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Paradoxical embolism of fat, thrombus and bone marrow during orthopaedic surgery can be associated with confusion, stroke and death. A patent foramen ovale (PFO) is the most common venousto arterial circulation shunt (v-aCS) permitting paradoxical embolism. Transcranial Doppier ultrasound (TCD) is capable of detecting emboli during surgery and quantifying a shunt but the reproducibility of this technique and the association between paradoxical embolism and organ dysfunction is unclear.