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Aims: The aim of this study was to assess whether it is possible to predict the mortality, and the extent and time of neurological recovery from the time of the onset of symptoms and MRI grade, in patients with the cerebral fat embolism syndrome (CFES). This has not previously been investigated., Methods: The study included 34 patients who were diagnosed with CFES following trauma between 2012 and 2018. The clinical diagnosis was confirmed and the severity graded by MRI. We investigated the rate of mortality, the time and extent of neurological recovery, the time between the injury and the onset of symptoms, the clinical severity of the condition, and the MRI grade. All patients were male with a mean age of 29.7 years (18 to 70). The mean follow-up was 4.15 years (2 to 8), with neurological recovery being assessed by the Glasgow Outcome Scale and the Mini-Mental State Examination., Results: In all, seven who had early-onset CFES (< 24 hours), and a severe Takahashi grade on MRI, died. There was a significant association between the time of onset of neurological signs and mortality (p = 0.035). Mortality was also significantly associated with a severe Takahashi grade (p < 0.001). Among the 27 surviving patients, 26 (96.3%) recovered completely. One (3.7%) had a cognitive deficit. The mean time to recovery was 4.7 weeks (2 to 13), with late recovery aftereight eight weeks being recorded in three patients., Conclusion: There was a significantly increased rate of mortality in patients with CFES who had an early onset of symptoms and a severe grade on MRI. Complete neurological recovery can be expected in most patients with CFES who survive. Cite this article: Bone Joint J  2022;104-B(1):142-149.

Fat embolism syndrome in sickle cell disease is associated with great mortality, while more than half of survivors suffer severe neurological sequelae. Release of fat droplets leads to obstruction of the microcirculation as well as generation of proinflammatory cytokines that can cause direct tissue injury. Red cell exchange transfusion can be life-saving but the addition of therapeutic plasma exchange may further improve outcomes by removing such inflammatory mediators. Here, we describe the case of a 27-year-old male patient with sickle cell anaemia presenting with typical features of fat embolism syndrome including neurological involvement with greatly reduced level of consciousness. MRI of his brain showed multiple widespread microhemorrhages giving the characteristic "star field" pattern but also a cytotoxic lesion of the corpus callosum, known to be the result of direct neurotoxicity by proinflammatory cytokines. The patient underwent emergency red cell exchange transfusion leading only to modest clinical improvement but fully regained consciousness after three cycles of therapeutic plasma exchange. This case highlights the deleterious effect of the hyperinflammatory state characteristic of many sickle cell complications and supports further exploring the potential benefit from plasma exchange as an adjunct to red cell exchange in order to remove proinflammatory cytokines during acute complications of sickle cell disease., (Copyright © 2021. Published by Elsevier Ltd.)

Organ shortage is a major cause of delayed liver transplantation and increased waitlist time. The level of donor steatosis is a significant determinant in organ selection. Scarcity of organs has led some programs to expand their acceptable criteria for the percentage of steatosis. We report two cases of liver transplantation of steatotic donor organs that resulted in mortality within hours from transplantation. Postmortem analysis showed evidence of diffuse pulmonary fat microemboli likely originating from the donor organ, with marked preservation reperfusion injury. The mechanism of diffuse fat microemboli in this setting and possible relationship to other perioperative syndromes (transfusion-related lung injury, acute kidney injury, and postreperfusion syndrome) is discussed., (© 2019 The American Society of Transplantation and the American Society of Transplant Surgeons.)

Given the widespread utility and therapeutic potential of autogenous fat grafting, plastic surgeons should be familiar with its safety profile and associated adverse events. This article provides a critical review of the literature and delineates risk factors associated with various complications when grafting to the breast and gluteal regions. The majority of adverse events are related to fat necrosis and require minimal diagnostic or therapeutic intervention. Larger graft volumes, as in cosmetic augmentation, are associated with higher incidences of fatty necrosis. The oncologic safety of fat grafting is supported by multiple clinical studies with thousands of breast cancer patients, albeit predominantly retrospective in nature. Although less frequent, serious complications include fat emboli during gluteal augmentation. Identification of associated risk factors and implementation of proper surgical techniques may minimize the occurrence of life-threatening complications.

Background: Deaths secondary to gluteal lipoinjection are relatively recent events of major importance. However, little is known in relation to their behavior and clinical evolution. Therefore, an analysis was performed of case records from clinical cases that encountered this problem, correlating the results with the findings during autopsies., Methods: An analysis was performed of records from patients who died secondary to gluteal lipoinjection. Patient-specific data, surgical procedure, clinical picture, evolution, and outcome were analyzed. The findings of the autopsies and the involvement of other organs were also analyzed and correlated., Results: From 2000 to 2009, 16 files were obtained that fulfilled the indicated requirements. There were no statistically significant differences in the general characteristics of the patients, such as age, body mass index, or volume lipoinjected or liposuctioned. The clinical pictures were similar in all cases, and the autopsy findings showed the presence of microembolism in all cases and macroembolism in the most severe cases., Conclusions: The most significant parameter of severity in patients who undergo gluteal lipoinjection is the presence of fat in macroscopic form in the circulation. The volumes of liposuctioned or lipoinjected fat have little influence. Hypoxemia, hypotension, and bradycardia are the characteristic clinical features. Although there is no specific treatment, immediate aggressive vital support to attempt to stabilize the patient is crucial., Clinical Question/level of Evidence: Therapeutic, V.

