Conjunctivitis outbreak among divers.

In March 2006, an outbreak of conjunctivitis that occurred over a six day period among twenty-nine individuals who partook in recreational scuba diving trips on two boats off Vitu Levu Island, Fiji. We investigated the likelihood that a communal container used to store diving masks facilitated the spread of conjunctivitis among individuals. The diagnosis of conjunctivitis was based on clinical assessment by a physician. Transmission of conjunctivitis from person to person was documented with eventual identification of the index case, the dive master, a Fijian resident. Topical antibiotics were dispensed accordingly and detergent and bleach were used as mask cleaning agents in an effort to control the outbreak. Follow up surveys were mailed to all twenty-nine participants. Ultimately, fourteen cases of conjunctivitis were documented (46.7%). Eleven cases were verified during the six days in Fiji, two upon arrival back in the U.S., and one case of familial transmission in the U.S. All but two cases resolved within one week. Unknown to these divers was a coincidental, generalized outbreak of acute haemorrhagic conjunctivitis among the Fijian Residents. The communal container used to store diving masks was the likely vector for the spread of infectious conjunctivitis, the first such documented outbreak involving communal diving equipment.

Liver-directed gene transfer and prolonged expression of three major human ApoE isoforms in ApoE-deficient mice.

Apolipoprotein E (apoE) plays a key role in lipoprotein metabolism and may have other important biological functions. In humans, there are three common, naturally occurring isoforms of apoE that are associated with differences in lipid levels and atherosclerosis. However, the direct in vivo effects of the apoE isoforms on lipoprotein metabolism and atherosclerosis are not yet fully understood. To investigate the effect of the apoE isoforms in vivo, we constructed second-generation recombinant adenoviruses encoding each of the apoE isoforms. These recombinant adenoviruses were injected intravenously into apoE-deficient mice fed a Western diet (mean baseline cholesterol level 1401 mg/dl) in order to study their effects in the absence of endogenous mouse apoE. Hepatic expression of apoE3 and apoE4 completely normalized the lipoprotein profile; 3 d after injection, mean plasma cholesterol levels were 194 and 217 mg/ dl, respectively, and this effect was maintained for at least 6 wk. Expression of apoE2 had much less effect on lipoprotein levels (mean cholesterol level 752 mg/dl 3 d after injection), despite much higher plasma levels of apoE2 compared with apoE3 and apoE4; by 6 wk after injection the cholesterol levels had returned to baseline levels in the apoE2-expressing mice. Expression of all three isoforms significantly increased HDL cholesterol levels by approximately threefold and was independent of the cholesterol-lowering effect. ApoE transgene expression was substantially prolonged compared with that achieved using a first generation adenovirus and apoE was readily detected in plasma 3 mo after virus injection. These studies demonstrate: (a) prolonged in vivo expression of human apoE isoforms in apoE deficient mice after second-generation recombinant adenovirus-mediated somatic gene transfer; and (b) significantly impaired ability of apoE2 in vivo to mediate clearance of remnant lipoproteins in apoE-deficient mice fed a Western diet compared with apoE3 and apoE4.

Effects of metabolic inhibitors on the synthesis and release of lipoprotein lipase in cultured cells derived from the stromal-vascular fraction of rat adipose tissue.

Cultured cells derived from the stromal-vascular fraction of rat epididymal adipose tissue have been used to study the release of lipoprotein lipase in response to heparin. In the presence of heparin, lipoprotein lipase appeared in the medium biphasically, with an initial rapid rise followed by a slower linear release. The initial increase in activity in the medium was paralleled by a decrease in cell-associated activity. Over the course of the slower phase of release, cell-associated lipoprotein lipase levels remained constant. Treatment of cultures with cycloheximide or 2-deoxyglucose eliminated the second phase of release as well as cell-associated lipoprotein lipase activity. Treatment of cultures with Colcemid decreased the second phase of release but increased cell-associated lipoprotein lipase activity. These data suggest that exposure to heparin results in a rapid release of pre-formed enzyme and that continued release is dependent on both protein synthesis and transport of the enzyme to the cell surface.

tRNA methyltransferases from rat liver. Differences in response of partially purified enzymes to polyamines and inorganic salts.

