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Background: A recent report has suggested that local injection of botulinum toxin type A is an effective method of treatment for chronic tennis elbow. The toxin is thought to provide temporary paralysis of the painful common extensor origin, thereby allowing a healing response to occur. To test this theory, we performed a double-blind, randomized, controlled, pilot trial comparing injections of botulinum toxin type A with those of a placebo (normal saline solution) in the treatment of chronic tennis elbow.Methods: Forty patients with a history of chronic tennis elbow for which all conservative treatment measures, including steroid injection, had failed were randomized into two groups. Half the patients received 50 units of botulinum toxin type A, and the remainder received normal saline solution. The intramuscular injections were performed 5 cm distal to the maximum point of tenderness at the lateral epicondyle, in line with the middle of the wrist. The two solutions used for the injections were identical in appearance and temperature. The results of a quality-of-life assessment with the Short Form-12 (SF-12), the pain score on a visual analogue scale, and the grip strength measured with a validated Jamar dynamometer were recorded before and three months after the injection.Results: Three months following the injections, there was no significant difference between the two groups with regard to grip strength, pain, or quality of life.Conclusions: With the numbers studied, we failed to find a significant difference between the two groups; thus, we have no evidence of a benefit from botulinum toxin injection in the treatment of chronic tennis elbow. [ABSTRACT FROM AUTHOR]

The scope of this study was to apply advances in materials science, specifically the use of organosilicate nanoparticles as a high surface area platform for passive sampling of chemicals or pre-concentration for active sensing in multiple-phase complex environmental media. We have developed a novel nanoporous organosilicate (NPO) film as an extraction phase and proof of concept for application in adsorbing hydrophobic compounds in water and sediment. We characterized the NPO film properties and provided optimization for synthesis and coatings in order to apply the technology in environmental media. NPO films in this study had a very high surface area, up to 1325 m 2 /g due to the high level of mesoporosity in the film. The potential application of the NPO film as a sorbent phase for sensors or passive samplers was evaluated using a model hydrophobic chemical, polychlorinated biphenyls (PCB), in water and sediment. Sorption of PCB to this porous high surface area nanoparticle platform was highly correlated with the bioavailable fraction of PCB measured using whole sediment chemistry, porewater chemistry determined by solid-phase microextraction fiber methods, and the Lumbriculus variegatus bioaccumulation bioassay. The surface-modified NPO films in this study were found to highly sorb chemicals with a log octanol-water partition coefficient (K ow ) greater than four; however, surface modification of these particles would be required for application to other chemicals.

Freshwater bivalve populations are stressed by watershed development at the global scale. Though pharmaceuticals released from wastewater treatment plant effluent discharges are increasingly reported to bioaccumulate in fish, an understanding of bioaccumulation in bivalves is less defined. In the present study, we examined accumulation of 12 target pharmaceuticals in C. fluminea during a 42 day in situ study in Pecan Creek, an effluent dependent wadeable stream in north central Texas, USA. Caged clams were placed at increasing distances (5 m, 643 m, 1762 m) downstream from a municipal effluent discharge and then subsampled on study days 7, 14, 28 and 42. Acetaminophen, caffeine, carbamazepine, diltiazem, diphenhydramine, fluoxetine, norfluoxetine, sertraline, desmethylsertraline, and methylphenidate were identified in C. fluminea whole body tissue homogenates via isotope dilution liquid chromatography-tandem mass spectrometry. Tissue concentrations ranged from low μg/kg (methylphenidate) to 341 μg/kg (sertraline). By study day 7, rapid and apparent pseudo-steady state accumulation of study compounds was observed in clams; this observation continued throughout the 42 d study. Notably, elevated bioaccumulation factors (L/kg) for sertraline were observed between 3361 and 6845, which highlights the importance of developing predictive bioaccumulation models for ionizable contaminants with bivalves. Future research is also necessary to understand different routes of exposure and elimination kinetics for pharmaceutical accumulation in bivalves., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Insensitive munitions (IMs) are replacing conventional munitions, improving safety from unintended detonation. IMs are deployed in mixture formulations but little is known about their mixture toxicology. We characterized mixture effects of the IM formulations IMX-101 (mixture of 2,4-dinitroanisole [DNAN], 3-nitro-1,2,4-triazol-5-one [NTO], and nitroguanidine [NQ]) and IMX-104 (DNAN, NTO, and hexahydro-1,3,5-trinitro-1,3,5-triazine [RDX]) in subchronic (10 d) and chronic (35 d) water-only tests in Hyalella azteca assessing impacts on survival, growth and reproduction. In 10-d single chemical exposures, DNAN was the most potent constituent, eliciting an LC50 of 16.0 mg/L; the LC50s for NTO and NQ were 891 and 565 mg/L, respectively. RDX did not elicit significant mortality up to 29.5 mg/L, a concentration near its solubility limit. Based on toxic-units (TUs), the toxicity of IMX-101 was driven by the effective concentration of DNAN; however, the presence of NTO, RDX, or both elicited interactive effects causing an approximately 2-fold decrease in lethality for IMX-104. Growth reduction was observed in 10-d exposures to DNAN, IMX-101 and IMX-104, but not for NQ, NTO, or RDX. Longer exposure duration (35 d) to IMX-101, IMX-104, and DNAN resulted in 3-6 times higher sensitivity for lethality and resulted in the most sensitive endpoint for DNAN, RDX, and IMX-101 exposures, decreased reproduction. Slight, but statistically significant, antagonistic responses among IMX-101 constituents were observed for survival and reproduction at 35d. Overall, the results support response-additive summation as a sufficient method to provide conservative hazard assessments of subchronic, chronic, and sublethal IMX-101 and IMX-104 mixture impacts in H. azteca., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Within the US military, new insensitive munitions (IMs) are rapidly replacing conventional munitions improving safety from unintended detonation. Toxicity data for IM chemicals are expanding rapidly, however IM constituents are typically deployed in mixture formulations, and very little is known about their mixture toxicology. In the present study we sought to characterize the mixture effects and toxicology of the two predominant IM formulations IMX-101 and IMX-104 in acute (48 h) larval fathead minnow (Pimephales promelas) exposures. IMX-101 consists of a mixture of 2,4-dinitroanisole (DNAN), 3-nitro-1,2,4-triazol-5-one (NTO), and nitroguanidine (NQ) while IMX-104 is composed of DNAN, NTO, and hexahydro-1,3,5-trinitro-1,3,5-triazine (RDX). DNAN was the most potent constituent in IMX-101 eliciting an LC50 of 36.1 mg/L, whereas NTO and NQ did not elicit significant mortality in exposures up to 1040 and 2640 mg/L, respectively. Toxic unit calculations indicated that IMX-101 elicited toxicity representative of the component concentration of DNAN within the mixture. Toxicogenomic responses for the individual constituents of IMX-101 indicated unique transcriptional expression and functional responses characteristic of: oxidative stress, impaired energy metabolism, tissue damage and inflammatory responses in DNAN exposures; impaired steroid biosynthesis and developmental cell-signaling in NQ exposures; and altered mitogen-activated protein kinase signaling in NTO exposures. Transcriptional responses to the IMX-101 mixture were driven by the effects of DNAN where expression and functional responses were nearly identical comparing DNAN alone versus the fractional equivalent of DNAN within IMX-101. Given that each individual constituent of the IMX-101 mixture elicited unique functional responses, and NTO and NQ did not interact with DNAN within the IMX-101 mixture exposure, the overall toxicity and toxicogenomic responses within acute exposures to the IMX-101 formulation are indicative of "independent" mixture toxicology. Alternatively, in the IMX-104 exposure both DNAN and RDX were each present at concentrations sufficient to elicit lethality (RDX LC50 = 28.9 mg/L). Toxic-unit calculations for IMX-104 mixture formulation exposures indicated slight synergistic toxicity (ΣTU LC50 = 0.82, 95% confidence interval = 0.73-0.90). Unique functional responses relative to DNAN were observed in the IMX-104 exposure including responses characteristic of RDX exposure. Based on previous transcriptomics responses to acute RDX exposures in fathead minnow larvae, we hypothesize that the potentially synergistic responses within the IMX-104 mixture are related to interactive effects of each DNAN and RDX on oxidative stress mitigation pathways., (Published by Elsevier B.V.)

