Operating Room Fires in Orthopaedic Surgery

Introduction

• Operating room fires are rare but preventable events, occurring up to six hundred and fifty times annually.
• The Manufacturer and User Facility Device Experience database tracks device-related adverse events.
• Orthopaedic procedures account for:
  • Approximately fourteen percent of reported injuries
  • Approximately one percent of reported deaths related to device incidents
• Fire risk is commonly analyzed using the fire triangle, which consists of:
  • Ignition source
  • Fuel source
  • Oxidizer
• Rapid and coordinated response by the surgical team is essential to minimize injury and damage.
• Significant gaps exist in standardized education and training related to fire prevention and response.
• Educational initiatives such as the Fundamental Use of Surgical Energy curriculum and the Virtual Electrosurgical Skill Trainer system have demonstrated benefit but are not widely adopted.
• Orthopaedic surgery accounts for more than twenty percent of litigation related to surgical fires.

The Fire Triangle in Orthopaedic Surgery

• The fire triangle is a framework used to understand and prevent fires.
• It consists of:
  1. Ignition source
  2. Fuel source
  3. Oxidizer
• All three components are present in every surgical procedure.
• Orthopaedic surgery involves unique ignition sources and fuel materials that increase risk.

Ignition Sources in Orthopaedic Operating Rooms

Common Ignition Sources

• Monopolar electrosurgery
• Bipolar electrosurgery
• Battery-powered surgical devices
• Surgical light sources
• Drills, saws, and high-speed burrs
• Laser devices

Monopolar Electrosurgery

• Consists of a surgeon-controlled active electrode and a patient-attached dispersive electrode.
• Used for tissue cutting and hemostasis.
• Temperatures can exceed one thousand degrees Celsius.
• Fire risk increases near flammable materials such as:
  • Alcohol-based skin preparations
  • Bone cement
• Both indirect and inadvertent activation can result in fires.
• Newer safety designs include monopolar instruments that deliver carbon dioxide around the activation site to reduce oxidizer concentration.

Bipolar Electrosurgery

• Utilizes two electrodes on forceps with current confined between them.
• Commonly used in hand, spine, laparoscopic, and endoscopic procedures.
• Reduces thermal spread and injury risk.
• Frequently used in orthopaedic hand surgery.
• Accounts for a smaller proportion of orthopaedic fire-related injuries.

Battery-Powered Devices

• Includes battery-powered drills and saws.
• Provide mobility and precision without cords.
• Generate higher heat than manual tools.
• Risk includes thermal injury and bone necrosis.
• Most reported incidents involved battery-interface failures rather than direct bone contact.

Light Sources

• Includes overhead lights, retractor-mounted lights, and arthroscopic light sources.
• Arthroscopic light tips and unattached cables generate significant heat.
• Unattached light cables can ignite surgical drapes within seconds at close distances.
• Fires related to retractor-mounted light sources are rare but documented.

Potential Fuel Sources in Orthopaedic Surgery

Categories of Fuel Sources

1. Patient-dependent materials
2. Irrigants and skin preparation solutions
3. Bone cement
4. Surgical drapes and materials

Patient-Dependent Fuel

• Includes hair, soft tissue, and luminal contents.
• Hair clipping reduces infection risk but does not reduce fire risk.

Irrigants and Skin Preparation Solutions

• Alcohol-based skin preparations remain flammable in approximately ten percent of cases even after recommended drying times.
• Irrigation is frequently used for infection control.
• Some irrigants used in prosthetic joint infection management contain flammable alcohol.
• Use of flammable irrigants with electrosurgery significantly increases fire risk.

Bone Cement

• Polymethyl methacrylate is commonly used in orthopaedic surgery.
• Contains flammable methyl methacrylate monomer.
• Cement polymerization generates temperatures exceeding eighty degrees Celsius.
• Heat is usually dissipated but contributes to overall fire risk.

Surgical Drapes and Materials

• Sponges, gauze, drapes, and gowns are easily ignited.
• Moistening materials reduces but does not eliminate risk.
• Approximately nine percent of orthopaedic fires involved these materials as fuel.
• Awareness of material placement near ignition sources is essential.

Oxidizers in the Operating Room

• Oxygen is the primary oxidizer in the fire triangle.
• High concentrations lower ignition thresholds and intensify combustion.
• Oxygen-rich environments may form under surgical drapes.
• Risk is highest:
  • Above the level of the sternum
  • During upper extremity and cervical spine procedures
• Caution is required when using high-temperature devices near oxygen-enriched areas.

Fire Safety Protocols

• Prevention requires:
  • Awareness of fire risks
  • Team communication
  • Training and preparation
• Institutional and professional guidelines should be readily available.
• Surgeons must be familiar with fire prevention strategies and response algorithms.
• Continuous improvement in education, preparedness, and reporting is essential.

Fire Risk Assessment

• Surgical checklists and time-out procedures help reduce fire risk.
• Preoperative fire risk should be classified as routine or high.
• Existing checklists often fail to address:
  • Alcohol-based skin preparations
  • Flammable irrigants
• Modified risk assessment tools are recommended for improved outcomes.

Operating Room Fire Management Algorithm

Fire Prevention Phase

• Identify high-risk procedures during preoperative assessment.
• Assign roles and review fire management plans with the surgical team.
• Position extinguishing equipment for high-risk cases.
• Avoid activating ignition sources near fuels or oxygen-rich environments.

Fire Management Phase

• Initiated when fire is suspected or confirmed.

Non-Airway Fires

• Anesthesia team stops delivery of airway gases.
• Surgeon removes burning materials from the field.
• Small fires:
  • Smother with sterile towels or blankets
• Persistent fires:
  • Extinguish with sterile water or saline
• Spreading fires:
  • Remove surgical drapes
  • Cover the surgical site with sterile materials
• Uncontrolled fires:
  • Use carbon dioxide fire extinguishers

Airway Fires

• Immediate cessation of airway gases
• Surgical procedure may need to be halted
• Post-extinguishing assessment of airway and surgical field

Post-Fire Assessment

• Evaluate for patient and staff injuries.
• Assess contamination of the surgical field.
• Decide whether to proceed or abort the procedure in coordination with anesthesia.

Education and Training

Current Knowledge Gaps

• Nearly half of orthopaedic surgeons lack formal training in fire prevention.
• Many surgeons participate in fire time-out protocols but are unaware of extinguisher locations.

Training Initiatives

• Structured curricula focusing on surgical energy safety improve preparedness.
• Simulation-based training improves recognition and response to fire scenarios.

Recommendations

• Surgeons should identify:
  • Potential fuel sources
  • Location of fire extinguishers
  • Suction and saline availability
• Clear communication within the operating room team is critical when fire risks are present.

Conclusion

• Operating room fires in orthopaedic surgery are uncommon but largely preventable.
• Understanding ignition sources, fuel materials, and oxidizers is essential.
• Improved education, structured risk assessment, and adherence to safety algorithms can significantly reduce fire-related injuries.
• Continued emphasis on training and prevention is critical for patient and staff safety.