Three tRNA methyltransferases, purified from rat liver, have been compared for their activity in the presence of various amines and Mg2+. The enzymes differ with respect to the ion which permits maximal activity; they also differ with respect to the concentration of a given ion necessary for maximal activity. The methyltransferase which forms N2-methylguanine in the region between the dihydrouridine loop and the acceptor stem (2mG I), when assayed using purified tRNA as substrate, shows high activity with 3--5 mM sperimidine or 20 mM putrescine and significantly lower rates of methylation with 200--350 mM ammonium acetate or 1--10 mM magnesium acetate. The enzyme responsible for forming N2-methylguanine between the dihydrouridine and anticodon loops (2mG II) works well in the presence of 0.2--0.5 mM spermidine, 10 mM putrescine or 200--300 mM ammonium acetate and shows slightly lower activity with 1 mM magnesium acetate. The optimal conditions for assaying 1-adenine methyltransferase (1mA) with purified tRNAs are either 200--300 mM ammonium acetate or 30 mM putrescine; spermidine is slightly less effective and magnesium acetate permits less than 25% of maximal activity. The addition of 10 mM Mg2+, in combination with polyamines or NH4+, depresses slightly the activity of the guanine methyltransferases but completely abolishes the polyamine or ammonium-stimulated activity of the adenine methyltransferase. When unfractionated (Escherichia coli) tRNA is used as substrate, the concentrations of polyamines required for optimal methyltransferase activity are increased but the patterns of response of the three enzymes do not differ significantly from those obtained with purified tRNA substrates. Based on the studies with these three enzymes, unfractionated tRNA and 40 mM putrescine should provide the most reliable system for detecting methylating activity if the nature of the tRNA methyltransferase is unknown.

Efflux of phospholipid from fibroblasts with normal and elevated levels of cholesterol.

To address the hypothesis that phospholipid efflux from cells contributes to lipoprotein structure, we have examined the efflux of biosynthetically labeled [32P]phospholipid from cells to lipoproteins. With normal human skin fibroblasts in monolayer culture, high density lipoprotein (HDL3) promoted the efflux of phospholipid in a concentration-dependent manner. As analyzed by TLC, the major phospholipids released from fibroblasts were phosphatidylcholine, sphingomyelin, lysophosphatidylcholine and phosphatidylethanolamine. At identical concentrations, HDL3 and dimethylsuberimidate treated-HDL3 promoted similar efflux, suggesting that efflux did not depend on specific binding of HDL3 to the cell surface. When the content of cholesterol in fibroblasts was doubled by pre-incubation with LDL and cholesterol-rich liposomes, the fractional efflux of phospholipid to HDL3 and other acceptors was stimulated about 2-fold. Most of this stimulation was due to enhanced release of phosphatidylcholine. Similar effects of enrichment were found with Fu5AH rat hepatoma cells, but not with J774 mouse macrophages. The results support the hypothesis that the efflux of phospholipid from cells contributes to the phospholipid content of HDL. This may enhance the ability of HDL to remove cholesterol from cells, the initial step in reverse cholesterol transport.

Purification and characterization of two tRNA-(guanine)-methyltransferases from rat liver.

