A numerical study of dehydration induced fracture toughness degradation in human cortical bone.

A 2D plane strain extended finite element method (XFEM) model was developed to simulate three-point bending fracture toughness tests for human bone conducted in hydrated and dehydrated conditions. Bone microstructures and crack paths observed by micro-CT imaging were simulated using an XFEM damage model. Critical damage strains for the osteons, matrix, and cement lines were deduced for both hydrated and dehydrated conditions and it was found that dehydration decreases the critical damage strains by about 50%. Subsequent parametric studies using the various microstructural models were performed to understand the impact of individual critical damage strain variations on the fracture behavior. The study revealed the significant impact of the cement line critical damage strains on the crack paths and fracture toughness during the early stages of crack growth. Furthermore, a significant sensitivity of crack growth resistance and crack paths on critical strain values of the cement lines was found to exist for the hydrated environments where a small change in critical strain values of the cement lines can alter the crack path to give a significant reduction in fracture resistance. In contrast, in the dehydrated state where toughness is low, the sensitivity to changes in critical strain values of the cement lines is low. Overall, our XFEM model was able to provide new insights into how dehydration affects the micromechanisms of fracture in bone and this approach could be further extended to study the effects of aging, disease, and medical therapies on bone fracture.

Impact of heavy alcohol consumption on cortical bone mechanical properties in male rhesus macaques.

Chronic heavy alcohol consumption may influence the skeleton by suppressing intracortical bone remodeling which may impact the quality of bone and its mechanical properties. However, this aspect has not been thoroughly assessed in either humans or animal models whose cortical bone microstructure resembles the microstructure of human cortical bone. The current study is the first to investigate the effects of chronic heavy alcohol consumption on various mechanical properties of bone in a non-human primate model with intracortical remodeling. Male rhesus macaques (5.3 years old at the initiation of treatment) were induced to drink alcohol and then given the choice to voluntarily self-administer water or ethanol (4 % w/v) for approximately 14 months, followed by three abstinence phases (lasting 34, 41, and 39-46 days) with approximately 3 months of ethanol access in between. During the initial 14 months of open-access, monkeys in the alcohol group consumed an average of 2.9 ± 0.8 g/kg/d ethanol (mean ± SD) resulting in a blood ethanol concentration of 89 ± 47 mg/dl in longitudinal samples taken at 7 h after the daily sessions began. To understand the impact of alcohol consumption on material properties, various mechanical tests were conducted on the distal tibia diaphysis of 2-5 monkeys per test group, including dynamic mechanical analysis (DMA) testing, nano-indentation, microhardness testing, compression testing, and fracture resistance curve (R-curve) testing. Additionally, compositional analyses were performed using Fourier-transform infrared (FTIR) spectroscopy. Significant differences in microhardness, compressive stress-strain response, and composition were not observed with alcohol consumption, and only minor differences were detected in hardness and elastic modulus of the matrix and osteons from nanoindentation. Furthermore, the R-curves of both groups overlapped, with similar crack initiation toughness, despite a significant decrease in crack growth toughness (p = 0.032) with alcohol consumption. However, storage modulus (p = 0.029) and loss factor (p = 0.015) from DMA testing were significantly increased in the alcohol group compared to the control group, while loss modulus remained unchanged. These results indicate that heavy alcohol consumption may have only a minor influence on the material properties and the composition of cortical bone in young adult male rhesus macaques.

Effect of gamma irradiation and supercritical carbon dioxide sterilization with Novakill™ or ethanol on the fracture toughness of cortical bone.

Sterilization of structural bone allografts is a critical process prior to their clinical use in large cortical bone defects. Gamma irradiation protocols are known to affect tissue integrity in a dose dependent manner. Alternative sterilization treatments, such as supercritical carbon dioxide (SCCO2 ), are gaining popularity due to advantages such as minimal exposure to denaturants, the lack of toxic residues, superior tissue penetration, and minor impacts on mechanical properties including strength and stiffness. The impact of SCCO2 on the fracture toughness of bone tissue, however, remains unknown. Here, we evaluate crack initiation and growth toughness after 2, 6, and 24 h SCCO2 -treatment using Novakill™ and ethanol as additives on ~11 samples per group obtained from a pair of femur diaphyses of a canine. All mechanical testing was performed at ambient air after 24 h soaking in Hanks' balanced salt solution (HBSS). Results show no statistically significant difference in the failure characteristics of the Novakill™-treated groups whereas crack growth toughness after 6 and 24 h of treatment with ethanol significantly increases by 37% (p = .010) and 34% (p = .038), respectively, compared to an untreated control group. In contrast, standard 25 kGy gamma irradiation causes significantly reduced crack growth resistance by 40% (p = .007) compared to untreated bone. FTIR vibrational spectroscopy, conducted after testing, reveals a consistent trend of statistically significant differences (p < .001) with fracture toughness. These trends align with variations in the ratios of enzymatic mature to immature crosslinks in the collagen structure, suggesting a potential association with fracture toughness. Additional Raman spectroscopy after testing shows a similar trend with statistically significant differences (p < .005), which further supports that collagen structural changes occur in the SCF-treated groups with ethanol after 6 and 24 h. Our work reveals the benefits of SCCO2 sterilization compared to gamma irradiation.

