Bullet-induced synovitis as a cause of secondary osteoarthritis of the hip joint: A case report and review of literature
© Rehman et al; licensee BioMed Central Ltd. 2007
Received: 17 May 2007
Accepted: 05 December 2007
Published: 05 December 2007
With increasing prevalence of gunshot injuries we are seeing more patients with retained bullet fragments lodged in their bodies. Embedded lead bullets are usually considered inert after their kinetic energy has dissipated hence these are not removed routinely. However, exposure of any foreign body to synovial fluid may lead to rapid degradation and hence result in systemic absorption, causing local and systemic symptoms. We present the case of a thirty year old man who came to our out patient department with a history of progressive, severe hip pain ten years after a gun shot injury to his right hip.
The common belief that intraarticular bullets should not be removed has no benefit and may result in unwanted long term complications.
With increasing prevalence of gunshot injuries we are seeing more and more patients with retained bullet fragments lodged in their bodies . Embedded lead particles are usually considered inert after their kinetic energy has dissipated hence these are not removed routinely. Removal is indicated if they impinge on vital structures or are easily accessible during operation for other reasons [2–5]. A review of literature shows that retained intra-articular bullets have been associated with significant morbidity [6–9], joint degeneration and ultimately resulting in joint replacement.
Intra-articular bullet fragments behave differently due to direct contact with synovial fluid. Lead being soluble in synovial fluid [3, 10] can cause both local and systemic effects. Lead poisoning from retained intra articular bullets has been recognized in the literature since 1867 [3, 11–13]. Although in most of the cases the cause of arthropathy is not known but it's attributed mainly to mechanical forces along with local effects of lead poisoning [3, 4, 6, 7, 10, 14]. A retained bullet can not only produce foreign body reaction, mechanical articular cartilage damage and proliferative synovitis, leading to destructive arthritis but can also lead to systemic absorption of lead. However, there is considerable variation in extent of lead absorption, onset of time to symptoms, severity of symptoms and toxicity . Symptoms of systemic lead poisoning are usually vague; headache, nausea, fatigue and abdominal pain .
Rapid encapsulation of most foreign bodies composed of lead occurs via fibrosis, and this process essentially removes them from exposure to circulating body fluid with a subsequent drop in serum lead levels [13, 16, 17]. However, exposure of a leaded bullet to synovial fluid leads to rapid degradation and hence result in systemic absorption, causing local and systemic symptoms of lead intoxication [3, 4, 6, 7, 10, 14]. Two factors responsible for the dissolution of lead fragments in synovial fluid are the presence of hyaluronic acid and the ph of synovial fluid . On the other hand mechanical destruction of joint may be caused by several factors. Firstly the initial trauma may cause fractures of articular bone, leading to an incongruous and irregular joint surface. Motion of such surfaces against each other may lead to joint destruction. Secondly, when a bullet hits the bone; its articular cartilage, bone and pieces of lead may fragment, leading to intra articular debris that can pit and erode the joint surfaces. Thirdly, a bullet embedded in bone may extend partially into the joint; further motion can results in additional destruction of cartilage [10–12, 14, 18]. Toxic histologic manifestations of intra-articular lead have also been reported in animal models by Bolanos et al  and Harding et al . Harding et al  studied the effects of intra-articular lead implants on the synovium, articular cartilage and meniscus of white rabbits at 4, 6, 10 and 14 weeks. Articular and meniscal changes that Harding et al came across were chondrocyte proliferation, disorganization of the columnar epithelium. Tide mark duplication and unequal thickness of the cartilage was observed in the articular cartilage while the synovium showed both cellular and stromal hyperplasia .
If lead arthropathy is identified, removal of lead fragments [14, 15, 21] is mandatory along with other procedure/s as indicated by the condition of the joint. Intraarticular lead poisoning has been reported in the literature in the context of gout, synovitis and degenerative joint diseases along with systemic lead poisoning [3, 4, 7, 10, 13, 14, 16, 22, 23]. All patients with lead arthropathy should be evaluated for systemic lead toxicity .
Although bullet dislodgement into the joint space is very rare, its urgent removal is warranted if found. Its early removal will prevent both local and systemic lead intoxication. If not removed, it can result in lead arthropathy ultimately resulting in joint replacement. The common belief that intra-articular bullets should not be removed has no benefit and might cause a lot of long term complications.
The authors confirm that a formal written consent was taken for the publication of this case report.
