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This pilot study evaluated the immediate effect of different herbal solutions in oral use on the tensile strength of the sutures used in oral surgical procedures. Three frequently used suture materials, polyglactin 910 (PGA), poliglecaprone (PGCL), and polypropylene (PP), were chosen in a 4-0-gauge size. The sutures' tensile stress was evaluated before being immersed (baseline) and after immersion at 24 h, 1 week, and 2 weeks in four different media: artificial saliva, chlorhexidine, Commiphora myrrh, and frankincense. The tensile strength was assessed by applying a 50 N load at a standardized speed of 2 mm/min. The data were analyzed using one-way and three-way analysis of variance (ANOVA) and the Tukey post hoc test with a significance level of p ≤ 0.05 significance level. The mean values of the maximum load showed a significant statistical difference across the three types of sutures (PGA, PGCL, and PP). The mean tensile strength of the PP suture was statistically lower than that of the other sutures. There was a statistically significant difference in the mean tensile strength of the PGA suture when stored in chlorohexidine media and the PGCL suture for frankincense media. The tensile strength for all sutures was the lowest value when immersed in Commiphora myrrh media. Home-prepared herbal solutions can affect the tensile strength and maximum load of suture materials. Careful and controlled use of herbal solutions after any dental surgical procedures is advisable.

Background: Abdominal hernia repair surgeries involve the fixation of a surgical mesh to the abdominal wall with different means such as suture, tacks, and glues. Currently, the most effective mesh fixation system is still debated. This review compares outcomes of mesh fixation in different surgical procedures, aiding surgeons in identifying the optimal technique. Methods: A meta-analysis was conducted according to PRISMA guidelines. Articles published between January 2003 and January 2023 were searched in electronic databases. Randomized controlled trials (RCTs) comparing mesh fixation with cyanoacrylate-based or fibrin glues with classical fixation techniques (sutures, tacks) in open and laparoscopic procedures were included. Results: 17 RCTs were identified; the cumulative study population included 3919 patients and a total of 3976 inguinal hernias. Cyanoacrylate-based and fibrin glues were used in 1639 different defects, suture and tacks in 1912 defects, self-gripping mesh in 404 cases, and no mesh fixation in 21 defects. Glue fixation resulted in lower early postoperative pain, and chronic pain occurred less frequently. The incidence of hematoma was lower with glue fixation than with mechanical fixation. Recurrence rate, seroma formation, operative and hospitalization time showed no significant differences; but significantly, a higher number of people in the glue group returned to work by 15- and 30-days after surgery when compared to the tacker and suture groups in the same time frame. Conclusion: Cyanoacrylate and fibrin glue may be effective in reducing early and chronic pain and hematoma incidence without increasing the recurrence rate, the seroma formation, or the operative and hospitalization time.

Technique: The CHN•WU wound suture technique uses barbed sutures. The needle is inserted from the basal part of the superficial fascia at the left edge of the wound and passed through half of the reticular dermis to reach a point (1A) approximately 0.5–2 cm away from the wound edge. Occlusion is achieved at 1A at the level of the reticular dermis, and if done correctly, a shallow concavity will appear at the occlusion point on the skin. The needle is then walked along the natural curvature until it reaches the center of the wound and then moved out from the junction between the dermis and subcutaneous tissue. On the other side of the incision, the needle is inserted into the contralateral position at the junction between the dermis and subcutaneous tissue and moved along its natural curvature to achieve occlusion at the mirror site of 1A in the reticular dermis. This process is repeated until the entire wound is closed. In the end, two stitches should be applied in the opposite direction. The left barbed suture is cut and thrown. Results: This technique does not break through the epidermis, has high suture efficiency and satisfactory cosmetic appearance, disperses mechanical tension, and maintains wound tensile strength. Conclusion: This technique was especially effective in closing high-tension wounds in the chest and extremities where the blood supply to both sides of the wound was not affected after suturing, and wound closure could be performed quickly and efficiently in one stage.

Background: Pelvic injuries in the paediatric population are relatively rare and thus there are scanty reports in the literature about their management. Traditionally these injuries were managed conservatively; however, recent studies have shown more inclination towards operative management because of the limited remodeling potential. Case report: In this report, we describe an uncommon, unstable pelvic injury in a 5-year-old child which needed open reduction and stabilization of the pubic symphysis. Conclusion: We report a rare injury, management, and innovative technique of stabilization of the pubic symphysis in a 5-year-old child. We recommend adding non-absorbable sutures to the armamentarium for the management of paediatric pelvic injuries.

Objective: Suspicion of early anterior fontanel (AF) closure is a common reason for referral to a pediatric neurosurgeon because of the suspected increased risk of developing craniosynostosis (CS) in spite of the absence of evidence in the literature. The aim of this study was to analyze the association between AF closure and the diagnosis of non-syndromic CS in Brazilian children. Methods: An observational and case-cohort study was conducted to compare the incidence of closed AF between healthy children (group 1) and children diagnosed with non-syndromic CS (group 2) at a pediatric neurosurgery referral center. The accuracies of completely closed AF and diagnosis of CS were assessed. Results: High-resolution three-dimensional reconstruction computed tomography scans were obtained for 140 children aged < 13 months, of whom 62.9% were boys and 37.1% were girls (p < 0.001). The most common types of non-syndromic CS were trigonocephaly (34, 48%) and scaphocephaly (25, 35.7%). Closed fontanel (27, 38.6%) was observed in both groups, and a sensitivity of 36.1%, specificity of 72%, the positive predictive value of 59%, and negative predictive value of 51% were observed in the patients diagnosed with CS when AF closure occurred before the age of 6 months. Conclusion: The results of this comparative study of AF closure and CS diagnosis suggest that early AF closure does not imply a diagnosis of CS. Pediatricians should be aware of the risk of misdiagnosis of CS in cases with a widely open AF in spite of the presence of CS.

The necessity of an ‘adequate’ keratinized mucosa at the emergence profile of dental implants is a controversial and debated topic. But, in recent years, research suggests that a minimum of at least 2mm of keratinized mucosa is recommended for the maintenance of peri-implant health. The latest systematic reviews on this topic are largely in favor of keratinized mucosa, as are the recommendations of some expert panels. The present paper presents a novel technique for peri-implant flap suturing that can be used in combination with soft tissue augmentation procedures, such as laterally positioned flaps, roll-flaps, and decellularized dermal matrix xenografts. The technique stabilizes the flap on the buccal surface of the healing screw or the emergence profile of the tissue-level implant with a circumferential continuous mattress design that is anchored on the buccal margins and/or periosteum with a final knot. The technique is carried out with a sterile 6/0 synthetic absorbable glyconate monofilament surgical suture (Monosyn, Bbraun, B. Braun Milano S. p.A., Via Vincenzo da Seregno, 14, 20,161 Milan, Italy). This type of suture is ideal, as it slides smoothly through the tissues and allows for the ideal adjustment of the tension and the position of the flap margins until the final knot is positioned. Furthermore, these augmentative procedures make use of second-intention healing and mattress sutures are always ideal to stabilize flap margins without excess tension in such cases. This case series involves patients with a reduced band of keratinized mucosa and, as such, in need of augmentative flap procedures.

