Successful management of severe manifestation bone cemented implantation syndrome during hemiarthroplasty surgery in patient with multiple comorbidities: A case report

Hemodynamic Effects of Bone Cement Implantation in Hip Arthroplasty: Insights from a Prospective Study in Eastern India

Introduction

Bone cementation has various effects on hemodynamics including potentially fatal bone cement implantation syndrome (BCIS). Most of the studies on BCIS are from developed countries. We have studied the effect of bone cement on hemodynamics in hip arthroplasty in the eastern Indian population and compared it with the available literature.

Materials and Methods

This prospective study was done by a team of orthopedic surgeons and anesthesiologists in a tertiary center in eastern India between March 2020 and December 2022.

Result

Seventy-two patients (Male 38: and Female 34) of age between 25 and 100 years fulfilling the inclusion criteria were included. In 43 patients (43/72, 59.72%) systolic and diastolic blood pressure fell in the range of 10 mmHg, in 22 patients (22/72, 30.56%) fall in blood pressure was in the range of 10-20 mmHg, and more than 20 mmHg fall in blood pressure were seen in seven patients (7/72, 9.72%). SPO2 decreased from 97-100% to 94-96% in 28 patients and 90-93% in six patients, which began to rise after 5 min of cementing and returned to normal after 10 min. Arrhythmias were seen in 16 patients with multiple comorbidity. Two patients had a cardiac arrest and one patient died after 6 h in the intensive care unit.

Conclusion

Pre-operative evaluation, perioperative monitoring of hemodynamic parameters during cementing especially in high-risk patients with multiple comorbidities, and taking essential precautions during cemented arthroplasty are the key to preventing complications like BCIS.

The Bone Cement Hypercoagulation Syndrome: Pathophysiology, Mortality, and Prevention

Since Charnley introduced acrylic cement to seal metallic hip prostheses in the 1950s, reports of perioperative fatal cardiorespiratory and vascular dysfunctions have been published. Studies on humans and animals have shown neurogenic stimulation and substantial local and systemic activation of coagulation are caused by surgical bone marrow damage and chemical cell destruction by toxic monomeric methyl methacrylate from the implanted cement and other tissue-released substances. Venous blood-borne cell fragments and conjugates of activated cells from the surgical site are sequestered and trapped in the pulmonary microcirculation. A substantial hypercoagulation occurs in the lung circulation. Hypercoagulable blood is passed over to the arterial side and may cause vessel obliteration and organ damage. This process may affect the brain, heart, and kidneys and, through the release of vasoactive substances, introduce hemodynamic imbalances that can lead to fatal outcomes in susceptible populations such as elderly patients with hip fractures. The main underlying pathophysiologic processes leading to these occasionally devastating outcomes are a substantial activation of coagulation and cell destruction caused by the toxic substance released by curing bone cement and several vasoactive substances.

Bone cement implantation syndrome induced by antibiotic-loaded bone cement covering the infected bone surface: A case report

INTRODUCTION AND IMPORTANCE

Bone cement implantation syndrome (BCIS) typically occurs during bone cementation and prosthesis insertion. Almost all of the models used to explain BCIS are based on studies related to hip arthroplasty. BCIS induced by bone cement implantation in superficial wounds has not been reported.

CASE PRESENTATION

We report the case of a 37-year-old man with chronic osteomyelitis of the left tibia (Cierny - Mader type II), who developed BCIS after covering the infected bone surface with antibiotic-loaded bone cement. BCIS presented as acute massive pulmonary exudation and hypoxemia. Early application of awake prone positioning effectively improved oxygenation and lung injury, and prevented the need for a more advanced means of respiratory support. The patient was discharged without any clinical complications on postoperative day 15.

CLINICAL DISCUSSION

We assessed the cause of acute respiratory events in this patient using Naranjo Adverse Drug Reaction Probability Scale, and BCIS was finally considered. Despite the lack of "driving force" (e.g., increased intramedullary pressure), the bone cement monomer may be absorbed into circulation through the wound surface due to its penetrability. Subsequent immune-mediated amplification resulted in pulmonary exudation and hypoxemia. As a pathophysiologically change-oriented strategy, effective drainage after awake prone positioning significantly improved clinical outcomes.

CONCLUSION

Bone cement monomer absorbed through the wound should be of concern, and pathophysiological change-oriented management should be emphasized in BCIS.

Bone cement implantation syndrome during hip replacement in a patient with pemphigus and Parkinson’s disease: A case report

BACKGROUND

Bone cement implantation syndrome (BCIS) is characterized by hypotension, arrhythmia, diffuse pulmonary microvascular embolism, shock, cardiac arrest, any combination of these factors, or even death following bone cement implantation.

CASE SUMMARY

An 80-year-old patient with pemphigus and Parkinson’s disease underwent total hip replacement under spinal subarachnoid block and developed acute pulmonary embolism after bone cement implantation. The patient received mask mechanical ventilation with a continuous intravenous infusion of adrenaline (2 μg/mL) at a rate of 30 mL/h. Subsequently, the symptoms of BCIS were markedly alleviated, and the infusion rate of adrenaline was gradually reduced until the infusion was completely stopped 45 min later. The patient was then transferred to the Department of Orthopedics, and anticoagulation therapy began at 12 h postoperatively. No other complications were observed.

CONCLUSION

This is a rare case of BCIS in a high-risk patient with pemphigus and Parkinson’s disease.