Anaesthesia type and cement reactions in hip fracture surgery

The Effect of Anesthetic Regimen on Bone Cement Implantation Syndrome in Cemented Hemiarthroplasty for Hip Fracture

INTRODUCTION

Bone cement implantation syndrome (BCIS) is characterized by hypoxia, hypotension, and cardiovascular compromise during cementation in arthroplasty cases. This study examines the association between anesthetic regimen and risk of BCIS in cemented hemiarthroplasty for hip fractures. We hypothesized that neuraxial anesthesia would be associated with markedly lower BCIS incidence compared with general anesthesia alone or in combination with regional anesthesia.

METHODS

This retrospective cohort study included patients aged 50 years or older who underwent cemented hemiarthroplasty for hip fractures at a single institution between January 2017 and December 2022. Patient demographics, comorbidities, procedural factors, anesthetic characteristics including anesthetic regimen (general, general plus regional, or neuraxial), cement timing, BCIS development, postoperative complications, and mortality data were extracted. BCIS was identified by changes in postcementation vitals and its severity classified according to previously established criteria. Univariate statistical analyses and multivariate logistic regression were conducted.

RESULTS

Of the 137 included patients, 58 (43%) developed BCIS. No notable differences were observed in demographics, comorbidities, or procedural characteristics between patients who developed BCIS and those who did not. However, anesthetic regimen was markedly correlated with BCIS development, with general anesthesia demonstrating the highest rates (26/43, 55%), followed by general plus regional anesthesia (26/58, 45%) and neuraxial anesthesia (6/32, 19%; P = 0.005). Compared with neuraxial anesthesia, general anesthesia and general plus regional anesthesia conferred 6.8 and 5.5 times greater odds of developing BCIS, respectively. The development of BCIS was associated with significantly higher rates of postoperative hypoxia (P = 0.04) and unplanned prolonged intubation (P = 0.04).

CONCLUSION

BCIS was highly prevalent among patients undergoing cemented hemiarthroplasty for hip fractures. The anesthetic regimen was the only variable markedly associated with BCIS development and is a potentially modifiable risk factor.

LEVEL OF EVIDENCE

III.

Comparative efficacy of Neuraxial and general anesthesia for hip fracture surgery: a meta-analysis of randomized clinical trials

Background

The choice of anesthesia technique remains debatable in patients undergoing surgical repair of hip fracture. This meta-analysis was performed to compare the effect of neuraxial (epidural/spinal) versus general anesthesia on perioperative outcomes in patients undergoing hip fracture surgery.

Methods

Medline, Cochrane Library, Science-Direct, and EMBASE databases were searched to identify eligible studies focused on the comparison between neuraxial and general anesthesia in hip fracture patients between January 2000 and May 2019. Perioperative outcomes were extracted for systemic analysis. Sensitivity analyses were conducted using a Bonferroni correction and the leave-one-out method. The evidence quality for each outcome was evaluated by the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system.

Results

Nine randomized controlled trials (RCTs) including 1084 patients fulfilled our selection criteria. The outcomes for the meta-analysis showed that there were no significant differences in the 30-day mortality (OR = 1.34, 95% CI 0.56, 3.21; P = 0.51), length of stay (MD = − 0.65, 95% CI -0.32, 0.02; P = 0.06), and the prevalence of delirium (OR = 1.05, 95% CI 0.27, 4.00; P = 0.95), acute myocardial infarction (OR = 0.88, 95% CI 0.17, 4.65; P = 0.88), deep venous thrombosis (OR = 0.48, 95% CI 0.09, 2.72; P = 0.41), and pneumonia (OR = 1.04, 95% CI 0.23, 4.61; P = 0.96) for neuraxial anesthesia compared to general anesthesia, and there was a significant difference in blood loss between the two groups (MD = − 137.8, 95% CI -241.49, − 34.12; p = 0.009). However, after applying the Bonferroni correction for multiple testing, all the adjusted p-values were above the significant threshold of 0.05. The evidence quality for each outcome evaluated by the GRADE system was low.

Conclusions

In summary, our present study demonstrated that there might be a difference in blood loss between patients receiving neuraxial and general anaesthesia, however, this analysis was not robust to adjustment for multiple testing and therefore at high risk for a type I error. Due to small sample size and enormous inconsistency in the choice of outcome measures, more high-quality studies with large sample size are needed to clarify this issue.