Insensitive munitions (IMs) improve soldier safety by decreasing sympathetic detonation during training and use in theatre. IMs are being increasingly deployed, although the environmental effects of IM constituents such as nitroguanidine (NQ) and IM mixture formulations such as IMX-101 remain largely unknown. In the present study, we investigated the acute (96h) toxicity of NQ and IMX-101 to zebrafish larvae (21d post-fertilization), both in the parent materials and after the materials had been irradiated with environmentally-relevant levels of ultraviolet (UV) light. The UV-treatment increased the toxicity of NQ by 17-fold (LC50 decreased from 1323mg/L to 77.2mg/L). Similarly, UV-treatment increased the toxicity of IMX-101 by nearly two fold (LC50 decreased from 131.3 to 67.6mg/L). To gain insight into the cause(s) of the observed UV-enhanced toxicity of the IMs, comparative molecular responses to parent and UV-treated IMs were assessed using microarray-based global transcript expression assays. Both gene set enrichment analysis (GSEA) and differential transcript expression analysis coupled with pathway and annotation cluster enrichment were conducted to provide functional interpretations of expression results and hypothetical modes of toxicity. The parent NQ exposure caused significant enrichment of functions related to immune responses and proteasome-mediated protein metabolism occurring primarily at low, sublethal exposure levels (5.5 and 45.6mg/L). Enriched functions in the IMX-101 exposure were indicative of increased xenobiotic metabolism, oxidative stress mitigation, protein degradation, and anti-inflammatory responses, each of which displayed predominantly positive concentration-response relationships. UV-treated NQ had a fundamentally different transcriptomic expression profile relative to parent NQ causing positive concentration-response relationships for genes involved in oxidative-stress mitigation pathways and inhibited expression of multiple cadherins that facilitate zebrafish neurological and retinal development. Transcriptomic profiles were similar between UV-treated versus parent IMX-101 exposures. However, more significant and diverse enrichment as well as greater magnitudes of differential expression for oxidative stress responses were observed in UV-treated IMX-101 exposures. Further, transcriptomics indicated potential for cytokine signaling suppression providing potential connections between oxidative stress and anti-inflammatory responses. Given the overall results, we hypothesize that the increased toxicity of UV-irradiated NQ and the IMX-101 mixture result from breakdown products with elevated potential to elicit oxidative stress., (Published by Elsevier B.V.)

Life cycle assessment (LCA) has considerable merit for holistic evaluation of product planning, development, production, and disposal, with the inherent benefit of providing a forecast of potential health and environmental impacts. However, a technical review of current life cycle impact assessment (LCIA) methods revealed limitations within the biological effects assessment protocols, including: simplistic assessment approaches and models; an inability to integrate emerging types of toxicity data; a reliance on linear impact assessment models; a lack of methods to mitigate uncertainty; and no explicit consideration of effects in species of concern. The purpose of the current study is to demonstrate that a new concept in toxicological and regulatory assessment, the adverse outcome pathway (AOP), has many useful attributes of potential use to ameliorate many of these problems, to expand data utility and model robustness, and to enable more accurate and defensible biological effects assessments within LCIA. Background, context, and examples have been provided to demonstrate these potential benefits. We additionally propose that these benefits can be most effectively realized through development of quantitative AOPs (qAOPs) crafted to meet the needs of the LCIA framework. As a means to stimulate qAOP research and development in support of LCIA, we propose 3 conceptual classes of qAOP, each with unique inherent attributes for supporting LCIA: 1) mechanistic, including computational toxicology models; 2) probabilistic, including Bayesian networks and supervised machine learning models; and 3) weight of evidence, including models built using decision-analytic methods. Overall, we have highlighted a number of potential applications of qAOPs that can refine and add value to LCIA. As the AOP concept and support framework matures, we see the potential for qAOPs to serve a foundational role for next-generation effects characterization within LCIA. Integr Environ Assess Manag 2016;12:580-590. Published 2015. This article is a US Government work and is in the public domain in the USA., (Published 2015. This article is a US Government work and is in the public domain in the USA.)

Carbon nanotubes were previously demonstrated to accumulate on the carapace and in the gut of daphnids in aquatic exposures. The purpose of the present study was to assess the effects of multiwalled carbon nanotube (MWCNT) exposure on the sublethal Daphnia magna endpoints swimming behavior, algal feeding, growth, and reproduction and to determine the relative magnitude of difference between lethal and sublethal toxicity thresholds in 48-h and 14-d exposures. A stable dispersion of MWCNTs was prepared using 100 mg/L natural organic matter (NOM), and all treatments were compared statistically to a NOM control. The swimming behavior endpoints of mean velocity and total distance moved were determined using digital tracking software. For the acute (48-h) exposure, a 50% lethal concentration (LC50) of 29.3 (23.6-36.3) mg/L and a 50% effective concentration (EC50) of 6.7 mg/L in the swimming velocity endpoint were determined. When swimming response was nonmonotonic below 2 mg/L, consistent reductions in velocity were observed at 6.9 mg/L and above. Median effect concentrations were lower in the chronic (14-d) bioassay. The 14-d LC50 was 4.3 mg/L (3.3-5.6 mg/L), and the reproduction EC50 was 5.0 mg/L. Lowest-observed-effect concentrations for survival and reproduction were 5.4 mg/L and 1.7 mg/L, respectively. Significantly fewer (23.1%) algal cells were consumed in the 3.9-mg/L treatment relative to the control. No significant effects on swimming behavior were observed for the 14-d bioassay. Less traditional sublethal endpoints such as swimming behavior and feeding rate may be especially important to assess for MWCNTs and other materials expected to be more physically than chemically toxic through mechanisms such as gut clogging., (Published 2015 Wiley Periodicals Inc. on behalf of SETAC. This article is a US Government work and is in the public domain in the United States of America.)

