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Fat embolism syndrome (FES) remains a diagnostic dilemma on a world scale. It has a variable degree of presentation, which makes the diagnostic confirmation hard to obtain. FES is a life-threatening condition which is usually associated with orthopedic trauma, particularly long bones fractures whose early fixation helps in preventing it. It requires supportive care, and no specific treatment is needed. Here, we report the case of a FES in a 20 year-old male patient with right femoral shaft fracture following a motorbike accident, which is diagnosed by Gurd’s criteria and confirmed after exclusion of other diagnosis with similar clinical presentation.

Intractable ascites is a rare condition in children mainly caused by cirrhosis or lymphatic disorders. Internal drainage may be considered as rescue therapy. In our department, 4 patients ages from 2 months to 15 years old underwent a peritoneovenous shunt (PVS) placement between 2010 and 2020. The surgically inserted device was a pumping device that enabled to drain ascites from the peritoneum into the venous system via the internal jugular vein (Denver shunt, BD Company, NJ). Immediate efficient drainage was achieved in all cases and lasted up to 9 years. Two major complications occurred: a postoperative fat embolism requiring urgent temporary ligation of the shunt and endocarditis shortly after inguinal hernia repair performed 16 months after placement of the shunt. Implementation of a PVS may be a useful procedure in patients with refractory ascites. Chylous ascites should be drained and washed totally before activating the device to avoid fat embolism. Antibiotic prophylaxis is required when abdominal surgery is planned while the device is in place.

Background Fat embolism syndrome (FES) is a rare syndrome resulting from a fat embolism, which is defined by the presence of fat globules in the pulmonary microcirculation; it is associated with a wide range of symptoms. Research Question What are the specific unknown risk factors for FES after we have controlled for basic characteristics and patient’s severity? Study Design and Methods This was a nested case-control study that used the Japan Trauma Data Bank database from 2004 and 2017. We included patients with FES and identified patients without FES as control subjects using a propensity score matching. The primary outcome was the presence of FES during a hospital stay. Results There were 209 (0.1%) patients with FES after trauma; they were compared with 2,090 matched patients from 168,835 candidates for this study. Patients with FES had long bone and open fractures in their extremities more frequently than those without FES. Regarding treatments, patients with FES received bone reduction and fixation more than those without FES. Among patients who received bone reduction and fixation, time to operation was not different between the groups (P = .63). The overall in-hospital mortality rate was 5.8% in patients with FES and 3.4% in those without FES (P = .11). Conditional logistic regression models to identify risk factors associated with FES shows long bone and open fractures in extremities injury were associated with FES. Primary bone reduction and fixation was not associated independently with FES (OR, 1.80; 95% CI, 0.92-3.54), but delay time to the operation was associated with FES (OR, 2.21; 95% CI, 1.16-4.23). Interpretation Long bone and open fractures in injuries to the extremities were associated with FES. Although bone reduction and fixation were not associated with FES, delay time to the operation was associated with FES.

Nonthrombotic pulmonary embolism is an uncommon life-threatening complication following liposuction. We report a rare incidental autopsy finding associated with this procedure. A 43-year-old female who underwent liposuction presented with hypotension, respiratory distress, loss of consciousness and cardiorespiratory arrest during the intraoperative period. The patient died 2 h after admission to the emergency department. Autopsy reported a massive hemoperitoneum (2.2 L) secondary to liver perforation associated with liposuction as the cause of death. Pelvic, umbilical and lumbar peritoneal perforations were also observed. The histological study showed segments of the pulmonary arteries occluded by mixed emboli of skeletal muscle fibers coexisting with fatty tissue. We discuss the origin, pathophysiology and clinical manifestations of this new kind of mixed pulmonary embolism.

Introduction. Severe trauma is one of the leading causes of disability and mortality in all age groups. Long bone fractures of lower extremities, in particular the femur, have increased risk of complications. The choice of surgical treatment tactic, timing and methods of fixing of long bone fractures of lower extremities in patients with severe associated trauma is relevant and controversial issue.Objective: to conduct a retrospective analysis of injury structure in polytrauma center and evaluate treatment outcomes in polytrauma patients with multiple long bone fractures of lower extremities, frequency of complications and mortality.Materials and methods: the retrospective study was conducted, included a group of patients had applied to the admission department of Kyiv City Clinical Hospital No17 during the period from January 2010 to December 2019.Results: the study included 54,613 patients at the first stage. 69.3% of patients were received outpatient care, 30.7% were hospitalized. Among all patients, 13.7% were diagnosed with polytrauma, of which 80.2% had chest injury, 78.4% had traumatic brain injury, and 71.1% had musculoskeletal injuries. In the structure of musculoskeletal system trauma the multiple bone fractures of lower extremities were in 16.7% of patients, among them long bone fractures were in 57.6%.The study included 220 patients at the second stage. The incidence of pulmonary embolism occurred in 4.1% of patients, fat embolism – 12.7%, nosocomial pneumonia was diagnosed in 38.2% of patients, acute respiratory distress syndrome (ARDS) – 16.8%. The incidence of sepsis, according to the criteria of definition «Sepsis II» was 30.9%, according to the criteria «Sepsis III» – 9.5%, multiple organ failure (MOF) – 18.6%.The duration of mechanical ventilation was 19.1±10.8 days. The length of stay in intensive care unit was 24.8±12.6 days and the hospital length of stay was 48.9±22.4 days. The mortality rate was 22.3%. Among the main causes of death – hemorrhagic shock (46.9%), MOF (34.7%), refractory septic shock 18.4%.Conclusions: the frequency of polytrauma was 13.7% in trauma structure and frequency of polytrauma with combined multiple long bone fractures of lower extremities – 0.5%. Most common localizations of injuries were chest trauma (78.6%), traumatic brain injury (73.6%), injuries of musculoskeletal system (71.1%). Multiple bone fractures of lower extremities were in 16.7% of patients in the structure of musculoskeletal system trauma, among them fractures of long bones were in 57.6% of patients.Ultrasound examination according to the protocol «Focused Assessment with Sonography for Trauma» (FAST) and whole body computed tomography were not performed after patient hospitalization in 100% of cases, as required by international protocols. The frequency of Early Total Care tactics application – 1.4% that was too low, the definitive osteosynthesis in some cases was performed unreasonably late, and 17.2% of primary and definitive cases and 23.9% of temporary stabilization of fractures were performed by conservative methods.The most common complications were pulmonary: nosocomial pneumonia, ARDS and fat embolism syndrome, and also sepsis and MOF.

