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- •Foreword
- •Preface
- •Contents
- •2.3 Diagnostic Modalities
- •2.4 Antibiotic Stewardship Principles
- •1.1 Historical Background
- •1.2 Epidemiology
- •1.4 Management
- •1.5 Conclusion
- •References
- •2.1 Introduction
- •2.5 Surgical Management
- •Bibliography
- •3.1 Introduction
- •3.2 Pharmacokinetics
- •3.3 Fluoroquinolones
- •3.6 Cephalosporins
- •3.7 Ceftobiprole
- •3.9 Linezolid
- •3.11 Daptomycin
- •3.12 Fosfomycin
- •3.15 Conclusion
- •References
- •4.1 Aetiology
- •4.1.2 Risk Factors
- •4.1.2.2 Bacteria
- •4.1.2.3 Other Causative Agents
- •4.2 Negative Pressure Wound Therapy
- •4.2.1 Summary
- •References
- •5: Bacterial Resistance
- •5.1 Introduction
- •5.3.1 Antibiotic Destruction
- •5.3.4 Target Replacement or Target Bypass
- •5.3.5 Target Site Alteration
- •References
- •6.1 Blood Chemistry Tests
- •References
- •7.1 Introduction
- •7.2 New Diagnostic Tools
- •7.2.1 Serological Tests
- •7.2.1.1 D-dimer
- •7.2.1.2 Fibrinogen
- •7.2.1.3 Neutrophil-to-Lymphocyte Ratio
- •7.2.1.4 Procalcitonin
- •7.2.2 Synovial Tests
- •7.2.2.1 Mass Spectrometry
- •7.2.2.2 Alpha Defensin
- •7.2.2.3 Synovial C-Reactive Protein
- •7.2.2.4 Synovial Interlukin-6
- •7.2.2.5 Calprotectin
- •7.2.3.1 Culture Sonication
- •7.3 Conclusion
- •References
- •8.1 Introduction
- •8.2 Etiology
- •8.4 Clinical Diagnosis
- •8.5 Laboratory Investigations
- •8.6 Biopsy
- •8.7 Radiological Investigations
- •8.8 Medical Management
- •8.8.1 Acute Osteomyelitis
- •8.8.2 Septic Arthritis
- •8.9 Pyomyositis
- •8.10 Surgical Management
- •8.11 Acute Osteomyelitis
- •8.12 Septic Arthritis
- •8.13 Complications
- •8.14 Chronic Osteomyelitis
- •8.15 Pathological Fractures
- •8.16 Post-infective Segmental Bone Loss
- •8.17 Post-infective Physeal Growth Arrest
- •8.18 Post-septic Hip Sequelae
- •8.19 Summary
- •References
- •9.2 Locations
- •Bibliography
- •10: Chronic Osteomyelitis
- •10.1 Introduction
- •10.2 Etiology
- •10.3 Epidemiology
- •10.4 Pathophysiology
- •10.7 Laboratory Test
- •10.8 Diagnostic Radiology
- •10.11 The Host
- •10.12 The Disease
- •10.13 Treatment
- •10.14 Systemic Antibiotic Therapy
- •10.15 Local Antibiotic Depots
- •10.16 Surgical Treatment
- •10.18 Soft Tissue Coverage
- •11.1.6 Imaging
- •11.2 Risk Factors
- •11.3 Common Species
- •10.20 Results
- •10.21 Summary
- •References
- •11.1 Diagnosis
- •11.1.2 Labs
- •11.1.3 Synovial Fluid
- •11.1.4 Culture
- •11.1.5 Histopathology
- •11.4.1 Soft Tissue
- •11.4.2 Bone
- •11.4.3 Joint
- •11.4.4 Periprosthetic
- •References
- •Further Readings
- •12.6 Conclusion
- •12.7 Biography
- •References
- •13.1 Vertebral Osteomyelitis
- •13.1.1 History
- •13.1.2 Epidemiology
- •13.1.3 Pathophysiology
- •13.1.4 Most Common Manifestations
- •13.1.5 Diagnosis
- •13.1.6 Imaging Studies
- •13.1.7 Treatment
- •13.2 Vertebral Tuberculosis
- •13.2.1 History
- •13.2.2 Epidemiology
- •13.2.3 Pathophysiology
- •13.2.4 Most Common Manifestations
- •13.2.5 Pediatric Spinal Tuberculosis
- •13.2.6 Diagnosis
- •13.2.7 Treatment
- •References
