Abstract
Purpose
To report a case of fat embolism syndrome (FES) following elective left knee arthroplasty and review the diagnosis, investigation, prevention and perioperative management of this condition.
Clinical features
A 76-yr-old lady presented for left total knee arthroplasty under general anesthesia. After an uneventful anesthetic and initial recovery, she developed respiratory and neurological complications six hours postoperatively necessitating supportive care in the intensive care unit. Following extensive investigation, a clinical diagnosis of FES was made 48 hr postoperatively supported by the development of diffuse encephalopathy, thrombocytopenia, hypoxemia, chest petechiae and chestx-ray changes. A magnetic resonance imaging scan five days postoperatively confirmed this diagnosis. Her postoperative course showed gradual improvement consistent with a slowly resolving encephalopathy.
Previous published cases of FES associated with knee arthroplasty present either with intraoperative cardiorespiratory collapse or, as with this patient, in the postoperative period with respiratory, cardiovascular and/or cerebral dysfunction.
Conclusions
The clinical diagnosis of FES is essentially one of exclusion, supported by laboratory and radiological investigations. Preoperative identification of at-risk patients, use of appropriate invasive perioperative monitoring and modified surgical techniques may minimize the development of the syndrome. Treatment is supportive.
Résumé
Objectif
Décrire un cas d’embolie graisseuse (EG) survenue après une arthroplastie du genou non urgente et réexaminer le diagnostic, la recherche, la prévention et le traitement périopératoire entourant cette situation.
Éléments cliniques
Une femme de 76 ans s’est présentée pour une arthroplastie totale du genou gauche sous anesthésie générale. La récupération, d’abord sans incident, s’est compliquée de troubles respiratoires et neurologiques six heures après l’intervention, ce qui a nécessité un traitement de soutien à l’unité des soins intensifs. À la suite d’une investigation poussée, un diagnostic d’EG a été fait, 48 h après l’opération, confirmé par le développement d’encéphalopathie diffuse, de thrombocytopénie, d’hypoxémie, de pétéchies thoraciques et de modifications radiographiques pulmonaires. Un examen d’imagerie par résonance magnétique a confirmé le diagnostic cinq jours après l’opération. L’état de la patiente s’est graduellement amélioré en faveur d’une lente résolution de l’encéphalopathie.
Dans les cas déjà publiés d’EG associée à l’arthroplastie du genou, on retrouve soit un collapsus cardiorespiratoire peropératoire, soit un dérèglement postopératoire respiratoire, cardiovasculaire et/ou cérébral comme dans le cas présent.
Conclusion
Le diagnostic clinique d’EG est essentiellement un diagnostic d’exclusion, corroboré par les examens de laboratoire et de radiographie. L’identification préopératoire des patients à risque, l’usage d’un monitorage périopératoire effractif approprié et de techniques chirurgicales modifiées peuvent minimiser le développement de ce syndrome. Le traitement consiste en une thérapie de soutien.
Article PDF
Similar content being viewed by others
References
Bulger EM, Smith DG, Maier RV, Jurkovich GJ. Fat embolism syndrome. A 10-year review. Arch Surg 1997; 132: 435–9.
Robert JH, Hoffmeyer P, Broquet P-E, Cerutti P, Vasey H. Fat embolism syndrome. Orthop Rev 1993; 22: 567–71.
Fabian TC, Hoots AV, Stanford DS, Patterson CR, Mangiante EC. Fat embolism syndrome: prospective evaluation in 92 fracture patients. Crit Care Med 1990; 18: 42–6.
Kallenbach J, Lewis M, Zaltzman M, Feldman C, Orford A, Zwi S. ‘Low-dose’ corticosteroid prophylaxis against fat embolism. J Trauma 1987; 27: 1173–6.
Lindeque BGP, Schoeman HS, Dommisse GF, Boeyens MC, Vlok AL. Fat embolism and the fat embolism syndrome. A double-blind therapeutic study. J Bone Joint Surg Br 1987; 69: 128–31.
Schonfeld SA, Ploysongsang Y, DiLisio R, et al. Fat embolism prophylaxis with corticosteroids. A prospective study in high-risk patients. Ann Intern Med 1983; 99: 438–43.