Magnetic Nanofibrous Hydrogels for Dynamic Control of Stem Cell Differentiation.

The extracellular matrix in tissue consists of complex heterogeneous soft materials with hierarchical structure and dynamic mechanical properties dictating cell and tissue level function. In many natural matrices, there are nanofibrous structures that serve to guide cell activity and dictate the form and function of tissue. Synthetic hydrogels with integrated nanofibers can mimic the structural properties of native tissue; however, model systems with dynamic mechanical properties remain elusive. Here we demonstrate modular nanofibrous hydrogels that can be reversibly stiffened in response to applied magnetic fields. Iron oxide nanoparticles were incorporated into gelatin nanofibers through electrospinning, followed by chemical stabilization and fragmentation. These magnetoactive nanofibers can be mixed with virtually any hydrogel material and reversibly stiffen the matrix at a low fiber content (≤3%). In contrast to previous work, where a large quantity of magnetic material disallowed cell encapsulation, the low nanofiber content allows matrix stiffening with cells in 3D. Using adipose derived stem cells, we show how nanofibrous matrices are beneficial for both osteogenesis and adipogenesis, where stiffening the hydrogel with applied magnetic fields enhances osteogenesis while discouraging adipogenesis. Skeletal myoblast progenitors were used as a model of tissue morphogenesis with matrix stiffening augmenting myogenesis and multinucleated myotube formation. The ability to reversibly stiffen fibrous hydrogels through magnetic stimulation provides a useful tool for studying nanotopography and dynamic mechanics in cell culture, with a scope for stimuli responsive materials for tissue engineering.

EDP2PDF: a computer program for extracting a pair distribution function from an electron diffraction pattern for the structural analysis of materials.

Pair distribution function (PDF) analysis is a powerful technique to understand atomic scale structure in materials science. Unlike X-ray diffraction (XRD)-based PDF analysis, the PDF calculated from electron diffraction patterns (EDPs) using transmission electron microscopy can provide structural information from specific locations with high spatial resolution. The present work describes a new software tool for both periodic and amorphous structures that addresses several practical challenges in calculating the PDF from EDPs. The key features of this program include accurate background subtraction using a nonlinear iterative peak-clipping algorithm and automatic conversion of various types of diffraction intensity profiles into a PDF without requiring external software. The present study also evaluates the effect of background subtraction and the elliptical distortion of EDPs on PDF profiles. The EDP2PDF software is offered as a reliable tool to analyse the atomic structure of crystalline and non-crystalline materials.

Defect Engineering of a High-Entropy Metallic Glass Surface for High-Performance Overall Water Splitting at Ampere-Level Current Densities.

Platinum-based electrocatalysts possess high water electrolysis activity and are essential components for hydrogen evolution reaction (HER). A major challenge, however, is how to break the cost-efficiency trade-off. Here, a novel defect engineering strategy is presented to construct a nanoporous (FeCoNiB0.75 )97 Pt3 (atomic %) high-entropy metallic glass (HEMG) with a nanocrystalline surface structure that contains large amounts of lattice distortion and stacking faults to achieve excellent electrocatalytic performance using only 3 at% of Pt. The defect-rich HEMG achieves ultralow overpotentials at ampere-level current density of 1000 mA cm-2 for HER (104 mV) and oxygen evolution reaction (301 mV) under alkaline conditions, while retains a long-term durability exceeding 200 h at 100 mA cm-2 . Moreover, it only requires 81 and 122 mV to drive the current densities of 1000 and 100 mA cm-2 for HER under acidic and neutral conditions, respectively. Modelling results reveal that lattice distortion and stacking fault defects help to optimize atomic configuration and modulate electronic interaction, while the surface nanoporous architecture provides abundant active sites, thus synergistically contributing to the reduced energy barrier for water electrolysis. This defect engineering approach combined with a HEMG design strategy is expected to be widely applicable for development of high-performance alloy catalysts.