tRNA(guanine-1-)-methyltransferase (EC 2.1.1.31) and tRNA(N2-guanine)-methyltransferase I (EC 2.1.1.32) were isolated from rat liver. The (guanine-1-)-methyltransferase preparation is 6800-fold purified and is free from contaminating methyltransferases or ribonuclease. The molecular weight of (guanine-1-)-methyltransferase is 83 000. Of seven purified Escherichia coli tRNAs examined, only tRNAMetf was utilized as substrate by (guanine-1-)-methyltransferase. The methylation of tRNAMetf is maximally stimulated by 40 mM putrescine with a pH optimum of 8.0. Using E. coli K-12 tRNA, the Km for S-adenosylmethionine is 3 micrometer and Ki for S-adenosylhomocysteine is 0.11 micrometer for (guanine-1-)-methyltransferase. (N2-Guanine-)-methyltransferase is 6200-fold purified and is also free of interfering enzymes. It has a molecular weight of 69 000. E. coli tRNAPhe, tRNAVal and tRNAArg are substrates for this enzyme which introduces a methyl at the 2-amino group of the guanine at position 10 from the 5'-terminus of these tRNAs. The methylation of tRNAPhe is maximally stimulated by 100 micrometer spermidine with a pH optimum of 8.0. (N2-Guanine-)-methyltransferase has a Km for S-adenosylmethionine of 2 micrometer and a Ki for S-adenosylhomocysteine of 23 micrometer with E. coli K-12 tRNA as methyl acceptor.

Hydrolysis of lipid monolayers and the substrate specificity of hepatic lipase.

The substrate specificities of the phospholipase and triglyceridase activities of purified rat liver hepatic lipase were compared using lipid monolayers so that the substrates were presented to the enzyme in a controlled physical state. The rate of hydrolysis of 14C-labeled lipid at constant surface pressure in the presence of hepatic lipase and fatty acid-free bovine serum albumin at 33 degrees C was determined by monitoring the decrease of surface radioactivity. In monolayers of sphingomyelin/cholesterol (2:1, mol/mol) containing either 1 mol% triacylglycerol, 1 mol% phosphatidylethanolamine, or 10 and 20 mol% phosphatidylcholine, hepatic lipase clearly showed a preference for unsaturated over saturated lipids. In addition, with a sphingomyelin/cholesterol (2:1) monolayer containing 1 mol% of lipid substrate, hepatic lipase showed the following preference: triolein = dioleoylphosphatidylethanolamine much greater than dioleoylphosphatidylcholine; the respective rates of hydrolysis were 15.3 +/- 1.2, 14.9 +/- 0.8, and 0.5 +/- 0.1 mumol fatty acid produced/h per mg hepatic lipase. Overall, it appears that when comparing rates of hydrolysis of molecules within a given lipid class, hydrocarbon chain interactions are important. However, when comparing different lipid classes such as phosphatidylcholines and phosphatidylethanolamines, it is apparent that the polar group has a significant influence on the rate of hydrolysis. The rate of [14C]triolein hydrolysis, when mixed at surface concentrations of up to 2 mol% in a sphingomyelin/cholesterol (2:1) monolayer, was significantly faster than when triolein was present in a 1-oleyl-2-palmitylphosphatidylcholine monolayer; the rates of hydrolysis were 47.7 +/- 5.4 and 8.9 +/- 0.8 mumol fatty acid produced/h per mg hepatic lipase, respectively. The monolayer physical state and the miscibility of the substrate in the inert matrix influence the presentation of the substrate to the enzyme, thereby affecting the hydrolysis rate.

Effect of fatty acid supplementation on cholesterol and retinol esterification in J774 macrophages.

