Cardiac output during hemiarthroplasty of the hip

Bone Cement and Its Anesthetic Complications: A Narrative Review

The concept of bone cement implantation syndrome (BCIS) is not yet fully understood. In patients undergoing cemented hip arthroplasty, it is a significant factor in intraoperative mortality and morbidity. It may also manifest in a milder form postoperatively, resulting in hypoxia and confusion. In the older population, hip replacement surgery is becoming more prevalent. The risks of elderly patients suffering BCIS may be increased due to co-existing conditions. In this article, we present a narrative review of BCIS including its definition, incidence, risk factors, etiology, pathophysiology, clinical features, prevention, and management, all from an anesthetic point of view.

The Bone Cement Hypercoagulation Syndrome: Pathophysiology, Mortality, and Prevention

Since Charnley introduced acrylic cement to seal metallic hip prostheses in the 1950s, reports of perioperative fatal cardiorespiratory and vascular dysfunctions have been published. Studies on humans and animals have shown neurogenic stimulation and substantial local and systemic activation of coagulation are caused by surgical bone marrow damage and chemical cell destruction by toxic monomeric methyl methacrylate from the implanted cement and other tissue-released substances. Venous blood-borne cell fragments and conjugates of activated cells from the surgical site are sequestered and trapped in the pulmonary microcirculation. A substantial hypercoagulation occurs in the lung circulation. Hypercoagulable blood is passed over to the arterial side and may cause vessel obliteration and organ damage. This process may affect the brain, heart, and kidneys and, through the release of vasoactive substances, introduce hemodynamic imbalances that can lead to fatal outcomes in susceptible populations such as elderly patients with hip fractures. The main underlying pathophysiologic processes leading to these occasionally devastating outcomes are a substantial activation of coagulation and cell destruction caused by the toxic substance released by curing bone cement and several vasoactive substances.

The Influence of a Modified 3rd Generation Cementation Technique and Vaccum Mixing of Bone Cement on the Bone Cement Implantation Syndrome (BCIS) in Geriatric Patients with Cemented Hemiarthroplasty for Femoral Neck Fractures

Background and Objectives: Cemented hemi arthroplasty is a common and effective procedure performed to treat femoral neck fractures in elderly patients. The bone cement implantation syndrome (BCIS) is a severe and potentially fatal complication which can be associated with the implantation of a hip prosthesis. The aim of this study was to investigate the influence of a modified cementing technique on the incidence of BCIS. Material and Methods: The clinical data of patients which were treated with a cemented hip arthroplasty after the introduction of the modified 3rd generation cementing technique were compared with a matched group of patients who were treated with a 2nd generation cementing technique. The anesthesia charts for all patients were reviewed for the relevant parameters before, during and after cementation. Each patient was classified as having no BCIS (grade 0) or BCIS grade 1,2, or 3 depending on the severity of hypotension, hypoxia loss of consciousness. Results: A total of 92 patients with complete data sets could be included in the study. The mean age was 83 years. 43 patients (Group A) were treated with a 2nd and 49 patients (Group B) with a 3rd generation cementing technique. The incidence of BCIS grade 1,2, and 3 was significantly higher (p = 0,036) in group A (n = 25; 58%) compared to group B (n = 17; 35%). Early mortality was higher in group A (n = 4) compared to group B (n = 0). Conclusions: BCIS is a potentially severe complication with a significant impact on early mortality following cemented hemiarthroplasty of the hip for the treatment of proximal femur fracture. Using a modified 3rd generation cementing technique, it is possible to significantly reduce the incidence of BCIS and its associated mortality.

Analysis of the Effect of Component Ratio Imbalances on Selected Mechanical Properties of Seasoned, Medium Viscosity Bone Cements

The paper presents the results of experimental strength tests of specimens made of two commercially available bone cements subjected to compression, that is a typical variant of load of this material during use in the human body, after it has been used for implantation of prostheses or supplementation of bone defects. One of the factors analysed in detail was the duration of cement seasoning in Ringer's solution that simulates the aggressive environment of the human body and material degradation caused by it. The study also focused on the parameters of quantitative deviation from the recommended proportions of liquid (MMA monomer, accelerator and stabiliser) and powder (PMMA prepolymer and initiator) components, i.e., unintentional inaccuracy of component proportioning at the stage of cement mass preparation. Statistical analysis has shown the influence of these factors on the decrease in compressive strength of the cements studied, which may be of significant importance in operational practice.

