Prosthetic Replacement of the Ocular Surface Ecosystem for Terrien Marginal Degeneration: A Case Series.

OBJECTIVES: To assess outcomes of the Prosthetic Replacement of the Ocular Surface Ecosystem (PROSE) treatment in patients with advanced Terrien marginal degeneration (TMD). METHODS: This is a retrospective case series of patients with advanced TMD who were assessed and fit with customized PROSE lenses. Data were collected on PROSE fitting details including visual acuity (VA) before and after PROSE, slit-lamp findings, and corneal tomography scans. RESULTS: Six eyes in four patients were included. All patients attempted at least one other contact lens (CL) modality before PROSE. Some patients had corneal comorbidities such as pseudopterygium and pseudobleb that contributed to intolerance to previous lenses and warranted extra considerations in the fitting process. With PROSE, VA improved in all six eyes. Patients with structural corneal comorbidities achieved improved vision, comfort, and lens tolerance with PROSE. Two eyes had noncorneal ocular comorbidities that limited PROSE efficacy. Another eye discontinued PROSE wear because of limbal stem-cell disease progression necessitating a limbal stem-cell transplant. CONCLUSIONS: PROSE treatment can be an effective option to improve vision and comfort for patients with advanced TMD who are intolerant to first-line therapeutic CL modalities, even in the presence of other corneal comorbidities.

Echocardiography-guided Cardiac Implantable Electronic Device Implantation to Reduce Device Related Tricuspid Regurgitation: A Prospective Controlled Study.

BACKGROUND: Endocardial leads of permanent pacemakers (PPM) and implantable defibrillators (ICD) across the tricuspid valve (TV) can lead to tricuspid regurgitation (TR) or can worsen existing TR with subsequent severe morbidity and mortality. OBJECTIVES: To evaluate prospectively the efficacy of intraprocedural 2-dimentional-transthoracic echocardiography (2DTTE) in reducing/preventing lead-associated TR. METHODS: We conducted a prospective randomized controlled study comparing echocardiographic results in patients undergoing de-novo PPM/ICD implantation with intraprocedural echo-guided right ventricular (RV) lead placement (Group 1, n=56) versus non-echo guided implantation (Group 2, n=55). Lead position was changed if TR grade was more than baseline in Group 1. Cohort patients underwent 2DTTE at baseline and 3 and/or 6 months after implantation. Excluded were patients with baseline TR > moderate or baseline ≥ moderate RV dysfunction. RESULTS: The study comprised 111 patients (74.14 ± 11 years of age, 58.6% male, 19% ICD, 42% active leads). In 98 patients there was at least one follow-up echo. Two patients from Group 1 (3.6%) needed intraprocedural RV electrode repositioning. Four patients (3.5%, 2 from each group, all dual chamber PPM, 3 atrial fibrillation, 2 RV pacing > 40%, none with intraprocedural reposition) had TR deterioration during 6 months follow-up. One patient from Group 2 with baseline mild-moderate aortic regurgitation (AR) had worsening TR and AR within 3 months and underwent aortic valve replacement and TV repair. CONCLUSIONS: The rate of mechanically induced lead-associated TR is low; thus, a routine intraprocedural 2DTTE does not have a significant role in reducing/preventing it.

Scanning Electron Microscopic Assessment of Stent Coating Integrity in Jailed Wire Technique for Bifurcation Treatment.

OBJECTIVES: To assess the impact of different guidewires on stent coating integrity in jailed wire technique (JWT) for bifurcation treatment. BACKGROUND: JWT is commonly adopted to protect side branch in provisional one-stent strategy for coronary bifurcation lesions. However, this technique may cause defects in stent coatings. The degree of coating damage caused by different types of jailed wires remains unknown. METHODS: A fluid model with a bifurcation was established to mimic the condition in vivo. One-stent strategy was performed with three types of guidewire (nonpolymer-jacketed wire, intermediate polymer-jacketed wire, and full polymer-jacketed wire) tested for JWT. Scanning electron microscopy (SEM) was used to evaluate stent coating integrity and wire structure. The degrees of coating defects were recorded as no, slight, moderate, and severe defects. RESULTS: A total of 27 samples were tested. Analyses of SEM images showed a significant difference in the degree of coating damage among the three types of wire after the procedure of JWT (P < 0.001). Nonpolymer-jacketed wire could inevitably cause a severe defect in stent coatings, while full polymer-jacketed wire caused the least coating damages. Besides, there were varying degrees of coil deformation in nonpolymer-jacketed wires, while no surface damage or jacket shearing was observed in full polymer-jacketed wires. CONCLUSIONS: Although nonpolymer-jacketed wire has long been recommended for JWT, our bench-side study suggests that full polymer-jacketed wire may be a better choice. Further clinical studies are needed to confirm our findings.

