Research progress in etiology and prevention of bone cement implantation syndrome_Chinese Journal of Reparative and Reconstructive Surgery

Authors：

HAN Guangtao , WANG Qin , SUN Shuo ,  KANG Pengde

Department of Orthopedics, West China Hospital, Sichuan University, Chengdu Sichuan, 610041, P. R. China;

Corresponding author：

KANG Pengde, Email: kangpd@163.com

Keywords：

Bone cement implantation syndrome; joint arthroplasty; etiology; prevention

DOI：

10.7507/1002-1892.202410068

Video：

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Objective To introduce the etiology and prevention of bone cement implantation syndrome (BCIS). Methods The literature about BCIS at home and abroad in recent years was extensively reviewed, and the incidence, clinical manifestations, etiology, and prevention of BCIS were summarized and analyzed. Results The clinical manifestations of BCIS are diverse. The etiology of BCIS is not completely clarified, and it may be related to circulating methyl methacrylate-mediated model, embolus-mediated model, histamine release and hypersensitivity response, complement activation and multimodal model. BCIS prevention begins with the identification of high-risk patients in preoperative evaluation and communication between surgeon and anesthesiologist about the choice of implant type, surgical procedure, and technique to minimize the risk of cardiovascular complications in high-risk patients with multiple or severe risk factors or comorbidities. Preoperative assessment and optimization of a patient’s cardiovascular reserve is also critical to prevent BCIS. Conclusion BCIS is a possible complication after hip joint arthroplasty, and its pathogenesis needs to be further research in order to provide new ideas for prevention and treatment.

Citation： HAN Guangtao, WANG Qin, SUN Shuo, KANG Pengde. Research progress in etiology and prevention of bone cement implantation syndrome. Chinese Journal of Reparative and Reconstructive Surgery, 2025, 39(2): 237-242. doi: 10.7507/1002-1892.202410068 Copy

