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Delayed neurological deficit after total hip arthroplasty.

P atients undergoing total hip arthroplasty (THAI may rarely develop neurological complications that may present as transient confusion or, if severe, as coma or death (1). Suggested etiologies for these impairments include hypoxia caused by pulmonary embolism or from paradoxical cerebral emboli passing through a patent foramen ovale or other intracardiac shunt (2,3). The pathogenesis of neurological problems surrounding arthroplastic surgery is thought to be fat emboli from the bone marrow being released by an increase in intramedullary pressure (2,4). We report two cases in which patients underwent successful and uncomplicated THA but developed critical neurologic impairment hours later, leading to the death of one patient and the prolonged recovery of the other. The symptoms of this neurological complication were atypical in that they did not present until 2-3 h after what seemed to be a normal recovery from anesthesia and surgery. Neither patient, on close examination, had demonstrable intracardiac shunts.