Surgical site infections (SSI) are amongst the most common medical infections, occurring in 2 to 4% of patients undergoing a surgical procedure. Smart surgical sutures can play an important role in preventing infection. For example, antimicrobial sutures detectable via clinical imaging modalities can support monitoring wounds post-surgery and enhance patient recovery. However, no commercial suture products possess these properties. Herein, contrasting iodine carbon nanoparticles (ICPs) are synthesized using a solvothermal approach. These ICPs were incorporated into polycaprolactone (PCL) via a coaxial extrusion technique inspired by the ''core-shell'' multilayered suture structure, which integrates multiple clinically favourable functions into one suture device. This system exhibits high imaging contrast capabilities for real-time imaging even after 22 days in-vitro, with strong antimicrobial properties and a reduction in biofilm formation. The multifunctional and biocompatible suture composite developed in this study shows strong antimicrobial properties and can act as an immobilized marker to monitor the surgical site during and after surgical procedures. Identifying suture integrity and location within the body through minimally invasive methods can alleviate patient discomfort and minimize the risk of infection.

Surgical suture plays an important role in increasing wound repair. However, the healing efficacy of sutures currently is still not satisfactory due to their failure in regulating healing biology. Therefore, developing functional sutures are highly required. Herein, we fabricated a new degradable suture to control the release of basic fibroblast growth factor (bFGF) for incisional wound healing. The suture (bFGF-DA@PCL) was simply made by anchoring bFGF onto the surface of the electrospun polycaprolactone (PCL) suture through the assistance of dopamine with a bFGF loading efficiency around 80 %. The introduction of dopamine to the suture also increased the mechanical strength of suture from 17 kPa to 27 kPa. The in vitro data evidenced that the suture could effectively prolong bFGF release up to 10 days and enhance cell adhesion and proliferation. Further in vivo results demonstrated that the suture could increase wound healing and induce a complete wound closure within 13 days. Moreover, the suture was found to accelerate skin mechanical restoration with a recovery of maximum strength to 87.1 % of the healthy skin. The suture was also revealed to help the skin wound healing by promoting granulation tissue formation, collagen deposition, reepithelization, and basement membrane reconstruction.

Background: Cerclage fixation is a known orthopedic technique shown to be beneficial for circumferential augmentation when screw fixation cannot be used or is undesirable. However, ongoing advances in suture materials and knot techniques exist, and there is a paucity of evidence existing which evaluates comparisons between the two. The objective of this study was to investigate the strength and durability of cerclage fixation between the Nice knot suture technique and monofilament wire. Methods: Static displacement over time and compression load testing were analyzed. Compression testing was conducted with the Jamar Hydraulic Hand Dynamometer. Distraction testing was conducted using the Instron test system with its associated program. The Nice knot was tied using number 2 and number 5 FiberWire (Arthrex) and compared to monofilament wire. Clinical failure (displacement of 10 mm), absolute failure (opening of the knot or material failure), maximum compression achieved, and steady state compression maintained were the outcomes of interest. Results: Double-stranded monofilament wire produces maximum consistent compression of 90 kg, followed by single-stranded monofilament wire (60 kg). Number 5 FiberWire has a higher maximum compression load than number 2 FiberWire (50 kg vs. 22 kg), but it is lower than that of the double-stranded monofilament wire constructs. When compared to the single-stranded monofilament construct, the number 5 FiberWire Nice knot is comparable (P < .05). Average steady state compression achieved after 10 minutes of resting showed double-stranded monofilament wire to be 65 kg compared to single- stranded monofilament wire at 42 kg, which when, compared to suture, number 5 FiberWire measured at 15 kg and number 2 FiberWire at 8 kg. Average tension results from Instron distraction testing showed the double-stranded monofilament wire construct was able to withstand greater forces up to a displacement of 6 mm, after which the number 5 FiberWire Nice knot was stiffer. Number 5 FiberWire shows the most linear tension relationship, revealing it more efficiently withstands elastic forces. Load to failure was higher in the number 5 FiberWire Nice knot construct than that in both the monofilament wire constructs. The modes of failure for the Nice knot were always at the knot suture interface rather than at the knot. Conclusion: We propose this suture technique to be a viable alternative method for cerclaging to fix upper limb long-bone fractures.

Wound closing is one of the widely performed and prominent clinical practices in the surgical intervention process. A physician or surgeon has several options ranging from surgical sutures and adhesive strips to fibrin glue for effective wound closure to close the commonly occurring surgical cuts and deep skin tissue injuries. However, all the commercially available wound closure devices have some limitations in each and another perspective. From the beginning of the late 90s, surgical staples got tremendous attention as efficient wound closure devices for their time-effective and sufficient mechanical strength, performance feasibility, fewer chances of surgical site infection and require minimal expertise characteristics in consideration of remote location. Even in the context of the recent COVID19 pandemic, the clinical acceptance and patient compliance for the staples have increased due to minimizing the chances of prolonged interaction between the patient and physicians. The surgical staples application is extensive and diversified, ranging from common external cuts to highly complex surgery procedures like laparoscopic appendectomy, intestinal anastomosis, etc. Thus, in this literature review, we try to give a comprehensive glimpse of the development and current state-of-the-art surgical staples in consideration with research from a commercial point of view. On a special note, this review also describes a very brief outline of the regulatory aspects and some common internationally acceptable ‘de jure standards for the development of commercially viable surgical staples.

Surgical site infection (SSI) significantly affects patient recovery time, health outcomes and quality of life which is closely associated with the use of implants or mesh. Sutures are the most frequently used implants that play a significant role in the development of SSI. Studies have demonstrated that the administration of effective bactericidal and anti-inflammatory treatments can significantly decrease the incidence of SSI. To address this concern, a versatile suture was engineered by coating MoO 3-X nanodots in this study. The incorporation of MoO 3-X nanodots endowed the suture with desirable antibacterial and anti-inflammatory properties that were evaluated in in vitro and in vivo experiments. The results showed its remarkable ability to facilitate wound healing and prevent SSI through its dual action of combating bacterial infection and reducing inflammation. These findings highlight the promising potential of this multifunctional surgical suture as a versatile tool to promote better outcomes in surgical procedures., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Use of surgical skin staples to close the subdural drain exit site after drain removal is often associated with pain. This prospective study compared the degree of pain between staple closure and a technique in which a purse-string suture is placed around the exit site the time of the operation in consecutive patients who underwent one-stage surgery for bilateral chronic subdural hematoma. Methods: In each patient, on one side, a purse-string suture that was later manually ligated immediately after drain removal was placed around the drain exit site during the operation. On the other side, the drain exit site was closed using staples immediately after drain removal. Pain scores were compared according to method of drain exit site closure. Results: Twenty-two patients were included for analysis. The mean Numerical Rating Scale score was significantly lower in the suture group than in the staple group (3.7 ± 2.2 vs. 7.3 ± 2.1; p

Synthetic polymers are widely used in medical devices and implants where biocompatibility and mechanical strength are key enablers of emerging technologies. One concern that has not been widely studied is the potential of their microplastics (MPs) release. Here we studied the levels of MP debris released following 8-week in vitro tests on three typical polyglycolic acid (PGA) based absorbable sutures (PGA 100, PGA 90 and PGA 75) and two nonabsorbable sutures (polypropylene-PP and polyamide-PA) in simulated body fluid. The MP release levels ranked from PGA 100 > > PGA 90 > PGA 75 > > PP ∼ PA. A typical PGA 100 suture released 0.63 ± 0.087 million micro (MPs > 1 µm) and 1.96 ± 0.04 million nano (NPs, 200-1000 nm) plastic particles per centimeter. In contrast, no MPs were released from the nonabsorbable sutures under the same conditions. PGA that was co-blended with 10-25% L-lactide or epsilon-caprolactone resulted in a two orders of magnitude lower level of MP release. These results underscore the need to assess the release of nano- and microplastics from medical polymers while applied in the human body and to evaluate possible risks to human health., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 The Authors. Published by Elsevier B.V. All rights reserved.)

