At 7 months postoperatively the patient was weight-bearing without hip pain with radiographs showing a healed fracture and a well-preserved hip joint without sign of avascular necrosis or posttraumatic arthritis.
A 20-year-old man was transferred from an outside hospital after sustaining gunshot wounds to the chest and right hip. Before transfer, he underwent irrigation and debridement of his right lower hip wounds. On arrival, imaging confirmed a retained bullet in the anteroinferior recess of the right hip capsule (Figs. 4A, B). This imaging showed the foreign body was within the anteroinferior recess of the hip capsule. He underwent an arthrotomy of his right hip via Smith-Peterson approach and removal of the retained foreign body.
At operative procedure, the bullet fragment had migrated posteriorly within the joint as noted on fluoroscopy. Moderate external rotation of the hip was performed, and the Satinsky vascular clamp was inserted through the capsulotomy and easily guided around the femoral head with care taken not to further injure the articular cartilage. Under fluoroscopic guidance, the bullet fragment was removed uneventfully (Figs. 5A, B).
The patient experienced no postoperative complications. He was recovering as expected at 2 months postoperatively with a benign, healed surgical site, and resolving pain. However, he was shot in the head in a second shooting within 2 months of the first shooting. Fortunately, he remained cognitively intact following this ballistic head trauma and in a discussion regarding his safety with the senior author (W.D.L.) the patient related his plan to move from the region to avoid further injury.
This report describes 2 patients with intra-articular bodies of the hip successfully removed with the use of a Satinsky clamp that would have otherwise been inaccessible through the approach being used. To our knowledge this has not been reported in the orthopedic literature. We find this technique to be useful when presented with a posteriorly located intra-articular body while treating coincident hip pathology through an anterior approach.
Other techniques remain options under different circumstances. Initially described in 1998 and subsequently repeated in multiple studies, hip arthroscopy remains an option for removal of foreign and loose bodies of the hip.2 While use of hip arthroscopy boasts advantages such as concomitant irrigation and the ability to address concomitant pathology such as labral tears, it does have significant drawbacks including a steep-learning curve, potential for nerve injury, and abdominal compartment syndrome.3,4 Other methods described to retrieve foreign and loose bodies include surgical hip dislocation which poses risks such as iatrogenic fracture, heterotopic ossification, and osteonecrosis of the femoral head.5
We describe the use of a Satinsky clamp as an option for removal of intra-articular bodies from within hip under specific clinical conditions. As a vascular clamp it was designed to minimize trauma to surrounding structures and thus its fine teeth are inlaid within the jaw. The Satinsky clamp is available with multiple overall instrument and DeBakey jaw lengths including jaw lengths of small (57×6 mm with 10.7 mm radius of curvature), medium (64×10 mm with 15.9 mm radius of curvature), and large (70×13 mm with 15.9 mm radius of curvature). Anecdotally, the 241 mm overall instrument length with medium jaw size has a length that allows access to the hip and a curvature that approximates that of the femoral head, allowing the clamp to easily reach otherwise inaccessible recesses within the hip in an atraumatic manner. The varying sizes and radii of curvature available may allow this technique to be used in children as well as adults, although the authors have not used this technique in children. Use of the clamp requires no advanced surgical technique or set up, and does not require an additional approach. When an anterior approach has been used and an intra-articular foreign body is identified at an otherwise inaccessible location, the described technique allows for its atraumatic removal without further dissection, hip dislocation, or morbidity to the patient.
The authors to thank Aaron Mahramas for providing the inspiration for this technique.
1. DeMartini J, Wilson A, Powell JS, et al. Lead arthropathy and systemic lead poisoning from an intraarticular bullet. AJR Am J Roentgenol. 2001;176:1144.
2. Cory JW, Ruch DS. Arthroscopic removal of a .44 caliber bullet from the hip
. Arthroscopy. 1998;14:624–626.
3. Hoppe DJ, de Sa D, Simunovic N, et al. The learning curve for hip
arthroscopy: a systematic review. Arthroscopy. 2014;30:389–397.
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. Bone Joint Res. 2012;1:131–144.
5. Delaney R, Albright M, Rebello G. Utilization of the safe surgical dislocation approach of the hip
to retrieve a bullet from the femoral head. Case Rep Orthop. 2011;2011:160591.
Keywords:Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved
intra-articular bodies; hip; anterior approach