What Are the Frequency, Related Mortality, and Factors Associated with Bone Cement Implantation Syndrome in Arthroplasty Surgery?

Abstract

Background Bone cement implantation syndrome (BCIS) is characterized by hypoxia, hypotension, and the loss of consciousness during cemented arthroplasty; it may result in death. Its incidence has only been explored for hemiarthroplasty and THA after fracture or cancer. To our knowledge, there are no studies that comprehensively explore and compare the incidence of BCIS in other arthroplasty procedures. Questions/purposes (1) To report the incidence of BCIS in TKA, unicondylar knee arthroplasty, hip hemiarthroplasty, THA, shoulder arthroplasty, TKA, and revision THA and TKA; (2) to determine whether severe BCIS is associated with an increased risk of death within 30 days of surgery; and (3) to identify factors associated with the development of severe BCIS. Methods All patients undergoing cemented arthroplasty for any reason (TKA [11% cemented, 766 of 7293], unicondylar knee arthroplasty [100% cemented, 562 procedures], hip hemiarthroplasty for femur fractures [100% cemented, 969 procedures], THA [8% cemented, 683 of 8447], shoulder arthroplasty [84% cemented, 185 of 219], and revision arthroplasty of the hip and knee [36% cemented, 240 of 660]) between January 2008 and August 2019 were considered for inclusion in the current retrospective observational study. Fixation choice was dependent on surgeon preference (THA and TKA), prosthesis design (shoulder arthroplasty), or bone quality (revision arthroplasty). The following procedures were excluded because of insufficient data: < 1% (1 of 766) of TKAs, 1% (4 of 562) of unicondylar knee arthroplasties, 6% (54 of 969) of hip hemiarthroplasties, 1% (6 of 683) of THAs, 6% (12 of 185) of shoulder arthroplasties, and 14% (34 of 240) of revision procedures. This resulted in a final inclusion of 3294 procedures (765 TKAs [23%], 558 unicondylar knee arthroplasties [17%], 915 hip hemiarthroplasties [28%], 677 THA [21%], 173 shoulder arthroplasties [5%], and 206 revision arthroplasties [6%]), of which 28% (930 of 3294) had an emergent indication for surgery. Of the patients, 68% (2240 of 3294) were females, with a mean age of 75 ± 11 years. All anesthetic records were extracted from our hospital’s database, and the severity of BCIS was retrospectively scored (Grade 0 [no BCIS], Grade 1 [O2% < 94% or fall in systolic blood pressure of 20% to 40%], Grade 2 [O2% < 88% or fall in systolic blood pressure of > 40%], and Grade 3 [cardiovascular collapse requiring CPR]). Procedures were dichotomized into no or moderate BCIS (Grades 0 and 1) and severe BCIS (Grades 2 and 3). The adjusted 30-day mortality of patients with severe BCIS was assessed with a multivariate Cox regression analysis. A multivariate logistic regression analysis was performed to identify factors associated with the development of severe BCIS. Results BCIS occurred in 26% (845 of 3294) of arthoplasty procedures. The incidence was 31% (282 of 915) in hip hemiarthroplasty, 28% (210 of 765) in TKA, 24% (165 of 677) in THA, 23% (47 of 206) in revision arthroplasty, 20% (113 of 558) in unicondylar knee arthroplasty, and 16% (28 of 173) in shoulder arthroplasty. Patients with severe BCIS were more likely (hazard ratio 3.46 [95% confidence interval 2.07 to 5.77]; p < 0.001) to die within 30 days of the index procedure than were patients with less severe or no BCIS. Factors independently associated with the development of severe BCIS were age older than 75 years (odds ratio 1.57 [95% CI 1.09 to 2.27]; p = 0.02), American Society of Anesthesiologists Class III or IV (OR 1.58 [95% CI 1.09 to 2.30]; p = 0.02), and renal impairment (OR 3.32 [95% CI 1.45 to 7.46]; p = 0.004). Conclusion BCIS is common during cemented arthroplasty; severe BCIS is uncommon, but it is associated with an increased risk of death within 30 days of surgery. Medically complex patients undergoing hip hemiarthroplasty may be at particular risk. Patients at high risk for severe BCIS (renal impairment, ASA III/IV, and age older than 75 years) should be identified and preventive measures such as medullary lavage before cementation, femoral venting, and avoidance of excessive pressurization of implants should be taken to reduce the likelihood and consequences of BCIS. Because of the increased risk of periprosthetic fractures in uncemented hip stems, factors associated with the development of BCIS should be weighed against the risk factors for sustaining periprosthetic fractures (poor bone quality, female sex) to balance the risks of fixation method against those of BCIS for each patient. Level of Evidence Level III, therapeutic study.

Total Hip Arthroplasty: Minimal Clinically Important Difference and Patient Acceptable Symptom State for the Forgotten Joint Score 12

“…This surgery is related to a high number of risk factors and complications. Bone cement implantation syndrome [ 7 ], hip fractures [ 8 ] and residual lateral hip pain [ 9 ] could affect patients during and after THA surgery. The complications could influence the outcomes [ 10 ], the quality of life and the functionality of the joint [ 8 ].…”

Mechanism of novel enoxaparin sodium high viscosity bone cement reducing thrombosis by regulating the expression of CD40 in endothelial cells

“…After the application of high viscosity bone cement in clinical practice, arti cial joint replacement can greatly bene t patients who need this operation due to osteoarthritis and femoral neck fracture. However, the application of this operation is accompanied by the complication of bone cement implantation syndrome [15,16], with the incidence rate as high as 28%. One of the causes of bone cement implantation syndrome is the embolism caused by bone cement implantation, including pulmonary embolism and lower limb venous embolism [17][18][19][20].…”

Bilateral Intracapsular Hip Fracture in a Patient With Low Functional Demand Treated With a One-stage Bilateral Hemiarthroplasties. A Case Report and Literature Review.

“…Continuing with neurological disorders, bilateral FNF was also documented in a patient with cerebral palsy mimicking abdominal pain that was resolved with a bilateral uncemented total hip arthroplasty due to his young age (4). In our case, unipolar uncemented hemiarthroplasties were chosen due to the low functional demand, the short life expectancy and the possibility of BCIS in this group of patients (9).…”

“…The patient was operated under spinal anesthesia through a posterolateral approach. The right-sided fracture was rst resolved, implanting an Austin Moore-type uncemented unipolar hemiarthroplasty to prevent bone cement implantation syndrome (BCIS) (9). Immediately, left fracture was treated with the same technique and implant selection as the contralateral side (Fig.…”