No smoke without fire--simple recommendations to avoid arthroscopic burns

Thermal Damage in Orthopaedics

There are numerous potential sources of thermal damage encountered in orthopaedic surgery. An understanding of the preclinical mechanisms of thermal damage in tissues is necessary to minimize iatrogenic injuries and use these mechanisms therapeutically. Heat generation is a phenomenon that can be used to a surgeon's benefit, most commonly for hemostasis and local control of tumors. It is simultaneously one of the most dangerous by-products of orthopaedic techniques as a result of burring, drilling, cementation, and electrocautery and can severely damage tissues if used improperly. Similarly, cooling can be used to a surgeon's advantage in some orthopaedic subspecialties, but the potential for harm to tissues is also great. Understanding the potential of a given technique to rapidly alter local temperature-and the range of temperatures tolerated by a given tissue-is imperative to harness the power of heat and cold. In all subspecialties of orthopaedic surgery, thermal damage is a relevant topic that represents a direct connection between preclinical and clinical practice.

Laparoscopic light source skin burn

Skin burn injury from light cables is a rare complication of laparoscopic surgery, but it can be severe and distressing for both the patient and the surgeon. A case report of skin burns due to laparoscopic light source is presented in this article, followed by an experimental trial to confirm the findings, and review of literature. The light source is usually connected to the camera to give adequate light inside the abdominal cavity for visualization of the internal organs, and hence, safe surgery. The light source should deliver cool light to prevent any burn from heat to skin or internal organs, but in fact, it is not usually cool and can reach high temperatures. Precautions and recommendations to avoid skin burns due to the light source are included. Surgeons should be aware of burns from light sources in laparoscopic surgery and take precautions to prevent them.

Temperature and luminosity outputs of endoscopes used in transcanal endoscopic ear surgery: an experimental study

OBJECTIVE

To establish the relationship between endoscope temperatures and luminosity with a variety of light source types, endoscope ages, endoscope sizes, angles and operative distance in transcanal endoscopic ear surgery.

METHODS

Transcanal endoscopic ear surgery was simulated in an operating theatre using 7 mm plastic suction tubing coated in insulating tape. An ATP ET-959 thermometer was used to record temperatures, and a Trotec BF06 lux meter was used to measure luminosity. Luminosity and temperature recordings were taken at 0 mm and 5 mm from the endoscope tip.

RESULTS

Thermal energy transfer from operating endoscopes is greatest when: the light intensity is high, there is a light-emitting diode light source and the endoscope is touching the surface. Additionally, larger-diameter endoscopes, angled endoscopes and new endoscopes generated greater heat.

CONCLUSION

It is recommended that operative light intensity is maintained at the lowest level possible, and that the surgeon avoids contact between patient tissues and the endoscope tip.

Orthopaedic Operating Room Fire Risks: FDA Database and Literature Review

»

Inadvertent activation of electrosurgical device was more likely to result in patient burns and harm.

»

There are significant knowledge gaps in the orthopaedic surgery community relating to fire prevention, fire safety, and fire management.

»

Arthroplasty was the most common procedure with reported fire events.

»

It is the responsibility of the orthopaedic surgeon to understand the risks of surgical fire in the operating room and implement actions to reduce those risks.

Catching Fire: Are Operating Room Fires a Concern in Orthopedics?

OBJECTIVE

Operating room (OR) fires are considered "never events," but approximately 650 events occur annually in the United States. Our aim was to detail fires occurring during orthopedic procedures via a questionnaire because of the limited information present on this topic.

METHODS

A 25-question survey on witnessing surgical fires, hospital policies on surgical fires, and surgeons' perspective on OR fires was sent to 617 orthopedic surgeons in 18 institutions whose residency program is a member of the Collaborative Orthopaedic Educational Research Group. The response rate was 28%, with 172 surgeons having completed the survey.

RESULTS

Twelve of the 172 orthopedic surgeons surveyed reported witnessing at least 1 surgical fire in an OR setting. Electrocautery was the leading ignition source, causing fires in 7 events. A saw, laser, and light source were reported to have caused 1 fire each. Regarding fuel source for the fires, bone cement was a common culprit (n = 4), followed by gauze (n = 3). Oxygen delivery to patients was via a closed system in most cases (n = 9). No patient harm was reported in any of these cases.Just under half of the respondents (47.7%) reported not receiving any formal OR fire prevention or response training. The most common answer for frequency of concern about a surgical fire was "never" (42.4%).

CONCLUSIONS

Fires pose a risk in surgery, even in an orthopedics setting. Room oxygen can supply enough oxidizing power for a fire to occur, especially with the ubiquitous nature of ignition sources and fuels in the OR. Prevention is key with these events. Operating room personnel education must be sought, and surgeons should be mindful of the fire components in the OR.

