Bone Cement Implantation Syndrome: Management and Prevention
Definition and Clinical Significance
Bone cement implantation syndrome (BCIS) is a potentially fatal complication occurring in approximately 20% of cemented arthroplasty procedures, characterized by hypoxia, hypotension, or loss of consciousness during cement insertion, prosthesis placement, or joint reduction—and prevention requires meticulous surgical technique combined with aggressive hemodynamic optimization. 1
BCIS presents as a graded severity spectrum: Grade 1 (oxygen saturation <94% or >20% fall in systolic blood pressure), Grade 2 (oxygen saturation <88% or >40% fall in systolic blood pressure or loss of consciousness), and Grade 3 (requiring cardiopulmonary resuscitation). 1 Severe BCIS (Grades 2-3) increases 30-day mortality risk 3.5-fold compared to patients without severe BCIS. 2
Risk Stratification
High-Risk Patient Factors
Identify patients at elevated risk before surgery:
- Age >75 years (OR 1.57) 2
- ASA Class III or IV (OR 1.58) 2
- Renal impairment (OR 3.32) 2
- Male sex 1
- Significant cardiopulmonary disease 1
- Diuretic medication use 1
- Osteoporosis (enlarged porous cavities increase emboli generation) 3
- Femoral canal diameter >21 mm 3
Hip hemiarthroplasty for fracture carries the highest incidence (31%), followed by TKA (28%), THA (24%), and shoulder arthroplasty (16%). 2
Prevention Strategies
Pre-operative Team Communication
All theatre team members must be briefed on BCIS risk during pre-list briefing and WHO Safe Surgery checklist "time-out." 1 The surgeon must verbally announce intent to instrument the femoral canal, and the anesthesiologist must verbally confirm awareness. 1
Surgical Technique Modifications
Critical surgical steps to minimize BCIS risk:
- Carefully prepare, wash, and dry the femoral canal using pressurized lavage system to remove fat and marrow contents 1, 4
- Place distal suction catheter on top of intramedullary plug 1
- Insert cement from gun in retrograde fashion on top of the plug 1, 4
- Pull suction catheter out immediately when blocked with cement 1, 4
- Avoid excessive manual pressurization or pressurization devices in high-risk patients 1, 4
- Minimize prosthesis length and insertion force 1
- Ensure femoral venting 2
Anesthetic Management
Hemodynamic optimization is mandatory:
- Ensure adequate hydration before induction and throughout surgery 1, 4
- Maintain systolic blood pressure within 20% of pre-induction values using vasopressors and/or fluids 1, 4
- Increase inspired oxygen concentration to 100% at time of cementation 1, 4
- Use invasive blood pressure monitoring in high-risk patients 1
- Have vasopressors immediately available (metaraminol/epinephrine) 1
- Avoid intravascular volume depletion 1, 3
Cardiac output-guided fluid administration reduces hospital stay and improves outcomes. 1
Intraoperative Management of BCIS
Critical Timing
Maintain heightened vigilance during four high-risk moments:
- Femoral head removal 1
- Femoral canal preparation 1
- Cement insertion 5
- Prosthesis insertion and joint reduction 5
Immediate Treatment Protocol
When BCIS occurs, implement aggressive resuscitation:
- Deliver 100% oxygen immediately 1
- Fluid resuscitation guided by CVP measurement 1
- Vasopressor/inotropic support 1, 3
- Initiate high-quality CPR if Grade 3 BCIS 3
- All theatre staff execute predefined roles per institutional protocols (e.g., Coventry "cement curfew") 1
Some evidence suggests H1/H2 antagonists, methylprednisolone, and inotropes may prevent BCIS progression, though this is not universally established. 3
Postoperative Considerations
Continue vigilance in the immediate postoperative period:
- Administer supplemental oxygen for at least 24 hours 1, 4
- Monitor in recovery unit or HDU/ICU as clinically indicated 1
- Maintain ward care with nurse:patient ratio of 1:4 1
- Regular vital sign monitoring including oxygen saturation 1
Patients remain at high risk for complications in the early postoperative phase. 1
Special Considerations
Cement Leakage vs. BCIS
While cement leakage is the most feared complication of cementoplasty, symptomatic leakage is rare (<2%) and distinct from BCIS. 1 Leakage can cause spinal cord compression, nerve root compression, or pulmonary cement embolism. 1
Cemented vs. Uncemented Prostheses
Despite BCIS risk, cemented prostheses for hip fracture surgery provide pain-free mobility, reduce re-operation risk, and are associated with lower 30-day mortality compared to uncemented prostheses. 1 The decision must balance BCIS risk factors (renal impairment, ASA III/IV, age >75) against periprosthetic fracture risk factors (poor bone quality, female sex). 2
Multiorgan Microembolization
Autopsy studies confirm BCIS involves multiorgan disseminated microembolization of bone marrow and cement material, explaining the systemic cardiovascular collapse. 6