Review Article

Fat Embolism and Fat Embolism

Syndrome

Abstract
David L. Rothberg, MD Fat embolism (FE) occurs frequently after trauma and during
Christopher A. Makarewich, MD orthopaedic procedures involving manipulation of intramedullary
contents. Classically characterized as a triad of pulmonary distress,
neurologic symptoms, and petechial rash, the clinical entity of FE
syndrome is much less common. Both mechanical and biochemical
pathophysiologic theories have been proposed with contributions of
vascular obstruction and the inflammatory response to embolized fat
and trauma. Recent studies have described the relationship of
embolized marrow fat with deep venous thrombosis and postsurgical
cognitive decline, but without clear treatment strategies. Because
treatment is primarily supportive, our focus must be on prevention. In
trauma, early fracture stabilization decreases the rate of FE syndrome;
however, questions remain regarding the effect of reaming and
management of bilateral femur fractures. In arthroplasty, computer
navigation and alternative cementation techniques decrease fat
embolization, although the clinical implications of these techniques
are currently unclear, illustrating the need for ongoing education and
research with an aim toward prevention.

F at embolism (FE) is defined as the

presence of fat globules in the
pulmonary or peripheral circulation,
However, likely, it is a result of vas-
cular obstruction, the body’s response
to embolized fat, and the trauma-
and FE syndrome (FES) refers to the induced inflammatory response. Di-
clinical symptoms that follow an agnosis can be challenging, relying
identifiable insult; it can result in the on a combination of clinical symp-
From the Department of triad of respiratory distress, neuro- toms, laboratory results, and imaging
Orthopaedics, University of Utah, Salt logic symptoms, and petechial rash. findings. Further research directions
Lake City, UT. Frequently, FE occurs after trauma include improving our understanding
Neither of the following authors nor and during orthopaedic procedures.1,2 of predicting those at the risk of de-
any immediate family member has Although typically considered benign, veloping FES, accurately diagnosing
received anything of value from or has recent studies have identified possible the condition, and recognizing the
stock or stock options held in a
commercial company or institution
links to neurocognitive impairment more subtle effects of FE.
related directly or indirectly to the and deep venous thrombosis (DVT)
subject of this article: Dr. Rothberg formation.3-5 Although FES exhibits
and Dr. Makarewich. potentially life-threatening effects, it is History
J Am Acad Orthop Surg 2019;27: much less common. Despite its origi-
e346-e355 nal description in the 17th century, The clinical study of FES began in
DOI: 10.5435/JAAOS-D-17-00571 FES remains incompletely understood. 1861 with Zenker, who reported the
Both mechanical and biochemical presence of fat droplets in lung
Copyright 2018 by the American
Academy of Orthopaedic Surgeons. mechanisms have been proposed to capillaries of a railroad worker who
explain the clinical picture of FES. died from a crush injury.6 This report

e346 Journal of the American Academy of Orthopaedic Surgeons

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 David L. Rothberg, MD and Christopher A. Makarewich, MD