Fat emboli are a common phenomenon, but are rarely detected or reported on extremity CT imaging. We present a case of fat embolus in the popliteal vein in the setting of a femoral fracture. This is the most distal fat embolus described in the literature. There are no guidelines regarding intervention if a fat embolus is detected in a peripheral vein on CT. A review of all the previous cases of peripheral fat emboli is presented for reference.

Cerebral fat embolism (CFE) causes the neurological involvement observed in fat embolism syndrome, which is a post-traumatic complication seen mostly after long bone fractures and usually presents 24-72 h after the injury. An early 80s female who sustained an isolated traumatic fracture of the left distal femur without dislocation was alert on admission but fell into a coma 55 min after the injury. Brain computed tomography showed no abnormalities. Brain magnetic resonance imaging was performed approximately 5 h after the accident, and diffusion-weighted images revealed hyperintense, dot-like lesions disseminated in a "starfield" pattern in the brain. The patient was diagnosed with CFE and admitted to the intensive care unit. The day after the injury, the patient developed petechiae on the palpebral conjunctiva and was still comatose 4 months after the trauma. The current patient developing CFE in less than 1 h after a traumatic injury illustrates that CFE should be considered in patients with sudden deterioration of consciousness within 1 h after long bone fractures.

The aim of the study was to evaluate the effect of infusion therapy on postoperative fat globulemia and cognitive dysfunction in patients after hip replacement. Material and methods . In group I, patients received perioperative therapy with 0.9% NaCl solution, and in group II, during the operation — Sterofundin iso and a modified gelatin preparation Gelofuzin, and after the operation — Remaxol. Results . In group II, the number of embolus globules 2 hours after surgery was lower by 51.4%, followed by a faster decrease compared to group I. 3 days after the operation, the MMSE score in group II was higher than in the domains responsible for memory and speech. On day 15, the number of patients without cognitive dysfunction was almost 2 times higher. On day 30, there were no patients with severe cognitive impairment (20–23 points), in group II they were 11.3%. Discussion . The emulsifying effect of the drugs led to a decrease in embolic cerebral damage by fat globules that exceed the size of the shaped blood elements. This may be due to sorption of free fatty acids by modified gelatin and recovery of their utilization. Conclusions . А correlation was found between the appearance of large fat globules in the bloodstream and the development of cognitive dysfunction. Application Gelofuzin, Sterofundin iso and Remaxol reduces the severity of fat globules and cognitive dysfunction.

The patient was an 88-year-old woman with a 10-year history of hypertension. She was suspected to have been hit by a car. At the time of the event, she was conscious and able to stand on her own and had no obvious injuries. She was sent home, but she lapsed into unconsciousness and was nonresponsive after 2 hours. She was sent to the hospital, and her heartbeat and breathing stopped. After half an hour of rescue attempts, her heartbeat did not recover, and she was declared dead. During the autopsy, a small subcutaneous hemorrhage was observed below the right knee joint. No obvious internal organ injuries or bone fractures were observed. The deceased also had mild atherosclerosis in the coronary arteries and an old cerebral infarction in the right cerebellum. The tissue histopathological tests showed distinct fat embolism in multiple organs, including the brain, lungs, kidneys, liver, and pancreas. A postmortem blood biochemistry test of the heart blood showed that the levels of low-density lipoprotein, cholesterol, triglycerides, and free fatty acids in the blood were increased, and the level of C-reactive protein was elevated. According to the autopsy results, the direct cause of death was multiorgan fat embolism. This case suggests that aging, hypertension, and hyperlipidemia may be risk factors for nontraumatic fat embolism under stressful conditions.