J774 macrophages exposed to medium containing cholesterol-rich phospholipid dispersions accumulate cholesteryl ester. Supplementing this medium with 100 micrograms oleate/ml increased cellular cholesteryl ester contents 3-fold. Cell retinyl ester contents increased 8-fold when medium containing retinol dispersed in dimethyl sulfoxide was supplemented with oleate. These increases were not the result of increases in total lipid uptake by the cells but rather of redistribution of cholesterol and retinol into their respective ester pools. Effective oleate concentration of 15-30 micrograms/ml increased cellular retinyl and cholesteryl ester contents. The effective oleate concentration was reduced to 5 micrograms/ml when the fatty acid/albumin molar ratio was increased. The oleate-stimulated increase in cholesterol esterification was blocked by incubating cells with Sandoz 58-035, a specific inhibitor of acyl-CoA:cholesterol acyltransferase (ACAT), indicating that the effect of fatty acid exposure is mediated through changes in ACAT activity. When cholesterol or retinol was added to cells which had been exposed to oleate for 24 h to provide a triacylglycerol store, the cellular contents of cholesteryl or retinyl ester were also significantly increased compared to cells not previously exposed to oleate. The oleate-stimulated increase in the esterification of cholesterol and/or retinol was also observed in P388D1 macrophages, human (HepG2) and rat (Fu5AH) hepatomas, human fibroblasts, rabbit aortic smooth muscle cells and MCF-7 breast carcinoma cells. In addition to oleate, a number of other fatty acids increased retinol esterification in J774 macrophages; however, cellular cholesterol esterification in these cells was increased only by unsaturated fatty acids and was inhibited in the presence of saturated fatty acids. Although the cellular uptake of radiolabeled oleate and palmitate was similar, a significant difference in the distribution of these fatty acids among the lipid classes was observed. These data demonstrate that exogenous fatty acids are one factor that regulate cellular cholesteryl and retinyl ester contents in cultured cells.

Effect of substrate physical state on the activity of acid cholesteryl ester hydrolase.

The effects of the physicochemical properties of the substrate vehicle on the activity of acid cholesteryl ester hydrolase (ACEH; EC 3.1.1.13) isolated from rat liver lysosomes have been studied. In particular, the influence of the physical state of the neutral lipid core of substrate emulsion particles on the enzymatic activity has been probed in the light of previous studies on the clearance of cholesteryl esters (CE) from lipid-loaded cells which indicated that inclusions that are in the isotropic (liquid) state can be hydrolyzed faster than those in the anisotropic (liquid-crystalline) state. In the present study, such lipid inclusions were isolated from cultured cells and used as substrates for the hydrolase. No appreciable difference between the hydrolysis rates of isotropic and anisotropic inclusions was observed; the Vmax values were 93.0 +/- 6.7 and 84.0 +/- 3.3 nmol CE/mg.h, respectively. To elucidate the factors which affect the activity of ACEH, model inclusions were prepared by sonication and used as substrates. The physical state of these models was varied in a systematic way by changes of droplet composition and incubation temperature. The rate of hydrolysis was found to be insensitive to the physical state of the core of the model inclusions in good agreement with the results obtained with cellular inclusions. However, the activity of ACEH is sensitive to such interfacial properties of the lipid droplets as surface area available to the enzyme, net surface charge and surface solubility of the substrate CE molecules. The enzymatic activity is also sensitive to the amount of free cholesterol present in the emulsion droplets. The interfacial concentration and molecular packing of substrate CE molecules in the droplet surface significantly affect the hydrolytic activity of ACEH.

Metabolism of cholesteryl ester lipid droplets in a J774 macrophage foam cell model.

J774 macrophages rapidly incorporated [3H]cholesteryl oleate droplets by a non-saturable phagocytic process. In less than 2 h, foam cell morphology was acquired. The extent of loading obtained after 2 h was a linear function of the mass of cholesteryl oleate provided to the cells. The cholesteryl oleate incorporated was hydrolyzed in the cells at a linear rate over 24 h and the fractional hydrolysis was constant over a wide range of cellular esterified cholesterol contents. The rate of hydrolysis was influenced by the physical state of the cholesteryl ester; cholesteryl oleate in isotropic droplets was hydrolyzed 2-3-fold more rapidly than cholesteryl oleate in anisotropic droplets. The hydrolysis of both types of droplets was inhibited by lysosomotropic agents, indicating that hydrolysis occurred in the lysosomes. Only a small fraction (less than 10% after 24 h) of the free [3H]cholesterol generated in the lysosomes was esterified by ACAT resulting in a doubling of the cell free cholesterol content. Electron microscopy of cells treated with digitonin revealed the accumulation of free cholesterol in lipid-laden lysosomes. ACAT was active as endogenous free [14C]cholesterol was esterified in a linear manner over 24 h and was responsive to the presence of lysosomally-derived cholesterol, as the extent of esterification of the endogenous pool was directly proportional to the mass of [3H]cholesterol generated in the lysosomes.