Background: The inside-out repair technique is the gold standard for treatment of meniscal tears, while some soft tissues can be hung as the sutures are tied outside the capsule. The purpose was to clarify the association between the suture site and knot location in the arthroscopic inside-out technique., Methods: Inside-out meniscal suture was arthroscopically performed on medial and lateral menisci in twenty-three cadaveric knees, on the assumption that longitudinal tear existed. A retractor was inserted above the semi-membranous tendon and anterior to the gastrocnemius for the medial side, while the retractor was placed in the anterior space of the gastrocnemius for the lateral side. After identifying three segments (anterior, middle and posterior segments), eight sutures were inserted into the following eight areas in each knee: anterior (M1, L1) and posterior (M2, L2) areas of the middle segment, and anterior (M3, L3) and posterior (M4, L4) areas of the posterior segment. Twelve knees underwent meniscal repair on femoral side and eleven passed sutures on the tibial side, while knots were tied outside of the joint. Attentive dissection was performed to assess the relation between knot locations and the principal structures around the knee joint., Results: In medial meniscal suture, most sutures for the middle portion (M1, 2) bound medial collateral ligament (MCL), while a few cases included the semi-membranous tendon for the M4 area. In lateral meniscal suture, sutures for the L1 area tied some fibers of lateral collateral ligament (LCL) in high frequency, while popliteal muscles/tendons were tied over at the L3 area., Conclusions: Most suture knots were located on MCL or capsule in medial meniscus suture, while more than half sutures passed through LCL or popliteal tendon/muscle in lateral meniscus suture. An assistant should retract LCL under direct observation and the surgeon must confirm the direction of needle for lateral meniscal repair., Competing Interests: Declarations of competing interest The authors declare no conflicts of interest., (Copyright © 2022 The Japanese Orthopaedic Association. Published by Elsevier B.V. All rights reserved.)

Objectives: Surgical site infections (SSI) are common causes of postoperative morbidity at cesarean delivery (CD). The objective of this study was to compare the risk of SSI and other wound complications associated with different suture materials for subcuticular skin closure at CD., Data Sources: We searched Cochrane Library, MEDLINE, Embase, and Clinicaltrials.gov from inception to June 3, 2021, and limited our search to English, peer-reviewed, randomized controlled trials and cohort studies., Study Selection: Of 1541 titles identified, 4 studies met the selection criteria and were included. Studies were included if the population was pregnant individuals undergoing transverse incision primary or repeat, elective or emergent CD with subcuticular skin closure, and if outcomes related to SSI, wound seroma, hematoma, or dehiscence were reported. We completed the assessment using Covidence review management software., Data Extraction and Synthesis: Two authors independently reviewed studies and assessed the risk of bias using the Cochrane 'Risk of bias' tool for randomized trials (RoB 2.0) and the Cochrane Risk of Bias in Non-Randomized Studies-of Interventions (ROBINS-I) tools for cohort studies. We compared SSI risk and secondary outcomes of hematoma, seroma, and dehiscence between skin closure with monofilament (poliglecaprone 25 or polypropylene) versus multifilament (polyglactin 910) sutures using a fixed-effects meta-analysis. Statistical heterogeneity was estimated using the I 2 statistic. Monofilament sutures were associated with a reduced risk of SSI (RR = 0.71, 95% CI 0.52-0.98, I 2  = 0%) compared to multifilament sutures. There was no difference in the risk of secondary outcomes., Conclusion: Monofilament suture for subcuticular skin closure at CD was associated with decreased risk of SSI compared to multifilament suture., (Copyright © 2023 The Society of Obstetricians and Gynaecologists of Canada/La Société des obstétriciens et gynécologues du Canada. Published by Elsevier Inc. All rights reserved.)

Major challenges in traditional wound closure methods (e.g. using sutures and skin staplers) remain inadequately unaddressed; these invasive treatments induce extra puncture wounds, anesthetic side effects, and severe scarring. Herein, an oxidized starch/gelatin-based shape memory hydrogel (OSG) was fabricated as a self-contracting wound dressing to facilitate noninvasive wound closure. The self-contracting properties were attributed by introducing crosslink net-points in the hydrogel polymer structure through Schiff base reaction between oxidized starch (OS) and gelatin. We systematically investigated the self-contracting properties to determine the feasibility of the hydrogel to treat wounds and promote wound closure noninvasively. Following elongation, OSGs could be entirely fixed in a temporary shape at 4 °C, and then contracted under infrared irradiation (IR) for shape memory activation near human physiological temperature (38 °C), providing sufficient recovery force (4 kPa) for successful noninvasive wound closure. Additionally, H&E staining revealed that thicker epidermis and dermis layers were achieved upon OSG treatment, confirming that the OSG facilitated tissue reconstruction in an in vivo rabbit model. Moreover, the OSG-treated wounds displayed smoother skin and no visible scarring compared to sutured wounds. Such excellent performance suggests that OSG hydrogel exhibits high potential as an alternative to medical sutures to facilitate noninvasive would closure.

Purpose: To evaluate and compare the perioperative wound management and healing of intraoral surgical incisions between the conventional and knotless barbed Polydioxanone suture materials., Materials and Methods: A Randomized Controlled Trial was conducted with well-constructed inclusion and exclusion criteria. 46 participants were allotted into the control and test groups based on a computer-generated randomization sequence. The materials used were 3-0 Stratafix™ knotless barbed PDS suture and conventional 3-0 Ethicon PDS TM II suture materials. Parameters assessed included intraoperative time taken for closure and assessment with Early Wound Healing Score (EHS) on postoperative day 1 and Landry, Turnbull, and Howley (LTH) Healing index on postoperative days 3 and 7. Statistical analyses were done using the Chi-square test and student's t -test with a p-value less than 0.05 indicating statistical significance., Results: 32 patients had surgical intervention for maxillofacial fracture management and 14 patient for orthognathic osteotomies. Surgical sites (n = 60) included maxillary and mandibular vestibules. Intraoperative closure time was better in the test group with statistical significance (p-value = 0.0472). The healing scores on the 3rd and 7th postoperative days were compared between the control and test groups exhibiting statistical significance favouring the test group. The p-values were 0.0479 and 0.0393 respectively., Conclusion: To conclude, our study concurred with the existing literature in terms of reduced operating time, and better wound healing observed with the knotless barbed suture. Along with statistical significance, all the variables exhibited clinical relevance and better wound management in the test group., (© 2023 Published by Elsevier B.V. on behalf of Craniofacial Research Foundation.)