OBJECTIVE: Patient-specific templates promises to be able to increase alignment while decreasing operative time, increasing patient throughput, decreasing instrumentation, reducing risk of fat embolism and intraoperative bleeding, decreasing tissue loss, shortening recovery, reducing post-operative pain and decreasing incidence of infection. However, multiple studies have shown conflicting results regarding these potential benefits. This study serves to critically evaluate the potential advantages and disadvantages of using a patient-specific templating technique through a single-surgeon study. METHODS: All patients who underwent primary total knee arthroplasty (TKA) for osteoarthritis of the knee using TruMatch® Personal Solutions total knee replacement by a single surgeon were identified. An age-, gender-, side-, diagnosis- and surgeon-matched cohort who underwent conventional primary TKAs was randomly identified for comparison. RESULTS: The average distal medial femur (p

A embolia cerebral gordurosa é uma patologia decorrente da liberação de glóbulos de gordura na circulação sanguínea provenientes, principalmente, de fraturas de ossos longos. A presença de êmbolos significativos de gordura no sangue resulta oclusão vascular e manifestações clínicas dependentes da localização da obstrução. O caso relatado apresenta um paciente jovem, vítima de acidente automobilístico com fratura de acetábulo e diáfise femoral direita, que evoluiu com rebaixamento do sensório. Diante do quadro clínico, foi solicitada ressonância magnética, que apresentou resultado compatível com o diagnóstico de embolia cerebral gordurosa. Realizado os devidos cuidados para tratamento da embolia, o paciente apresentou prognóstico favorável.

BackgroundVisceral obesity is a critical determinant of severe coronavirus disease-2019 (COVID-19). Methods: In this study, we performed a comprehensive histomorphologic analysis of autoptic visceral adipose tissues (VAT), lungs and livers of 19 COVID-19 and 23 non-COVID-19 subjects.ResultsAlthough there were no between-groups differences in body-mass-index and adipocytes size, higher prevalence of CD68+ macrophages in COVID-19 subjects’ VAT was detected (p=0.005) and accompanied by crown-like structures presence, signs of adipocytes stress and death. Consistently, human adipocytes were successfully infected by SARS-CoV2 in vitro and displayed lower cell viability. Being VAT inflammation associated with lipids spill-over from dead adipocytes, we studied lipids distribution employing Oil-Red-O staining (ORO). Lipids were observed within lungs and livers interstitial spaces, macrophages, endothelial cells, and vessels’ lumen, features suggestive of fat embolism syndrome, more prevalent among COVID-19 individuals (pConclusionsThis study describes for the first time novel COVID-19-related features possibly underlying the unfavorable prognosis in obese SARS-CoV2-infected-subjects.

Fat embolism in the subarachnoid space has a unique pathophysiology and clinical picture when compared to fat embolism syndrome. Lipid deposits in the subarachnoid space—most commonly the sequela of dermoid rupture in the neuraxis—can cause an inflammatory reaction leading to irritation of nearby neurovascular structures. Herein, we report the only case in the United States, to our knowledge, of a patient diagnosed with subarachnoid fat emboli secondary to sacral fracture who initially presented with a normal head CT and subsequently developed visual changes.

BACKGROUND: A potential complication of extensive injuries is an episode of fat embolism, also referred to as fat embolism syndrome. The main causes of fat embolism include long bone and pelvic fractures. Symptoms of fat embolism may also develop after elective orthopedic surgery, removal of subcutaneous fat tissue, multiple rib fractures, acute pancreatitis, or parenteral nutrition with fat-containing products.Most of the possible clinical signs are non-specific. The triad of clinical signs including gas exchange disorders in the lungs, central nervous system disorders, and bloody petechiae on the skin makes fat embolism syndrome diagnosis much easier. However, the final diagnosis is based on meeting one large criterion, four small criteria, and one laboratory criterion in accordance with Gurd’s assumptions. METHODS : Manuscript description a case of 44-year-old woman with a multiple injury following a traffic accident. Computed tomography revealed a extensive head injury, numerous fractures of ribs, transverse processes of thoracic vertebrae and right scapula. As a result of the injuries developed full-blown fat embolism syndrome. CONCLUSIONS: This case highlights the importance of appropriate knowledge of the pathomechanism and clinical presentation of fat embolism syndrome and interdisciplinary therapeutic team approach. A quick correct diagnosis is crucial to improve treatment results. Access to laboratory and imaging tests considerably facilitates the diagnostic process, which should be followed by optimal therapeutic management. The lack of a golden standard of treatment necessitates a flexible and interdisciplinary therapeutic approach.