Incubation of acetylated low-density lipoprotein with cholesterol-rich dispersions enhances cholesterol uptake by macrophages.

Incubation of J774 macrophages with mixtures of acetylated low-density lipoprotein (acLDL) and free cholesterol-rich phospholipid dispersions increases cellular cholesterol deposition 2-4-fold over that achieved with either acLDL or dispersions alone. Both free and esterified cholesterol accumulate in cells incubated with the mixture of acLDL and dispersions. A similar result is observed when acLDL is replaced by malondialdehyde-LDL. The enhanced deposition of cholesterol is not unique to J774 macrophages, as P388D1 macrophages also accumulate more cholesterol when incubated with the mixture of acLDL and dispersions than either particle alone. A preincubation of the particles for at least 6 h prior to incubation with cells is required in order to observe maximal cholesterol delivery. Both dispersion free cholesterol and phospholipid accumulate in J774 cells, suggesting that a complex is formed between acLDL and dispersions which results in a cholesterol-rich acLDL/dispersion particle. Partial purification of the acLDL-dispersion complex revealed increases in the size distribution of the particles compared to acLDL and increases in free cholesterol and phospholipid contents. Cholesterol uptake from the mixture of acLDL and dispersions was saturable and the enhanced cellular uptake of both cholesterol and phospholipid from the complex could be abolished by inhibitors of the scavenger receptor pathway. In addition to the receptor-mediated uptake of cholesterol from the acLDL-dispersion complex, it was observed that approx. 30% of the total cholesterol uptake from the complex was via non-specific components, including surface transfer.

S-adenosylhomocysteine analogues as inhibitors of specific tRNA methylation.

Of 17 base- or amino acid-modified analogues of S-adenosylhomocysteine, six were found to produce at least 50% inhibition of the activity of an unfractionated tRNA methyltransferase extract at concentrations of 200 micron. The inhibitory effects of these six analogues on five purified rat liver tRNA methyltransferases were examined. The purified enzymes differed greatly in their sensitivity to the analogues. Ki values for the inhibitory analogues were determined for the three most highly purified methyltransferases. The kinetic analyses indicated that inhibition is competitive for nearly all enzyme/inhibitor combinations. The Ki values for good enzyme/inhibitor pairs were in the range of 0.11--2 micron. Each analogue appears to inhibit one methylation more strongly than others; e.g. the Ki values obtained for N6-methyl-S-adenosyl-L-homocysteine are approx. 0.4 micron for guanine-1 tRNA methyltransferase, 6 micron for adenine-1 tRNA methyltransferase and 100 micron for N2-guanine tRNA methyltransferase I. Structural features which are important for inhibitory activity are presence of a terminal amino group on the amino acid and the presence of adenosine rather than any other base. Ring nitrogens, a terminal carboxyl group and conformation at the asymmetric carbon appear to be important for some but not all of the tRNA methyltransferases examined.

Characterization of a bile salt-dependent cholesteryl ester hydrolase activity secreted from HepG2 cells.

HepG2 cells and medium were assayed for cholesteryl ester hydrolase (CEH) activity in the presence and absence of sodium cholate. Although bile salt-dependent CEH activity was measured in the medium at 6 to 96 h (up to 4500 pmol/h per mg cell protein), there was very little activity detected in the corresponding cell homogenates (less than 70 pmol/h per mg cell protein). Activity in the medium was expressed only in the presence of trihydroxy bile salts and was maximal at 40 mM cholate and pH 7.5. Incubation of HepG2 cells with brefeldin A resulted in an 80 to 90% inhibition of secretion of the bile salt-dependent CEH activity, while only inhibiting total protein secretion by 42%. Bile salt-dependent CEH activity could also be detected in rat liver perfusates. Although there was measurable activity in all of 14 livers analyzed (47 +/- 10 and 53 +/- 17 nmol/h per g liver per h perfusion during two 5-min collections after 15 and 30 min of perfusion, respectively), it did not correlate with the activity found in corresponding liver homogenates, as only four livers had detectable bile salt-dependent CEH activity. These results provide evidence for the secretion of a bile salt-dependent CEH activity, from both a hepatic cell line and the intact liver, that has similar properties to the enzyme previously isolated from rat liver homogenates and rat pancreas.