remained an isolated case until 1865 patients with blood sampling from the decrease by 10% in each decade of
when Wagner described the corre- right atrium. Major emboli greater life.14 In addition, marrow fat com-
lation of FE with fractures and than 1 cm were found in 43% of position in children may play a role.
attributed the origin of fat in the patients. Children have a greater proportion
lungs to bone marrow. Von Berg- The clinical entity of FES is much of palmitin and stearin, which are
mann was the first to describe the less common. In the older literature, it less likely to cause an inflammatory
symptoms of FES, and in 1873, he has been reported in up to 30% of response in comparison to olein
reported a patient who fell from a orthopaedic trauma patients; how- found in adults.13 However, patients
roof and sustained a comminuted ever, recent studies show a much with Duchenne muscular dystrophy
distal femur fracture. Sixty hours lower incidence.6,7,12 In one of the warrant special consideration because
after the injury, he developed con- largest clinical studies, a group from they develop FES at a relatively high
fusion, dyspnea, and petechiae and the Harborview reviewed 10 years rate of 1% to 20% after minor trauma
died after 19 hours. A massive pul- of patients from their trauma data- and fractures.15
monary FE was found at autopsy. base.6 Using Gurd criteria,10 27 ca- Although FES is most commonly
Czerny further examined the neuro- ses of FES were identified from 3,000 associated with trauma, it has also
logic symptoms of FES and described patients with long bone fractures been reported rarely in nontrauma
them in 1875.7 Although these ob- with an incidence of 0.9%. The av- patients. Case reports document the
servations were key in establishing a erage age of patients was 31 years, occurrence of FES during bone
clinical pattern, it was not until the and the onset was typically 24 to 48 marrow harvest, lung transplant,
1920s that the two main patho- hours after an injury. Ninety-five cesarean section, liposuction, and
physiologic theories of FES were first percent of these patients had frac- cosmetic procedures.7,12,16,17
proposed. In 1924 Gauss8 described tures of the lower extremities, and it
the mechanical theory, and in 1927, was more common in closed frac-
Lehman and Moore 9 theorized tures. A more recent study in 2008 Clinical Presentation
about a biochemical explanation. examined the International Classifi-
Finally, in 1970, Gurd10 presented cation of Diseases, Ninth Revision The classic triad of symptoms of FES
the first set of diagnostic criteria codes from the National Hospital is respiratory distress, neurologic
(Table 1) based on his experience Discharge Survey over a 26-year changes, and a petechial rash.10 Pul-
with a series of 100 patients with period including one billion pa- monary symptoms occur first, typi-
long bone fractures and coined the tients.13 Among all patients with cally 24 to 72 hours after trauma;
term “fat embolism syndrome.” fractures, the incidence was 0.17%. but symptoms have been reported as
Of isolated fractures, femur fractures early as 12 hours. A large embolus
were the most common with a rate of can cause sudden cardiopulmonary
Epidemiology 0.54%. This investigation excluded collapse; but more often, FES has
fractures of the femoral neck, which an insidious onset with dyspnea,
Fat in the peripheral circulation (FE) had only 0.09% incidence. Multiple tachypnea, and hypoxemia. About
occurs fairly frequently. At autopsy, fractures that included the femur had half of all patients with FES develop
pulmonary FE has been found in 68% the highest incidence of 1.29%. The respiratory failure that necessitates
to 82% of blunt trauma patients.1,2 incidence was more common in male mechanical ventilation.18 In a patient
During orthopaedic procedures, fat subjects, with a relative risk of 5.7, under anesthesia, findings include
globules have been observed regularly and it was more common in those respiratory deterioration with hyp-
passing through the heart and pul- aged 10 to 40 years. oxemia, pulmonary edema, and de-
monary circulation on ultrasonogra- Pediatric patients have a much crease in lung compliance.7
phy (Figure 1). In 1995, Christie et al11 lower incidence of FES. Although FE Neurologic symptoms are present in
performed transesophageal echocar- have been identified in 30% of pedi- up to 80% of patients, and usually,
diography (TEE) in 111 orthopaedic atric cadavers at autopsy,14 Stein although not always, this symptoms
surgeries, including reaming of tibia et al13 found no cases of FES among occur after pulmonary symptoms. They
and femur fractures, as well as ce- 1,178,000 children in their discharge begin with confusion and agitation
mented and uncemented hemiarthro- database study. This discrepancy similar to delirium, and it can progress
plasty. Echogenic material was found may be the result of the lower fat to focal deficits, such as hemiplegia and
traveling through the heart in 87% of content in pediatric patients, where aphasia, as well as seizures and coma.
procedures, and this material was hematopoietic cells occupy nearly Commonly, upper motor neuron signs
confirmed as FE in a subset of 12 100% of the volume at birth and are also present.7,12

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Fat Embolism Syndrome

Table 1 festations of FES: the mechanical and

biochemical theories. The mechani-
Criteria for the Diagnosis of Fat Embolism Syndrome
cal theory was first presented by
Criteria Findings Points Gauss8 in 1924. He proposed that
Gurd criteriaa Major trauma and fractures of long bones
disrupts fat in the marrow and also
Respiratory insufficiency —
tears intraosseous blood vessels.
Cerebral involvement —
Typically, veins are characterized as
Petechial rash —
having weak, flexible walls; how-
Minor —
ever, in bone, they are contained
Fever —
within calcified tubules with rigid
Tachycardia —
perivascular sheaths. This allows
Retinal changes — ruptured vein ends to remain open,
Jaundice — and the negative venous pressure can
Renal changes — draw free fat globules into the cir-
Anemia — culation. In cases of arthroplasty and
Thrombocytopenia — during intramedullary instrumenta-
Elevated ESR — tion, intramedullary pressure in-
Fat macroglobulinemia — creases forcing fat into the veins.19
Schonfeld criteriab Petechia 5 Once fat enters the circulation, it can
Chest radiograph changes 4 create mechanical emboli and focal
Hypoxemia (PaO2 , 9.3 kPA) 3 ischemia.
Fever (.38C) 1 It was originally thought that to
Tachycardia (.120 bpm) 1 pass from the venous to the arterial
Tachypnea (.30 bpm) 1 circulation, the fat material (because
Lindeque criteriac Sustained Pao2 , 8 kPa — of its large size) would have to pass
Sustained PCo2 . 7.3 kPa or pH , 7.3 — through a foramen ovale from the
Sustained respiratory rate . 35 bpm — right to the left atrium (present in
Increased work of breathing (dyspnea, — 20% to 25% of adults),20 either one
accessory muscles, tachycardia, anxiety) that remained open from birth or
one that reopened because of ele-
ESR = erythrocyte sedimentation rate, FES = fat embolism syndrome vated pulmonary artery pressures.
a
At least 1 major feature and 4 minor features needed for diagnosis.
b
Cumulative score .5 required for diagnosis. However, neurologic symptoms and
c
One of the criteria indicates a diagnosis of FES. skin lesions occur in patients without
these anatomic variants. Other ex-
planations are that fat is able to
Although part of the “classic triad” and are then distributed through the deform to travel through capillaries
of symptoms, a petechial rash occurs carotid and subclavian vessels to or that it passes through arteriove-
in only 20% to 50% of patients. Its nondependent areas.12 nous shunts present around the
typical distribution is over the head, Although found to be nonspecific, lungs.20 Although logical, this theory
neck, thorax, axillae, subcon- other frequently reported signs and does not explain the 24- to 72-hour
junctival space, and oral mucous symptoms include tachycardia, delay in presentation, and just hav-
membranes12 (Figure 2). A similar hypotension, right heart strain, fever, ing fat in the circulation, even a large
rash can be found in sepsis and dis- retinopathy, renal changes, and coa- quantity of fat, does not in itself lead
seminated intravascular coagulation; gulopathy. Overall mortality rates to the development of FES.11
however, the rash of FES is only are 5% to 20%, usually because of To explain cases of atruamatic FES,
found anteriorly on the body in respiratory failure or right heart Lehman and Moore9 described a
nondependent areas, and it has never failure.7,12 biochemical theory in 1927. They
been reported on the back. Theo- proposed that after an insult or
retically, this pattern of rash occurs trauma, fat was mobilized from body
because in a supine patient, the fat Pathophysiology stores and embolized into the tissues,
droplets (which float like oil on Two pathophysiologic mechanisms initiating an inflammatory response.
water) accumulate in the aortic arch were proposed for the clinical mani- Since that time, we have learned that

e348 Journal of the American Academy of Orthopaedic Surgeons

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 David L. Rothberg, MD and Christopher A. Makarewich, MD

Figure 1 Figure 2

Transesophageal echocardiography
images showing microemboli in the
right atrium during total knee
arthroplasty. LA = left atrium, LV =
left ventricle, RA = right atrium, RV =
right ventricle. (Reproduced with
permission from Zhao J, Zhang J, Ji
X, et al: Does intramedullary canal
irrigation reduce fat emboli? A
randomized clinical trial with
transesophageal echocardiography.
J Arthroplasty 2015;30[3]:451-455.)

Clinical images of axillary petechiae (A) and subconjunctival hemorrhage (B).

bone marrow fat embolized to the (Reproduced with permission from Maghrebi S, Cheikhrouhou H, Triki Z, Karoui
lungs causes the local releases of A: Transthoracic Echocardiography in Fat Embolism: A Real-Time Diagnostic
lipase, which breaks fat down into Tool. J Cardiothorac Vasc Anesth 2017;31[3]:e47-e48.)
free fatty acids and glycerol. Free
fatty acids are toxic to endothelial
Diagnosis all based on small series, and none
cells and cause vasogenic edema and
have been prospectively validated.
hemorrhage.20 These conditions re- Diagnostic Criteria
lease proinflammatory cytokines, One of the challenges in the study
such as tumor necrosis factor-alpha, and identification of FES is that there Laboratory Studies
interleukin (IL)-1 and IL-6, which is no benchmark test. Gurd10 was There are no laboratory tests specific
can cause acute respiratory distress the first to identify diagnostic cri- to FES (Table 2); however, common
syndrome (ARDS). Elevated acute- teria based on a series of 100 pa- findings include anemia, thrombo-
phase reactants, such as C-reactive tients. He divided his observations cytopenia, and elevated inflamma-
protein, have also been observed, into major and minor criteria and tory markers.7 Elevated serum lipase
and these reactants can cause lipids suggested needing at least one major can cause hypocalcemia, and albu-
in the blood to agglutinate into and four minor findings to make min binds to free fatty acids leading
larger molecules, which can occlude the diagnosis (Table 1). Lindeque to a decrease in free albumin. The
vessels. In addition, bone marrow focused on respiratory symptoms presence of fat globules in the blood
fat is prothrombotic, and in the cir- and created criteria based on a small and urine has also been observed,
culation, it is quickly covered in series of 55 patients with long bone but this is not specific to FES.12,20
platelets and fibrin setting off the fractures and decreased oxygen Inflammatory cytokines have also
coagulation cascade, leading to saturation (Table 1).7,12 Schonfeld been investigated as a predictor of
thrombocytopenia and, in extreme described another set of criteria FES. Based on the relationship of FES
cases, disseminated intravascular based on his opinion of the most with systemic inflammation, Prakash
coagulation.20 important features7,12 (Table 1). He et al21 examined IL-6 levels in
In reality, the clinical symptoms weighted findings based on their trauma patients. They found that at
of FES are likely a combination of observed specificity and chose scores 12 hours after injury, IL-6 was sig-
mechanical vascular obstruction and of 5 or greater to define FES. Al- nificantly elevated in patients who
the body’s inflammatory response to though these criteria have tried to went on to develop FES, diagnosed
trauma and embolized fat (Figure 3). standardize the diagnosis, they are using Gurd criteria.

April 15, 2019, Vol 27, No 8 e349

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Fat Embolism Syndrome

Figure 3 radiographs show bilateral diffuse or

patchy ill-defined opacities (Figure 4),
but this can also be seen in ARDS,
pulmonary edema, aspiration, or
infection.23 High-resolution CT has
more specific findings. It shows
patchy ground glass opacities and
consolidation with interlobular
thickening called the “crazy paving”
pattern23 (Figure 5). The extent of
these findings has correlated with
disease severity.24
Although in some cases, brain CT
may show diffuse edema with scat-
tered hemorrhage, usually, it shows a
negative result. However, MRI is
more sensitive, and T2-weighted im-
ages typically demonstrate a “starfield
pattern” with multiple, small, non-
confluent, hyperintense lesions.25
These lesions are also bright on
diffusion-weighted imaging and
appear dark on susceptibility-weighted
sequences (Figure 6). Brain MRI of
these lesions is also very consistent in
where they appear anatomically and
correlate with autopsy findings. The
lesions occur in the periventricular,
subcortical, and deep white matter.
This finding is in contrast to diffuse
axonal injury, which has a similar
appearance but with lesions at the
gray-white matter junction.25

Treatment and Prevention

Flowchart showing proposed pathophysiologic mechanisms for the clinical Treatment is primarily supportive
manifestations of fat embolism syndrome. DIC = disseminated intravascular care with goals being to maintain
coagulation. (Reproduced with permission from KosovaE, Bergmark B, oxygenation and ventilation, support
Piazza G: Fat embolism syndrome. Circulation 2015 January 20;131 hemodynamics, and resuscitate with
[3]:317-320.)
fluids and blood products. Beginning
in the 1950s, some targeted therapies
Although fat in the lungs is nonspe- and 2% in normal control subjects. In were attempted, including heparin,
cific and can be seen in multiorgan addition, there are significantly ele- hypertonic glucose, increased fluid
failure and sepsis, bronchoalveolar vated total cholesterol (10.2 mg/mg intake, aspirin, and corticosteroids,
lavage may also aid in diagnosis. phospholipid in FES as compared with all without conclusive benefit.7,12
Studies have attempted to determine 3.7 to 4.2 in ARDS and 2.0 in control Recently, experimental studies
specific characteristics of the amount subjects) and lipid esters.22 have attempted to alter the renin-
and composition of this fat in FES. In angiotensin pathway to prevent FES.
FES, it has been shown that bronchial Imaging In addition to acting as a vasocon-
lavages had .30% of alveolar mac- Imaging studies can be a useful adjunct strictor, angiotensin II is also proin-
rophages filled with lipid inclusions as to provide additional diagnostic infor- flammatory and profibrotic. This may
compared with 13% to 15% in ARDS mation (Table 2). Typically, chest contribute to the pathogenesis of FES

e350 Journal of the American Academy of Orthopaedic Surgeons

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 David L. Rothberg, MD and Christopher A. Makarewich, MD

Table 2 Figure 4
Laboratory and Imaging Findings of Fat Embolism Syndrome
Lab/Imaging Study Potential Findings

Laboratory studies Anemia, thrombocytopenia, elevated ESR, CRP,

and inflammatory cytokines, hypoalbuminemia,
fat macroglobulinemia
Bronchoalveolar lavage .30% alveolar macrophages with lipid inclusions
Elevated total cholesterol and lipid esters
Chest radiograph Bilateral diffuse or patchy opacities
Chest CT Consolidation with interlobar thickening (“crazy
paving” pattern)
Brain CT Diffuse edema with scattered hemorrhage
Brain MRI Multiple small nonconfluent hyperintense lesions Chest radiograph of a patient with fat
on T2 (“starfield” pattern) embolism syndrome showing
Bright on diffusion, dark on susceptibility- bilateral diffuse patchy infiltrates.
weighted sequences

CRP = C-reactive protein, ESR = erythrocyte sedimentation rate

They noted that while the number of
fractures treated with early surgical
fixation increased, the number of
in that fat in the lungs is taken up by steroid group developed FES as cases of FES decreased. When grouped
macrophages, leading to the local compared with 60 patients in the by treatment type, they found FES
release of renin followed by increased control group (P , 0.05). It is diffi- rates of 22% in the nonsurgical
levels of angiotensin I and II. Fletcher cult to interpret the results of these group versus 4.5% in the surgical
et al26 attempted to alter this pathway articles because they are based on group. This was not randomized,
in a rat model by treating with the small studies that used markedly and over this same period, support-
renin inhibitor aliskiren. In rats with different dosing regimens and had ive measures and resuscitation have
FES induced by triolein injection, different duration of treatment. also been changed; however, it was
groups with aliskiren administration Because of the lack of high quality the first to give insight into the issue
1 hour after the injection showed evidence, as well as the low incidence of fracture fixation timing. This was
significantly greater vessel diameter, of FES and the potential risks of followed by a prospective random-
decreased fibrosis, and lower fat con- corticosteroid treatment, routine ized trial in 1989 that compared
tent in vessels as compared with the prophylaxis is not recommended. patients with isolated femur frac-
control rats. Although experimental, tures with those with multiple in-
this may represent a way to treat or juries.30 Within each group, patients
provide prophylaxis against FES. Applications in Trauma were randomized to fixation either
Given the lack of direct treatment before 24 hours or after 48 hours.
Concerns in orthopaedic trauma
options, an important goal is preven- Significantly more pulmonary com-
affecting FES that have been debated
tion. Based on the proposed role of the plications were found with late stabi-
include timing to surgery, fracture
inflammatory process in FES, many lization, both in the cases with isolated
fixation method, and the manage-
randomized trials have examined the femur fractures and the multiply
ment of bilateral femur fractures.
use of prophylactic corticosteroids. injured group. These studies were the
These are outlined in a 2009 meta- basis for the principle of early total
analysis that included seven random- Timing to Surgery care.
ized trials. From the pooled data of 389 One of the earliest studies to examine However, FES and pulmonary
patients, corticosteroids reduced the the effect of timing was in 1976 by complications are just one of a mul-
risk of FES by 78%, with no difference Riska et al.29 He reported on a series titude of factors to consider in the
in the rates of infection and mortal- of trauma patients seen with pelvic optimal timing of fracture stabiliza-
ity.27 A 2012 systematic review of or long bone fractures or both from tion in multitrauma patients. Al-
randomized clinical trials found simi- 1967 to 1974. During this time, though early definitive surgery is
lar results.28 Of a total of 223 patients at their institution, a transition from advantageous for most, there is a
receiving corticosteroids and 260 nonsurgical treatment to surgical subset of patients for whom damage
control subjects, 9 patients in the treatment of fractures took place. control orthopaedics followed by