1.	Chulsomlee K, Prukviwat S, Tuntiyatorn P, et al. Correlation between shape-closed femoral stem design and bone cement implantation syndrome in osteoporotic elderly femoral neck fracture undergoing cemented hip arthroplasty: A retrospective case-control study in 128 patients. Orthop Traumatol Surg Res, 2023, 109(1): 103450. doi: 10.1016/j.otsr.2022.103450.
2.	Chiu YH, Chen IC, Su CY, et al. Development of injectable calcium sulfate and self-setting calcium phosphate composite bone graft materials for minimally invasive surgery. Int J Mol Sci, 2022, 23(14): 7590. doi: 10.3390/ijms23147590.
3.	仇飞燕. 老年患者术中应用骨水泥护理分析及效果. 实用临床护理学电子杂志, 2018, 3(51): 32-33.仇飞燕. 老年患者术中应用骨水泥护理分析及效果. 实用临床护理学电子杂志, 2018, 3(51): 32-33.
4.	Dumanlı Özcan AT, Kesimci E, Balcı CA, et al. Comparison between colloid preload and coload in bone cement implantation syndrome under spinal anesthesia: A randomized controlled trial. Anesth Essays Res, 2018, 12(4): 879-884.
5.	Rassir R, Schuiling M, Sierevelt IN, et al. What are the frequency, related mortality, and factors associated with bone cement implantation syndrome in arthroplasty surgery? Clin Orthop Relat Res, 2021, 479(4): 755-763.
6.	陈建德, 樊晓琦, 景成伟, 等. 甲泼尼龙在PKP术中预防骨水泥植入综合征的作用. 浙江创伤外科, 2018, 23(4): 793-795.
7.	Donaldson AJ, Thomson HE, Harper NJ, et al. Bone cement implantation syndrome. Br J Anaesth, 2009, 102(1): 12-22.
8.	Hines CB. Understanding bone cement implantation syndrome. AANA J, 2018, 86(6): 433-441.
9.	Razuin R, Effat O, Shahidan MN, et al. Bone cement implantation syndrome. Malays J Pathol, 2013, 35(1): 87-90.
10.	Griffiths R, Babu S, Dixon P, et al. Guideline for the management of hip fractures 2020: Guideline by the Association of Anaesthetists. Anaesthesia, 2021, 76(2): 225-237.
11.	Bonfait H, Delaunay C, De Thomasson E, et al. Bone cement implantation syndrome in hip arthroplasty: Frequency, severity and prevention. Orthop Traumatol Surg Res, 2022, 108(2): 103139. doi: 10.1016/j.otsr.2021.103139.
12.	Weingärtner K, Störmann P, Schramm D, et al. Bone cement implantation syndrome in cemented hip hemiarthroplasty-a persistent risk. Eur J Trauma Emerg Surg, 2022, 48(2): 721-729.
13.	Giebel G, Hardt S, Perka C, et al. The cemented stem in hip arthroplasty—state of the art technique and recommendations. EFORT Open Rev, 2024, 9(11): 1047-1059.
14.	Yang Y, Meng X, Huang Y. Study of the cement implantation syndrome: A review. Medicine (Baltimore), 2024, 103(24): e38624. doi: 10.1097/MD.0000000000038624.
15.	Dahl OE, Pripp AH, Jaradeh M, et al. The bone cement hypercoagulation syndrome: pathophysiology, mortality, and prevention. Clin Appl Thromb Hemost, 2023, 29: 10760296231198036. doi: 10.1177/10760296231198036.
16.	Griffiths R, Parker M. Bone cement implantation syndrome and proximal femoral fracture. Br J Anaesth, 2015, 114(1): 6-7.
17.	Hines CB, Collins-Yoder A. Bone cement implantation syndrome: key concepts for perioperative nurses. AORN J, 2019, 109(2): 202-216.
18.	Bhadani JS, Kumar I, Ahmed W, et al. Hemodynamic effects of bone cement implantation in hip arthroplasty: insights from a prospective study in Eastern India. J Orthop Case Rep, 2024, 14(8): 212-221.
19.	Rao SS, Suresh KV, Margalit A, et al. Regional or neuraxial anesthesia may help mitigate the effects of bone cement implantation syndrome in patients undergoing cemented hip and knee arthroplasty for oncologic indications. J Am Acad Orthop Surg, 2022, 30(3): e375-e383.
20.	Izumi Y, Ishihara S, Cammack I, et al. Massive mass embolism detected by transesophageal echocardiography in bone cement implantation syndrome: a case report. JA Clin Rep, 2019, 5(1): 5. doi: 10.1186/s40981-019-0225-2.
21.	Jain D, Jain K, Dhillon MS. Does surgical technique add to the risk of bone cement implantation syndrome? Br J Anaesth, 2015, 115(3): 477-478.
22.	Mordà M, Pini S, Celli F, et al. Bone cement implantation syndrome: a thromboelastographic study of the effect of bone cement on coagulation. J Biol Regul Homeost Agents, 2017, 31(4 suppl 1): 121-127.
23.	Valiton V, Giannakopoulos G, Müller H. Catastrophic bone cement implantation syndrome treated with venoarterial extracorporeal membrane oxygenation: A case report. CASE (Phila), 2021, 6(1): 24-26.
24.	Huang WC, Lee P, Ling Wong TG, et al. Diagnosis of bone cement implantation syndrome using point of care ultrasound examination. Ann Card Anaesth, 2021, 24(3): 372-374.
25.	Qin Z, Deng Y, Li X, et al. Bone cement implantation syndrome induced by antibiotic-loaded bone cement covering the infected bone surface: A case report. Int J Surg Case Rep, 2021, 89: 106627. doi: 10.1016/j.ijscr.2021.106627.
26.	Kumbasar U, Bonde P. Delayed presentation of bone cement implantation syndrome requiring extracorporeal membrane oxygenation support. Turk Gogus Kalp Damar Cerrahisi Derg, 2021, 29(3): 412-414.
27.	E George N. CORR Insights^®: What are the frequency, related mortality, and factors associated with bone cement implantation syndrome in arthroplasty surgery? Clin Orthop Relat Res, 2021, 479(4): 764-766.
28.	Bökeler U, Bühler A, Eschbach D, et al. The influence of a modified 3rd generation cementation technique and vaccum mixing of bone cement on the bone cement implantation syndrome (BCIS) in geriatric patients with cemented hemiarthroplasty for femoral neck fractures. Medicina (Kaunas), 2022, 58(11): 1587. doi: 10.3390/medicina58111587.
29.	Sullivan C, Russo CM, Wilson L, et al. Total knee arthroplasty revision in the setting of periprosthetic joint infection resulting in bone cement implantation syndrome (BCIS), pulseless electrical activity (PEA) arrest, and intraoperative death: a case report and literature review. Cureus, 2024, 16(4): e57662. doi: 10.7759/cureus.57662.
30.	Schwarzkopf E, Sachdev R, Flynn J, et al. Occurrence, risk factors, and outcomes of bone cement implantation syndrome after hemi and total hip arthroplasty in cancer patients. J Surg Oncol, 2019, 120(6): 1008-1015.
31.	Yang TH, Yang RS, Lin CP, et al. Bone cement implantation syndrome in bone tumor surgeries: incidence, risk factors, and clinical experience. Orthop Surg, 2021, 13(1): 109-115.
32.	Zhou W, Zhang WJ, Zhao GQ, et al. Bone cement implantation syndrome during hip replacement in a patient with pemphigus and Parkinson’s disease: A case report. World J Clin Cases, 2021, 9(14): 3342-3349.
33.	Cheong MA, Chew KM. All that clots is not blood: bone cement implantation syndrome presenting as an intracardiac mass and pulmonary embolism. Thromb Haemost, 2022, 122(8): 1432-1434.
34.	Dradjat RS, Pradana AS, Putra DP, et al. Successful management of severe manifestation bone cemented implantation syndrome during hemiarthroplasty surgery in patient with multiple comorbidities: A case report. Int J Surg Case Rep, 2021, 78: 331-335.
35.	Tsai MC, Ng YY, Chen WM, Tsai SW, Wu SC. The effects of cement fixation on survival in elderly patients with hip hemiarthroplasty: a nationwide cohort study. BMC Musculoskelet Disord, 2019, 20(1): 628. doi: 10.1186/s12891-019-3013-2.
36.	Chatterjee K, Mittadodla PS, Colaco C, et al. A rare cause of pulmonary edema in the postoperative period. Indian J Crit Care Med, 2017, 21(2): 108-109.