- •14.1 Introduction
- •14.2.2 Primary Injury
- •14.2.3 Early Versus Late Infection
- •14.2.5.1 Sequestrum
- •14.2.6 Patient Comorbid Factors
- •14.3 Treatment Options
- •14.3.3 Soft Tissue Coverage
- •14.3.4 External Fixation
- •14.3.5 Antibiotic Loaded Cement/Bioceramics
- •14.3.6 Membrane-Induced Osteogenesis (Masquelet Technique)
- •References
- •15.1 Introduction
- •15.1.1 Conservative Approach
- •15.1.2 Reconstructive Approach
- •15.2 Pedicled Flaps
- •15.2.1 Rectus Abdominis Musculocutaneous Flap
- •15.2.1.1 Surgical Technique
- •15.2.3 Gastrocnemius Flap
- •15.2.3.1 Surgical Technique
- •15.2.4 Soleus Flap
- •15.2.4.1 Surgical Technique
- •15.2.5 Vascularized Fibula Flap
- •15.2.5.1 Surgical Technique
- •15.2.6.1 Surgical Technique
- •15.2.7 Sural Flap
- •15.2.7.1 Surgical Technique
- •15.3 Microsurgical Flaps
- •15.3.1 Anterolateral Thigh Flap
- •15.3.1.1 Surgical Technique
- •15.3.2 Latissimus Dorsi Muscle Flap
- •15.3.2.1 Surgical Technique
- •15.3.3 Gracilis Free-Flap
- •15.3.3.1 Surgical Technique
- •References
- •16: Diabetic Foot Osteomyelitis (DFO)
- •16.1 Introduction
- •16.3.3 Radiographic Examinations
- •16.3.3.1 X-ray
- •16.3.3.2 MRI
- •16.3.3.3 PET-CT
- •16.3.4 Biopsy
- •16.4.1 Antibiotics Therapy
- •16.4.2 Conservative Surgery
- •16.4.3 Aggressive Surgery
- •References
- •17.1.1 Osteoradionecrosis (ORN)
- •17.1.1.1 Prevalence
- •17.1.1.3 Management
- •17.1.2 Risk Prediction
- •17.1.2.1 Conclusion
- •17.1.3.1 Medications
- •17.1.3.3 Patients At-Risk
- •17.2 Pathophysiology
- •17.2.1 Bone Remodeling Inhibition
- •17.2.3 Angiogenesis Inhibition
- •17.2.4 Acquired Immune Dysfunction
- •17.3.2 Local Factors
- •17.3.2.1 Dentoalveolar Procedures
- •17.3.2.2 Anatomic Factors
- •17.3.2.3 Concomitant Oral Disease
- •17.3.2.4 Treatment Goals
- •17.3.3 MRONJ Prevention Strategies
- •17.3.4 Treatment Strategies
- •17.3.4.1 Nonoperative Therapy
- •17.3.5 Operative Therapy
- •17.3.6.1 Pulpitis
- •17.3.6.2 Acute Apical Periodontitis (Periapical Abscess)
- •17.3.6.3 Periapical Granuloma
- •17.3.6.4 Periapical Cyst
- •17.3.7.3 Garre’s Sclerosing Osteomyelitis
- •References
- •18.1 Introduction
- •18.2 Risk Factors
- •18.3 Evidence-Based Preventive Measures
- •18.3.1 Preoperative Measures
- •18.3.1.1 Surgical Hand Preparation
- •18.3.1.5 Preoperative Bathing or Showering
- •18.3.1.6 Preoperative Skin Preparation
- •18.3.1.7 Hair Removal
- •18.3.1.8 Glycemic Control
- •18.3.2 Intraoperative Measures
- •18.3.2.2 Second Dose Antibiotic
- •18.3.2.3 Incisional Wound Irrigation
- •18.3.2.4 Perioperative Oxygenation
- •18.3.2.8 Behavioral Aspects
- •18.3.3 Postoperative Measures
- •18.3.3.1 Postsurgical Wound Care
- •18.3.3.2 Postoperative Antibiotics
- •References
- •19: Periprosthetic Joint Infection: General Aspects
- •19.2 “Local” Patient Risk Factors
- •19.4.1 Presurgical
- •19.4.2 Intraoperative
- •19.4.3 Post-operative
- •19.4.3.1 “Mechanical” Thromboembolic Prophylaxis [101, 102]
- •References
- •20: Low-Grade Periprosthetic Infections
- •20.1 Diagnosis
- •20.3 Outcomes
- •20.4 Conclusion
- •References
