Arthroscopic Removal of Shotgun Pellet From Within the Medial Meniscus Kyle Lacy, M.D., M.S., Chris Cooke, M.D., Pat Cooke, B.A., Frederick Tonnos, D.O.  Arthroscopy Techniques  Volume 5, Issue 1, Pages e27-e32 (February 2016) DOI: 10.1016/j.eats.2015.09.004 Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 1 Left knee radiographs and computed tomography scans. (A) Anteroposterior and (B) lateral radiographs are standard in the radiographic workup of a gunshot wound to the knee. For cases in which the missile appears intra-articularly on radiography, a computed tomography scan is next performed to confirm the intra-articular or extra-articular location of metallic fragments. In this example, 1 shotgun pellet is located intra-articularly within the medial compartment, just distal to the weight-bearing surface of the medial femoral condyle, as seen on the (C) coronal and (D) sagittal views. Arthroscopy Techniques 2016 5, e27-e32DOI: (10.1016/j.eats.2015.09.004) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 2 Knee diagnostic arthroscopy in left knee after gunshot wound. The diagnostic arthroscopy for a gunshot wound to the knee begins with the patient supine, the knee flexed to 90°, and the arthroscope inserted through the anterolateral portal. (A) The patellofemoral articulation is first visualized with the knee in extension. (B) With the arthroscope in this same position, the trochlea is next visualized by simply rotating the arthroscope 120°. (C) The arthroscope is then advanced into the suprapatellar pouch to look for metallic debris. The (D) lateral gutter and (E) medial gutter are then visualized; in this example, the shotgun pellet entered the joint, piercing the capsule of the medial gutter. (F) The popliteal hiatus is a common location for metallic debris and bullet fragments to collect and therefore must be thoroughly visualized. (G) The femoral condyles are then inspected for signs of articular cartilage damage. (H) The posterior compartment and the posterior horn of the medial and lateral menisci are inspected; loose bodies and bullet fragments can also collect posteriorly. (I) In this case example, there are no obvious signs of the shotgun pellet within the medial compartment at first glance. Arthroscopy Techniques 2016 5, e27-e32DOI: (10.1016/j.eats.2015.09.004) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 3 Shotgun pellet removal from medial meniscus in left knee. (A) The body of the medial meniscus is viewed through the anterolateral portal. The (B) superior and (C) inferior surfaces of the meniscus are then probed, assessing for any metallic debris or meniscal tears. (D) A reactive hyperemic synovial response near the capsular rim of the meniscus is a useful finding because it confirms the meniscal entry site of the pellet. An 18-gauge (18 G) spinal needle is next inserted through the anteromedial portal and is used to pierce the meniscus, probing for the pellet location. (E) The subtle finding of a dark structure beneath the superior surface of the meniscus (black arrow) is also a useful clue. (F) An up-biter punch is next inserted through the anteromedial portal and is used to trim the inner rim of the white-white zone, exposing the pellet location. (G) The shotgun pellet is removed with a grasper, and the inner rim of the meniscus is recontoured using a shaver. The removed pellet is then (H) photographed, (I) measured, and sent to police authorities for ballistic analysis. Arthroscopy Techniques 2016 5, e27-e32DOI: (10.1016/j.eats.2015.09.004) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions