Removal of retained bullets from the hip joint in civilian gunshot injuries.

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Sithombo Maqungo, Andrew Nicol, Ntambue Kauta, Simon Graham, Stefan Swanepoel, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4705380/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Purpose Removal of bullets retained within joints is indicated to prevent mechanical blockade, 3 rd body wear and resultant arthritis, plus lead arthropathy and rarely, systemic lead poisoning. We aimed to report on the largest series of removal of bullets from the hip joint using open surgical techniques. Methods This is a retrospective cohort study of all patients who presented to a single Level 1 Trauma Unit with civilian gunshot injuries that had breached the hip joint between 01 January 2009 and 31 December 2022. Results: We identified one hundred and seventeen (117) adult patients who met our inclusion criteria. Of these patients 72 had bullets retained within the hip joint area. Forty-six patients underwent bullet removal using the following techniques: hip arthrotomy (n=19), surgical hip dislocation (n=18), direct removal without capsulotomy (tractotomy) (n=5), removal at site of fracture fixation/replacement (n=3), posterior wall osteotomy (n=1). No patients underwent hip arthroscopy. In 26 patients we did not remove bullets for the following reasons: final location was extra-capsular embedded in the soft tissues (n=17), clinical decision to not remove though bullet due to the patients’ clinical condition not allowing for further surgery (n=8) and patient refusal (n=1). Conclusion: With adequate pre-operative imaging and surgical planning, removal of retained bullets from the hip joint can be achieved using open surgical techniques without the need for hip arthroscopy. civilian gunshots low velocity gunshots hip joint bullet removal Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Figure 7 Introduction Civilian gunshot injuries of the hip are relatively rare injuries comprising 2% − 17% of all gunshot injuries ( 1 ). Removal of bullets retained within joints is indicated to prevent mechanical blockade, 3rd body wear and resultant arthritis, plus lead arthropathy and rarely, systemic lead poisoning (plumbism). Bullets also act as potential nidus for infection ( 2 – 4 ). The myth that bullets auto-sterilize upon discharge has been disproved by Wolf et al ( 5 ). They coated bullets with Staphylococcus aureus and fired into sterile ballistic blocks, and they cultured the same organism from the bullet tracts. Infrequently, bullets are removed for forensic analysis to aid law enforcement agencies ( 6 ). Aims We present a series of 46 patients who had removal of retained bullets from the hip joint using open surgical techniques of arthrotomy, surgical hip dislocation, tractotomy, as well as posterior wall osteotomy. Methods We reviewed prospectively collected data of skeletally mature patients who presented to a single Level 1 Trauma institution with civilian gunshot injuries that breached the hip joint capsule between 01 January 2009 and 31 December 2021. Inclusion criteria We included all cases where the bullet was then retained within the hip joint area. We defined breaching the hip joint as the presence of a bullet or shrapnel retained in the joint or presence of a femoral head or neck fracture. We defined the hip joint area as the area covered by a line drawn from pelvic brim 2cm above acetabulum dome, to greater trochanter laterally, and proximal pole of lesser trochanter inferiorly and the lateral border of the obturator foramen medially (Fig. 1 ). Exclusion criteria we excluded cases where the hip joint was not breached, bullets were not retained within the hip area as described or cases with isolated acetabulum involvement and no bullet retention. We used pre-operative plain x-ray films and CT scans to confirm intra-articular location of the bullet (Fig. 2 a & b). Results One hundred and nineteen (119) patients with bullets traversing the hip joint were identified. The majority of patients were male (88,5%) with a mean age of 28 years (range 18–63). One patient was excluded as the bullet embedded in the femur neck was sustained 10 years earlier. Out of the remaining 118 patients, 46 of them had the bullet traverse the hip joint, but the final resting position was outside of the hip joint area. These were also excluded from the final analysis. This left a final sample size of 72 patients where the bullets were retained within the hip joint area. In 46 of these 72 patients, we undertook bullet removal using the following methods: hip arthrotomy (n = 19), surgical hip dislocation (n = 18), direct removal without capsulotomy (tractotomy) (n = 5), removal at site of fracture fixation/replacement (n = 3) and posterior wall osteotomy (n = 1). In 26 patients we did not remove bullets for the following reasons: final location was extra-capsular and embedded in the soft tissues (n = 17), clinical decision to not remove due to patients’ clinical condition not allowing for further surgery (n = 8) and patient refusal (n = 