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.