Silent burn: the hidden danger and effects of bright light from fibre-optic cables in arthroscopic knee surgery

Following an uneventful arthroscopic menisectomy of the right knee, a white circular skin lesion, 1 cm in diameter, was noted on the anterior left thigh of a 23-year-old patient. The overlying paper surgical drape had not ignited nor produced smoke. Close inspection revealed a minute perforation in the drape with slight discolouration. No electro-cautery, radio-ablation or irritant skin preparation had been used during surgery. Tests failed to identify fault with the light source, fibre-optic cable or arthroscope.

The lesion was diagnosed as a full-thickness thermal burn resulting from heat transmitted from a 300-W Xenon lamp via a detached fibre-optic cable. The effects of contact between an illuminated fibre-optic light cable and living human skin are described, with changes in appearances followed over 2 years. Patients may be burnt and permanently scarred without the knowledge of staff in operating theatres if detached light cables rest against surgical drapes.

Inadvertent thermal injury following knee arthroscopic surgery in a pediatric patient

Inadvertent thermal injury can occur in pediatric patients under general anesthesia during knee arthroscopic surgery. Here, we report the case of a 10-year-old boy who underwent knee arthroscopic surgery under general anesthesia. After the surgery, he complained of pain in the left lower part of his chin and was diagnosed as having a thermal burn. At three-month follow-up, he recovered without any abnormalities except mild hypertrophy of the wound area. Although rare, arthroscopic surgery has the potential to cause thermal injury from the light source. We recommend that the light source should be connected to the arthroscope before switching the power on and disconnected after a considerable time of switching the power off when not in use.

Endoscopic ear surgery: a hot topic?

OBJECTIVES

To summarise published research investigating maximal temperatures associated with endoscopes used in otology. Possible thermal issues surrounding the use of endoscopes in middle-ear surgery are discussed, and recommendations regarding the safest ways to use endoscopes in endoscopic ear surgery are made.

METHODS

A non-systematic review of the relevant literature was conducted, with descriptive analysis and presentation of the results.

RESULTS

There are currently no reports of any temperature-related deleterious effects in patients having undergone endoscopic ear surgery. There is debate regarding heat issues in endoscopic ear surgery, with a limited body of work documenting potential negative impacts of middle-ear heat exposure from endoscopes. The diameter of endoscope, type of light source used, distance from endoscope tip and duration of exposure are highlighted potential factors for high temperatures in endoscopic ear surgery.

CONCLUSION

There is a trend towards endoscopes being used routinely in ear surgery. Simple practice points are recommended to minimise potential thermal risks.

[Knee and shoulder arthroscopy. Positioning and thermal injuries]

Intraoperative positioning injuries during shoulder- and knee arthroscopy are rare complications and affect mainly nerves and soft tissue. Although the majority of these complications are reversible, in some cases serious negative consequences for the patient persist. This article describes the frequency of several positioning injuries including their prevention and the appropriate treatment. The legal responsibilities are illustrated as well as the importance of an intense preoperative investigation of preexisting diseases and possible risk factors. Furthermore, a review of possible thermal injuries of the patient during arthroscopy caused by e.g. electrosurgical instruments or the cold light source, is given as well as prevention strategies.

Cutaneous burns from a fiberoptic cable tip during arthroscopy of the knee

Thermal skin injury is a rare complication of arthroscopy. The potential of fiberoptic light cable tips to cause cutaneous burns has been previously investigated, but no cases have been reported. We present a case report of such an injury. In order to improve patient safety, we further recommend always checking that the light source is set on standby prior to disconnecting the light cable from the arthroscope and that the light cable tip is never left on the patient when not in use.

Thermal properties of operative endoscopes used in otorhinolaryngology

Objectives:

To measure the thermal properties of operative endoscopes used in otorhinolaryngological practice.

Methods:

A series of endoscopes of varying diameters and angulations were attached to a light source and temperature measurements taken of their shaft and tip; a measurement was also taken 5 mm in front of the endoscope tip.

Results:

Temperature changes took place rapidly. The amount of heat produced by the endoscopes was maximal at the tip, with larger diameter endoscopes attaining a higher temperature. Temperatures on the shaft and in front of the tip reached relatively constant temperatures independent of the type of endoscope. The maximum temperature achieved was 104.6°C for the 4 mm, 0° endoscope. Cooling occurred rapidly after the light source was switched off.

Conclusion:

The heat produced by some endoscopes is sufficiently great to cause thermal injury to tissues. Awareness of the temperatures produced by these endoscopes should prompt clinicians to actively cool their endoscopes during a procedure, before any thermal injury is caused.