- •21.1 Introduction
- •21.5.1 Multidisciplinary Approach
- •21.5.2 Surgical Strategies
- •21.5.3 Other Therapeutic Strategies
- •References
- •22.1.1 Introduction
- •22.2 PJI After Shoulder Arthroplasty
- •22.2.1 Epidemiology
- •22.2.2 Risk Factors
- •22.2.3.2 Diagnostic Criteria
- •22.2.3.3 Clinical Presentation
- •22.2.3.4 Radiology
- •22.2.3.6 Synovial Aspirate
- •22.2.4 Management
- •22.2.4.1 Prevention
- •22.2.4.2 Treatment
- •Implant Retention
- •One-Stage Revision Arthroplasty
- •Two-Stage Revision Arthroplasty
- •Antibiotic Spacer
- •Resection Arthroplasty
- •22.3 PJI after Elbow Arthroplasty
- •22.3.2 Risk Factors
- •22.3.3 Diagnosis
- •22.3.4 Treatment
- •22.3.4.1 Implant Retention
- •22.3.4.2 One-Stage Revision Arthroplasty
- •22.3.4.3 Two-Stage Revision Arthroplasty
- •22.3.4.4 Salvage Procedures
- •References
- •23.1 Introduction
- •23.2 Epidemiology
- •23.3 Pathophysiology
- •23.4 Etiology
- •23.6 Diagnosis
- •23.6.1 Lab Test
- •23.6.2 Imaging
- •23.6.3 Cultures
- •23.7 Risk Factors
- •23.8 Surgical Treatment
- •23.8.2 One-Stage Revision Surgery
- •23.8.3 Two-Stage Revision Surgery
- •23.9 Conclusions
- •References
- •24.1 Introduction
- •24.2 Knee
- •24.2.1 Overview
- •24.2.3 Static Spacers
- •24.2.4 Static Versus Articulating Spacers
- •24.2.5 Distal Femoral or Proximal Tibial Replacement Infection
- •24.2.6 Stage 1 Arthrodesis Spacers
- •24.2.7 Articulating DFR/PTR Spacers
- •24.3 Hip
- •24.3.1 Static Spacers
- •24.3.2 Articulating Spacers
- •References
- •25: Native Hip Joint Infection
- •25.1 Introduction
- •25.2.1 Epidemiology
- •25.2.2 Etiology
- •25.2.3 Clinical Presentation
- •25.2.4 Diagnosis
- •25.2.6 Treatment
- •25.3 Infection Following Hip Preservation Surgery
- •25.3.1 Hip Arthroscopy
- •25.3.1.1 Epidemiology
- •25.3.1.2 Diagnosis
- •25.3.1.4 Treatment
- •25.3.2 Periacetabular Osteotomy
- •25.3.2.1 Epidemiology
- •25.3.2.2 Diagnosis
- •25.3.2.4 Treatment
- •25.3.3 Surgical Hip Dislocation
- •25.3.3.1 Epidemiology
- •25.4.1 Epidemiology
- •25.4.2 Diagnosis
- •25.4.3 Treatment
- •References
- •26: Infective Complications After Trauma Surgeries
- •26.1 Introduction
- •26.3 Epidemiology
- •26.4 Risk Factors
- •26.5 Pathogenesis
- •26.8 Treatment
- •26.8.1 Radical Debridement
- •26.8.2 Implant Handling
- •26.9 Local Antimicrobial Therapy
- •26.9.1.1 Ilizarov Technique
- •26.9.1.2 The Masquelet Technique
- •26.9.1.4 3D Printing
- •26.12.1 Pre-operative Measures
- •26.12.1.1 Skin Preparation Solutions
- •26.12.1.2 Skin Hair Management
- •26.12.2 Peri-operative Management
- •26.12.2.1 Drapes
- •26.12.2.2 Double Gloving
- •26.12.2.3 Antibiotics Coated Implants
- •References
- •27: Infective Complications After Open Fractures
- •27.1 Introduction
- •27.2 Epidemiology
- •27.3 Pathophysiology
- •27.4 Risk Factors
- •27.5.1 Laboratory Examination
- •27.5.2 Imaging Procedures
- •27.6 Nuclear Imaging
- •27.7 Microbiology
- •27.8 Molecular Technologies
- •27.9 Histopathology
- •Irrigation
- •27.10.1.2 Appropriate Intravenous Antibiotics
- •Timing
- •Local Antibiotics