Introduction Four-corner arthrodesis with excision of the scaphoid is an accepted salvage procedure for scapholunate advanced collapse (SLAC) and scaphoid nonunion advanced collapse (SNAC) and has been performed in our unit for over 20 years. We have undertaken a retrospective review of 116 of these procedures performed in 110 patients between 1992 and 2009. Fifty-eight patients attended for a clinical evaluation, and 29 responded by postal questionnaire. Methods The surgical technique undertaken was standard. That is, through a dorsal approach the scaphoid and tip of the radial styloid were excised. The capitate, lunate, triquetrum, and hamate articular surfaces were then prepared down to bleeding bone. Bone grafts from the scaphoid and radial styloid were then inserted and fixation undertaken. For the latter, various methods were used, including Kirschner (K-)wires, staples, bone screws, but predominantly the Spider plate (Integra Life Sciences, USA). Thereafter the wrist was immobilized for a minimum period of 2 weeks prior to rehabilitation. Results Follow-up was done at a mean of 9 years and 4 months (range 3-19 years). All patients reported a significant improvement in pain relief and ∼50% of flexion extension, although only 40% of radioulnar deviation. Grip strength was again ∼50% of the contralateral side. Most patients reported a significant improvement in function with 87% returning to work. In addition, radiologic evaluation identified 28 patients (31%) who demonstrated ongoing signs of nonunion, particularly around the triquetrum. Fourteen of these (15%) underwent a further procedure, generally with success. Finally, none of the patients demonstrated any arthritic changes in the lunate fossa on follow-up X-ray, and all secondary procedures were undertaken within 2 years of the primary. Discussion This research has demonstrated that four-corner fusion fixed with a circular plate can result in a satisfactory outcome with a reduction in pain, a functional range of motion, and a satisfactory functional outcome. The bulk of the complications appear to occur in the first 2 years after surgery. Thereafter, analysis shows long-term satisfaction with little deterioration. Nonunion, particularly around the triquetrum, continues to be a problem, but it may be that this bone should be excised along with the scaphoid, resulting in a three-part fusion only. Alternatively, a simple capitolunate fusion may be satisfactory.

The manufacturing of explosives and their loading, assembling, and packing into munitions for use in testing on training sites or battlefields has resulted in contamination of terrestrial and aquatic sites that may pose risk to populations of sensitive species. The bioaccumulative potential of the conventional explosives 2,4,6-trinitrotoluene (TNT) and hexahydro-1,3,5-trinitro-1,3,5-triazine (RDX) and of the insensitive munitions (i.e., less shock sensitive) compound 2,4-dinitroanisole (DNAN) were assessed using the Northern leopard frog, Rana pipiens. Trinitrotoluene entering the organism was readily biotransformed to aminodinitrotoluenes, whereas no transformation products were measured for RDX or DNAN. Uptake clearance rates were relatively slow and similar among compounds (1.32-2.19 L kg(-1) h(-1) ). Upon transfer to uncontaminated water, elimination rate was very fast, resulting in the prediction of fast time to approach steady state (5 h or less) and short elimination half-lives (1.2 h or less). A preliminary bioconcentration factor of 0.25 L kg(-1) was determined for the insensitive munitions compound 3-nitro-1,2,4-trizole-5-one (NTO) indicating negligible bioaccumulative potential. Because of the rapid elimination rate for explosives, tadpoles inhabiting contaminated areas are expected to experience harmful effects only if under constant exposure conditions given that body burdens can rapidly depurate preventing tissue concentrations from persisting at levels that may cause detrimental biological effects., (© 2014 SETAC.)

An initiative within the US military is targeting the replacement of traditional munitions constituents with insensitive munitions to reduce risk of accidental detonation. The purpose of the present study was to comparatively assess toxicity of the traditional munitions constituents 2,4,6-trinitrotoluene (TNT) and 1,3,5-trinitroperhydro-1,3,5-triazine (RDX) with the new insensitive munitions constituents 2,4-dinitroanisole (DNAN) and 3-nitro-1,2,4-triazol-5-one (NTO). The following exposure durations were performed with Rana pipiens (leopard frog) tadpoles: TNT and DNAN, 96 h and 28 d; RDX, 10 d and 28 d; NTO, 28 d. The 96-h 50% lethal concentration (LC50) values and 95% confidence intervals for TNT and DNAN were 4.4 mg/L (4.2 mg/L, 4. 7 mg/L) and 24.3 mg/L (21.3 mg/L, 27.6 mg/L), respectively. No significant impacts on survival were observed in the 10-d exposure to RDX up to 25.3 mg/L. Effects on tadpole swimming distance were observed with a lowest-observed-effect concentration (LOEC) of 5.9 mg/L RDX. In the 28-d exposures, the LOECs for survival for TNT, DNAN, and NTO were 0.003 mg/L, 2.4 mg/L, and 5.0 mg/L, respectively. No significant mortality was observed in the RDX chronic 28-d exposure up to the highest treatment level tested of 28.0 mg/L. Neither tadpole developmental stage nor growth was significantly affected in any of the 28-d exposures. Rana pipiens were very sensitive to chronic TNT exposure, with an LOEC 3 orders of magnitude lower than those for insensitive munitions constituents DNAN and NTO., (© 2015 SETAC.)