1). No patients underwent hip arthroscopy. Discussion Bullet wounds affecting the hip joint are relatively rare injuries, accounting for 2% − 17% of all civilian gunshot wounds ( 1 , 7 , 8 ). The final resting place of the missile can be free-floating within the joint, located peri-articularly or lodged within the bone of the femur head, neck or acetabulum. Retained intra-articular bullets are removed for a variety of reasons, mainly to prevent infection, 3rd body wear, lead arthropathy and rarely, systemic lead poisoning ( 9 ). The literature on bullet removal from the hip joint is sparse, with mostly small case series and sporadic case reports. Twenty-five publications appear in the English literature regarding removal of retained hip bullets, with a total of number of 48 bullets removed over a 47-year period. We report on the largest series with 46 hip bullets removed at a single institution over a 13-year period, using open surgical techniques (Table 1 ). Table 1 Bullet removal methods. Removal technique Number of cases Hip Arthrotomy 19 Surgical hip dislocation 18 Tractotomy 5 Direct removal at site of fracture fixation/replacement 3 Posterior wall osteotomy 1 Hip arthroscopy is the most commonly used modality to remove retained bullets in the hip. Goldman was the first to report its use to remove a bullet from the hip joint though this was combined with a limited open approach for insertion of the posterior portal ( 10 ). Hip arthroscopy offers the advantages of minimally invasive surgery with quicker recovery and reduced hospitalization days. It can be performed in lateral or decubitus positions, using traditional anterior portals or inferomedial or posterior portals. Hip arthroscopy can be performed in isolation or with ‘tractoscopy’ or combined with limited open techniques ( 11 ). It also offers opportunity for treatment of concomitant lesions such as debridement of chondral flaps, chondroplasty and microfractures. It however has a steep learning curve, requires additional specialized equipment like C-arms for screening, and is not readily available in most institutions. Grasping the bullet may also prove challenging and there are reports of fluid extravasation leading to cardiac arrest ( 12 , 13 ). Despite limitations, removal of bullets has been one the most common indications for hip arthroscopy in the trauma setting ( 2 , 3 , 11 , 14 – 26 ). In all our cases we were able to remove the bullets utilizing open surgical techniques. Sometimes the final resting place of the soft missile may be embedded in hard bone which can lead to iatrogenic joint damage during attempts at removal( 27 ). To ensure complete inspection of the femoral head and acetabulum, and to aid safe removal of retained missiles, Maqungo et al performed surgical hip dislocation (SHD) to remove retained missiles and they reported a 100% success rate ( 28 ). SHD also allowed for treatment of associated chondral lesions with debridement and microfracture techniques. SHD is a safe procedure first described by Ganz for treatment of femoro-acetabular impingement ( 29 ). In this series we successfully used SHD with a trochanteric step osteotomy to remove 18 bullets (Fig. 3 ). Other open techniques like posterior wall osteotomy and open arthrotomy have also been reported ( 8 , 30 ). Krishnan et al used an extra-articular approach without dislocating the hip to remove a bullet that was lodged into acetabulum posterior column, with only the tip protruding into the hip joint ( 31 ). The bullet was removed by creating a window in the posterior column, guided by a K-wire placed under fluoroscopic guidance. Williams used a DHS triple reamer to remove a bullet that was lodged in the femoral head ( 20 ). We used open arthrotomy via anterior Smith-Petersen (n = 12) or posterior approaches (n = 7) in a total of 19 patients. In one case, the bullet had been observed to be lodged anteriorly inside the hip joint capsule. The patient was booked for insertion of a sliding hip screw plus removal of bullet. However, during attempts at removal using the Smith-Petersen approach, the bullet was noted to have migrated and was by then lodged posteriorly. The anterior approach was abandoned and a posterior arthrotomy was performed two days later and the bullet successfully removed (Fig. 5 ). A tractotomy was utilized in cases where the bullet was resting in bone and in direct communication with the hip joint. This entails following the bullet tract without the need to perform an arthrotomy. The hip joint is then washed through the bullet tract. In two patients this was achieved via a modified Stoppa approach (anterior intrapelvic approach) to retrieve bullets that were lodged medially in the quadrilateral plate of the hip joint (Fig. 4 ). This approach has been described for a similar indication previously ( 32 ). Three patients had direct bullet removal from the fracture site at the time of surgical fixation (n = 2) or total hip arthroplasty (n = 1). Total hip arthroplasty has been described for post-traumatic arthritis secondary to gunshot injuries ( 33 – 37 ). Ours is a rare case of primary total