevance
The lecture cites: "Hongkongers already enjoy the longest life expectancy in the world — 81.7 years for males and 87.7 for females" (SCMP, 2018). [1]
Why include this? Because degenerative conditions (OA, spondylosis, osteoporotic fractures) are becoming the largest burden in orthopaedics as the population ages. This underpins why joint replacement, osteoporosis management, and geriatric hip fracture pathways are high-yield exam topics.
4. Principles of Management
The three aims are:
- Relieve pain
- Improve function
- Correct deformity [1]
These are not mutually exclusive — a total knee replacement relieves pain (aim 1), improves walking ability (aim 2), and corrects valgus/varus malalignment (aim 3) simultaneously. But in exam answers, explicitly state all three.
Every orthopaedic problem should be considered for conservative management first before deciding on surgery. [1]
| Conservative | Operative | |
|---|---|---|
| Examples from slides | Plaster of Paris (closed reduction + cast), bracing for scoliosis [1] | Open reduction & internal fixation (ORIF), instrumentation & spinal fusion [1] |
| Philosophy | Non-invasive, lower risk, first-line for many conditions | When conservative fails, or condition demands it (e.g., displaced fracture, malignancy, progressive neurological deficit) |
4.3 The "5 Rs" of Operative Management
The lecture frames operative orthopaedic management around five key actions. This is the most exam-testable framework from this lecture.
Operative management aims to: Remove, Release, Repair, Reconstruct, Rehabilitate [1]
Indications for removal include:
- Torn meniscus, loose bodies, synovitis — typically via arthroscopy
- Prolapsed intervertebral disc — discectomy for nerve root compression
- Benign tumours or tumour-like lesions — e.g., dorsal wrist ganglion
- A limb (amputation) — for malignancy, severe infection, severe trauma — "To save life!" [1]
Why remove? The pathological tissue is causing symptoms (pain, mechanical block, compression) or threatening life. Removal eliminates the source.
Amputation: When and Why
Students often forget that amputation is a legitimate orthopaedic procedure. It is not a failure — it is a life-saving intervention when the limb is unsalvageable (e.g., gas gangrene, unreconstructable vascular injury, extensive malignancy). The slide explicitly states the purpose: "To save life!" [1]
Indications for release include:
- Trigger finger — release of the A1 pulley
- Carpal tunnel syndrome — release of the transverse carpal ligament (flexor retinaculum)
- Contracted soft tissues — e.g., equinus deformity of ankle (Achilles tendon lengthening) [1]
Why release? A tight structure (tendon sheath, ligament, contracted tissue) is causing mechanical restriction or nerve compression. Dividing it restores normal excursion or decompresses the nerve.
Repair targets:
Professor SP Chow performed the first successful thumb replantation in Hong Kong in 1977. [1]
Why repair? The structure is disrupted but still has potential for healing if anatomically restored. Repair provides the conditions (alignment, stability, blood supply) for biological healing.
| Repair Method | When Used | Mechanism |
|---|---|---|
| Plating | Articular fractures, forearm fractures — anatomic reduction needed | Plate and screws provide absolute stability → primary bone healing |
| Nailing | Long bone diaphyseal fractures (femur, tibia) | Intramedullary nail provides relative stability → secondary bone healing (callus) |
| Tendon repair | Acute tendon lacerations/ruptures | Suture maintains continuity while collagen healing occurs |
| Nerve repair | Clean nerve transection | Epineural or fascicular repair → axonal regeneration (1 mm/day) |
| Vascular repair | Arterial injury threatening limb viability | Direct repair or vein graft to restore perfusion |
Reconstruction targets:
Why reconstruct? The original structure is damaged beyond repair. A new construct (prosthesis, graft, transferred tissue) must be created to restore form and function.
Repair vs Reconstruct — Know the Difference
Repair = restoring the original structure (e.g., suturing a torn tendon back together). Reconstruct = building a new structure to replace something that cannot be repaired (e.g., ACL reconstruction using a hamstring or patellar tendon graft, or total joint replacement). This distinction is a common exam discriminator. [1]
Rehabilitation aims to:
- Preserve function — prevent deterioration
- Restore function — using splints, orthotics, prosthetics
- Enhance function — through training
- Advanced rehabilitation — e.g., paraplegic walking with exoskeleton [1]
Why rehabilitate? Surgery alone does not restore function. Post-operative rehabilitation (physiotherapy, occupational therapy, assistive devices) is essential to translate surgical success into real-world functional gains.
