However, it is unknown if the observed relationship between mechanical properties with static balance parameters generalise to dynamic balance. Thus, we determined the relationship between static and dynamic balance parameters with muscle mechanical properties of the ankle plantar flexors [lateral gastrocnemius (GL)] and knee extensors [vastus lateralis (VL)] in vivo. Twenty-six participants  were assessed for static balance [centre of pressure (COP) movements during quiet standing], dynamic balance  and mechanical properties (stiffness and tone) of the GL and VL measured in the standing and lying position. Significant (p < .05) small to moderate inverse correlations were observed between the mean COP velocity during quiet standing with stiffness  and tone  of the GL and VL (lying and standing). Tone and stiffness explained 16%–33% of the variance in the mean COP velocity. Stiffness and tone of the VL measured in the lying (supine) condition were also inversely significantly correlated with Y balance test performance . These findings highlight that individuals with low muscle stiffness and tone exhibit faster COP movements during quiet standing, indicative of reduced postural control but also reveal that low VL stiffness and tone are associated with greater reach distances in a lower extremity reaching task, indicative of greater neuromuscular performance.There is emerging evidence that mechanical properties of  It is firmly established that a considerable proportion of postural sway is controlled at the ankle joint during static balance conditions  , with anin vivo, including shear wave elastography, tensiomyography and myotonometry, each with their own advantages and disadvantages. Myotonometry has proven a promising technique that provides a reliable assessment of stiffness in postural muscles . Twenty-six healthy young adults  volunteered to take part in the study. All participants self-reported as being recreationally active (IPAQ = 2.2 ± 1.8 h wk-1) and completed a health screening questionnaire to assess eligibility for the study and were free from any musculoskeletal injury or history of injury in the previous 6 months. Prior to data collection, the study received approval by the institutional ethics committee  with participants were providing written, informed consent and the experimental procedures were carried out in accordance with the Declaration of Helsinki (1964).Previous studies have reported large magnitude associations between mechanical properties and postural sway parameters . Power a-1)  and non-neural tension or tone  . Test-retest reliability revealed ‘excellent’ ICC-values for the VL in the standing  and lying  condition. For the GL, we also obtained ‘excellent’ ICC-values in the standing  and lying  condition.Muscle mechanical properties of the GL and VL were measured using a hand-held myotonometer . Participants were asked to rest for 10 minutes before assessment with all measurements taken on the dominant side , under two conditions: 1) lying on an assessment table in a prone (for GL) and supine (for VL) position with the feet hanging off the table at an ankle angle of 90°, and 2) standing quietly with the feet together. The lying and standing positions were employed to represent relaxed and semi-contracted states, respectively. The lying position examination was always performed first. Measurement regions were marked by the same experienced examiner to eliminate inter-tester variability. The measurement sites were standardised for all participants and established according to previous studies; VL was measured at 50% of the straight-line distance between the greater trochanter and fibulae capitulum  and the -1) were subsequently calculated . The AP and ML ranges express the distance between the most distal points of the COP displacement in the frontal (ML) and sagittal (AP) planes, whilst the mean COP velocity is obtained by dividing the total distance travelled  by the sampling duration  with the eyes open. Participants were unshod with the hands clasped together in front of the body and with the feet together . During duration . An averduration .Two minutes following the assessment of static balance, participants completed the dynamic balance assessment using the Y Balance Test Kit™. While maintaining a single-leg stance with the dominant limb, participants were asked to push a reach indicator along a pipe with the contralateral limb  in a randomised order in the anterior (ANT), posteromedial (PM), and posterolateral (PL) reach directions. Participants were instructed to place the arms akimbo to remove the potential effects of arm movements on postural control . The tesr = .10 to .35), moderate (r = .36 to .67), or strong (r = .68 to 1.00) .Data were analysed using SPSS version 26.0  and are presented as mean ± standard deviation (SD) and range. After normal distribution was confirmed (Shapiro-Wilk tests), associations between muscle mechanical properties with COP parameters and normalised reach distances were separately assessed using Pearson’s product moment correlation coefficient. Values were interpreted as weak (to 1.00) . The alpAssociations between muscle mechanical properties with static and dynamic balance parameters were examined by Pearson’s correlation matrix .p = .009, r = −.50) and GL  stiffness measured in the standing condition with the mean COP velocity. Similarly, statistically significant small inverse correlations were observed for VL  and GL  tone measured in the standing condition with the mean COP velocity. During the lying condition, GL tone  and stiffness  and VL tone  and stiffness  were small to moderately inversely associated with the mean COP velocity. Muscle mechanical properties of the GL and VL explained 16%–33% of the variance  in the mean COP velocity during quiet standing (p > .05).The analyses revealed significant moderate magnitude inverse correlations for VL  and VL stiffness  were detected when measured in the lying (supine) condition. Similarly, ANT reach distance was inversely associated with VL tone  and VL stiffness  when measured in the lying (supine) condition. Muscle stiffness and tone of the VL when measured in the lying (supine) condition explained 15%–21% of the variance  in ANT and COMP Y Balance Test performance , but not the amplitude , of the COP during quiet standing . Second, VL stiffness and tone measured in the lying (supine) condition were inversely correlated with ANT and COMP reach distance . These findings highlight that individuals with low muscle stiffness and tone exhibit faster COP movements during quiet standing, indicative of reduced postural control, but also reveal that low VL stiffness and tone are associated with greater reach distances in a lower extremity reaching task, indicative of greater dynamic balance performance.In the present study, we explored the relationship between muscle mechanical properties of Although there is emerging evidence linking passive muscle mechanical properties with static balance performance , a uniquThe distinct correlations between muscle mechanical properties with the velocity, but not the amplitude, of COP movements during quiet standing may be explained by the different types of information provided by these COP measures regarding postural performance and stability. For example, the range of COP movements in the AP and ML direction reflects the precision (or effectiveness) achieved by the postural control system , whilst The relationships between lower extremity reaching performance with muscle tone and stiffness were examined in the present study which is, to our knowledge, the first to directly examine the interdependence between dynamic balance performance and muscle mechanical properties. Given the critical involvement of the knee extensors during lower extremity reaching tasks , we initThis exploratory study provides a novel contribution to the literature and a solid platform for future investigations to scrutinise relationship between muscle mechanical properties with static and dynamic balance. However, the findings of the present study should be interpreted in light of the study limitations. Firstly, only the GL and VL muscles on the dominant side were assessed and therefore, our findings should not be generalised to other muscles within these muscle groups or to the contralateral limb. Additional examinations of other ankle  and hip  muscles and the Achilles tendon would be quite valuable given their importance to postural control. Secondly, the study was based on a relatively small convenience sample of 26 healthy young adults and whilst the homogeneity of our sample may have limited the influence of confounding demographic variables, the external validity of this study’s findings to broader groups, such as the older adults, is limited. This is especially important when we consider that older adults often change from an ankle to a hip strategy to control postural sway . Future in vivo muscle tissues are separately related to static and dynamic balance tasks. For the first time, our results highlight that muscle mechanical properties of the GL and VL are uniquely correlated with velocity but not magnitude indices of postural sway . More specifically, high muscle GL and VL tone and stiffness is associated with a more “efficient” postural control during quiet standing. We further found that muscle mechanical properties of the VL tone and stiffness are associated with anterior dynamic reach distance . Future work should explore the relationship between muscle mechanical properties and postural control in more challenging task situations  and in different populations .This work provides additional insights into how muscle mechanical properties of


Myocardial fibrosis progression and imbalanced redox state are closely associated with increased extracellular matrix (ECM) stiffness. Candesartan (CAN), an angiotensin II (Ang II) receptor inhibitor, has shown promising anti-fibrosis and antioxidant efficacy in previous cardiovascular disease studies. However, the effect of ECM stiffness on CAN efficacy remains elusive. In this study, we constructed rat models with three different degrees of myocardial fibrosis and treated them with CAN, and then characterized the stiffness, cardiac function, and NADPH oxidase-2 (NOX2) expression of the myocardial tissues. Based on the obtained stiffness of myocardial tissues, we used polyacrylamide (PA) gels with three different stiffness to mimic the ECM stiffness of cardiac fibroblasts (CFs) at the early, middle, and late stages of myocardial fibrosis as the cell culture substrates and then constructed CFs mechanical microenvironment models. We studied the effects of PA gel stiffness on the migration, proliferation, and activation of CFs without and with CAN treatment, and characterized the reactive oxygen species (ROS) and glutathione (GSH) levels of CFs using fluorometry and scanning electrochemical microscopy (SECM). We found that CAN has the best amelioration efficacy in the cardiac function and NOX2 levels in rats with medium-stiffness myocardial tissue, and the most obvious anti-fibrosis and antioxidant efficacy in CFs on the medium-stiffness PA gels. Our work proves the effect of ECM stiffness on CAN efficacy in myocardial anti-fibrosis and antioxidants for the first time, and the results demonstrate that the effect of ECM stiffness on drug efficacy should also be considered in the treatment of cardiovascular diseases. Myocardial fibrosis, a common pathological process that occurs during the progression of various cardiovascular diseases, exhibits an imbalance between the production and degradation of extracellular matrix (ECM), which results in an increase in ECM stiffness ,2, and t1R, a key membrane protein in the renin-angiotensin system (RAS), is considered an important receptor for mechanical signaling [1R expression