In the article we will describe the use of a simple, reproducible and practical urinary catheter model for tendon repair simulation. The structure of the model gives a satisfactory imitation of a tendon's texture, contour and flexibility. This model is easily stored and disposed of. It is free of any ethical committee restrictions. In addition, it can be reused and is easy to handle. There are no disease transmission risks and one catheter can be divided into multiple segments such that several trainees can use one catheter at any one time, therefore saving on costs. In addition, different techniques can be performed on the same model. Tendon repair is an important surgical skill to be attained by all core surgical trainees; especially in Plastic and Orthopedic Surgery. However, tendon repair simulation materials can be relatively expensive. In the Basic Surgical Skills Course®, trainees learn tendon repair techniques using a pig's trotter. The caveat to this is the difficulty in obtaining animal models, and ethical dilemmas that this presents. A simple, effective and cheap method to practice tendon repair techniques is by dividing a Urinary Catheter into multiple pieces, which can be secured to cardboard or perspex using clips, staples, or pins. The Catheter thus simulates a divided tendon, providing a pragmatic medium for practice. The two ends can be opposed and repaired with various suture techniques. Trainees will be able to practice different repair techniques, surgical skills as well as basic surgical principles. The surgical skills include the handling of tissues and instruments effectively and safely, disposal of sharps, suture choice and use, suturing technique and knot tying and surgical dexterity. Principles that can be demonstrated during the simulation session include planning operative approach and choosing appropriate instruments.

Technique: The CHN•WU wound suture technique uses barbed sutures. The needle is inserted from the basal part of the superficial fascia at the left edge of the wound and passed through half of the reticular dermis to reach a point (1A) approximately 0.5-2 cm away from the wound edge. Occlusion is achieved at 1A at the level of the reticular dermis, and if done correctly, a shallow concavity will appear at the occlusion point on the skin. The needle is then walked along the natural curvature until it reaches the center of the wound and then moved out from the junction between the dermis and subcutaneous tissue. On the other side of the incision, the needle is inserted into the contralateral position at the junction between the dermis and subcutaneous tissue and moved along its natural curvature to achieve occlusion at the mirror site of 1A in the reticular dermis. This process is repeated until the entire wound is closed. In the end, two stitches should be applied in the opposite direction. The left barbed suture is cut and thrown., Results: This technique does not break through the epidermis, has high suture efficiency and satisfactory cosmetic appearance, disperses mechanical tension, and maintains wound tensile strength., Conclusion: This technique was especially effective in closing high-tension wounds in the chest and extremities where the blood supply to both sides of the wound was not affected after suturing, and wound closure could be performed quickly and efficiently in one stage., (Copyright © 2023 Asian Surgical Association and Taiwan Robotic Surgery Association. Published by Elsevier B.V. All rights reserved.)

Circumferentially protruding haemorrhoids (CPH) are troublesome lesions for both patients and surgeons, and in most cases demand surgical intervention. However, such surgery carries the risks of complications and recurrence. This study compared two surgical procedures in order to identify the optimal approach for CPH. Methods: All patients underwent an open haemorrhoidectomy for primary haemorrhoids, after which patients underwent either of the two procedures for secondary haemorrhoids. Group 1 (n = 104) comprised patients who underwent submucosal excision with repair using remnant anodermal flaps; this procedure was performed between 1991 and 1996. Group 2 (n = 113) comprised patients who underwent suture-ligation; this procedure was performed between 1997 and 2002. Surgical outcomes including surgical variables, wound healing, complications and patient satisfaction were compared between the two groups. Results: For group 2, surgical time and duration of analgesic use (mean ± SEM, 22 ± 0 minutes and 3 ± 0 days, respectively) were significantly shorter than for group 1 (28 ± 1 minutes and 4 ± 0 days, respectively; p < 0.001 for both comparisons). In terms of complication rates, there was no significant difference between group 2 (15 patients, 14%) and group 1 (25 patients, 22%), and most complications were satisfactorily treated using conservative management. Skin tags and perianal abscesses were more frequent in group 1 than in group 2. The final follow-up was undertaken at 6 months postoperatively, at which time there were no recurrences in patients of either group. For both groups, over 90% of patients reported that they were satisfied with the outcome of surgery. Conclusion: Although both surgical approaches were successful for treating CPH, open haemorrhoidectomy for primary haemorrhoids combined with suture-ligation for secondary haemorrhoids appears to be the optimal approach considering its rapidity, simplicity and lower associated costs.

Purpose: We evaluated the effectiveness of an original simulation training system in improving the suturing performance of medical students using a previously developed web application for scoring suturing performance., Methods: Medical students were recruited for this study and trained on vascular graft anastomosis. Prosthetic grafts were anastomosed and evaluated after orientation, and after 1 hr and 10 hr after training. Vascular surgeons were recruited as controls. Using a previously developed web application, suturing performance was evaluated on the basis of procedural time, coefficient of variation of bite (length of a stitch across the graft), coefficient of variation of pitch (interval between stitches), and skewness (symmetry of the angles between stitches)., Results: Forty-eight medical students and 10 vascular surgeons were recruited. After 1 hr of training, only the students' procedural time improved. After 10 hr of training, all scores improved compared with those in the first trial, and all students' scores except procedural time were statistically similar to those of the vascular surgeons., Conclusions: Ten-hour training improved all factors, including bite, pitch, skewness, and time. Our simple and inexpensive training system and web application for calculating anastomosis scores can be a useful open educational resource., (Copyright © 2022. Published by Elsevier Inc.)

Purpose: Traditional tension band fixation of patella fracture is associated with high reoperation rates. The purpose of the study was to assess strength of fixation in patella fractures treated with either a non-metallic all suture-based technique or traditional metallic tension band wiring., Methods: Ten paired human cadaveric specimens were included. A transverse fracture was created, reduced and fixated with a non-metallic or metallic approach. Non-metallic fixation was done according to a previously published technique, metallic fixation was done according to AO description. Specimens were fixed in 90° of flexion and underwent 200 cycles of loading by pulling the Quadriceps tendon to 300 Newton. Fracture displacement was optically monitored. Primary outcome was fracture displacement after 200 cycles compared to the first cycle. Subsequently, load-to-failure was assessed by a monotonic pull to 1000 N., Results: For cyclic loading analysis, one specimen from each group was excluded due to machine synchronization, resulting in a total population of 18 specimens. Median (min-max) fracture displacement was 0.65 mm (0.06-1.3) in the non-metallic group and 0.68 mm (0-1.23), (p=0.931) in the metallic group. No difference in displacement was found between the two groups in the repeated measures analysis of variance (p=0.5524). For load-to-failure analysis one specimen was excluded due to machine synchronization, resulting a total population of 19 specimens. 2/9 specimens failed in the non-metallic group (at 979 and 635 N) and 2/10 failed in the metallic group (745 and 654 N)., Conclusion: Non-metallic technique is a biomechanically viable alternative to traditional tension band fixation and it can hopefully lead to fewer implant-related complications., Competing Interests: Conflicts of Interest None of the authors have any conflicts of interest or financial ties to disclose., (Copyright © 2022. Published by Elsevier Ltd.)

