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Views: 0 Author: Site Editor Publish Time: 2026-05-25 Origin: Site
During total hip arthroplasty (THA) and hemiarthroplasty procedures, implantation of bone cement may cause transient or severe hypotension, decreased PaO2, and even cardiac arrest in approximately 0.6%–1% of patients. This potentially life-threatening complication is known as Bone Cement Implantation Syndrome (BCIS).
BCIS is a rare but critical perioperative complication that orthopedic surgeons, anesthesiologists, and operating room teams must recognize immediately.
A 78-year-old female patient weighing 62 kg underwent left total hip arthroplasty under combined spinal-epidural anesthesia for a femoral neck fracture.
Preoperatively, the patient presented with severe hypokalemia (2.5 mmol/L) and frequent premature ventricular contractions (PVCs) on ECG. After potassium supplementation and antiarrhythmic treatment, her condition improved.
The patient had a history of hypertension controlled around 160/90 mmHg. After anesthesia induction, blood pressure stabilized at approximately 135/80 mmHg.
Ten minutes after bone cement insertion, the patient suddenly developed:
Severe hypotension (80/45 mmHg)
Nausea and vomiting
Ventricular arrhythmia with frequent PVC bigeminy
Intravenous ephedrine (15 mg) and lidocaine (40 mg) restored blood pressure to 130/85 mmHg, but ventricular arrhythmias persisted.
Continuous lidocaine infusion was maintained until surgery completion. Postoperatively, the patient continued to experience ventricular bigeminy and trigeminy and was transferred to the ICU.
Four hours later, ventricular arrhythmias improved, and sinus rhythm gradually returned within 12 hours.
A 78-year-old woman underwent right hip replacement for avascular necrosis of the femoral head.
Preoperative examinations were unremarkable except for hypertension (160/90 mmHg). Epidural anesthesia was performed successfully, and intraoperative vital signs remained stable.
Approximately five minutes after bone cement implantation:
Heart rate suddenly dropped to 40 bpm
Cardiac arrest and respiratory arrest occurred
Blood pressure became unmeasurable
Immediate cardiopulmonary resuscitation (CPR) was initiated.
After administration of:
Atropine (2 mg)
Epinephrine (2 mg)
Dexamethasone (10 mg)
the patient's circulation recovered within 5 minutes.
Ten minutes later, pulmonary edema symptoms appeared, including bilateral moist rales. Mannitol, morphine, furosemide, sodium bicarbonate, and PEEP ventilation were administered.
The event was considered a severe allergic-type BCIS reaction. The patient eventually recovered and was discharged 15 days later.
A 78-year-old female with metastatic breast cancer, type 2 diabetes, and chronic pharyngitis underwent cemented hemiarthroplasty for a pathological femoral head fracture.
During cement implantation, the patient developed:
Sudden oxygen desaturation
Severe hypotension
Cardiac arrest
Although resuscitation was initially successful, the patient later developed disseminated intravascular coagulation (DIC) in the ICU.
She died 24 hours later.
Autopsy confirmed fat embolism as the cause of death.
Bone Cement Implantation Syndrome (BCIS) is a potentially fatal complication associated with cemented orthopedic procedures, particularly:
Total hip arthroplasty
Hemiarthroplasty
Total knee arthroplasty
It typically occurs during:
Cement insertion
Prosthesis implantation
Joint reduction
BCIS commonly presents with:
Hypotension
Hypoxemia
Cardiac arrhythmias
Pulmonary hypertension
Loss of consciousness
Cardiac arrest
Reported mortality ranges from 0.6% to 1%, with higher mortality in high-risk patients.
The exact mechanism of BCIS remains multifactorial.
Certain components of bone cement, particularly methyl methacrylate monomer, may exert direct toxic effects on the myocardium.
Potential effects include:
Reduced myocardial contractility
Conduction abnormalities
Arrhythmias
Decreased cardiac output
Studies have demonstrated postoperative elevations in cardiac enzymes such as AST and CK-MB in cemented arthroplasty patients.
Researchers such as Tryba et al. found significant increases in serum histamine concentration following bone cement implantation.
This histamine release can cause:
Systemic vasodilation
Severe hypotension
Cardiovascular instability
Importantly, pretreatment with H1 and H2 receptor antagonists may reduce cardiovascular complications.
Elderly patients with:
Cardiovascular disease
Hypovolemia
Poor cardiac reserve
are especially vulnerable even to moderate histamine release.
