Pathophysiology of Fat Embolism after Intramedullary Reaming

Abstract

Primary operative stabilization by an intramedullary procedure is the treatment of first choice for fractures of long tubular bones for reasons of biomechanics, the minimally invasive approach, and the early loadability of the injured limb. Additionally, in the case of multiple injuries, the pulmonary situation can be improved so that both the duration of ventilation and the period spent in intensive care are reduced. However, a postoperative increase in the incidence of posttraumatic lung failure has been found following early intramedullary nailing and seen as being linked to the procedure. The increase in intramedullary pressure occurring on intramedullary nailing or reaming can result in release of bone marrow and fat into the venous blood system. The potentially lethal consequences may be adult respiratory distress syndrome (ARDS) and multiple organ failure.For these reasons, a method was sought to bring about a reduction in intramedullary pressure at primary nailing. These efforts led to further developments in implant and reamer design as well as in nailing techniques. However, a clear release of fat was still apparent under these conditions. This review gives an overview of pathophysiologic aspects of reamed intramedullary nailing and suggestions for the optimal reaming system. A new-designed rinsing-suction reamer is briefly presented.

The Implications of Pulmonary Embolism in a Multiorgan Donor for Subsequent Pulmonary, Renal, and Cardiac Transplantation

“…In fact, the highest number of microscop- ically obstructed pulmonary capillaries after trauma is found after 24 hours, with vascular congestion and edema developing over a further 24 hours. 15,16 Although the average donor intubation time before organ procurement (close to the time from brain death to organ procurement) was more than 24 hours (46 Ϯ 7 hours in the Fat Emboli Group), there may be a time-sensitive major deleterious effect of donor PE apparent only after transplant. If this damage to the lungs was already evident, such lungs might have been rejected before a PE diagnosis.…”

Biocompatibility, bone healing, and safety evaluation in rabbits with an IlluminOss bone stabilization system

“…This pathophysiology has been well discussed in the literature and purported to involve multiple mechanisms including: physical disruption of endosteum and its blood supply; thermal injury to tissue elements associated with cavity clearing (e.g., irrigation/aspiration, “reaming,” etc. ); exothermic polymerization of surgical resins (e.g., polymethylmethacrylate or PMMA); toxicity to tissue elements related to release of bone resin compounds (e.g., PMMA), or occlusion of cortical (i.e., Haversian) vasculature by intravasated marrow or adipose associated with increased IM pressure related to these procedures …”

“…Pulmonary inflammation/infarction is a potential adverse response associated with surgical manipulation of long bones, primarily associated with liberation, and embolization of adipose tissue or liquefied (i.e., “free”) fat, secondary to increased IM pressure, during disruption/removal of bone marrow necessary for implantation of IM fixation devices . In addition, rare embolization of liquid phase bone resins (e.g., PMMA) to the lungs have been reported .…”

Evaluation of an intramedullary bone stabilization system using a light‐curable monomer in sheep

“…With potential extramedullary embolization from manipulation of the intramedullary canal, the impact of this new device was also examined in peripheral tissues, specifically, the lung and popliteal lymph nodes. Pulmonary inflammation and infarction is a potential adverse response associated with the surgical manipulation of long bones, primarily associated with the embolization of adipose tissue or liquefied fat, secondary to the increased intramedullary pressure, during disruption of bone marrow necessary for the implantation of intramedullary fixation devices . The rare embolization of liquid‐phase bone resins (e.g., PMMA) to the lungs has been reported .…”

“…Pulmonary inflammation and infarction is a potential adverse response associated with the surgical manipulation of long bones, primarily associated with the embolization of adipose tissue or liquefied fat, secondary to the increased intramedullary pressure, during disruption of bone marrow necessary for the implantation of intramedullary fixation devices. [19][20][21] The rare embolization of liquid-phase bone resins (e.g., PMMA) to the lungs has been reported. 22,23 However, there was no evidence of pulmonary embolization in PBSS nonfracture sheep associated with long-bone surgical treatment.…”