Transcranial Doppler detection of cerebral fat emboli and relation to paradoxical embolism: a pilot study.

BACKGROUND: The fat embolism syndrome is clinically characterized by dyspnea, skin petechiae, and neurological dysfunction. It is associated mainly with long bone fracture and bone marrow fat passage to the systemic circulation. An intracardiac right-to-left shunt (RLS) could allow larger fat particles to reach the systemic circulation. Transcranial Doppler can be a useful tool to detect both RLS and the fat particles reaching the brain. METHODS AND RESULTS: We prospectively studied patients with femur shaft fracture with RLS evaluation, daily transcranial Doppler with embolus detection studies, and neurological examinations to evaluate the relation of RLS and microembolic signals to the development of fat embolism syndrome. Forty-two patients were included; 14 had an RLS detected. Seven patients developed neurological symptoms; all of them had a positive RLS (P=<0.001). The patients with an RLS showed higher counts and higher intensities of microembolic signals (P=<0.05 and P=<0.01, respectively) compared with those who did not have an RLS identified. The presence of high microembolic signal counts and intensities in patients with RLS was strongly predictive of the occurrence of neurological symptoms (odds ratio, 204; 95% confidence interval, 11 to 3724; P<0.001) with a positive predictive value of 86% and negative predictive value of 97%. CONCLUSIONS: In patients with long bone fractures, the presence of an RLS is associated with larger and more frequent microembolic signals to the brain detected by transcranial Doppler study and can predict the development of neurological symptoms.

A minimally disruptive surgical technique for the treatment of osteitis pubis in athletes.

BACKGROUND: MULTIPLE SURGICAL PROCEDURES EXIST FOR THE TREATMENT OF OSTEITIS PUBIS: curettage of the symphysis joint, wedge resection, complete resection of the joint, placement of extraperitoneal retropubic synthetic mesh, and arthrodesis of the joint. However, a paucity of literature has reported long-term successful outcomes with the aforementioned approaches. Patients treated operatively have reported recalcitrant pain resulting from iatrogenic instability. The article presents the results of a conservative operative technique that avoids disruption of adjacent ligaments. HYPOTHESIS: Preserving the adjacent ligamentous structures will allow competitive athletes to return to competition and activities of daily living free of iatrogenic pelvic instability and pain. STUDY DESIGN: Case series. METHODS: Four competitive athletes (2 professional and 2 collegiate football players) diagnosed with osteitis pubis were treated conservatively for a minimum of 6 months. Patients underwent surgical intervention upon failure to respond to nonoperative management. The degenerative tissue was resected, allowing only bleeding cancellous bone to remain while preserving the adjacent ligaments. An arthroscope was used to assist in curettage, allowing the debridement to be performed through a small incision in the anterior capsule. RESULTS: The symptoms of all 4 patients resolved, and they returned to competitive athletics. This ligament-sparing technique provided a solid, stable repair and pain relief. CONCLUSION: This surgical technique preserves the adjacent ligamentous structures and allows competitive athletes to return to competition and activities of daily living free of pain and void of pelvic instability. CLINICAL RELEVANCE: This technique is a surgical treatment option for athletes with osteitis pubis who fail conservative treatment.