1. Chulsomlee K, Prukviwat S, Tuntiyatorn P, et al. Correlation between shape-closed femoral stem design and bone cement implantation syndrome in osteoporotic elderly femoral neck fracture undergoing cemented hip arthroplasty: A retrospective case-control study in 128 patients. Orthop Traumatol Surg Res, 2023, 109(1): 103450. doi: 10.1016/j.otsr.2022.103450.
2. Chiu YH, Chen IC, Su CY, et al. Development of injectable calcium sulfate and self-setting calcium phosphate composite bone graft materials for minimally invasive surgery. Int J Mol Sci, 2022, 23(14): 7590. doi: 10.3390/ijms23147590.
3. 仇飞燕. 老年患者术中应用骨水泥护理分析及效果. 实用临床护理学电子杂志, 2018, 3(51): 32-33.仇飞燕. 老年患者术中应用骨水泥护理分析及效果. 实用临床护理学电子杂志, 2018, 3(51): 32-33.
4. Dumanlı Özcan AT, Kesimci E, Balcı CA, et al. Comparison between colloid preload and coload in bone cement implantation syndrome under spinal anesthesia: A randomized controlled trial. Anesth Essays Res, 2018, 12(4): 879-884.
5. Rassir R, Schuiling M, Sierevelt IN, et al. What are the frequency, related mortality, and factors associated with bone cement implantation syndrome in arthroplasty surgery? Clin Orthop Relat Res, 2021, 479(4): 755-763.
6. 陈建德, 樊晓琦, 景成伟, 等. 甲泼尼龙在PKP术中预防骨水泥植入综合征的作用. 浙江创伤外科, 2018, 23(4): 793-795.
7. Donaldson AJ, Thomson HE, Harper NJ, et al. Bone cement implantation syndrome. Br J Anaesth, 2009, 102(1): 12-22.
8. Hines CB. Understanding bone cement implantation syndrome. AANA J, 2018, 86(6): 433-441.
9. Razuin R, Effat O, Shahidan MN, et al. Bone cement implantation syndrome. Malays J Pathol, 2013, 35(1): 87-90.
10. Griffiths R, Babu S, Dixon P, et al. Guideline for the management of hip fractures 2020: Guideline by the Association of Anaesthetists. Anaesthesia, 2021, 76(2): 225-237.
11. Bonfait H, Delaunay C, De Thomasson E, et al. Bone cement implantation syndrome in hip arthroplasty: Frequency, severity and prevention. Orthop Traumatol Surg Res, 2022, 108(2): 103139. doi: 10.1016/j.otsr.2021.103139.
12. Weingärtner K, Störmann P, Schramm D, et al. Bone cement implantation syndrome in cemented hip hemiarthroplasty-a persistent risk. Eur J Trauma Emerg Surg, 2022, 48(2): 721-729.
13. Giebel G, Hardt S, Perka C, et al. The cemented stem in hip arthroplasty—state of the art technique and recommendations. EFORT Open Rev, 2024, 9(11): 1047-1059.
14. Yang Y, Meng X, Huang Y. Study of the cement implantation syndrome: A review. Medicine (Baltimore), 2024, 103(24): e38624. doi: 10.1097/MD.0000000000038624.
15. Dahl OE, Pripp AH, Jaradeh M, et al. The bone cement hypercoagulation syndrome: pathophysiology, mortality, and prevention. Clin Appl Thromb Hemost, 2023, 29: 10760296231198036. doi: 10.1177/10760296231198036.
16. Griffiths R, Parker M. Bone cement implantation syndrome and proximal femoral fracture. Br J Anaesth, 2015, 114(1): 6-7.
17. Hines CB, Collins-Yoder A. Bone cement implantation syndrome: key concepts for perioperative nurses. AORN J, 2019, 109(2): 202-216.
18. Bhadani JS, Kumar I, Ahmed W, et al. Hemodynamic effects of bone cement implantation in hip arthroplasty: insights from a prospective study in Eastern India. J Orthop Case Rep, 2024, 14(8): 212-221.
19. Rao SS, Suresh KV, Margalit A, et al. Regional or neuraxial anesthesia may help mitigate the effects of bone cement implantation syndrome in patients undergoing cemented hip and knee arthroplasty for oncologic indications. J Am Acad Orthop Surg, 2022, 30(3): e375-e383.
20. Izumi Y, Ishihara S, Cammack I, et al. Massive mass embolism detected by transesophageal echocardiography in bone cement implantation syndrome: a case report. JA Clin Rep, 2019, 5(1): 5. doi: 10.1186/s40981-019-0225-2.