Background: The aim of this review was to evaluate the most used suture materials with regards to their inflammatory response, their bacterial adhesion, and their physical properties when used to close oral wounds., Methods: Four databases (PubMed, Scopus, Dentistry & Oral Sciences, and OVID) were searched to retrieve relevant studies from January 1, 2000, to January 31, 2020., Results: Out of the 269 articles, only 13 studies were selected as they were relevant and met the systematic review's protocol. These studies showed that almost all suture materials studies (catgut, polyglycolic acid [PGA] sutures, nylon, expanded polytetrafluoroethylene, and silk sutures) caused bacterial adherence and tissue reaction. In nylon and chromic catgut, the number of bacteria accumulated was lowest. Silk and nylon were found to be more impacted than catgut and PGA in terms of physical characteristics such as tensile strength. PGA, on the other hand, was said to be the most susceptible to knot unwinding., Conclusions: Following an oral surgical operation, all sutures revealed varied degrees of irritation and microbial accumulation. Nonresorbable monofilament synthetic sutures, however, exhibited less tissue response and less microbial accumulation., Competing Interests: Conflict of interest None disclosed., (Copyright © 2022 The Authors. Published by Elsevier Inc. All rights reserved.)

Here, we have studied the prevalence and spectrum of genetic alterations in syndromic forms of sagittal and pansynostosis. Eighteen patients with sagittal synostosis (isolated or combined with other synostoses, except coronal) or pansynostosis were phenotypically assessed by retrospective analysis of medical records, three-dimensional computed tomography skull reconstructions, and registered photos. Patient DNAs were analyzed using a targeted next-generation sequencing (NGS) panel including 63 craniosynostosis (CS) related genes. Pathogenic and likely pathogenic variants were found in 72% of the cases, mainly affecting FGFR2, TWIST1, IL11RA, and SKI. Two patients that were negative at NGS screening - one with a supernumerary marker chromosome with duplication of 15q25.2q26.3 and one with a pathogenic PHEX variant - were identified using microarray and single gene analysis, respectively. The overall diagnostic rate in the cohort was thus 83%. We identified two novel likely pathogenic variants in FGFR2 (NM&#95;022970.3: c.811&#95;812delGGinsCC, p.Gly271Pro) and TWIST1 (NM&#95;000474.3: c.476T > A, p.Leu159His), and a novel variant of unclear phenotypic significance in RUNX2 (NM&#95;001024630.3: c.340G > A, p.Val114Ile) which could suggest a modulatory effect. Notably, we also identified three new patients with pansynostosis and a Crouzon-like phenotype with IL11RA mutation. Targeted NGS using a broad panel of CS-related genes is a simple and powerful tool for detecting pathogenic mutations in patients with syndromic forms of CS and multiple suture involvement, in particular pansynostosis. Our results provide additional evidence of an association between pansynostosis and IL11RA, an emerging core gene for autosomal recessive CS., (Copyright © 2022 The Authors. Published by Elsevier Masson SAS.. All rights reserved.)

Left atrial appendage (LAA) epicardial exclusion has been associated with addressing 2 potential deleterious consequences attributed to the LAA, namely, thrombus formation and an arrhythmogenic contributor in advanced forms of atrial fibrillation. With more than 60 years of history, the surgical exclusion of the LAA has been firmly established. Numerous approaches have been used for surgical LAA exclusion including surgical resections, suture ligation, cutting and non-cutting staples, and surgical clips. Additionally, a percutaneous epicardial LAA ligation approach has been developed. A discussion of the various epicardial LAA exclusion approaches and their efficacy will be discussed, along with the salient beneficial affects on LAA thrombus formation, LAA electrical isolation and neuroendocrine homeostasis., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: Primary repair of anterior cruciate ligament (ACL) ruptures has re-emerged as a treatment option for proximal tears, with internal brace augmentation often utilised. The aim of this study is to provide an overview of the current evidence presenting outcomes of ACL repair with internal bracing to assess the safety and efficacy of this technique., Methods: All studies reporting outcomes of arthroscopic primary repair of proximal ACL tears, augmented with internal bracing from 2014-2021 were included. Primary outcome was failure rate and secondary outcomes were subjective patient reported outcome measures (PROMs) and objective assessment of anteroposterior knee laxity., Results: Nine studies were included, consisting of 347 patients, mean age 32.5 years, mean minimum follow up 2 years. There were 36 failures (10.4%, CI 7.4% - 14.1%). PROMs reporting was variable across studies. KOOS, Lysholm and IKDC scores were most frequently used with mean scores > 87%. The mean Tegner and Marx scores at follow-up were 6.1 and 7.8 respectively. The mean side to side difference measured for anteroposterior knee laxity was 1.2mm., Conclusions: This systematic review with meta-analysis shows that ACL repair with internal bracing is a safe technique for treatment of proximal ruptures, with a failure rate of 10.4%. Subjective scores and clinical laxity testing also revealed satisfactory results. This suggests that ACL repair with internal bracing should be considered as an alternative to ACL reconstruction for acute proximal tears, with the potential benefits of retained native tissue and proprioception, as well as negating the need for graft harvest., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2022 The Author(s). Published by Elsevier B.V. All rights reserved.)

Background: A variety of different techniques or methods for treatment of tibial eminence fracture (TEF) have been reported, but there is still controversy on the optimum choice for treating TEFs. The aim of the current work was to compare the clinical outcomes of arthroscopic cannulated screw fixation and a new arthroscopic anchor fixation technique for tibial eminence fracture., Methods: We included 69 isolated tibial eminence fracture patients from June 2012 to February 2017; 36 patients received the cannulated screw fixation and 33 received the transosseous anchor knot (TAK) fixation under arthroscopy. The two techniques were performed by two different high-volume surgeons. The clinical efficacies of the two techniques were assessed by radiographs, extension deficit, flexion deficit, anterior drawer test (ADT), Lachman test, Lysholm scores and International Knee Documentation Committee (IKDC) scores in follow ups., Results: Patients were followed up for 35.8 months on average (range, 24-54 months). There were 40 (58%) males and 29 (42%) females included, and four (6%) patients were ＜18 years old. Asymptomatic grade II laxity was found in two patients in the CS group and three patients in the TAK group from the results of Lachman test. Postoperative radiographs in all patients showed anatomic reductions and bony unions were achieved within 12 weeks. There were no significant differences in extension deficit, flexion deficit, ADT, Lachman test, Lysholm scores and IKDC scores between groups (P > 0.05)., Conclusions: The TAK technique shows satisfactory clinical and radiological outcomes equal to the cannulated screw fixation, which is applicable for TEFs as a reliable effective method., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2022. Published by Elsevier B.V.)

