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Arthroscopic removal of a 44 caliber bullet from the hip
Case Report
Arthroscopic Removal of a .44 Caliber Bullet From the Hip John W. Cory, M.D., and David S. Ruch, M.D.
Summary: Hip arthroscopy is far less invasive than standard open arthrotomy and offers unparalleled visualization of the acetabulum and femoral head. Diagnostic arthroscopy is becoming increasingly accepted as therapeutic options are still evolving. We report the case of the arthroscopic removal of a .44 caliber bullet from the femoral head of a 45-year-old man. The procedure afforded the opportunity to thoroughly irrigate the joint, debride the articular surface, and remove several loose bodies. Key Words: Arthroscopy—Hip—Gunshot wound— Foreign body.
H
ip arthroscopy, although first described in 1931 by Burman,1 is still used infrequently for diagnosing and treating intra-articular hip disorders. Hip arthroscopy has been used for definitive diagnosis of labral tears, osteochondral defects, arthritis, pigmented villonodular synovitis, inflammatory arthropathy, loose bodies, labral tears, and avascular necrosis.2-5 Although the indications for hip arthroscopy are currently being defined, there are many real and theoretical advantages to this procedure over open arthrotomy. First, it provides an unparalleled view of the articular surface of the femoral head and acetabulum without dislocation of the femoral head. Second, there is minimal soft tissue disruption, theoretically decreasing the risk of avascular necrosis as well as postoperative stiffness. Third, the capsuloligamentous structures, including the labrum, remain intact, diminishing the possibility of instability postoperatively. Yet despite these perceived advantages and the diagnostic superiority of the technique, the bony architecture makes surgical procedures technically difficult and often frustrating. Despite these constraints, hip arthrosFrom the Department of Orthopaedics, Wake Forest University School of Medicine, Winston-Salem, North Carolina, U.S.A. Address correspondence and reprint requests to David S. Ruch, M.D., Wake Forest University School of Medicine, Medical Center Blvd, Winston-Salem, NC 27157-1070, U.S.A. r 1998 by the Arthroscopy Association of North America 0749-8063/98/1406-1848$3.00/0
624
copy has been used in the treatment of avascular necrosis, synovial chondromatosis, synovial diseases, and labral lesions.2 The authors report the use of the arthroscope in the removal of a large caliber bullet that passed though the pelvis and into the femoral head.
CASE REPORT A 45-year-old man presented to the emergency department after sustaining a gunshot wound to the left pelvis. The entrance wound was superolateral to the inguinal crease with no exit wound. The patient was complaining of left knee pain without signs of trauma to the knee. Physical examination revealed 2⫹ proximal distal pulses in both extremities, with manual motor testing revealing 2⫹/5 hip flexion, 2⫺/5 knee extension, 4⫺/5 knee flexion, and 5/5 plantar flexion/ dorsiflexion. Plain radiographs and a computed tomograph of the pelvis showed a retained projectile in the left femoral head with projection into the joint. There was a significant comminuted yet nondisplaced intra-articular fracture (Fig 1). There were no obvious intraarticular bony fragments noted in the joint. Three days after the injury, the patient was taken to the operating room for hip arthroscopy. The patient was placed supine on a fracture table with 45 lbs of distraction in 30° abduction (Fig 2A). Standard anterior and anterior
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 14, No 6 (September), 1998: pp 624–626
ARTHROSCOPIC REMOVAL OF A BULLET
FIGURE 1. Anteroposterior radiograph and computed tomograph of the hip showing comminuted fracture of the femoral head with the impacted bullet.
lateral portals were placed with good visualization of the entire joint (Fig 2B). Arthroscopy showed comminution of approximately 30% of the femoral head. A large loose osteochondral fragment with a medial hinge was present. The bullet was easily seen and
FIGURE 2. (A) Diagram showing the patient supine on the fracture table with traction applied. (B) Anterior, adjacent, and anterolateral portals routinely used for this procedure.
625
FIGURE 3. View through the anterolateral portal of the femoral head with retained bullet in the anterior superior quadrant.
probing revealed loose cancellous bone surrounding the projectile. The bullet was manipulated using the standard anterior portal as well as the adjacent portal previously described (Fig 3).6 A large pituitary rongeur was required to grasp the bullet and remove it through the anterior portal. Postoperatively, the patient did well and remained non-weight bearing on crutches. Physical examination at 1-month follow-up revealed mildly antalgic gait, painless range of motion, and no crepitus. Follow-up at 1 year revealed hip flexion of 120°, abduction of 65°, external rotation of 60°, internal rotation of 50°, and a negative heel impaction test. He had no mechanical symptoms and was able to sleep on the affected side without pain. Radiographs showed joint space narrowing with subchondral sclerosis but no evidence of avascular necrosis (Fig 4).
