J Orthop Sci (2007) 12:497–501
DOI 10.1007/s00776-007-1150-1
Case report
Gossypiboma (foreign body granuloma) mimicking a soft tissue tumor
with hip hemiarthroplasty
Toshiki Iwase1, Takachika Ozawa2, Atsushi Koyama1, Kotaro Satake1, Ryoji Tauchi1, and Yohei Ohno1
1
Department of Orthopedic Surgery, Hamamatsu Medical Center, 328 Tomitsuka-cho, Naka-ku, Hamamatsu, Shizuoka 432-8580, Japan
2
Department of Pathology, Hamamatsu Medical Center, Hamamatsu, Shizuoka, Japan
Introduction
Gossypiboma is a mass lesion caused by surgical swabs
or sponges left after a surgical intervention. Because it
is less common in the orthopedic field than in the fields
of abdominal or thoracic surgery, an exact preoperative
diagnosis is difficult. The authors encountered a gos-
sypiboma mimicking a false aneurysm around a loos-
ened hip hemiarthroplasty. The patient and her families
were informed that data from the case would be sub-
mitted for publication and gave their consent.
Case report
A 72-year-old woman (height 145 cm, weight 35 kg),
who was a rheumatoid arthritis patient (Steinbrocker
stage III, class III), presented with a 2-year history of
right thigh pain on weight bearing. There was a soft
tissue mass about 8 cm in diameter on her right anterior
thigh. She had a past history of a displaced right hip
fracture 12 years before and had undergone cementless
bipolar hip hemiarthroplasty at another hospital.
Although she had been aware of a small mass (2–3 cm
in diameter) on her right anterior thigh that she first
noticed 2 years after the bipolar hip arthroplasty, there
had been no pain associated with the mass and she had
ignored it. Ten years after the bipolar hip arthroplasty,
a falling-down incident triggered right thigh pain on
weight bearing, and 12 years after the initial operation
she was referred to our institution by her general prac-
titioner for treatment of right thigh pain and the mass
lesion on her right thigh.
Bilateral hip radiography showed a subsided right
cementless bipolar endoprosthesis with an attenuated
Offprint requests to: T. Iwase
Received: December 25, 2006 / Accepted: April 24, 2007
femoral cortex and proximal medial segmental bone
wall defect at the calcar region combined with a round
soft tissue-density area at the lateral part of the right
proximal thigh (Fig. 1). Coronal magnetic resonance
imaging (MRI) revealed an oval mass lesion in the right
thigh. The mass comprised a thick capsule formation of
low signal intensity on both T1- and T2-weighted images
and slight enhancement on gadolinium (Gd)-enhanced
T1-weighted imaging. The signal of the contents in the
capsule was almost homogeneously low on T1-weighted
imaging and was heterogeneous on T2-weighted
imaging, being low in the center and surrounded by a
high signal area. This high signal area on the T2-weighted
image was more enhanced than the capsular area on the
Gd-enhanced T1-weighted image (Fig. 2). Enhanced
computed tomography (CT) imaging of the middle part
of the mass showed contrast medium staining in the
mass; and three-dimensional reconstruction clearly
demonstrated extravasation from a small branch of the
right lateral femoral circumflex artery (Fig. 3).
As these radiological findings gave rise to the need
for a differential diagnosis that included false aneurysm,
chronic expanding hematoma, soft tissue sarcoma, and
a tumorous mass related to the loosened hip hemiar-
throplasty, open biopsy was performed.
During an open biopsy, the thick fibrous capsule was
excised for pathological and microbiological examina-
tion, and rich blood flow in the capsule was noted, sug-
gesting that this mass region constituted false aneurysm
formation around the loosened hip hemiarthroplasty.
Microscopic pathological findings revealed that the
mass was composed of granulation tissue with a foreign-
body reaction containing many thread-like foreign
bodies without malignancy (Fig. 4). The microbiological
examination was negative.
At this moment, the preoperative diagnosis was
tumor-like granulation tissue caused by some kind of
foreign body (e.g., a surgical sponge) containing a hema-
toma combined with aseptic loosening of the hip endo-
 498
prosthesis. However, the relation between the mass and
the hip endoprosthesis was unclear.
One day before the resection, transcatheter arterial
embolization was performed to prevent massive intra-
operative bleeding around the mass (Fig. 5). Resection
of the mass was performed with revision hip hemiar-
throplasty through a longitudinal lateral skin incision of
the right proximal thigh. The mass was located just
distal to the anterior margin of the right gluteus medius
muscle and was easily resected without adhesions or
massive bleeding. Revision hip hemiarthroplasty using
impaction bone allogafting was performed through a
Fig. 1. Preoperative radiograph showed a loosened cement-
less bipolar hip endoprosthesis of the right hip joint with a
round soft-tissue density area on the right proximal thigh
(arrows)
a,b
Fig. 2. Preoperative magnetic resonance imaging (MRI) findings (coronal view). a T1-weighted image. b T2-weighted image.
c Gadolinium-enhanced T1-weighted image
T. Iwase et al.: Gossypiboma with hip arthroplasty
posterolateral approach for the hip joint (Fig. 6).
Because of the low activity level and muscle weak-
ness around the right hip joint of the patient, a bipolar
head, instead of an acetabular cup, was selected as the
new implant to reduce the risk of postoperative
dislocation.
A crumbled surgical sponge-like mass surrounded by
fresh coagula was found in the central part of the granu-
loma (Fig. 7). There were no malignant findings or
tumor tissue during the postoperative pathological
examination of the whole mass.
Discussion
Gossypiboma is the term used to describe a mass in the
body that comprises retained surgical sponges, swabs,
or towels with reactive tissue. This condition is most
frequently reported after abdominal or thoracic
surgery1–6 because of the procedures associated with
these cavities. In contrast, in English-language publica-
tions reports of gossypibomas after orthopedic proce-
dures are rare,7–12 and some of these reported cases
were initially suspected to be malignant soft tissue
tumors.9,10,12
Various symptoms are reported, such as abdominal
pain, a mass-related obstruction, erosion into the bowel,
a septic condition or continuous discharge from the sur-
gical wound due to gossypibomas in the abdominal
cavity,2,4 cough, expectoration, and hemoptysis due to
affected regions in the thorax.6,13 In contrast, it is often
the case that a gradually enlarging mass is the only sign
of a gossypiboma in the extremities.
Olnick et al. classified gossypibomas into two types
depending on the body’s reaction to the foreign sub-
c
 T. Iwase et al.: Gossypiboma with hip arthroplasty 499