Cemented versus uncemented hemiarthroplasty for the management of femoral neck fractures in the elderly: a meta-analysis and systematic review

INTRODUCTION

Hemiarthroplasty is commonly used to treat unstable femoral neck fractures in older patients. However, there is no consensus on the use of cement during hemiarthroplasty. Therefore, we performed a systematic review to focus on the outcomes of cemented and uncemented hemiarthroplasty for the treatment of femoral neck fractures in older patients.

MATERIALS AND METHODS

Pubmed, Cochrane Central Register of Controlled Trials, and Ovid were searched for studies related comparison of cemented versus uncemented hemiarthroplasty for unstable femoral neck fractures from inception to Jan 20, 2020. The quality of the included randomized controlled trials (RCTs) was assessed using the Cochrane Collaboration tool. The meta-analysis was performed using the RevMan 5.2 software.

RESULTS

Eleven RCTs were included in the meta-analysis. Cemented hemiarthroplasty was found to be superior to uncemented arthroplasty with respect to reoperation rate (RR 0.6, 95% CI 0.38-0.96, p = 0.03), complications related to prosthesis (RR 0.39, 95% CI 0.23-0.68, p = 0.0008), residual pain (RR 0.66, 95% CI 0.52-0.83, p = 0.0004), and operation time (MD 8.22, 95% CI 6.30-10.14, p < 0.00001). There were no significant between-group differences with respect to local and general complications, duration of hospital stay, hip function, and mortality.

CONCLUSIONS

This meta-analysis showed cemented hemiarthroplasty might be an optimum choice for treating unstable femoral neck fractures in older patients. However, the results of this meta-analysis should be interpreted cautiously owing to some limitations. Further studies are required to provide more robust evidence.

Cement augmentation of the proximal femur nail antirotation: is it safe?

BACKGROUND

Cement augmentation of the proximal femur nail antirotation (PFNA; Fa. DePuy Synthes) showed good biomechanical and clinical results regarding increased stability and functional outcome [Linden et al. in J Orthop Res 24:2230-2237, 2006;Kammerlander et al. in Injury 49:1436-1444, 2018;]. Cement-associated complications are well known in orthopedic procedures like hip arthroplasty, vertebra- and kyphoplasty. This study investigates outcome and safety of augmentation of the proximal femur nail blade.

MATERIALS AND METHODS

The retrospective review of the 299 patients (mean age 80 ± 13 years; 205 women and 94 men) focused on perioperative complications after augmentation which was performed with Traumacem V+ Cement (Fa. DePuy Synthes) in 152 cases. The decision for augmentation of the blade was made by the attending surgeon and based on the factors age, bone quality, and fracture pattern. Primary outcome measures were changes in blood pressure, heart rate or oxygen saturation, and the number of needed vasoactive drugs during augmentation. Secondary outcome measures where the rate of cement leakage into the joint, mechanical failure, and perioperative complications like pulmonary embolism, stroke, or heart attack.

RESULTS

In 152 augmented cases, no leakage of cement into the joint could be detected. No signs of mechanical failure like cut-out of the blade were seen after 6 weeks and 3 months. Also, augmentation did not show a higher rate of mortality or postoperative complications like stroke, heart attack, embolism, or infection. 57 of 152 augmented cases received an intraoperative intervention with vasoactive medication at the time of augmentation either prophylactically or because of a blood pressure fall. Out of the non-augmented cases, 21 of 147 needed vasoactive medication in the second half of the operation. The difference between these groups was significant (p < 0.05). In the cases without an intervention, there was a significant blood pressure fall of about 8 ± 7.4 mmHg during the augmentation (p < 0.001). Still, none of the augmented cases showed a change in heart rate or oxygen saturation.

CONCLUSION

The augmentation of the PFNA blade proved to be a safe procedure. Cement augmentation will not increase postoperative complications or mortality. The risk for leakage of cement into the joint is low and mechanical cut-out might be prevented. The decision for augmentation should be made carefully and always be declared loud and in advance to allow the anesthetist to prepare, because blood pressure changes can occur.

