Blood-gas and circulatory changes during total knee replacement. Role of the intramedullary alignment rod.

Fahmy, N. R.; Chandler, Hugh P.; Danylchuk, K; Matta, E; Sunder, N.; Siliski, John M.

doi:10.2106/00004623-199072010-00004

Cited by 95 publications

(56 citation statements)

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“…Associated cardiovascular deterioration was characterized by transient but severe pulmonary hypertension, arterial hypotension, decreased cardiac output, and respiratory acidosis in this animal model 11 . Fat embolism is a well-known complication during total hip and knee arthroplasty [12][13][14][15] , intramedullary reaming 16,17 , and Disclosure: In support of their research for or preparation of this work, one or more of the authors received, in any one year, outside funding or grants in excess of $10,000 from the Wesley Foundation, Brisbane, Australia; the AO Foundation, Davos, Switzerland; and AOSpine, Dübendorf, Switzerland (SRN 02/105). Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity.…”

mentioning

confidence: 99%

Influence of Bone Marrow Fat Embolism on Coagulation Activation in an Ovine Model of Vertebroplasty

Krebs

Ferguson

Hoerstrup

et al. 2008

The Journal of Bone & Joint Surgery

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Influence of bone marrow fat embolism on coagulation activation in an ovine model of vertebroplasty Abstract BACKGROUND: Intraoperative cardiovascular deterioration as a result of pulmonary embolization of bone marrow fat is a potentially serious complication during vertebroplasty. The release of fatty material and thromboplastin from the bone marrow cavity during vertebroplasty may activate the coagulation cascade resulting in thrombogenesis, and pharmacological prophylaxis may therefore prevent cardiovascular complications. Thus, the effects of bone marrow fat embolism on coagulation activation during vertebroplasty were investigated with use of an animal model. METHODS: Polymethylmethacrylate was injected into three lumbar vertebrae of six sheep in order to force bone marrow fat into the circulation. Invasive blood pressures and heart rate were recorded continuously until sixty minutes after the last injection. Cardiac output, arterial and mixed venous blood gas parameters, and coagulation parameters were measured at selected time-points. Postmortem lung biopsy specimens were assessed for the presence of intravascular fat. RESULTS: Embolization of bone marrow fat resulted in a sudden and dramatic increase in mean pulmonary arterial pressure and a decrease in mean arterial blood pressure. There were no significant changes in any coagulation parameter from before the injection to after the injection. Intravascular fat and bone marrow cells were present in all lung lobes. CONCLUSIONS: Injection of polymethylmethacrylate into vertebral bodies caused embolization of bone marrow fat with subsequent transient cardiovascular deterioration, but no changes in coagulation parameters were observed. Thromboembolism did not contribute to the observed cardiovascular changes.

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mentioning

confidence: 99%

Influence of Bone Marrow Fat Embolism on Coagulation Activation in an Ovine Model of Vertebroplasty

Krebs

Ferguson

Hoerstrup

et al. 2008

The Journal of Bone & Joint Surgery

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“…Cardiovascular deterioration during FE includes hypotension, hypoxemia, arrhythmia, cardiac arrest and sudden death. Fat embolism is observed intraoperatively during cemented and cementless hip and knee arthroplasty (Herndon et al 1974, Fahmy et al 1990, Ereth et al 1992, Parmet et al 1993, Christie et al 1994, Morawa et al 1996, during intramedullary nailing of fractured long bones (Talucci et al 1983, Pell et al 1993) and also during vertebroplasty (VP) (Aebli et al 2002, Chen et al 2002. Intraoperative cardiac arrest during hip arthroplasty has been noted in 0.6-10% of patients and intraoperative deaths have been reported in 0.02-0.5% (Coventry et al 1974, Duncan 1989, Patterson et al 1991, Hofmann et al 1999, Parvizi et al 1999.…”

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confidence: 99%

Polymethylmethacrylate causes prolonged pulmo-nary hypertension during fat embolism: A study in sheep

et al. 2005

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Background Fat embolism (FE), the release of bone marrow contents into the circulation and the subsequent cardiovascular changes, is still a potentially fatal complication during orthopedic surgery. Different causative factors have been suggested, but the exact pathomechanism of FE still remains unclear. We investigated the role of polymethylmethacrylate (PMMA) in FE during vertebroplasty in sheep.Methods In 8 sheep, two vertebral bodies were augmented alternatively with PMMA or bone wax. Pulmonary and cardiovascular parameters were monitored during the procedure.Results The peak response was similar for both groups and characterized by hypotension, a drop in cardiac output and pulmonary hypertension. However, the recovery in pulmonary arterial pressure and pulmonary vascular resistance was quicker in the wax group.Interpretation The injection of PMMA may cause prolonged pulmonary hypertension during vertebroplasty and also arthroplasty. Surgeons should be aware of this potential cardiovascular complication, especially in patients with impaired pulmonary and cardiovascular function.

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“…Previous experiments show oversizing the entry hole and using a fluted alignment rod had less increase in femoral intramedullary pressure than not oversizing the entry hole and using a rounded alignment rod [6,19]. Overdrilling, combined with changes in shape and size of the alignment rod, has not yielded consistent reduction in intramedullary pressure below a threshold that may induce embolic phenomena.…”

Section: Introductionmentioning

confidence: 94%

“…Some researchers have explored the use of different shapes and sizes of TKA intramedullary instrumentation and different surgical steps to prevent elevating the femoral intramedullary pressure during surgery [6,14,19]. Previous experiments show oversizing the entry hole and using a fluted alignment rod had less increase in femoral intramedullary pressure than not oversizing the entry hole and using a rounded alignment rod [6,19].…”

Section: Introductionmentioning

confidence: 99%

The Reamer/Irrigator/Aspirator Reduces Femoral Canal Pressure in Simulated TKA

Gorp

Falk

Kmiec

et al. 2009

Clinical Orthopaedics &Amp; Related Research

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Inserting the femoral intramedullary alignment rod during total knee arthroplasty (TKA) can generate high intramedullary pressure, which increases the risk of intraoperative complications caused by fat embolism. Despite modifications to the surgical procedure, the best method to prevent this increase in pressure remains unknown. The reamer/irrigator/aspirator is a surgical instrument designed for use during femoral canal entry to increase the canal size and remove intramedullary fat and may prevent this pressure increase. We posed two hypotheses: (1) using the reamer/ irrigator/aspirator system will result in lower maximum femoral intramedullary pressure than using only conventional instrumentation during the initial steps of a TKA; and (2) using the reamer/irrigator/aspirator system in the initial steps of TKA will result in a mean maximum intramedullary pressure less than 200 mm Hg. We simulated a TKA on 14 cadaveric femurs to compare the femoral intramedullary pressure using both methods. Considerable decreases in femoral intramedullary pressure of 86% proximally and 87% distally were obtained by using the reamer/irrigator/aspirator system. The mean maximum pressure using the reamer/irrigator/aspirator system was less than 200 mm Hg. Additional clinical studies are needed to confirm any reduction in complications using the reamer/irrigator/aspirator system.

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Blood-gas and circulatory changes during total knee replacement. Role of the intramedullary alignment rod.

Cited by 95 publications

References 0 publications

Influence of Bone Marrow Fat Embolism on Coagulation Activation in an Ovine Model of Vertebroplasty

Influence of Bone Marrow Fat Embolism on Coagulation Activation in an Ovine Model of Vertebroplasty

Polymethylmethacrylate causes prolonged pulmo-nary hypertension during fat embolism: A study in sheep

The Reamer/Irrigator/Aspirator Reduces Femoral Canal Pressure in Simulated TKA

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