Background: Within the field of peripheral nerve surgery, the use of fibrin glue as an alternative to conventional microsurgical suture repair is becoming increasingly popular. Advantages of fibrin glue for nerve reconstruction include technical ease of use, less tissue manipulation, and shorter operation times. Although fibrin glue seems a promising alternative to conventional microsurgical repair, further insight into the outcomes of nerve recovery is essential., Objective: To summarize the current literature on the use of fibrin glue for peripheral nerve repair and compare these results with outcomes following conventional suture repair., Methods: A systematic search in Embase, MEDLINE, Web of Science, Cochrane, and Google Scholar databases was performed. The search included animal, cadaveric, and human studies assessing outcomes following peripheral nerve repair using fibrin glue. Data on outcomes were subdivided into functional outcomes, electrophysiology, histopathology, biomechanical outcomes, and operation times. We calculated standardized mean differences and combined these in a random effects model to estimate the overall effect., Results: From a total of 2057 references, 37 animal, two cadaveric, and four human studies were included. Fibrin glue repairs resulted in similar functional and electrophysiology outcomes and shorter operation times than suture repairs. However, fibrin glue alone resulted in lower strength and more dehiscence. No dehiscence was reported when fibrin glue was combined with one or two sutures. Yet, we also found that methodological details were poorly reported in animal studies, resulting in an unclear risk of bias. This should be taken into consideration when interpreting the results., Conclusion: The results indicate that nerve regeneration may be similar in fibrin glue repairs and suture repairs. Combining fibrin glue with one or two positional sutures allows for a precise realignment of the nerve fibers and seems to provide sufficient strength to prevent dehiscence., Competing Interests: Declaration of Competing Interest The authors declare no conflict of interest., (Copyright © 2022 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Midfacial hypoplasia is a type of facial dysplasia. The technique of trans-sutural distraction osteogenesis promotes midface growth so as to ameliorate this symptom. In the process of distraction osteogenesis, the fiber matrix in the suture acts as a mechanical sensor. Compared with osteogenesis, the formation of collagen fibers by fibroblasts is significant in the early stage of sutural distraction. However the transformation of fibroblasts during sutural bone formation induced by tensile force is poorly characterized. Here, we used single-cell RNA sequencing to define the cell classification of the zygomatic maxillary suture and the changes of cell clusters in the suture before and after seven-day distraction. We identified twenty-nine cell subsets spanning monocyte/macrophages, neutrophils, red blood cells, B cells and fibroblasts. Compared with the control group, Monocle analysis revealed the emergence of a unique fibroblast subset (Cdh5+, Col4a1+, Fat1-, and Acta2-) (cluster 27) that expressed vascular endothelial cell genes within the distracted zygomatic maxillary suture. We constructed the differentiation trajectories of the fibroblast population (cluster 23, 27) in the suture before and after distraction. In addition, we clarified that a subset of fibroblasts (cluster 27) lost expression of Fat1, an upregulator of the Hippo pathway, and upregulated Cyr61, a downstream gene of the Hippo pathway, during the distraction process. Further enrichment analysis suggests that cells of the new subset (cluster 27) are undergoing conversion of their identity into a vascular endothelial cell-like state in response to mechanical stimulation, associated with upregulation of angiogenesis genes along the single-cell trajectory. Further immunofluorescence staining confirmed this phenomenon. A combined general transcriptome RNA sequencing data analysis demonstrated that the fibroblasts expressed a number of extracellular matrix-related genes under mechanical strain. These data together provide a new view of the role of fibroblasts in tension-induced sutural angiogenesis via interaction with the Hippo pathway., (Copyright © 2021. Published by Elsevier Inc.)

Collagen microfiber-based constructs have garnered considerable attention for ligament, tendon, and other soft tissue repairs, yet with limited clinical translation due to strength, biocompatibility, scalable manufacturing, and other challenges. Crosslinking collagen fibers improves mechanical properties; however, questions remain regarding optimal crosslinking chemistries, biocompatibility, biodegradation, long-term stability, and potential for biotextile assemble at scale, limiting their clinical usefulness. Here, we assessed over 50 different crosslinking chemistries on microfluidic wet-extruded collagen microfibers made with clinically relevant collagen to optimize collagen fibers as a biotextile yarn for suture or other medical device manufacture. The endogenous collagen crosslinker, glyoxal, provides extraordinary fiber ultimate tensile strength near 300MPa, and Young's modulus of over 3GPa while retaining 50% of the initial load-bearing capacity through 6 months as hydrated. Glyoxal crosslinked collagen fibers further proved cytocompatible and biocompatible per ISO 10993-based testing, and further elicits a predominantly M2 macrophage response. Remarkably these strong collagen fibers are amenable to industrial braiding to form strong collagen fiber sutures. Collagen microfluidic wet extrusion with glyoxal crosslinking thus progress bioengineered, strong, and stable collagen microfibers significantly towards clinical use for potentially promoting efficient healing compared to existing suture materials. STATEMENT OF SIGNIFICANCE: Towards improving clinical outcomes for over 1 million ligament and tendon surgeries performed annually, we report an advanced microfluidic extrusion process for type I collagen microfiber manufacturing for biological suture and other biotextile manufacturing. This manuscript reports the most extensive wet-extruded collagen fiber crosslinking compendium published to date, providing a tremendous recourse to the field. Collagen fibers made with clinical-grade collagen and crosslinked with glyoxal, exhibit tensile strength and stability that surpasses all prior reports. This is the first report demonstrating that glyoxal, a native tissue crosslinker, has the extraordinary ability to produce strong, cytocompatible, and biocompatible collagen microfibers. These collagen microfibers are ideal for advanced research and clinical use as surgical suture or other tissue-engineered medical products for sports medicine, orthopedics, and other surgical indications., Competing Interests: Declaration of Competing Interest The authors declare that they are or were employes and/or shareholders of Embody Inc. ., (Copyright © 2021. Published by Elsevier Ltd.)

Study Objective: To demonstrate the importance of planning all the steps of laparoscopic myomectomy, including incision, techniques to reduce blood loss, and suturing., Design: Step-by-step video demonstration of the technique, with narration in the background. The video was approved by the local institutional review board., Setting: Live surgery at Hospital PIO XII, Institute for Research into Cancer of the Digestive System and American Institute of Telesurgery, Barretos., Interventions: We describe a case of a 33-year-old woman with no pregnancy and diagnosed with endometriosis and chronic pelvic pain associated with a 5-cm posterior transmural myoma. We performed a laparoscopic myomectomy, with temporary clipping of the uterine arteries associated with the treatment of endometriosis lesions. Specimen extraction was performed inside a bag [1]. The patient was discharged the next day with no complications. Ten months after the procedure, the patient reported that there was no pain, and that her menses were normal., Conclusion: The laparoscopic approach remains the gold standard for myomectomy [2]. Planning the steps before execution is fundamentally important to ensure the security of the procedure. A seromuscularis baseball suture associated with figure-of-8 knotting with an H3H2 sequence at the internal layers seems to be an adequate technique for myometrium closure [3]. Choosing the correct angle for the incision, clipping the uterine artery, and developing the suture in 2 layers results in less bleeding, reduced operating time, decrease in hospital length of stay, and fewer complications., (Copyright © 2020 AAGL. Published by Elsevier Inc. All rights reserved.)

