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-orthopedic surgery. A review of 26 lower limb cases (Table 1) underscores prolonged latency periods, nonspecific symptoms, and diagnostic complexities due to variable imaging findings.

To address these shortcomings, RFID and barcode-based tracking systems have emerged as adjunct technologies to enhance surgical safety. Comparative studies demonstrate that RFID-assisted counting reduces detection time and nearly eliminates missed sponges during simulated operations, while barcode systems improve accountability and documentation^3,4,5 . For instance, Cima et al.⁶ reported that RFID integration reduced retained sponge incidents by up to 100% in pilot hospitals, with additional benefits of real-time verification and audit trails. Unlike visual counting, RFID/barcode systems provide objective, automated confirmation, thereby minimizing reliance on memory or manual recordkeeping^7,8.

Nevertheless, practical implementation requires consideration of cost, workflow integration, and potential technical failure modes. RFID systems are particularly advantageous in high-volume or emergency surgical settings where manual counting is prone to error, but their use can be limited by device cost, compatibility with sterilization processes, or signal interference from metallic instruments. Barcode systems, while less expensive, depend on consistent labeling and scanner access, which can be cumbersome in fluid-contaminated or restricted fields^4,5. Therefore, institutions must tailor technology adoption to their resources, case complexity, and staff training levels to achieve an optimal balance between safety and practicality.

This case report details a 65-year-old male with a chronic calf wound caused by a retained cotton ball persisting for 1 year after orthopedic surgery. A review of 26 lower limb gossypiboma cases underscores the diagnostic complexity and emphasizes the value of incorporating RFID/barcode systems alongside traditional counting to prevent RSIs^{5,9,10,11,12,13,14,15,16,17,18,19,20,21,22,23,24,25,26}. Strengthening systemic vigilance through technological aids, procedural audits, and communication can substantially reduce physical, emotional, and financial burdens associated with these adverse events.

Case presentation:

A 65-year-old male presented with a chronic localized skin wound and a sinus tract in the right lower extremity, persisting for 1 year. The patient was afebrile with a normal white blood cell count, normal CRP levels, and no purulent discharge. Physical examination revealed swelling, increased local skin temperature, and discharge from the fistula in the lower segment of the right calf. An MRI scan demonstrated an abnormal signal in the lower segment of the right calf, suggesting an abscess (Figure 1). During the surgical exploration, a retained cotton ball was discovered in the infected area, which was confirmed to be the source of the foreign body (Figure 2). Subsequent debridement was performed, and the fistula tract was excised. The surgical site was then closed with a local skin flap, and vancomycin 1.2 g once every 12 h was administered for targeted anti-infective treatment. Postoperatively, the patient demonstrated satisfactory wound healing during the 2-week follow-up period.

Diagnosis, Assessment, and Plan:

The initial tests performed on the 65-year-old male patient included a physical examination and an MRI scan. The physical examination revealed localized swelling, increased skin temperature, and discharge from a fistula in the lower segment of the right calf. These findings suggested an underlying infection or foreign body reaction. The MRI was conducted to provide a detailed visualization of the soft tissues and potential abscess formation. The MRI of the right calf demonstrated a well-defined lesion in the posterior-lateral compartment of the lower third of the leg. On T1-weighted spin-echo images (TR/TE = 600/12 ms), the lesion showed a markedly hypointense signal relative to skeletal muscle, surrounded by a thin, low-signal fibrotic capsule. Corresponding T2-weighted fast spin-echo images (TR/TE = 4000/90 ms) revealed a characteristic whorled or spiral-like internal architecture consisting of a central low-signal core interlaced with fine curvilinear strands, bordered by a peripheral hyperintense rim representing inflammatory granulation tissue and fluid accumulation²⁷. Fat-suppressed T2 sequences accentuated the peripheral high-signal halo and perilesional edema, confirming the chronic inflammatory nature of the lesion. No obvious communication with the bone cortex or marrow edema was observed, and adjacent neurovascular bundles were intact. These features, together with the patient's surgical history, strongly suggested a retained cotton-based foreign body (gossypiboma) rather than abscess or soft-tissue neoplasm.

Clinical examination alone could not definitively identify the nature of the mass. The diagnosis of gossypiboma was reached based on the combination of the patient's history of prior orthopedic surgery, the clinical presentation, and the specific MRI findings. The symptoms of localized swelling, warmth, and discharge, along with the non-healing wound and sinus tract, further supported this diagnosis. Surgical exploration confirmed the diagnosis,revealing and removing the retained cotton ball. This surgical intervention not only confirmed the presence of a gossypiboma but also allowed for the removal of the foreign body, which was essential for resolving the chronic wound and sinus tract.

The differential diagnosis considered included chronic infection, abscess formation, and soft tissue tumor. However, the MRI findings and the surgical exploration results ruled out these alternatives, confirming the gossypiboma as the cause of the patient's symptoms.