without the involvement of angiotensin, indicating that AT1R also has the mechanical signal transduction effect [1R and FAK may be involved in the process that ECM stiffness affects the progression of myocardial fibrosis.Mechanical and biochemical factors are interdependent in the biological processes of CFs differentiation . For insignaling , and itsn effect . Focal an effect ,13. FAK n effect  prolifern effect , and adhn effect , and aren effect  and celln effect . Thus, iMechanical properties of ECM not only regulate the biochemical behavior of cells but also affect the pharmacodynamics and therapeutic efficacy of drugs. For example, previous studies reported that increased bronchial wall stiffness reduced bronchodilator-induced bronchodilation , and incIn this work, we first obtained the cardiac tissue stiffness by constructing rat models with three different degrees of myocardial fibrosis and treated them with/without CAN. Then, we cultured CFs with/without CAN intervention on the PA gels with different stiffness to mimic the ECM stiffness of CFs at three degrees of myocardial fibrosis. The therapeutic effect of CAN was evaluated by comparing the myocardial fibrosis index and oxidative stress before and after CAN treatment both in vivo and in vitro. Finally, based on the p-FAK and AT1R expression results, we discussed the possible mechanism of the ECM stiffness effect on the efficacy of CAN in myocardial fibrosis. Our study proves the interaction between ECM stiffness and CAN efficacy in myocardial fibrosis, which can provide useful insights into the anti-fibrosis and antioxidant efficacy of CAN from the biomechanopharmacology perspective.For any procedures not mentioned below, see Male Sprague-Dawley rats (6–8 weeks old and weighing 250–300 g) were obtained from the experimental animal center of the School of Medicine of Xi’an Jiaotong University. The myocardial fibrosis model was constructed by subcutaneous injection of isoprenaline  once daily for 7–28 days. The treatment groups of rats received CAN  by gastric gavage once daily for 28 days. The detailed treatment procedure of rats is presented in The cardiac function of rats was assessed using an ultrasonic diagnostics instrument  equipped with an S12-4 linear array ultrasound transducer.Paraffin sections were stained with a Masson’s trichrome staining kit . The ratios of the stained fibrotic areas to the total ventricular areas were calculated and used as the collagen volume fraction.E) was measured using a Nanoindenter instrument  with a probe with a radius of 47 µm and a cantilever stiffness of 0.5 N/m. We randomly selected six locations on the whole ventricular wall in the tissue slice for measurements and indented the probe at each position 30 times (5 × 6 matrix) to measure the stiffness . The stiffness of the slices  and cardiac troponin T (c-TnT) in plasma were measured using a commercial enzyme-linked immunosorbent assay kit  according to the manufacturer’s instructions. The absorbance of the plasma sample at 450 nm was recorded using a Spark 10 M Multimode Microplate Reader .1R, 1:100 dilution, Proteintech, 25343-1-AP, Chicago, IL, USA), the anti-focal adhesion kinase (phospho Y397) antibody , anti-focal adhesion kinase antibody  and NOX2 rabbit polyclonal antibody  at 4 °C and subsequently washed with PBS for three times. Then, the sections were incubated with second antibodies includes: IgG-horseradish peroxidase (HRP)  and Alexa Fluor-488 goat anti-rabbit antibody  at room temperature for 1 h. Finally, the sections were incubated with 4′,6-diamidino-2-phenylindole (DAPI). After dying, 3,3′ diaminobenzidine tetrahydrochloride (DAB) horseradish peroxidase Color Development Kit  was used for chromogenic development. Microphotographs were acquired and analyzed with fluorescence microscopy . The analysis of the fluorescence area was performed using CaseViewer2.4 software.Paraffin sections of rat heart were incubated overnight with the anti-angiotensin II type-1 receptor antibody (ATw/v) acrylamide monomers , 2% (w/v) N,N-methylene-bis-acrylamide (MBA) (Macklin), 10% (w/v) ammonium persulfate  and tetramethylethylenediamine  were prepared. To prepare the PA gels with different stiffness , the mass/volume concentrations of APS and TEMED were kept at 1% and 0.1% and the ratios of acrylamide (%)/MBA (%) were 10/0.3, 10/0.5 and 15/0.9, respectively. Then, 50 μL of the prepared polymer solution was dropped onto the hydrophilic-treated glass bottom of a petri dish, and an 18 mm-in-diameter glass coverslip treated with dichlorodimethylsilane was carefully placed on the top of the solution. After the PA gel polymerization, the top coverslips were peeled off, and the remaining monomers and cross-linkers were removed by washing with PBS. Then, 1 mg mL−1 of the cross-linker N-sulfosuccinimidyl 6-(4′-azido-2′-nitrophenyl amino) hexanoate  was added to the PA gels and photoactivated through ultraviolet light exposure for 10 min. The PA gels were then washed with 50 mM HEPES (pH 8.5) and incubated overnight in a solution of 50 μg mL−1 rat tail tendon collagen type I . The Young’s modulus of the PA gels was measured by the nanoindenter instrument .PA gels for culturing CFs were prepared using the procedure described in the previous literature ,28. Firs−1 collagenase type II enzyme solution at 37 °C for vibration digestion several times. The dissociated cells were suspended in DMEM/F12 . Then, the cells were obtained by filtering and centrifuging the mixed solution. The differential adhesion method was used to obtain NRCFs after 1 h. The purity of NRCFs was determined by vimentin protein staining and the NRCFs were extracted before each experiment.Neonatal rat cardiac fibroblasts (NRCFs) were isolated from 1–3-day-old Sprague-Dawley rats following the NIH guidelines . In Brie1R, 1:100 dilution, Proteintech, 25343-1-AP, Chicago, IL, USA). Then, the cell samples were incubated with the following secondary antibodies in the dark at 37 °C for 2 h: Alexa Fluor-488 goat anti-mouse antibody  or Alexa Fluor-594 goat anti-rabbit antibody . Cell nuclei were stained using DAPI . Images of the cell samples were obtained using a laser scanning confocal microscope .CFs were penetrated and incubated with the following primary antibodies at 4 °C overnight: anti-alpha smooth muscle actin antibody , anti-focal adhesion kinase (phospho Y397) antibody , and anti-angiotensin II type-1 receptor antibody , collagen III , and matrix metalloproteinase-2  were determined by western blotting (WB). All cell samples were lysed in RIPA lysis buffer . The protein concentration was determined using a bicinchoninic acid (BCA) protein assay kit . The protein samples were loaded into the prepared SDS-PAGE separation gel (8% (w/v) acrylamide gel) and concentrated gel (5% (w/v) acrylamide gel), followed by electrophoresis under a constant voltage of 80 V. When the protein samples ran to the interface between the concentrated gel and the separated gel, the electrophoresis was converted to 120 V constant voltage until the marker ran to the bottom of the separated gel. Then, the target proteins are transferred to polyvinylidene difluoride (PVDF) membranes  by electrophoresis under a constant current of 230 mA. After transferring the membrane, the PVDF membrane was immersed in the configured skim milk (5%) for sealing. After sealing, the diluted primary antibodies were added to the PVDF membrane and incubated at room temperature for 2 h. After the primary antibody was well incubated, the secondary antibody was added and incubated at room temperature for 2 h. The immunoreactive bands were obtained using a chemiluminescence imaging system . The results were quantified using ImageJ software and normalized to those of GAPDH.The expression levels of α-SMA, p-FAK, ATBefore SECM measurements, the CFs were incubated in an L15 culture medium  containing 0.5 mM ferrocenecarboxylic acid  for 30 min. All the SECM measurements were conducted using a commercial SECM instrument  integrated with an inverted optical microscope , and a typical three-electrode system with a 10 μm-in-diameter Pt disk electrode  as the SECM probe and the working electrode, a platinum wire (0.5 mm in diameter) as the counter electrode and an Ag/AgCl wire (0.6 mm in diameter) as the reference electrode.x-axis and y-axis on the cell surface with aid of an inverted optical microscope [z-axis direction with a speed of 0.5 μm s−1 with recording the approach curve, from which the z-axis position of the highest point of CF was determined. For the cell length characterization, the longest distance in the x-axis or y-axis was selected as the length of CF. For the cell height characterization, the approach curves to the highest point of CF, and the surface of the PA gel next to the CF were recorded. The height of the CF was obtained by the difference in the absolute distances of the two approach curves. The obtained average heights and lengths of the CFs on the PA gels were inputted into the SECM simulation model  of FcCOOH, which represent the outflow rates of GSH. The model geometry, simulation parameters, and boundary conditions of the developed simulation model are described in detail in the To quantitatively analyze the content of the GSH released by CFs on the PA gels, we used COMSOL multiphysics software  with finite element simulation to acquire the regeneration rate .Statistical analysis was performed using GraphPad Prism 9 . Statistics are presented as the mean ± standard error of the mean (SEM) for all quantitative data, with The rat models with three degrees of myocardial fibrosis were established through subcutaneous injection of ISO for different days in rats. The heart weight index of the three groups of rats without and with CAN treatment has no significant difference . After oTo quantify the cardiac function of myocardial fibrosis rats, we measured the echocardiography and plasma markers of heart failure and myocardial injury (BNP and c-TnT). From the ultrasonic indicators A, we obs1R and p-FAK, two important mechanical signal transduction proteins, are important for understanding the role of mechanical signals in fibrosis. From 1R expressions of the rat heart tissues are up-regulated with the extension of ISO induction time without CAN treatment, while the AT1R expressions in the groups with CAN treatment are down-regulated. Moreover, the inhibition efficacy of CAN in the ISO-2 W group is better than those in the ISO-1 W and ISO-4 W groups  released by living cells [+ at the probe diffuses to the CF surface and reacts with the GSH released by the CF to regenerate FcCOOH, which diffuses back to the probe surface and results in an oxidation current of FcCOOH. When the SECM probe approaches the CF surface, a pure negative feedback current can be obtained, which results from the hindering effect of CF on the FcCOOH diffusion to the probe surface. When approaching the SECM probe to the surfaces of CFs on the stiff PA gels (67.7 and 125.5 kPa), the lower probe oxidation currents of FcCOOH compared with those of the CFs on the soft PA gels (29.4 kPa) are obtained  of FcCOOH, which can represent the outflow rate of GSH. From the obtained average k values of the CFs on the PA gels through six repeated SECM measurements, we can see a decreasing trend of k values with the increased PA gel stiffness, indicating that the less extracellular GSH levels of CFs on the stiff ECM produced. Comparably, the average k values of CFs with CAN treatment are higher than those of CFs on the PA gels without CAN treatment. Based on the analysis of the difference in the average k values without and with CAN treatment . The obtained fluorescence and western blotting results both show that the expressions of α-SMA, NOX2, and ROS significantly decreased after the PF-573228 intervention , indicat1R expression of CFs on the PA gels with three stiffness, which