hip arthroplasty in a 31-year-old male performed in the acute setting following a gunshot injury (Fig. 6 ). This was due to the extensive comminution of the femoral head and neck as well a very vertical fracture line which would increase the likelihood of fixation failure as these cases have a poor prognosis with fixation and have been described as ‘doomed to failure’ ( 38 ). We have been following this case up for 2 years and he continues to do well with excellent function and no signs if infection. Table 2 summarizes the cases where the bullets were not removed. In 17 cases the final resting place of the bullet was extracapsular even though the bullet had traversed the hip joint capsule en route to its final resting position. In these instances, it is expected that the soft tissues will close and seal the missile from contact with the hip joint. Projectiles located in soft tissues are sealed off by non-vascular scar tissue which reduces the chances of infection or lead poisoning ( 9 ). Table 2 Reason for bullets not removed. Reason for not removal Number of cases Final location extracapsular 17 Clinical decision not to remove (patient unwell) 8 Patient refusal 1 In 8 cases a clinical decision was made to not remove the bullets due patients’ clinical condition not allowing further surgery and 7 of these patients subsequently demised. In one of these cases the final location of the bullet was being deeply imbedded in the femoral neck and a decision was made to not remove it (Fig. 7 ). This is a clinical stance supported by Howse et al as well as Christie et al ( 11 , 39 ). One patient refused bullet removal and was discharged without further follow-up. In all the cases in this series, as well as in the quoted studies, the bullets were removed early in the clinical course because missed injuries and late retrievals have been shown to have poor outcomes with increased risk of septic arthritis ( 8 , 40 ). Our average time to removal was 6 days (range 1–12). Limitations The relatively low numbers represent a limitation of our study. This is however the largest series to date published from a single institution. Long-term clinical outcomes are beyond the scope of this manuscript as our endpoint was successful removal of bullets utilizing proven surgical techniques with known long-term outcomes. The epidemiology of associated injuries is also beyond the scope of this manuscript. Conclusion We present the largest series of bullet removal from the hip joint in which all bullets were successfully removed. With adequate pre-operative imaging and careful surgical planning, safe surgical removal of retained bullets in the hip joint can be achieved without the use of hip arthroscopy, using the traditional open surgical approaches of arthrotomy, tractotomy and surgical hip dislocation. Declarations Compliance with Ethical Standards Ethics approval was obtained from our institution on 16 October 2023. Approval number 440/2020. Informed consent was obtained from all subjects for both clinical intervention as well as use of clinical information for research purposes. Author Contribution Conceptualization SMMethodology SMFormal analysis and investigation SM, AAWriting – original draft preparation SMWriting – review and editing SM, ML, SG, AAFunding acquisition SMResources SM, SSSupervision ANAll authors reviewed the manuscript. 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Southern Orthopaedic Association [Internet]. 2020;29(3):135–40. https://www.researchgate.net/publication/347964329 . Christie DB, Bozeman AP, Stapleton TR, Ashley DW. Gunshot wound to the femoral neck: A unique case. J Trauma - Injury Infect Crit Care. 2007;62(3):785. Brien E, Brien W, Long W, Kuscnher S. Concomitant Injuries Of The Hip Joint And Abdomen Resulting From Gunshot Wounds. Orthopaedics. 1992;15(11):1317–20. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4705380","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":332549796,"identity":"bcbfaec7-dca4-4b76-9daa-a31f83756051","order_by":0,"name":"Sithombo 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dislocation\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-4705380/v1/d66e60c8c31ffb6c21f9e89f.png"},{"id":62218506,"identity":"edf1602f-ecc6-49dd-b80d-95083cda7891","added_by":"auto","created_at":"2024-08-11 12:03:14","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":124852,"visible":true,"origin":"","legend":"\u003cp\u003eStoppa approach\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-4705380/v1/958f1e91aa1236fff6fd020f.png"},{"id":62217666,"identity":"b5888eda-6f93-41f4-8ad9-0e030ed91697","added_by":"auto","created_at":"2024-08-11 11:55:14","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":371143,"visible":true,"origin":"","legend":"\u003cp\u003ea, b \u0026amp; c. Migrating bullet\u003c/p\u003e","description":"","filename":"5.png","url":"https://assets-eu.researchsquare.com/files/rs-4705380/v1/986982f1e007deb371f61f95.png"},{"id":62217663,"identity":"b7a44fab-c2df-4599-a3f1-8de37ba0de77","added_by":"auto","created_at":"2024-08-11 11:55:14","extension":"png","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":293181,"visible":true,"origin":"","legend":"\u003cp\u003ea, b \u0026amp; c. \u0026nbsp;Total hip arthroplasty\u003c/p\u003e","description":"","filename":"6.png","url":"https://assets-eu.researchsquare.com/files/rs-4705380/v1/03d91a95c7116d70656b4d91.png"},{"id":62217667,"identity":"96d53699-6102-4540-a1b6-89852228bcc1","added_by":"auto","created_at":"2024-08-11 11:55:14","extension":"png","order_by":7,"title":"Figure 7","display":"","copyAsset":false,"role":"figure","size":243352,"visible":true,"origin":"","legend":"\u003cp\u003ea \u0026amp; b. Bullet embedded in bone.