Bone Cement and The Implications For Anaesthesia

Bone cement and the implications for anaesthesia
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10.1093/bjaceaccp/mks011
Continuing Education in Anaesthesia, Critical Care & Pain

ceaccp.oxfordjournals.org
Contin Educ Anaesth Crit Care Pain (2012) doi: 10.1093/bjaceaccp/mks011
First published online: February 23, 2012

Ga utam Kha nna, FCARCSI, EDRA
Jan Cernovsky, FRCA
+ Author Affiliations
Tel: +44 7960205145 E-mail: drgautamkhanna@yahoo.co.uk (for correspondence)
Key words
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Key points
Bone cement is a radio-opaque compound composed of

poly(methyl methacrylate) (90%) and a small quantity of radioopaque crystals.
Antibiotic-loaded bone cement combined with systemic antibiotics
provides the best prophylaxis against postoperative infection.
Bone cement implantation syndrome (BCIS) is poorly understood,
and clinical features include hypoxia, hypotension, cardiac
arrhythmias, and cardiac arrest.
The effects of BCIS can be moderated by the recognition of
high-risk patients and modifications of surgical technique to
reduce cardiopulmonary compromise.
Management of BCIS is mainly focused towards treating pulmonary
arterial hypertension and right ventricular failure.
Poly(methyl methacrylate) (PMMA) was developed in 1928 and was first
marketed under the name of Plexiglas. Since then, PMMA has been used
in a huge number of applications, including transparent glass substitutes
in windows, semiconductor research, and for the bodies of electric
guitars. PMMA has a good degree of biocompatibility, which has made it
an important component of replacement intraocular lenses, dentures,
and dental filling composite materials. In orthopaedic surgery, PMMA
bone cement is used to affix implants and to remodel lost bone.
The medical orthopaedic use of PMMA is universally credited to Sir John
Charnley, who was inspired by his dentist to use dental acrylic for
prosthetic fixation in total hip replacement (THR) procedures in 1957. In
1965, he began to use bone cement (CMW Bone Cement) that was
developed specifically for THRs rather than dental acrylic. Bone cement is
now routinely used in a variety of orthopaedic procedures.
The microscopic structure of bone cement comprises two substances
glued together. The so-called pearls in bone cement consist of small
particles of pre-polymerized PMMA, which are present as white powder.
The second substance is a liquid monomer of methyl methacrylate
(MMA). Both substances are mixed together in theatre after the addition
of a catalyst that initiates the polymerization of the monomer fluid. When
the bone cement hardens, the individual pearls are entrapped and glued
within the net of the polymerized monomer, but no chemical binding
occurs between the pearls and the polymerized monomer.
Antibiotics can be incorporated within the polymerized matrix in the form
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of a soluble powder that is subsequently released into the joint cavity.

Bone cement is used to fill all small openings in the spongy skeleton and
to fill all of the hollows on uneven surfaces. This means that bone
cement can be strongly adherent to the surface of the THR prosthesis
(Table 1).
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Ta ble 1
Composition of bone
cement
The role of antibiotics in bone cement
Data from the Scandinavian Joint Registries showed that antibiotic-loaded

bone cement was used in 95% of revision hip or knee arthroplasties. In
Norway, 48% of surgeons, compared with 85% of those in Sweden, used
antibiotic-loaded bone cement for primary joint replacements. In the
National Hip Replacement Outcome Project in Great Britain,1 69% of the
surgeons who responded stated that they used antibiotic-loaded bone
cement in their primary THR procedures.
Antibiotic-loaded bone cement is a well-accepted adjunct for the
treatment of an established infection. However, its role in the prevention
of infection remains controversial. Many different antibiotics, including
gentamicin, cefuroxime, vancomycin, and tobramycin,2 have been loaded
into bone cement. In contrast to the treatment of infection, prophylaxis
requires low doses of antibiotics in the bone cement. The use of low
doses also avoids the adverse mechanical effects of the antibiotics on the
cement. In general, low-dose antibiotic-loaded bone cement is defined as
1 g of powdered antibiotic per 40 g of bone cement.
Antibiotic-loaded bone cements have also been implicated as a cause of
postoperative renal failure. This is a rare cause of postoperative renal
failure as serum antibiotic levels after the placement of antibiotic laden
bone cement remain below toxic levels; however, there have been recent
case reports3 describing patients who developed acute renal failure after
placement of aminoglycoside laden bone cement. The development of
renal failure in these case reports was associated with pre-existing
co-morbidities (which placed them at high risk of renal failure) and with
the dose of the antibiotics used in the cement.
Thus, the use of antibiotic-loaded bone cement should follow national
guidelines with careful monitoring of patients at high risk of developing
renal failure (Table 2).
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Ta ble 2
Potential disadvantages of
antibiotic-loaded bone
cement
Bone cement implantation syndrome
Bone cement implantation syndrome (BCIS) is a poorly understood