is manifested by the most obvious decline of AT1R expression of CFs on the 67.7 kPA gels. The difference in the AT1R expression regulates the difference in the reduction of p-FAK, further leading to the different improvements of CF activation and oxidative stress state  is higher accompanied by the progressive deterioration of cardiac function, from which we can see a positively correlated relationship between the stiffness of myocardial tissue and the degree of fibrosis within the physiological and pathological ranges of fibrosis. This proves that the increase of ECM stiffness and the injury of cardiac function promote each other and the myocardium stiffness can be a valuable new metric for determining the cardiac dysfunction in patients with heart disease and reflecting the development and prognosis of myocardial fibrosis to a certain extent .1R expression and a relative decline in the CAN efficacy for CFs on the 29.4 kPa PA gels. FAK, an enzyme widely existing in the cytoplasm, plays a vital role in various types of fibrosis [1R can be induced by ECM stiffness, and the expression level of AT1R increases with the increase of ECM stiffness, demonstrating the activation effect of ECM stiffness on AT1R. For the group with CAN treatment, CAN leads to the decrease of AT1R expression, which shows the opposite effect to the increase of AT1R expression induced by ECM stiffness. It can be due to that CAN can selectively and non-competitively bind AT1R, resulting in the decreased expression of AT1R. In addition, our results also prove the upstream and downstream relationship between p-FAK and AT1R, i.e., AT1R is an upstream protein of FAK and mediates ECM stiffness-induced CF activation through FAK. Therefore, the resistance effect between the pharmacological efficacy of CAN and the ECM stiffness influence leads to the difference in AT1R expression of CFs on the PA gels with different stiffness, further leading to the change of downstream p-FAK expression, which is also the reason for the difference in the CAN efficacy. Our results also prove that AT1R can only regulate FAK to a certain extent, which can be due to that FAK as a downstream molecule is also affected by other membrane mechanosensitive proteins . However, the differences in drug efficacy caused by the complex mechanical regulation mechanisms and biochemical factors deserve further analysis and discussion.The concept of “biomechanopharmacology” has been introduced in 2002, which is a new discipline established by combining biomechanics/mechanobiology and pharmacology . It not fibrosis . Phosphafibrosis ,52, and fibrosis . the expOxidative stress injury is one of the main features of fibrosis. The elevation of NOX2 and ROS  and the 1R-FAK activity co-regulated by ECM stiffness and CAN. This study can contribute to a better understanding of the interaction between ECM stiffness and the efficacy of CAN in treating myocardial fibrosis, deepening the understanding of the physiological role of ECM stiffness in vivo and calls for attention to the weakening effect of mechanical factors on drug efficacy in the clinical treatment of myocardial fibrosis. We can, thus, speculate that blocking mechanical signals can be a strategy for the treatment of myocardial fibrosis.The main finding of this study is that ECM stiffness has a certain impact on the CAN efficacy in anti-fibrosis and antioxidative efficacy, and CAN shows the obvious antioxidative and anti-fibrosis efficacy at the medium-stiffness (67.7 kPa) range of ECM. First, we constructed the rat models with three different myocardial fibrosis degrees and confirmed the difference in the anti-fibrosis and antioxidant efficacy of CAN in the hearts with different stiffness. Then, using the in vitro ECM stiffness-mediated myocardial fibrosis models constructed on the stiffness-adjustable PA gels, the differences in the therapeutic efficacy of CAN on the functions of CFs under different ECM stiffness were identified. Finally, based on the p-FAK and AT1R expression results, we considered that the difference in CAN efficacy is related to the difference in AT


Metal orthodontic brackets were bonded to monolithic zirconia surface by two-component orthodontic adhesive. After 500 cycles of thermocycling, shear bond strength values were measured by a universal testing machine at a cross head speed of 0.5 mm/min. The data was recorded as MPa and statistically analyzed with One-way ANOVA, Levene’s LSD tests with Bonferroni corrections. The significance level was α = 0.05. The surface topography of one specimen of each group was evaluated by scanning electron microscopy (SEM). Statistically significant difference was observed among study groups (p = 0.018). The lowest shear bond strength was observed in the control group (3.92 ± 1.9). Tribochemical coating showed the highest bond strength (7.44 ± 2.9), which was statistically different from the control and nano second laser (4.3 ± 1.4) groups but not statistically different from grinding (6.15 ± 3.1) or sandblasting (6.47 ± 3.3). SEM images showed comprehensive results of each surface treatment on monolithic zirconia. All failure modes were recorded as adhesive between the composite resin and monolithic zirconia. Based on the findings of this study, it can be concluded that grinding, sandblasting and tribochemical coating techniques showed clinically acceptable bond strength within the range of 6–8 MPa. These surface treatments can be considered suitable for achieving a durable bond between metal orthodontic brackets and monolithic 4Y-TZP ceramic surfaces.The aim of this study was to evaluate the effect of different surface treatments on the shear bond strength (SBS) between metal orthodontic brackets and monolithic zirconia surfaces bonded with resin composite. Fifty monolithic zirconia (4Y-TZP) disks were sintered and glazed. Specimens were divided into five groups ( At room temperature, this material primarily consists of a tetragonal phase. The opaque appearance of traditional zirconia (3Y-TZP) does not meet aesthetic expectations, which is why veneering is often recommended. Nevertheless, a common technical issue encountered with veneered zirconia-based restorations is porcelain chipping [With the increasing demand for adult orthodontic treatment and the growing popularity of esthetic dentistry, clinicians face challenges when bonding orthodontic brackets onto various types of dental restorations compared to enamel ,2,3. Zirchipping ,5. To adchipping ,5,6. HowAchieving adequate bracket bond strength is crucial for successful fixed orthodontic treatment. Maintaining brackets on ceramic restorations, including zirconia, can be problematic, necessitating pre-treatment of ceramic surfaces for successful bonding ,8. VarioWith the introduction of the laser, the idea of using it as a means of reinforcing bond strength has become popular ,14,15. FAlthough several studies have examined the impact of different surface treatment methods on the bond strength of orthodontic attachments to feldspathic and lithium disilicate ceramics, there is limited research regarding the effect of surface treatments on the bond strength of brackets to monolithic zirconia restorations ,16,17. ATherefore, the objective of this in-vitro study was to evaluate the shear bond strength (SBS) of metal orthodontic brackets to monolithic zirconia subjected to various surface treatments. The null hypothesis tested in this study was that the SBS of orthodontic metal brackets to the surface of monolithic zirconia would not be affected by different surface treatment methods.n = 10) based on different surface treatments:A study was conducted using 50 disk-shaped  monolithic zirconia specimens  obtained from pre-sintered zirconia blocks through Computer Aided Design/Computer Aided Manufacturing (CAD/CAM) technology. To achieve a standardized flat surface on the specimens, the specimens were gradually abraded with silicon carbide abrasive papers of varying grain sizes  under constant water cooling for 20 s. One surface of the specimens was glazed and polished using coarse polishing discs. The polished surfaces were then embedded in acrylic resin molds, and the specimens were randomly divided into 5 groups  .2O3 particles using a sandblasting machine under 2.5 bars pressure and at a distance of 10 mm away from the specimen surface. The application time was 10 s for each specimen.Group Sandblasting: The surfaces were sandblasted with 50 μm AlGroup Grinding: The surfaces were roughened using ultrafine 20 μm grit cylindrical diamond burrs for 10 s under water cooling. Care was taken during the ultrafine grinding process to prevent exceeding the depth of surface flaws, while focusing solely on the removal of the polished surface.2O3 particles  sprayed onto the zirconia surface for 10 s under 2.5 bar pressure at 10 mm distance.Group Tribochemical Silica Coating: The surfaces were treated with silica coated AlAfter the surface treatments, the specimens in each group were cleaned in an ultrasonic cleaner for 15 min and air-dried. BISGMA- and TEGDMA-based primer  was applied to monolithic zirconia surfaces, according to manufacturer’s instructions. Then, upper incisor metal orthodontic brackets  were manually positioned on the zirconia surface, and orthodontic light cure adhesive resin  was applied to bond the brackets onto the zirconia surfaces. The adhesive was then light cured using a light-emitting diode light-curing unit (LED) for 20 s before testing . All theA shear bond test was performed using a Universal testing machine  at a crosshead speed of 0.5 mm/min to measure the strength of the bond between the brackets and the monolithic zirconia surfaces. To evaluate the failure modes of the bond, the surfaces of failed specimens were observed under fluorescent light. The failure modes were categorized as adhesive, cohesive, or mixed. Adhesive failure referred to the separation between the resin and the bracket while cohesive failure indicated failure within the resin or zirconia itself. Mixed-type failure indicated both adhesive and cohesive failure occurring simultaneously in this study.p < 0.05. Descriptive statistics, including the mean, standard deviation (SD), median, minimum, and maximum SBS (MPa) values, were calculated at 95% confidence intervals. The homogeneity of the data was evaluated using the Levene test. One-way ANOVA and Levene’s LSD multiple comparison tests with Bonferroni corrections were used for post-hoc analysis to determine the statistically significant differences within and between groups (p < 0.05).Statistical analyses were conducted by using the SPSS 23.0 package program . The significance level for this study was set at The descriptive statistics for shear bond strength (SBS) values between metal orthodontic brackets and monolithic zirconia surfaces modified by different surface treatment techniques are presented in p = 0.003 and p = 0.010, respectively). The CoJet group did not show a statistically significant difference in SBS value compared to the grinding (6.15 ± 3.1) or sandblasting (6.47 ± 3.3) groups (p > 0.05).The SBS values between metal orthodontic brackets and monolithic zirconia surfaces, after modification with various surface treatment techniques, ranged from (3.92 ± 1.9) to (7.44 ± 2.9) MPa. The tribochemical coating group exhibited the highest SBS value (7.44 ± 2.9) while the control group displayed the lowest SBS value (3.92 ± 1.9). The tribochemical coating group demonstrated a significantly higher SBS value compared to the control (3.92 ± 1.9) and laser (nano second laser) groups (4.3 ± 1.4) (p = 0.038). Based on these statistical evaluations, it can be observed that the SBS value of the sandblasting group was superior to the control group, but there was no statistically significant difference between sandblasting (6.47 ± 3.3) and the laser (4.3 ± 1.4), grinding (6.15 ± 3.1) or tribochemical coating groups (7.44 ± 2.9) (p > 0.05).Group sandblasting (6.47 ± 3.3) exhibited a statistically higher SBS value compared to the control group (3.92 ± 1.9) . It should be noted that since the restorations typically remain in the mouth after debonding the brackets, it is important to avoid excessive roughening of the surfaces during pretreatment or debonding. After debonding, the ceramic surface should be polished using a porcelain polishing kit to avoid damage to the ceramic. Therefore, ultrafine diamond burrs were utilized in the grinding group to prevent crack initiation within the ceramic. Scanning electron microscope (SEM) images of the grinding group showed scratches on the monolithic zirconia surface, but no cohesive fractures were observed in the grinding groups after undergoing 500 cycles of thermocycling. However, it is important for clinicians to exercise caution and avoid deep roughening during grinding, opting for ultrafine grinding instead. In this study, the zirconia surfaces were roughened using ultrafine cylindrical diamond burrs at 40,000 rpm for 10 s with high-speed rotary instruments under water cooling to remove the polished layer on the zirconium surface. Adequate shear bond strength (6.15 ± 3.1 MPa) was achieved with the grinding method.In this study, the grinding, sandblasting and tribochemical coating groups demonstrated higher bond strength within the acceptable threshold range (6–8 MPa) compared to the control group . The specific type of ceramic material being used may necessitate different surface treatment approaches.The study findings indicated that the scanning electron microscopy (SEM) images of the tribochemical coating group showed similar differences compared to the sandblasting group. This suggests that both methods have comparable effects on the ceramic surface, supporting their effectiveness in achieving micromechanical retention and improving bonding.The researchers proposed that the high bond strength observed in the tribochemical coating group can be attributed to both mechanical locking and chemical retention. Besides the physical interlocking of the coating with the ceramic surface, the chemical reaction between the embedded silica and alumina particles and the phosphate monomer of the resin cement played a significant role in achieving strong bonding. It is likely that the adhesive cement used in the study flowed into the micro-porosities created by the surface treatment, and the presence of the phosphate monomer further enhanced the bond strength. Consequently, the tribochemical coating group exhibited the highest bond strength, with an average value of 7.44 ± 2.9, specifically in monolithic zirconia.These findings suggest that the tribochemical coating, which provides both mechanical and chemical retention, along with the use of a phosphate monomer in combination with the adhesive cement, can significantly improve bond strength when bonding resin cement to monolithic zirconia surfaces. These results align with previous studies ,12,40 thThe principal effect of laser energy is the conversion of light energy into heat, and the most important interaction between laser and substrate is the absorption of the laser energy by the substrate . During Recent studies have reported an increase in bond strength between titanium surfaces and resin cement or acrylic structures when treated with nano-second fiber laser application ,41. FibeWithin the limitations of this study, generalization of results to the clinical setting should be done with caution. The forces applied to the brackets under experimental conditions are different from the forces that occur in vivo. In the mouth, brackets are influenced by different types of stretching, shear, rotational and combined forces, and the forces that are applied for the removal of brackets in the clinic are different from the pure shear force that is applied gradually in a laboratory. It should also be noted that achieving optimal bond strength is influenced by various factors beyond just the ceramic surface treatment method. These factors include the type of ceramic material, the type of bracket and its base surface design or retention mode, properties of the bonding adhesive, the light curing source used, the oral environment and the experience of the clinician ,20,28,43In conclusion, following appropriate surface roughening techniques can lead to an acceptable surface structure and successful bonding during surface treatment in patients with monolithic zirconia restorations.The shear bond strength (SBS) values between metal orthodontic brackets and monolithic zirconia, modified by different surface treatment methods, ranged from (3.92 ± 1.9) to (7.44 ± 2.9).The tribochemical coating group exhibited the highest bond strength (7.44 ± 2.9), which was not statistically different from the grinding (6.15 ± 3.1) or sandblasting (6.47 ± 3.3) groups.The bond strength achieved using the nano second fiber laser (4.3 ± 1.4) fell below the acceptable threshold range of 6–8 MPa.Additionally, the nano second fiber laser significantly altered the color of the monolithic zirconia specimens.The grinding, sandblasting and tribochemical coating techniques demonstrated clinically acceptable bond strength within the range of 6–8 MPa, suggesting their potential suitability for use in clinical practice.Based on the mean SBS values and SEM images, several conclusions can be drawn from this in vitro study:


Arterial stiffness and hypertension are closely related in pathophysiology. Chronic high blood pressure (BP) can lead to arterial wall damage by mechanical stress, endothelial dysfunction, increased inflammation, oxidative stress, and renin–angiotensin–aldosterone system (RAAS) activation. Hypertension also increases collagen fiber production and accelerates elastin fiber degradation. Stiffened arteries struggle with BP changes, raising systolic BP and pulse pressure. The resulting increased systolic pressure further hardens arteries, creating a harmful cycle of inflammation and calcification. Arterial stiffness data can predict target organ damage and future cardiovascular events in hypertensive patients. Thus, early detection of arterial stiffness aids in initiating preventive measures and treatment plans to protect against progression of vascular damage. While various methods exist for measuring arterial stiffness, pulse wave velocity is a non-invasive, simple measurement method that maximizes effectiveness. Healthy lifestyle changes, RAAS blockers, and statins are known to reduce arterial stiffness. Further research is needed to ascertain if improving arterial stiffness will enhance prognosis in hypertensive patients. Hypertension, commonly known as high blood pressure (BP), is a prevalent medical condition where the force of the blood against the artery walls is consistently too high. This chronic condition is a significant global health burden because it is associated with an increased risk of cardiovascular and cerebrovascular diseases, which are among the leading causes of death worldwide , 2.With age or due to prolonged exposure to cardiovascular disease risk factors, such as high BP, hyperglycemia, dyslipidemia, smoking, and chronic inflammation, the arterial wall tends to stiffen , 4. As aArterial stiffness and hypertension are intricately intertwined, each significantly influencing the other. By elucidating the relationship between arterial stiffness and hypertension, we can gain valuable insights that can be applied to the diagnosis, treatment, and prognosis of patients with hypertension. In this review, I will explore the complex interplay between arterial stiffness and hypertension, and discuss the clinical implications derived from this relationship.Arterial stiffness refers to the reduced ability of an artery to expand and contract in response to pressure changes. With age and certain diseases, there are changes in the structure of the arterial wall. The arterial wall is made up of three layers: the intima (inner layer), the media (middle layer), and the adventitia (outer layer). The media is primarily made up of smooth muscle cells and elastin. Over time, there is a reduction in the elastin content and an increase in collagen, leading to stiffening of the arteries. In addition, there can be calcification within the arterial wall, contributing to increased stiffness . The endThere are numerous methodologies for evaluating arterial stiffness, among which pulse wave velocity (PWV) is the most widely accepted and validated. PWV quantifies the rate at which the arterial pulse travels through the arterial system—a faster pulse wave indicates increased arterial stiffness. The most commonly utilized PWVs are carotid-femoral PWV (cfPWV) and brachial-ankle PWV (baPWV). Initially developed and primarily used in the West, cfPWV is considered the gold standard for noninvasive arterial stiffness measurement, as it focuses on the elastic artery portion between the carotid and femoral arteries . A wealtThe augmentation index (AIx) quantifies the extent to which the reflected pulse wave enhances the primary forwarding pulse wave . InfluenPP, defined as the difference between systolic and diastolic BP, serves as a rudimentary surrogate marker of arterial stiffness . Both brAnother less common method of evaluating arterial stiffness involves directly measuring changes in arterial diameter in response to BP variations. While not frequently used in clinical practice, this method may be utilized in research settings. Ultrasound techniques, computed tomography, or magnetic resonance imaging can capture these changes by measuring the maximal (systolic) and minimal (diastolic) arterial diameters .Chronic hypertension can lead to arterial damage. High BP exerts additional strain on the walls of blood vessels. This augmented mechanical stress can directly damage the endothelium, the inner lining of the blood vessels, and stimulate vascular remodeling, resulting in thicker, stiffer arteries . HyperteHypertension can cause significant alterations to the collagen and elastin composition within arterial walls, thereby contributing to vascular stiffness and remodeling. Collagen and elastin are two key structural proteins found in the walls of arteries. While elastin provides elasticity, allowing the arterial wall to stretch and recoil with each heartbeat, collagen provides strength and stability. Chronic high BP can stimulate the production of collagen in the arterial wall . The excThe relationship between arterial stiffening and BP is bidirectional. As arterial stiffness increases, the capacity of the artery to expand and contract in response to fluctuations in BP decreases. Over time, this diminished elasticity can lead to an increase in systolic BP and PP. This is because arteries with greater stiffness are less capable of expanding to accommodate the surge of blood ejected from the heart during each heartbeat . MoreoveFigure Numerous studies suggest that arterial stiffness predicts future hypertension. Kaess et al.  discoverThese findings suggest the potential of arterial stiffness measures in early identification and prevention strategies for hypertension. However, further research is needed to determine how these measures can be best incorporated into routine clinical practice and public health efforts.Arterial stiffness plays a significant role in the development and detection of target organ damage in hypertensive patients. Target organs in hypertension include the heart, kidneys, brain, and peripheral arteries . Damage Figure As outlined in the previous sections, arterial stiffness plays a crucial role in causing organ damage in hypertensive patients. This organ damage is intrinsically linked to the occurrence of cardiovascular events . TherefoThere are several benefits of reducing arterial stiffness in hypertensive