Purpose: To determine the survivorship and clinical outcomes of ulnar head arthroplasty., Methods: The study design included a review of medical records and clinical assessment of all patients who had an ulnar head arthroplasty more than 2 years previously. Survivorship of 79 implants in 74 patients was determined. Forty-seven of these patients participated in a clinical review using the Patient Examination Measure, Patient-Related Wrist Examination, Wrightington Wrist Score, and EQ5D to measure outcomes. Analysis of outcomes was performed for diagnostic subgroups (inflammatory arthritis, posttraumatic, osteoarthritis/impingement, and other), primary versus revision surgery, and whether the procedure was performed for ulnar stump instability (related to either a previous Darrach or Sauvé-Kapandji procedure)., Results: The 5- and 15-year survival of the implants was 90% for both, with mean follow-up of 7 ± 4 years. Mean age at surgery was 50 ± 13 years (range, 24-76). Mean range of motion was within the functional range and grip strength was 67% that of the contralateral side. Patient satisfaction was generally high, but outcomes scores indicated substantial residual disability. Overall scores were 41 for the Patient Examination Measure, 52 for the Patient-Related Wrist Examination, and 70 for the WWS. Patients in the "other" category had the worst scores for all measures. Patients with prior wrist surgery had poorer outcomes than those for whom the arthroplasty was a primary procedure. Patients with posttraumatic diagnoses had worse EQ5D scores and were less likely to recommend the procedure to others., Conclusions: Ulnar head arthroplasty had good long-term survival and acceptable patient satisfaction. Substantial disability remained in all groups, with the posttraumatic, "other", and revision groups faring worse. Patients should be counseled about the expected outcomes of this specialized procedure as they pertain to the patient's specific situation., Type of Study/level of Evidence: Therapeutic IV., (Copyright © 2014 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Depleted uranium (DU) from the military testing and use of armor-piercing kinetic energy penetrators has been shown to accumulate in soils; however, little is known about the toxicity of DU geochemical species created through corrosion or weathering. The purpose of the present study was to assess the toxic effects and bioaccumulation potential of field-collected DU oxides to the model terrestrial invertebrates Eisenia fetida (earthworm) and Porcellio scaber (isopod). Earthworm studies were acute (72 h) dermal exposures or 28-d spiked soil exposures that used noncontaminated field-collected soils from the US Army's Yuma and Aberdeen Proving Grounds. Endpoints assessed in earthworm testing included bioaccumulation, growth, reproduction, behavior (soil avoidance), and cellular stress (neutral red uptake in coelomocytes). Isopod testing used spiked food, and endpoints assessed included bioaccumulation, survival, and feeding behavior. Concentration-dependent bioaccumulation of DU in earthworms was observed with a maximum bioaccumulation factor of 0.35; however, no significant reductions in survival or impacts to cellular stress were observed. Reproduction lowest-observed-effect concentrations (LOEC) of 158 mg/kg and 96 mg/kg were observed in Yuma Proving Ground and a Mississippi reference soil (Karnac Ferry), respectively. Earthworm avoidance of contaminated soils was not observed in 48-h soil avoidance studies; however, isopods were shown to avoid food spiked with 12.7% by weight DU oxides through digital tracking studies., (© 2014 SETAC.)

There is an increasing likelihood of interactions between nanomaterials and munitions constituents in the environment resulting from the use of nanomaterials as additives to energetic formulations and potential contact in waste streams from production facilities and runoff from training ranges. The purpose of the present research was to determine the ability of nano-aluminum oxide (Al(2)O(3)) and multiwalled carbon nanotubes (MWCNTs) to adsorb the munitions constituents cyclotrimethylenetrinitramine (RDX) and tungsten (W) from aqueous solution as a first step in determining the long-term exposure, transport, and bioavailability implications of such interactions. The results indicate significant adsorption of RDX by MWCNTs and of W by nano-Al(2)O(3) (but not between W and MWCNT or RDX and nano-Al(2)O(3)). Kinetic sorption and desorption investigations indicated that the most sorption occurs nearly instantaneously (<5 min), with a relatively slower, secondary binding leading to statistically significant but relatively smaller increases in adsorption over 30 d. The RDX sorption that occurred during the initial interaction was irreversible, with long-term, reversible sorption likely the result of a secondary interaction; as interaction time increased, however, the portion of W irreversibly sorbed onto nano-Al(2)O(3) also increased. The present study shows that strong interactions between some munitions constituents and nanomaterials following environmental release are likely. Time-dependent binding has implications for the bioavailability, migration, transport, and fate of munitions constituents in the environment., (© 2014 SETAC.)

Triaminoguanidinium-1-methyl-5-nitriminotetrazolate (TAG-MNT) is a nitrogen-rich energetic compound being developed as a potential component of insensitive munition formulations. The purpose of the present study was to assess the toxicity of TAG-MNT to the green alga Pseudokirchneriella subcapitata as well as to determine whether the high N content of TAG-MNT could result in increased algal growth in aquatic systems and potentially contribute to eutrophication using a 96-h algal growth bioassay in N-limited test media. Results were compared with algal exposures to current-use energetics 2,4,6-trinitrotoluene (TNT) and royal demolition explosive (RDX). The TNT exposure resulted in a lowest-observed-adverse-effect concentration (LOAEC) for algal growth of 1.72 mg/L and a 50% inhibition concentration (IC50) and 95% confidence limits of 0.972 mg/L (0.955, 0.973). The RDX algal growth LOAEC was 0.10 mg/L, and the RDX IC50 was 0.635 (0.416, 0.875). Neither TNT nor RDX exposure resulted in stimulation of algal growth. In repeated testing, TAG-MNT exposure resulted in LOAECs of 0.55 and 5.20 mg/L. Stimulation of algal growth was observed at 0.06 mg/L at a mean increase of 163.2% (± 71.7) relative to the control in TAG-MNT test A and at the 0.005 mg/L treatment at a mean increase of 174.3% (± 59.9) in TAG-MNT test B. The authors' results indicate the potential for high-N energetics to significantly stimulate algal growth at low concentrations in N-limited systems., (© 2013 SETAC. This article is a US Government work and is in the public domain in the USA.)

Polybrominated diphenyl ethers are compounds widely used as flame-retardants, which are of increasing environmental concern due to their persistence, and potential adverse effects. This study had two objectives. First, we assessed if BDE-209 in sediment was bioavailable and bioaccumulated into zebrafish embryos. Secondly, we assessed the potential impact on human and environmental health of bioavailable BDE-209 using human in vitro cell assays and zebrafish embryos. Zebrafish were exposed from 4h to 8days post-fertilization to sediments spiked with 12.5mg/kg of BDE-209. Zebrafish larvae accumulated ten fold more BDE-209 than controls in unspiked sediment after 8days. BDE-209 impacted expression of neurological pathways and altered behavior of larvae, although BDE-209 had no visible affect on thyroid function or motoneuron and neuromast development. Zebrafish data and in silico predictions suggested that BDE-209 would also interact with key human transcription factors and receptors. We therefore tested these predictions using mammalian in vitro assays. BDE-209 activated human aryl hydrocarbon receptor, peroxisome proliferator activating receptors, CF/b-cat, activator protein 1, Oct-MLP, and the estrogen receptor-related alpha (ERRα) receptor in cell-based assays. BDE-209 also inhibited human acetylcholinesterase activity. The observation that BDE-209 can be bioaccumulated from contaminated sediment highlights the need to consider this as a potential environmental exposure route. Once accumulated, our data also show that BDE-209 has the potential to cause impacts on both human and environmental health., (Copyright © 2013 Elsevier Ltd. All rights reserved.)

