Retained broken outflow cannula recovered 6 years post-knee arthroscopy

Area of Science:

• Orthopedic Surgery
• Surgical Complications
• Medical Device Integrity

Background:

• Knee arthroscopy is a common orthopedic procedure with potential complications.
• Retained surgical instruments represent a significant and avoidable complication.
• Ensuring patient safety necessitates rigorous protocols for instrument management.

Observation:

• A patient presented with acute knee pain six years post-arthroscopy.
• A fractured piece of an outflow cannula from the initial arthroscopic procedure was identified within the knee joint.
• The instrument fracture was subtle and not immediately apparent during post-operative checks.

Findings:

• Delayed diagnosis of a retained surgical instrument (outflow cannula fragment) occurred due to subtle fracture.
• The complication remained undetected for six years, leading to the patient's acute pain presentation.
• Instrument failure, even when not obvious, can lead to significant patient harm if not identified.

Implications:

• Emphasizes the critical importance of meticulous pre- and post-operative surgical instrument inspection.
• Highlights the need for vigilance regarding potential instrument failures and their reporting.
• Underscores the necessity of thorough patient evaluation for undiagnosed complications, even years after a procedure.