patients. Arterial stiffness is a known independent risk factor for cardiovascular diseases , 9. As sAlthough not exclusive to hypertensive patients, there are several methods available to reduce arterial stiffness . The corPharmacological interventions can be also applied for reducing arterial stiffness. Drugs with established cardiovascular protective effects, such as RAAS blockers  and statBased on what has already been described above, it is important to obtain early information on arterial stiffness in hypertensive patients. Increased arterial stiffness is a strong independent predictor of future cardiovascular events and all-cause mortality. It can help identify high-risk individuals who may require more aggressive treatment and monitoring. The detection of arterial stiffness can be useful for the early initiation of preventive and therapeutic strategies to limit the progression of vascular damage. This includes lifestyle modifications, such as dietary changes, increased physical activity, smoking cessation, and BP control, as well as the appropriate use of medication. Changes in arterial stiffness can also serve as a measure of the effectiveness of therapeutic interventions. If a particular treatment is effective in reducing arterial stiffness, it can suggest that the treatment is beneficial for vascular health and potentially reducing future cardiovascular risk. Hypertension and arterial stiffness often coexist and can exacerbate each other. Understanding the degree of arterial stiffness can provide insights into the underlying pathophysiology of an individual’s hypertension, potentially guiding more personalized treatment approaches. Studies have shown that arterial stiffness, measured by techniques like PWV, provides prognostic information beyond traditional risk factors. Patients with high arterial stiffness often have worse long-term cardiovascular outcomes, and knowing this can help shape the management plan. When patients understand that they have an increased arterial stiffness that can be improved with healthy lifestyle changes, it may provide additional motivation for them to make and maintain these changes. In summary, early detection of arterial stiffness in hypertensive patients can guide therapeutic decisions, help monitor the effectiveness of interventions, improve risk stratification, and potentially improve outcomes.Hypertension and arterial stiffness are closely related to each other. When BP is high, arterial stiffness progresses, and conversely, when arterial stiffness progresses, BP also increases. Arterial stiffness information can be used in hypertensive patients to predict the cardiovascular risk. Several methods are available for measuring arterial stiffness; however, the use of non-invasive techniques makes the information highly beneficial in treating hypertensive patients. The suggestion has been made that a healthy lifestyle, RAAS blockers, and statins are beneficial in reducing arterial stiffness. Further research is required to determine if a treatment strategy that ameliorates arterial stiffness can enhance the prognosis of patients with hypertension.


Potato virus Y (PVY), Potato virus S (PVS), and Potato virus M (PVM) infection of potato plants leads to decreased dry matter and starch content in tubers. Starch samples from potato tubers infected with PVY, PVS, and PVM had higher amylose content. Granules of starch isolated from potato tubers infected by PVS exhibit larger granules than starch granules isolated from tubers of healthy plants. In contrast, in the case of PVM and PVY infection, starch granules were significantly smaller in diameter. A decrease in the degree of crystallinity has been observed in all samples of starches obtained from the tubers of infected plants compared to starch isolated from tubers of healthy plants. A slight decrease in gelatinization temperature was noted for starch samples isolated from tubers infected by PVY and PVM, and a slight increase in gelatinization temperature for starch samples isolated from tubers infected by PVS compared to starch isolated from tubers of healthy plants. In all samples of starch obtained from tubers of infected plants, an increase in the value of gelatinization enthalpy was observed. Thus, it can be concluded that damage to potato plants by PVM and PVY leads to a significant decrease in the quality of starch in tubers. At the same time, infection by PVS had practically no considerable effect. Damage to potato plants by potato viruses M and Y leads to a significant decrease in the quality of starch in tubers. At the same time, infection by Potato virus S had practically no considerable effect. According to numerous sources, there are 40–50 viruses that infect potato plants all over the world  usually produce tubers unsuitable for sale    were selected from Agrofirma Rodina LLP, Tselinograd district, Akmola region. After selection, 90 labeled tubers were germinated in the laboratory to obtain sprouts, which were tested by ELISA for the presence of viruses. To avoid reinfection with viruses, the tested monoinfected and virus‐free germinated tubers of potato plants were grown in separate pots under isolated phytotron conditions. To confirm the presence or absence of virus infection in potato clones grown in the phytotron, their leaf samples were again checked by RT‐PCR. The sample size of tuber samples for further research was 30 pcs.2.22.2.1The DAS ELISA was used according to the attached instructions using 96‐well polystyrene tablets “Medpolymer.” The ELISA results were considered using a vertical light flow spectrophotometer  at a wavelength of 492 nm. When carrying out this variant of ELISA, Russian commercial diagnostic kits of ELISA to determine potato viruses  of the Russian Potato Research Centre named after A.G. Lorkh were used  and starch content were determined by the Evers polarimetric method.2.52.5.1Scanning electron microscopy (SEM) micrographs were taken using a scanning electron microscope . A starch sample adhered to an SEM stub using double‐sided adhesive conductive tape and coated with a thin layer of gold to make the sample conductive. The mounted sample was then placed on the SEM stage, and images were digitally captured at the accelerating voltage of 10 kV.2.5.2The starch sample was suspended in a 1:1 glycerol solution  and was observed using light microscopy  with the polarized light filter at 40‐time magnification.2.6The particle size distribution was measured using a laser light‐scattering particle size analyzer . The starch was placed in water and analyzed automatically by laser diffraction.2.7n = 4–6) were analyzed.Amylose levels were determined using the Juliano  method. Starch moisture contents were determined by drying weighed amounts of starch in predried aluminum dishes in an air oven at 103°C to reach constant weight . Samples of starch (approximately 10.0 mg dry weight) were weighed directly into an aluminum crucible , and distilled water was added in a 1:3 ratio. The crucible was sealed and equilibrated for 1 h before analysis. An empty hermetically sealed crucible was used as a reference. Then, the samples were heated from 30°C to 170°C at a rate of 10°C/min. As a result, the initial temperature (Tn), peak temperature (Tn), final temperature (Tk), and enthalpy (ΔH) were determined. The range was calculated by subtracting the initial temperature from the final temperature.2.9Samples were analyzed using an X‐ray diffractometer , equipped with a copper tube at 40 kV. The scanning range of the diffraction angle (2θ) was from 4° to 60° at a speed of 6°/min, with a step size of 0.02°. The degree of crystallinity is calculated by Jade software (Jade 5.0).2.10p < .05.All the experiments were the average of at least two replicates. The data were statistically analyzed using the SPSS 16.0 statistical package and expressed as mean value ± standard deviation. Statistical significance was established at 33.1In the first research stage, samples were taken from the potato tuber sprouts. To obtain healthy and monoinfected clones, a DAS‐ELISA test was conducted to identify the PVY, PVX, PVS, PVM, and PLRV.The ELISA testing results of 90 samples showed a positive reaction mainly on PVY and its complexes with other viruses . No PLRV and PVA were detected. Artemis sample No. 65 showed a positive reaction to PVM (0.217 OD compared with 0.023 OD of negative control), Artemis sample No. 34 on PVS (0.845 OD compared to 0.021 OD of negative control), samples Artemis No. 1 and Artemis No. 13 are 0.534 and 0.458 OD compared to 0.008 OD, respectively. The ELISA optical density of Artemis sample No. 65 was at the same level as other viruses' negative control.To confirm the monoinfection and virus‐free potato clones, the samples were tested by RT‐PCR. Figure As a result of PCR, several monoinfected samples were identified and selected for further studies: PVM – Artemis No. 65 with a molecular weight of the PCR product of 160 bp Figure , PVS – A3.2As noted before, researchers found a decrease in the starch content in the tubers of potatoes infected with the virus  was noted in PVY starch. According to Lal et al. , ToLCNDVAsh content in all samples correlates with the phosphate content. PVY and PVM increased ash content and phosphates in starch, while PVS slightly reduced it compared with the virus‐free sample.Morphological studies of potato starch samples are presented in Table Even though the variety of sizes and shapes of starch grains is of various origins, the internal organization of these grains in starch is practically the same. Starch macromolecules are ordered in amorphous and semicrystalline parts  are shown in Table 4Infection of potato plants by PVM, PVY, and PVS leads to a decrease in the dry matter and starch content in tubers. Starch samples from potato tubers infected with PVM, PVY, and PVS had higher amylose content. Granules of starch isolated from potato tubers infected by PVS exhibit larger granules than starch granules isolated from tubers of healthy plants. In contrast, in the case of PVM and PVY infection, starch granules were significantly smaller in diameter. All starch samples had B‐type crystalline structure typical of potato starches, a decrease in the degree of crystallinity has been observed in all samples of starches obtained from the tubers of infected plants compared to starch isolated from virus‐free samples. A slight decrease in gelatinization temperature was noted for starch samples isolated from tubers infected by potato viruses PVM and PVY, and a slight increase in gelatinization temperature for starch samples isolated from tubers infected by PVS compared to starch isolated from tubers of healthy plants. In all samples of starch obtained from tubers of infected plants, an increase in the value of gelatinization enthalpy is observed. Thus, it can be concluded that damage to potato plants by PVY and PVM leads to a significant decrease in the quality of starch in tubers. At the same time, infection by PVS had practically no considerable effect.Gulnazym Ospankulova: Formal analysis ; funding acquisition ; project administration ; resources ; supervision ; writing – original draft . Vadim Khassanov: Investigation . Svetlana Kamanova: Formal analysis . Dana Toimbayeva: Methodology . Saule Saduakhasova: Conceptualization . Berdibek Bulashev: Data curation . Gulnar Aidarkhanova: Validation . Yernaz Yermekov: Software . Linara Murat: Data curation . Bakhyt Shaimenova: Methodology . Marat Muratkhan: Data curation ; formal analysis ; software .This research was funded by the Science Committee of the Ministry of Education and Science of the Republic of Kazakhstan, grant number AP08857439.The authors declare that they do not have any conflict of interest.This study does not involve any human or animal testing.Written informed consent was obtained from all study participants.


