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

Hip fracture surgery is common and associated both with frequent perioperative complications [⁶] and postoperative deaths. Thirty-day mortality rates after hip fracture fixation are as high as 10.5%, and more than a quarter of our patients who have hip fractures treated surgically (27.3% in one study [⁹]) do not survive the first year.

When treating older patients with arthroplasty for femoral neck fractures, there is considerable debate about whether to use cemented or uncemented devices. While much evidence favors using cement for this indication [²], concerns remain about this approach. A central argument for using uncemented arthroplasty in older (> 75 years of age), medically fragile patients with femoral neck fractures is avoiding the risk death on the table or shortly thereafter because of complications associated with cement.

The findings in the current study [¹⁰] shed light on a poorly understood and underrecognized phenomenon that causes both short-term morbidity and mortality: bone cement implantation syndrome (BCIS). This surgical complication is defined as hypoxia, hypotension, and/or loss of consciousness occurring during the course of cemented bone surgery, most commonly at the time of cementation and prosthesis insertion [³]. The pathophysiology of BCIS may involve one or a combination of cement pressurization and expansion, polymethyl methacrylate mediator release, hypersensitivity reaction, and complement activation, culminating in changes in pulmonary and systemic vascular resistance and the consequent hemodynamic instability [^{3, 8}].

The current study was a single-center retrospective analysis of all patients who underwent cemented unicondylar knee arthroplasty, primary and revision total knee and hip arthroplasty, hip hemiarthroplasty, and anatomic and reverse total shoulder arthroplasty between January 2008 and August 2019, with the aim of identifying risk factors for and associated mortality following severe BCIS [¹⁰]. They found that 26% of patients experienced BCIS, with 6% of all patients experiencing severe BCIS. Factors associated with severe BCIS included age (older than 75 years of age), ASA class III/IV, and renal impairment (Cr > 150µmol/L). Moreover, 57% of patients who went on to develop severe BCIS (Olsen Grade 2 or 3) were undergoing an elective procedure. Interpretation of these findings, in isolation, may push orthopaedic surgeons to reflexively select cementless implantation in older, less healthy patients.

The risk of BCIS may be part of the reason why use of uncemented hip hemiarthroplasty stems is on the rise, as shown in registry-based research [¹]. Cemented hip hemiarthroplasty has been associated with increased 1-year mortality relative to uncemented hemiarthroplasty [⁷], and patients who experience severe BCIS following hemiarthroplasty are at a 16-fold increased risk for 30-day mortality [⁸]. In addition, a recent meta-analysis of patients with displaced femoral neck fractures found that those who underwent cemented hemiarthroplasty fixation had increased odds of dying within 48 hours of surgery, including nine intraoperative deaths [⁴]. Although uncemented hemiarthroplasty avoids this particular risk and saves an average of 20 minutes of operative time [⁵], it is associated with serious complications as well. Patients treated with uncemented hip arthroplasty implants are more likely to experience periprosthetic fractures, as well as early revision [¹¹]. Specifically, uncemented arthroplasty has a 17-fold increased risk for revision from periprosthetic fracture or for aseptic revision due to loosening compared with cemented hip arthroplasty [⁵]. Since additional surgery carries an additional mortality risk, circumventing the cementation step in sicker patients who are more likely to fall and undergo revision surgery may not be the best choice, either.