Accidental burn injury during knee arthroscopy

A case is described in which hot irrigation fluid used during a routine knee arthroscopy caused severe morbidity. The patient sustained full-thickness skin burns requiring debridement, a muscle flap, and split-skin grafting. The extent of the joint damage required fusion. The underlying factors included equipment failure but also a delay in appreciating the severity of the soft-tissue damage. This case highlights the need for a robust protocol for the management of warming the irrigation fluid, as well as monitoring the actual fluid temperature.