The treatment plan involved surgical excision of the retained cotton ball, followed by debridement and closure of the surgical site with a local skin flap. Vancomycin was administered postoperatively to address any potential infection. The rationale behind this treatment plan was to remove the source of the chronic inflammation and infection, promote wound healing, and prevent further complications. The use of vancomycin was based on its broad-spectrum antibacterial properties, targeting potential pathogens that could have contributed to the chronic wound²⁸.

Potential complications and side effects of the treatment included surgical site infection, wound dehiscence, and recurrence of the gossypiboma if any part of the cotton ball was left behind. Additionally, the use of vancomycin could lead to side effects such as nephrotoxicity or ototoxicity, although these risks were considered minimal given the patient's overall clinical status and the necessity of treating any underlying infection.

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 clinical evaluation

1. The patient presented with a chronic right calf wound and sinus tract persisting for 1 year following prior orthopedic surgery (internal fixation for fracture).
2. Upon admission, a detailed medical and surgical history was obtained, including prior operative reports, implant details, antibiotic history, and wound progression timeline.
3. Physical examination was conducted systematically: inspection (size, depth, and margins of wound and sinus tract), palpation (tenderness, induration, temperature), and assessment for fluctuance or crepitus. Wound discharge was sampled for culture and sensitivity. The extent of scarring, local edema, and presence of fixation hardware were documented. Vital parameters and systemic signs (fever, malaise) were recorded. Baseline tests included complete blood count (CBC), C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), and renal function tests (for antibiotic dosing consideration).
4. Preoperative photography was performed for documentation, and informed consent included discussion of the potential discovery of retained foreign material and the need for reconstructive closure.

2. Diagnostic imaging

1. MRI of the right calf using T1-weighted and T2-weighted sequences was done to evaluate soft tissue pathology. Magnetic resonance imaging (MRI) of the right calf was performed using a 1.5 Tesla superconducting MRI system equipped with an eight-channel phased-array knee coil to enhance signal-to-noise ratio for distal leg visualization. The imaging field extended from the lower third of the calf to just above the ankle joint.
2. Multiplanar acquisitions were obtained in axial, sagittal, and coronal planes. Sequences included T1-weighted spin-echo (TR/TE = 600/12 ms) for soft tissue and capsule delineation, T2-weighted fast spin-echo (TR/TE = 4000/90 ms) for fluid and inflammatory changes, and T2 fat-suppressed (TR/TE = 4200/85 ms) sequences to highlight edema and inflammatory infiltration. The slice thickness was 4 mm, with an interslice gap of 0.5 mm and a field of view (FOV) of 18 cm. No gadolinium-based contrast agent was administered, as the non-contrast sequences sufficiently demonstrated the lesion morphology and signal features.
3. MRI revealed a well-defined mass with low signal intensity on T1-weighted images and a central low-signal spiral-like structure on T2-weighted images, consistent with a retained cotton ball (gossypiboma) surrounded by fibrotic capsule and chronic inflammatory tissue.

3. Surgical intervention

1. Prior to induction, all patients undergo comprehensive pre-anesthetic evaluation, including cardiopulmonary function tests, renal and hepatic panels, and assessment for comorbidities such as diabetes or hypertension that may affect anesthesia safety. Airway evaluation (Mallampati classification, neck mobility) and allergy history-especially to anesthetics, latex, and antibiotics-are verified.
2. Anesthesia equipment, resuscitation tools, and emergency drugs (e.g., epinephrine, atropine, vasopressors) must be checked before induction. Any abnormalities are reported immediately to the anesthesiology team leader before proceeding.
3. Under combined spinal-epidural anesthesia using 0.5% ropivacaine (12 mg) at the L3-L4 level and target-controlled propofol infusion (2.5 µg/mL) for sedation, the patient was placed in a prone position with a soft pad beneath the ankle. A pneumatic tourniquet was applied at the mid-thigh level with an inflation pressure of 260 mmHg and a total duration not exceeding 90 min.
4. Strict aseptic technique is mandatory from patient preparation to wound closure. The surgical field was fully draped using sterile materials, with all team members performing a standardized hand scrub and donning sterile gowns and gloves.
5. Surgical instruments were opened and counted on a sterile table, with contamination immediately prompting replacement. Intraoperative re-draping is recommended if exposure time exceeds 2 h or if the sterile barrier is compromised.
6. Following sterile preparation, a longitudinal incision approximately 8 cm in length was made over the previous scar in the lower posterior-lateral calf. The subcutaneous tissue was dissected along the sinus tract using scissors and blunt dissection until a fibrotic capsule was encountered.
7. A gray-white cotton-like mass was identified and extracted in one piece using toothed forceps. The abscess cavity was irrigated sequentially with 3% hydrogen peroxide, normal saline, and 0.5% povidone-iodine solution until the return fluid was clear.
8. Necrotic and granulation tissue were sharply debrided using a curette and a scalpel until viable bleeding tissue was exposed. Real-time RFID/barcode tracking of sponges, gauze, and instruments supports manual counting and ensures reconciliation before closure. Any discrepancy immediately triggered re-inspection of the wound cavity under direct vision. The scrub nurse, circulating nurse, and surgeon verbally verified completion of counts before dressing application.
9. A local rotational skin flap (length-to-width ratio 2:1) was designed to achieve tension-free closure. The flap was raised in the subdermal plane, rotated to cover the defect, and inset using 3-0 absorbable sutures for the deep layer and 4-0 nylon interrupted sutures for the skin.
10. A closed-suction drain was placed beneath the flap and connected to continuous low-negative pressure (90-120 mmHg), removed after 48 h.
11. At the completion of the operation, the wound cavity was completely debrided, and no residual foreign material was visualized. The rotational skin flap demonstrated uniform pink coloration and brisk capillary refill (<2 s). The operating room temperature was maintained at 22 °C, and warmed, humidified saline was used intermittently to prevent flap desiccation.