21. Jain D, Jain K, Dhillon MS. Does surgical technique add to the risk of bone cement implantation syndrome? Br J Anaesth, 2015, 115(3): 477-478.
22. Mordà M, Pini S, Celli F, et al. Bone cement implantation syndrome: a thromboelastographic study of the effect of bone cement on coagulation. J Biol Regul Homeost Agents, 2017, 31(4 suppl 1): 121-127.
23. Valiton V, Giannakopoulos G, Müller H. Catastrophic bone cement implantation syndrome treated with venoarterial extracorporeal membrane oxygenation: A case report. CASE (Phila), 2021, 6(1): 24-26.
24. Huang WC, Lee P, Ling Wong TG, et al. Diagnosis of bone cement implantation syndrome using point of care ultrasound examination. Ann Card Anaesth, 2021, 24(3): 372-374.
25. Qin Z, Deng Y, Li X, et al. Bone cement implantation syndrome induced by antibiotic-loaded bone cement covering the infected bone surface: A case report. Int J Surg Case Rep, 2021, 89: 106627. doi: 10.1016/j.ijscr.2021.106627.
26. Kumbasar U, Bonde P. Delayed presentation of bone cement implantation syndrome requiring extracorporeal membrane oxygenation support. Turk Gogus Kalp Damar Cerrahisi Derg, 2021, 29(3): 412-414.
27. E George N. CORR Insights^®: What are the frequency, related mortality, and factors associated with bone cement implantation syndrome in arthroplasty surgery? Clin Orthop Relat Res, 2021, 479(4): 764-766.
28. Bökeler U, Bühler A, Eschbach D, et al. The influence of a modified 3rd generation cementation technique and vaccum mixing of bone cement on the bone cement implantation syndrome (BCIS) in geriatric patients with cemented hemiarthroplasty for femoral neck fractures. Medicina (Kaunas), 2022, 58(11): 1587. doi: 10.3390/medicina58111587.
29. Sullivan C, Russo CM, Wilson L, et al. Total knee arthroplasty revision in the setting of periprosthetic joint infection resulting in bone cement implantation syndrome (BCIS), pulseless electrical activity (PEA) arrest, and intraoperative death: a case report and literature review. Cureus, 2024, 16(4): e57662. doi: 10.7759/cureus.57662.
30. Schwarzkopf E, Sachdev R, Flynn J, et al. Occurrence, risk factors, and outcomes of bone cement implantation syndrome after hemi and total hip arthroplasty in cancer patients. J Surg Oncol, 2019, 120(6): 1008-1015.
31. Yang TH, Yang RS, Lin CP, et al. Bone cement implantation syndrome in bone tumor surgeries: incidence, risk factors, and clinical experience. Orthop Surg, 2021, 13(1): 109-115.
32. Zhou W, Zhang WJ, Zhao GQ, et al. Bone cement implantation syndrome during hip replacement in a patient with pemphigus and Parkinson’s disease: A case report. World J Clin Cases, 2021, 9(14): 3342-3349.
33. Cheong MA, Chew KM. All that clots is not blood: bone cement implantation syndrome presenting as an intracardiac mass and pulmonary embolism. Thromb Haemost, 2022, 122(8): 1432-1434.
34. Dradjat RS, Pradana AS, Putra DP, et al. Successful management of severe manifestation bone cemented implantation syndrome during hemiarthroplasty surgery in patient with multiple comorbidities: A case report. Int J Surg Case Rep, 2021, 78: 331-335.
35. Tsai MC, Ng YY, Chen WM, Tsai SW, Wu SC. The effects of cement fixation on survival in elderly patients with hip hemiarthroplasty: a nationwide cohort study. BMC Musculoskelet Disord, 2019, 20(1): 628. doi: 10.1186/s12891-019-3013-2.
36. Chatterjee K, Mittadodla PS, Colaco C, et al. A rare cause of pulmonary edema in the postoperative period. Indian J Crit Care Med, 2017, 21(2): 108-109.

Chinese Journal of Reparative and Reconstructive Surgery

Research progress in etiology and prevention of bone cement implantation syndrome

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