April 15, 2019, Vol 27, No 8 e351

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Fat Embolism Syndrome

Figure 5 Figure 6

Axial section of a chest CT scan

showing interlobular septal
thickening of the anterior bilateral
lungs, described as the “crazy
paving” pattern. (Reproduced with
permission from Newbigin K,
Souza CA, Torres C, Marchiori E,
Gupta A, Inacio J: Fat embolism
syndrome: State-of-the-art review Brain MRI of a patient with fat embolism syndrome showing multiple small
focused on pulmonary imaging nonconfluent lesions in the periventricuar and subcortical white matter that are
findings. Respir Med bright on T2 sequences (A) and dark on susceptibility-weighted sequences (B).
2016;113:93-100.)

in clinical studies. In reviewing pul- small sample sizes, studies examining

definitive treatment at a later date monary complications, Bosse et al16 this topic may be underpowered.
may increase the chance of survival. compared reamed intramedullary
Pape et al31 recommend using find- nails with plating in 453 patients. No
ings of shock, coagulopathy, tem- significant differences in pulmonary Decreasing Embolic Load:
perature, and soft tissue injury to complications or mortality were Trauma
risk stratify patients and guide observed. This study was conducted Several strategies for decreasing
treatment with early total care versus at two different hospitals, one where embolic load involve alterations to
damage control. This concept has nailing was more common and one intramedullary reaming technique.
since been supported in multiple where plating was routinely per- In a sheep model, Mousavi et al36
clinical studies, showing improved formed, which likely introduced tested different reaming speeds, both
outcomes following similar algo- confounding variables. Pape et al34 advancement of the reamer and rev-
rithms.32 Following these recom- randomized multiply injured pa- olution of the reamer head. They
mendations helps to balance the tients in the borderline stable group created a midshaft osteotomy, in-
desire to prevent FES with the pa- to intramedullary nail versus exter- duced hemorrhagic shock, and then
tient’s physiologic ability to undergo nal fixation. Six times greater inci- resuscitated the sheep before ream-
surgical fixation. dence in acute lung injury was found ing. The amount of embolized fat on
in the intramedullary nail group, but TEE and intramedullary pressure
no difference was found in ARDS or was significantly lower with slower
Fixation Method mortality. Reamed versus unreamed advancement and faster revolutions.
The mainstay of definitive treatment nails have also been investigated. The use of a reamer irrigator aspi-
of femoral shaft fractures is a reamed The suggested benefits of reamed nails rator (RIA) has also been proposed to
intramedullary nail. It is known from are higher union rates (particularly in decrease embolic load. In a canine
animal and human studies that in- distal fractures); the ability to place a model, Miller et al37 compared three
tramedullary reaming increases canal biomechanically advantaged, larger nailing scenarios, including un-
pressures and stimulates an inflam- diameter implant; and depending on reamed, standard reaming, and RIA.
matory response.33 Theoretically, fracture pattern, allow for early A lower embolic load at the carotid
this situation leads to an increased weightbearing.6 The potential for in- artery was found on ultrasonogra-
the incidence of FES compared with creased pulmonary complications in phy in the RIA group. On brain
other fixation methods; however, reamed nailing has not been bourn histologic assessment, the levels of
this has not been conclusively shown out in the literature;35 however, given heat shock protein (representing brain