Purpose: To compare 2 different, commercially available fibrin glue products with nylon suture with regard to repair strength, muscle function, and axon regeneration after delayed nerve repair in an animal model., Methods: A total of 120 Lewis rats underwent transection of the sciatic nerve. On day 3 after transection, the nerves were reexposed. A primary repair was performed on 40 rats from each group using nylon suture, Tisseel fibrin glue, or Evicel fibrin glue. On days 0, 3, and 7 after repair, 10 rats from each group underwent burst strength testing. Seventy days after repair, 10 rats from each group underwent functional muscle testing and histomorphic analysis of the nerve, with the contralateral limb serving as the control., Results: There was no significant difference in burst strength among the groups on days 0 and 3. On day 7, the burst strength of the Evicel and nylon suture groups was significantly greater than that of the Tisseel group. There were 5 total coaptation failures in both fibrin glue groups and none in the suture group. Seventy days after repair, tetanic muscle strength, muscle mass, axon inner diameter, and g-ratio were equivalent among all groups. Axon counts were equivalent between the nylon suture and Evicel groups, although in the nylon group axon counts were higher than for the Tisseel group., Conclusions: In an animal model with a 3-day delay in nerve repair, although dehiscences occurred, when the initial repair held, fibrin glue was not inferior to nylon suture with regard to repair strength and muscle recovery., Clinical Relevance: Historical concerns regarding spontaneous fibrin glue-based nerve repair dehiscences are well-founded. However, when coaptation is maintained, commercially available fibrin glues support nerve regeneration., (Copyright © 2021 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

One way to give some properties such as antibacterial and good frictional properties to sutures is the application of natural antibacterial and hydrophilic components on their surfaces through layer by layer assembly (LBL) technique. In this regard, Chitosan as an antibacterial polycationic natural polymer along with Hyaluronic acid (HA) as a polyanionic polysaccharide could be used to form a polyelectrolyte complex. In this study, HA was extracted from rooster comb using different solvents. Characterization of the extracted HA by FTIR and GPC analysis showed extracted HA with M w  = 2.53 × 10 5  Da had no cytotoxicity. Then, a nylon monofilament (NMy) was coated by the extracted HA and chitosan with different concentrations using bilayer coating technique. Two dyes also were loaded to coating layer to investigate the release behavior of these two drug models. The morphology of coated layer showed that coating NMy by chitosan (4% w/v) following by HA (8% w/v) with roughness of 164 ± 129 nm and friction coefficient of 0.26 had suitable interaction between two layers to prevent from exfoliation of coating layers. The antibacterial activity and controlled release of coated NMy indicated how a NMy coated by Chitosan and HA is a promising material for using as a suture., (Copyright © 2020 Elsevier B.V. All rights reserved.)

The imitation of biological tissue in a synthetic physical model can benefit many medical applications, e.g. pre surgical planning or education. For a quantitative validation of the model's mechanical behavior, standardized testing on both, the biological original and the artificial material, is necessary. In four parts, this study focuses on the biomechanical analysis of the impact of sutures for aortic modelling using 3D printed silicone. Testing methods are developed and executed on biological and synthetic samples. The first part is the determination of the pullout strength of a single stitch. The second part is the investigation of the reduction of the tensile strength and elongation of tensile bars due to stitching. Third, the tensile testing of biological and artificial vessels repaired with an anastomosis gives information about the transferability to real surgical applications. A qualitative feedback study with surgical experts concludes the evaluation. The study reveals that the pullout strength is independent from the fiber or notch direction, but that repaired aortic tensile bars show a dependency on the fiber direction of the tissue. Additionally, the circular seam of the anastomosis provides a more stable connection than multiple single stitches. For the artificial models, the mechanical behavior mainly depends on the mechanical properties of the base silicone, here represented by the Shore A hardness, rather than the manufacturing process. When compared to the biological original the most similar material varies depending on the mechanical property in focus., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Second-generation stent-grafts (SGs) have addressed many of the mechanical problems reported for first-generation endoprostheses, such as graft tear and stent rupture; however, suture wear and detachment due to pulsatile fatigue remains an issue. Numerical studies on the mechanical behavior of these endoprostheses usually model the attachment between stents and graft as a continuous ''tie'' constraint, which does not provide information on the mechanical loads acting on individual sutures. This paper presents a suitable approach for Finite Element (FE) simulations of SGs which allows for a qualitative evaluation of the loads acting on sutures. Attachment between stents and graft is modeled as rigid beams at discrete locations of the endoprostheses, and the reaction forces on the beams are analyzed. This modeling strategy is employed for four different SG models (two Z-stented commercial models and two circular-stented models) subjected to a severe 180° U-bend, followed by intraluminal pressurization. Results show that, for all models, the majority of sutures is experiencing fluctuating forces within a cardiac cycle (between 80 and 120 mmHg), which points to pulsatile fatigue as potential failure mode. In addition, the highest loads are concentrated in kinks and, for Z-stented models, at the apexes of stents. Moreover, suture loads for circular-stented models are lower than for Z-stented models, indicating better resistance to suture detachment. All these observations are in line with experimental results published in the literature, and, therefore, the procedure herein proposed may serve as a valuable tool in the development of new SG models with better suture resistance to pulsatile wear and fatigue., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Sutures, the soft collagenous tissue joining interdigitating bony protrusions on the edges of bone plates, play a significant mechanical role in allowing a turtle shell to respond optimally to a range of loading regimes. In this contribution, qualitative and quantitative aspects of the mechanical behaviour of turtle shell suture regions are investigated by means of mathematical modelling. Notable features of the model include: (i) a geometrically realistic three dimensional model for the suture geometry; (ii) taking the hyperelastic, anisotropic and incompressible nature of the suture material into account; and (iii) a novel method for defining the collagen fibre directions within the suture. The model is validated against a physical three point bending test and replicates many of the qualitative and quantitative aspects of the mechanical behaviour. The model is then used to elucidate the effect that sutures have on the shell's mechanical behaviour during a predator attack. It is found that the sutures increase the energy required from a predator during an attack whilst cushioning the brittle bone, and so protecting it from fracture. Additionally, longer bony protrusions increase strain energy absorption but also increase the likelihood of fracture., (Copyright © 2020 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Objectives: This study sought to assess patent fossa ovalis (PFO) anatomy by transesophageal echocardiography (TEE) in patients undergoing percutaneous suture-mediated PFO closure to identify predictors of post-procedural residual atrial right-to-left shunt (RLS)., Background: Percutaneous suture-mediated PFO closure has been proven to be a safe and effective technique in most PFO patients., Methods: From June 2016 to October 2019, 247 consecutive patients underwent percutaneous suture-mediated PFO closure at our institution. Of them, 230 (46 ± 13 years of age, 146 women) had complete and technically evaluable pre-procedural TEE. The following parameters in short-axis view were assessed: presence and grade of spontaneous RLS, PFO length and width, presence of atrial septal aneurysm and its maximal bulge, and presence of an embryonic or fetal remnant (Chiari network or Eustachian valve)., Results: At the first follow-up transthoracic echocardiography performed between 3 and 6 months from the closure procedure, a residual RLS ≥2 grade was found in 37 (16%) patients. Grade of pre-procedural spontaneous RLS (hazard ratio: 1.99; 95% confidence interval: 1.14 to 3.48; p = 0.016) shunt and PFO width (hazard ratio: 2.52; 95% confidence interval: 1.85 to 3.43; p < 0.001) were both found to be significantly associated with significant residual RLS at multivariable analysis. The presence of atrial septal aneurysm and its maximal bulge and of congenital remnants was not associated with significant residual RLS., Conclusions: Percutaneous suture-mediated PFO closure is feasible in the majority of septal anatomies; however, PFO >5 mm in width and spontaneous large RLS are less likely to be closed with 1 stitch only., (Copyright © 2020 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Competing Interests: Disclosure Dr G.A. Dumanian is the inventor and has financial interest in Advanced Suture Inc. and Mesh Suture Inc. He could potentially benefit from changes to established methods to close the abdominal wall, including the use of mesh suture. Neither of the authors has any additional financial disclosures.

