|Year : 2015 | Volume
| Issue : 2 | Page : 258-260
Foreign body in the knee with no history of trauma
Jesudoss Prabhakaran, Amutha, Justin Prashanth
Department of Physical Medicine and Rehabilitation, K J Nursinghome, 272, T. H. Road, Old Washermenpet, Chennai, India
|Date of Web Publication||13-Mar-2015|
K J Nursinghome, 272, T. H. Road, Old Washermenpet, Chennai - 600 021
Source of Support: None, Conflict of Interest: None
Foreign bodies in the knee joint are not uncommon. We report a case of sewing needle that migrated and embedded inside the knee with no history of trauma. Searching for any small foreign body in the knee joint is not easy in either open or arthroscopic procedures. In this case, the surgery was made by open method avoiding arthroscopy due to technical reasons. We emphasize careful history taking, clinical examination and, preferably, an open procedure for migrating tiny foreign bodies to facilitate accurate diagnosis, superior visualization and easier instrumentation to remove embedded foreign bodies in the knee.
Keywords: Arthroscopy, foreign body, intra-articular, knee, needle
|How to cite this article:|
Prabhakaran J, Amutha, Prashanth J. Foreign body in the knee with no history of trauma. Med J DY Patil Univ 2015;8:258-60
| Introduction|| |
The presence of foreign body in the knee is rare, but is usually encountered on occasions by a trauma. We report a case of sewing needle that migrated inside the knee joint of a 50-year-old woman. Awareness of the difficulties in operative exploration and removal of the tiny needle is needed to avoid complications. Temporary joint immobilization with a splint is beneficial to avoid intra-articular migration of tiny foreign bodies in the knee. The judicial administration of antimicrobial drugs may be necessary from the preoperative period onwards to prevent the most common microorganisms causing septic arthritis in the presence of foreign body in the knee.  This usually requires treatment with an extended course of antimicrobial agents. Migration of foreign body in and out of the knee joint resulted in pain and restricted movements of the joint, very similar to a ruptured meniscus or a degenerating chondral lesion. Several authors highlighted the importance of accurate history taking and thorough physical examination for such cases. 
| Case Report|| |
A 50-year-old woman presented to the outpatient department of our hospital reporting pain in the right knee for a period of more than 1 week. The patient felt the pain in the right knee when she noticed an insect biting the popliteal area, which woke her up while asleep. Several hours later, she felt mild discomfort in the right knee, which was progressively worsened on the next day. She had consulted the private medical practitioners nearby and had her medication as prescribed by them. When she found no relief, she consulted an orthopedician and was referred to a physiotherapist for further management. Unable to bear the worsening pain with difficulty in walking, she was brought to our hospital by her son to consult a neurosurgeon. The neurosurgeon persuaded her to report to a physician where the clinical examination and laboratory investigations were carried out. On examination, no swelling or deformity was noted. No abrasion was found around the right knee [Figure 1]a and b. She was tender over the superomedial side of the popliteal fossa. Knee extension was normal but flexion was limited to 60 degrees and straight leg raise to 25 degrees by pain. Because of the absence of a clear cause but with definite clinical findings, it was decided to radiograph the right knee joint. Radiographs disclosed a foreign body in the posteromedial aspect of the knee at the level of the intercodylar eminence [Figure 2].
Tetanus prophylaxis was administered and, after 2 h, knee surgery was performed by making a small incision on the medial side of the popliteal fossa. When the knee was explored toward the anteromedial and superomedial aspects, it revealed the presence of a sewing needle in the posterior compartment of the joint [Figure 3] and [Figure 4]. The needle was embedded in the synovium covering the fat pad, between the origin of the anterior cruciate ligament and medial femoral condyle. It was removed with its entirety by using a grasping forceps. The joint was then carefully inspected and generously irrigated before closure. Antibiotic prophylaxis with a first-generation cephalosporin was administered for 7 days. No complications were observed. Two weeks postoperatively, the patient showed a complete recovery and has remained symptom free.
| Discussion|| |
The clinical events of this case were interesting. A small needle in the relatively thick fat planes may be sufficiently bound and is comparatively painless.  In our case, a sewing needle was retained within the patient's knee for more than 1 week. The ability to detect the presence of this fine foreign body on clinical examination is difficult with a peculiar history that has no correlation for her presenting complaints. It was at this point that her son rather hesitantly volunteered that, unknown to her mother, his sister carried out some sewing work on the bed and must have left that sewing needle without the thread. We presume that after the prick of the needle the blood must have oozed out and the insect as the patient claims must have been attracted by its odor. The knee movements during sleep must have pushed the needle into the joint. Retrieving a moving needle in the knee joint is not an easy procedure. A foreign body that is superficial initially may later enter deeper planes or the joint itself. The surgeon must be aware of the possibility of migration. Difficult retrieval should be anticipated. Appropriate expertise must be used, and to visualize it arthroscopically is challenging. Arthroscopic direct visualization and transillumination of soft tissues are some techniques described to help retrieve foreign bodies from the knee joint. ,, A magnetic probe was considered, but was disappointing because they can only pick up extremely light objects and must be used very close to the object because of the weak magnetic field. Although arthroscopy is recommended for intra-articular foreign body of the knee, the cost of treatment is expensive. Arthrotomy, an open procedure, allows an accurate visualization of the minute-sizes migrating foreign body that is very difficult to be removed by arthroscopy.  This case emphasizes the importance of attention to preoperative clinical symptoms and events, intraopertaive clues and the judicious use of readily available operative techniques when trying to localize a target considering the economical background of the patient.
| Conclusion|| |
In this case, the patient had no history of trauma and no external or internal abrasions or scars. Although it is a more invasive procedure, the mini-arthrotomy incision provided direct visualization of the foreign body and enabled improved access to the femoral condyle thus facilitating the complete removal of the tiny foreign body. The root cause of this injury proved to be an ill-advised self-help teaching of tailoring. Therefore, it is a mandate that sewing needles have always to be replaced in the respective containers or to be kept as threaded to avoid an element of bad luck.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]