Phenotypic correction of lipid storage and growth arrest in wolman disease fibroblasts by gene transfer of lysosomal acid lipase.

Wolman disease is a lethal lysosomal storage disease due to deficiency of lysosomal acid lipase (LAL). Wolman disease is characterized by pronounced hepatic involvement while neurological symptoms are uncommon, making Wolman disease an attractive candidate for liver-directed gene therapy. This study was performed to test the effects of gene replacement in fibroblasts lacking LAL, using a recombinant adenovirus encoding the human LAL cDNA (AdhLAL). Human fibroblasts from a Wolman disease patient were infected with AdhLAL and showed a dose-dependent increase in LAL protein and activity up to 5-fold above levels in control fibroblasts. Furthermore, 72 hr after infection with AdhLAL there was a dose-dependent correction of the severe lipid storage phenotype of Wolman disease fibroblasts. Electron microscopy confirmed significant correction of the lysosomal lipid storage in AdhLAL-infected Wolman disease fibroblasts at the ultrastructural level. Intravenous injection of AdhLAL into wild-type mice resulted in a 13.5-fold increase in hepatic LAL activity, and overexpression of LAL was not associated with toxic side effects. These data demonstrate high-level lysosomal expression of recombinant LAL in vitro and in vivo and show the feasibility of gene therapeutic strategies for the treatment of Wolman disease.

Cholesteryl ester cycle in cultured hepatoma cells.

The existence of a cholesteryl ester cycle in cultured Fu5AH hepatoma cells was documented and factors affecting the rate of turnover of the cholesteryl ester cycle in this cell line were explored. The influence of the physical state of the lipid inclusion in which the cholesteryl esters are stored could be addressed in this cell line because these cells can be induced to store cholesteryl esters in anisotropic (liquid-crystalline) cytoplasmic inclusions by exposure to free cholesterol-rich phospholipid dispersions or in isotropic (liquid) inclusions by addition of oleic acid to the phospholipid dispersions. To examine the relative rates of turnover of the cholesteryl ester cycle in the cells with the two types of inclusions, the fraction of cholesteryl linolenate, a cholesteryl ester present in low amounts in these inclusions, was examined after cells were exposed to medium containing linolenate. After 12 h, cells with anisotropic inclusions contained 17.5% cholesteryl linolenate and cells with isotropic inclusions contained 29.8% cholesteryl linolenate, suggesting an approximately 2-fold difference in turnover of the cholesteryl ester pool. To determine whether this difference was due to a differential rate of cholesteryl ester hydrolysis, the acyl CoA: cholesterol acyl transferase arm of the cholesteryl ester cycle was blocked using a specific inhibitor, Sandoz 58-035. In the presence of this compound, cholesteryl ester was hydrolysed twice as fast in cells with isotropic inclusions as compared to that in cells with anisotropic inclusions. The difference in rate of turnover of the cholesteryl ester cycle was shown to be related to the rate of hydrolysis of cholesteryl ester which, in turn, is related to the physical state of the stored cholesteryl ester.

Potential problems in the use of commercial preparations of radiolabeled cholesterol.

Through a series of biological and analytical procedures, we demonstrate that a compound purchased from a commercial supplier as [7-3H]cholesterol was not cholesterol. In mouse peritoneal macrophages, this compound was metabolized differently than other radiolabeled cholesterol preparations and was accumulated in the steryl ester pool. In contrast, Fu5AH rat hepatoma cells did not discriminate this compound from cholesterol. Further analysis of the anomalous [7-3H]cholesterol by TLC after cholesterol oxidase treatment and by HPLC indicated that this radiochemical was less polar than cholesterol standard and other radiolabeled cholesterol preparations tested. Mass spectrometry analysis disclosed that the chemical has a similar fragmentation pattern and the same molecular weight (386) as cholesterol.