- •27.10.1.3 Meticulous Injury Zone Excision (Debridement)
- •Irrigation
- •27.10.1.4 Fracture Stabilization
- •27.10.1.5 Second Look
- •27.10.1.6 Soft Tissue Closure
- •27.10.2.1 Advantages
- •References
- •28.1 Introduction
- •References
- •29: Infective Complications After Spinal Instrumentation
- •29.1 Introduction
- •29.4 Diagnosis
- •29.5 Treatment
- •29.7 Conclusions
- •References

Bone and Joint
Infections
PietroRuggieri
RohanParwani
KhaledM.Emara
AndreaAngelini
Editors
123

Bone and Joint Infections

Pietro Ruggieri • Rohan Parwani •
Khaled M. Emara • Andrea Angelini
Editors
Bone and Joint
Infections

Editors
Pietro Ruggieri
Department of Orthopedics &
Orthopedic Oncology
University of Padova
Padova, Italy
Khaled M. Emara
Department of Orthopedic Surgery
Ain Shams University Hospital
Cairo, Egypt
Rohan Parwani
Department of Orthopedics
PDU Medical College
Rajkot, Gujarat, India
Andrea Angelini
Department of Orthopedics &
Orthopedic Oncology
University of Padova
Padova, Italy
ISBN 978-3-031-96382-7 ISBN 978-3-031-96383-4 (eBook)
https://doi.org/10.1007/978-3-031-96383-4
© The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature
Switzerland AG 2025
This work is subject to copyright. All rights are solely and exclusively licensed by the Publisher,
whether the whole or part of the material is concerned, specically the rights of translation,
reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microlms or in any
other physical way, and transmission or information storage and retrieval, electronic adaptation,
computer software, or by similar or dissimilar methodology now known or hereafter developed.
The use of general descriptive names, registered names, trademarks, service marks, etc. in this
publication does not imply, even in the absence of a specic statement, that such names are
exempt from the relevant protective laws and regulations and therefore free for general use.
The publisher, the authors and the editors are safe to assume that the advice and information in
this book are believed to be true and accurate at the date of publication. Neither the publisher nor
the authors or the editors give a warranty, expressed or implied, with respect to the material
contained herein or for any errors or omissions that may have been made. The publisher remains
neutral with regard to jurisdictional claims in published maps and institutional afliations.
This Springer imprint is published by the registered company Springer Nature Switzerland AG
The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland
If disposing of this product, please recycle the paper.

Foreword
This project began as the vision of Professor Pietro Ruggieri, then Chair of
the SICOT Infection Committee. The committee had the ambitious goal of
creating a comprehensive textbook dedicated to infections, particularly those
affecting the musculoskeletal system. The editors—Pietro Ruggieri, Andrea
Angelini, Rohan Parwani, and Khaled Emara—were all inspired by their collective work on this committee and sought to share their expertise in this
crucial eld.
