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Postmortem Findings in Bone Cement Implantation Syndrome–Related Deaths

de Froidmont, Sébastien MD*; Bonetti, Luca Reggiani MD; Villaverde, Raquel Vilariño MD*; del Mar Lesta, Maria MD*; Palmiere, Cristian MD*

The American Journal of Forensic Medicine and Pathology: September 2014 - Volume 35 - Issue 3 - p 206–211
doi: 10.1097/PAF.0000000000000110
Original Articles

Several mechanisms have been postulated as potentially involved in life-threatening complications during cemented surgery. In this study, we evaluated the role of anaphylaxis and pulmonary fat embolism in the pathophysiology of bone cement implantation syndrome in a series of fatal cases that underwent medicolegal investigations. Postmortem findings in these cases were compared with those obtained from individuals who died after other injuries and/or interventions and in which activated mast cells and pulmonary fat embolism were involved in the pathogenesis of death. Fifty subjects were selected including 6 individuals who had undergone cemented total hip arthroplasty and died intraoperatively, 32 subjects who died shortly after being involved in traffic accidents, 8 individuals who died shortly after the injection of contrast material, and 4 subjects who had undergone orthopedic surgery and died postoperatively. Massive pulmonary fat embolism was determined to be the cause of death in all the 6 subjects who died intraoperatively as well as the main cause of death in traffic-road victims with rapid respiratory function deterioration. Mast cell activation was identified exclusively in the group of subjects who died shortly after contrast material administration. Massive pulmonary fat embolism appears to be the most important factor responsible for severe cardiorespiratory function deterioration during cemented arthroplasty. Cardiac comorbidities can also significantly influence the severity of intraoperative complications, thus corroborating the hypothesis of a multifactorial model in the pathogenesis of bone cement implantation syndrome.

From the *University Center of Legal Medicine, Lausanne University Hospital, Lausanne, Switzerland; and †Department of Diagnostic Services, Pathology and Legal Medicine, Section of Pathology, University of Modena and Reggio Emilia, Modena, Italy.

Manuscript received April 10, 2014; accepted June 9, 2014.

This study was not supported by any grant.

The authors report no conflicts of interest.

Reprints: Cristian Palmiere, MD, Centre Universitaire Romand de Médecine Légale, 21 rue du Bugnon, 1011, Lausanne Suisse. E-mail:

© 2014 by Lippincott Williams & Wilkins.