Cosmetic procedures are common and utilize many techniques to obtain aesthetically good outcomes for patient satisfaction with acceptable safety standards. Cosmetic procedures that involve the gluteal region are becoming increasingly popular as various procedures can target the gluteal region such as liposuction, tumescent liposuction, cosmetic filler injections, autologous fat transfer, depot drug delivery, and implants. Complications of cosmetic gluteal procedures can be localized or systemic with systemic complications being responsible for most deaths. These reported systemic complications include sepsis, thromboembolism, fat embolism with or without fat embolism syndrome, macroscopic fat embolism, anesthesia-related and blood volume abnormalities. We herein report 10 deaths due to elective gluteal cosmetic procedures. Autologous fat transfer (fat grafting, lipoinjection) following liposuction resulted in 8 of 10 fatal outcomes of the gluteal aesthetic procedures. A comprehensive discussion of gluteal anatomy, gluteal contouring procedures, and the approach to such cases is presented along with the autopsy findings of the reported cases., (© 2018 American Academy of Forensic Sciences.)

Paroxysmal sympathetic hyperactivity represents an uncommon and potentially life-threatening complication of severe brain injuries, which are most commonly traumatic. This syndrome is a clinical diagnosis based on the recurrent occurrence of tachycardia, hypertension, diaphoresis, tachypnea, and occasionally high fever and dystonic postures. The episodes may be induced by stimulation or may occur spontaneously. Underdiagnosis is common, and delayed recognition may increase morbidity and long-term disability. Trigger avoidance and pharmacological therapy can be very successful in controlling this complication. Fat embolism syndrome is a rare but serious complication of long bone fractures. Neurologic signs, petechial hemorrhages and acute respiratory failure constitute the characteristic presenting triad. The term cerebral fat embolism is used when the neurological involvement predominates. The diagnosis is clinical, but specific neuroimaging findings can be supportive. The neurologic manifestations include different degrees of alteration of consciousness, focal deficits or seizures. Management is supportive, but good outcomes are possible even in cases with very severe presentation. We report two cases of paroxysmal sympathetic hyperactivity after cerebral fat embolism, which is a very uncommon association.

Background: Gluteal fat grafting is among the fastest growing aesthetic procedures in the United States and around the world. Given numerous anecdotal and published reports of fatal and nonfatal pulmonary fat embolism resulting from this procedure, the Aesthetic Surgery Education and Research Foundation (ASERF) formed a Task Force to study this complication., Objectives: To determine the incidence of fatal and nonfatal pulmonary fat embolism associated with gluteal fat grafting and provide recommendations to decrease the risks of the procedure., Methods: An anonymous web-based survey was sent to 4843 plastic surgeons worldwide. Additional data on morbidity and mortality was collected through confidential interviews with plastic surgeons and medical examiners, public records requests for autopsy reports in the United States, and through the American Association for the Accreditation of Ambulatory Surgical Facilities (AAAASF)., Results: Six hundred and ninety-two (692) surgeons responding to the survey reported 198,857 cases of gluteal fat grafting. Over their careers, surgeons reported 32 fatalities from pulmonary fat emboli as well as 103 nonfatal pulmonary fat emboli. Three percent (3%) of respondents experienced a patient fatality and 7% of respondents reported at least one pulmonary fat embolism in a patient over their careers. Surgeons reporting the practice of injecting into the deep muscle experienced a significantly increased incidence rate of fatal and nonfatal pulmonary fat emboli. Twenty-five fatalities were confirmed in the United States over the last 5 years through of autopsy reports and interviews with surgeons and medical examiners. Four deaths were reported from 2014 to 2015 from pulmonary fat emboli in AAAASF facilities., Conclusions: Despite the growing popularity of gluteal fat grafting, significantly higher mortality rates appear to be associated with gluteal fat grafting than with any other aesthetic surgical procedure. Based on this survey, fat injections into the deep muscle, using cannulae smaller than 4 mm, and pointing the injection cannula downwards should be avoided. More research is necessary to increase the safety of this procedure., (© 2017 The American Society for Aesthetic Plastic Surgery, Inc.)

Background: Intramuscular gluteal lipoinjection has become one of the most commonly used surgical procedures for achieving improvement in the gluteal contour; however, there are few studies that report and analyze the causes of secondary death from this surgical procedure., Methods: An analysis of secondary deaths from gluteal lipoinjection procedures was performed in Mexico and Colombia over periods of 10 and 15 years, respectively. In Mexico, the study was performed through a survey of all members of the Mexican Association of Reconstructive, Plastic and Aesthetic Surgery. In Colombia, the study was performed through an analysis of deaths and autopsies documented by the National Institute of Legal Medicine and Forensic Sciences Regional Bogotá., Results: A total of 413 Mexican plastic surgeons reported 64 deaths related to liposuction, with 13 deaths caused by gluteal lipoinjection. In Colombia, nine deaths were documented. Of the 13 deaths in Mexico, eight (61.6 percent) occurred during lipoinjection, whereas the remaining five (38.4 percent) occurred within the first 24 hours. In Colombia, six deaths (77.7 percent) occurred during surgery and three occurred (22.2 percent) immediately after surgery. In the Colombian autopsy results, seven cases of macroscopic fat embolism and two cases with a microscopic embolism were reported, with abundant fatty tissue in the infiltrated gluteal muscles., Conclusions: In this study, the authors found that intramuscular gluteal lipoinjection is associated with mortality caused by gluteal blood vessel damage allowing macroscopic and microscopic fat embolism; therefore, buttocks lipoinjection should be performed very carefully, avoiding injections into deep muscle planes., Clinical Question/level of Evidence: Therapeutic, V.