Background There are few studies in the literature that correlates the level of IL-6 with fat embolism syndrome (FES). But there is no conclusive correlative evidence of its specific relation to the establishment of FES. Also it is a proven fact that polytrauma due to its associated multiple long bone fracture and/or associated shock can predispose an individual to FES. By hypothesizing that polytrauma induces Fat Embolism in the animal; it was considered worthwhile to study the association of IL-6 in polytrauma induced Fat Embolism (FE) and to compare it with induced FE by injecting fatty acids in rabbits. Materials and methods An animal study was conducted in 32 New Zealand white rabbits. The animals were divided into 3 groups: control, fat embolism and polytrauma group. We injected 6 ml of normal saline and 0.2 ml of linoleic acid in the control and fat embolism group respectively. In the polytauma group we created bilateral femur and tibial shaft factures which were stabilized with intramedullary K- wires. Blood was taken before and at 6, 12 and 24 h after the procedure to measure plasma IL-6 levels. The rabbits were euthanized at 24 h and lungs were removed and stained for fat globules. Results All rabbits in the fat embolism group and around 72.22% rabbits in polytrauma group had fat embolism. The IL-6 levels were raised in all the groups reaching a peak at 6 h after procedure with a decline in the values at 12 h for polytrauma and fat embolism group. IL-6 in the control group was stationary after an initial raise at 6 h. There was no statistically significant difference seen among the groups (p value > 0.05) at 6 h. Conclusion IL-6 is not a specific marker to fat embolism per se or polytrauma who later develop complications like FES. Even though the recent literature says that IL-6 is an early marker of fat embolism, still the diagnosis of fat embolism syndrome is clinical only and can be supplemented by laboratory markers. None of the laboratory markers individually is good enough to predict the development of FES in an individual.

Background And Objectives: Floating knee, referred to as ipsilateral fractures of the femur and tibia, is a condition resulting from high energy trauma usually associated with minor to life threatening associated injuries. The type of fractures, soft tissue and associated injuries make this a challenging problem in terms of management. This study analyses the prognostic factors, plan of management and functional outcomes of the complex injury. Methods: A prospective with forty patients of floating knee injuries treated over a period of 18 months are included. After management of life threatening injuries and stabilisation of general condition, floating knee injury were classified according to Fraser`s classification and were surgically fixed using different modalities and followed up for mean duration of 10 months. The outcome was assessed using Karlstrom criteria following union. Results: The mechanism of injury was road traffic accident in 36/40 patients. There were 9 associated injuries. 15/40 patients had intramedullary nailing for both fractures. The immediate complication was hypotension, early being fat embolism and late complications were knee pain and stiffness mainly ,with infection ,delayed union and non-union in open fractures . The mean bony union time was 20 weeks According to the Karlstrom criteria the end results were Excellent – 21, Good – 14, Acceptable – 3 and Poor – 2. Conclusion: The associated injuries and the type of fracture (open, intraarticular, comminution) are prognostic indicators in the Floating knee. Appropriate management of the associated injuries, intramedullary nailing of both the fractures and post-operative rehabilitation are necessary for good final outcome Keywords: Floating knee, Intramedullary nailing,karlstrom criteria

An anastomotic leak is the most dreaded complication after low anterior resection. Adipose tissue grafting may induce healing in a persistent anastomotic defect. The aim of the present study was to report retrospectively reviewed outcomes for a series of patients who were managed with heterotopic grafted adipose tissue to facilitate anastomotic healing. Patients with anastomotic leakage after low anterior resection sequentially treated with grafting of adipose tissue were included in the study. All patients had pelvic radiation during treatment and had a diverting ileostomy in situ. The cohort had a persistent defect despite being treated with available modalities such as suture repair, fibrin glue, Endo-Sponge and surgical debridement. The outcomes were reviewed and reported. There were 11 patients (8 males and 3 females) with a median age of 54 years (range 33–72 years). Five patients experienced complete healing of the anastomotic defect with successful reversal of the diverting ileostomy. The anastomotic defect of one other patient in the series appeared to have healed and hence his diverting ileostomy was reversed. However, he presented with a recurrent leak, which ultimately necessitated an abdominoperineal resection. Another patient had a persistent defect after an attempt at adipose tissue grafting and opted to proceed with a takedown of the anastomosis. In the remaining four patients, the outcome after adipose tissue grafting remains unknown, as two patients succumbed to metastatic disease, one was lost to follow-up and the remaining patient developed a recurrence which required pelvic exenteration. Procedural associated morbidity occurred in one patient who developed fat embolism, which was treated expectantly. Adipose tissue grafting is safe and feasible, though its effectiveness remains uncertain. It may be useful selectively in the management of persistent anastomotic leak after radiation and low anterior resection.

To elucidate postmortem computed tomography (PMCT) and postmortem magnetic resonance (PMMR) imaging findings suggesting massive fat embolism. Consecutive forensic cases with PMCT and PMMR scans of subjects prior to autopsy were assessed. For PMCT, 16- or 64-row multidetector CT scans were used; for PMMR, a 1.5 T system was used. MRI sequences of the chest area included T2- and T1-weighted fast spin-echo imaging, T2*-weighted imaging, T1-weighted 3-dimensional gradient-echo imaging with or without a fat-suppression pulse, short tau inversion recovery, and in-phase/opposed-phase imaging. At autopsy, forensic pathologists checked for pulmonary fat embolism with fat staining; Falzi’s grading system was used for classification. Of 31 subjects, four were excluded because fat staining for histopathological examination of the lung tissue could not be performed. In three of the remaining 27 subjects, histology revealed massive fat embolism (Falzi grade III) and the cause of death was considered to be associated with fat embolism. CT detected a “fat-fluid level” in the right heart or intraluminal fat in the pulmonary arterial branches in two subjects. MRI detected these findings more clearly in both subjects. In one subject, CT and MRI were both negative. There were no positive findings in the 24 subjects that were fat embolism–negative by histology. In some subjects, a massive fat embolism can be suggested by postmortem imaging with a “fat-fluid level” in the right heart or intraluminal fat in the pulmonary arterial branches. PMMR potentially suggests fat embolism more clearly than PMCT.