Western-designed total knee implants mismatch Saudi patient knees. Anatomical bony measurements documented by computed tomography.

OBJECTIVES: To determine the anthropometric features of Saudi knees compared with knees of other ethnicities and reveal mismatches among different knee implant systems. METHODS: All knee computed tomography images obtained between January 2016 and September 2016 for varying medical reasons in a tertiary care hospital in Southwestern Saudi Arabia were retrospectively evaluated. Patients aged less than 18 years, with trauma or soft tissue or bone tumors were excluded.  Eleven parameters were measured for each knee joint. RESULTS: We evaluated 100 knees of 50 Saudi patients (25 men, 25 women) aged 28-85 (mean, 57.3) years. No statistically significant differences were found in age and Sasaki angle measurements between male and female patients. All other parameters were significantly larger in male than female knees. Our measurements were close to those published for Chinese, Thai, and Korean patients; however, published measurements were larger for Caucasian and Indian knees than our measurements. CONCLUSION: The Saudi population has morphological features of knee bone anatomy that do not match with the widely available prostheses designed for Caucasian knees. As several studies of different ethnicities have documented considerable prosthesis mismatch; our study further indicates the need for new implant designs that take these variations into account.

2020 Otto Aufranc Award: Malseating of modular dual mobility liners.

AIMS: This combined clinical and in vitro study aimed to determine the incidence of liner malseating in modular dual mobility (MDM) constructs in primary total hip arthroplasties (THAs) from a large volume arthroplasty centre, and determine whether malseating increases the potential for fretting and corrosion at the modular metal interface in malseated MDM constructs using a simulated corrosion chamber. METHODS: For the clinical arm of the study, observers independently reviewed postoperative radiographs of 551 primary THAs using MDM constructs from a single manufacturer over a three-year period, to identify the incidence of MDM liner-shell malseating. Multivariable logistic regression analysis was performed to identify risk factors including age, sex, body mass index (BMI), cup design, cup size, and the MDM case volume of the surgeon. For the in vitro arm, six pristine MDM implants with cobalt-chrome liners were tested in a simulated corrosion chamber. Three were well-seated and three were malseated with 6° of canting. The liner-shell couples underwent cyclic loading of increasing magnitudes. Fretting current was measured throughout testing and the onset of fretting load was determined by analyzing the increase in average current. RESULTS: The radiological review identified that 32 of 551 MDM liners (5.8%) were malseated. Malseating was noted in all of the three different cup designs. The incidence of malseating was significantly higher in low-volume MDM surgeons than high-volume MDM surgeons (p < 0.001). Pristine well-seated liners showed significantly lower fretting current values at all peak loads greater than 800 N (p < 0.044). Malseated liner-shell couples had lower fretting onset loads at 2,400 N. CONCLUSION: MDM malseating remains an issue that can occur in at least one in 20 patients at a high-volume arthroplasty centre. The onset of fretting and increased fretting current throughout loading cycles suggests susceptibility to corrosion when this occurs. These results support the hypothesis that malseated liners may be at risk for fretting corrosion. Clinicians should be aware of this phenomenon. Cite this article: Bone Joint J 2020;102-B(7 Supple B):20-26.

Role of positioning of femoral component in the anterior-posterior direction on postoperative anterior pain in TKA.