FIGURE 4. Radiograph 1 year after the procedure. The patient was ambulatory without assistance. He denied mechanical symptoms or functional limitations resulting from hip pain.
626
J. W. CORY AND D. S. RUCH DISCUSSION
While still in its relative infancy, hip arthroscopy is no longer a procedure in search of an indication. This case demonstrates many of the advantages of such a procedure over a formal arthrotomy. The arthroscope permitted debridement of several loose articular fragments, thorough irrigation of the joint, and the removal of large caliber bullet from the central portion of the femoral head. Such a procedure would have been difficult from either a traditional posterior approach or from an anterior arthrotomy. In addition, the remainder of the articular surface was spared leaving the patient with a serviceable femoral head. Finally, this patient was out of bed on crutches with minimal pain 1 day after the procedure and ambulatory without crutches at 1 month. Obviously, this technique is not universally
applicable, but it underscores the potential advantages that hip arthroscopy offers. REFERENCES 1. Burman MS. Arthroscopy or the direct visualization of joints. J Bone Joint Surg 1931;13:669-695. 2. Edwards DJ, Lomas D, Villar RN. Diagnosis of the painful hip by magnetic resonance imaging and arthroscopy. J Bone Joint Surg Br 1995;77:374-376. 3. McCarthy JC, Day B, Buscont B. Hip arthroscopy: Applications and technique. J Am Acad Orthop Surg 1995;3:115-122. 4. Schindler A, Lechevallier JC, Nitin SR, Bowen JR. Diagnostic and therapeutic arthroscopy of the hip in children and adolescents: Evaluation of results. J Pediatr Orthop 1995;15:317321. 5. Hawkins RB. Arthroscopy of the hip. Clin Orthop 1989;249: 44-47. 6. Hunter DM, Ruch DS. Hip arthroscopy. J South Orthop Assoc 1996;5:243-250.
Arthroscopic Removal of a .44 Caliber Bullet From the Hip John W. Cory, M.D., and David S. Ruch, M.D.
Summary: Hip arthroscopy is far less invasive than standard open arthrotomy and offers unparalleled visualization of the acetabulum and femoral head. Diagnostic arthroscopy is becoming increasingly accepted as therapeutic options are still evolving. We report the case of the arthroscopic removal of a .44 caliber bullet from the femoral head of a 45-year-old man. The procedure afforded the opportunity to thoroughly irrigate the joint, debride the articular surface, and remove several loose bodies. Key Words: Arthroscopy—Hip—Gunshot wound— Foreign body.
H
ip arthroscopy, although first described in 1931 by Burman,1 is still used infrequently for diagnosing and treating intra-articular hip disorders. Hip arthroscopy has been used for definitive diagnosis of labral tears, osteochondral defects, arthritis, pigmented villonodular synovitis, inflammatory arthropathy, loose bodies, labral tears, and avascular necrosis.2-5 Although the indications for hip arthroscopy are currently being defined, there are many real and theoretical advantages to this procedure over open arthrotomy. First, it provides an unparalleled view of the articular surface of the femoral head and acetabulum without dislocation of the femoral head. Second, there is minimal soft tissue disruption, theoretically decreasing the risk of avascular necrosis as well as postoperative stiffness. Third, the capsuloligamentous structures, including the labrum, remain intact, diminishing the possibility of instability postoperatively. Yet despite these perceived advantages and the diagnostic superiority of the technique, the bony architecture makes surgical procedures technically difficult and often frustrating. Despite these constraints, hip arthrosFrom the Department of Orthopaedics, Wake Forest University School of Medicine, Winston-Salem, North Carolina, U.S.A. Address correspondence and reprint requests to David S. Ruch, M.D., Wake Forest University School of Medicine, Medical Center Blvd, Winston-Salem, NC 27157-1070, U.S.A. r 1998 by the Arthroscopy Association of North America 0749-8063/98/1406-1848$3.00/0
624
copy has been used in the treatment of avascular necrosis, synovial chondromatosis, synovial diseases, and labral lesions.2 The authors report the use of the arthroscope in the removal of a large caliber bullet that passed though the pelvis and into the femoral head.