Synthesis of Submicrometric Chitosan Particles Loaded with Calcium Phosphate for Biomedical Applications.

Chitosan particles loaded with dibasic calcium phosphate anhydrous (DCPA) is a promising strategy for combining antimicrobial and osteoconduction properties in regenerative medicine. However, mostly micrometer-sized particles have been reported in the literature, limiting their use and reducing their effect in the biomedical field. We have recently overcome this limitation by developing submicrometer-sized particles with electrospray technique. The objective of this study was to understand how the process parameters control the size and properties of submicrometer chitosan particles loaded with DCPA. Solutions of 10 mg/mL chitosan and 2.5 mg/mL DCPA in a 90% acetic acid were electrosprayed under three distinct flow rate conditions: 0.2, 0.5, and 1.0 mL/h. The particles were crosslinked in a glutaraldehyde atmosphere and characterized in terms of their morphology, inorganic content, zeta potential, and minimum inhibitory concentration (MIC) against S. mutans. All conditions showed particles with two similar morphologies: one small-sized with a spherical shape and another larger-sized with a bi-concave shape. All generated a broad particle size distribution, with a similar mean size of ~ 235 nm. The addition of DCPA decreased the zeta potential for all the samples, but it was above 30 mV, indicating a low aggregation potential. The lower flow rate showed the worst efficacy for DCPA incorporation. Antimicrobial activity was greater in chitosan/DCPA particles with flow rate of 0.5 mL/h. It can be concluded that the flow rate of 0.5 mL/h presents the best compromise solution in terms of morphology, zeta potential, MIC, and inorganic content.

Fatigue and wear of human tooth enamel: A review.

Human tooth enamel must withstand the cyclic contact forces, wear, and corrosion processes involved with typical oral functions. Furthermore, unlike other human tissues, dental enamel does not have a significant capacity for healing or self-repair and thus the longevity of natural teeth in the oral environment depends to a large degree on the fatigue and wear properties of enamel. The purpose of this review is to provide an overview of our understanding of the fatigue and wear mechanisms of human enamel and how they relate to in vivo observations of tooth damage in the complex oral environment. A key finding of this review is that fatigue and wear processes are closely related. For example, the presence of abrasive wear particles significantly lowers the forces needed to initiate contact fatigue cracking while subsurface fatigue crack propagation drives key delamination wear mechanisms during attrition or attrition-corrosion of enamel. Furthermore, this review seeks to bring a materials science and mechanical engineering perspective to fatigue and wear phenomena. In this regard, we see developing a mechanistic description of fatigue and wear, and understanding the interconnectivity of the processes, as essential for successfully modelling enamel fatigue and wear damage and developing strategies and treatments to improve the longevity of our natural teeth. Furthermore, we anticipate that this review will stimulate ideas for extending the lifetime of the natural tooth structure and will help highlight where our understanding is too limited and where additional research into fatigue and wear of human tooth enamel is warranted.

Impact of test environment on the fracture resistance of cortical bone.

Water is a crucial component of bone, affecting the interplay of collagen and minerals and contributing to bone's high strength and ductility. Dehydration has been shown to significantly effect osseous mechanical properties; however, studies comparing the effects of various dehydrating environments on fracture toughness of bone are scarce. Accordingly, the crack resistance curve (R-curve) behavior of human and sheep cortical bone was characterized in a bio-bath, in ambient pressure air, and in scanning electron microscopes (SEMs) under three different environmental conditions (water vapor pressure, air pressure, and high-vacuum). The aim of this work was to better understand the impact of test environment on both intrinsic and extrinsic toughening and hence crack initiation toughness, K0 and crack growth resistance, dK/dΔa. Results show significantly lower K0 values for samples that were tested inside SEMs combined with pronounced extrinsic toughening through microcracking and crack path deflections out of the mode I plane. Importantly, all three SEM test environments gave similar results, and thus it does not matter which type of SEM is used. Ex situ testing of hydrated samples revealed similar K0 for both environments but elevated crack growth resistance for testing in ambient air relative to the bio-bath. Our data reveals the experimental difficulties to directly observe microscale crack propagation in cortical bone that resembles the in vivo situation. Ex situ testing immersed in Hanks' Balanced Salt Solution (HBSS) with subsequent crack path analysis, while tedious, is thought to presents the most realistic picture of the in vivo structure-fracture property relations in biological tissue.