We report here a case of bone marrow necrosis and fat embolism syndrome in a 23-year-old sickle-cell disease (HbSS) patient. A brutal and severe bicytopenia conducted to suspect bone marrow necrosis, confirmed by bone marrow aspiration and analysis. This was the first life-threatening medical event for this patient. In the present case, a complex alloimmunization against blood group antigens complicated the treatment because of the risks associated with the transfusion strategy. These rare complications of sickle-cell disease may be fatal, but an efficient symptomatic treatment generally allows for recovery. Medical biologists should be aware of the danger of bone marrow necrosis in sickle-cell disease, so that they can help clinicians and accurately diagnose this serious complication.

Purpose: Fat embolism syndrome (FES) is systemic manifestation of fat emboli in the circulation seen mostly after long bone fractures. FES is considered a lethal complication of trauma. There are various case reports and series describing FES. Here we describe the clinical characteristics, management in ICU and outcome of these patients in level I trauma center in a span of 6 months. Methods: In this prospective study, analysis of all the patients with FES admitted in our polytrauma intensive care unit (ICU) of level I trauma center over a period of 6 months (from August 2017 to January 2018) was done. Demographic data, clinical features, management in ICU and outcome were analyzed. Results: We admitted 10 cases of FES. The mean age of patients was 31.2 years. The mean duration from time of injury to onset of symptoms was 56 h. All patients presented with hypoxemia and petechiae but central nervous system symptoms were present in 70% of patients. The mean duration of mechanical ventilation was 11.7 days and the mean length of ICU stay was 14.7 days. There was excellent recovery among patients with no neurological deficit. Conclusion: FES is considered a lethal complication of trauma but timely management can result in favorable outcome. FES can occur even after fixation of the fracture. Hypoxia is the most common and earliest feature of FES followed by CNS manifestations. Any patient presenting with such symptoms should raise the suspicion of FES and mandate early ICU referral. Key words: Fat embolism; Trauma centers; Intensive care units; Patient outcome assessment

Liposuction is a well-tolerated and safe procedure performed by plastic surgeons. Rare, major complications include infection, perforation of abdominal wall/viscus, and fat emboli. Fat emboli, seen more often after long bone fractures, are rarely associated with liposuction. We report the only known case of myocardial infarction (MI) secondary to fat embolism in the setting of post-procedural liposuction. A review of the literature was undertaken to elucidate the pathophysiology of liposuction-associated fat embolism, identify patient and procedural risk factors, discuss diagnostic criterion, and identify management of this rare but potentially fatal complication. Level of Evidence: V Type of study: Risk study

Lipomodelling has been increasingly used recently for the correction of defects and asymmetry following oncologic breast cancer treatment [1]. Current evidence on the efficacy of breast reconstruction using lipomodelling after breast cancer treatment is inadequate and the evidence raises no major safety concerns [2]. We have audited our outcome results against the NICE guidelines criteria for both safety and efficacy. Data was collected retrospectively of all the lipomodelling cases performed in Northumbria Healthcare NHS Foundation Trust between 04/2011-04/2013. A total of 36 patients were included in the study, the average amount of fat injected was 113.91mls per session, Cytori technique gave the least complications rate 11% vs Coleman and body jet techniques 44% and 45% respectively. We met the NICE guidelines criteria in; number of sessions for each patient, the duration of hospital stay and we documented the amount of fat harvested and injected in each patient. We didn’t fulfil the guidelines in: volume change; as no definite tool was used other than clinical assessment; 80% were very good and good aesthetic outcome compared to NICE’s 87%, while aesthetic outcome was absent in 8% compared to NICE’s 2.7%. Regarding the safety, we met the NICE’s guidelines in local recurrence rates