A hormetic response is characterized by an opposite effect in small and large doses of chemical exposure, often resulting in seemingly beneficial effects at low doses. Here, we examined the potential mechanisms underlying the hormetic response of Daphnia magna to the energetic trinitrotoluene (TNT). Daphnia magna were exposed to TNT for 21 days, and a significant increase in adult length and number of neonates was identified at low concentrations (0.002-0.22 mg/L TNT), while toxic effects were identified at high concentrations (0.97 mg/L TNT and above). Microarray analysis of D. magna exposed to 0.004, 0.12, and 1.85 mg/L TNT identified effects on lipid metabolism as a potential mechanism underlying hormetic effects. Lipidomic analysis of exposed D. magna supported the hypothesis that TNT exposure affected lipid and fatty acid metabolism, showing that hormetic effects could be related to changes in polyunsaturated fatty acids known to be involved in Daphnia growth and reproduction. Our results show that Daphnia exposed to low levels of TNT presented hormetic growth and reproduction enhancement, while higher TNT concentrations had an opposite effect. Our results also show how a systems approach can help elucidate potential mechanisms of action and adverse outcomes.

Though decentralized on-site technologies are extensively employed for wastewater treatment around the globe, an understanding of effluent water quality impairments associated with these systems remain less understood than effluent discharges from centralized municipal wastewater treatment facilities. Using a unique experimental facility, a novel comparative analysis of effluent water quality was performed from model decentralized aerobic (ATS) and septic (STS) on-site wastewater treatment systems and a centralized municipal wastewater treatment plant (MTP). The ATS and STS units did not benefit from further soil treatment. Each system received common influent wastewater from the Waco, Texas, USA Metropolitan Area Regional Sewerage System. We tested the hypothesis that MTP effluent would exhibit higher water quality than on-site effluents, based on parameters selected for study. A tiered testing approach was employed to assess the three effluent discharges: select routine water quality parameters (Tier I), whole effluent toxicity (Tier II), and select endocrine-active compounds (Tier III). Contrary to our hypothesis, ATS effluent was not statistically different from MTP effluents, based on Tier I and III parameters, but reproductive responses of Daphnia magna were slightly more sensitive to ATS than MTP effluents. STS effluent water quality was identified as most degraded of the three wastewater treatment systems. Parameters used to assess centralized wastewater treatment plant effluent water quality such as whole effluent toxicity and endocrine active substances appear useful for water quality assessments of decentralized discharges. Aerobic on-site wastewater treatment systems may represent more robust options than traditional septic systems for on-site wastewater treatment in watersheds with appreciable groundwater - surface water exchange., (Copyright © 2013 Elsevier Ltd. All rights reserved.)

On December 22, 2008, failure of an earthen containment structure resulted in the release of approximately 4.1 million m(3) of coal fly ash into the Emory River and the surrounding area from the Tennessee Valley Authority Kingston Fossil Plant near Kingston, Tennessee, USA. The purpose of the present study was to assess the potential of dredging activities performed to remove the fly ash from the river to result in increased risk to pelagic fish, with special consideration of mobilization of metals. Elutriates were created using two sources of fly ash by bubbling with air over 10 d. This elutriate preparation method was designed to represent worst-case conditions for oxidation, metal release, and dissolution. Larval and juvenile Pimephales promelas underwent 10-d exposures to these elutriates. Larval end points included survival and biomass, and juvenile end points included survival, length, biomass, liver somatic index, and bioaccumulation. No significant toxicity was observed. Bioaccumulation of metals in juveniles was found to be primarily attributable to metals associated with particles in the gut. Results suggest little potential for toxicity to related fish species due to fly ash removal dredging activities given the extreme conditions represented by the elutriates in the present study., (Copyright © 2013 SETAC.)

Studies investigating the impact of particle size and capping agents on nanosilver toxicity in pristine laboratory conditions are becoming available. However, the relative importance of known environmental mitigating factors for dissolved silver remains poorly characterized for nanosilver in context with existing predictive toxicity models. This study investigated the implications of freshly prepared versus stored 20 and 100 nm nanosilver stocks to freshwater zooplankton (Ceriodaphnia dubia) in presence and absence of dissolved organic carbon (DOC). Results indicated that while the acute toxicity of nanosilver decreased significantly with larger size and higher DOC, storage resulted in significant increases in toxicity and ion release. The most dramatic decrease in toxicity due to DOC was observed for the 20 nm particle (2.5-6.7 fold decrease), with more modest toxicity reductions observed for the 100 nm particle (2.0-2.4 fold) and dissolved silver (2.7-3.1 fold). While a surface area dosimetry presented an improvement over mass when DOC was absent, the presence of DOC confounded its efficacy. The fraction of dissolved silver in the nanosilver suspensions was most predictive of acute toxicity regardless of system complexity. Biotic Ligand Model (BLM) predictions based on the dissolved fraction in nanosilver suspensions were comparable to observed toxicity.

Interspecies uncertainty factors in ecological risk assessment provide conservative estimates of risk where limited or no toxicity data is available. We quantitatively examined the validity of interspecies uncertainty factors by comparing the responses of zebrafish (Danio rerio) and fathead minnow (Pimephales promelas) to the energetic compound 1,3,5-trinitroperhydro-1,3,5-triazine (RDX), a known neurotoxicant. Relative toxicity was measured through transcriptional, morphological, and behavioral end points in zebrafish and fathead minnow fry exposed for 96 h to RDX concentrations ranging from 0.9 to 27.7 mg/L. Spinal deformities and lethality occurred at 1.8 and 3.5 mg/L RDX respectively for fathead minnow and at 13.8 and 27.7 mg/L for zebrafish, indicating that zebrafish have an 8-fold greater tolerance for RDX than fathead minnow fry. The number and magnitude of differentially expressed transcripts increased with increasing RDX concentration for both species. Differentially expressed genes were enriched in functions related to neurological disease, oxidative-stress, acute-phase response, vitamin/mineral metabolism and skeletal/muscular disorders. Decreased expression of collagen-coding transcripts were associated with spinal deformity and likely involved in sensitivity to RDX. Our work provides a mechanistic explanation for species-specific sensitivity to RDX where zebrafish responded at lower concentrations with greater numbers of functions related to RDX tolerance than fathead minnow. While the 10-fold interspecies uncertainty factor does provide a reasonable cross-species estimate of toxicity in the present study, the observation that the responses between ZF and FHM are markedly different does initiate a call for concern regarding establishment of broad ecotoxicological conclusions based on model species such as zebrafish.