phenomenon and currently has no agreed definition. It is an important
cause of intraoperative mortality and morbidity and is most commonly,
but not restricted to, being associated with cemented hip arthroplasty.
The clinical features of BCIS typically occur at the time of cementation,
prosthesis insertion, reduction in the joint, or deflation of a limb
tourniquet. A classification system for BCIS has been proposed according
to its severity4 as follows:
Grade 1: moderate hypoxia (
arterial pressure (SAP) >20%.
<94%) or a decrease in systolic
Grade 2: severe hypoxia (

<88%) or hypotension (decrease in SAP
>40%) or unexpected loss of consciousness.
Grade 3: cardiovascular collapse requiring cardiopulmonary
resuscitation.
BCIS has a wide spectrum of clinical features that range from transient
desaturation and hypotension to cardiac arrhythmias and cardiac arrest
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at the time of cement deployment. Clinical reports and studies all

demonstrate the presence of right ventricular failure secondary to
increased pulmonary artery pressure (PAP) as the underlying cause of
systemic hypotension and sudden cardiac arrest. The cause of the acute
increase in pulmonary vascular resistance (PVR) remains uncertain. It may
be due to deposition of cement or fat emboli or may be a result of
systemic absorption of the volatile monomer. Regardless of the cause,
the thin-walled and compliant right ventricle rapidly dilates and shifts of
the interventricular septum to the left thereby reducing the volume of the
left ventricular cavity. This occurs because the total volume of the heart
cannot expand within such a rapid time frame, as it is constrained by the
pericardium.
These changes cause an immediate decrease in left ventricular
compliance, reduced ventricular filling, and cardiac output (CO). Studies
in humans have demonstrated the presence of emboli in the cerebral
circulation in patients undergoing cemented hip arthroplasty using
transcranial Doppler imaging.5 This may occur as a result of the
transpulmonary passage of the emboli or emboli passing through a
patent foramen ovale, but none of the patients in these studies
developed any neurological deficit. However, these emboli may be a
contributory factor for postoperative delirium that commonly occurs in
elderly patients (Table 3).
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Ta ble 3
Risk factors for the

development of BCIS
Aetiology and pathophysiology of BCIS
While the aetiology and pathophysiology of BCIS is poorly understood,

several models have been proposed. First, the monomer-mediated model
arose after it was demonstrated that circulating MMA monomers cause
vasodilatation in vitro.6 However, this hypothesis is not supported in vivo,
where the plasma MMA concentration after cemented hip arthroplasty is
considerably lower than the concentration required to cause adverse
pulmonary or cardiovascular effects.
The embolus-mediated model proposes two possible aetiologies:
mechanical and mediator effects. According to the former, debris,
including marrow, fat, cement particles, air, bone particles, and
aggregates of platelets and fibrin, embolize to the right atrium, right
ventricle, and pulmonary artery intraoperatively. High intramedullary
pressure is the main causative factor for the release of these deposits
into the circulation, and this has been confirmed in both in vitro and in
vivo studies.
Furthermore, one study compared the incidence of embolic events using
conventional vs modified cementing techniques in 120 patients
undergoing THR procedures.7 The modification consisted of a suction
catheter placed in the proximal femur to reduce the increase in
intramedullary pressure during the insertion of the prosthesis. Embolic
events were imaged during the insertion of the prosthetic stem in 93.4%
of the patients with the use of the conventional cementing technique and
13.4% of the patients with the modified technique. It should be noted that
the degree of cardiovascular compromise is not necessarily proportional
to the degree of the embolic load.
In terms of the mediator effects, vasoactive or pro-inflammatory
substances are released as a result of systemic embolization of the bone
cement. These can directly increase PVR by raising the blood levels of
thrombin and tissue thromboplastin. Other mechanisms that cause
mediator release include mechanical stimulation or endothelial damage
by the cement emboli, which induce reflex vasoconstriction through the
release of endothelial mediators.
These mechanisms result in increased PVR, which is responsible for V/Q
mismatch resulting in hypoxaemia. C3a and C5a are potent mediators of
vasoconstriction and bronchoconstriction. An increase in C3a and C5a
levels has been demonstrated in cemented hemiarthroplasty in some
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desaturation seen during cement implantation. Raised levels of histamine