The role of bone cement for the development of intraoperative hypotension and hypoxia and its impact on mortality in hemiarthroplasty for femoral neck fractures

Background and purpose - The bone cement implantation syndrome characterized by hypotension and/or hypoxia is a well-known complication in cemented arthroplasty. We studied the incidence of hypotension and/or hypoxia in patients undergoing cemented or uncemented hemiarthroplasty for femoral neck fractures and evaluated whether bone cement was an independent risk factor for postoperative mortality.Patients and methods - In this retrospective cohort study, 1,095 patients from 2 hospitals undergoing hemiarthroplasty with (n = 986) and without (n = 109) bone cementation were included. Pre-, intra-, and postoperative data were obtained from electronic medical records. Each patient was classified for grade of hypotension and hypoxia during and after prosthesis insertion according to Donaldson's criteria (Grade 1, 2, 3). After adjustments for confounders, the hazard ratio (HR) for the use of bone cement on 1-year mortality was assessed.Results - The incidence of hypoxia and/or hypotension was higher in the cemented (28%) compared with the uncemented group (17%) (p = 0.003). The incidence of severe hypotension/hypoxia (grade 2 or 3) was 6.9% in the cemented, but not observed in the uncemented group. The use of bone cement was an independent risk factor for 1-year mortality (HR 1.9, 95% CI 1.3-2.7), when adjusted for confounders.Interpretation - The use of bone cement in hemiarthroplasty for femoral neck fractures increases the incidence of intraoperative hypoxia and/or hypotension and is an independent risk factor for postoperative 1-year mortality. Efforts should be made to identify patients at risk for BCIS and alternative strategies for the management of these patients should be considered.

Radiological subsidence and acetabular erosion after tapered uncemented hemiarthroplasty in femoral neck fractures a 10- to 13- year follow-up study

BACKGROUND

Contemporary uncemented hemiarthroplasties are being used after displaced femoral neck fractures, however, their functional and radiological results remain controversial. The aim of this study was to evaluate the clinical and radiological results of a tapered uncemented stem combined with a uni- or bipolar hemiarthroplasty after a minimum follow-up of ten years.

PATIENTS AND METHODS

135 patients underwent uncemented hip hemiarthroplasty after a displaced femoral neck fracture between 2004 and 2007. Their mean age was 81.5 years old (range, 70 to 90). 38 patients were evaluated with a minimum follow-up of ten years. We analysed the complications and the postoperative clinical result according to the Merle D´Aubigné and Postel scale. Radiological femoral type according to Dorr et al., femoral canal filling and the appearance of stem loosening, subsidence and acetabular erosion according to Baker et al., were also assessed.

RESULTS

There were two early periprosthetic femoral fractures. The mean clinical score was 15.8 (range, 9 to 17). Six hips were converted to a total hip arthroplasty due to acetabular erosion, and three stems were revised due to an infection, a late periprosthetic fracture and one aseptic loosening. The survival rate for any cause was 85.4% (Confidence interval (CI) 76 - 92.4%). The survival rate for revision surgery on the acetabular side at 10 years was 92.6% (CI 85 - 100%) and on the femoral side was 97.6% (CI 94.4 - 100%). 14 hips showed non-progressive radiological subsidence and 9 acetabular erosion. Stem subsidence was related to a femoral canal filling < 80% (p = 0.035) and acetabular erosion to a cylindrical femur (p = 0.024).

CONCLUSION

Bone fixation can be obtained with a contemporary uncemented stem in hemiarthroplasty for patients over 70 years old with a femoral neck fracture. Acetabular erosion was frequent after ten years, however, the rate of revision surgery was low.

Cemented versus uncemented hemi-arthroplasty for femoral neck fractures in elderly patients: A systematic review and meta-analysis of randomized controlled trials

AIM

To compare the efficacy and safety of cemented and uncemented hemiarthroplasty in elderly patients with femoral neck fracture.

MATERIALS AND METHODS

We searched PubMed, EMBASE, and Cochrane Library databases for published randomized clinical trials comparing cemented hemiarthroplasty with uncemented hemiarthroplasty in elderly patients with a femoral neck fracture. The search was not limited to language, time, or other factors. The quality of each study was assessed using the revised Jadad scale. Two researchers independently extracted data from all selected studies, including the following base line data: study period, fracture stage, number of patients, male female ratio, average age, and per-protocol (PP) or intent-to-treat (ITT), and the interest outcomes: the mortality at 12 months, operative time, hospital stay, common complications, prosthetic-related complications, blood loss and Harris Hip Score (HHS). Fixed-effects or random-effects models with mean differences and odds ratios were used to pool the continuous and dichotomous variables to determine heterogeneity of the included studies.