Purpose: To report the outcome and complications from pyrocarbon proximal interphalangeal (PIP) joint arthroplasty at a minimum of 2 years of follow-up., Methods: A retrospective case review was performed on 72 patients with an average age of 57 years, and a total of 97 pyrocarbon PIP joint arthroplasties. Patient demographics, diagnosis, implant revisions, and other repeat surgeries were recorded. Subjective outcome was evaluated at latest follow-up with the Disabilities of the Arm, Shoulder, and Hand score; Patient Evaluation Measure; and visual analog scores of pain, satisfaction, and appearance. Objective outcomes included PIP joint range of motion, grip strength, and radiographic assessment of alignment and loosening., Results: The principal diagnosis was primary osteoarthritis in 43 patients(60%), posttraumatic arthritis in 14 (19%), rheumatoid arthritis in 9 (13%), and psoriatic arthritis in 6 (8%). The average follow-up was 60 months (range, 24-108 mo). Twenty-two of 97 digits (23%) had repeat surgery without revision, and 13 digits (13%) had revision at an average of 15 months. There were no significant differences in preoperative and postoperative range of motion. The average Disabilities of the Arm, Shoulder, and Hand score was 22, and the average pain score was zero. Implant migration and loosening was observed but was not related to clinical outcome or revision., Conclusions: The survival of pyrocarbon PIP joint arthroplasty was 85% (83 of 97) at 5 years of follow-up, with high patient satisfaction. Patients should be advised that the procedure achieves good relief of pain but does not improve range of motion., Type of Study/level of Evidence: Therapeutic IV., (Copyright © 2012 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Pharmaceuticals in the environment are often present at trace levels (e.g., ng/L) in surface waters and effluents of developed countries, yet represent contaminants of emerging concern. Attributes of many of these substances, such as potency, chirality, and ionization, present challenges to historical environmental risk assessment and management paradigms. In this chapter, we critically examine several important aspects of pharmaceuticals, specifically highlighting some of the lessons we have learned from studying these substances in the environment over the past 15 years. We submit that incorporating such "lessons learned" during environmental risk assessments promises to reduce uncertainties and support more sustainable management efforts., (Copyright © 2012 Elsevier Inc. All rights reserved.)

We assessed the impacts of exposure to an environmentally representative concentration (0.83 mg/L) of the explosive cyclotrimethylenetrinitramine (RDX) on fathead minnows (Pimephales promelas) in one-year and multigenerational bioassays. In the one-year bioassay, impacts were assessed by statistical comparisons of females from breeding groups reared in control or RDX-exposure conditions. The RDX had no significant effect on gonadosomatic index or condition factor assayed at 1 d and at one, three, six, nine, and 12 months. The liver-somatic index was significantly increased versus controls only at the 12-month timepoint. RDX had no significant effect on live-prey capture rates, egg production, or fertilization. RDX caused minimal differential-transcript expression with no consistent discernable effect on gene-functional categories for either brain or liver tissues in the one-year exposure. In the multigenerational assay, the effects of acute (96 h) exposure to RDX were compared in fish reared to the F(2) generation in either control or RDX-exposure conditions. Enrichment of gene functions including neuroexcitatory glutamate metabolism, sensory signaling, and neurological development were observed comparing control-reared and RDX-reared fish. Our results indicated that exposure to RDX at a concentration representing the highest levels observed in the environment (0.83 mg/L) had limited impacts on genomic, individual, and population-level endpoints in fathead minnows in a one-year exposure. However, multigenerational exposures altered transcript expression related to neural development and function. Environ., (Copyright © 2011 SETAC.)

A prospective longitudinal study was carried out on a cohort of 86 patients who had undergone surgery for diverse wrist conditions. Disabilities of Arm Shoulder and Hand questionnaire, a pain assessment, a wrist functional score, range of movement and grip strength measures were completed. The Mayo Clinic wrist score was also calculated. The World Health Organization International Classification of Function was used as a framework for analysis. The responsiveness of each outcome measure was calculated in terms of distribution- and anchor-based methods. Pain was the most important factor in determining outcome. Changes in objective measures were less important. The responsiveness of the various measures was similar except for the Mayo Clinic wrist score, which was less responsive than the others. Patient-completed measures currently in use are multidimensional. Classifying the content according to the International Classification of Function would clarify the effects of wrist surgery on the different aspects of health.

The volume of sediment required to perform a sediment toxicity bioassay is a major driver of the overall cost associated with that bioassay. Sediment volume affects bioassay cost because of sediment collection, transportation, storage, and disposal costs as well as labor costs associated with organism recovery at the conclusion of the exposure. The objective of the current study was to evaluate reduced sediment volume versions of the standard U.S. Environmental Protection Agency (U.S. EPA) 10-d acute Leptocheirus plumulosus method that uses a beaker size of 1,000 ml and 20 organisms. The test design used evaluated the effects of beaker size (250 and 100 ml) and associated sediment volume (75 and 30 ml, respectively) as well as organism loading density (10 and 20 organisms) on test endpoint responsiveness relative to the standard 10-d test method. These comparisons were completed with three different types of contaminated sediments: a field-collected polycyclic aromatic hydrocarbon (PAH)-contaminated sediment, a lead-spiked control sediment, and a control sediment spiked with mineral oil. Assessment criteria included test endpoint sensitivity, endpoint consistency, statistical power, water quality, and logistical assessments. Results indicate that the current U.S. EPA method is preferable to the reduced sediment volume methods we assessed, but that a 250-ml beaker/10 organism experimental design is of comparable utility and may be advantageous when reduced sediment volumes are desirable because of high contaminant (spiking studies) or sediment disposal costs. In addition, the results of the current study provide toxicity reference values for PAHs, lead, and an oil surrogate for petroleum hydrocarbons., (Copyright © 2010 SETAC.)

