Bone Cement Implantation Syndrome in Bone Tumor Surgeries: Incidence, Risk Factors, and Clinical Experience

Bone cement implantation syndrome in patients with cemented endoprostheses for metastatic bone disease in the femur

Background

Patients with bone metastases in the femur (BMf) may experience pathological fractures requiring surgery with cemented endoprostheses (EPR). At cementation and prosthesis insertion, patients are at risk of experiencing hypoxia, hypotension, cardiac failure and potentially death, known as bone cement implantation syndrome (BCIS). We aimed to 1) investigate the incidence and grade of BCIS in patients with BMf treated with cemented EPR, and 2) examine if the incidence or extent of BCIS has decreased after a change of a combined anesthesiologic and surgical protocol.

Methods

We retrospectively assessed patients with BMf operated with cemented EPR in two periods 2017 - 2018 (early cohort) and 2019 - 2020 (late cohort) and stratified before and after the intervention.

Results

Comparing the early and late cohorts, 26/86 (32 %) vs. 30/80 (35 %) experienced BCIS, but mild BCIS (grade 0 + 1) was seen in 79 % vs. 86 %, and severe BCIS (grade 2 + 3) in 21 % vs. 14 %. In the late cohort the per-operative use of vasopressors was higher (86 % vs. 59 %, p < 0.001), we found fewer pulmonary embolisms (PE) (p = 0.024), and a trend toward a reduced length of stay (LOS). 30-day survival was lower for patients with grade 0 + 1 compared to grade 2 + 3 (p = 0.03).

Conclusions

BCIS occurs in more than 1/3 of patients operated for BMf with cemented EPR. An increased multidisciplinary focus on BCIS may reduce the complications of BCIS, such as PE and LOS.

[Research progress in etiology and prevention of bone cement implantation syndrome]

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.

A Novel Implant Design for Cemented Endoprosthesis Stems to Reduce the Risk of Bone Cement Implantation Syndrome

BACKGROUND

 Bone cement implantation syndrome (BCIS) is a life-threatening risk of cemented stems. There are limited methods to prevent BCIS and few published studies. A survey of the Musculoskeletal Tumor Society (MSTS) surgeons was conducted to evaluate their experiences with BCIS. A novel stem designed to reduce intramedullary pressure during insertion was evaluated.

METHODS

 A survey was distributed to MSTS members, and data was collected. The novel stem featured a hollow longitudinal channel, an entry hole at the tip, and an egress hole at the collar for cement to flow from the intramedullary canal during insertion. Bending stiffness was compared using finite element analysis to a standard solid stem. Stems were cemented into cadaveric femurs. Specimens were loaded with 8000 N tensile force and then maximally torqued until failure. Intramedullary pressures were measured for novel and standard stems cemented into sawbones.

RESULTS

 In 107 survey responses, 58% (n = 63) experienced severe BCIS, and 83% (n = 52) of those had ≥1 death from BCIS complications. Many surgeons avoid cementing long stems, and 78% (n = 14) report concern for BCIS as the reason. Seventy-nine percent (n = 84) use an average of 4.75 different methods to reduce BCIS risk. The novel stem demonstrated 2.8% reduced bending stiffness. When cemented into cadaveric bone, both stem designs achieved 8000 N of tensile force, and there was no significant difference in torque failure (140.6 Nm in the novel stem; 128 Nm in the standard stem). The average peak pressure was significantly lower for the novel stem (77 psi vs. 151 psi).

CONCLUSIONS

 The majority of surgeons have concerns regarding BCIS based on their experience and use multiple methods to reduce risk. A novel stem can reduce the intramedullary insertion pressure by approximately half and possibly reduce the risk of BCIS. Testing demonstrates similar stiffness and stability compared to standard solid stems.

Bone cement implantation syndrome: the role of echocardiography and multidisciplinarity

Bone cement implantation syndrome (BCIS) is a potentially serious complication after joint replacement surgery, resulting from bone marrow debris and cement embolisation, culminating in pulmonary and cardiovascular collapse. Echocardiography aids in diagnosis and management. We present a woman in her 80s with grade II BCIS. CT angiogram was inconclusive, but echocardiography revealed hyperechogenic material and right ventricular dysfunction, confirming the diagnosis. She received cardiovascular and respiratory support in a level II intensive care unit, showing full recovery of the right ventricle function when it was later reassessed. This potentially fatal condition is successfully managed if recognised early with adequate supportive care. Echocardiography might guide the diagnosis, consolidating supportive measures.

Study of the cement implantation syndrome: A review

Bone cement implantation syndrome (BCIS) is a critical and potentially life-threatening condition that manifests during implantation. Characterized by a constellation of symptoms, including hypoxemia, hypotension, cardiac arrhythmias, elevated pulmonary vascular resistance, and occasionally cardiac arrest, BCIS typically ensues shortly after cement introduction, albeit with rare instances of delayed onset. Primarily attributed to the exothermic reaction of bone cement implantation, this syndrome is caused by local tissue damage, histamine and prostaglandin release, and microemboli formation, ultimately triggering a systemic immune response that culminates in respiratory and circulatory failure. The current hypotheses regarding BCIS include embolism, allergic reactions, and cement autotoxicity. BCIS management emphasizes preventative strategies, encompassing meticulous patient risk assessment, comprehensive preoperative and intraoperative evaluations, and precise cement application techniques. Treatment primarily involves symptomatic therapy and life-support measures to address the systemic effects of the syndrome.

Cemented vs uncemented megaprostheses in proximal femur metastases: a multicentric comparative study

BACKGROUND

Hip megaprostheses are a long known reconstructive method in the treatment of proximal femur metastases. The use of cemented or uncemented stems is still matter of debate. The aim of this study to compare cemented and uncemented megaprostheses on functional outcomes and complications, in order to establish the role of cementation.

METHODS

We retrospectively analysed 51 metastatic patients with proximal femur metastases treated with endoprosthetic reconstruction by megaprostheses, 25 with cementless stems and 26 with cemented ones with different megaprosthetic implants. The primary endpoint was MSTS score, and the secondary endpoint was to state the incidence of surgical and clinical complications in the two groups. An un-paired T test was used to compare anthropometric, anamnestic data, and MSTS. Chi-square test was performed for evaluation of complication in the two group. Multiple linear regression was used to match the functional outcomes and complications' incidence in the population study. Logistic regression was performed to analyse the odds ratio of different parameters and their role in the incidence of complications.

RESULTS

The mean follow-up was 50.1 months (+ 12.5). In thirty case right side was involved. No statistical differences were noticed between Group A and B regard the age, gender, active fracture/impending fracture. Comparing the MSTS results within the two groups at last follow-up, the score cemented group was higher than cementless one (17.9 + 7.8 vs 24.2 + 5.3; statistical significance p = 0.001). Regarding surgical complications a logistic regression was performed to analyse the odds ratio of age, cementation and length of resection; cementation confirm and odds ratio of 11 times in the incidence of surgical complications.

CONCLUSIONS

Cementation seems to be more liable to complications onset, while improves functional score in metastatic patients compared to uncemented megaprostheses. More studies have to be conducted in order to create a protocol and establish criteria to use cemented or uncemented stems in a frail population like metastatic patients.