Foreign and loose bodies within the hip joint may be a source of pain, accelerate damage to the chondral surfaces, and if metallic, put a patient at risk for lead toxicity.1 Foreign bodies may arise iatrogenically through a surgical procedure when an instrument or implant is fractured or be the result of penetrating trauma. There are few nonarthroscopic methods described to successfully remove hip intra-articular bodies in the absence of surgically dislocating the hip. Furthermore, the retrieval of intra-articular foreign bodies through an anterior approach can prove difficult, depending upon the location within the joint. Intra-articular bodies may also be mobile within the hip and visualization through an anterior approach can be limited and often blind posteriorly.

We introduce a new technique utilizing a Satinsky vascular clamp to remove intra-articular bodies from a variety of locations within hip capsule through a standard anterior approach. Figure 1 shows the introduction of the clamp through an anterior approach, depicting how the shape of the Satinsky clamp is optimal for accessing remote recesses of the hip. The authors have obtained the patients’ informed written consent for print and electronic publication of the case reports.

FIGURE 1:

A, A Satinsky clamp with medium size jaws is introduced through an anterior approach to retrieve a foreign body within the posterior recesses of the hip. B, The shape of the jaws is optimal for accessing remote recesses of the hip and the smooth outer contour of the jaw surface with inlaid teeth allows for access to be achieved in as atraumatic manner as possible.

TECHNIQUE AND CASES Case 1

A 44-year-old woman was transferred from an outside hospital after a motorcycle accident with multiple fractures and extensive injury to her right lower extremity. Before transfer she underwent irrigation and debridement of right open tibia plateau and patella fractures, application of an external fixator to her right lower extremity, and closed reduction of her right posterior hip dislocation. Following transfer to our hospital further imaging revealed a displaced right femoral head fracture. An open reduction internal fixation of her right femoral head fracture was performed in addition to treatment of her other injuries.

Utilizing an anterior approach (Smith-Peterson) to the hip, the displaced femoral head fracture was directly visualized and an anatomic reduction was confirmed with direct visualization and fluoroscopy. Kirschner wires were used for provisional fixation. Three headless compression screws were used for femoral head fracture fixation and their position confirmed on fluoroscopy. During screw insertion, the tip of one of the Kirschner wires broke. On fluoroscopy the metal tip, measuring ∼3×1.6 mm, was loose within the acetabulum (Fig. 2). Gentle manual traction on the limb was applied and a Satinsky vascular clamp was inserted through the anterior approach incision and capsulotomy without further dissection and the steel tip was retrieved and fixation completed (Figs. 3A, B).

FIGURE 2:

Intraoperative fluoroscopy anteroposterior right hip showing broken Kirschner-wire tip within the right hip joint. Circle around broken Kirschner wire.

FIGURE 3:

A and B, Anteroposterior and lateral right hip x-rays showing open reduction and internal fixation of the right femoral head with interval removal of the broken Kirschner-wire tip.

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.

Case 2

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.

FIGURE 4:

A and B, Anteroposterior and lateral right hip x-rays showing retained bullet within the hip joint.

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).

FIGURE 5:

A and B, Intraoperative fluoroscopy anteroposterior and lateral right hip showing removal of bullet with Satinsky clamp.

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.

DISCUSSION

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.

ACKNOWLEDGMENT

The authors to thank Aaron Mahramas for providing the inspiration for this technique.

REFERENCES 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. 4. Papavasiliou AV, Bardakos NV. Complications of arthroscopic surgery of the hip. 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.