The article deals with a multicenter study that demonstrates the possibility and feasibility of noninvasive ventilation in patients with skeletal trauma complicated wiith fat embolism syndrome. The authors found additional criteria for the severity of the condition of patients with trauma. Important criteria for the choose a type of ventilation (non-invasive and invasive) is the lack of consciousness, desynchronization of a patient with ventilator and the need for a specialized regimes or miorelaxation to synchronize with the respirator.

Fat embolism syndrome (FES) due to extensive bone marrow necrosis (BMN) in sickle cell disease (SCD) is a potentially under-diagnosed complication associated with severe morbidity and mortality. We identified 58 cases reported in the world literature to date. Typically, patients presented with a seemingly uncomplicated vaso-occlusive crisis (VOC) and subsequently deteriorated rapidly with a drop in their haemoglobin and platelets, development of respiratory failure, encephalopathy and varying degrees of involvement of other systems. Overall mortality in the reported cases was 64% but differed according to the use of transfusion and was 29%, 61% and 91% for patients receiving exchange, top-up or no transfusion respectively. Patients most at risk appear to be those with a "milder" form of SCD as 81% of patients had a genotype other than HbSS and the majority had no history of significant sickle-related complications. Human parvovirus B19 (HPV B19) infection was documented in 24% of cases., (Copyright © 2014 Elsevier Ltd. All rights reserved.)

Objective: To analyze the general and forensic pathological characteristics of death due to fat embolism syndrome (FES) and to provide reference data for forensic identification., Methods: Twenty autopsy cases due to FES were selected from the forensic center of a medical college from 1999 to 2012. The general and forensic pathological characteristics such as the ways and types of injuries, clinical manifestation and the pathological changes were summarized., Results: Fat embolism mainly occurred after long bone fracture or a large area of soft tissue injury with the majority of cases being fat embolism of lung and occasional cases being combined embolisms of lung and brain as well. The onset of symptoms appeared shortly after the injury or surgery. Lipid droplets could be observed within small pulmonary vessels and verified by special staining., Conclusion: There are particular characteristics in death due to FES in concern with types of injuries, onset of symptoms and pathological findings. In order to find out the direct evidence of FES, special staining (oil red O staining) can be used in the forensic identification.

We evaluated the peripheral release of inflammatory mediators after femoral fracture and subsequent intramedullary reaming using the RIA reamers. IL-6 was elevated after trauma, and reaming with RIA induced a measurable second hit response. However, despite a higher ISS, the levels of IL-6 in the RIA group were similar to the levels measured in a group of patients where reaming of the femoral canal was performed using conventional reamers. There was one death related to fat embolism syndrome in the conventional reamers group. However, the overall incidence of complications was low and similar between the 2 groups of studied patients. In polytrauma patients, large scale studies are desirable to evaluate further the immuno-inflammatory response using the RIA reamers prior to the instrumentation of the femoral canal., (Copyright © 2010 Elsevier Ltd. All rights reserved.)

Background: Fat embolism syndrome (FES) is a potentially fatal complication of long bone fractures. There have been no reports of FES in long bone fractures in this decade in Taiwan. The purpose of this study was to review the FES experiences in a tertiary referral center between January 1997 and February 2008., Methods: Between January 1997 and February 2008, 13 patients with long bone fractures with documented FES in our institution were reviewed. FES was diagnosed clinically by at least 2 major criteria or 1 major with at least 4 minor signs of Gurd's criteria., Results: The incidences of FES, less than those reported in the literature, were 0.15% in fracture of the tibia, 0.78% in fracture of the femur and 2.4% in multiple fractures. The mortality rate of FES, similar to other available results, was about 7.7%. All cases were less than 35 years old, except for 1 70-year-old male. Fat embolism occurred within an average of 48.5 hours after long bone fracture. Eleven presented with sudden drop in hemoglobin level, dropping 4.2 g/dL on average. Nine presented with thrombocytopenia, and 10 presented with sudden drop in platelet count, dropping 140,000/dL on average. Two had cerebral sequelae without recovery at the last 48-month follow-up., Conclusion: This 12-year interval retrospective study revealed modern epidemiologic results for FES in long bone fracture. Compared with the available literature in the recent decade, the incidence of FES in long bone fracture in our institution is less and the mortality rate is similar., (Copyright 2010 Elsevier. Published by Elsevier B.V. All rights reserved.)

Objective: To analyze the prevalence and frequency spectrum of the most relevant diseases found in the autopsies of patients who underwent a lung transplant and died in the first month after transplantation. To evaluate the consistency of the pre-and post-mortem diagnoses, comparing them with the Goldman et al. scale modified by Battle et al., Material and Methods: Retrospective and longitudinal analysis, comparison of the medical records and records of autopsies of patients who received a lung transplant in our center (University Hospital Marques de Valdecilla) from 1997 to 2007, who died in the early postoperative period (first month post-transplant). The discordance between clinical and pathological diagnosis was classified according to the classification of Goldman et al. and Battle et al. The Student t test for quantitative variables and chi-square for qualitative variables were used for the comparison of the groups., Results: The five class I errors are limited to respiratory diseases: 2 undiagnosed acute rejection, 1 bilateral pulmonary thromboembolism, 1 fat embolism and 1 hemorrhagic infarction of the lung graft. We found a significant difference (p=0.05) between days of survival of patients with group Class I errors (6+/-4.52 days) and patients from the group with no discrepancy (15.42+/-8.99)., Conclusion: The short time between transplant and death of the patient reduces the possibility of reaching a correct diagnosis. Because of this information, diagnostic possibilities must be maximized in life-threatening diseases during this period. Therefore, the rate of autopsy studies in this period should be 100%.

