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Late bullet migration into the knee joint
Technical Note
Late Bullet Migration Into the Knee Joint Vicente Gutie´rrez, M.D., and Fernando Radice, M.D.
Abstract: A 25-year-old active-duty police officer was found to have an intra-articular foreign body on radiographic study of his left knee joint. He had a gunshot wound to the midthigh 54 months prior to the presentation of symptoms. The bullet was lodged in the soft tissue without involving neurovascular structures. The patient complained of limited range of motion of the joint and a “rattle” sensation of the knee. Arthroscopically, a deformed metallic foreign body was found and retrieved. There was no injury inside the joint related to the loose body. These findings were consistent with a migrating bullet from the midthigh to the knee joint. The patient recovered uneventfully and returned to work. Key Words: Arthroscopy—Knee—Loose Body.
I
n October 1992 a 20-year-old policeman was shot in his left thigh and the bullet did not exit. A radiograph showed a deformed bullet located in soft tissue in the union of the middle and distal third of the thigh, close to the femur anteromedially. The bullet was not retrieved and the patient recovered and returned to full activities without complaints. Fifty-four months later, the patient reported a catching sensation in the left knee while performing the normal movements of flexo-extension. He stated that the knee locked and with some assistance it unlocked. The physical examination showed no special signs and there was no history of knee injury. Radiographs showed a 23 ⫻ 22 mm metallic loose body within the intercondylar notch. Arthroscopy of the left knee was performed and a metallic body was found floating freely in the lateral compartment close to the posterior horn of the lateral meniscus, which was easily retrieved through the an-
From the Servicio de Ortopedia y Traumatologı´a Hospital Dipreca, Santiago, Chile. Address correspondence and reprint request to Vicente Guti´errez, M.D., Camino Otonal 1648 Las Condes, Santiago, Chile. E-mail: [email protected] © 2003 by the Arthroscopy Association of North America 1526-3231/03/1903-2954$30.00/0 doi:10.1053/jars.2003.50065
FIGURE 1. Anteroposterior radiograph after the gunshot wound to the midthigh.
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 19, No 3 (March), 2003: E15
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V. GUTIE´ RREZ AND F. RADICE
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attributed to various factors, such as osteochondritis dissecans,1,2 osteochondral fracture,1,2 synovial chondromatosis,1-3 fracture of osteophytes,1,2 localized pigmented synovitis,4-6 intra-articular tophus in chronic tophaceous gout,7 or a bioabsorbable screw.8 Radiography is still the modality of choice when a loose body is suspected on clinical grounds. Plain film radiographs are panoramic and not expensive. Ultrasound also can be used when a calcified image consistent with a loose body is shown on radiographs to prove its intra-articular location and rule out para-articular calcification.9 Magnetic resonance imaging can show intra-articular soft tissue or a bioabsorbable interference screw that may act as a loose body.8 In this case, the bullet migrated through soft tissue into the knee joint most probably by effect of gravity and it was favored by its weight and shape adopted after the impact and the cyclic impact of the lower limb during daily activities.
FIGURE 2. midthigh.
Lateral radiograph after the gunshot wound to the
terolateral portal. The joint was fully inspected and there was no sign of injury related to the loose body. The retrieved metallic loose body size was 23 ⫻ 18 ⫻ 6 mm and corresponded to the bullet located in the thigh 54 months previously that migrated to the knee joint. The patient was sent to physical therapy and reported complete relief of symptoms. Two weeks after the bullet removal, the patient returned to full activities required for an active-duty police officer. DISCUSSION The migration of a bullet originally located in the thigh to the knee joint has not previously been reported. In this case, the bullet reached the knee joint 4 years and 6 months after the bullet was located in the union of the middle and distal third of the thigh. Clinically, the patient presented with symptoms of a loose body and radiography showed an intra-articular metallic object. A loose body in the knee can be
FIGURE 3. Anteroposterior radiograph of the knee showing a metallic loose body within the intercondylar notch.
