Arthroscopic bullet removal from the acetabulum (hip joint)

Abstract

Hip arthroscopy has been shown to offer minimally invasive access to the hip joint compared with standard open arthrotomy. The use of arthroscopy for diagnosing and treating disorders about the hip continues to evolve. This study describes a case that involves arthroscopic removal of a bullet from a low-velocity gunshot wound. The patient sustained a gunshot wound that entered the abdomen and traversed the small bowel, sigmoid colon then penetrated the urinary bladder before ending up in the medial wall of the acetabulum. After surgical repair of the viscus, the bullet was retrieved from the hip joint using standard arthroscopic portals and a fracture table. A number of issues led to the decision to use arthroscopy. Most importantly was the need to minimize soft tissue dissection, which was required to access the bullet, without interfering with previous wound at the suprapubic area. The risks of potential bullet fragmentation and migration, as well as a possible abdominal compartment syndrome were considered before proceeding. Arthroscopy allowed adequate inspection of the articular surface, irrigation of the joint, and removal of the foreign body while avoiding an invasive arthrotomy with its associated morbidity and soft tissue disruption. This surgical technique afforded a very satisfactory outcome for this patient and serves as a model for others when encountering a similar injury pattern in a trauma patient. It is a procedure that can be performed safely, quickly, and with minimal complications for surgeons with experience in arthroscopy of the hip joint.

Keywords: Acetabulum; arthroscopy; bullet; foreign body; gunshot; hip.

Figure 1

The bullet after retrieval from the hip joint

Figure 2

Anteroposterior view of the pelvis showing the bullet in the right acetabulum

Figure 3

(a) Axial computed tomography scan showing the bullet embedded in the medial acetabular wall intra-articularly, (b) Coronal computed tomography scan showing the bullet embedded in the medial acetabular wall intra-articularly

Figure 4

Fluoroscopic image showing the site of the bullet

Figure 5

(a) Arthroscopic view showing the bullet embedded in the medial acetabular wall, (b) Arthroscopic view showing the bullet embedded in the medial acetabular wall

Figure 6

Bullet removed from the joint with a grasper

Figure 7

The surface of the femoral head was damaged by the projectile

Figure 8

Intraoperative fluoroscopy verified removal of almost the entire fragment

Figure 9

Post-operative plain-film radiographs showed very small bony fragments beside the entry point

Figure 10

Post-operative computed tomography scan showed very small bony fragments beside the entry point