Background: Fat embolism syndrome (FES) is a potentially lethal condition most commonly seen in polytrauma patients with multiple long-bone fractures. Treatment has centred around supportive care and early fracture fixation. Several small clinical trials have suggested corticosteroids benefit patients with FES, but this treatment remains controversial. Our objective was to determine the effect of corticosteroids in preventing FES in patients with long-bone fractures., Methods: We conducted a meta-analysis of published studies of patients with long-bone fractures who were randomly assigned to groups receiving corticosteroids or standard treatment for the prevention of FES (1966-2006). Data were extracted on quality, population, intervention and outcomes. Our primary outcome was the development of FES. We used random-effects models to pool results across studies, assessing for study heterogeneity., Results: Of the 104 studies identified, 7 met our eligibility criteria. Overall, the quality of the trials was poor. Our pooled analysis of 389 patients found that corticosteroids reduced the risk of FES by 78% (95% confidence interval [CI] 43%-92%) and that only 8 patients needed to be treated (95% CI 5-13 patients) to prevent 1 case of FES. Similarly, corticosteroids significantly reduced the risk of hypoxia. We found no differences in the rates of mortality or infection. Rates of avascular necrosis were not reported in any of these studies., Conclusion: Evidence suggests that corticosteroids may be beneficial in preventing FES and hypoxia but not mortality in patients with long-bone fractures. The risk of infection is not increased with the use of corticosteroids. However, methodological limitations of these trials necessitate a large confirmatory randomized trial.

Objectives: To assess the incidence and risk factors for fat embolism syndrome., Materials and Methods: Data from the National Hospital Discharge Survey (NHDS) were analyzed using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes., Results: From 1979 through 2005 among 928,324,000 patients discharged from short-stay hospitals in the United States, 41,000 (0.004%) had fat embolism syndrome. Among 21,538,000 patients with an isolated fracture of the femur (any site), tibia, fibula, pelvis, ribs, humerus, radius, or ulna, 25,000 (0.12%) developed fat embolism syndrome. Patients with multiple fractures of the femur (excluding neck) more often had fat embolism syndrome than those with isolated fractures (1.29% versus 0.54%). The incidence of fat embolism syndrome was lower with isolated fractures of the tibia or fibula (0.30%) and even lower with isolated fractures of the neck of the femur (0.06%). The incidence of fat embolism was too low to calculate with isolated fractures of the pelvis, ribs, humerus, radius, or ulna. Nonorthopedic conditions rarely, if ever, were accompanied by fat embolism syndrome. The fat embolism syndrome was more frequent in men (relative risk 5.71). Children, aged 0 to 9 years rarely had fat embolism syndrome. The fat embolism syndrome most commonly affected patients aged 10 to 39 years., Conclusions: The incidence of the fat embolism syndrome depends on the bone involved, whether fractures are isolated or multiple, the age of the patient and the gender. It rarely occurs as a result of medical conditions.

Fat embolism syndrome (FES) after liposuction is likely a life-threatening disorder, though its incidence is low. The three chief clinical manifestations include respiratory insufficiency, cerebral involvement, and petechial rash. Although FES is a multisystem disorder, the most seriously affected organs are the lungs, brain, cardiavascular system, and skin. Many laboratory findings are characteristic but nonspecific. The pathogenesis of FES after liposuction has been looked at both mechanically and biochemically. Diagnosis is difficult; Gurd and Wilson's diagnostic criteria based on clinical examination is still extensively used in clinics at present. There is no specific therapy for FES after liposuction for the moment, so prevention, early diagnosis, and supportive therapies are important. In this article we discuss the clinical presentation, pathogensis, and current methods to prevent FES and, if possible, ways to treat this complication.

Several methods are available for progressive limb lengthening, including centromedullary nailing, external fixation, or a combination. Each technique has its own advantages and drawbacks. In trauma victims, use of centromedullary nailing is associated with potentially fatal fat embolism. This fatal outcome might also occur during limb lengthening, particularly in bilateral procedures. To our knowledge, fat embolism has not been reported with the use of centromedullary nail for limb lengthening. This was a multicentric study of three cases of fat embolism, including one fatal outcome. In all, 36 centromedullary lengthening nails were inserted in the three centers before these acute episodes. The first two cases occurred during single-phase bilateral procedures, the third during unilateral lengthening. Fat embolism could result from several factors, as reported in the literature. While the bilateral nature of the procedure has been incriminated, the observation of an embolism during a unilateral procedure suggests other factors may be involved. Considerable increase in endomedullary pressure during reaming and insertion of the nail has been demonstrated. At the same time, there is the question as to whether the reduction of the diminution of medullary pressure by corticotomy would be an efficient way of reducing the risk of fat embolism. Based on the analysis of our three cases, we suggest that the best way to avoid fat embolism might be to drill several holes within the area of the osteotomy before reaming, in order to reduce endomedullary pressure. This can be achieved via a short skin incision, sparing the periosteum before low energy osteotomy. Since applying this protocol, the three centers have implanted 17 lengthening nails, without a single case of fat embolism.