Bone cement monomers may promote:
Platelet aggregation
Coagulation cascade activation
Thrombin generation
Studies have shown:
2.5-fold increases in thrombin-antithrombin complexes (TAT)
7-fold increases in tissue plasminogen activator activity (tPA)
Severe cases may progress to disseminated intravascular coagulation (DIC).
Intramedullary manipulation during reaming and prosthesis insertion creates high intramedullary pressure.
This pressure may force:
Fat droplets
Bone marrow debris
Cement particles
Air emboli
into the bloodstream.
Massive embolic events can lead to:
Pulmonary hypertension
Right ventricular failure
Severe hypoxemia
Cardiovascular collapse
Modern techniques such as vacuum cementing and non-cemented arthroplasty have demonstrated reduced embolic complications.
Patients at greatest risk include:
Elderly patients (>65 years)
Patients with cardiovascular disease
Patients with pulmonary disease
Hypovolemic patients
Patients with poor cardiopulmonary reserve
Patients with metastatic bone disease
Osteoporotic fracture patients
Hypotension is the most common presentation.
Observed features include:
Mean arterial pressure decrease of 15–40 mmHg
Refractory hypotension
Pulmonary edema
Shock
Cardiovascular collapse
Some patients respond to ephedrine or dopamine, while others may require aggressive vasopressor support.
Arrhythmias may include:
Bradycardia
Tachycardia
Ventricular premature beats
Malignant ventricular arrhythmias
Bradycardia is particularly common and may rapidly progress to cardiac arrest.
Following cement implantation, patients may develop:
Pulmonary microemboli
Decreased arterial oxygen tension
Reduced end-tidal CO2
Persistent postoperative hypoxemia
Autopsy studies have confirmed pulmonary marrow emboli and polymethylmethacrylate particles in fatal BCIS cases.
Some reports also show significantly higher rates of deep vein thrombosis (DVT) in cemented arthroplasty compared with non-cemented procedures.
Figure 1.Autopsy of 13 patients who died during bone cement hip arthroplasty revealed pulmonary bone marrow microembolism in 11 cases .
Figure 2.PMMA particles were visible in 3 cases.
Hypoxemia often occurs immediately after cement implantation and may persist for several postoperative days.
Potential contributing mechanisms include:
Fat embolism
Cement emboli
Atelectasis
Ventilation-perfusion mismatch
Cardiac arrest associated with BCIS has been widely reported.
Potential mechanisms include:
Massive embolization
Severe pulmonary hypertension
Right heart failure
Thermal blood injury from cement polymerization
Venous air embolism
Mortality rates may exceed 10% in severe cases.
Most patients undergoing joint replacement are elderly and often have:
Hypertension
Coronary artery disease
Diabetes
Pulmonary dysfunction
Optimizing cardiopulmonary function before surgery is critical.
Recommended preventive strategies include:
Reducing intramedullary pressure during cement insertion
Thorough lavage of the medullary canal
Using diluted epinephrine irrigation
Adequate preoperative hydration
Administration of H1/H2 blockers
Prophylactic dexamethasone
Preventive vasopressor support when necessary
Essential monitoring includes:
Continuous ECG
Blood pressure monitoring
Pulse oximetry
End-tidal CO2 monitoring
Advanced monitoring may include:
Transesophageal echocardiography (TEE)
Pulmonary artery catheterization in high-risk patients
TEE can directly visualize embolic material passing through the heart.
Management priorities include:
Rapid correction of hypovolemia
Immediate vasopressor support
Maintaining oxygen delivery
Recommended interventions:
Dual intravenous access
Rapid fluid infusion
Ephedrine
Dopamine
Phenylephrine
Epinephrine
For severe hypotension:
Intravenous epinephrine (4–50 μg/kg) may be required
For bradycardia:
Repeated atropine administration may be necessary
Cardiac arrest should be managed according to advanced CPR protocols.
Once BCIS occurs, aggressive oxygen therapy is mandatory.
Depending on severity, management may include:
High-flow oxygen
Positive pressure ventilation
Endotracheal intubation
Mechanical ventilation with PEEP
Persistent refractory hypotension or arrhythmias should immediately raise suspicion for massive embolism.
In catastrophic cases, advanced support such as extracorporeal circulation may be necessary.
Bone Cement Implantation Syndrome (BCIS) remains one of the most dangerous complications during cemented orthopedic arthroplasty procedures.
Early recognition, aggressive monitoring, rapid hemodynamic intervention, and multidisciplinary cooperation are essential for improving patient survival.
For elderly patients and those with preexisting cardiopulmonary disease, prevention and preparedness are especially critical during cemented joint replacement surgery.