Structural aspects controlling the mechanical and biological properties of tough, double network hydrogels.

Anticipating an increasing demand for hybrid double network (DN) hydrogels in biomedicine and biotechnology, this study evaluated the effects of each network on the mechanical and biological properties. Polyethylene glycol (PEG) (meth)acrylate hydrogels with varied monomer molecular weights and architectures (linear vs. 4-arm) were produced with and without an added ionically bonded alginate network and their mechanical properties were characterized using compression testing. The results showed that while some mechanical properties of PEG single network (SN) hydrogels decreased or changed negligibly with increasing molecular weight, the compressive modulus, strength, strain to failure, and toughness of DN hydrogels all significantly increased with increased PEG monomer molecular weight. At a fixed molecular weight (10 kDa), 4-arm PEG SN hydrogels exhibited better overall mechanical performance; however, this benefit was diminished for the corresponding DN hydrogels with comparable strength and toughness and lower strain to failure for the 4-arm case. Regardless of the PEG monomer structure, the alginate network made a relatively larger contribution to the overall DN mechanical properties when the covalent PEG network was looser with a larger mesh size (e.g., for larger monomer molecular weight and/or linear architecture) which presumably enabled more ionic crosslinking. Considering the biological performance, adipose derived stem cell cultures demonstrated monotonically increasing cell area and Yes-associated protein related mechanosensing with increasing amounts of alginate from 0 to 2 wt.%, demonstrating the possibility for using DN hydrogels in guiding musculoskeletal differentiation. These findings will be useful to design suitable hydrogels with controllable mechanical and biological properties for mechanically demanding applications. STATEMENT OF SIGNIFICANCE: Hydrogels are widely used in commercial applications, and recently developed hybrid double network hydrogels have enhanced strength and toughness that will enable further expansion into more mechanically demanding applications (e.g., medical implants, etc.). The significance of this work is that it uncovers some key principles regarding monomer molecular weight, architecture, and concentration for developing strong and tough hybrid double network hydrogels that would not be predicted from their single network counterparts or a linear combination of the two networks. Additionally, novel insight is given into the biological performance of hybrid double network hydrogels in the presence of adipose derived stem cell cultures which suggests new scope for using double network hydrogels in guiding musculoskeletal differentiation.

Enhanced perfusion of elliptical wound closures using a novel adhesive suture retention device.

BACKGROUND AND AIMS: The purpose of this investigation was to test the hypothesis that a novel adhesive retention suture device (ARSD) can increase perfusion at elliptical wound closures by distributing stress away from the suture site. METHODS: Stress in the skin around a suture both with and without support from an ARSD was evaluated using a finite element model. A single-center, randomized split-scar comparison trial using laser speckle contrast analysis was used to quantify the perfusion at elliptical wound closures in human patients both with and without an ARSD. RESULTS: The finite element model revealed that the ARSD promoted load transfer to the skin over a larger area, thus reducing the local stress and deformation in the skin around the suture site. Results from the split-scar study showed a mean improvement of 25% perfusion units with the ARSD, and the improvement was statistically significant (p = 0.002). CONCLUSION: The reduction in local stress and enhanced perfusion around the suture site reveals the potential benefit of using an ARSD to enable more efficient healing by avoiding complications associated with both low perfusion and skin tearing, such as dehiscence, infection, and cheese wiring.

Fiber reinforcement of a resin modified glass ionomer cement.

OBJECTIVES: Understand how discontinuous short glass fibers and braided long fibers can be effectively used to reinforce a resin modified glass ionomer cement (RMGIC) for carious lesion restorations. METHODS: Two control groups (powder/liquid kit and capsule) were prepared from a light cured RMGIC. Either discontinuous short glass fibers or braided polyethylene fiber ribbons were used as a reinforcement both with and without pre-impregnation with resin. For the former case, the matrix was the powder/liquid kit RMGIC, and for the latter case the matrix was the capsule form. Flexural strength was evaluated by three-point beam bending and fracture toughness was evaluated by the single-edge V-notch beam method. Compressive strength tests were performed on cylindrical samples. Results were compared by analysis of variances and Tukey's post-hoc test. Flexural strength data were analyzed using Weibull statistical analysis. RESULTS: The short fiber reinforced RMGIC both with and without pre-impregnation showed a significant increase of ∼50% in the mean flexural strength and 160-220% higher fracture toughness compared with the powder/liquid RMGIC control. Reinforcement with continuous braided fibers gave more than a 150% increase in flexural strength, and pre-impregnation of the braided fibers with resin resulted in a significant flexural strength increase of more than 300% relative to the capsule control. However, for the short fiber reinforced RMGIC there was no significant benefit of resin pre-impregnation of the fibers. The Weibull modulus for the flexural strength approximately doubled for the fiber reinforced groups compared to the control groups. Finally, compressive strength was similar for all the groups tested. SIGNIFICANCE: By using a RMGIC as a matrix, higher flexural strength was achieved compared to reported values for short fiber reinforced GICs. Additionally, the short fibers provided effective toughening of the RMGIC matrix by a fiber bridging mechanism. Finally, continuous braided polyethylene fibers gave much higher flexural strength than discontinuous glass fibers, and their effectiveness was enhanced by pre-impregnation of the fibers with resin.