Background: We intended to determine if an acromion or distal clavicle bone graft could restore large glenoid defects using two novel, screw-free graft fixation techniques. Methods: Twenty-four sawbone shoulder models were divided into four groups (n = 6 per group) according to fixation technique and bone graft: (1) modified buckle-down technique with clavicle graft, (2) modified buckle-down technique with acromion graft, (3) cross-link technique with acromion graft, (4) cross-link technique with clavicle graft. Testing was performed sequentially in (1) intact models, (2) after creation of a 30% by-width glenoid defect and (3) after repair. The shoulder joint was translated anteriorly, and glenohumeral contact pressures and load were measured to quantify the biomechanical stability. Results: Maximum contact pressures were restored to 42–56% of intact glenoid using acromion and clavicle grafts with novel fixation techniques. Acromion grafts attained higher maximum contact pressures than clavicle grafts in all groups. Peak translational forces increased by 171–368% after all repairs. Conclusions: This controlled laboratory study on sawbone models found that both the acromion and distal clavicle are suitable autologous bone graft options for treating large anterior glenoid defects, having appropriate dimensions and contours for reconstructing the glenoid arc. The modified buckle-down and cross-link techniques are two graft fixation techniques that restore stability to the shoulder joint upon repairing a large glenoid defect and are advantageous in being screw-free and simple to execute. A number of authors have recommended using bone grafting procedures to restore the glenoid shape when treating large glenoid defects of approximately 6 mm to 8 mm bone loss, or 20–30% of the glenoid width ,2,3,4,5.Anatomical studies into autologous bone grafts found both the acromion and distal clavicle graft have comparable dimensions to the coracoid process and can restore similar-sized glenoid defects when compared to the Latarjet procedure ,16,17. HBicortical screws are one method for graft fixation ,18. HoweWe were interested in determining if an acromion or distal clavicle bone graft could restore the glenoid articular surface area after the creation of a large anterior glenoid defect. The second aim was to develop two screw-free fixation techniques and investigate if they were biomechanically sound for repairing large anterior glenoid defects and restoring shoulder stability.The study used sawbone models to evaluate two graft fixation techniques and two free bone grafts for the reconstruction of an anterior glenoid. Twenty-four sawbone models of the left scapula  were obtained and provided the control and defect states of the glenoid and the acromion grafts. Twelve sawbone models of the clavicle  were obtained for the clavicle grafts. The 24 scapula models were divided into four groups of six scapulae according to the repair technique and bone graft: (1) modified buckle-down technique with clavicle graft, (2) modified buckle-down technique with acromion graft, (3) cross-link technique with acromion graft, (4) cross-link technique with clavicle graft. A total of four humerus sawbone models  were used for testing, allowing a fresh humerus for each of the five repair groups.The glenoid dimensions of the intact scapula were measured using a digital calliper. The borders of the glenoid were marked at the 12, 3, 6 and 9 o’clock positions. The 12 o’clock position was defined at the supraglenoid tubercle. The remaining 3, 6 and 9 o’clock positions on the left-sided scapula model corresponded with the posterior, inferior and anterior borders of the glenoid, respectively. The centre of the glenoid was defined as being equidistant from the 3, 6 and 9 o’clock positions. The creation of the glenoid defect was adapted from a previous biomechanical study described by Smith et al. . The gleFree bone grafts were obtained from the acromion and clavicle. The acromion was marked 10 mm from its anterior edge, and a single vertical cut using a handsaw was made to obtain the acromion graft . The acrIn all bone grafts, two bone tunnels were hand-drilled parallel to the articular surface. These bone tunnels were 5 mm medial to the articular surface and spaced approximately 10 mm apart. For repairs with the modified buckle-down technique, a 1.5 mm drill bit was used, consistent with the description by Smith et al. . For repTwo screw-free graft fixation techniques for the glenoid defect were investigated: a modified buckle-down technique  Figure  and the The suture strands of the superior and inferior anchors were passed through the respective holes in the free bone graft and Endobutton   control glenohumeral joint with no osseous defect of the anterior glenoid rim, (2) after the creation of a 30% by-width defect of the anterior glenoid rim, (3) after the repair technique . In eachGlenohumeral adduction was fixed by aligning the humeral shaft parallel to the defect line on the glenoid such that any anterior–posterior force would be perpendicular to the defect line. An L-plate was fastened against the lateral border of the humeral head to maintain this position between tests and directed the anterior translational force linearly against the glenoid rim by preventing lateral displacement of the humeral head.The measurements of the contact pressure film  were electronically recorded as the humerus was translated anteriorly. The repair time from drilling of the glenoid to the insertion of the final anchor was measured as a secondary outcome.The reliability of the testing apparatus was assessed by testing 30 glenoids in their intact state . Two-wayThe glenoid dimensions (mean ± SD) of the 24 intact scapula sawbone models had an anterior–posterior width of 30.3 ± 0.2 mm. A total of 12 acromion grafts and 12 clavicle grafts with dimensions shown in The modified buckle-down repair technique took an average of 5 min  to complete. The cross-link technique required an average of 10.5 min  to complete.As the joint was dislocated through testing, the mechanism for failure for all repairs was noted to be secondary to mechanical suture stretching. The sutures from the inferior anchors that passed through the inferior bone tunnel of the free bone grafts demonstrated greater mechanical stretching in all repair specimens.In all groups, the maximum contact pressure obtained at dislocation and at displacements of 2 and 4 mm decreased by 84–99% after the creation of a 30% by-width glenoid defect compared to the control glenoid. After repair, the maximum contact pressure increased significantly in all groups compared to the defect glenoid, achieving 42–56% of the control glenoid value .p < 0.05) than the modified buckle-down technique with acromion (102 ± 2 N) and cross-link technique with acromion (104 ± 1 N) (The maximum contact pressure (mean ± SEM) of the modified buckle-down technique with clavicle was the lowest (73 ± 6 N), which was 47% of the control. This was significantly lower (4 ± 1 N) .At 4 mm displacement, clavicle graft repairs attained 36–39% lower contact pressures than acromion grafts. At 2 mm, clavicle graft repairs attained 14–40% lower contact pressures than acromion grafts .In all repair groups, the load at 2 mm, load at 4 mm and peak translational force obtained at dislocation decreased by 85–97% after the creation of a 30% by-width glenoid defect compared to the control glenoid. After repair, the peak translational force increased by 171–368% compared to the defect glenoid, achieving between 23 and 44% of the control glenoid value .The peak translational force (mean ± standard error of mean) of the modified buckle-down technique with acromion was the highest (18 ± 2 N), which was 44% of the control (40 ± 0.3 N). The cross-link technique with clavicle restored the lowest peak translational force (10 ± 3 N), which was 23% of the control (44 ± 5 N) .At 4 mm displacement, the modified buckle-down technique with clavicle restored the highest load (10 ± 1 N), which was 42% of control (23 ± 1 N). At 2 mm displacement, the cross-link technique with acromion restored the highest load (6 ± 2 N), which was 32% of the control (18 ± 2 N) .This study used sawbone models to investigate an acromion and distal clavicle bone graft in reconstructing large glenoid defects. Two novel screw-free graft fixation techniques were used for repairs. Both the acromion and clavicle grafts were large enough to reconstruct a 30% by-width glenoid defect, and maximum contact pressures were restored to 42–56% of intact glenoid values. The modified buckle-down technique and cross-link technique both restored joint stability equally well, with repairs improving peak translational forces by 171–368% compared to the defect glenoids.No prior studies have biomechanically tested an acromion graft for glenoid reconstruction. Only one previous biomechanical study examined a distal clavicle graft in repairing large glenoid defects. Petersen et al.  found thHarvesting a bone graft from the acromion or distal clavicle allows a single surgical operating field and may reduce donor site morbidity seen with iliac crest graft harvests ,28. ThisDistal clavicle graft harvests for glenoid reconstruction have been performed clinically by Tokish et al. . The autThe buckle-down technique was first described by Smith et al.  as a scrTaverna et al.  previousA strength of this study was using standardised sawbone models allowing for a reproducible 30% by-width glenoid defect and consistent bone graft shape and size. Both fixation techniques in this study avoided using screws, reducing the risk of intraoperative neurovascular injury and postoperative hardware complications ,33,34. TThere are several limitations to this study. The sawbone models simplify glenohumeral stability mechanisms by testing in the absence of other dynamic stabilisers. Shoulder stability was tested in a single neutral arm position across all groups, which is unlikely to represent commonly seen clinical dislocation presentations of the arm in an abducted and externally rotated position . The strThis controlled laboratory study on sawbone models found that both the acromion and distal clavicle are suitable autologous bone graft options for treating large anterior glenoid defects, having appropriate dimensions and contours for reconstructing the glenoid arc. The modified buckle-down and cross-link techniques are two graft fixation techniques that restore stability to the shoulder joint upon repairing a large glenoid defect and are advantageous in being screw-free and simple to execute.