INTRODUCTION AND PURPOSE: The patellofemoral joint has proved to be the most problematic element of modern TKA for postoperative anterior knee pain; the positioning of the femoral component constitutes a critical phase in this issue. The objective of our study was to evaluate the possible role of either anterior positioning or posterior positioning of the femoral shield compared to the reference plane represented by the anterior cortex, on the anterior knee pain after knee arthroplasty. METHODS: Forty-eight patients treated with TKA were followed up approximately 12 months. None of them have been submitted to any patellar treatment. We observed the position of femoral shield with respect to the anterior cortical line of femur dividing patients into three groups: patients with significant notching, patients with no notching (shield corresponding to anterior cortical line) and patients with anterior positioning of shield. We evaluated clinical and functional outcomes with KSS, anterior knee pain with Kujala's score and adverse events such as periprosthetic fractures. RESULTS: We found a better clinical and functional result for patients with femoral shield positioned in line with anterior cortical cortex with respect to both TKAs with femoral notching and to protruding anterior femoral components; there were no main differences in anterior postoperative score by Kujala's system. We observed a periprosthetic fracture in a patient with an important femoral notching. CONCLUSIONS: We cannot consider our study as an objective conclusion to the argument. We need more RCTs in order to study the proper influence of either notching or protrusion of femoral shield component onto anterior postoperative pain. Anyway positioning of femoral shield in anterior-posterior direction could be an interesting new critical object of study about anterior knee pain after TKA.

Fassier-Duval Rod Failure: Is It Related to Positioning in the Distal Epiphysis?

BACKGROUND: The relationship between Fassier-Duval (FD) rod placement and rod failure rates has not previously been quantified. METHODS: Retrospective review was conducted on patients with osteogenesis imperfecta treated with FD rods between 2005 and 2017. Age at first surgery, sex, Sillence type of osteogenesis imperfecta, bisphosphonate treatment, location of rod (side of body and specific bone), and dates of surgeries, radiographs, and rod failures were collected. C-arm images determined rod fixation within the distal epiphysis at the time of surgery. C-arm variables included rod deviation (percent deviation from the midline of the distal epiphysis) and anatomical direction of deviation (anterior/posterior and medial/lateral). X-ray images were examined for rod failure, which was defined as bending, pulling out of the physis, protrusion out of the bone, and/or failure to telescope. Cox proportional hazards regression models were used to compare failure rates with location of placement within the distal epiphysis allowing for clustering of the data by side (left or right) and bone (femur or tibia). RESULTS: The cohort was 13 patients (11 female individuals and 2 male individuals) with a total of 66 rods and 75 surgeries. Mean time from the first surgery to the last follow-up visit was 8.9 years (SD=5 y). There was a 7% increase in hazard of failure per 1-mm increase in antero-posterior (AP) deviation [hazard ratio (HR), 1.07; 95% confidence interval (CI), 1.01-1.14; P=0.029)]. Similarly, there was a 9% increase in hazard of failure for every 1-mm increase in lateral deviation (HR, 1.09; 95% CI, 1.01-1.18; P=0.019). A 12% increase in hazard of failure per 10% increase in deviation from the midline for both AP and lateral radiograph views was also found, although this was only statistically significant for lateral deviation on the AP radiograph view (HR, 1.12; 95% CI, 1.01-1.25; P=0.030). CONCLUSIONS: FD rod placement within the distal epiphysis has significant impact on increasing rod survival. LEVEL OF EVIDENCE: Level III-therapeutic study.

Effect of temperature-control liner materials on long-term outcomes of lower limb prosthesis use: a randomized controlled trial protocol.

BACKGROUND: In people living with limb loss, addressing the resulting functional deficit with prostheses increases the risk for secondary conditions such as pressure sores, impaired blood perfusion, and injuries from accidental falls. Any of those occurrences can render the prosthesis temporarily useless, making it challenging for users to engage in many activities of daily life, including work, exercise, and social participation. Many of the described issues originate at the interface between residual limb and prosthetic socket, where the objectives of sufficient weight distribution and suspension are conflicting with the necessity to facilitate heat exchange and limit contact pressure and friction. Recently, prosthesis liners that contain phase-change material have become commercially available, holding the promise that the micro climate at the interface between the residual limb skin and the prosthetic socket can be regulated to reduce the users' tendency to sweat. Preliminary studies on these liners indicate that the socket temperatures inside the socket stayed lower and rose slower than in conventional liners. However, the clinical relevance of those findings remains unclear. The purpose of this study is to investigate whether longer (6+ months) periods of use of phase-change material based temperature-control liners have clinically meaningful effects. METHODS: The protocol is a double-blind longitudinal cross-over research design. A sample of trans-tibial prosthesis users are wearing their regular gel or silicone liners for six months and phase-change material liners for another six months in a randomized sequence. Their prostheses is equipped with activity monitors to detect days when they could not wear their prosthesis. In six-week intervals, individuals' activity, physical performance, and overall prosthesis assessment is recorded using standardized methods. DISCUSSION: Expected results will inform prescription and reimbursement practice of phase-change material-based prosthesis liners and will help improve and economize prosthetic fitting for people with limb loss. The design and duration of the protocol, including randomization, blinding, and within-subject comparison, will generate scientific evidence of a comparably high level. Inclusion of a comparably large sample and different climates, e.g. across all four seasons, will make findings applicable to a large number of prosthesis users. TRIAL REGISTRATION: Clinicaltrials.gov, NCT03428815. Registered on 12 February 2018.

