Burns during arthroscopy due to use of electrosurgical devices: Prevention, causes, and treatment

There were thousands of arthroscopic procedures performed in the United States each year. Roughly 85% of all surgical procedures will employ some type of electrocautery. Burns and other thermal injuries, from direct electrocautery and arthroscopic devices, can create lifelong morbidity and even mortality. The components of electrocautery are the power generator, a handheld monopolar or bipolar electrode, and, if necessary, a patient return electrode. Heat generation is dependent upon several factors, including type and duration of the current, type of tissue, tissue cross section, humidity of the skin, and more. In monopolar electrocautery, the current, which has entered through a single, small-surface-area point, must be dissipated and complete the circuit through a patient return electrode (PRE). The current, which entered the body though the small surface area electrode, exits through a large surface area pad. Safety guidelines regarding skin temperature are built into some electrocautery devices. "Aberrant grounding" can occur with a wide variety of operating room materials as well. These are unexpected areas of low or high resistance which influence the direction of current and can be a risk factor for burns. Arthroscopic fluid is an essential part of arthroscopic surgery; it creates a working space and functions to flush debris and blood from the operative field. Case reports are emerging regarding the significant intra-articular temperatures these fluids can reach with use of electrocautery.The amount of flow during arthroscopy is important to heat regulation, with low-flow states reaching higher temperatures and taking longer to cool than high-flow states. Arthroscopic light sources have been shown to cause cutaneous burns, and have started fires when placed on drapes. The most important factors to prevent burns using electrocautery are the surgeons themselves. Inspecting the patient for sources of impedance, medical history, body hair, scars and implants should all be considered. The grounding pad, if necessary, should be kept cool and placed on a clean, dry, hairless area. Power settings and alarms should all be preset before beginning a case. Local wound care has been shown effective in many burns associated with electrocautery. Antibiotic ointments and sterile dressings are often all that is necessary to resolve these burns. For deeper burns, it is reasonable to obtain a plastic surgery consultation, even intra-operatively. Rarely, surgical intervention has been necessary to resolve these issues, including skin grafts and muscle flaps.