A storage pond dike failure occurred at the Tennessee Valley Authority Kingston Fossil Plant that resulted in the release of over 3.8 million cubic meters (5 million cubic yards) of fly ash. Approximately half of this material deposited in the main channel of the Emory River, 3.5 km upstream of the confluence of the Emory and Clinch Rivers, Tennessee, USA. Remediation efforts to date have focused on targeted removal of material from the channel through hydraulic dredging, as well as mechanical excavation in some areas. The agitation of the submerged fly ash during hydraulic dredging introduces river water into the fly ash material, which could alter the redox state of metals present in the fly ash and thereby change their sorption and mobility properties. A series of extended elutriate tests were used to determine the concentration and speciation of metals released from fly ash. Results indicated that arsenic and selenium species released from the fly ash materials during elutriate preparation were redox stable over the course of 10d, with dissolved arsenic being present as arsenate, and dissolved selenium being present as selenite. Concentrations of certain metals, such as arsenic, selenium, vanadium, and barium, increased in the elutriate waters over the 10d study, whereas manganese concentrations decreased, likely due to oxidation and precipitation reactions., (Published by Elsevier Ltd.)

In the patient in whom primary distal radioulnar joint surgery has failed, consideration must be given to the anatomy and biomechanics of the native joint; how this has been disrupted by injury, disease, and previous trauma; and what is required to reconstruct the joint. The forearm relies on a congruent condylar cam of the distal ulna, with intact soft tissue restraints for normal biomechanics. Surgical reconstruction using tendon graft, autologous bone graft, allograft interposition, and prosthetic reconstruction are discussed in this article. If these procedures fail, then salvage procedures including wide excision of the ulna or one-bone forearm can be performed., (Copyright © 2010 Elsevier Inc. All rights reserved.)

Nano-sized aluminum is currently being used by the military and commercial industries in many applications including coatings, thermites, and propellants. Due to the potential for wide dispersal in soil systems, we chose to investigate the fate and effects of nano-sized aluminum oxide (Al2O3), the oxidized form of nano aluminum, in a terrestrial organism. The toxicity and bioaccumulation potential of micron-sized (50-200 microm, nominal) and nano-sized (11 nm, nominal) Al2O3 was comparatively assessed through acute and subchronic bioassays using the terrestrial earthworm, Eisenia fetida. Subchronic (28-d) studies were performed exposing E. fetida to nano- and micron-sized Al2O3-spiked soils to assess the effects of long-term exposure. No mortality occurred in subchronic exposures, although reproduction decreased at >or=3,000 mg/kg nano-sized Al2O3 treatments, with higher aluminum body burdens observed at 100 and 300 mg/kg; no reproductive effects were observed in the micron-sized Al2O3 treatments. In addition to toxicity and bioaccumulation bioassays, an acute (48-h) behavioral bioassay was conducted utilizing a soil avoidance wheel in which E. fetida were given a choice of habitat between control, nano-, or micron-sized Al2O3 amended soils. In the soil avoidance bioassays, E. fetida exhibited avoidance behavior toward the highest concentrations of micron- and nano-sized Al2O3 (>5,000 mg/kg) relative to control soils. Results of the present study indicate that nano-sized Al2O3 may impact reproduction and behavior of E. fetida, although at high levels unlikely to be found in the environment., (Copyright (c) 2010 SETAC.)

Nano-aluminum oxide (Al(2)O(3)) is used commercially in coatings and abrasives. Nano-Al(2)O(3) can also be generated through the oxidation of nano-aluminum in military propellants and energetics. The purpose of the present study was to assess toxicity and bioaccumulation of nano-Al(2)O(3) to a variety of sediment organisms (Tubifex tubifex, Hyalella azteca, Lumbriculus variegatus, and Corbicula fluminea). The bioaccumulation and toxicity of nano-Al(2)O(3) was compared with that of micron-sized Al(2)O(3) to investigate potential size-related effects. Results of the present study show species-specific differences in relative bioaccumulation of nano and micron-sized Al(2)O(3). Significant toxic effects (survival and growth) were observed in H. azteca testing, but only at high concentrations unlikely to be found in the environment. Nano-Al(2)O(3) was found to be more toxic than micron-sized Al(2)O(3) to H. azteca survival in a 14-d study in which organisms were in direct contact with a thin layer of 625 or 2,500 mg of Al(2)O(3) dispersed on the surface of either sediment or sand. A significant growth effect was also observed for nano but not micron-sized Al(2)O(3) at the highest treatment level tested (100 g/kg Al(2)O(3)) in a 10-d H. azteca bioassay in which Al(2)O(3) was homogenized with sediment. However, differences in measured sediment Al concentrations (micron-sized = 55.1 [+/-0.6] g/kg Al; nano-sized = 66.2 [+/-0.6] g/kg Al) in the nano and micron-sized Al(2)O(3) preclude direct comparison of the toxicity of these two treatments based on particle size., (Copyright 2009 SETAC.)

Background: The radial and ulnar styloids as well as Lister's tubercle are important surgical landmarks in the surgical treatment of distal forearm fractures. There have been limited studies assessing their relative safety in terms of their distance from superficial nerves which are in danger during surgical procedures. The aim of this cadaveric study was to assess and compare the distance of superficial nerves to these important surgical landmarks., Methods: Twenty embalmed cadaveric upper limbs were dissected exposing the nerves and tendons around the wrist. The radial styloid, Lister's tubercle, ulnar styloid and nerve branches were marked with pins. The distance of the nearest nerve branch to each landmark was measured with a digital calliper. Statistical analysis of the data was performed using SPSS for Windows 11.5 (SPSS Inc., Chicago, IL) using Friedman Tests and Wilcoxon Signed Ranks tests., Results: The median distance of the nearest nerve branch to the radial styloid was 5.42 mm, to the Lister's tubercle was 16.68 mm and to the ulnar styloid was 13.56 mm. There was unequal safety for these three surgical landmarks regarding proximity to nerve branches (p < 0.00001). Paired comparison using Wilcoxon Signed Ranks Test showed that the Lister's tubercle was safer than the radial styloid (p < 0.0001) and ulnar styloid (p = 0.04). In addition, the ulnar styloid was safer than the radial styloid (p < 0.001)., Conclusions: There is a higher risk of injury to superficial nerves when operating near the radial styloid as it is significantly closer to nerve branches as compared to Lister's tubercle and ulnar styloid.