\u003c/p\u003e","description":"","filename":"7.png","url":"https://assets-eu.researchsquare.com/files/rs-4705380/v1/74f7f0e38584cc93f7670cec.png"},{"id":62221311,"identity":"a0aa6a5a-7caa-497a-8e4b-7bb642cb6ba4","added_by":"auto","created_at":"2024-08-11 12:27:17","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":3434326,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4705380/v1/d6cc3a36-f14f-49d2-8f66-62b411ec6e97.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Removal of retained bullets from the hip joint in civilian gunshot injuries.","fulltext":[{"header":"Introduction","content":"\u003cp\u003eCivilian gunshot injuries of the hip are relatively rare injuries comprising 2% \u0026minus;\u0026thinsp;17% of all gunshot injuries (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). Removal of bullets retained within joints is indicated to prevent mechanical blockade, 3rd body wear and resultant arthritis, plus lead arthropathy and rarely, systemic lead poisoning (plumbism). Bullets also act as potential nidus for infection (\u003cspan additionalcitationids=\"CR3\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). The myth that bullets auto-sterilize upon discharge has been disproved by Wolf et al (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). They coated bullets with \u003cem\u003eStaphylococcus aureus\u003c/em\u003e and fired into sterile ballistic blocks, and they cultured the same organism from the bullet tracts. Infrequently, bullets are removed for forensic analysis to aid law enforcement agencies (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e\n\u003ch3\u003eAims\u003c/h3\u003e\n\u003cp\u003eWe present a series of 46 patients who had removal of retained bullets from the hip joint using open surgical techniques of arthrotomy, surgical hip dislocation, tractotomy, as well as posterior wall osteotomy.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eWe reviewed prospectively collected data of skeletally mature patients who presented to a single Level 1 Trauma institution with civilian gunshot injuries that breached the hip joint capsule between 01 January 2009 and 31 December 2021.\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eInclusion criteria\u003c/strong\u003e \u003cp\u003eWe included all cases where the bullet was then retained within the hip joint area.\u003c/p\u003e \u003c/p\u003e \u003cp\u003eWe defined breaching the hip joint as the presence of a bullet or shrapnel retained in the joint or presence of a femoral head or neck fracture.\u003c/p\u003e \u003cp\u003eWe defined the hip joint area as the area covered by a line drawn from pelvic brim 2cm above acetabulum dome, to greater trochanter laterally, and proximal pole of lesser trochanter inferiorly and the lateral border of the obturator foramen medially (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eExclusion criteria\u003c/strong\u003e \u003cp\u003ewe excluded cases where the hip joint was not breached, bullets were not retained within the hip area as described or cases with isolated acetabulum involvement and no bullet retention.\u003c/p\u003e \u003c/p\u003e \u003cp\u003eWe used pre-operative plain x-ray films and CT scans to confirm intra-articular location of the bullet (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003ea \u0026amp; b).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eOne hundred and nineteen (119) patients with bullets traversing the hip joint were identified. The majority of patients were male (88,5%) with a mean age of 28 years (range 18\u0026ndash;63). One patient was excluded as the bullet embedded in the femur neck was sustained 10 years earlier.\u003c/p\u003e \u003cp\u003eOut of the remaining 118 patients, 46 of them had the bullet traverse the hip joint, but the final resting position was outside of the hip joint area. These were also excluded from the final analysis.\u003c/p\u003e \u003cp\u003eThis left a final sample size of 72 patients where the bullets were retained within the hip joint area.\u003c/p\u003e \u003cp\u003eIn 46 of these 72 patients, we undertook bullet removal using the following methods: hip arthrotomy (n\u0026thinsp;=\u0026thinsp;19), surgical hip dislocation (n\u0026thinsp;=\u0026thinsp;18), direct removal without capsulotomy (tractotomy) (n\u0026thinsp;=\u0026thinsp;5), removal at site of fracture fixation/replacement (n\u0026thinsp;=\u0026thinsp;3) and posterior wall osteotomy (n\u0026thinsp;=\u0026thinsp;1).