have also been found in patients8 who were hypotensive after cemented
hip arthroplasties, which could be either the result of a hypersensitivity
reaction or a direct effect of the cement.
In vitro studies found that the quantity of emboli and the severity of
cardiorespiratory changes observed during total hip arthroplasty with the
use of bone cement were greater than those seen when cement was not
used. A study that involved the use of transoesophageal
echocardiography in humans showed that the insertion of the femoral
component with cement caused more severe and more prolonged
embolic cascades than the insertion of the component without cement.9
Intraoperative pulmonary shunt values increased significantly when the
femoral component was inserted with cement, but the shunt values did
not change when the component was inserted without cement. 10 These
findings suggest that patients who require a total hip arthroplasty,
especially those who have underlying cardiorespiratory disease, may have
less morbidity if the femoral component is inserted without cement than
if it is inserted with cement.
Prevention of BCIS
The anaesthetist should be fully involved in the preoperative assessment

of patients. This involves the identification of high-risk surgical patients
before operation, the assessment and optimization of their
cardiovascular reserve before surgery, and the appropriate use of this
information to select the type of prosthesis, surgical procedure, and
techniques in order to minimize the risk of cardiovascular complications.
Patient risk factors that have been implicated in genesis of BCIS after
cemented THRs include grade III and IV ASA levels, old age, poor
pre-existing physical reserve, impaired cardiopulmonary function,
pre-existing pulmonary hypertension, osteoporosis, bony metastases,
and concomitant hip fractures, particularly pathological or
intertrochanteric fractures.
There is no clear evidence with regards to the effect of anaesthetic
technique on the severity of BCIS. The general principles of management
include the maintenance of normovolaemia to avoid the cardiovascular
consequences of cementing and the maintenance of high inspired
concentrations of oxygen. The use of high anaesthetic vapour
concentrations should be avoided as it is associated with greater
haemodynamic compromise with the same embolic load.
The use of intraoperative CO monitoring has been recommended in
patients with one or more risk factors for BCIS. This can be in the form of
semi-invasive transoesophageal Doppler monitor or invasive CO monitor
(pulmonary artery flotation catheter). The use of intraoperative
transoesophageal Doppler has been shown to aid the early detection of
cardiovascular changes around the time of cementing, improve fluid
management, and reduce postoperative cardiopulmonary complications
in hip surgery. A transoesophageal Doppler study11 involving patients
undergoing hip arthroplasty demonstrated the superiority in detecting
cardiovascular changes during cementing compared with standard
haemodynamic monitoring, recommending its use in high-risk patients.
Pulmonary artery flotation catheter and transoesophageal
echocardiography should also be considered in high-risk patients. But
their use is limited by their availability and expertise required to use
them.
Role of surgery in prevention of bone cement-associated complications
The use of a cementless hip prosthesis can reduce the morbidity

associated with cement embolization and must be considered on an
individual basis. Surgical measures that can reduce the incidence of
complications associated with bone cement, especially BCIS, include
thorough lavage of the intramedullary canal of the femoral shaft in order
to remove debris, good haemostasis, the use of non-cemented
prostheses, and drilling a venting hole in the distal femoral shaft.10 The
latter technique reduces air trapping during the cementing process and
acts as a pressure-relieving opening during the intramedullary reaming
of the femoral canal. However, drilling a venting hole increases the risk
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of fracture and prosthetic instability.

The bone-vacuum cementing technique has been shown to reduce the
embolic load during total hip arthroplasty. In this technique, a suction
pressure of 800 mbar (80 kPa) is applied to a proximal drainage
cannula placed along the linea aspera and a distal drainage cannula is
placed in the diaphysis to produce a vacuum in the medullary cavity of
the femur during the application of cement and the insertion of the stem.
The reduction in embolic load using this technique was evident in
intraoperative transoesophageal imaging.12
The retrograde insertion of cement (from distal to proximal) by a cement
gun causes the compartmentalization of the bone marrow contents. This
can lead to a more uniform increase in intramedullary pressure and less
physiological disturbance. Furthermore, mixing bone cement in a specific
cement-mixing set, which is in a vacuum, reduces the load of volatile
vasoactive compounds. This, and the use of low-viscosity cement, can
reduce the incidence of BCIS.
Management of BCIS
Human and animal studies have shown that BCIS is a reversible,