The lecture concludes with a philosophical summary of what makes orthopaedics unique:
Orthopaedics is:
- Not limited to one organ or one anatomical region — it spans the entire body (spine to toes)
- Not limited by age or sex — from neonates (DDH, clubfoot) to the elderly (hip fractures, OA)
- Quality of life rather than life & death — most orthopaedic conditions are not immediately life-threatening but profoundly affect daily function (exception: polytrauma, necrotising fasciitis, malignancy)
- Based on biological AND engineering principles — unique among surgical specialties in applying biomechanics, material science, and implant design
- An art and a science — the lecture invokes Michelangelo's David to illustrate the aesthetic dimension of restoring human form
- One of the fastest advancing specialties — highlighted by 3D printing, robotic-assisted surgery, artificial intelligence/machine learning [1]
Multidisciplinary Nature
Orthopaedics is multidisciplinary, involving:
- Doctors — anaesthesiologist, radiologist, physician, rheumatologist, pathologist, oncologist
- Nurses — wards, outpatient department, operating theatre
- Allied health — physiotherapist, occupational therapist, prosthetist & orthotist, podiatrist
- Others — clinical psychologist, medico-social worker, engineers, material scientists
- Patient family members [1]
High Yield: Multidisciplinary Team
Exams often ask you to "describe the multidisciplinary team involved in managing [condition X]." The lecture slide gives you a comprehensive list. For orthopaedic conditions, always mention: surgeon, anaesthetist, physiotherapist, occupational therapist, and if relevant, oncologist (bone tumour), rheumatologist (inflammatory arthritis), or prosthetist/orthotist (amputee). [1]
While the primary lecture is introductory, the supporting orthopaedic history-taking material [2] provides the clinical approach that complements this lecture:
| History Component | Orthopaedic Specifics |
|---|---|
| Presenting complaint | Pain, deformity, stiffness, instability, weakness, numbness, loss of function |
| Pain characterisation | SOCRATES: Site, Onset, Character, Radiation, Associated features, Timing, Exacerbating/relieving, Severity |
| Functional assessment | ADLs: can you walk? How far? Stairs? Dress independently? Need walking aids? |
| Red flags | Night pain (tumour), weight loss (malignancy), fever (infection), neurological deficit (cord/cauda equina compression), trauma mechanism (high energy) |
| Past medical history | DM (diabetic foot, poor healing), RA (inflammatory joint disease), malignancy (metastases), osteoporosis |
| Drug history | Steroids (AVN, osteoporosis), anticoagulants (surgical risk), NSAIDs (current analgesia) |
| Social history | Occupation (functional demands), sporting activities (mechanism, return-to-sport goals), smoking (impaired healing) |
| Related GC Lecture | How It Connects |
|---|---|
| GC 228: Knee OA [3] | Degeneration category → conservative then TKR (reconstruct) |
| GC 229: Hip Arthritis [5] | Degeneration + neurovascular (AVN) → THR (reconstruct) |
| GC 230: Knee Sports Injuries [6] | Trauma → meniscal tear (remove), ACL tear (reconstruct) |
| GC 227: Cervical Spine Pathology [7] | Degeneration + neurovascular → myelopathy → decompression (release/remove) |
| GC 231: High Energy Trauma [8] | Trauma → fracture fixation (repair), amputation (remove) |
| GC 237: MSK Infection [9] | Infection → osteomyelitis, septic arthritis, necrotising fasciitis (remove/debride) |
| CFB OT02: Children's Ortho [10] | Congenital/developmental → DDH, CTEV, scoliosis (correct deformity) |
| Bone Tumour lecture [11] | Neoplasm → osteosarcoma (remove via wide excision) |
9. Exam Intelligence
| Question Format | What They Test | Example Stem |
|---|---|---|
| MCQ | Terminology (valgus vs varus), disease classification, management principle | "A goniometer is most useful for examining which complaint?" → Stiffness/ROM (Past paper Q13, 2020) [12] |
| SAQ | Red flags for back pain, differential diagnosis using the sieve, principles of fracture management | "Name four red flag signs for back pain" (2023 Minicase) [13] |
| Minicase | Orthopaedic presentation requiring structured history, investigation, and management plan | Spine infection minicase (2023) — directly tests the infection category from this sieve [13] |
| Viva/OSCE | Demonstrate orthopaedic examination, explain management aims | "What are the three aims of orthopaedic management?" |
| Past Paper | Relevant Connection |
|---|---|
| 2020 MCQ Q13 [12] | Goniometer for shoulder examination — tests "function" assessment (ROM measurement) |
| 2020 MCQ Q14 [12] | Greenstick fracture management → conservative (cast) — tests conservative vs operative decision |
| 2022 MCQ Q60 [14] | Osteosarcoma surgical method → wide local resection — tests tumour surgery principle (remove) |
| 2023 Minicase Case 3 [13] | Back pain + fever → spinal infection → red flags, DDx, Ix — directly tests the "infection" category |
| 2023 SAQ Q8 [15] | Spinal cord injury → motor/sensory distribution — tests neurovascular category |
| 2024 SAQ Q8 [16] | Neck of femur fracture → post-op DVT — tests trauma + rehabilitation complications |
Common Mistakes
- Confusing valgus and varus — Remember: in vaLgus, the distal segment angles away from the midLine (toward lateral); in varus, toward midline (medial).
- Forgetting rehabilitation as part of management — The "5 Rs" includes rehabilitate. Post-op rehab is always expected in management plans.
- Listing only operative options — Always mention conservative management first, then operative. The exam rewards structured thinking.
- Confusing repair vs reconstruct — Repair = fix the original structure. Reconstruct = build something new. ACL reconstruction uses a graft (not primary repair in most cases).