\u003c/p\u003e \u003cp\u003eIn 26 patients we did not remove bullets for the following reasons: final location was extra-capsular and embedded in the soft tissues (n\u0026thinsp;=\u0026thinsp;17), clinical decision to not remove due to patients\u0026rsquo; clinical condition not allowing for further surgery (n\u0026thinsp;=\u0026thinsp;8) and patient refusal (n\u0026thinsp;=\u0026thinsp;1).\u003c/p\u003e \u003cp\u003eNo patients underwent hip arthroscopy.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eBullet wounds affecting the hip joint are relatively rare injuries, accounting for 2% \u0026minus;\u0026thinsp;17% of all civilian gunshot wounds (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). The final resting place of the missile can be free-floating within the joint, located peri-articularly or lodged within the bone of the femur head, neck or acetabulum.\u003c/p\u003e \u003cp\u003eRetained intra-articular bullets are removed for a variety of reasons, mainly to prevent infection, 3rd body wear, lead arthropathy and rarely, systemic lead poisoning (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe literature on bullet removal from the hip joint is sparse, with mostly small case series and sporadic case reports. Twenty-five publications appear in the English literature regarding removal of retained hip bullets, with a total of number of 48 bullets removed over a 47-year period. We report on the largest series with 46 hip bullets removed at a single institution over a 13-year period, using open surgical techniques (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eBullet removal methods.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRemoval technique\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNumber of cases\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHip Arthrotomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSurgical hip dislocation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTractotomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDirect removal at site of fracture fixation/replacement\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePosterior wall osteotomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eHip arthroscopy is the most commonly used modality to remove retained bullets in the hip.\u003c/p\u003e \u003cp\u003eGoldman was the first to report its use to remove a bullet from the hip joint though this was combined with a limited open approach for insertion of the posterior portal (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eHip arthroscopy offers the advantages of minimally invasive surgery with quicker recovery and reduced hospitalization days. It can be performed in lateral or decubitus positions, using traditional anterior portals or inferomedial or posterior portals. Hip arthroscopy can be performed in isolation or with \u0026lsquo;tractoscopy\u0026rsquo; or combined with limited open techniques (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). It also offers opportunity for treatment of concomitant lesions such as debridement of chondral flaps, chondroplasty and microfractures.\u003c/p\u003e \u003cp\u003eIt however has a steep learning curve, requires additional specialized equipment like C-arms for screening, and is not readily available in most institutions. Grasping the bullet may also prove challenging and there are reports of fluid extravasation leading to cardiac arrest (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). Despite limitations, removal of bullets has been one the most common indications for hip arthroscopy in the trauma setting (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan additionalcitationids=\"CR15 CR16 CR17 CR18 CR19 CR20 CR21 CR22 CR23 CR24 CR25\" citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn all our cases we were able to remove the bullets utilizing open surgical techniques.\u003c/p\u003e \u003cp\u003eSometimes the final resting place of the soft missile may be embedded in hard bone which can lead to iatrogenic joint damage during attempts at removal(\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e). To ensure complete inspection of the femoral head and acetabulum, and to aid safe removal of retained missiles, Maqungo et al performed surgical hip dislocation (SHD) to remove retained missiles and they reported a 100% success rate (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). SHD also allowed for treatment of associated chondral lesions with debridement and microfracture techniques. SHD is a safe procedure first described by Ganz for treatment of femoro-acetabular impingement (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e). In this series we successfully used SHD with a trochanteric step osteotomy to remove 18 bullets (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eOther open techniques like posterior wall osteotomy and open arthrotomy have also been reported (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eKrishnan et al used an extra-articular approach without dislocating the hip to remove a bullet that was lodged into acetabulum posterior column, with only the tip protruding into the hip joint (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e). The bullet was removed by creating a window in the posterior column, guided by a K-wire placed under fluoroscopic guidance.