BULLET MIGRATION INTO KNEE JOINT
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FIGURE 6. View of the deformed bullet after it was retrieved from the knee joint.
REFERENCES
FIGURE 4. Lateral radiograph of the knee showing a metallic loose body within the intercondylar notch.
FIGURE 5. Intra-articular view of the bullet when was removed with a grasper.
1. Weh L, Korn U, Dahmen G. Free bodies in the knee joint. Etiology, clinical course and therapeutic plan. Fortschr Med 1982;100:1939-1943. 2. Kondo H. Classification and growth of loose bodies in joints. Nippon Seikeigeka Gakkai Zasshi 1979;53:1767-1789 3. Ogilvie-Harris DJ, Saleh K. Generalized synovial chondromatosis of the knee: A comparison of removal of the loose bodies alone with arthroscopic synovectomy. Arthroscopy 1994;10: 166-170. 4. Bronstein RD, Sebastianelli WJ, DeHaven KE. Localized pigmented villonodular synovitis presenting as a loose body in the knee. Arthroscopy 1993;9:596-598. 5. Muscolo DL, Makino A, Costa-Paz M, Ayerza M. Magnetic resonance imaging evaluation and arthroscopic resection of localized pigmented villonodular synovitis of the knee. Orthopedics 2000;23:367-369. 6. Woods C Jr, Alade CO, Anderson V, Ashby ME. Pigmented villonodular synovitis of the knee presenting as a loose body. A case. Clin Orthop 1997;129:230-231. 7. Hammoudeh M, Siam AR, Shah S. Intra-articular tophus presenting as a loose body. Clin Rheumatol 1998;17:400-402. 8. Bottonni C, Deberardino T, Fester E, Mitchell D, Penrod B. An intra-articular bioabsorbable interference screw mimicking an acute meniscal tear 8 months after an anterior cruciate ligament reconstruction. Arthroscopy 2000;16:395-398. 9. Bianchi S, Martinoli C. Detection of loose bodies in joints. Radiol Clin North Am 1999;37:679-690.
Late Bullet Migration Into the Knee Joint Vicente Gutie´rrez, M.D., and Fernando Radice, M.D.
Abstract: A 25-year-old active-duty police officer was found to have an intra-articular foreign body on radiographic study of his left knee joint. He had a gunshot wound to the midthigh 54 months prior to the presentation of symptoms. The bullet was lodged in the soft tissue without involving neurovascular structures. The patient complained of limited range of motion of the joint and a “rattle” sensation of the knee. Arthroscopically, a deformed metallic foreign body was found and retrieved. There was no injury inside the joint related to the loose body. These findings were consistent with a migrating bullet from the midthigh to the knee joint. The patient recovered uneventfully and returned to work. Key Words: Arthroscopy—Knee—Loose Body.
I
n October 1992 a 20-year-old policeman was shot in his left thigh and the bullet did not exit. A radiograph showed a deformed bullet located in soft tissue in the union of the middle and distal third of the thigh, close to the femur anteromedially. The bullet was not retrieved and the patient recovered and returned to full activities without complaints. Fifty-four months later, the patient reported a catching sensation in the left knee while performing the normal movements of flexo-extension. He stated that the knee locked and with some assistance it unlocked. The physical examination showed no special signs and there was no history of knee injury. Radiographs showed a 23 ⫻ 22 mm metallic loose body within the intercondylar notch. Arthroscopy of the left knee was performed and a metallic body was found floating freely in the lateral compartment close to the posterior horn of the lateral meniscus, which was easily retrieved through the an-
From the Servicio de Ortopedia y Traumatologı´a Hospital Dipreca, Santiago, Chile. Address correspondence and reprint request to Vicente Guti´errez, M.D., Camino Otonal 1648 Las Condes, Santiago, Chile. E-mail: [email protected] © 2003 by the Arthroscopy Association of North America 1526-3231/03/1903-2954$30.00/0 doi:10.1053/jars.2003.50065
FIGURE 1. Anteroposterior radiograph after the gunshot wound to the midthigh.