4. Postoperative management

1. Vancomycin (1 g diluted in 100 mL of normal saline) was administered intravenously 30 min before skin incision as perioperative prophylaxis, infused over 60 min. Postoperatively, vancomycin was continued at a dose of 1 g every 12 h for 7 days, followed by oral linezolid 600 mg 2x daily for an additional 5 days to ensure infection control and prevent recurrence.
2. Continuous monitoring for rash, hypotension, or bronchospasm was performed. In case of hypersensitivity, the infusion was stopped immediately, and antihistamines or corticosteroids were administered per protocol.
3. Renal function and serum creatinine were monitored daily during vancomycin use to avoid nephrotoxicity. 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. Transition to oral agents (e.g., linezolid 600 mg 2x daily) was based on culture sensitivity and tolerance, with patient education on recognizing signs of hematologic toxicity.
4. Pain management included intravenous acetaminophen 1 g every 8 h and intermittent cold compresses for the first 24 h. The limb was elevated for 48 h, and the flap was monitored daily for color, temperature, and capillary refill. Drain output was recorded, and dressing changes were performed under aseptic conditions.
5. Given the immobilization associated with lower limb surgeries, pharmacologic and mechanical prophylaxis are essential. Low-molecular-weight heparin (LMWH) was initiated 12 h postoperatively (or per institutional guideline) and continued for 7-10 days, unless contraindicated. Graduated compression stockings or intermittent pneumatic compression devices were applied intraoperatively and maintained until full ambulation. Risk stratification (Caprini score) should guide the duration and intensity of prophylaxis.
6. Sutures were removed on postoperative day 14, and the patient gradually resumed weight-bearing as tolerated. No wound complications or recurrence were observed during the follow-up period.

5. Follow-up and monitoring

1. A 2-week postoperative follow-up was scheduled to assess wound healing, flap viability, and absence of recurrence or infection. Parameters recorded included wound integrity, absence of recurrence, and patient satisfaction with scar appearance. The patient's wound surface was completely dry, the incision was well aligned, there was no recurrence, and the patient's satisfaction with the scar appearance was 4 points.
2. At 2 weeks, the flap was supple and well integrated. No erythema, discharge, or tenderness was observed. Sutures were removed, and the incision demonstrated linear healing with intact skin edges. Laboratory reassessment confirmed normalization of inflammatory parameters.
3. Laboratory marker analysis (CRP, ESR) was repeated at 1 month. Ultrasound at 1 month confirmed the absence of residual fluid or foreign material. The patient was advised to maintain local hygiene and report any discharge, swelling, or pain promptly.

6. Preventive measures

1. Counting protocol: Three sequential counts of sponges and instruments (initial, closure, final) were performed and audibly verified by both scrub and circulating nurses, recorded in the operative log.
2. Implementation of RFID or barcode tracking systems to enhance item accountability was done. All sponges, gauze, cotton balls, and surgical instruments were pre-labeled with RFID microchips or printed barcodes before entering the sterile field. Each tag corresponds to a unique item identification number recorded in the operating room (OR) management system.
3. Each time an item was introduced, removed, or replaced within the surgical field, it was scanned by the circulating nurse or scrub nurse. The system updates the count in real-time, displaying the total number of active items. The RFID or barcode software issues an audible or visual alert if an item remains unscanned for removal, signaling a potential discrepancy before wound closure.
4. Prior to wound closure, both the scrub nurse and circulating nurse performed a synchronized scan of the field. The final system count must match the baseline inventory before the surgeon proceeds to closure. If a mismatch occurs, the system locks the case record and prompts an immediate recount and physical inspection before the patient leaves the OR.
5. Monthly safety audits and quarterly multidisciplinary team training emphasized adherence to WHO surgical safety checklists and RSI prevention algorithms.

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 postoperati...

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