As a traditional and popular dietary supplement, lotus rhizome starch (LRS) has health benefits for its many nutritional components and is especially suitable for teenagers and seniors. In this paper, the approximate composition, apparent amylose content (AAC), and structural characteristics of five LRS samples from different regions were investigated, and their correlations with the physicochemical properties of granular and gelatinized LRS were revealed. LRS exhibited rod-shaped and ellipsoidal starch granules, with AAC ranging from 26.6% to 31.7%. LRS-3, from Fuzhou, Jiangxi Province, exhibited a deeper hydrogel color and contained more ash, with 302.6 mg/kg iron, and it could reach the pasting temperature of 62.6 °C. In comparison, LRS-5, from Baoshan, Yunnan Province, exhibited smoother granule surface, less fragmentation, and higher AAC, resulting in better swelling power and freeze-thaw stability. The resistant starch contents of LRS-3 and LRS-5 were the lowest (15.3%) and highest (69.7%), respectively. The enzymatic digestion performance of LRS was positively correlated with ash content and short- and long-term ordered structures but negatively correlated with AAC. Furthermore, the color and network firmness of gelatinized LRS was negatively correlated with its ash content, and the retrograde trend and freeze-thaw stability were more closely correlated with AAC and structural characteristics. These results revealed the physicochemical properties of LRS from different regions and suggested their advantages in appropriate applications as a hydrogel matrix. Differences in starch composition and structure lead to different properties that often vary with region and variety; these properties contribute to the various applications of starch. In addition, changes in structure and composition are generally related to the digestibility and glycemic index of starch . By compe starch . Many fae starch ,4,5. Evee starch ,7,8,9. Te starch . Therefoe starch . In genee starch .Nelumbo nucifera Gaertn.) is widely cultivated in Asia. After thousands of years of artificial cultivation in China, more than 200 cultivars of lotus with edible rhizomes are available [Lotus , protein (Kjeldahl determination), fat (Soxhlet extraction), and ash (dry ashing) contents, were measured following a modified version of the standard procedure  . The sta2, w/v) were volumetric to 50 mL with deionized water, mixed immediately, and stored in darkness for 20 min. The AAC was evaluated from the absorbance at 620 nm. The recorded values were converted to percent of amylose by referencing a standard curve prepared with purified amylose from potato  and amylopectin from corn .The AAC in LRS samples was measured by an improved method . The samThe granule morphology of five LRS samples was characterized by a scanning electron microscope . The sample powders were fixed at a conductive adhesive tape, sputter-coated with gold, and then observed at 2 kV accelerating voltage. Images of LRS granules at ×500 and ×2000 magnification were observed and collected.The colors of granular and gelatinized LRS samples were determined using an UltraScan PRO spectrophotometer  following CIE guidelines. The whiteness value was calculated from Equation (1) :(1)Whitein vitro was determined by a method proposed by Englyst et al. [The enzymatic digestibility of the LRS samples t et al. , with mot et al. . LRP . Spectra were scanned at a resolution of 4 cmThe crystalline patterns of five LRS samples from 5° to 40° (2 θ) were obtained using an X-ray diffractometer  with a scanning speed of 2°/min and a step size of 0.02° as the X-ray source at 30 mA and 40 kV. The relative crystallinity (RC) of the LRS samples was calculated by MDI Jade software v6.w/v, DB) LRS in water or oil were gently stirred at ambient temperature for 30 min in preweighed centrifuge tubes, followed by centrifugation at 3500× g for 10 min. The water and oil retention capacities were calculated using Equations (2) and (3), respectively:The suspensions of 10%  LRS suspensions were heated at 50, 60, 70, 80, and 90 °C for 30 min in a water bath with regular stirring. The sample was then naturally cooled and centrifuged , and the sediment and supernatant were separated. The swelling power and solubility were calculated by Equations (4) and (5), respectively:The 2% . The 3 mg LRS sample (DB) was sealed with 6 μL deionized water in the sample pan and equilibrated for 12 h. The sample pans and the empty reference pan were heated from 30 to 100 °C at a rate of 10 °C/min.w/v, DB) went through a programmed heating-cooling cycle as follows: heat at 25 °C for 60 s, heat from 25 °C to 100 °C at 10 °C/min, hold at 100 °C for 600 s, cool to 25 °C at 10 °C/min, and store at 25 °C for 60 s. The shear rate and gap were set at 200 s−1 and 500 μm, respectively.Following a procedure by Jin and Xu , the pasw/v, DB), heated at 95 °C, and stirred regularly. After cooling, LRS gels were prepared. The gel microstructure of LRS was photographed by a cryogenic transfer scanning electron microscopy system (cryo-SEM). After the LRS gel sample was pre-frozen in liquid nitrogen slush, it was transferred to the cooled stage of the preparation chamber  under vacuum. Frozen samples were subjected to fracture, sublimation , and sputtering Pt coating followed by imaging in the cryo-stage SU8010 SEM . Moreover, the cryo-SEM images were analyzed using AngioTool software v0.5 for quantitative network analysis [The LRS samples were dispersed in deionized water to create suspensions . The samples were stored at 4 °C for 5 days, and the turbidity was measured and recorded at 640 nm UV absorbance every 24 h [LRS was dispersed in water and heated at 95 °C for 30 min with regular agitation to prepare the suspension  was heated to 95 °C for 30 min with regular agitation. The gel samples obtained were thawed in a 30 °C water bath for 3 h after 24 h of freezing at −18 °C and centrifuged at 6000× g for 15 min to remove the supernatant. Then, the syneresis was calculated using Equation (6). The number of freeze–thaw cycles was set to 5 in this experiment.The freeze–thaw stability of starch materials is directly related to their application in frozen food . In addip < 0.05 were considered significant. In addition, principal component analysis (PCA) and Pearson correlation were used to find the relationships between the studied variables, and all graphs were drawn with Origin software v9.8.Triplicate determinations were performed. The data were subjected to variance analysis and expressed as the means ± standard deviations. Multiple comparisons were performed between the two groups using the S-N-K method, and levels of p < 0.05), and the ranges were 74.4–120.3 g/kg, 718.8–886.7 g/kg, and 3.5–11.8 g/kg, respectively. Among them, LRS-5 had the highest starch content, and LRS-3 contained a higher ash content. Compared to the other four, the starch content of LRS-5 and ash content of LRS-3 were 1.1–1.2-fold and 2.4–3.4-fold greater, respectively. This result indicated the possibility that LRS-5 exhibited higher starch purity, and LRS-3 exhibited lower starch purity. In addition to the significant starch components, LRS also contained tiny amounts of proteins, lipids, and beneficial metal elements  is the amylose and amylopectin long-chain (DP > 60) component content determined by the iodine-binding method, which is generally the key determinant of the processing, cooking, and eating quality of starch products . In partThe morphology of starch granules is among its basic physical properties and could be used to roughly distinguish the classification of starch . The grain vitro enzymatic digestive properties of the five LRS samples are presented in p < 0.01) but positively correlated with AAC . The results indicated that LRS powder with high ash content had relatively poor anti-digestibility, and higher AAC content contributed to the resistance of starch to hydrolysis. Therefore, higher AAC in LRS might have specific health benefits in terms of delayed starch digestion. Moreover, it has been reported that high-amylose starch is less easily hydrolyzed than normal starch and waxy starch, which may result from the highly dense amorphous region in high-amylose starch granules due to the extensive interchain binding of amylose polymers [The polymers ,49. Ther−1), and 1022/995 cm−1 was related to the ratio of amorphous to ordered structure [−1 and 1045/1022 cm−1, as shown in p < 0.05) correlated with the structural properties of LRS (1045/1022 (Pearson correlation coefficient −0.93599) or RC (−0.95901) but positively correlated with R1022/995 (0.71926). As the crucial parameters of starch granules, the structural and crystal properties significantly influenced the physicochemical and functional properties of starch. It was suggested that LRS with higher AAC was characterized by lower short-range and long-range order as well as a higher amorphous region, which further contributed to the slower digestibility; this result has been confirmed with the millet starch data [The degree of short-range ordered structure in the outer region of starch was usually quantified by the ratio of absorbance  of the five LRS samples ranged from 63.7 °C to 68.9 °C, which mainly resulted from double-helix crystallization dissociation [To), Tp, and conclusion temperature (Tc), indicating that a relatively low amount of energy is needed to initiate gelatinization; this could be related to the higher ash content of LRS-3  otructure . A possigranules . TherefoThe pasting properties of starch are commonly quantified via the temperature-dependent viscosity of starch dispersion; these properties mainly depend on certain factors, such as RC, swelling power, amylose leaching, and friction between swollen granules . The pasAfter gelatinization, the swelling starch granules ruptured into fragments and aggregated to form a starch paste . The visTypically, the light transmittance of gelatinized starch is mainly related to the degree by which starch undergoes molecular rearrangement after gelatinization and retrogradation, which could reflect the retrograde trend of starch hydrogels during short-term storage . A higheFreeze-thaw stability is among the critical factors that reflects the stability of the food quality of starch-based foods during temperature changes . Syneresin vitro enzymatic digestion, with a digestibility of less than 23%, among which LRS-5 contained the most RS, mainly due to its smoother granule surface, lower fragmentation, and higher AAC. In conclusion, this study could provide a theoretical basis for the appropriate applications of LRS as a hydrogel matrix in future food realms, such as nutrition enhancement and additive manufacturing, through the provision of knowledge on the physicochemical properties of LRS from different regions.LRS from different regions exhibited varying physicochemical properties, mainly depending upon varied approximate compositions and structural characteristics. The ash content, AAC, and ordered structure were significantly correlated with the physicochemical properties of granular and gelatinized LRS. LRS with more intact and smooth granule morphology and higher AAC exhibited better swelling, gelatinization viscosity, network structure firmness, light transmittance, and freeze-thaw stability. In comparison, LRS with higher ash content, especially iron content, showed less RS, lower swelling power and gelatinization temperature, a darker gel color, and looser microstructure. The differences in thermal and pasting properties among LRS samples were probably the result of a combination of multiple factors, including starch granule morphology, ash content, AAC, as well as short- and long-range ordered structure. In addition, LRS was resistant to


Several surgical techniques have been described to restore the anatomy of the medial collateral ligament, involving suture repair and reconstruction, with the latter having been associated with superior postoperative outcomes. Recently, a growing interest in anatomic isometric medial collateral ligament reconstruction (MCLR) has been developed, involving careful evaluation and finding the most appropriate location for the femoral placement of the allograft. Therefore, the purpose of this article is to describe anatomic MCLR aiming to restore medial knee stability by focusing on isometric positions within the native anatomy of the MCL. Anatomic technique for medial collateral ligament (MCL) reconstruction performed using flattened double-bundle allograft such as peroneus longus or semitendinosus graft. Intraoperative physical examination includes valgus stress testing at 0° and 20°. The surgical procedure begins with the patient positioned supine on the operating room table. A skin incision is made extending from the medial femoral condyle to the pes anserinus. The fascia overlying the pes anserinus is thereafter opened in such a manner that it can be closed afterward. The anterior and posterior borders of the distal MCL are visualized, and a K-wire is placed at the center of the distal tibial insertion of the superficial MCL (sMCL), approximately 6 cm below the joint line. The femoral MCL insertion is visualized and palpated, and a K-wire is placed in the anatomic center of the MCL origin. Graft isometry is checked throughout joint range of motion by wrapping a suture around both K-wires. The ends of the suture are then clamped at the proximal femoral K-wire. Suture displacement should not exceed 1 to 2 mm as the knee is ranged from flexion to extension, starting from 30°. Once graft isometry has been confirmed, one 5.5-mm Healix Advance PEEK anchor and one 5.5-mm Healix Advance BR anchor with 4 nonabsorbable sutures and needles are placed: one at the distal tibial insertion of the sMCL and the other about 10 mm below the joint line, central to the course of the native MCL, at the proximal insertion of the sMCL. The femoral guidewire is removed and changed to a Beath pin to pass the sutures. The looped MCL allograft is thereafter placed and tied firmly to the distal tibial sMCL suture anchor. Each graft arm is additionally tied to the proximal tibial suture anchor to provide a second tibial attachment closer to the joint line. Both proximal graft ends are now whipstitched together at a length of at least 25 mm using a No. 2 nonabsorbable suture. Any excess graft should be removed at this point. The femoral guidewire is then over-reamed using a drill based on the diameter of the whipstitched graft. The lead sutures are shuttled through the bone tunnel and lateral soft tissue using the Beath pin, allowing the insertion of the graft into the bone tunnel. With the knee in 30° of knee flexion and neutral rotation, a fully threaded cannulated Bioresorbable Matryx Interference Screw is inserted over a nitinol guidewire. The sutures of the proximal and distal tibial suture anchors are now used to tie the MCL graft with whipstitches to the native MCL, followed by cutting of the remaining sutures, to obtain the final flat double-bundle MCL reconstruction. After induction of general anesthesia, a well-padded tourniquet is placed around the thigh and knee examination is performed including ligament tests, such as the valgus stress test at 0° and 20°. The lower extremity is thereafter prepared and draped according to standard sterile routine.Possible graft choices include both autograft and allograft. Autograft options include the semitendinosus tendon and the anterior half of the peroneus longus tendon. We, however, prefer allograft to reduce donor-site morbidity and to prevent weakness on the medial side of the knee. The semitendinosus tendon is an important dynamic stabilizer to valgus stressThe allograft is opened and thawed in normal saline solution. The graft is placed on a graft preparation station and measured to the appropriate length of at least 25 cm. If an autograft is used, all muscle tissue should be removed. The graft is looped, providing an about 9- to 10-mm-thick, double-bundle construct.A skin incision is made extending from the medial femoral condyle to the pes anserinus  A Video . If a miThe fascia overlying the pes anserinus is opened in such a manner that it can be closed afterward. The anterior and posterior borders of the distal MCL are visualized, and a K-wire is placed right at the center of the distal insertion of the sMCL, approximately 6 cm below the joint line and just above the pes anserinus insertion. One should note that special care must be taken to place the K-wire at the center of the distal MCL insertion because placement too far anterior or posterior will significantly affect graft isometry.The femoral MCL insertion is visualized and palpated, and a K-wire is placed in the anatomic center of the MCL origin. The landmarks on the medial side of the femoral condyle should be studied extensively in advance as the adductor tubercle often serves as the light house of the medial side. The anatomic MCL origin can be found approximately 1 cm anterior and distal to the adductor tubercle. In case of extensive scarring after femoral MCL injury, it can be challenging to identify the correct origin of the MCL, and special care must be taken to identify the correct anatomic K-wire position to provide optimal graft isometry. To avoid tunnel collision during multiligament surgery, the K-wire should be directed 30° anteriorly and 30° proximally.Graft isometry is checked throughout joint range of motion by wrapping a suture around both K-wires. The ends of the suture are then clamped at the proximal femoral K-wire. Suture displacement should not exceed 1 to 2 mm as the knee is ranged from flexion to extension, starting from 30° B.Once graft isometry has been confirmed, a 5.5-mm Healix Advance PEEK (polyether ether ketone) anchor (DePuy Synthes Mitek) (anchor 1) with 4 nonabsorbable sutures and needles is placed at the distal insertion of the sMCL A. The prThe looped MCL graft is now placed and tied firmly to the distal tibial suture anchor (anchor 1) . Each grBoth proximal graft ends are now whipstitched together at a length of approximately 25 to 30 mm using a No. 2 nonabsorbable suture. Any excess graft should be removed. It is recommended to insert the graft into the femoral tunnel at least 25 mm.The femoral guidewire is then over-reamed using a drill based on the diameter of the whipstitched graft. To facilitate MCL graft and interference screw placement, care should be taken to remove all soft tissue around the bone tunnel. The surgeon should make sure to over-drill at least 10 mm extra in the tunnel so that the graft can be tensioned correctly without reaching bone.The lead sutures are shuttled through the bone tunnel and lateral soft tissue using the Beath pin. Subsequently, the graft is inserted into the bone tunnel.With the knee in 30° of knee flexion and neutral rotation, a fully threaded cannulated Bioresorbable Matryx Interference Screw (ConMed) is inserted over a nitinol guidewire . It shouThe sutures of the proximal and distal tibial suture anchors are now used to tie the MCL graft with whipstitches to the native MCL. This provides additional fixation strength, stiffness, and flattening of the graft. The remaining sutures are cut to obtain the final flat double-bundle MCLR.After operative treatment of the MCL, the patient is recommended to wear a brace for approximately 6 weeks. Range of motion and weight bearing should be limited during the first 6 weeks, with a gradual increase in knee flexion after the first week. Full weight bearing can be started as soon as it is tolerated by the patient. Starting physical therapy as early as possible after MCLR is recommended to ensure both good postoperative strength and range of motion.The anatomic flat double-bundle MCLR described in this article is a surgical procedure aiming to restore medial knee stability in patients with MCL-deficient knees. Anatomic MCLR can be achieved by identifying the important landmarks for the MCL, including the femoral insertion of the MCL, as well as the tibial insertions of the sMCL . Intraop,,,,,,,Biomechanical and clinical studies have previously reported increased anteromedial and rotatory instability in MCL-deficient knees, thus increasing the risk of failure after ACLR.In conclusion, anatomic flat double-bundle MCLR is a treatment option for a MCL injury and we recommend performing this procedure when surgical treatment is indicated.


Correction to: International Journal of Behavioral Medicine (2019) 26:645–657 10.1007/s12529-019-09821-3The authors have provided a link to the dataset, which was not available at the time of publication. The additional link is 10.15125/BATH-01245.