Johnson MJ, Lucas GL. Fat embolism syndrome. Orthopedics 1996; 19: 41–50.
Weiss SJ, Cheung AT, Stecker MM, Garino JP, Hughes JE, Murphy FL Jr. Fatal paradoxical cerebral embolization during bilateral knee arthroplasty. Anesthesiology 1996; 84: 721–3.
Hume Adams J, Graham DI, Mills E, Sprunt TG. Fat embolism and cerebral infarction after use of methylmethacrylate cement. Brit Med J 1972; 3: 740–1.
Letournel E, LaGrange J. Total knee replacement with the “LL” type prosthesis. Clin Orthop 1973; 94: 249–56.
Mallory TH, Kolodzik S. Fat embolization after total knee replacement (Letter). JAMA 1976; 236: 1451.
Browne CH. A case of fat embolism following Shiers arthroplasty. Postgrad Med J 1976; 52: 247–9.
Bisla RS, Inglis AE, Lewis RJ. Fat embolism following bilateral total knee replacement with the Guepar prosthesis. A case report. Clin Orthop 1976; 115: 195–8.
Lachiewicz PF, Ranawat CS. Fat embolism syndrome following bilateral total knee replacement with total condylar prosthesis: report of two cases. Clin Orthop 1981; 160: 106–8.
Zimmerman RL, Kroner IIILF, Blomberg DJ, Nollet DJ. Fatal fat embolism following total knee arthroplasty. Minn Med 1983; 66: 213–6.
Orsini EC, Richards RR, Mullen JMB. Fatal fat embolism during cemented total knee arthroplasty: a case report. Can J Surg 1986; 29: 385–6.
Byrick RJ, Forbes D, Waddell JP. A monitored cardiovascular collapse during cemented total knee replacement. Anesthesiology 1986; 65: 213–6.
Caillouette JT, Anzel SH. Fat embolism syndrome following the intramedullary alignment guide in total knee arthroplasty. Clin Orthop 1990; 251: 198–9.
Monto RR, Garcia J, Callaghan JJ. Fatal fat embolism following total condylar knee arthroplasty. J Arthroplasty 1990; 5: 291–9.
Hall TM, Callaghan JJ. Fat embolism precipitated by reaming of the femoral canal during revision of a total knee replacement. A case report. J Bone Joint Surg Am 1994; 76: 899–903.
Enneking FK. Cardiac arrest during total knee replacement using a long-stem prosthesis. J Clin Anesthesia 1995; 7: 253–63.
Gurd AR, Wilson RI. The fat embolism syndrome. J Bone Joint Surg Br 1974; 56 B: 408–16.
Byrick RJ. Fat embolism and postoperative coagulopathy (Editorial). Can J Anesth 2001; 48: 618–21.
Jacobsen DM, Terrance CF, Reinmuth OM. The neurologic manifestations of fat embolism. Neurology 1986; 36: 847–51.
Stoeger A, Daniaux M, Felber S, Stockhammer G, Aichner F, zur Nedden D. MRI findings in cerebral fat embolism. Eur Radiol 1998; 8: 1590–3.
Hagen PT, Scholz DG, Edwards WD. Incidence and size of patent foramen ovale during the first ten decades of life: an autopsy study of 965 normal hearts. Mayo Clin Proc 1984; 59: 17–20.
Berman AT, Price HL, Hahn JF. The cardiovascular effects of methylmethacrylate in dogs. Clin Orthop 1974; 100: 265–9.
Byrick RJ, Mullen JB, Wong PY, Kay JC, Wiggleworth D, Doran RJ. Prostanoid production and pulmonary hypertension after fat embolism are not modified by methylprednisolone. Can J Anaesth 1991; 38: 660–70.
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Jenkins, K., Chung, F., Wennberg, R. et al. Fat embolism syndrome and elective knee arthroplasty. Can J Anesth 49, 19–24 (2002). https://doi.org/10.1007/BF03020414
Accepted:
Issue Date:
DOI: https://doi.org/10.1007/BF03020414