Retained Surgical Cotton Ball Leading to Chronic Calf Wound

Summary

A 65-year-old male developed a chronic calf wound due to a retained surgical cotton ball (gossypiboma), identified by MRI and surgical exploration. This case highlights the critical need for strict intraoperative item counting, enhanced communication, and radiofrequency identification (RFID)/barcode technologies to prevent retained foreign bodies and ensure patient safety.

Abstract

Retained surgical items, such as cotton balls (gossypibomas), are rare yet preventable complications that may cause chronic infection and diagnostic difficulty. We report the case of a 65-year-old man with a non-healing right calf wound and sinus tract persisting for 1 year following orthopedic surgery. Magnetic resonance imaging (MRI) revealed an abscess characterized by T1-weighted hypointensity and T2-weighted spiral-like low-signal fringes, prompting surgical exploration. A retained cotton ball was identified and excised, followed by debridement and local rotational flap closure. The patient achieved complete recovery without recurrence. A review of 26 published lower-limb cases indicates that most gossypibomas occur after fracture fixation, often presenting with long latency, nonspecific symptoms, and variable MRI appearances. Preventive strategies include rigorous counting, enhanced team communication, and emerging tracking technologies such as radio-frequency identification (RFID) and barcode systems. This case emphasizes early recognition of atypical chronic wounds and supports incorporating automated tracking into surgical workflows to prevent retained foreign bodies and improve patient safety.

Introduction

Retained surgical items (RSIs), such as gossypibomas (surgical sponges or cotton balls inadvertently left in the body), represent a critical yet preventable surgical complication. With an incidence ranging from 1 in 100 to 1 in 5,000 procedures, RSIs lead to chronic infections, fistulas, and medicolegal consequences, despite stringent counting protocols¹. Despite strict item-counting procedures by surgical teams, procedural oversights can still occur, leading to severe consequences². This case report details a 65-year-old male with a chronic calf wound caused by a retained cotton ball, persisting for 1 year post-orthoped....

Protocol

The patient is informed and consents to publication. This study was conducted in accordance with the ethical standards of the institutional and national research committees and with the 1964 Helsinki Declaration and its later amendments. The protocol, including data collection, imaging evaluation, surgical management, and publication of anonymized clinical details and images, was reviewed and approved by the Ethics Committee of The First Affiliated Hospital, Zhejiang University (No. 2024-0844). Written informed consent for participation and publication was obtained from the patient prior to all study procedures.

1. Patient admission and clini....

Results

The patient underwent successful surgical exploration, during which the retained cotton ball was excised, followed by debridement and closure with a local skin flap. Postoperatively, vancomycin (1.2 g every 12 h) was administered to address potential infection. Renal function remained stable throughout treatment, with serum creatinine ranging from 0.86 to 0.96 mg/dL and eGFR between 84 and 94 mL/min/1.73 m².

A 2-week postop.......

Discussion

The intraoperative retention of foreign objects remains a critical concern in surgical practice. Such events can inflict substantial physical and psychological harm on patients, impose considerable financial burdens, and expose hospitals to serious reputational and legal risks³⁰. In our case, a cotton ball left within the surgical field led to chronic wound and fistula formation. A gossypiboma, sometimes known as cottonoid or textiloma, denotes a retained foreign body, for instance, a surgical spo.......

Materials

List of materials used in this article

Name	Company	Catalog Number	Comments
0.5% Povidone-Iodine Solution	Shanghai Likang Disinfection Co., Ltd.	LK-PI-500ML
0.5% Ropivacaine Hydrochloride Injection	AstraZeneca	NDC 0310-0520-10
1.5 Tesla MRI Scanner (Superconducting)	Siemens Healthineers	Magnetom Avanto 1.5T
3% Hydrogen Peroxide Solution	Sinopharm Chemical Reagent Co., Ltd.	10011218
4-0 Nylon Sutures	Ethicon (Johnson & Johnson)	1660H
8-Channel Phased-Array Knee Coil	Siemens Healthineers	MRI-COIL-KNEE-8CH
Acetaminophen Injection 1 g/100 mL	Baxter International Inc.	NDC 0338-7209-10
Closed-suction Drain System	B. Braun Medical	4265003
Continuous Low-negative Pressure Device (90–120 mmHg)	Yuyue Medical	NPWT-120
Hydrogen Peroxide 3%	Sinopharm	10011218
Linezolid Tablets 600 mg	Pfizer	NDC 0009-5150-04
Low-Molecular-Weight Heparin (LMWH)	Sanofi	Clexane 4000 IU/0.4 mL
Normal Saline 0.9%	China Otsuka Pharmaceutical Co., Ltd.	100 mL/500 mL
Nylon Sutures 4-0	Ethicon	1660H
Povidone-Iodine Solution 0.5%	Likang	LK-PI-500ML
Propofol Injection 1% (10 mg/mL)	Fresenius Kabi	NDC 63323-162-10
RF/Barcode Surgical Tracking System	Haldor Advanced Technologies Ltd.	ORLocate
Ropivacaine Hydrochloride 0.5%	AstraZeneca	NDC 0310-0520-10
Saline Irrigation Set (Sterile)	BD Medical	BD-IRR-500
Vancomycin Hydrochloride 1 g	Eli Lilly and Company	NDC 0002-0103-01