Infections related to bone and prostheses present unique challenges for
orthopedic surgeons. Not only must they navigate complex medical issues,
but they also need a deep understanding of infectious lesions, which can be as
difcult to treat as tumors. In some cases, the approach to managing an infection, mirrors that of treating tumors, demanding a blend of knowledge for
surgical intervention. While recent meta-analyses and reviews provide valuable information, nothing surpasses the insight gained from personal experience, which this book seeks to offer.
The authors, drawing on their work with the SICOT committee, have compiled their collective experience and knowledge into this volume. Each chapter serves as an update, addressing specic problems faced by orthopedic
surgeons in the diagnosis and treatment of infections. The book covers not
only surgical techniques but also diagnostic methods and tailored antibiotics
treatments. Special attention is given to imaging, from traditional X-rays to
advanced techniques like CT scans, MRIs, cytology, and bacterial cultures.
Current knowledge is supported by important references, providing a thorough guide to diagnosis, pathology, and treatment. Richly illustrated, the
chapters include detailed pictures and tables to enhance understanding. This
volume represents the collective work of the SICOT committee and will be an
important educational resource within the eld of orthopedic surgery. The
four editors deserve both admiration and gratitude for their commitment to
this signicant work.
v

vi
Finally, this book covers the tenure of three SICOT Presidents: Ashok
Johari, Philippe Hernigou, and Vikas Khanduja.
Foreword
Children’s Orthopaedic Centre, Mahim (West)
Mumbai, India
Henri Mondor Hospital, University Paris
Créteil, France
Department of Trauma and Orthopedics
Addenbrooke’s-Cambridge University Hospital
NHS Foundation Trust, Cambridge, UK
AshokJohari
PhilippeHernigou
VikasKhanduja

Preface
It is a great pleasure to present this volume on bone and joint infections published by Springer Nature.
This idea originated by a proposal of one of us (PR) to the other editors.
We were all happy to work on this topic for several reasons. First of all, infections are becoming more and more a social and medical issue that raises
concern for the future and implies the role and use of antibiotics. In fact,
antibiotics are generally losing their efcacy for infectious diseases, this also
due to the wide—maybe too wide—use that has been and is currently done.
The second reason is more specically related to the eld of orthopedics.
As a matter of fact, the problem of periprosthetic infections in primary prosthetic reconstructions and complex revision surgeries in orthopedic oncology
is increasing: it represents a true “emergency” for all us surgeons. Moreover,
infections on bone and joint not related with primary surgery is an issue and
it cannot always nd a proper treatment in all orthopedic hospitals. One reason for that is that the treatment of orthopedic infections is becoming more
and more a multidisciplinary task.
This book cannot have the ambition of completeness, as the topic of bone
and joint infections is really an ocean; rather it tries to summarize in 28 chapters the crucial problems, in order to help orthopedic surgeons to refresh their
knowledge and provide them with the most relevant references for each
reported topic.
We wish to thank rst of all the members of the SICOT Committee of
Infections involved in authoring this book. Besides to them, other prominent
members of SICOT contributed as authors: they all worked very hard, and we
appreciate their tremendous effort and commitment.
We are sincerely thankful to Springer Nature for accepting our proposal
and taking care of this publication with their usual precision and highstandard level.
Last, but not least: this volume could have never been possible without the
strong approval and support of SICOT Presidential Line. Since it required a
fair amount of time, we wish to make our acknowledgments to three consecutive Society Presidents for trusting us: Vikas Khanduja, Philippe Hernigou,
Ashok Johari. To them, our sincerest gratitude.
vii

viii
We hope that this book can be useful to all orthopedic surgeons: the young
ones for their education and progress, to the old ones for an update on the
subject.
We wish all of you a pleasant, productive reading.