\u003c/p\u003e \u003cp\u003eWilliams used a DHS triple reamer to remove a bullet that was lodged in the femoral head (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eWe used open arthrotomy via anterior Smith-Petersen (n\u0026thinsp;=\u0026thinsp;12) or posterior approaches (n\u0026thinsp;=\u0026thinsp;7) in a total of 19 patients.\u003c/p\u003e \u003cp\u003eIn one case, the bullet had been observed to be lodged anteriorly inside the hip joint capsule. The patient was booked for insertion of a sliding hip screw plus removal of bullet. However, during attempts at removal using the Smith-Petersen approach, the bullet was noted to have migrated and was by then lodged posteriorly. The anterior approach was abandoned and a posterior arthrotomy was performed two days later and the bullet successfully removed (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eA tractotomy was utilized in cases where the bullet was resting in bone and in direct communication with the hip joint. This entails following the bullet tract without the need to perform an arthrotomy. The hip joint is then washed through the bullet tract. In two patients this was achieved via a modified Stoppa approach (anterior intrapelvic approach) to retrieve bullets that were lodged medially in the quadrilateral plate of the hip joint (Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e4\u003c/span\u003e). This approach has been described for a similar indication previously (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThree patients had direct bullet removal from the fracture site at the time of surgical fixation (n\u0026thinsp;=\u0026thinsp;2) or total hip arthroplasty (n\u0026thinsp;=\u0026thinsp;1). Total hip arthroplasty has been described for post-traumatic arthritis secondary to gunshot injuries (\u003cspan additionalcitationids=\"CR34 CR35 CR36\" citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e). Ours is a rare case of primary total hip arthroplasty in a 31-year-old male performed in the acute setting following a gunshot injury (Fig.\u0026nbsp;\u003cspan refid=\"Fig6\" class=\"InternalRef\"\u003e6\u003c/span\u003e). This was due to the extensive comminution of the femoral head and neck as well a very vertical fracture line which would increase the likelihood of fixation failure as these cases have a poor prognosis with fixation and have been described as \u0026lsquo;doomed to failure\u0026rsquo; (\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e). We have been following this case up for 2 years and he continues to do well with excellent function and no signs if infection.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e summarizes the cases where the bullets were not removed. In 17 cases the final resting place of the bullet was extracapsular even though the bullet had traversed the hip joint capsule \u003cem\u003een route\u003c/em\u003e to its final resting position. In these instances, it is expected that the soft tissues will close and seal the missile from contact with the hip joint. Projectiles located in soft tissues are sealed off by non-vascular scar tissue which reduces the chances of infection or lead poisoning (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eReason for bullets not removed.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eReason for not removal\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNumber of cases\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFinal location extracapsular\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eClinical decision not to remove (patient unwell)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePatient refusal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eIn 8 cases a clinical decision was made to not remove the bullets due patients\u0026rsquo; clinical condition not allowing further surgery and 7 of these patients subsequently demised. In one of these cases the final location of the bullet was being deeply imbedded in the femoral neck and a decision was made to not remove it (Fig.\u0026nbsp;\u003cspan refid=\"Fig7\" class=\"InternalRef\"\u003e7\u003c/span\u003e). This is a clinical stance supported by Howse et al as well as Christie et al (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eOne patient refused bullet removal and was discharged without further follow-up.\u003c/p\u003e \u003cp\u003eIn all the cases in this series, as well as in the quoted studies, the bullets were removed early in the clinical course because missed injuries and late retrievals have been shown to have poor outcomes with increased risk of septic arthritis (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e). Our average time to removal was 6 days (range 1\u0026ndash;12).\u003c/p\u003e\n\u003ch3\u003eLimitations\u003c/h3\u003e\n\u003cp\u003eThe relatively low numbers represent a limitation of our study. This is however the largest series to date published from a single institution.