Case Report

Surgical Sponge Retained in Femoral Canal for 22 Years: A Case Report

Abstract

Background: Retained surgical items (RSIs) are not very common in the orthopedic surgery. Here, we are reporting a case of a sponge pad left in the femoral canal for 22 years. We could not find any other reported case of retained surgical sponge in the femoral canal and that is what makes this case report unique.

 

Case Report: The patient was a 42 year-old man who underwent surgery for the fixation of a fractured femur 22 years ago. In August 2020, this patient was seen complaining about pain at the surgical site. The assessments revealed a sponge pad retained in the femoral canal, which was removed by surgery. The union of fractured bone did not take place in the first surgery, so after 6 months a second surgery was performed and the dynamic compression plate (DCP) placed was successfully replaced with an intramedullary nail.

 

Conclusion: The surgeon could not detect the pad 22 years ago and the patient had no significant symptoms all this time. The most important take-away lesson of this paper is that retention of surgical pads could also occur with correct gauze counting, so detection and prevention protocols for RSIs must be taken seriously.

1. Hempel S, Maggard-Gibbons M, Nguyen DK, Dawes AJ, Miake-Lye I, Beroes JM, et al. Wrong-site surgery, retained surgical items, and surgical fires : A systematic review of surgical never

events. JAMA Surg. 2015;150(8):796-805. doi:

10.1001/jamasurg.2015.0301. [PubMed: 26061125].

2. Copeland AW. Retained surgical sponge (gossypiboma) and other retained surgical foreign bodies: Prevention and management [Online]. [cited 2011]; Available from: URL: https://somepomed.org/articulos/contents/mobipreview.htm? 4/59/5041

3. Steelman VM, Shaw C, Shine L, Hardy-Fairbanks AJ. Retained surgical sponges: A descriptive study of 319 occurrences and contributing factors from 2012 to 2017. Patient Saf Surg. 2018;12:20. doi: 10.1186/s13037-018-0166-0. [PubMed: 29988638]. [PubMed Central: PMC6027759].

4. Feldman DL. Prevention of retained surgical items. Mt Sinai J Med. 2011;78(6):865-71. doi: 10.1002/msj.20299. [PubMed: 22069210].

5. Stawicki SP, Cook CH, Anderson HL 3rd, Chowayou L, Cipolla J, Ahmed HM, et al. Natural history of retained surgical items supports the need for team training, early recognition, and prompt retrieval. Am J Surg. 2014;208(1):65-72. doi: 10.1016/j.amjsurg.2013.09.029. [PubMed: 24524864].

6. Steelman VM. Retained surgical items: Evidence review and recommendations for prevention. Aorn J. 2019;110(1):92-6. doi: 10.1002/aorn.12740. [PubMed: 31246305].

7. De Buren N. Causes and treatment of non-union in fractures of the radius and ulna. J Bone Joint Surg. 1962;44-B(3):614-25. doi: 10.1302/0301-620X.44B3.614.
Files
IssueVol 7, No 2 (2021) QRcode
SectionCase Report
DOI https://doi.org/10.18502/jost.v7i2.7005
Keywords
Retained Surgical Items; Retained Surgical Sponge; Gossypiboma
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Creative Commons License This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.
How to Cite
1.
Mirhoseini M, Azarsina S, Tavakoli M, Kohandel Gargari O. Surgical Sponge Retained in Femoral Canal for 22 Years: A Case Report. J Orthop Spine Trauma. 2021;7(2):67-70.