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Bone cement implantation syndrome

Intraoperative deaths during hip arthroplasty occur
less frequently but are almost exclusively associated
with cementing of the femoral prosthesis.1,2 Although
cardiac arrest and death are the most catastrophic
symptoms associated with cemented arthroplasty,
bone cement implantation syndrome (BCIS) is a wellrecognized
complex of sudden physiologic changes
that occur within minutes of the use of methyl
methacrylate cement to secure a prosthetic component
into the femur.1-4 The cardiopulmonary complications
of BCIS can be reduced through modern cementing
techniques, appropriate anesthesia interventions,
and adequate patient preparation, as well as
avoiding the use of cement altogether.

Use of cement, with its main component
of methylmethacrylate (MMA),
has been linked to a clinical scenario
consisting of hypotension, bronchoconstriction,
hypoxia, cardiac arrest, and
sudden death. The terms bone implantation
syndrome and bone cement implantation
syndrome have been coined
to describe this phenomenon Longnecker

Bone cement implantation syndrome (BCIS) is poorly understood. It is an important cause of

intraoperative mortality and morbidity in patients undergoing cemented hip arthroplasty and
may also be seen in the postoperative period in a milder form causing hypoxia and confusion.
Hip arthroplasty is becoming more common in an ageing population. The older patient may
have co-existing pathologies which can increase the likelihood of developing BCIS donaldson

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. Khannna 2012

The femoral prosthesis can be fixed to the femoral canal through methyl methacrylate cement or
bony ingrowth. Cemented fixation of the femoral prosthesis has been complicated by the bonecement implantation syndrome, which may result in intraoperative hypotension, hypoxia, and
cardiac arrest and FES postoperatively Miller 2005

Manifestasi klinis

Th e clinical manifestations of bone cement

implantation syndrome include hypoxia
(increased pulmonary shunt), hypotension, arrhythmias
(including heart block and sinus arrest), pulmonary
hypertension (increased pulmonary vascular
resistance), and decreased cardiac output (Morgan 2013)

khanna 2012
MMA (more correctly polymethylmethacrylate), is a vinyl
polymer formed by free-radical polymerization from the
monomer MMA. This polymer is a strong, lightweight
material, commonly seen as Plexiglas at hockey games or
as large windows at aquariums. It is also utilized in acrylic
latex paints and as a viscosity-reducing agent in oils and
fluids. The strength and lightness of MMA and its ability to
be shaped and molded also make it an ideal spaceoccupying,
load-transferring material for distributing the
forces of the various prosthetic components used in arthroplasty
severity classification
Grade 1: moderate hypoxia (SpO2
,94%) or a decrease in
systolic arterial pressure (SAP) .20%.
Grade 2: severe hypoxia (SpO2
,88%) or hypotension
(decrease in SAP .40%) or unexpected loss of consciousness.
Grade 3: cardiovascular collapse requiring cardiopulmonary
resuscitation. Khanna 2012

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Morbidity and mortality

The lack of a standard definition for BCIS goes
against accurate reporting. In a study of 48 patients undergoing
elective cemented THR, one patient (2%) suffered
significant hypotension (.30% reduction in SBP) and
eight patients (17%) developed significant desaturation
(reduction in oxygen saturation .5%).31 Long-stem hip
arthroplasty appears to be associated with a higher incidence
of BCIS. The true incidence of cardiac arrest secondary to BCIS
is unknown, and mortality data are not systematically collected
or published. The intraoperative mortality for cemented hemiarthroplasty
was 0.43% (95% CI: 0.190.67); this group
includes patients with and without femoral fractures.50
If the procedure is undertaken to repair a fracture, the
type of fracture greatly affects the outcome Donaldson

Etiologi dan patofisiologi

While the aetiology and pathophysiology of BCIS is poorly understood,
several models have been proposed. First, the monomermediated
model arose after it was demonstrated that circulating
MMA monomers cause vasodilatation in vitro. The embolus-mediated model proposes two possible
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. Khanna 2012

. Mixing polymerized methylmethacrylate

powder with liquid methylmethacrylate
monomer causes polymerization and cross-linking
of the polymer chains. Th is exothermic reaction
leads to hardening of the cement and expansion
against the prosthetic components. Th e resultant
intramedullary hypertension (500 mm Hg) can
cause embolization of fat, bone marrow, cement, and
air into venous channels. Systemic absorption of

residual methylmethacrylate monomer can produce

vasodilation and a decrease in systemic vascular
resistance. Th e release of tissue thromboplastin may
trigger platelet aggregation, microthrombus formation
in the lungs, and cardiovascular instability as a
result of the circulation of vasoactive substances Morgan 2013
Post-mortem examinations performed after intraoperative
deaths during cemented arthroplasty also confirm the
presence of marrow,5 29 50 53 61 fat,5 50 53 61 bone emboli,61
and MMA microparticles50 in the lungs. Fat emboli have
also been demonstrated post-mortem in the brain, kidneys,
and myocardium of a patient who had a cardiac arrest
during insertion of the femoral prosthesis. Donaldson

Transoesophageal echocardiography
Use of
transesophageal echocardiography can
clearly demonstrate the increased load
of debris entering the right atrium
during cementing of the long bone. Longnecker

Anaphylaxis (Type 1 hypersensitivity) was implicated as a

potential cause for a fatal case of BCIS in 1972 Anaphylaxis and BCIS share many similar
clinical features.
A significant increase in plasma histamine concentration
in hypotensive patients undergoing cementation has
been demonstrated. The anaphylatoxins C3a and C5a are potent mediators of
vasoconstriction and bronchoconstriction.1 An increase in
C3a and C5a levels, suggesting activation of the complement
pathway, has been demonstrated in cemented hemiarthroplasty
but not in uncemented hemiarthroplasty donaldson

4 ruang jantung menunjukkan embolisme a small emboli <5mm b. medium

5-10 c. small emboli right atrium d. large emboli in right atrium

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. Khanna 2012
Patient risk factors
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. Khanna 2012
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.

We recommend that, in addition to standard anaesthetic

monitoring, patients with one or more significant risk
factors for developing BCIS (Table 4) should have a high
level of perioperative vital signs monitoring. This should
include invasive arterial pressure monitoring and a central
venous catheter. donaldson

Newer cementless implants

are made of a porous material that allows natural
bone to grow into them. Cementless prostheses
generally last longer and may be advantageous for
younger, active patients; however, healthy active
bone formation is required and recovery may be
longer compared to cemented joint replacements.
Th erefore, cemented prostheses are preferred for
older (80 years) and less active patients who oft en
have osteoporosis or thin cortical bone. Practices

continue to evolve regarding selection of cemented

versus cementless implants, depending on the joint
aff ected, patient, and surgical technique. Morgan 2013

Management of BCIS
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

The cement implantation syndrome is a time-limited

phenomenon. Human and animal studies strongly
suggest that pulmonary artery pressure normalizes
within 24 hours. Is,I9 Healthy hearts recover in seconds
to minutes even from large embolic loads. If supportive
therapy can maintain haemodynamic stability
even elderly, critically ill patients, will survive. The
underlying problem, acute pulmonary hypertension
and secondary RV failure, is reversible. This reversibility
makes immediate recognition of the situation and
application of aggressive supportive measures in the
operating room essential. Byrick 1997

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