\u003c/p\u003e \u003cp\u003eLong-term clinical outcomes are beyond the scope of this manuscript as our endpoint was successful removal of bullets utilizing proven surgical techniques with known long-term outcomes.\u003c/p\u003e \u003cp\u003eThe epidemiology of associated injuries is also beyond the scope of this manuscript.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eWe present the largest series of bullet removal from the hip joint in which all bullets were successfully removed.\u003c/p\u003e \u003cp\u003eWith adequate pre-operative imaging and careful surgical planning, safe surgical removal of retained bullets in the hip joint can be achieved without the use of hip arthroscopy, using the traditional open surgical approaches of arthrotomy, tractotomy and surgical hip dislocation.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e \u003ch2\u003eCompliance with Ethical Standards\u003c/h2\u003e \u003cp\u003e Ethics approval was obtained from our institution on 16 October 2023. Approval number 440/2020. Informed consent was obtained from all subjects for both clinical intervention as well as use of clinical information for research purposes.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eConceptualization SMMethodology SMFormal analysis and investigation SM, AAWriting \u0026ndash; original draft preparation SMWriting \u0026ndash; review and editing SM, ML, SG, AAFunding acquisition SMResources SM, SSSupervision ANAll authors reviewed the manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eBartkiw MJ, Sethi A, Coniglione F, Holland D, Hoard D, Colen R et al. Civilian Gunshot Wounds of the Hip and Pelvis. 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Southern Orthopaedic Association [Internet]. 2020;29(3):135\u0026ndash;40. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.researchgate.net/publication/347964329\u003c/span\u003e\u003cspan address=\"https://www.researchgate.net/publication/347964329\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChristie DB, Bozeman AP, Stapleton TR, Ashley DW. Gunshot wound to the femoral neck: A unique case. J Trauma - Injury Infect Crit Care. 2007;62(3):785.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBrien E, Brien W, Long W, Kuscnher S. Concomitant Injuries Of The Hip Joint And Abdomen Resulting From Gunshot Wounds. Orthopaedics. 1992;15(11):1317\u0026ndash;20.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"civilian gunshots, low velocity gunshots, hip joint, bullet removal","lastPublishedDoi":"10.21203/rs.3.rs-4705380/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4705380/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003ePurpose\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eRemoval of bullets retained within joints is indicated to prevent mechanical blockade, 3\u003csup\u003erd\u003c/sup\u003e body wear and resultant arthritis, plus lead arthropathy and rarely, systemic lead poisoning. We aimed to report on the largest series of removal of bullets from the hip joint using open surgical techniques.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis is a retrospective cohort study of all patients who presented to a single Level 1 Trauma Unit with civilian gunshot injuries that had breached the hip joint between 01 January 2009 and 31 December 2022.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eWe identified one hundred and seventeen (117) adult patients who met our inclusion criteria. Of these patients 72 had bullets retained within the hip joint area. Forty-six patients underwent bullet removal using the following techniques: hip arthrotomy (n=19), surgical hip dislocation (n=18), direct removal without capsulotomy (tractotomy) (n=5), removal at site of fracture fixation/replacement (n=3), posterior wall osteotomy (n=1).\u003c/p\u003e\n\u003cp\u003eNo patients underwent hip arthroscopy.\u003c/p\u003e\n\u003cp\u003eIn 26 patients we did not remove bullets for the following reasons: final location was extra-capsular embedded in the soft tissues (n=17), clinical decision to not remove though bullet due to the patients’ clinical condition not allowing for further surgery (n=8) and patient refusal (n=1).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion: \u003c/strong\u003eWith adequate pre-operative imaging and surgical planning, removal of retained bullets from the hip joint can be achieved using open surgical techniques without the need for hip arthroscopy.\u003c/p\u003e","manuscriptTitle":"Removal of retained bullets from the hip joint in civilian gunshot injuries.","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-08-11 11:55:09","doi":"10.21203/rs.3.rs-4705380/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"f5bc3c37-2f22-48f3-bf5c-a93c3019bada","owner":[],"postedDate":"August 11th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-08-11T11:55:11+00:00","versionOfRecord":[],"versionCreatedAt":"2024-08-11 11:55:09","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4705380","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4705380","identity":"rs-4705380","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}