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Accidental burn injury during knee arthroscopy
Simon Huang1, David Gateley, Anthony L H Moss
1Department of Plastic and Reconstructive Surgery, St. George's Hospital, London, England.
Summary
Routine knee arthroscopy using overheated irrigation fluid led to severe patient burns and joint damage. This case underscores the critical need for strict protocols in managing irrigation fluid temperature during arthroscopic procedures.
Area of Science:
- Orthopedic Surgery
- Medical Device Safety
Background:
- Arthroscopy is a common minimally invasive surgical procedure.
- Maintaining correct irrigation fluid temperature is crucial for patient safety.
Observation:
- A patient undergoing knee arthroscopy experienced severe full-thickness skin burns due to overheated irrigation fluid.
- The burns necessitated extensive treatment, including debridement, muscle flap reconstruction, and skin grafting.
Findings:
- The incident resulted from a combination of equipment malfunction and delayed recognition of the burn severity.
- The knee joint damage was significant, ultimately requiring arthrodesis (fusion).
Implications:
- Highlights the potential for severe patient harm from seemingly routine procedures.
- Emphasizes the necessity for rigorous protocols for warming and monitoring irrigation fluid temperature during arthroscopy.
- Underscores the importance of prompt assessment and management of thermal injuries in surgical settings.