stance14: the aseptic fibrous type, which produces adhe-

sions and encapsulation; and the exudative type, which
exhibits abscess formation with or without secondary
bacterial invasion. As there were no inflammatory clini-
cal symptoms and no sinus discharge around the mass,
the present case can be classified as the aseptic fibrous
type.
On the other hand, because periprosthetic mass
lesions such as malignant tumors,15 granulomatous
lesions with wear particles,16 and a pseudoaneurysm

Fig. 4. Histological findings of the biopsy specimen showed

granulation tissue with numerous thread-like foreign bodies
(arrows). × 200

Fig. 3. Three-dimensional reconstruction enhanced computed

tomography (CT) image shows extravasation from a small
branch of the right lateral femoral circumflex artery
(arrows)

Fig. 5. a Selective angiogram of the

right deep femoral artery showed
hypervascularity of the mass. b After
transcatheter embolization for the
a b feeding arteries of the mass
500
Fig. 6. Radiograph 1 year after the revision surgery. Calcar
was reconstructed with metal wire mesh and bone graft. The
strut allogeneic bone plate was applied at the level of the stem
tip to prevent postoperative femoral fracture.
around a loosened hip arthroplasty17,18 have been
reported, the differential diagnosis for these conditions
is important.
In fact, we thought that there might be a relation
between the mass and the loosened hip hemiarthro-
plasty in the present case. As MRI and enhanced CT
findings suggested that the mass included a hematoma-
tous region with active bleeding, our initial suspicion
based on radiological examinations was false aneurysm
formation due to a small vascular injury by the mechani-
cally loosened hemiarthroplasty or hemangioma. The
final preoperative diagnosis, however, was confirmed by
open biopsy, which indicated granulation tissue forma-
tion containing numerous thread-like foreign bodies.
There were no apparent findings of vascular wall or
hemangioma formation. Although hypervascularity
around a gossypiboma has been mentioned in the litera-
ture,10 to our knowledge, active intracapsular bleeding
of a gossypiboma detected by enhanced CT and angi-
ography has not been previously reported.
Why the present patient’s gossypiboma formed false
aneurysm-like tissue is unclear. Possible explanations
include the following: The surgeon for the initial surgery
might have tried to perform compressive hemostasis
using the retained cotton swab. Alternatively, intracap-
sular hemorrhage may occur after gossypiboma forma-
T. Iwase et al.: Gossypiboma with hip arthroplasty
Fig. 7. Sagittal section of the mass. The clearly capsulated
mass contained crumbled surgical sponge in its center sur-
rounded by fresh coagula
tion owing to repetitive movement of the right hip joint
during the period after the initial surgery.
Angiosarcoma developing in the fibrous capsule of a
gossypiboma has been described in the literature.19–21
Ben-Izhak et al. speculated that the proliferation of
mesenchymal cells that mature to form fibroblasts and
endothelial cells is probably related to the development
of malignant mesenchymal tumors in this area.19 This
fact indicates that careful preoperative clinical, radio-
logical, and pathological investigation is necessary when
we encounter a gossypiboma. Postoperative pathologi-
cal examination of the present case showed no malig-
nancy or hemangioma in the entire mass.
Surgical excision with or without repair or recon-
struction around the mass is only one treatment method
after an exact diagnosis of gossypiboma without malig-
nancy has been made. In the present case, intracapsular
hemorrhage was apparent on enhanced CT. The authors
therefore performed preoperative transcatheter arterial
embolization to prevent massive intraoperative bleed-
ing, which led to almost no evident bleeding during the
resection procedure and to a successful revision hip
hemiarthroplasty using the impaction bone grating
technique.
Gawande et al. estimated that the incidence of
retained foreign bodies (e.g., surgical sponges or instru-
ments) may be more than 1500 cases per year in the
United States.5 They also reported the risk factors for
this iatrogenic complication, which included emergency
T. Iwase et al.: Gossypiboma with hip arthroplasty
surgery, unplanned changes during the operation, and
a higher body mass index of the patient.
As the operative record of the initial surgery of the
present case at another hospital has been lost, the exact
background of that procedure is unknown. However, as
the initial operation was an ordinary procedure for
almost all orthopedic surgeons and the patient was not
particularly obese, the cause of the present case may
have been the usage of a cotton swab without a radi-
opaque marker and/or inaccurate gauze counting at the
end of the initial surgery. Concerning medical error
prevention, important points are to use swabs with radi-
opaque markers, repetitive and correct gauze counting,
and intraoperative radiographic examination just before
surgical wound closure if necessary.
Conclusion
The present case showed us the necessity of considering
gossypiboma as one of the differential diagnoses in the
case of a soft tissue mass around a previous operative
scar.
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