Recent studies have demonstrated that the administration of regional prophylactic antibiotics by intraosseous (IO) injection achieves tissue concentrations around the knee that are 10- to 15-fold higher than intravenous (IV) delivery of prophylactic antibiotics. It is currently unknown whether the use of regional prophylactic antibiotics for primary TKA would result in a lower risk of prosthetic joint infection (PJI).(1) Is IO injection of prophylactic antibiotics associated with a decreased risk of early (12 months) deep PJI compared with traditional IV prophylactic antibiotics? (2) What other patient factors are associated with an increased risk of early PJI after TKA, and do regional prophylactic antibiotics influence these risk factors? (3) Can IO antibiotics be administered to all patients, and what complications occurred from the delivery of IO prophylactic antibiotics?A retrospective comparative study of all primary TKAs (1909 TKAs) over a 5-year period (January 2013 to December 2017) was performed to determine the risk of early PJI. Three primary TKAs did not meet the study inclusion criteria and were excluded from the study, leaving a total of 1906 TKAs (725 IO, 1181 IV) for analysis at a minimum of 12 months after index procedure. Both cohorts exhibited similar ages, BMI, and American Society of Anesthesiologists (ASA) grades; however, a greater proportion of patients in the IO cohort were smokers (p = 0.01), while a greater proportion of patients were diabetic in the IV cohort (p = 0.006). The PJI risk between IO and IV delivery techniques was compared while adjusting for patient demographics and medical comorbidities. Complications related to IO delivery-inability to administer via IO technique, compartment syndrome, fat embolism, and red man syndrome with vancomycin use-were recorded.The delivery of regional prophylactic antibiotics by the IO technique resulted in a lower PJI risk than IV prophylactic antibiotics (0.1% [1 of 725] compared with 1.4% [16 of 1181]; relative risk 0.10 [95% CI 0.01 to 0.77]; p = 0.03). BMI (β = -0.17; standard error = 0.08; p = 0.02), diabetes (β = -1.80; standard error = 0.75; p = 0.02), and renal failure (β = -2.37; standard error = 0.84; p = 0.01) were factors associated with of PJI, while smoking, sex, and ASA score were not contributing factors (p0.05). Although BMI, diabetes, and renal failure were identified as infection risk factors, the use of IO antibiotics in these patients did not result in a lower PJI risk compared with IV antibiotics (p0.05). IO antibiotics were able to be successfully administered to all patients in this cohort, and there were no complications related to the delivery of IO antibiotics.Surgeons should consider administering regional prophylactic antibiotics in primary TKA to reduce the risk of early PJI. Future randomized prospective clinical trials are needed to validate the efficacy of regional prophylactic antibiotics in reducing the PJI risk in primary TKA.Level III, therapeutic study.

Case Here, we present the case of a pediatric polytrauma patient found to have lower extremity intra-arterial fat embolism causing ischemic necrosis and ultimately necessitating below-the-knee amputation. Conclusion Fat embolism, a common complication of long bone fractures in adults, can be associated with significant morbidity. Although rare, it should be considered among the possible etiologies for a pulseless limb after trauma. Early fracture stabilization may prevent fat embolism and fat embolism syndrome; however, there is no known definitive treatment, and management is supportive.

Autologous fat grafting for buttock augmentation is one of the fastest growing plastic surgery procedures, but has also received significant publicity for the relatively high mortality rate secondary to fat emboli. The literature has grown exponentially in the past 5 years on this subject, helping to clarify our knowledge and providing recommendations to minimize risks, including avoiding intramuscular injections, placing the patient in the jackknife position, and utilizing larger-bore cannulas. Since the application of these recommendations, the rate of pulmonary fat embolism has decreased from 0.097% to 0.04%, with a current mortality of 1 in 14,921, making it statistically safer than abdominoplasty. Despite the evolution in our knowledge, techniques, and outcomes, it remains of utmost importance to properly select and educate patients about the safety of fat grafting for buttock augmentation. Level of Evidence: 4

Background Facial rejuvenation and reconstruction with autologous fat injection are a common and effective procedure used worldwide. Most surgeons and patients are satisfied with the favorable outcomes. However, catastrophic complications from arterial and venous occlusion resulting in visual loss and stroke may occur. Case presentation We herein report a case of isolated venous occlusion from fat embolism. The patient developed acute painful proptosis and blurred vision of her right eye while undergoing an esthetic autologous fat injection into her forehead. Based on her clinical manifestations and radiologic findings, the patient was diagnosed with superior ophthalmic vein occlusion. Symptomatic and supportive treatments were given. Spontaneous clinical improvement occurred without secondary complications. Therefore, the initially planned endovascular therapy with transfemoral transvenous embolectomy of the right superior ophthalmic vein was canceled. Conclusions Facial augmentation with autologous fat injection can cause superior ophthalmic vein embolism. Surgeons should therefore perform this procedure very cautiously. Prompt ophthalmological evaluation and proper management are important for improving clinical outcomes. Level of Evidence V This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Cerebral fat embolism following facial autologous fat injection is a rare and serious complication. There are limited long-term follow-up data on the motion, cognitive and mental outcomes of surviving patients with cerebral fat embolism following facial autologous fat injection. In this study, the authors reported a patient with a 22-year-old woman with a massive right hemisphere infarction following facial autologous fat injection had normal cognitive function, independent living ability, and social function at 5 years follow-up visit, even though computed tomography showed her entire right cerebral hemisphere had atrophied with softening lesions.

In this chapter, we analyze the causes of the increase in complications related to gluteal fat augmentation and identify the risk factors related to fatal outcomes. We also make recommendations in order to prevent those complications decreasing the morbidity and the mortality of the procedure.

With the increase in the demand for gluteal augmentation, there has been an evolution of the different surgical techniques. Fat grafting has shown to be the most popular procedure for gluteal augmentation, without the use of alloplastic material, with faster recovery and relatively low overall complication rates, 7.2% compared to 21.6% when gluteal implants are used. In this chapter, we will discuss the minor and major complications that can occur with gluteal fat augmentation.