- Davis JW, RMPr, Kaups KL: More guns and younger assailants. A combined police and trauma center study. Arch Surg. 1997, 132: 1067–70View ArticlePubMedGoogle Scholar
- Dillman O R, Crumb K C, Lidsky J M: Lead poisoning from a gunshot wound: report of a case and review of the literature. Am J Med. 1979, 66: 509-514. 10.1016/0002-9343(79)91083-0.View ArticlePubMedGoogle Scholar
- Slavin R, Swedo J, Cartwright J Jr, Viegas S, Custer EM: Lead arthritis and lead poisoning following bullet wounds: a clinicopathologic, ultrastructural, and microanalytic study of two cases. Hum Pathol. 1988, 19 (2): 223-235. 10.1016/S0046-8177(88)80353-8.View ArticlePubMedGoogle Scholar
- Sclafani SJA, J V, Twersky J: Lead arthropathy: arthritis caused by retained intraarticular bullets. Radiology. 1985, 156: 299-302.View ArticlePubMedGoogle Scholar
- Hollerman JJ, M F, Coldwell DM, Ben- Menachem Y: Gunshot wounds. Radiology. 1990, 155: 691-702.Google Scholar
- Jr. PDD: Lead arthropathy-progressive distruction of a joint by retainedbullet. J Bone Joint Surg Am. 1984, 66: 292-294.Google Scholar
- Peh WC, Reinus WR: Lead arthropathy: a cause of delayed lead poisoning. Skeletal Radiol. 1995, 24: 357-360.PubMedGoogle Scholar
- Farrell E S, Vandevander P, Schoffstall M J, Lee C D: Blood Lead Levels in Emergency Department Patients with Retained Lead Bullets and Shrapnel. Academic Emergency Medicine. 6 (3): 208-212.Google Scholar
- Khurana V, Bradley P T: Lead poisoning from a retained bullet: a case report and review. J Assoc Acad Minor Phys. 1999, 10 (2): 48-49.PubMedGoogle Scholar
- Leonard H M: The Solution of Lead by Synovial Fluid. Clin Orthop. 1969, 64 (): 255-261.PubMedGoogle Scholar
- Farber M J, Rafii M, Schwartz D: Lead arthropathy and elevated serum levels of lead after a gunshot wound of the shoulder. AJR Am J Roentgenol. 1994, 162 (2): 385-386.View ArticlePubMedGoogle Scholar
- Howland WS Jr, Ritchey SJ: Gunshot Fractures in Civilian Practice. An Evaluation of the Results of Limited Surgical Treatment. J Bone Joint Surg Am. 1971, 53 (1): 47-55.PubMedGoogle Scholar
- W. M: Lead absorption from bullets lodged in tissues, report of two cases. JAMA. 1940, 115: 1536View ArticleGoogle Scholar
- Switz DM EME Deyerle WM. . Arch Intern Med.: Bullets, joints, and lead intoxication: a remarkable and instructive case. 1976, 136 (8): 939-941.Google Scholar
- Kikano E G, Stange C K: Lead poisoning in a child after a gunshot injury. J Fam Pract. 1992, 34 (4): 498-504.PubMedGoogle Scholar
- Cagin R C, Diloy-Puray M, Westerman P M: Bullets, lead poisoning and thyrotoxicosis. Ann Intern Med. 1978, 89 (4): 509-511.View ArticlePubMedGoogle Scholar
- Goldman H R, White R, Kales N S, Hu H: Lead poisoning from mobilization of bone stores during thyrotoxicosis. Am J Int Med. 1994, 25: 417-424. 10.1002/ajim.4700250309.View ArticleGoogle Scholar
- Windler C E, Smith B R, Bryan J W, Woods W G: Lead Intoxication and Traumatic Arthritis of the Hip Secondary to Retained Bullet Fragments. A Case Report. J Bone Joint Surg Am. 1978, 60: 254-255.PubMedGoogle Scholar
- Bolanos A A, Vigorita J V, Meyerson I R, D'Ambrosio G F, Bryk E: Intraarticular histopathologic changes secondry to local lead intoxication in rabbit knee joints. J Trauma. 1995, 38: 668-671.View ArticlePubMedGoogle Scholar
- Harding R N, Lipton F J, Vigorita J V, Bryk E: Experimental Lead Arthropathy: An Animal Model. Journal of Trauma-Injury Infection & Critical Care. 1999, 47 (5): 951-10.1097/00005373-199911000-00025.View ArticleGoogle Scholar
- Bolanos A A, Demizio JP Jr, Vigorita J V, Bryk E: Lead poisoning from an intraarticular shotgun pellet in the knee treated with arthroscopic extraction and chelation therapy. J Bone Joint Surg Am. 1996, 78: 422-426.PubMedGoogle Scholar
- Disla E, Brar H, Taranta A: Gouty arthritis following gunshot wound: a case report. N Y State J Med. 1992, 92 (3): 110-111.PubMedGoogle Scholar
- Mankin J H, Dorfman H, Lippiello L, Zarins A: Biochemical and metabolic abnormalities in articular cartilage from osteoarthritic human hips. J Bone Joint Surg Am. 53 (3): 523-537.Google Scholar
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