Arthroscopically assisted excision of osteoid osteoma involving the hip.

Two cases of arthroscopically assisted excision of osteoid osteoma involving the femoral neck and acetabulum are presented. This technique allows for percutaneous excision of this benign bone lesion in those rare circumstances when it occurs in an intra-articular location. The approach enables direct visualization of the tumor as well as histologic confirmation. There was minimal morbidity, excellent relief of symptoms, and rapid functional restoration.

Hip arthroscopy using the lateral approach.

The benefits of hip arthroscopy are apparent. It produces little postoperative morbidity and can be performed on an outpatient basis. The prompt recovery from the operation is also beneficial, particularly for elderly patients. Distraction of the hip by traction on a fracture table is necessary. Suggested indications for this procedure include synovectomy and synovial biopsy; removal of loose bodies; removal of debris after a closed reduction of a fracture-dislocation; evaluation and treatment of osteochondritis dissecans; evaluation for arthroplasty; and unresolved hip pain. Whether the lateral approach is useful in the following situations is yet to be explored: (1) Evaluation of pediatric conditions such as Legg-Perthes disease and congenital dislocated hip; (2) treatment of localized infection; (3) removal of entrapped methylmethacrylate in total hip replacement; and (4) reducing and fixating an acetabular fracture (M. Brennan, oral communication, April 6, 1987). Arthroscopy of the hip joint by the lateral approach is a valuable addition to the evaluation and treatment of hip disorders.

Hip arthroscopy. The lateral approach.

The lateral approach provides an easy and safe access to the hip joint. The line from skin to the joint itself is a straight, downward drop (Fig. 18). The vital arteries and nerves are a safe distance from the portal sites. The potential problems that can arise from this procedure are from the traction applying a compression force on the branches of the pudendal nerve as they cross the ischium (Fig. 19) and traction force on the sciatic nerve. I have always maintained that traction should be treated like a tourniquet; that is, it should be applied for no more then 2 hours. [figure: see text] Furthermore, the amount of traction should not exceed 75 pounds. I use a tensiometer, but it is not mandatory because the major issue with traction is the duration of application. I have monitored the sciatic nerve using both evoke potentials and, in some cases, motor potentials in over 50 cases in the past year, and the poundage and time limits of the traction (75 pounds and 2 hours) were verified. In addition, if the fracture [figure: see text] table has a vertical post as well as a peroneal post, set the vertical post in the back of the patient, and not in the front. Flexing the hip around that post will greatly increase the traction and at the same time will place an extreme stretch on the sciatic nerve, setting up the chance of a significant sciatic nerve neuropraxia. To protect the pudendal nerve, Lyon et al suggest that the perineal post be at least 9 cm in diameter to distribute the forces in a wide area on the ischium and make sure that the pelvis is well supported so the pressure of the post is not placed directly on the this nerve. The perineal posts on most fracture tables are only 3 cm in diameter. These can be made larger by wrapping them with padding. In some fracture tables, the slats that support the lower leg can be removed, and consequently the support on the pelvis is lost. For hip arthroscopy, the slats do not have to be removed. The lateral approach provides a safe and simple way of performing hip arthroscopy. The instruments can be manipulated easily so that the entire confines of the joint can be visualized with the arthroscope and reached with operative instruments.

Hip arthroscopy.

The indications for performing arthroscopy of the hip are fewer than for the knee and shoulder. Yet, it is a very useful procedure when the occasion arises. The purpose of this article is to present a technique that is simple and safe. The lateral approach over the greater trochanter, not only meets these criteria, but it gives the surgeon enough maneuverability to completely visualize the joint and to perform surgery.