Unrecognized intraoperative thermal injury to the foot following arthroscopic anterior cruciate ligament reconstruction: a case report.

backgroundPerioperative burn or pressure-thermal skin injury is a rare but preventable complication of surgery. Although burns related to warming devices or electrosurgical instruments have been reported, such injuries following arthroscopic anterior cruciate ligament (ACL) reconstruction are exceedingly uncommon. CASE PRESENTATION: We report an unrecognized perioperative deep partial-thickness skin injury involving the dorsum of the foot, most consistent with a thermal or combined pressure-thermal injury, following revision arthroscopic ACL reconstruction under general anesthesia. A pneumatic tourniquet was applied for 120 min. A forced-air warming system was used for upper-body warming without direct contact with the operative limb, which was loosely covered with a stockinette without additional padding. Shortly after transfer from the post-anesthesia care unit to the ward, a 8 × 4 cm deep partial-thickness skin injury was identified on the ipsilateral dorsum of the foot. Conservative wound care was initiated, and the lesion gradually epithelialized over approximately three months. The injury resulted in transient soft-tissue contracture with plantar flexion restricted to approximately 30°, interfering with early postoperative rehabilitation. At 9 months after surgery, the wound had fully healed, ankle range of motion had recovered to 15° of dorsiflexion and 40° of plantar flexion, and the patient reported no resting pain, shoe-wear difficulty, or limitation in daily activities.

conclusionClinically significant perioperative deep partial-thickness skin injury can occur during routine knee arthroscopy even in the absence of an obvious direct thermal source. This case suggests that local pressure, drape-related insulation, impaired distal heat dissipation due to tourniquet use, and retained ambient heat may interact to produce occult injury. This case highlights system-level prevention opportunities, including distal extremity padding, avoidance of heat trapping under drapes, and routine whole-limb skin inspection in the post-anesthesia care unit and after ward transfer to facilitate early recognition of occult injuries.