Anisotropic fracture resistance of avian eggshell.

In order to understand the fracture toughness anisotropy of avian eggshells, we have investigated eggshells of the emu (Dromaius novaehollandiae) whereby the large size (~13 cm × 9.5 cm) enabled the fabrication of beam samples in various orientations. The emu eggshell was found to have a hierarchical microstructure similar to chicken eggshell, with the only significant difference being the absence of a continuous cuticle layer. Emu eggshell was found to have significantly lower strength when samples were tested in the outwards direction (i.e., a crack initiates on the inside of the shell and propagates towards the outer surface) as compared to the inwards testing direction. Furthermore, samples that were oriented parallel to the egg axis (i.e., the longitudinal direction) and tested inwards showed higher strength, ~24 MPa, compared to the samples that were made from the latitudinal orientation, ~20 MPa. Independent of orientation, the outwards testing direction resulted in strength values of ~15 MPa. The fracture toughness of the emu eggshell for cracking in the circumferential direction was ~0.3 MPa√m, independent of sample orientation, and this value was comparable to the fracture toughness of chicken eggshell tested in the same orientation. In the radial outwards direction, however, the fracture toughness was ~80% lower (~0.06 MPa√m) than in the circumferential direction. The low fracture toughness for this orientation was associated with the separation of the highly oriented calcite crystals in the mammillary cone layer of the eggshell structure which is easier compared to calcite crystal fracture. The large anisotropy in fracture toughness is thought to allow for easy escape of the chick while simultaneously protecting the embryo during development.

Role of Boron in Enhancing Electron Delocalization to Improve Catalytic Activity of Fe-Based Metallic Glasses for Persulfate-Based Advanced Oxidation.

Metallic glasses (MGs) with superior catalytic performance have recently been recognized as attractive candidates for wastewater treatment. However, further improving their performance will require knowledge of how to precisely regulate their electronic structures via compositional control. Here, two Fe-based MGs (Fe78Si9B13 and Fe80Si9B11) were prepared to compare how slightly altering boron content affected their electronic structure and catalytic performance. Density functional theory revealed that the Fe78Si9B13 MG with 2 atom % higher boron exhibits an attractive electron delocalization, a high persulfate adsorption energy, and a superb work function due to precise regulation of the electronic structure, leading to exceptional degradation performance for seven organic pollutants. Furthermore, it can be reused 23 times without significant deterioration of catalytic performance, amorphous structure, and surface morphology. This work provides a new paradigm for the fundamental theory explaining how electronic structure is controlled by composition, creating a solid foundation to explore novel catalysts for water treatment.

A Novel Multinary Intermetallic as an Active Electrocatalyst for Hydrogen Evolution.

Electrochemical water splitting offers an attractive approach for hydrogen production. However, the lack of high-performance cost-effective electrocatalyst severely hinders its applications. Here, a multinary high-entropy intermetallic (HEI) that possesses an unusual periodically ordered structure containing multiple non-noble elements is reported, which can serve as a highly efficient electrocatalyst for hydrogen evolution. This HEI exhibits excellent activities in alkalinity with an overpotential of 88.2 mV at a current density of 10 mA cm-2 and a Tafel slope of 40.1 mV dec-1 , which are comparable to those of noble catalysts. Theoretical calculations reveal that the chemical complexity and surprising atomic configurations provide a strong synergistic function to alter the electronic structure. Furthermore, the unique L12 -type ordered structure enables a specific site-isolation effect to further stabilize the H2 O/H* adsorption/desorption, which dramatically optimizes the energy barrier of hydrogen evolution. Such an HEI strategy uncovers a new paradigm to develop novel electrocatalyst with superior reaction activities.

Development of novel dental restorative composites with dibasic calcium phosphate loaded chitosan fillers.