RESULTS

A total of 8 studies involving 1577 hips (782 uncemented and 795 cemented) were included in this meta-analysis. The meta-analysis is indicated that the operation time of cemented hemiarthroplasty was longer than uncemented hemiarthroplasty and there was statistical significance between two groups (OR = -7.30, 95%CI, -13.13, -1.46; P = .01). However, there was no significant difference between the two methods of fixation in mortality at 12 months (OR = 1.22, 95%CI, 0.94-1.59; P = .14), hospital stay (OR = 0.26, 95%CI, -0.41, 0.93; P = .44), blood loss (OR = -17.94, 95%CI, -65.83, 29.95; P = .46), and HHS score. There were significant differences in the common complications of pulmonary embolism between the two groups, but there were no differences in the other five common complications. The results showed that uncemented hemiarthroplasty could reduce the incidence of pulmonary embolism after operation. Moreover, the outcomes of prosthetic-related complications showed that there were significant differences between the two groups in periprosthetic fracture (OR = 8.32, 95%CI, 3.85-17.98; P < .00001) and prosthetic subsidence and loosening (OR = 5.33, 95%CI, 2.18-13.00; P = .0002).

CONCLUSIONS

Our study shows that uncemented prosthesis can shorten the operation time and reduce the incidence of pulmonary embolism, but it does not reduce mortality, blood loss, and hospital stay. Most importantly, the incidence of prosthetic-related complications was higher in uncemented patients.

Occurrence, risk factors, and outcomes of bone cement implantation syndrome after hemi and total hip arthroplasty in cancer patients

BACKGROUND AND OBJECTIVES

Patients undergoing cement fixation for hip arthroplasty are at increased risk of developing bone cement implantation syndrome (BCIS). We sought to determine: what is the occurrence of BCIS in patients with cancer after hip arthroplasty? What are the risk factors in patients with cancer for the development of this syndrome? What is the outcome for patients with cancer having BCIS?

METHODS

We identified 374 patients with cancer who underwent cemented hip arthroplasty between 2010 and 2014. Patient characteristics, operative variables, and outcomes were collected.

RESULTS

BCIS occurred in 279 (75%) patients. A total of 353 (94%) patients had bone metastases and 179 (48%) patients had lung metastases at the time of surgery. Age greater than 60 (hazard ratio [HR] 2.09, P = .02) and the presence of lung metastases (HR 1.77, P = .019) were associated with increased risk of BCIS. Increased perioperative use of vasopressors (HR 1.72, P = .023) and increased hospital stay beyond 10 days (HR 2.67, P = .003) was associated with BCIS.

CONCLUSIONS

BCIS is a frequent clinical event in patients with cancer undergoing femoral cemented arthroplasty with increased risk for patients over age 60 and those with compromised lung function due to lung metastases and lung cancer. Patients who develop BCIS are more likely to require longer postoperative hospitalization. Careful preoperative assessment and intraoperative communication are crucial steps to reduce the consequences of BCIS.

Major emergency orthopaedic surgery in patients with a concomitant acute coronary event following trauma

INTRODUCTION

This paper is a short series description of our experience with five cases managed surgically for orthopaedic trauma and who suffered meanwhile an acute coronary event.

MATERIALS AND METHODS

Five polytrauma, multiply fractured patients were treated in our institution for various lesions, including an open femur and knee articular fractures, major fractures around the pelvis and hips. They had suffered around the same time an acute coronary event complicating the orthopaedic management. One patient was treated for the orthopaedic condition as a delayed emergency, with a five day retard due to pre-operative pulmonary oedema. Four patients had cardiac evaluation, angiogram or echocardiogram. The patients were managed by a multi-disciplinary team.

RESULTS

One patient died post-operatively due to multiple complications, and four patients survived with a good functional outcome.

CONCLUSIONS

Patients with acute orthopaedic polytrauma presenting concomitant acute coronary events should be treated by multi-disciplinary teams, allowing early surgical management in a safe cardio-vascular and stable haemodynamic status.

The influence of bone cement and American Society of Anesthesiologists (ASA) class on cardiovascular status during bipolar hemiarthroplasty for displaced femoral-neck fracture: A multicenter, prospective, case-control study

BACKGROUND

Little is known about how bone cement and American Society of Anesthesiologists (ASA) classification influence the cardiovascular system in elderly patients with femoral-neck fractures treated with cemented hemiarthroplasty. Therefore, we performed a case-control study to investigate these questions and compared the following:≥ASA III with≤ASA II patients who underwent cemented hemiarthroplasty; and cemented with cementless hemiarthroplasty in≥ASA III patients.

HYPOTHESIS

ASA classification influences the cardiovascular system during cemented hemiarthroplasty and bone cement influences intraoperative blood pressure [IBP] in patients rated≥ASA III.