From October 1988 to March 2005, there were at least 92 autopsy cases where morbid obesity was present and/or where it was attributed to the cause of death in the coronial district of Auckland, New Zealand, a city with a population of over 1 million people. Obesity has been researched internationally, and much is known about associated comorbidities such as atherosclerotic disease, hypertension, and diabetes, to name a few. However, in the morbidly obese (body mass index>or=40 kg/m2), only 14 of 92 cases were found to have ischemic heart disease due to coronary atherosclerosis as the principal cause of death, and slightly over half (48/92) have some degree (mild, moderate, severe) of coronary atheroma. There is a strong positive correlation between heart weight and body weight. Only 8 livers were normal, all others showing some form of steatosis, venous congestion, and fibrosis/cirrhosis. The mean weights of the heart, lungs, and liver were above the normal reference range in almost all cases. In conclusion, the study did not follow the widely published finding of the positive correlation between morbid obesity and ischemic heart disease in terms of mortality, but the study was consistent with other studies on the organ manifestations of morbid obesity, particularly for the heart, lungs, and liver.

Background: Office-based surgery is an important method of health care delivery, and in 2000, the Florida Board of Medicine restricted office procedures. The objective of this study was to analyze the deaths resulting from office procedures in Florida., Methods: The authors reviewed all office surgical incidents that resulted in death, injury, or hospital transfer in Florida from January of 2000 to January of 2006. Various methods were used to determine board status, office accreditation, and hospital privileges., Results: In 6 years of Florida data, a total of 46 deaths related to office procedures were reported. Twenty of those were surgical procedures that are within the scope of plastic surgery, although non-board-certified plastic surgeons performed nine. Of those 20 related to plastic surgery, 11 died before discharge. Although all 11 survived long enough to be transferred to a hospital, we classified them as office deaths. The other nine died after appropriate discharge. Of the nine, seven deaths were from thromboembolism and the others from unknown causes. Thirty-five deaths were related to non-board-certified plastic surgeons and specialists in other fields. Board-certified plastic surgeons accounted for less than one-fourth of the deaths. There were no deaths from a board-certified plastic surgeon since April of 2004., Conclusions: There were over 600,000 operations during the study period. The fact that 11 office deaths were reported would suggest that the location in which these procedures were performed was not as much of a factor as the regulators have suggested. The most frequent cause of death after discharge was thromboembolism.

Background: The aim of this study was to evaluate the possible correlations between the grade of fat embolism and age, gender, severity of trauma and post-traumatic survival time., Methods: Thirty-one cases with pulmonary and/or systemic fat embolism, auotopsied at the Morgue Department of Council of Forensic Medicine were evaluated retrospectively., Results: Twenty-eight cases (90%) died due to trauma and its complications. Nineteen cases (61%) were injured in motor vehicle-related accidents. Post-traumatic survival time varied between 0-384 hours (61.6+/-86.2 hours). Abbreviated injury scale (AIS) was 8.1+/-3.9 and injury severity score (ISS) was 26.5+/-19.7 SD. Twenty-four (77%) cases were determined as isolated pulmonary fat embolism and 7 (23%) cases as systemic fat embolism on histopathological examination. Possible correlations between the grade of fat embolism and age, gender, severity of trauma and post-traumatic survival time were evaluated statistically with using Chi-square and Spearman's correlation tests., Conclusion: There were no correlations between the grade of fat embolism and age, gender, the severity of trauma. Post-traumatic survival time and the severity of trauma had a very weak negative correlation without any statistical significance.

This report describes the intraoperative course of a pediatric patient with neuromuscular scoliosis who died of massive fat and marrow emboli during posterior instrumentation for scoliosis surgery. In addition, the report describes the incidence and consequences of embolic events during spine surgery as well as the most common clinical sequelae. This patient's unique presentation is highlighted.

Introduction: Posttraumatic fat embolism follows the injury. The fat emboli in circulation could cause death in three ways: isolated lung fat embolism, systemic fat embolism and fat embolism syndrome (FES). In forensic pathology, only two trauma scores, based on disintegration of anatomic structures, could be used for objectivization, comparison and establishment of severity of injuries. One of them is Injury Severity Score--ISS, based on Abbreviated Injury Scale--AIS. The second one is Hannover Polytrauma Score--HPTS, based on the total sum of all injuries and age of the injured person., Objective: The objectives of this paper were to establish the correlation between outliving period and trauma severity (based on ISS and HPTS values), in persons died from posttraumatic fat embolism and/or its complications, and to establish which of these score systems could be better for prediction of development of the posttraumatic fat embolism., Method: The retrospective autopsy study was performed and it included the material of the Institute of Forensic Medicine in Belgrade for period 1988-2001. The autopsy reports and clinical medical data were analyzed, for persons died from posttraumatic fat embolism and/or its complications. In all cases, the fat embolism was the single cause of death, verified by autopsy. In each case, ISS and HPTS values were obtained. The sample was statistically prepared (chi2 test, correlation coefficient, regression line)., Results and Discussion: The sample included 50 persons: 41 males and 9 females. The proportion of men was statistically significant (chi2 = 20.480; p < 0.001). Average age of male was 55.26 years (SD = 21.39) and of female was 55.78 (SD = 17.45). There was no statistically significant disproportion among the age distribution of the sample (chi2 = 6.4; p > 0.05). The outliving period varied from 1-14 days: the average was 5.92 (SD = 3.39; Med. 5.50; Mod. 2). The average value of 1SS was 19 (SD = 7.70; Med. 19; Mod. 14), and for HPTS average value was 28.16 (SD = 12.87; Med. 26.50; Mod. 12). In literature, there have been data about critical ISS value: 12-20. HPTS value of 20 to 35 was lethal in 25%. Each injured of our sample had, at least, one long bone or pelvic fracture. There was negligible negative correlation between outliving period and 1SS and HPTS values in our sample: coefficient of linear correlation r = -0.117, t = 0.83 and r = -0.088, t = 0.59. Our sample was representative (t = 8.37). These data pointed out that the outliving period of the observed patients, died from post-traumatic fat embolism, was not in relation to general severity of injuries but to fat embolism per se and its consequences. There was low positive correlation between ISS and HPTS values: r = 0.296, t = 2.147, coefficient of determination r2 = 0.0876 and linear regression HPTS = 18.7588+0.4948 ISS. These data indicated that direct correlation between scores was only about 9% and the rest of correlation i.e. 91% depended on other factors., Conclusion: There was negative negligible correlation between outliving period and severity of injury based on ISS and HPTS, in patients died from posttraumatic fat embolism. So, these score systems are useless for prediction of duration of the outliving period in the injured died from fat embolism as well as for prediction of posttraumatic fat embolism as cause of death.

