Pathophysiology of Fat Embolism after Intramedullary Reaming

Abstract

Primary operative stabilization by an intramedullary procedure is the treatment of first choice for fractures of long tubular bones for reasons of biomechanics, the minimally invasive approach, and the early loadability of the injured limb. Additionally, in the case of multiple injuries, the pulmonary situation can be improved so that both the duration of ventilation and the period spent in intensive care are reduced. However, a postoperative increase in the incidence of posttraumatic lung failure has been found following early intramedullary nailing and seen as being linked to the procedure. The increase in intramedullary pressure occurring on intramedullary nailing or reaming can result in release of bone marrow and fat into the venous blood system. The potentially lethal consequences may be adult respiratory distress syndrome (ARDS) and multiple organ failure. For these reasons, a method was sought to bring about a reduction in intramedullary pressure at primary nailing. These efforts led to further developments in implant and reamer design as well as in nailing techniques. However, a clear release of fat was still apparent under these conditions. This review gives an overview of pathophysiologic aspects of reamed intramedullary nailing and suggestions for the optimal reaming system. A new-designed rinsing-suction reamer is briefly presented.