Background: The aim of this study is to assess the causes and rates of re-operation in olecranon fractures in adults treated with transosseous suture., Methods: We prospectively recruited 29 patients who were treated with this technique between 2010 and 2018. The type of suture used, tourniquet time and surgical time were analyzed for each one. X-rays were taken after 2 weeks, 6 weeks and 6 months, recording complications, causes, rates of re-operation and the final clinical condition., Results: Median time for ischemia and surgery were 51 (95% CI:48;62) and 45 (95% CI:42;55) minutes respectively. The radiologic studies showed diastasis of the posterior cortex in the X-rays taken after 2 weeks and after 6 weeks in 7 (24,1%) cases. Of these cases, two (6,8%) were no longer followed-up after 6 months. There was only one case of aseptic non-union. Among these cases, two patients (6.8%) required surgical debridement due to acute soft tissue infection. No complication had any clinical impact, maintaining all patients full range of motion and no pain. Osteosynthesis removal was not necessary in any case., Conclusion: Transosseous suture with high strength thread is a valid alternative for treating Mayo IIA olecranon fractures in adult patients, decreasing re-operation rates for implant removal. There may be, in a moderate percentage of cases, radiologic diastasis of the posterior cortex at the fracture site, without causing pain nor limiting mobility LEVEL OF EVIDENCE: III., Competing Interests: Declaration of Competing Interest All authors disclose no financial and personal relationships with other people or organisations that could inappropriately influence (bias) their work. Examples of potential conflicts of interest include employment, consultancies, stock ownership, honoraria, paid expert testimony, patent applications/registrations, and grants or other funding., (Copyright © 2020. Published by Elsevier Ltd.)

Suture interfaces are one of the most common architectural designs in natural material-systems and are critical for ensuring multiple functionalities by providing flexibility while maintaining connectivity. Despite intensive studies on the mechanical role of suture structures, there is still a lack of understanding on the fracture mechanics of suture interfaces in terms of their interactions with impinging cracks. Here we reveal an interfacial toughening effect of suture structures by means of "excluding" cracks away from interfaces based on a dimensionless micro-mechanical model for single-leveled and hierarchical suture interfaces with triangular-shaped suture teeth. The effective stress-intensity driving forces for crack deflection along, versus penetration through, an interface at first impingement and on subsequent kinking are formulated and compared with the corresponding resistances. Quantitative criteria are established for discerning the cracking modes and fracture resistance of suture interfaces with their dependences on sutural tooth sharpness and interfacial toughness clarified. Additionally, the effects of structural hierarchy are elucidated through a consideration of hierarchical suture interfaces with fractal-like geometries. This study may offer guidance for designing bioinspired suture structures, especially for toughening materials where interfaces are a key weakness. STATEMENT OF SIGNIFICANCE: Suture interfaces are one of the most common architectural material designs in biological systems, and are found in a wide range of species including armadillo osteoderms, boxfish armor, pangolin scales and insect cuticles. They are designed to provide flexibility while maintaining connectivity. Despite many studies on the mechanical role of suture structures, there is still little understanding of their role in terms of interactions with impinging cracks. Here we reveal an interfacial toughening effect of suture structures by means of "excluding" cracks away from interfaces based on a dimensionless micro-mechanical model for single-leveled and hierarchical suture interfaces with triangular-shaped suture teeth. Quantitative criteria are established for discerning the cracking mode and fracture resistance of the interfaces with their dependences on sutural tooth sharpness and interfacial toughness clarified., (Copyright © 2019 Acta Materialia Inc. Published by Elsevier Ltd. All rights reserved.)

Surgical sutures play important role during the wound healing of the surgical sites which are known to be sensitive to microbial infections. Silver nanoparticles (AgNPs) have been recently used as promising agents against multiple-drug resistant microorganisms. This study was designed to coat the sutures with silver nanoparticles obtained via a green synthesis approach. Microbial-mediated biological synthesis of AgNPs were carried out ecofriendly using Streptomyces sp. AU2 cell-free extract and deposited on silk sutures through an in situ process. Sutures coated with biosyntehsized AgNP (bio-AgNP coated sutures) were characterized using Scanning Electron Microscopy (SEM) and elemantal analysis were carried out using Energy Dispersive X-ray Spectroscopy (EDS). The silver amount released by the bio-AgNP coated sutures was calculated by Inductively Coupled Plasma-Mass Spectroscopy (ICP-MS) throughout a degradation process. Antimicrobial potential of the bio-AgNP coated sutures was determined against common pathogenic microorganisms Candida albicans, Escherichia coli and Staphylococcus aureus. To determine the biocompatibility/cytotoxicty of the bio-AgNP coated sutures, the MTT (3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium) assay was used through an indirect test method; that the elutions obtained by the extraction of the sutures at 1, 4, 8 and 10. days and were placed in contact with 3T3 fibroblast cell culture. To best of our knowledge, this is the first report about coating of the nonabsorbable silk sutures with silver nanoparticles biosynthesized using a microbial extract., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Cdc42 (cell division cycle 42) is ubiquitously expressed small GTPases belonging to the Rho family of proteins. Previously, we generated limb bud mesenchyme-specific Cdc42 inactivated mice (Cdc42 conditional knockout mice; Cdc42  fl/fl ; Prx1-Cre), which showed short limbs and cranial bone deformities, though the mechanism related to the cranium phenotype was unclear. In the present study, we investigated the role of Cdc42 in cranial bone development. Our results showed that loss of Cdc42 caused a defect of intramembranous ossification in cranial bone tissues which is related to decreased expressions of cranial suture morphogenesis genes, including Indian hedgehog (Ihh) and bone morphogenetic proteins (BMPs). These findings demonstrate that Cdc42 plays a crucial role in cranial osteogenesis, and is controlled by Ihh- and BMP-mediated signaling during cranium development., (Copyright © 2019 Elsevier Inc. All rights reserved.)