The incorporation of antimicrobial agents in restorative dental composites has the potential to slow the development of carious lesions. OBJECTIVE: The objectives of the present study were to develop experimental composite resins with chitosan or chitosan loaded with dibasic calcium phosphate anhydrous (DCPA) particles and to demonstrate their antimicrobial potential without loss of mechanical properties or biocompatibility. METHODS: Chitosan and chitosan/DCPA particles were synthetized by the electrospray method. Experimental composites were formulated by adding 0, 0.5, or 1.0 wt% particles into a resin matrix along with 60 wt% barium glass. The degree of conversion and mechanical properties were measured after 1 and 90 days of aging in water after photoactivation. Cytotoxicity and genotoxicity were evaluated using fibroblasts from dental pulp in conditioned medium. The antimicrobial activity against Streptococcus mutans was assessed by crystal violet biofilm assay. RESULTS: The experimental restorative composites were not found to be cytotoxic or genotoxic, with cell viability of 93.1 ± 8.0% (p = 0.328) and 3.0 ± 0.8% micronucleus per group (p = 0.1078), respectively. The antimicrobial results showed that all composites with approximately 20% less biofilm (p < 0.001) relative to the control. No chitosan release was detected from the composites, suggesting direct contact of the bacteria with exposed chitosan particles on the surface was responsible for the observed antimicrobial effect. The addition of the chitosan and chitosan/DCPA submicrometer (<250 nm average diameter) particles to restorative composites did not change the degree of conversion, flexural strength, elastic modulus and fracture toughness compared to the control group after 90 days aging in water. SIGNIFICANCE: It can be concluded that the addition of chitosan or chitosan/DCPA particles in the restorative composites induced antimicrobial activity without compromising the mechanical properties or biocompatibility of the composites.

A diet high in fat and fructose adversely affects osseointegration of titanium implants in rats.

OBJECTIVES: Diet-induced metabolic dysfunction such as type 2 diabetes mellitus increases the risk of implant failure in both dental and orthopaedic settings. We hypothesised that a diet high in fat and fructose would adversely affect peri-implant bone structure and function including osseointegration. MATERIALS AND METHODS: Thirty female Sprague-Dawley rats were divided into three groups (n = 10), control group (normal chow) and two intervention groups on a high-fat (60%), high-fructose (20%; HFHF) diet. Titanium implants were placed in the proximal tibial metaphysis in all groups either before commencing the diet (dHFHF group) or 6 weeks after commencing the diet (HFHF group) and observed for an 8-week healing period. Fasting blood glucose levels (fBGLs) were measured weekly. Structural and functional features of the peri-implant bone, including bone-to-implant contact (BIC), were analysed post euthanasia using microcomputed tomography, pull-out tests, and dynamic histomorphometry. RESULTS: The fBGLs were unchanged across all groups. Peri-implant trabecular bone volume was reduced in the HFHF group compared with controls (p = .02). Percentage BIC was reduced in both HFHF group (25.42 ± 3.61) and dHFHF group (28.56 ± 4.07) compared with the control group (43.26 ± 3.58, p < .05) and reflected the lower pull-out loads required in those groups. Osteoblast activity was reduced in both intervention groups compared with the control group (p < .05). CONCLUSION: The HFHF diet compromised osseointegration regardless of whether the implant was placed before or after the onset of the diet and, despite the absence of elevated fBGLs, confirming that changes in bone cell function affected both the initiation and maintenance of osseointegration independent of blood glucose levels.

Forces on sutures when closing excisional wounds using the rule of halves.

BACKGROUND: To close elliptical excisions, surgeons commonly use the rule of halves which involves initially closing of the middle portion of the wound, followed by closure of the remaining halves. Understanding the forces required for suturing such wounds can aid excisional surgery planning to decrease complications and improve wound healing. METHODS: Following full thickness excision for removal of skin cancers, back wounds with 3:1 ratio of length-to-width were closed using the rule of halves. The force required to bring the wound edges into contact at the middle portion of the wound was measured, followed by the two bisected halves. FINDINGS: The average force to close the center of the wounds averaged 3.7 N and was six times larger than that of the bisected halves. The forces to close the bisected halves were consistently small, and essentially negligible (<0.5 N) for ~50% of the cases. INTERPRETATION: When planning excisional surgery to avoid complications such as tearing the dermis (cheese wiring), the use of special wound closure techniques (high tension and/or pully sutures, skin support or suture retention devices, etc.) should focus on the center suture only when using the rule of halves, as the remaining sutures require very low forces.