- Overlooking the disease sieve — When asked for differentials of a musculoskeletal complaint, systematically go through: congenital, trauma, infection, neoplasm, inflammation, metabolic, neurovascular, degeneration, idiopathic.
"What are the aims of orthopaedic management?" → (1) Relieve pain (2) Improve function (3) Correct deformity [1]
"List the orthopaedic disease classification." → Congenital/developmental, Trauma, Infection, Neoplasm, Inflammation, Metabolic, Neurovascular, Degeneration, Idiopathic [1]
"What are the principles of operative orthopaedic management?" → Remove, Release, Repair, Reconstruct, Rehabilitate (the "5 Rs") [1]
"What is the Hong Kong Operation?" → Anterior radical debridement and bone grafting for spinal tuberculosis, pioneered by Professor Arthur Hodgson at HKU [1]
Q1: "List the nine subspecialties of orthopaedic surgery." → General, Trauma, Spine, Joint Replacement, Hand & Foot, Paediatrics, Sports, Oncology, Rehabilitation [1]
Q2: "A child presents with both knees touching but ankles wide apart. What is this deformity called?" → Genu valgum (knock knee). The distal segment (tibia) angles laterally away from the midline. [1]
Q3: "An elderly woman with knee OA presents with pain, stiffness, and varus deformity. What are the three aims of management?" → Relieve pain, improve function, correct deformity [1]. For this patient: analgesia + physiotherapy (conservative) → TKR if conservative fails (reconstruct).
Q4: "A 15-year-old boy has a bony swelling near the distal femur. X-ray shows a cartilage-capped bony outgrowth. What is the most likely diagnosis?" → Osteochondroma (exostosis) — most common benign bone tumour [1]
Q5: "Name five components of the multidisciplinary team in orthopaedics." → Orthopaedic surgeon, anaesthetist, physiotherapist, occupational therapist, prosthetist & orthotist. (Also accept: radiologist, rheumatologist, oncologist, MSW, nurse specialist) [1]
Q6 (Past paper style, 2023 Minicase): "A 75-year-old man presents with lower back pain for weeks and low-grade fever. Name four red flag signs for back pain." → (1) Fever/infection signs (2) Unexplained weight loss (3) Neurological deficit (weakness, numbness, bowel/bladder dysfunction) (4) Night pain/pain at rest (5) History of malignancy (6) Age > 50 or < 20 with new back pain (7) Trauma/osteoporosis risk [13]
High Yield Summary
Orthopaedic surgery = "straightening the child" (etymology) → now encompasses the entire musculoskeletal system (bone, joint, soft tissues) across all ages.
Disease sieve (9 categories): Congenital/Developmental, Trauma, Infection, Neoplasm, Inflammation, Metabolic, Neurovascular, Degeneration, Idiopathic.
Three aims of management: Relieve pain, Improve function, Correct deformity.
5 Rs of operative management: Remove (meniscus, disc, tumour, limb), Release (trigger finger, carpal tunnel, contracture), Repair (fracture fixation, tendon/ligament/nerve suture, replantation), Reconstruct (TKR, ACL reconstruction, toe-hand transfer), Rehabilitate (splints, orthotics, prosthetics, training, exoskeleton).
Conservative before operative — always consider non-surgical options first.
Multidisciplinary — orthopaedics involves surgeons, allied health (PT/OT/P&O), nurses, physicians, and patient families.
HKU historical fact: Professor Arthur Hodgson — "Hong Kong Operation" for spinal TB; Professor SP Chow — first thumb replantation in HK (1977).
Active Recall - Introduction to Orthopaedic Surgery
[1] Lecture slides: CFB (OT01) Introduction to Orthopaedic Surgery.pdf [2] Lecture slides: MBBS IV History taking Ortho.pdf [3] Lecture slides: GC 228. Knee Osteoarthritis_Part A.pdf [4] Senior notes: MBBS Final MB (Pediatrics) (Felix PY Lai).pdf (Osteosarcoma section) [5] Lecture slides: GC 229. Hip Arthritis.pdf [6] Lecture slides: GC 230. Knee Sport Injuries_Part 1.pdf [7] Lecture slides: GC 227. Cervical Spine Pathology.pdf [8] Lecture slides: GC 231. High Energy Trauma & Open Fracture_Part 1.pdf [9] Lecture slides: GC 237. Musculoskeletal infection [Updated in 2025].pdf [10] Lecture slides: CFB (OT02) Childrens Orthopaedics and Deformities.pdf [11] Lecture slides: Primary bone tumour and bone metastasis_Dr Ho Wai Yip.pdf [12] Past papers: 2020 Fourth Summative Assessment MCQ paper.pdf (Q13, Q14) [13] Past papers: 2023 Fourth Summative Minicase.pdf (Case 3) [14] Past papers: 2022 Fourth Summative MCQ.pdf (Q60) [15] Past papers: 2023 Fourth Summative SAQ.pdf (Q8) [16] Past papers: 2024 Fourth Summative SAQ.pdf (Q8)
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