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 19, No 3 (March), 2003: E15
1
V. GUTIE´ RREZ AND F. RADICE
2
attributed to various factors, such as osteochondritis dissecans,1,2 osteochondral fracture,1,2 synovial chondromatosis,1-3 fracture of osteophytes,1,2 localized pigmented synovitis,4-6 intra-articular tophus in chronic tophaceous gout,7 or a bioabsorbable screw.8 Radiography is still the modality of choice when a loose body is suspected on clinical grounds. Plain film radiographs are panoramic and not expensive. Ultrasound also can be used when a calcified image consistent with a loose body is shown on radiographs to prove its intra-articular location and rule out para-articular calcification.9 Magnetic resonance imaging can show intra-articular soft tissue or a bioabsorbable interference screw that may act as a loose body.8 In this case, the bullet migrated through soft tissue into the knee joint most probably by effect of gravity and it was favored by its weight and shape adopted after the impact and the cyclic impact of the lower limb during daily activities.
FIGURE 2. midthigh.
Lateral radiograph after the gunshot wound to the
terolateral portal. The joint was fully inspected and there was no sign of injury related to the loose body. The retrieved metallic loose body size was 23 ⫻ 18 ⫻ 6 mm and corresponded to the bullet located in the thigh 54 months previously that migrated to the knee joint. The patient was sent to physical therapy and reported complete relief of symptoms. Two weeks after the bullet removal, the patient returned to full activities required for an active-duty police officer. DISCUSSION The migration of a bullet originally located in the thigh to the knee joint has not previously been reported. In this case, the bullet reached the knee joint 4 years and 6 months after the bullet was located in the union of the middle and distal third of the thigh. Clinically, the patient presented with symptoms of a loose body and radiography showed an intra-articular metallic object. A loose body in the knee can be
FIGURE 3. Anteroposterior radiograph of the knee showing a metallic loose body within the intercondylar notch.
BULLET MIGRATION INTO KNEE JOINT
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FIGURE 6. View of the deformed bullet after it was retrieved from the knee joint.
REFERENCES
FIGURE 4. Lateral radiograph of the knee showing a metallic loose body within the intercondylar notch.
FIGURE 5. Intra-articular view of the bullet when was removed with a grasper.
1. Weh L, Korn U, Dahmen G. Free bodies in the knee joint. Etiology, clinical course and therapeutic plan. Fortschr Med 1982;100:1939-1943. 2. Kondo H. Classification and growth of loose bodies in joints. Nippon Seikeigeka Gakkai Zasshi 1979;53:1767-1789 3. Ogilvie-Harris DJ, Saleh K. Generalized synovial chondromatosis of the knee: A comparison of removal of the loose bodies alone with arthroscopic synovectomy. Arthroscopy 1994;10: 166-170. 4. Bronstein RD, Sebastianelli WJ, DeHaven KE. Localized pigmented villonodular synovitis presenting as a loose body in the knee. Arthroscopy 1993;9:596-598. 5. Muscolo DL, Makino A, Costa-Paz M, Ayerza M. Magnetic resonance imaging evaluation and arthroscopic resection of localized pigmented villonodular synovitis of the knee. Orthopedics 2000;23:367-369. 6. Woods C Jr, Alade CO, Anderson V, Ashby ME. Pigmented villonodular synovitis of the knee presenting as a loose body. A case. Clin Orthop 1997;129:230-231. 7. Hammoudeh M, Siam AR, Shah S. Intra-articular tophus presenting as a loose body. Clin Rheumatol 1998;17:400-402. 8. Bottonni C, Deberardino T, Fester E, Mitchell D, Penrod B. An intra-articular bioabsorbable interference screw mimicking an acute meniscal tear 8 months after an anterior cruciate ligament reconstruction. Arthroscopy 2000;16:395-398. 9. Bianchi S, Martinoli C. Detection of loose bodies in joints. Radiol Clin North Am 1999;37:679-690.