time-limited phenomenon. The PAPs can normalize within 24 h and
non-diseased hearts can recover within minutes to hours. This means
that aggressive resuscitation and supportive treatment is essential to
reduce the morbidity and mortality of this potentially life-threatening
situation.
When BCIS is suspected, resuscitation should be based on general
principles. The inspired oxygen concentration should be increased to
100%. The management of cardiovascular collapse should be in line with
the treatment of right ventricular failure, 4 including i.v. fluid therapy, the
use of pulmonary vasodilators for reducing PAP, and the use of inotropes
(dobutamine and milrinone) to maintain right ventricular contractility. If
simple measures fail, intraoperative CO monitoring should be used,
either in the form of non-invasive CO monitoring, such as
transoesophageal Doppler imaging and PiCCO (arterial pulse contour
analysis), or with invasive CO monitoring with the use of a pulmonary
artery flotation catheter to guide vascular filling and the use of
vasopressors and inotropes. Although central venous pressure
monitoring does not accurately reflect the PAP, the insertion of a central
venous catheter may be indicated for the administration of inotropic
drugs. After operation, the patient should be managed in an intensive
care unit setting.
Summary
BCIS is a poorly understood phenomena with a variety of clinical features.
A number of theories have been proposed to explain the pathophysiology
of this complex phenomenon, but it is postulated that the true aetiology
may encompass a combination of mechanisms, partly modified by the
patient's own physiological response and pre-existing pathology. The
identification of high-risk patients through thorough preoperative
assessment and modification of surgical technique tailored to patients'
general condition may help in reducing the incidence of BCIS.
Declaration of interest
None declared.
The Author [2012]. Published by Oxford University Press on behalf of the British Journal of
Anaesthesia. All rights reserved. For Permissions, please email:
journals.permissions@oup.com
References
1. Best AJ, Fender D, Harper WM, McCaskie AW, Oliver K, Gregg PJ. Current practice in
primary total hip replacement: results from the National Hip Replacement Outcome
Project. Ann R Coll Surg Engl 1998;80:350-5.
Medline
Google Scholar
2. Engesaeter LB, Lie SA, Espehaug B, Furnes O, Vollset SE, Havelin LI. Antibiotic
prophylaxis in total hip arthroplasty. Acta Orthop Scand 2003;74:644-51.
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CrossRef
Medline
Web of Science
3. Patrick BN. Acute renal failure associated with vancomycin- and tobramycin-laden
cement in total hip arthroplasty. Ann Pharmacother 2006;40:2037-42.
doi:10.1345/aph.1H173.
CrossRef
Medline
Web of Science
4. Donaldson J, Thomson HE, Harper NJ, Kenny NW. Bone cement implantation
syndrome. Br J Anaesth 2009;102:12-22. doi:10.1093/bja/aen328.
Abstract/FREE Full Text
5. Edmonds CR, Barbut D, Hager D, Sharrock NE. Intraoperative cerebral arterial

embolisation during total hip arthroplasty. Anesthesiology 2000;93:315-8.
doi:10.1097/00000542-200008000-00006.
CrossRef
Medline
Web of Science
6. Karlsson J, Wendling W, Chen D. Methylmethacrylate monomer produces direct

relaxation of vascular smooth muscle in vitro. Acta Anaesthesiol Scand
1995;39:685-9. doi:10.1111/j.1399-6576.1995.tb04148.x.
CrossRef
Medline
Web of Science
7. Koessler MJ, Fabiani R. The clinical relevance of embolic events detected by

transesophageal echocardiography during cemented total hip arthroplasty: a
randomized clinical trial. Anesth Analg 2001;92:49-55.
doi:10.1097/00000539-200101000-00010.
CrossRef
Medline
Web of Science
8. Tryba M, Linde I, Voshage G, Zenz M. Histamine release and cardiovascular

reactions to implantation of bone cement during total hip replacement.
Anaesthesia 1991;40:25-32.
Google Scholar
9. Christie J, Burnett R, Potts HR, Pell AC. Echocardiography of transatrial embolism

during cemented and uncemented hemiarthroplasty of the hip. J Bone Joint Surg Br
1994;76:409-12.
Medline
Google Scholar
10. Ries MD, Lynch F, Rausher LA, Richman J, Mick C, Gomez M. Pulmonary function
during and after total hip replacement. Findings in patients who have insertion of a
femoral component with and without cement. J Bone Joint Surg Am 1993;75:581-7.
Medline
Google Scholar
11. Clark DI, Ahmed AB, Baxendale BR, Moran CG. Cardiac output during
Online
ISSN 2058-5357
Print
ISSN
2058-5349controlled trial of cemented and
hemiarthroplasty
of -the
hip.
A prospective,
uncemented prostheses. J Bone Joint Surg 2001;83:414-8.
doi:10.1302/0301-620X.83B3.11477.
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12. Pitto RP. Comparison of fixation of the femoral component without cement and
fixation with use of a bone-vacuum cementing technique for the prevention of fat
embolism during total hip arthroplasty. J Bone Joint Surg 1999;81:831-43.
Medline
Google Scholar
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Medicine & Health BJA: CEACCP

Continuing Education in Anaesthesia, Critical Care & Pain