Padova, Italy PietroRuggieri
Padova, Italy AndreaAngelini
Rajkot, Gujarat, India RohanParwani
Cairo, Egypt KhaledEmara
Preface

Contents
1 Bone and Joint Infections: Introduction and Epidemiology . . . . 1
Andrea Angelini and Pietro Ruggieri
2 Antibiotic Stewardship in Orthopedic Surgery . . . . . . . . . . . . . . 9
Khaled M. Emara, Ramy A. Diab,
and Kyrillos Rashid
3 Optimizing Antibiotic Treatment of Bone
and Joint Infections: Pharmacokinetics
and Pharmacodynamics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Marco Trevenzoli, Vincenzo Scaglione,
and Annamaria Cattelan
4 Aetiology and Pathogenesis: Causative Agents . . . . . . . . . . . . . . 27
Franziska Ziegenhain and Gerrolt Nico Jukema
5 Bacterial Resistance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
Marco Trevenzoli, Vincenzo Scaglione,
and Annamaria Cattelan
6 “Diagnosis of Bone and Joint Infections from
Sample to Culture” . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
Ferdinando Da Rin de Lorenzo
7 New Diagnostic Tools for the Diagnosis of
Periprosthetic Joint Infection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69
Saad Tarabichi, Elizabeth A. Abe, Juan D. Lizcano,
and Javad Parvizi
8 Osteoarticular Infections in Children . . . . . . . . . . . . . . . . . . . . . . 77
Ashok N. Johari, Ashish S. Ranade,
and Raashid Anjum
9 Osteoarticular Infections in Adults . . . . . . . . . . . . . . . . . . . . . . . . 103
Ferdinando Da Rin de Lorenzo
10 Chronic Osteomyelitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129
Yangguan Wu and David Joseph
11 Fungal Infections in Orthopedics . . . . . . . . . . . . . . . . . . . . . . . . . 157
Yazan Kadkoy, Claire Park, Joseph A. Ippolito,
and Joseph Benevenia
ix

x
12 Bone and Joint Infection in Immunocompromised
Patients . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 165
Luísa Paganini Martins
13 Vertebral Osteomyelitis and Tuberculosis . . . . . . . . . . . . . . . . . . 171
Luisa Paganini Martin, Andrea Angelini,
and Pietro Ruggieri
14 Algorithm on Treatment in Fracture-Related
Infections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 183
Rohan Parwani
15 Orthoplasty in the Management of Lower Limb BJI . . . . . . . . . 201
Cesare Tiengo, Francesca Mazzarella, Daniele Brunelli,
Pasquale Zona, Franco Bassetto, Mariachiara Cerchiaro,
Andrea Angelini, and Pietro Ruggieri
16 Diabetic Foot Osteomyelitis (DFO) . . . . . . . . . . . . . . . . . . . . . . . . 221
Carlo Biz, Elisa Pagliarini, and Pietro Ruggieri
17 Osteomyelitis of the Jaws . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 239
Stefano Fusetti and Bacci Christian
18 Prevention of Postoperative Infections . . . . . . . . . . . . . . . . . . . . . 255
Khaled M. Emara and Mohamed O. Eissa
Contents
19 Periprosthetic Joint Infection: General Aspects . . . . . . . . . . . . . . 265
Ferdinando Da Rin de Lorenzo and Javad Parvizi
20 Low-Grade Periprosthetic Infections . . . . . . . . . . . . . . . . . . . . . . 295
Tomas Zamora, Ianiv Klaber, and Eduardo Botello
21 What Is New in Periprosthetic Joint Infection
After Hip and Knee Arthroplasty . . . . . . . . . . . . . . . . . . . . . . . . . 305
Shayan Hosseinzadeh, Jesus Villa,
and Carlos Higuera
22 PJI After Shoulder and Elbow Arthroplasty . . . . . . . . . . . . . . . . 319
Georg Hauer, Sebastian M. Klim,
and Andreas Leithner
23 Periprosthetic Joint Infection in Megaprostheses . . . . . . . . . . . . 333
Andrea Angelini, Elisa Pala, Giulia Trovarelli,
Mariachiara Cerchiaro, Elisa Pagliarini,
Alessia Fiumini, and Pietro Ruggieri
24 Antibiotic Spacers Used for Prosthetic Joint Infections . . . . . . . 351
Claire Park, Yazan Kadkoy, Luis Vallejo, Ashley Castan,
Joseph A. Ippolito, and Joseph Benevenia
25 Native Hip Joint Infection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 365
Agustin Albani-Forneris, Martin A. Buttaro,
and Pablo A. Slullitel
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