Background and purpose — The bone cement implantation syndrome characterized by hypotension and/or hypoxia is a well-known complication in cemented arthroplasty. We studied the incidence of hypotension and/or hypoxia in patients undergoing cemented or uncemented hemiarthroplasty for femoral neck fractures and evaluated whether bone cement was an independent risk factor for postoperative mortality. Patients and methods — In this retrospective cohort study, 1,095 patients from 2 hospitals undergoing hemiarthroplasty with (n = 986) and without (n = 109) bone cementation were included. Pre-, intra-, and postoperative data were obtained from electronic medical records. Each patient was classified for grade of hypotension and hypoxia during and after prosthesis insertion according to Donaldson’s criteria (Grade 1, 2, 3). After adjustments for confounders, the hazard ratio (HR) for the use of bone cement on 1-year mortality was assessed. Results — The incidence of hypoxia and/or hypotension was higher in the cemented (28%) compared with the uncemented group (17%) (p = 0.003). The incidence of severe hypotension/hypoxia (grade 2 or 3) was 6.9% in the cemented, but not observed in the uncemented group. The use of bone cement was an independent risk factor for 1-year mortality (HR 1.9, 95% CI 1.3–2.7), when adjusted for confounders. Interpretation — The use of bone cement in hemiarthroplasty for femoral neck fractures increases the incidence of intraoperative hypoxia and/or hypotension and is an independent risk factor for postoperative 1-year mortality. Efforts should be made to identify patients at risk for BCIS and alternative strategies for the management of these patients should be considered.

Background Hip fracture is a common osteoporotic fracture with great morbidity and mortality. The utility of ASA classification is limited, as most patients are ≥ASA 3. A reliable predictor of mortality risk could support decision‐making. We aimed to evaluate Nottingham hip fracture score (NHFS) for the prediction of 30‐day mortality and then to recalibrate the formula converting NHFS to risk of 30‐day mortality. Methods All patients >60 years with surgically treated hip fracture surgery during 2015–16 were assessed. Data was extracted manually from routinely collected clinical data in registry and medical records. Discriminative performance of NHFS and ASA was assessed with C‐statistics. The conversion formula from NHFS to risk of 30‐day mortality was recalibrated using logistic binominal regression. Observed vs expected ratios of 30‐day mortality were compared with the 2012 NHFS‐formula and recalibration was performed in a split dataset. Results 1864 patients were included, with 213 deaths within 30 days. C‐statistic were 0.64 for NHFS and 0.62 for ASA. Comparing expected values from the 2012‐revision with our observed deaths gave a ratio of 1.37. Relating predicted levels of 30‐day mortality based on 70% of our cohort vs. 30% test portion of our Swedish dataset gave a ratio of 0.97. Discussion NHFS underestimated mortality in our cohort and showed poor discrimination. Revision of the formula based on a split dataset improved calibration. We suggest NHFS to be routinely implemented to support clinical judgements, expand preoperative assessment and escalate intraoperative monitoring.

The use of bone cement in total hip arthroplasty increases pulmonary vascular resistance and the afterload of the RV with potentially negative effects on RV performance.