BONE CEMENT IMPLANTATION

SYNDROME (BCIS)
MODUL ORTHOPEDI – 2 R3
FUD – PAM – VIK – DRI – WIT – PIL – KIS – AYO – GAR – NAD
INTRODUCTION

Bone Cement Implantation BCIS is characterised by

Syndrome (BCIS) is a
potentially fatal complication
of orthopaedic surgery,
involving pressurised bone
cement
hypoxia and/or hypotension
(with potential loss of
consciousness), occurring
around the time of bone
cementation

The incidence of BCIS in

orthopaedic procedures: 20%
The incidence of a severe
reaction resulting in
cardiovascular collapse : 0.5-
1.7%
INTRODUCTION

Bone cement implantation syndrome (BCIS) is most likely to occur during

cemented orthopedic procedures, which most commonly use methyl
methacrylate (MMA) cement

There have been multiple reports of this phenomenon since the approval of
MMA cement by the FDA in 1971 for orthopedic procedures

Similar hemodynamic changes have been reported in patients undergoing

uncemented arthroplasty

The procedures most frequently described in patients experiencing BCIS

are hip arthroplasty, knee arthroplasty, and vertebroplasty
CLASSIFICATION

 This syndrome is classified according to severity of symptoms

generally ranging from grade 1, moderate hypoxia and
hypotension, to grade 3, cardiovascular collapse
 Proposed by Donaldson in 2009
 PATHOPHYSIOLOGY

Not all documented BCIS

Early theories focused on
phenomena can be
Yet the etiology and circulating MMA
explained by the embolus
pathophysiology of BCIS is monomers; recent
theory alone, and further
not fully established evidence proposes an
research is needed in this
embolus-mediated model
area

Additional proposed
theories focus on the role Nearly all the studies and
of histamine release, models used to explain
complement activation, BCIS are based on research
and multimodal involving hip arthroplasties
possibilities
PATHOPHYSIOLOGY
Embolic model
• The cement then expands in the space
between the bone and the prosthesis 
pressurising air and the medullary
contents  forcing into the circulation
• These embolic contents include fat,
marrow, cement, air, bone particles, and
aggregates of platelets and fibrin
• They may reach the lungs, heart, and
coronary circulation
• Showers of pulmonary emboli  hypoxia
and right ventricular dysfunction 
leading to hypotension
Multimodal Model
(Histamine release, hypersensitivity and
complement activation)
• Anaphylaxis and BCIS share many
features (significant increase in plasma
histamine concentration)
• Surgeon contact with Methyl
Methacrylate (MMA)  increase in
blood levels of C3a and C5a
(anaphylactoid complements and are
potent mediators of vasoconstriction and
bronchoconstriction)
• These mediators yield an increase in
pulmonary vascular resistance, causing
V/Q disturbances, hypoxia, right
ventricular failure, and cardiogenic shock
 PATHOPHYSIOLOGY

Mixing polymerized methylmethacrylate powder with liquid methylmethacrylate monomer causes

polymerization and cross-linking of the polymer chains

This exothermic reaction leads to hardening of the cement and expansion against the prosthetic
components

The resultant canintramedullary hypertension (>500 mm Hg) 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

The 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
RISK FACTOR
CLINICAL FEATURES

Physiologically, Bone Cement Implantation Syndrome results in reduced

arterial oxygenation, characterised by a combination of clinical features

Typically, it manifests at the time of cementation, prosthesis insertion,

reduction of joint, or deflation of tourniquet

Clinical signs of BCIS plus the sudden reduction in ETCO2 are strong
indicators of BCIS; however, a definitive diagnosis is made by computed
tomographic scan
CLINICAL FEATURES

Non-fulminant BCIS Fulminant BCIS

• Significant reduction in • Intraoperative cardiovascular
arterial oxygen saturation and changes, progressing to
systolic blood pressure (SBP) arrhythmias, shock, or cardiac
in the pericementation period arrest
CLINICAL FEATURES

The presence of these

Emboli in the cerebral cerebral emboli has been
circulation have also been cited as a possible
detected via transcranial explanation for the
Doppler imaging postoperative delirium
seen in older adults
MANAGEMENT

Early detection of BCIS is crucial for patient

survival

Rapid initiation of aggressive supportive

therapy is key to optimizing patient outcomes
 MANAGEMENT

Administration of 100% inspired oxygen is a first-line therapy, with airway

control dictated by clinical necessity

Fluid resuscitation to maintain RV preload, and inotropes to support

ventricular contractility are recommended

Increase aortic Improve

Vasopressors cause
blood pressure myocardial
peripheral
(supports coronary perfusion and
In cases of severe BCIS (the patient vasoconstriction
artery blood flow) contractility
has arrested, or in a peri-arrest
condition), standard (ACLS) Use of vasopressors and inotropes should be continued into the
algorithms and procedures should postoperative period as necessary
be followed
TREATMENT STRATEGIES

Increasing inspired oxygen concentration prior to cementing

Monitoring to maintain euvolemia

Creating a vent hole in the distal femur to relieve intramedullary pressure

Performing high-pressure lavage of the femoral shaft to remove debris

Using a femoral component that does not require cement

INTRAOPERATIVE ROLES
MONITORING

BCIS is a time-limited phenomenon pulmonary artery pressure normalises within 24 hours

Even with large embolic loads, healthy hearts may recover in seconds to minutes

The underlying mechanism – acute pulmonary hypertension and secondary right ventricular
failure – should be considered reversible

Aggressive stabilisation and supportive therapy are the cornerstones in managing BCIS

For patients who have not met the criteria for severe BCIS but who have a suspicious clinical
picture, they should be monitored closely in a high-dependency unit for at least the first 24 hours
after the operation
TERIMA KASIH