CASE REPORT A 45-year-old man presented to the emergency department after sustaining a gunshot wound to the left pelvis. The entrance wound was superolateral to the inguinal crease with no exit wound. The patient was complaining of left knee pain without signs of trauma to the knee. Physical examination revealed 2⫹ proximal distal pulses in both extremities, with manual motor testing revealing 2⫹/5 hip flexion, 2⫺/5 knee extension, 4⫺/5 knee flexion, and 5/5 plantar flexion/ dorsiflexion. Plain radiographs and a computed tomograph of the pelvis showed a retained projectile in the left femoral head with projection into the joint. There was a significant comminuted yet nondisplaced intra-articular fracture (Fig 1). There were no obvious intraarticular bony fragments noted in the joint. Three days after the injury, the patient was taken to the operating room for hip arthroscopy. The patient was placed supine on a fracture table with 45 lbs of distraction in 30° abduction (Fig 2A). Standard anterior and anterior
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 14, No 6 (September), 1998: pp 624–626
ARTHROSCOPIC REMOVAL OF A BULLET
FIGURE 1. Anteroposterior radiograph and computed tomograph of the hip showing comminuted fracture of the femoral head with the impacted bullet.
lateral portals were placed with good visualization of the entire joint (Fig 2B). Arthroscopy showed comminution of approximately 30% of the femoral head. A large loose osteochondral fragment with a medial hinge was present. The bullet was easily seen and
FIGURE 2. (A) Diagram showing the patient supine on the fracture table with traction applied. (B) Anterior, adjacent, and anterolateral portals routinely used for this procedure.
625
FIGURE 3. View through the anterolateral portal of the femoral head with retained bullet in the anterior superior quadrant.
probing revealed loose cancellous bone surrounding the projectile. The bullet was manipulated using the standard anterior portal as well as the adjacent portal previously described (Fig 3).6 A large pituitary rongeur was required to grasp the bullet and remove it through the anterior portal. Postoperatively, the patient did well and remained non-weight bearing on crutches. Physical examination at 1-month follow-up revealed mildly antalgic gait, painless range of motion, and no crepitus. Follow-up at 1 year revealed hip flexion of 120°, abduction of 65°, external rotation of 60°, internal rotation of 50°, and a negative heel impaction test. He had no mechanical symptoms and was able to sleep on the affected side without pain. Radiographs showed joint space narrowing with subchondral sclerosis but no evidence of avascular necrosis (Fig 4).
FIGURE 4. Radiograph 1 year after the procedure. The patient was ambulatory without assistance. He denied mechanical symptoms or functional limitations resulting from hip pain.
626
J. W. CORY AND D. S. RUCH DISCUSSION
While still in its relative infancy, hip arthroscopy is no longer a procedure in search of an indication. This case demonstrates many of the advantages of such a procedure over a formal arthrotomy. The arthroscope permitted debridement of several loose articular fragments, thorough irrigation of the joint, and the removal of large caliber bullet from the central portion of the femoral head. Such a procedure would have been difficult from either a traditional posterior approach or from an anterior arthrotomy. In addition, the remainder of the articular surface was spared leaving the patient with a serviceable femoral head. Finally, this patient was out of bed on crutches with minimal pain 1 day after the procedure and ambulatory without crutches at 1 month. Obviously, this technique is not universally
applicable, but it underscores the potential advantages that hip arthroscopy offers. REFERENCES 1. Burman MS. Arthroscopy or the direct visualization of joints. J Bone Joint Surg 1931;13:669-695. 2. Edwards DJ, Lomas D, Villar RN. Diagnosis of the painful hip by magnetic resonance imaging and arthroscopy. J Bone Joint Surg Br 1995;77:374-376. 3. McCarthy JC, Day B, Buscont B. Hip arthroscopy: Applications and technique. J Am Acad Orthop Surg 1995;3:115-122. 4. Schindler A, Lechevallier JC, Nitin SR, Bowen JR. Diagnostic and therapeutic arthroscopy of the hip in children and adolescents: Evaluation of results. J Pediatr Orthop 1995;15:317321. 5. Hawkins RB. Arthroscopy of the hip. Clin Orthop 1989;249: 44-47. 6. Hunter DM, Ruch DS. Hip arthroscopy. J South Orthop Assoc 1996;5:243-250.