Severe acute stent malapposition follow-up: 3-month and 12-month serial quantitative analyses by optical coherence tomography.

BACKGROUND: Optical coherence tomography (OCT) was used to assess serial changes in severe acute stent malapposition (ASM) after drug-eluting stent (DES) implantation. METHODS: The maximal depth and axial lengths of ASM after DES implantation were serially quantified at percutaneous coronary intervention (PCI), and at 3 and 12-month follow-up, for 100 lesions in 96 patients. Severe ASM was defined as a maximal malapposed depth ≥400 µm or maximal malapposed axial length ≥1 mm. RESULTS: Of the 100 lesions, 23 lesions (23%) had a severe ASM depth at PCI. At 3 months, the maximal depth decreased to <400 µm in 12 of 23 lesions (52%). At 12 months, the maximal depth further decreased to <400 µm in 8 of the remaining 11 lesions (73%). Similarly, of 53 lesions (53%) with a severe ASM length at PCI, the maximal length decreased to 0 mm in 26 (49%) but remained severe in 17 lesions (32%) at 3 months. At 12 months, 9 of the 17 remaining lesions (53%) further decreased to 0 mm. The cut-off values for the maximal malapposed depth and length to predict the absence of stent malapposition at 12 months were 565 µm at PCI and 165 µm at 3 months, and were 2.7 mm at PCI and 0.1 mm at 3 months, respectively. CONCLUSION: Half of the severe ASM cases resolved within 3 months, and another half resolved during 3-12 months of follow-up. Our findings provide a better understanding of the time-dependent natural course of severe ASM using OCT.

Clinical Approach After Complicated Ear Mold Fitting: A Case Series of Six Patients and Evaluation of Literature.

OBJECTIVES: Insertion of mold material into the middle ear is a complication of molding procedure for ear impression. These cases are referred to an ENT specialist. There is no standardized approach to this problem. Literature shows different clinical strategies. The aim of this study is to share our experience and to analyze the adverse outcome of different clinical approaches. METHODS: A case series of six patients with molding material inside the middle ear after complicated molding procedure for swimming earplugs are described. Additionally, available literature was reviewed to analyze results of the clinical approach after iatrogenic molding procedures. Forty-nine ears were included. RESULTS: In-office removal of the material is associated with a significant risk of adverse outcome if the eardrum cannot be examined. This also accounts for ossicular involvement. CONCLUSIONS: Temporal bone CT is advised in patients after complicated ear mold fitting if the tympanic membrane cannot be examined completely or the middle ear is involved. Blind removal should be avoided. Retroauricular transcanal tympanotomy or transmastoidal tympanotomy with facial recess approach is best practice in case the mold material has entered the middle ear. A clinical treatment algorithm is presented.

Radiological evaluation of inner ear trauma after cochlear implant surgery by cone beam CT(CBCT).

PURPOSE: Cochlear implantation (CI) has been extended to involve younger age group with higher incidence of residual hearing which increases the need of minimizing surgical inner ear trauma. Radiological evaluation for electrode position has been studied yet without assessment of inner ear trauma, our objective is radiological evaluation of post cochlear implantation inner ear trauma MATERIAL AND METHODS: 20 patients with CI for pre lingual SNHL were included in this study. Cone beam CT (CBCT) was used for evaluation of electrode position and assessment of inner ear trauma. A Neuroradiologist and an implant surgeon analyzed the relation of inserted electrode to the intra-cochlear structures, with introduction of novel radiological grading for inner ear trauma. RESULTS: The mean major cochlear diameter was 8.9 mm, the mean angular depth of insertion was 406.9944 (SD = 165.0559). Ten patients were with no cochlear trauma (grade 0), three patients were grade 1, two patients were grade 2 and five patients were grade 3 inner ear trauma. CONCLUSION: Radiological evaluation for electrode position should extend to involve assessment of inner ear trauma using relation of the implant to cochlear internal structures which could be performed by CBCT with high resolution and least metallic artifacts.

