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Journal of Bone and Joint Surgery - British Volume, Vol 86-B, Issue 1, 95-98.
doi: 10.1302/0301-620X.86B1.14108  
Copyright © 2004 by British Editorial Society of Bone and Joint Surgery
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Paradoxical cerebral embolisation

AN EXPLANATION FOR FAT EMBOLISM SYNDROME

G. Riding, FRCS, Lecturer in Surgery1; K. Daly, MRCS, Surgical Research Fellow1; S. Hutchinson, BSc, Research Assistant1; S. Rao, FRCS, Visiting Research Fellow1; M. Lovell, FRCS, Consultant Orthopaedic Surgeon2; and C. McCollum, MD, FRCS, Professor of Surgery1

1 Academic Surgery Unit, South Manchester University Hospital, Southmoor Road, Manchester M23 9LT, UK.
2 Department of Orthopaedic Surgery

Correspondence should be sent to Professor C. McCollum.

Fat embolism occurs following fractures of a long bone or arthroplasty. We investigated whether paradoxical embolisation through a venous-to-arterial circulation shunt (v-a) could lead to cerebral embolisation during elective hip or knee arthroplasty.

Transcranial Doppler ultrasound (TCD), following the intravenous injection of microbubble contrast, identified the presence of a shunt in 41 patients undergoing hip (n=20) or knee (n=21) arthroplasty. Intra-operative cerebral embolism was detected during continuous TCD monitoring. Of the 41 patients, 34 had a v-a shunt of whom 18 had an embolism and embolism only occurred in patients with a shunt (p = 0.012). Spontaneous and larger shunts were associated with a greater number of emboli (rs = 0.67 and rs = 0.71 respectively, p < 0.01). Observations in two patients with large spontaneous shunts revealed 368 and 203 emboli and unexplained post-operative confusion and pancreatitis.

Paradoxical cerebral embolisation only occurred in patients with a shunt and may explain both postoperative confusion and fat embolism syndrome following surgery.




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Hip, Knee, Trauma, Upper limb, Foot & Ankle, Paediatrics, Oncology, Spine, Arthroplasty, General