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Bone Cement Implantation Syndrome (BCIS)

Definition

• Bone Cement Implantation Syndrome (BCIS) is a peri-procedural cardiorespiratory disturbance characterised by any combination of hypoxia (SpO₂ < 94 %), hypotension (fall in systolic arterial pressure > 20 %), unexpected loss of consciousness, or cardiovascular collapse occurring around cementation, prosthesis insertion, joint reduction, or tourniquet release during orthopaedic surgery.
• Although most frequently associated with cemented hip arthroplasty, similar physiology is described in uncemented and spinal procedures, suggesting a multifactorial aetiology beyond cement alone.

Incidence

(Scoping reviews 2024-25 show stable incidence despite modern techniques.)

• Cemented hip arthroplasty: 15–47 % overall; severe (Grade 2-3) 4–7 %.
• Cemented knee arthroplasty: 28–71 %.
• Shoulder arthroplasty: ~16 %.
• Uncemented hip arthroplasty: < 22 %, usually Grade 1.

Clinical Grading (Donaldson)

Grade	Criteria	30-day mortality
1	SpO₂ < 94 % or SAP ↓ > 20 %	Baseline
2	SpO₂ < 88 % or SAP ↓ > 40 % or LOC	↑ 16-fold vs G1
3	Cardiovascular collapse / CPR required	up to 88 %

Timing “Danger Windows”

• Cement pressurisation and stem insertion
• Joint reduction (intramedullary pressure spike)
• Tourniquet deflation (knee/shoulder)
• Reaming of long bones or vertebral bodies

Pathophysiology

• Embolic Load
  • High intramedullary pressure drives fat, marrow, air, fibrin, platelet aggregates and cement particles into the venous system → RV outflow obstruction and raised pulmonary vascular resistance (PVR).
• Pulmonary Vasoreactivity
  • Endothelial injury and circulating mediators (thrombin, serotonin, thromboxane A₂, platelet-activating factor, endothelin-1) exacerbate acute pulmonary vasoconstriction, precipitating right-ventricular (RV) failure.
• Ventriculo-Ventricular Interaction
  • The thin-walled RV dilates against fixed pericardial volume, shifting the interventricular septum leftwards:
    • ↓ LV compliance & preload
    • ↓ Cardiac output
    • Systemic hypotension ± pulseless electrical activity
• Monomer & Thermal Effects (minor)
  • Circulating methyl-methacrylate (MMA) can cause vasodilation in vitro, and exothermic polymerisation injures marrow endothelium, but contemporary evidence suggests these are secondary contributors.

Risk Factors

Patient	Surgical	Anaesthetic
Age > 75 yr	Cemented long-stem or revision arthroplasty	GA with volatile agents ± N₂O
ASA III-IV	Pathological/inter-trochanteric fracture	Hypovolaemia
Pre-existing pulmonary hypertension or RV dysfunction	High-viscosity cement, poor lavage	Inadequate oxygenation
COPD, active malignancy (esp. lung mets)	Inadequate venting/cement restrictor	Diuretic or warfarin therapy
Chronic renal failure, frailty	Bilateral or simultaneous procedures	Lack of advanced haemodynamic monitoring

Risk-Reduction Strategies

Surgical

• Pulsatile lavage & canal drying before cementation
• Intramedullary venting or distal plug to limit pressure
• Retrograde, low-viscosity vacuum-mixed cement, small boluses
• Cement gun with pressure-relief holes; pause ventilation during pressurisation
• Consider cementless or short-stem prosthesis in extreme risk