Does ultrasound guidance for peripherally inserted central catheter (PICC) insertion reduce the incidence of tip malposition? - a randomized trial.

OBJECTIVE: The aim of the study was to evaluate the incidence of peripheral inserted central catheter (PICC) tip malposition when the catheter is inserted under real-time ultrasound (RTUS) guidance when compared with conventional landmark (CL) technique in neonates. Additional objectives were to evaluate the PICC longevity and central line associated blood stream infections (CLABSI). STUDY DESIGN: In this randomised controlled trial, neonates were randomised to 'RTUS' (n = 40) or 'CL' (n = 40) groups. PICC tip was placed under ultrasound guidance in lower third of superior vena cava in the RTUS group. In 'CL' group, PICC was inserted as calculated by anatomical landmarks. RESULTS: The birth weight (1286 (926, 1662) vs. 1061 (889, 1636) g) and gestation (31.12 (3.1) vs. 31.4 (3.6) wks) were comparable among the groups. RTUS guidance during PICC insertion reduced incidence of tip malposition by 52% (67.5 vs. 32.5%; RR: 0.48; 95% CI: 0.29-0.79). The longevity of PICC and episodes of CLABSI were however similar in the two groups. CONCLUSIONS: Real-time ultrasound guidance during PICC placement reduces the incidence of tip malposition.

Evaluation of salivary cortisol levels in relation to dento-maxillary prosthesis adjustment.

PURPOSE: The purpose of this study was to investigate the influence of dento-maxillary prosthesis adjustment procedure on levels of salivary cortisol. METHODS: Nine participants (six men, three women, mean age 65.9 years) took part in this study. Saliva samples were collected before and after dento-maxillary prosthesis adjustment during the four different visits. Free cortisol levels were determined using a salivary cortisol immunoassay kit (expanded-range high-sensitivity salivary cortisol enzyme immunoassay kit, Salimetrics). Besides, original self-report sheets, a 35-item food intake questionnaire, the University of Washington Quality of Life (UW-QOL) questionnaire version 4, and the Geriatric Oral Health Assessment Index (GOHAI) questionnaire were also administered. The changes of salivary cortisol levels were analyzed using 2-level multilevel linear regression, with adjustment for age, sex, and time. Wilcoxon signed-rank test was used to compare scores of the food intake questionnaire, UW-QOL questionnaire, and GOHAI questionnaire. RESULTS: Salivary cortisol levels decreased significantly after carrying out the dento-maxillary prosthesis adjustment procedure. During the third adjustment, the salivary cortisol levels were significantly low. In addition, salivary cortisol levels of participants aged 70 years and over were significantly higher than other aged groups. The total scores for grade III-V of the food intake questionnaire increased significantly. Other questionnaires had a trend toward increasing scores, yet the differences were not significant. CONCLUSIONS: Within the limitations of this study, the results suggest that a reduction in symptoms of discomfort may have an influence on the decrease of salivary cortisol levels in dento-maxillary prosthesis wearers.

Scleral Lens Issues and Complications Related to a Non-optimal Fitting Relationship Between the Lens and Ocular Surface.

INTRODUCTION: The advent of high oxygen permeability (Dk) of rigid contact lens materials has reduced complications related to hypoxia when using scleral contact lenses (ScCLs). However, new issues and complications have emerged. Some of these issues and complications are caused by the nonoptimal fitting relationship with the underlying ocular surface, which may pose a challenge in their management. METHOD: PubMed searches using different keywords and an investigation into the issues and complications etiology were conducted. Detailed guidelines for their management are provided. RESULTS: The literature provides a few reports of severe adverse reactions to ScCLs. The most common issues, unique to ScCL wear, have been described. Likewise, other anomalies in ScCL fitting may affect patient satisfaction and lead to drop out, promoting eye surgery or dramatic psychological effects. The management of these issues and complications may be also frustrating for clinicians who will, in turn, rarely, or not at all, prescribe them. CONCLUSION: Scleral contact lenses intimidate practitioners because of their large diameter and the lack of knowledge in regard to the fitting process but especially because of the challenging management of issues and complications that may occur relating to the lens fitting relationship with the underlying ocular surface. A detailed description of the etiology and management of these anomalies will allow practitioners to gain more confidence in fitting ScCLs and prescribe them more often. Patients are the primary beneficiaries from wearing these large rigid lenses; ScCLs represent a life-changing event for many patients.