Objective: To improve the diagnosis and treatment of severe cerebral fat embolism (SCFE)., Methods: The data of nine patients with SCFE were retrospectively analyzed. The manifestations of the central nerve system, respiratory system and hemorrhage were recorded, at the same time, accessory examination including arterial oxygen, fat macroglobules in venous blood and image examination was adapted. The patients were treated with exopexy, pharmocotherapy and oxygentherapy., Results: Two of the nine patients died of severe complications, the other seven recovered without severe sequela., Conclusions: Gurd standard should be improved for early diagnosis of SCFE. If svere complications can be prevented, patients who receive early treatment will have favourable prognosis.

Object: Sacral tumors are relatively rare, and experience related to resection of these tumors is therefore usually limited to a small number of patients. The purpose of this retrospective study was to review the authors' experience with sacral neoplasms over the last 12 years., Methods: Based on a review of records in 11 patients who underwent sacrectomy, and the various patient characteristics, presenting symptoms, histological findings for their tumors, as well as the type of surgical treatment used (including a whole spectrum of sacral amputations), and their outcome are reported., Conclusions: Despite the potential for complications, sacrectomy can be performed successfully, and is an important procedure in the treatment of primary sacral tumors.

Intraoperative circulatory and pulmonary problems occuring during the repair of femoral neck fractures with cemented hip arthroplasty are a common problem, that cannot be ultimately explained. As a possible reason for this problem is air embolism during the polymerisation of the methylmethacrylat discussed. We started a prospective randomised clinical examination with 72 patients to prove the efficiency of palacos mixed in vacuum, with respect to the reduction of severe cardiovascular complication during endoprosthetic repair of femoral neck fractures. In the control group with 36 patients, surgical repair was performed with palacos mixed conventionally. In the second group (vacuum group), also consisting of 36 patients, surgical repair was performed with palacos mixed in vacuum. Invasive hemodynamic monitoring and transesophageal echocardiography was performed in all cases. In the control group pulmonary embolism occurred echocardiographically in 86% of the cases vs. 14% in the vacuum group. 53% of the control patients--vs. 11% of the vacuum patients--showed clinical complications in form of significant decrease of arterial oxygenation and circulatory insufficiency with the need of catecholamines. Clinical complications occurred in the control group in 80% of the patients--vs. 13.7% in the vacuum group--whose pulmonal arterial pressure was higher than 30 mmHg preoperatively and only in 18.8% of the cases--vs. 7.1% in the vacuum group--with a normal pulmonal arterial pressure. Mortality in the control group amounted to 13.8% in the vacuum group to 2.8%. Through the use of methylmethacrylate mixed in vacuum for surgical repair of femoral neck fractures with cemented hip arthroplasty, the incidence of severe cardiac complications could be reduced significantly. Patients with increased pulmonal arterial pressure have the highest risk for cardiac complications.

Study Objectives: Acute chest syndrome (ACS) is a frequent and potentially severe pulmonary illness in sickle cell disease (SCD). The aim of the study was to report the clinical features and outcome of consecutive ACS episodes in adult patients in a French SCD center. All patients were treated according to an uniform therapeutic protocol applying transfusion only in the more severe clinical form of ACS., Results: There were 107 consecutive episodes in 77 adult patients (mean age, 29 +/- 7 years; 78% hemoglobin [Hb] SS; 14% Hb SC; and 8% Hb Sbeta + thalassemia) over a 6-year period. Seventy-eight percent of our patients had an associated vaso-occlusive crisis that preceded the chest signs in half of the cases. Comparison between acute and baseline levels showed a statistically significant difference in Hb levels (drop of 1.6 to 2. 25 g/dL depending on Hb genotype), WBC count (increase of 9.2 +/- 8. 3 x 10(9)/L); platelet count (increase of 67 +/- 209 x 10(9)/L); and lactate dehydrogenase values (increase of 358 +/- 775 IU/L) in ACS patients. Hypercapnia was detected in 42% of patients without sign of narcotic abuse. We identified a high percentage of alveolar macrophages containing fat droplets in 31 of 43 (77%) patients who underwent BAL. Bacterial culture findings were almost always negative, but were performed after starting antibiotic therapy that was administered in 96 episodes. Transfusion was required in 50 of 107 ACS events (47%). Five patients died, and all were transfused., Conclusions: These results confirm that fat embolism is probably a frequent mechanism of ACS in adult patients. However, fat embolism was not associated with a more severe clinical course, suggesting that bronchoscopy and BAL have little impact on the management of these patients. Restricting transfusion to the most severe ACS cases does not seem to increase the mortality rate.

