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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

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.

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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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  • DOI: https://doi.org/10.1007/BF03016194

Keywords

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