Transient corneal epithelial bullae associated with large diameter scleral lens wear: A case series.

With the increased fitting of scleral lenses by eye care practitioners, complications with lens wear need to be considered. Several prior studies have addressed complications specific to scleral lens wear and the incidence of hypoxia with extended wear, but few report the presence of epithelial bullae. This case series investigates three patients with differing ocular surface diseases, yet all developed transient epithelial bullae with concurrent large diameter scleral lens wear. These bullae appear to form due to weakened connections in the corneal epithelium at the level of basement membrane and Bowman's layer and flatten within minutes of lens removal. These bullae need to be further studied, as they can increase the patient's risk of epithelial defects, infections, and other complications in already compromised corneas.

Mild-moderate congenital hearing loss: secular trends in outcomes across four systems of detection.

BACKGROUND: Universal newborn hearing screening (UNHS) targets moderate or greater hearing loss. However, UNHS also frequently detects children with mild loss that results in many receiving early treatment. The benefits of this approach are not yet established. We aimed to (i) compare language and psychosocial outcomes between four hearing loss detection systems for children aged 5-8 years with congenital mild-moderate hearing loss; (ii) determine whether age of detection predicts outcomes; and (iii) compare outcomes between children identified via well-established UNHS and the general population. METHODS: Linear regression adjusted for potential confounding factors was used throughout. Via a quasi-experimental design, language and psychosocial outcomes were compared across four population-based Australian systems of hearing loss detection: opportunistic detection, born 1991-1993, n = 50; universal risk factor referral, born 2003-2005, n = 34; newly established UNHS, born 2003-2005, n = 41; and well-established UNHS, born 2007-2010, n = 21. In pooled analyses, we examined whether age of detection predicted outcomes. Outcomes were similarly compared between the current well-established UNHS system and typically developing children in the Early Language in Victoria Study, born 2003, n = 1217. RESULTS: Age at diagnosis and hearing aid fitting fell steadily across the four systems. For moderate losses, mean expressive language (P for trend .05) and receptive vocabulary (P for trend .06) improved across the four systems, but benefit was not obvious for mild losses. In pooled analyses, diagnosis before age six months predicted better language outcomes for moderate losses. Children with mild-moderate losses exposed to well-established UNHS continue to experience expressive language scores well below children in the general population (adjusted mean difference -8.9 points, 95% CI -14.7 to -3.1). CONCLUSIONS: Treatment arising from UNHS appears to be clearly benefitting children with moderate hearing losses. However, rigorous trials are needed to quantify benefits, versus costs and potential harms, of early aiding of children with mild losses.

Mitral annuloplasty ring suture forces: Impact of surgeon, ring, and use conditions.

OBJECTIVE: The study objective was to quantify the effect of ring type, ring-annulus sizing, suture position, and surgeon on the forces required to tie down and constrain a mitral annuloplasty ring to a beating heart. METHODS: Physio (Edwards Lifesciences, Irvine, Calif) or Profile 3D (Medtronic, Dublin, Ireland) annuloplasty rings were instrumented with suture force transducers and implanted in ovine subjects (N = 23). Tie-down forces and cyclic contractile forces were recorded and analyzed at 10 suture positions and at 3 levels of increasing peak left ventricular pressure. RESULTS: Across all conditions, tie-down force was 2.7 ± 1.4 N and cyclic contractile force was 2.0 ± 1.2 N. Tie-down force was not meaningfully affected by any factor except surgeon. Significant differences in overall and individual tie-down forces were observed between the 2 primary implanting surgeons. No other factors were observed to significantly affect tie-down force. Contractile suture forces were significantly reduced by ring-annulus true sizing. This was driven almost exclusively by Physio cases and by reduction along the anterior aspect, where dehiscence is less common clinically. Contractile suture forces did not differ significantly between ring types. However, when undersizing, Profile 3D forces were significantly more uniform around the annular circumference. A suture's tie-down force did not correlate to its eventual contractile force. CONCLUSIONS: Mitral annuloplasty suture loading is influenced by ring type, ring-annulus sizing, suture position, and surgeon, suggesting that reports of dehiscence may not be merely a series of isolated errors. When compared with forces known to cause suture dehiscence, these in vivo suture loading data aid in establishing potential targets for reducing the occurrence of ring dehiscence.