Purpose: Loosening is an important cause of failure of upper limb arthroplasty and improvement in cementation techniques may limit this. The currently accepted medullary canal preparation techniques use saline washing and gauze drying. Another method of bone preparation uses carbon dioxide compression gas jet which blows debris from the canal, whilst simultaneously drying the bone. We compared the push out strengths of cement plugs in sections of human cadaveric radii that had been prepared using either syringed saline or carbon dioxide jet cleaning., Methods: Following bone preparation, four radii in each group, were cemented in a standardised fashion, and cut into 1 cm sections. An Instron materials testing machine was used to measure the force needed to push the cement plug out of the bone section., Results: The force needed to push out the cement plug was significantly higher in the carbon dioxide jet (median 580.61, IQR 429.10-650.05) as compared to the saline group (median 366.57N, IQR 271.05-502.23), P = 0.009. The mechanism of failure of the bone-cement interface also differed between the two groups, with 100% of the sectioned cortices fracturing prior to cement extrusion in the carbon dioxide jet group, but only 23% of the sectioned cortices doing so in the saline group., Conclusion: Our results suggest that there is a statistically stronger macro-interlock at the bone-cement interface after preparation of the medullary canals of radii using a carbon dioxide compression gas jet as compared to saline irrigation.

Purpose: The aim of this cadaveric study was to assess and compare the distance of commonly used dorsal wrist portals to the dorsal ulnar and radial superficial nerves and their branches., Methods: Twenty embalmed cadaveric upper limbs were dissected, exposing the nerves and tendons, and wrist arthroscopy portal sites were marked with pins. The horizontal distance between the portals and closest nerve branch was measured with a digital caliper. Statistical analysis of the data was performed with SPSS software for Windows (version 11.5; SPSS, Chicago, IL) by use of Friedman tests and Wilcoxon signed rank tests., Results: The median distance of the nearest nerve branch to portal 1-2 was 1.82 mm; portal 3-4, 4.85 mm; portal 4-5, 16.13 mm; portal 6U, 2.47 mm; and midcarpal radial portal (MCP), 6.65 mm. The 4-5 portal was safer than the 1-2 portal (P < .0001), 3-4 portal (P = .015), MCP (P = .001), and 6U portal (P < .0001). The MCP was safer than the 1-2 portal (P = .01), 3-4 portal (P = .019), and 6U portal (P = .003)., Conclusions: The 4-5 portal is further away from a nerve branch than any other portal, followed by the MCP., Clinical Relevance: The results of this study may be of use in the planning of wrist arthroscopy.

A common distal radio-ulnar joint (DRUJ) stabilisation procedure uses a tendon graft running from the lip of the radial sigmoid notch to the ulnar fovea and through a bony tunnel to the ulnar shaft, before being wrapped round the distal ulna and sutured to itself. Such graft fixation can be challenging and requires a considerable tendon length. The graft length could be reduced by fixing the graft to the ulna using a bone anchor or interference screw. The aim of this study was to compare the strength of three distal ulna graft fixation methods (tendon wrapping and suturing, bone anchor and interference screw). Four human cadaveric ulnae were used. A tendon strip was run through a tunnel in the distal ulna and secured by: (1) wrapping round the shaft and suturing it to itself, (2) a bone anchor and (3) an interference screw in the bone tunnel. Load to failure was determined using a custom-made apparatus and an Instron machine. Maximum failure load was highest for the bone anchor fixation (99.3 +/- 23.7 N) followed by the suturing (96.2 +/- 12.1 N), and the interference screw fixation (46.9 +/- 5.6 N). There was no significant difference between the tendon suturing and bone anchor methods, but the tendon suturing was statistically significantly higher compared to the interference screw (P = 0.028). In performing anatomical stabilisation of the DRUJ fixation of the tendon graft to the distal ulna with a bone anchor provides the most secure fixation. This may make the stabilisation technique less demanding and require a smaller tendon graft.

Enantiomers of chiral contaminants can significantly differ in environmental fate as well as in effects. Despite this fact, such differences are often ignored in regulation and in practice, injecting uncertainty into the estimation of risk of chiral compounds. We review the unique challenges posed by stereochemistry to the ecological risk assessment of chiral contaminants and existing regulatory guidance for chiral pharmaceuticals and pesticides in the United States. We identify the advantages of obtaining data on fate and effects of each individual enantiomer of chiral contaminants that are either distributed as or may end up as enantiomer mixtures in the environment due to enantiomerization. Because enantiomers of the same compound are highly likely to coexist in the environment with each other and can result in nonadditive effects, we recommend treatment of enantiomers as components of a mixture using widely accepted mixture models from achiral risk assessment. We further propose the enantiomer hazard ratio for retrospectively characterizing relative enantiomer risk and examine uncertainty factor magnitudes for effects analysis.

The indications and applications for wrist arthroscopy continue to expand as new techniques and instrumentation evolve. Wrist arthroscopy is now the gold standard investigation for chronic wrist pain before definitive surgery. Although complications are uncommon, they may include infection, neuroma formation, tendon injury, dorsal skin slough, tourniquet neurapraxia, and reflex sympathetic dystrophy. We describe extensor tendon sheath fistula formation arising from the 3/4 portal after diagnostic wrist arthroscopy and our management in this novel case. The formation of a patent communication between the radiocarpal joint and the tendon sheath permitting the collection of synovial fluid has not previously been described.

After a wrist surgery in patients with rheumatoid arthritis, the extensor tendons have a tendency to shift toward the ulnar side of the wrist. This is caused by the dorsal tenosynovectomy, disruption of extensor retinaculum, and exteriorization and anatomical orientation of the superficial group of forearm extensor tendons. This article describes a technique as an adjunct to the wrist surgery, which aims to stabilize and centralize tendons of the fourth dorsal wrist compartment over the midline of the wrist. This is achieved by creating a distally based sling, harvested from the extensor carpi radialis longus tendon, then wrapped around the extensor digitorum communis and the extensor indicis proprius tendons, and finally anchored onto the extensor carpi radialis brevis. This adjunctive procedure is recommended in situations when after the wrist surgery, particularly wrist arthroplasty, tendons of the fourth dorsal wrist compartment tend to lay ulnar to the central axis of the hand.

There are few objective staging systems to assess severity of Dupuytren's disease (DD). Previous methods to assess severity of DD were based primarily on the degree of contracture of an affected digit measured using a goniometer. Nonetheless, this method of assessment alone may be incomplete, and other factors should be considered. White (n = 92) patients diagnosed with DD from northwest of England were assessed for DD. Objective criteria for evaluating severity incorporated quantified variables. The revised severity stage was correlated to a known staging system of DD (Tubiana's staging system) which measures total flexion deformity for a single affected digit. Total revised severity staging scores ranged between 4 and 53 (mean = 18.7) and revealed significant positive correlation to Tubiana's original staging system (r (2) = 0.8, p < 0.001). There was significant difference between severity staging scores in those with a positive family history compared to those without (p < 0.01). In current practice, often, the degree of contracture in an affected digit is used solely as a measure of disease severity. Additional objective clinical information may provide useful prognostic indices for disease progression as well as postoperative outcome.

We describe the use of a readily available ulnar shortening guide to perform large ulnar shortenings.