Even though many patients complaining of fever in emergency department (ED) have infection as an underlying disease, fever in some other patients is caused by non-infectious causes. Non-infectious conditions eliciting fever and related pulmonary abnormalities and becoming the cause of ED visit can be identified in two different conditions besides infection and they are connective tissue disease (CTD) and malignant condition such as leukemia and related condition capillary leak syndrome and lymphoma. Other conditions that cause pulmonary emergency without infection include drug-related pneumonitis (DRP), radiation pneumonitis, cardiogenic or renal and neurogenic pulmonary edema (PE), diffuse alveolar hemorrhage (DAH), adult respiratory distress syndrome (ARDS) and acute interstitial pneumonia (AIP), fat embolism, acute eosinophilic pneumonia (AEP), organizing pneumonia (OP) and acute fibrinous organizing pneumonia (AFOP). Diffuse alveolar damage pattern with diffuse or wide patchy areas of parenchymal opacity is the key feature and is seen in most diseases. Pattern approach is most important in differential diagnosis.

Background Current literature clearly outlines the complication rates of liposuction in general; however, data specific to large-volume liposuction (LVL) remain unclear. Objectives The authors aimed to synthesize the current evidence on the safety of LVL with this systematic review. Methods A comprehensive search in the MEDLINE, EMBASE, and CENTRAL databases was conducted for primary clinical studies reporting on safety or complications related to aesthetic LVL from 1946 to March 2020. The primary outcome measure was the incidence of surgical complication, and the secondary outcome measure was changes in metabolic profile. Meta-analyses were conducted to pool the estimated surgical complication incidence and metabolic changes. Results Twenty-three articles involving 3583 patients were included. The average aspirate volume was 7734.90 mL (95% CI = 5727.34 to 9742.45 mL). The pooled overall incidence of major surgical complications was 3.35% (95% CI = 1.07% to 6.84%). The most common major complication was blood loss requiring transfusion (2.89% [95% CI = 0.84% to 6.12%]) followed by pulmonary embolism (0.18% [95% CI = 0.06% to 0.33%]), hematoma (0.16% [95% CI = 0.05% to 0.32%]), necrotizing fasciitis (0.13% [95% CI = 0.04% to 0.29%]), and deep vein thrombosis (0.12% [95% CI = 0.03% to 0.27%]). No fat embolism or death was reported in the included studies. The pooled overall incidence of minor surgical complication was 11.62% (95% CI = 6.36% to 18.21%), with seroma being the most common minor complication (5.51% [95% CI = 2.69% to 9.27%]). Reductions in lipid profile, glucose profile, body weight, and hematocrit level were observed after LVL. Conclusions The authors meta-analyzed and highlighted the complication rates specifically related to LVL in this study; however, the current data are limited by the lack of level 1 evidence. Level of Evidence: 4

Cerebral fat embolism (CFE) syndrome is relatively rare in clinical practice. Currently, there is no uniform standard of magnetic resonance imaging for the diagnosis of the disease. In this report, we present head computed tomography and magnetic resonance images (T2-weighted images, fluid-attenuated inversion recovery images, diffusion-weighted images, and susceptibility-weighted images) in a case of CFE. This report explains the imaging characteristics of CFE and improves the clinician’s understanding of this disease and its etiology.

Complications of fat grafting by means of injection may lead to unwanted passage of substrate into vessel lumens resulting in catastrophic complications. Likewise, a similar trend of complications is observed with non-autologous fillers regardless of an almost generalized use of blunt cannulas, the latter being implicated in the majority of serious vascular complications of hyaluronic acid injection. This report is the product of investigation to review all cases that underwent an original technique of fat injection: “The smart fat injection” during the cannula’s brisk withdrawal technique. The aim of this research was to document the safety of this technique by searching if fat embolism had occurred and if yes, its incidence in this group of fat injection surgeries. This retrospective review included 3039 patients who underwent the smart fat injection at the facial or corporeal level between 2001 and 2019. The study focused on the search for complications linked to fat yet also cruorical embolism, as the latter may resemble the clinical symptoms of fat embolism. The assessment of the 3039 patients who underwent the smart fat injection during cannula’s brisk withdrawal, resulted in none presenting clinically detectable fat or a cruorical embolism. This report documents the safety of the smart fat injection developed over a period of 22 years. It further explains the rationale of the technique for avoiding fat embolism while simultaneously enhancing fat take. This technique should not be implemented without appropriate in vitro training. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine Ratings, please refer to Table of Contents or online Instructions to Authors www.springer.com/00266 .

Rationale: Polydimethylsiloxane, commonly referred as silicone, is an inert liquid compound used in esthetic procedures due to its durability and thermal stability, yet the application of non-pure silicone generates risks. One of the complications is systemic embolism syndrome which is presents with fever, hypoxemia, and progression to respiratory failure, diffuse alveolar damage and alveolar hemorrhage, as well as neurological alterations in one-third of the cases. Management is strictly supportive. We present the case of acute pneumonitis with alveolar hemorrhage after silicone injection. Patient concerns: 25-year-old transsexual man, who consulted 48 hours after liquid silicone injection in the buttocks and trochanteric area, with progressive dyspnea and chest tightness, with rapid progression to respiratory failure. Diagnosis: Clinical diagnosis of silicone embolism was made. Chest x-ray and CT angiography showed diffuse alveolar infiltrates and pleural effusion without evidence of acute venous thromboembolism. Bronchoscopy plus bronchoalveolar lavage showed hemorrhagic fluid, 60% macrophages with hemosiderin in cytology and negative cultures. Intervention: Sedation, relaxation, pronation, and protective ventilation were implemented until hemodynamic stabilization; as well as IV steroids and antibiotics. Outcomes: Clinical progress was slow towards improvement with resolution of radiological or physical abnormalities. Despite severity, the patient improved satisfactorily without late sequelae. Lessons: Silicone injection can trigger phenomena similar to that seen in fat embolism causing inflammation and immune response activation that lead to alveolar hemorrhage, diffuse alveolar damage, and acute respiratory distress syndrome. We reported pulmonary complications related to the illegal use of injected silicone for esthetic procedures.