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 David L. Rothberg, MD and Christopher A. Makarewich, MD

stress) and hypoxia-inducible factor and prolonged embolic events on were randomized to standard tech-
(representing ischemia) were signifi- TEE. Also, DVTs were detected in nique versus an additional irrigation
cantly lower in the RIA and unreamed 18% of the patients in the standard and suction step to remove medullary
groups as compared to the standard group compared with 3% of patients contents before reaming. A signifi-
reamer. Although seemingly promis- in the bone vacuum group. cantly lower amount of fat emboliza-
ing, these techniques have yet to show In addition, subtle cerebral findings tion was noted on TEE in the modified
clinical benefit in pulmonary or neu- have been attributed to FE. Several technique group.
rologic outcomes. review articles have discussed this Computer navigation may also lead
finding in the setting of arthroplasty to decreased embolization of medul-
Bilateral Femur Fractures and proposed that it could explain lary contents. Typically, conventional
postsurgical delirium and cognitive knee arthroplasty uses intramedullary
Another situation that deserves spe-
decline.3,4 This was originally studied instrumentation, particularly in
cial attention is the management of
in cardiac surgery requiring bypass, the femur, to set component align-
bilateral femur fractures. This is an
where increased fat embolic load ment. This can cause an increase in
uncommon injury pattern, and the
correlated with a decline in post- intramedullary pressure leading to
literature consists of small case series.
surgical cognitive function. In the embolic showers. Computer-assisted
These series have shown that bilateral
orthopaedic literature, despite being surgery can potentially decrease the
femur fractures treated with intra-
discussed in those recent review ar- embolic load because it uses extra
medullary nail have up to a 7.5%
ticles, just four original research ar- medullary guides. Several prospec-
incidence of FES, have higher injury
ticles have studied the relationship of tive randomized trials have compared
severity scores, resuscitation require-
FE on presurgical and postsurgical computer-assisted procedures with
ments, and rates of ARDS, as well as
cognitive testing, three in the setting standard total knee arthroplasty.
have longer hospital stays and higher
of arthroplasty and one in trauma.3,4 Malhotra et al19 evaluated embolic
mortality as compared with unilat-
None of these found a significant load after tourniquet release using
eral fractures with mortality rates of
correlation, but interestingly, three TEE, transcranial doppler, and blood
5% to 6%, about 5 to 6· higher than
out of four showed a trend that with sampling from the right atrium.
isolated femoral shaft fractures.38
increasing fat embolization, there Decreased pulmonary and cranial
No studies to date have compared
was a decrease in postsurgical neu- emboli were found in the computer
different treatment modalities and
rocognitive testing. The lack of navigation group as compared with
surgical timing in bilateral femur
significance may indicate that no standard total knee arthroplasty
fractures.
relationship exists; however, the group using an intramedullary femur
numbers in these studies are very guide.
Applications in small, and as such, they are likely These techniques may not be nec-
Arthroplasty underpowered. essary or cost-effective in all cases,
The use of an intramedullary bone but they may be useful for certain
Joint replacement procedures also cause vacuum during cementation was high-risk patient groups.
intramedullary pressurization, particu- shown to significantly decrease embo-
larly with cementing, leading to embo- lization of marrow contents.5 Second-
lization of fat into the circulation.11 ary cementation through a specially Summary
Fulminant FES with cardiopulmonary designed stem has also been described.
collapse is rare after arthroplasty, and In theory, this is a more gentle ce- Generally, FES is more common
descriptions are found only in case menting technique because the stem is in male subjects, those aged 10 to
reports. However, the recent literature placed first and cement injected 40 years, and those with closed long
has examined other effects of FE in the around it. Schmidutz et al39 found a bone fractures, particularly of the
setting of arthroplasty. significantly lower embolic load on femoral diaphysis, and multiple
Pitto et al5 evaluated the role of TEE with secondary cementation than fractures. The clinical presentation
marrow embolization on the incidence with standard cementation. includes respiratory distress, neuro-
of postsurgical DVT. They random- In another approach, Zhao et al40 logic symptoms, and petechial rash
ized 65 patients each to standard ce- attempted to alter the amount of em- 24 to 72 hours after injury. In trauma,
menting technique versus cementing bolized fat during total knee arthro- strategies to limit FE include early
with the use of an intramedullary bone plasty with an additional irrigation fracture stabilization in stable pa-
vacuum. The standard cementing and suction step. Using implants that tients, slow advancement, and fast
group had significantly more severe required tibial reaming, 30 patients revolutions of the reamer in reamed

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Fat Embolism Syndrome

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 David L. Rothberg, MD and Christopher A. Makarewich, MD

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