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Fat embolization and fatal cardiac arrest during hip arthroplasty with methylmethacrylate

Embolie graisseuse et arrêt cardiaque fatal pendant l’arthroplastie de la hanche réalisée avec du méthyle méthacrylate

Canadian Journal of Anesthesia volume 48, pages 626–629 (2001)Cite this article

Abstract

Purpose

This case report describes a cardiac arrest during a cemented hip arthroplasty procedure. Hemodynamic instability during methylmethacrylate use in arthroplasty surgery can be explained by fat embolization rather than the inherent toxicity of the monomer.

Clinical features

A 78-yr-old woman required a cemented hemiarthroplasty for a pathologic left subcapital fracture. The patient’s past medical history included stable angina, diet-controlled type II diabetes and metastatic breast cancer. During the cementing of the canal and insertion of the femoral prosthesis, desaturation, hypotension and cardiac arrest occurred. The patient underwent a successful intraoperative resuscitation and was transferred to the intensive care unit where she subsequently developed disseminated intravascular coagulopathy. The patient died 24 hr later and autopsy confirmed the cause of death as fat embolization.

Conclusion

The deleterious cardiovascular effects of methylmethacrylate have been discussed in the literature. However, clinical evidence supports fat embolization during arthroplasty surgery as a greater determinant of hemodynamic compromise. Surgical precautions are paramount in minimizing the sequelae of Bone Implantation Syndrome and anesthetic treatment consists of supportive care.

Résumé

Objectif

Rapporter un arrêt cardiaque survenu pendant l’arthroplastie de la hanche cimentée. L’instabilité hémodynamique notée pendant l’utilisation de méthyle méthacrylate pour une arthroplastie peut être secondaire à une embolie graisseuse plutôt qu’à la toxicité inhérente au monomère.

Éléments cliniques

Une femme de 78 ans devait subir une hémiarthroplastie cimentée pour une fracture sous-capitale gauche. L’histoire médicale de la patiente indiquait une angine stable, un diabète de type II sous contrôle diététique et un cancer du sein métastatique. Pendant la cimentation de la fracture et l’insertion de la prothèse fémorale, une désaturation, une hypotension et un arrêt cardiaque sont survenus. La patiente a été réanimée avec succès et dirigée à l’unité des soins intensifs. Une coagulopathie intravasculaire disséminée s’est ensuite développée et la patiente est décédée 24 h plus tard. L’autopsie a confirmé que l’embolie graisseuse avait causé le décès.

Conclusion

Les effets cardio-vasculaires nocifs du méthyle méthacrylate sont connus. Toutefois, des preuves cliniques démontrent que l’embolie graisseuse pendant l’arthroplastie constitue un facteur déterminant, plus important, des altérations hémodynamiques. Il est essentiel de prendre toutes les précautions chirurgicales pour réduire les séquelles du syndrome de l’implant intra-osseux. Le traitement anesthésique est essentiellement un traitement de soutien.

References

  1. Newman JR. Orthogeriatrics. Comprehensive Orthopaedic Care for the Elderly Patient, 1st ed. Oxford: Butterworth-Heinemann Ltd, 1992: 149–50.

    Google Scholar 

  2. Duthie EH Jr, Katz P. Practice of Geriatrics. Philadelphia: WB Saunders Company, 1998.

    Google Scholar 

  3. Orsini EC, Byrick RJ, Mullen JBM, et al. Cardiopulmonary function and pulmonary microemboli during arthroplasty using cemented or non-cemented components. J Bone Joint Surg 1987; 69: 822–31.

    PubMed  CAS  Google Scholar 

  4. Patterson BM, Healey JH, Cornell CN, Sharrock NE. Cardiac arrest during hip arthroplasty with a cemented long-stem component. J Bone Joint Surg 1991; 73: 271–7.

    PubMed  CAS  Google Scholar 

  5. McLaughlin RE, DiFazio CA, Hakaka M, et al. Blood clearance and acute pulmonary toxicity of methylmethacrylate in dogs after simulated arthroplasty and intravenous injection. J Bone Joint Surg 1973; 55: 1621–8.

    PubMed  CAS  Google Scholar 

  6. Murphy P, Edelist G, Byrick RJ, Kay JC, Mullen JB. Relationship of fat embolism to haemodynamic and echocardiographic changes during cemented arthroplasty. Can J Anaesth 1997; 44: 1293–1300.

    PubMed  CAS  Google Scholar 

  7. Wheelwright EF, Byrick RJ, Wigglesworth DF, et al. Hypotension during cemented arthroplasty. Relationship to cardiac output and fat embolism. J Bone Joint Surg Br 1993; 75: 715–23.

    PubMed  CAS  Google Scholar 

  8. Charnley J. Systemic effects of monomer.In: Charnley J (Ed). Acrylic Cement in Orthopaedic Surgery. Baltimore: Williams and Wilkins, 1970: 72–8.

    Google Scholar 

  9. Homsy CA, Fullos HS, Anderson MS, Diferrante NM, King JW. Some physiological aspects of prosthesis stabilization with acrylic polymer. Clin Orthop 1972; 83: 317–28.

    PubMed  Article  CAS  Google Scholar 

  10. Lafont ND, Kostucki WM, Marchand PH, Michaux MN, Boogaerts JG. Embolism detected by transoesophageal echogardiography during hip arthroplasty. Can J Anaesth 1994; 41: 850–3.

    PubMed  CAS  Article  Google Scholar 

  11. Ereth MH, Weber JG, Abel MD, et al. Cemented versus noncemented total hip arthroplastyembolism, hemodynamics, and intrapulmonary shunting. Mayo Clin Proc 1992; 67: 1066–74.

    PubMed  CAS  Google Scholar 

  12. Byrick RJ, Bell RS, Kay JC, Waddell JP, Mullen JB. High-volume, high-pressure pulsatile lavage during cemented arthroplasty. J Bone Joint Surg 1989; 71: 1331–6.

    PubMed  CAS  Google Scholar 

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Authors and Affiliations

  1. Department of Anesthesia, St. Joseph’s Health Care, 268 Grosvenor Street, N6A 4V2, London, Ontario, Canada

    Katherine M. Fallon, John G. Fuller & Patricia Morley-Forster

Authors
  1. Katherine M. Fallon
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  2. John G. Fuller
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  3. Patricia Morley-Forster
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Correspondence to John G. Fuller.

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Fallon, K.M., Fuller, J.G. & Morley-Forster, P. Fat embolization and fatal cardiac arrest during hip arthroplasty with methylmethacrylate. Can J Anesth 48, 626–629 (2001). https://doi.org/10.1007/BF03016194

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Keywords

  • Milrinone
  • Pulseless Electrical Activity
  • Cement Arthroplasty
  • Fatal Cardiac Arrest