Rationale: Fat embolism syndrome with cerebral fat embolism, rarely observed at our neurology department, is often associated with long bone fractures. Its diagnosis is based on medical history and supportive imaging data and is usually not difficult. However, its pathogenesis remains poorly understood. Patient concerns: A 46-year-old woman was urgently presented to a nearby hospital because of a femur fracture caused by an accident. She rapidly developed somnolence and was suspected to have fat embolism syndrome. Diagnoses: Due to patients history of trauma and supportive imaging data, she was diagnosed with fat embolism syndrome obviously. However, severe brain damage confused our understanding of the pathogenesis. The subsequent diagnosis of fat embolism syndrome with patent foramen ovale provided a reasonable explanation. Interventions: Initially, we did not consider the fact that the patient had developed fat embolism syndrome and thus designed a comprehensive treatment program for fat embolism syndrome. Then the routine cardiac and vascular ultrasound screening were followed up, but patent foramen ovale was diagnosed unexpectedly, which led to a more aggressive treatment of brain injury. Outcomes: After relevant symptomatic treatment continued for nearly 3 months, an overall improvement was observed. Patients consciousness was restored but language disorders were left. Lessons: Clinicians should consider patent foramen ovale as the embolization pathway, particularly in young and middle-aged patients with cerebral embolism because it is often mistaken for a rare situation.

In recent years, gluteal fat augmentation has exhibited some of the most significant growth among all plastic surgery procedures. However, as the popularity of and media attention to gluteal fat augmentation continue to rise, reports of fatalities, largely attributed to fat embolism, have raised valid concerns. Many plastic surgeons inject fat in the intramuscular plane and claim better graft take in the muscles and the possibility of injecting more volume in the gluteal region. Because of the large caliber of vessels, subcutaneous fat augmentation has been a preference of many. However, the long-term outcome of fat injected into the subcutaneous layer has been questionable, and there is a lack of prospective quantitative studies of subcutaneous-only fat grafting. Therefore, the authors evaluated the long-term maintenance of gluteal adipose thickness when fat was injected only subcutaneously. Fifty consecutive female patients were evaluated in this prospective clinical study. All patients underwent gluteal fat augmentation in the subcutaneous plane only. Ultrasound analysis of the adipose tissue thickness of the gluteal region was performed preoperatively, immediately postoperatively, and at 12 months postoperatively. Immediate postoperative measurements revealed an average increase in gluteal subcutaneous layer thickness of 56.51 percent (range, 39.5 to 108.6 percent) (p < 0.0001). At 12 months postoperatively, the gluteal adipose tissue thickness decreased by an average of 18.16 percent (range, 6.8 to 24.8 percent) (p < 0.0001). Subcutaneous-only gluteal fat augmentation is shown to be as effective as previous studies reporting intramuscular fat injection with regard to long-term fat retention in the buttocks. CLINICAL QUESTION/LEVEL OF EVIDENCE:: Therapeutic, IV.

There have been several reports of patients experiencing cerebral embolisms following the injection of autologous fat into the face during cosmetic surgery. These embolisms likely resulted from unintentional introduction of fat particles into facial arteries, which then reached the cerebral arteries by retrograde motion. We describe here a patient who developed an internal carotid artery (ICA) embolism after autologous fat injection for temporal augmentation. To our knowledge, this is the first report of a pathologically proven ICA embolism after fat injection into the face. Our results suggest that the fat particles reached the cerebral arteries via a previously unknown pathway. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Floating knee is a flail knee joint resulting from fractures of the shafts or adjacent metaphyses of the femur and ipsilateral tibia. Floating knee injuries may include a combination of diaphyseal, metaphyseal, and intra-articular fractures. Floating knee injuries are a group of complex injuries that require a careful assessment. This injury is generally caused by high-energy trauma with often extensive trauma to the soft tissues. There may also be life-threatening injuries to the head, chest, or abdomen and a high incidence of fat embolism. This complex injury has increased in proportion to population growth, number of motor vehicles on the road, and high-speed traffic. Although the precise incidence of a floating knee is not known, it is a relatively uncommon injury. Bilateral floating knee injuries are extremely rare, and there is only one case report in the literature with bilateral floating knee injuries. We present a case report of a 64-year-old lady who suffered a blunt abdominal injury (hemicolectomy and splenectomy) and bilateral floating knees during road traffic accident. We also offer guidance for the treatment of this complex injury, based on literature review.