Objective: To investigate the incidence, severity, and origin of pulmonary fat embolism (PFE) in persons dying from blunt force trauma within 24 hours of injury., Methods: The study population consisted of blunt force fatalities. Controls were subjects dying from natural causes or nonblunt force injury. Tissue was removed from lung lobes and prepared for histologic examination using osmium tetroxide to stain for fat. Lung sections were graded for PFE on a scale of 0 (no emboli) to 4 (five or more emboli in a majority of fields)., Results: The blunt force group consisted of 56 decedents. Mortality was 93% within 4 hours. Fractures were present in 54 (96%) of decedents, and soft tissue injury was universal. Thirty eight (68%) of decedents were positive for PFE vs. 3 of 20 (15%) in controls. Mean score for PFE was 2.94 +/- 1.15 and 1.01 +/- 0.94, respectively (p < 0.005). Bone marrow emboli were not observed in any of the sections. Severity of PFE was positively associated with survival time. Analysis of PFE against sex, age, height, weight, number of injuries, and number of fractures showed no significant correlations., Conclusions: A significant degree of PFE develops rapidly in a majority of persons dying of blunt force trauma. Although the source of fat for embolization has been suggested to be bone marrow, no evidence of myeloid tissue was found in any of the lung sections. Nor was there a correlation of PFE and number of fractures. Soft tissue injury is considered the primary cause of PFE.

In 1993, pulmonary fat embolism occurred in 92 cases (17%) out of 527 clinical autopsies. It was found in 62% of patients who had suffered bone fractures, in 9% with soft tissue surgery and in 53% after resuscitation; non-traumatic fat embolism was present in 6% of the cases. The comparison group of 50 persons with lethal polytrauma revealed pulmonary fat embolism in 52% of the cases. Bone-marrow embolism and microthrombi accompanied fat embolism of the lungs; furthermore some of the persons with pulmonary fat embolism also expressed minor degrees of renal (55%) and cerebral (25%) fat emboli. A retrospective analysis of the clinical data revealed no specific symptoms: a so called fat embolism syndrome had not been discovered clinically in any of the cases with histologically proven fat embolism. The significance of pulmonary fat embolism as a cause of death with regard to histological and clinical findings is discussed.

Since it was initially described, fat embolism syndrome (FES) has remained one of the least clearly understood complications of trauma. This article is a review of the classic and current literature on FES with regard to its causes, pathophysiology, clinical presentation, diagnosis, and treatment. FES is associated with many traumatic and nontraumatic conditions, but is most commonly associated with fractures of long bones of the lower extremity. The pathophysiology is thought to be a cascade of events which can lead to adult respiratory distress syndrome (ARDS). Signs and symptoms of clinical FES usually begin within 24 to 48 hours after trauma. The classic triad involves pulmonary changes, cerebral dysfunction, and petechial rash. Clinical diagnosis is key because laboratory and roentgenographic diagnosis is not specific. Treatment consists of careful initial handling, early stabilization of fractures, careful volume replacement, analgesia, respiratory support, and perhaps steroids. The vast majority of patients today survive FES without sequelae.

Between 1978 and 1994, 130 deaths after hip fractures were investigated at the Institute of Forensic Medicine of the Free University of Berlin. In this period more than 3500 such cases occurred in Berlin. Eight persons were found dead at home, 17 had conservative treatment or died before the planned operation, and 105 had an operation. Hip replacement was carried out in 49, nailing in 17, and other kinds of osteosynthesis (especially using screws) were used in 39 cases. In the surgically treated group, death occurred during the operation in 6 cases (all hip replacements), on the day of operation or the first postoperative day in 7 cases, and within the first week in 21 cases. In the conservative group 10 cases died during the first week after trauma. The main, clearly detectable causes of death were pneumonia (30) and thromboembolism of the lungs (22). Fat embolism was responsible for death in at least 6 cases (3 intra- and 3 postoperative); in 2 additional intraoperative and 7 early postoperative deaths, a potentially lethal fat or bone marrow embolism occurred together with other deadly factors. A fat embolism was present in 9 cases within the first week, diminishing with survival time. Hip replacement was clearly dominant for the genesis of pulmonary fat embolism: in none of the early post-endoprosthetic deaths was there little or no fat embolism in contrast to the other types of operation. Bone marrow embolization can induce the formation of multiple small, red intravenous thrombi-possibly a factor explaining the lethal outcome in only a few cases with intraoperative fat embolism. This form of "thromboembolism" must be differentiated from typical lung thromboembolism, originating from a preceding venous thrombosis.

Fat embolism syndrome is a potentially serious and life threatening complication of long bone trauma, blunt trauma, and intramedullary manipulation. In long bone fractures, fat embolism is encountered in 0.9% to 2.2% of cases. During intramedullary manipulations, such as prosthetic stem insertion or reaming, the incidence is typically lower (range, 0.5% to 0.8%). Diagnosis is dependent upon the clinical recognition of dyspnea, petechiae, and cognitive dysfunction in the first several days following fracture, trauma, or intramedullary surgery. Treatment consists of pulmonary support and aggressive resuscitation. Studies support early fracture fixation, but the role of systemic steroids, heparin, and other modalities remains speculative.