Anaesthetic

1. Preparation
   • Optimise volume status; avoid hypovolaemia
   • Pre-emptive arterial line ± cardiac output monitor (e.g. oesophageal Doppler/TEE) in ASA ≥ III
2. During High-Risk Steps
   • FiO₂ 0.8-1.0; turn off N₂O
   • Communicate “cement time” countdown with theatre team
   • Low-dose vasopressor (norepinephrine 0.02-0.05 µg kg⁻¹ min⁻¹) running before cement insertion in frail patients
3. Early Warning
   • Sudden ETCO₂ fall, SpO₂ drop, or RV dilation on echo precede haemodynamic collapse
4. Post-cement
   • Maintain vigilance for 15 min; continue supplemental O₂ into recovery

Composition of Polymethyl-Methacrylate (PMMA) Cement

Component	Function
Pre-polymerised PMMA powder (≈ 90 %)	Matrix
Dibenzoyl-peroxide	Polymerisation initiator
Liquid MMA monomer + N,N-dimethyl-p-toluidine	Activator & carrier
Radiopacifier 10 % (barium sulphate / zirconium dioxide)	Imaging
Optional antibiotics (gentamicin, tobramycin, clindamycin ≤ 1 g per 40 g cement)	Local prophylaxis

Antibiotic loading may weaken cement, encourage resistance, and cause nephrotoxicity in susceptible patients.

Management Algorithm

1. Suspect BCIS → Announce & stop further surgical pressurisation
2. 100 % O₂, manual ventilation; increase PEEP cautiously
3. Haemodynamics
   • Restore preload (crystalloid/colloid bolus)
   • Vasopressor of choice: norepinephrine (α₁ ± β) or phenylephrine if tachycardic
   • Add inotrope (dobutamine, epinephrine) if RV failure dominates (T-echo helpful)
4. Advanced Support
   • Pulmonary vasodilators (inhaled nitric oxide or prostacyclin) for refractory PVR
   • Mechanical circulatory/respiratory support (VA-ECMO) if collapse persist
5. Post-event
   • ICU admission; monitor troponin, renal function, coagulation
   • Consider postoperative CT pulmonary angiography if diagnostic doubt

Links

• Pulmonary Hypertension
• Neck of femur fracture
• Geriatrics

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References:

1. Donaldson, A., Thomson, H., Harper, N., & Kenny, N. W. (2009). Bone cement implantation syndrome. British Journal of Anaesthesia, 102(1), 12-22. https://doi.org/10.1093/bja/aen328
2. Association of Anaesthetists. Management of hip fractures 2020–includes updated guidance on BCIS risk mitigation. https://anaesthetists.org
3. Bone Cement Implantation Syndrome: a scoping review. Br J Anaesth 2025;135:1-12. PubMed
4. Barakat N, Browne JA. Is BCIS actually caused by cement? Systematic review using Bradford-Hill criteria. J Arthroplasty 2025;40(8S1):S353-S359.
5. Kaufmann KB et al. Goal-directed therapy and BCIS in cemented hip arthroplasty: RCT. BMC Anesthesiol 2018;18:63.
6. Rass J et al. Bone cement and its anaesthetic complications: narrative review. J Clin Med 2023;12:2105.
7. Study of the cement implantation syndrome. Medicine (Baltimore) 2024;103:e35127.
8. National Patient Safety Team. BCIS case review and safety alert. NHS England 2025.
9. FRCA Mind Maps. (2024). Retrieved June 5, 2024, from https://www.frcamindmaps.org/
10. Clarkson AJ et al. Principles of cemented stem implantation in hip arthroplasty–state-of-the-art technique. EFORT Open Rev 2024;9:1-13.
11. Donaldson AJ et al. Bone cement implantation syndrome. Br J Anaesth 2009;102:12-22.
12. Association of Anaesthetists, British Orthopaedic Association, British Geriatric Society. Safety guideline: reducing the risk from cemented hemiarthroplasty (reaffirmed 2021). Anaesthesia 2015;70:623-626 (current at time of writing).
13. Anesthesia Considerations. (2024). Retrieved June 5, 2024, from https://www.anesthesiaconsiderations.com/

Summaries:
Bone cement implantation syndrome

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© 2025 Francois Uys. All Rights Reserved.

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