The John Charnley Award. Prophylaxis of fat and bone marrow embolism in cemented total hip arthroplasty
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R P Pitto1, M Koessler, K Draenert
1Department of Orthopaedic Surgery, Friedrich-Alexander University of Erlangen-Nuremberg, Germany.
Insights
A novel vacuum cementing technique significantly reduced intraoperative pulmonary embolism during total hip replacement. This method, utilizing femoral drainage, offers a safer alternative to conventional cementing, minimizing embolic events and pulmonary impairment.
Area of Science:
- Orthopedic Surgery
- Biomedical Engineering
- Anesthesiology
Background:
- Intraoperative pulmonary embolism is a significant risk during total hip arthroplasty.
- Elevated intramedullary pressure during cementing is a primary cause of embolism.
- Conventional cementing techniques offer limited protection against embolic events.
Purpose of the Study:
- To assess the efficacy of a new vacuum cementing technique in preventing intraoperative pulmonary embolism.
- To compare the incidence of embolic events and pulmonary impairment between vacuum and conventional cementing methods.
Main Methods:
- A prospective, randomized clinical trial involving 70 patients with coxarthrosis undergoing total hip replacement.
- The vacuum group utilized proximal and distal femoral drainage to create a medullary vacuum during stem insertion.
- Both groups were monitored using blood gas analysis, hemodynamic monitoring, and transesophageal echocardiography.
Main Results:
- Severe transatrial embolic events occurred in 94% of the conventional group versus 14% in the vacuum group (statistically significant).
- Conventional cementing led to significant decreases in arterial partial pressure of O2 and increases in pulmonary shunt.
- The vacuum technique demonstrated minimal changes in these pulmonary parameters.
Conclusions:
- Vacuum cementing effectively reduces intraoperative pulmonary embolism during total hip arthroplasty.
- Femoral drainage creating a medullary vacuum is a key prophylactic measure against fat and bone marrow intravasation.
- This technique substantially reduces pulmonary impairment associated with total hip replacement surgery.
Abstract:
The efficiency of a new cementing technique developed to prevent the risk of intraoperative pulmonary embolism was assessed. Seventy patients with coxarthrosis entered into a prospective, randomized clinical trial. In the control group of 35 cases the total hip replacement was cemented conventionally. In the second group a proximal drainage placed along the Linea aspera, and a distal drainage placed in the diaphysis, created a vacuum in the medullary cavity of the femur during the insertion of the stem. The operation was performed with the patient under blood gas analysis and hemodynamic and transesophageal echocardiography monitoring. Severe transatrial embolic events were observed during the insertion of the femoral component in 94% of the cases of the control group and in 14% of the cases of the vacuum group; the difference is statistically significant. A significant decrease of arterial partial pressure of O2 (-40.8 mm Hg) and increase of the pulmonary shunt values (+28.3%) occurred 5 minutes after the observation of embolic events in the cases operated on conventionally, but these parameters showed minimal changes in the vacuum group. The rise of intramedullary pressure in the femur is the most decisive pathogenic factor of pulmonary embolism during total hip arthroplasty. The logical prophylactic measure to prevent intravasation of fat and bone marrow is to create sufficient drainage. The cohorted investigation showed the value of the vacuum cementing technique for a substantial reduction of intraoperative embolism and pulmonary impairment.