We performed transoesophageal echocardiography on 24 patients during reamed intramedullary nailing of 17 tibial and seven femoral fractures. In 14 patients there was only minimal evidence of emboli passing through the heart, but in six copious showers of small emboli (< 10 mm maximum dimension) were observed. In four other patients, there were also multiple large emboli (> 10 mm maximum dimension). Three of these patients developed fat embolism syndrome postoperatively and one died. Earlier nailing was associated with smaller quantities of emboli.

Twenty cases of clinically patent fat embolism syndrome (FES) were observed at the authors' institution between 1964 and 1989. There were 4 deaths (20%). The injury severity score (ISS) was computed for each patient upon admission and ranged from 9 to 50 (median, 17). The ISS was significantly higher in the 4 deceased patients (P = .014). The incidence of FES amounted to 0.26% of all patients hospitalized with at-risk fractures (femoral and tibial shaft fractures and pelvic fractures). The findings of the 25-year study indicate the following: (1) clinically patent postfracture FES is rare; (2) FES is significantly more frequent in patients with several at-risk fractures than in those with one at-risk fracture (P < .0003); and (3) prognosis appears to be more directly related to ISS than to FES itself.

Fatal fat embolism is usually thought of as a sequel to long-bone fracture, although cases secondary to soft tissue injury and atraumatic conditions have been infrequently reported. In this case of a two-year-old child-abuse victim who sustained multiple blunt traumatic injuries without skeletal fractures, pulmonary and systemic (brain and kidney) fat emboli were identified. At autopsy, all thoracic and abdominal viscera were intact; cranial contents exhibited only diffuse symmetrical petechial hemorrhages of the white matter. Because of the severe and widespread nature of soft tissue hemorrhage, and the absence of a grossly discernible cause of death, fat embolism was suspected. Using a combination of frozen section with oil red O staining and formalin-fixed osmium stained tissues, the immediate cause of death was determined to be diffuse fat embolism. Review of the literature reveals a pathophysiologic basis for fat embolism in the absence of fracture, both as a consequence of an acute increase in local pressure at the site of trauma and an alteration of the emulsification of blood lipids during shock. In light of these findings, we present this case to remind the forensic science community to consider fat embolism as the cause of death in cases of blunt-force injury without fracture.

Despite continuing interest in fat embolism, the precise pathogenesis and the best treatment of the syndrome are still in doubt. To assess the effect of a high index of suspicion about the outcome of the syndrome, we have compared 37 patients seen from 1962 to 1968 with 16 patients seen from 1968 to 1974. The study of the original group of patients generated considerable interest in the diagnosis and management of the syndrome at our institution. The two groups are well matched for age, sex, and source of injury. The more recent group (1968-1974) seemed to have had more severe injuries as judged by number of fractures and need for blood transfusions. Despite this increase in severity of injury, the mortality rate for the period 1968-1974 was only 12.5% as opposed to 21% for the period 1962-1968. This improvement in mortality was achieved without resort to many of the popular pharmacologic regimens, including steroids and heparin. A high index of suspicion leading to an early diagnosis of respiratory dysfunction and aggressive supportive therapy has been responsible for the improved results.

Because antemortem diagnosis is difficult, renal failure due to cholesterol atheroembolism has, until recently, been regarded as a uniformly irreversible and generally fatal disease. Of late, recovery of renal function in several patients in whom the diagnosis was made by organ or other invasive biopsy has been reported. Three cases of cholesterol atheroembolic renal failure in which the diagnosis was made by simple, noninvasive biopsy of the skin in areas showing livedo reticularis are described. Two of the patients, including 1 who required dialysis for 2 months, had an extended survival with recovery of renal function.

Twenty-four patients suffering from fat embolism syndrome, severe enough to warrant transfer to an artificial ventilation unit, are reviewed. All developed the condition following trauma. Five patients were managed with oxygen therapy and sedation, but the other 19 needed intubation and ventilation to achieve adequate arterial oxygenation. In spite of intensive supportive therapy, 6 patients (who had all required ventilation) died, one due to heparin therapy, the others from progression of the syndrome. A poor prognosis seemed to be associated with young age, a rapidly progressive condition and a continued need for 100 per cent oxygen after institution of artificial ventilation. There seemed to be no relationship between outcome and severity of injury, type of surgical management and time of onset after injury. The clinical features of these patients are discussed with reference to the many unanswered questions that surround this condition.

The clinical course and radiographs of 30 patients with fat embolism syndrome were reviewed. In all cases the classic triad of neurologic dysfunction, respiratory insufficiency, and petechiae were present. Three responses to embolized fat were noted. The hyperacute response was seen in two patients with paradoxical embolization of fat to the systemic circulation. A "classic response" was noted in 18 patients with transient respiratory compromise and variable radiographic findings. The two deaths in the group responding in the classical manner were attributed to massive pulmonary emboli. The third response, noted in ten patients, consisted of a chest radiograph compatible with pulmonary edema in the clinical setting of the adult respiratory distress syndrome. In this group the degree of respiratory dysfunction and pulmonary damage correlated with the development of disseminated intravascular coagulation. Pathologic correlations are presented and the mechanisms by which embolic fat produces tissue damage are discussed.

Initial radiological appearances and changes occurring during the course of post-traumatic fat emboli in 27 patients are described. An alveolar filling syndrome usually appears after a free interval of 44 hours, and is followed by an interstitial syndrome on about the 12th day which usually regresses completely by the 20th day without sequelae. Five of the 27 patients died of either secondary infection or anoxia.