MATERIALS AND METHODS

This multicenter, prospective study included patients with acute displaced femoral-neck fractures. Baseline data, medical history, anesthesia, FiO₂, vasopressor use, femoral component, IBP, SpO₂, and complications were evaluated. Of 200 patients, 100 were cemented (mean age, 77±10 years), and 100 were cementless (mean age, 78±9 years). Cemented hemiarthroplasty employed a third-generation technique (plugging, irrigating, drying and filling the canal with cement under pressurization).

RESULTS

Systolic blood pressure (SBP) decreased significantly during cementing, versus pre-rasping in≤ASA II patients (from 117.9±24.5 [range, 65-199] to 106.9±20.3 [range, 59-172]; p=0.007), in≥ASA III patients (from 129.5±21.0 [range, 90-169] to 110.4±17.9 [range, 79-157]; p=0.006), and post-stem-insertion, versus pre-rasping in≤ASA II patients (from 117.9±24.5 [range, 65-199] to 103.9±20.7 [range, 53-178]; p=0.0004), and in≥ASA III patients (from 129.5±21.0 [range, 90-169] to 111.2±24.6 [range, 70-156]; p=0.009). In≥ASA III patients, SBP decreased significantly during cementing or rasping, versus pre-rasping in cemented patients (from 129.5±21.0 [range, 90-169] to 110.4±17.9 [range, 79-157]; p=0.006), in cementless patients (from 115.0±17.7 [range, 85-150] to 100.7±15.7 [range, 75-142]; p=0.004), and post-stem-insertion, versus pre-rasping in cemented patients (from 129.5±21.0 [range, 90-169] to 111.2±SD [range]; p=0.009), and in cementless patients (from 115.0±17.7 [range, 85-150] to 89.4±17.5 [range, 58-140]; p<0.0001). There were no lethal complications.

CONCLUSIONS

This study indicate a similar hemodynamic change intraoperatively between≤ASA II patients and≥ASA III patients in the cemented group, and between patients with cemented and cementless hemiarthroplasty in the≥ASA III patients. With modern hemiarthroplasty techniques, bone cement might be as safe as cementless techniques in elderly,≥ASA III patients.

LEVEL OF EVIDENCE

III, multicenter case-control cohort study.

A Rare Cause of Pulmonary Edema in the Postoperative Period

With the increasing longevity of the population, the annual rates of hip arthroplasties performed have been steadily increasing over the past decade. Given the presence of medical comorbidities in the older patients, the peri-operative care of these individuals requires multi-specialty care, now more than ever. Hip arthroplasty is generally well tolerated, with early mortality after the procedure being <1%. Bone cement implantation syndrome (BCIS) is an entity that is occasionally encountered during or after the surgery. It is characterized by hypoxemia, hypotension, cardiac arrhythmias, and cardiac arrest leading to death, in severe cases. We report a case of a middle-aged female who developed refractory hypotension and pulmonary edema while undergoing hemiarthroplasty for a pathological femoral neck fracture and experienced cardiac arrest in the immediate postoperative period. Critical care physicians must familiarize themselves with promptly diagnosing and managing BCIS.

The effect of intravertebral anesthesia on bone cement implantation syndrome in aged patients: A single-center 5-year retrospective study

The aim of the study was to assess the effect of commonly used intravertebral anesthesia on bone cement implantation syndrome (BCIS) in aged patients undergoing hemiarthroplasty.The medical records of 1210 aged patients receiving hemiarthroplasty under intravertebral anesthesia were retrospectively reviewed. Anesthesia charts for all patients were reviewed for central venous pressure, mean arterial pressure, arterial oxygen saturation, and heart rate before, during, and after cementation. Each patient was classified into no BCIS (grade 0) or BCIS grade 1, 2, or 3 according to the degree of hypotension, arterial desaturation, or loss of consciousness around cementation. Changes in these grades after cementation were compared according to the ways of intravertebral anesthesia used.Among all included patients, 72.2% (874/1210) showed grade 1 or higher grade of BCIS after cementation. Compared with spinal-epidural anesthesia, single epidural anesthesia showed adjusted odds ratios (95% confidence interval) of 1.25 (1.13-1.43) for grade 1, 1.36 (0.83-2.06) for grade 2, and 3.55 (1.52-7.06) for marked postoperatively grade 3 of BCIS versus grade 0 (Type III P < 0.0001).Single epidural anesthesia was associated with increased odds for elevation of these grades after cementation compared with spinal-epidural anesthesia.

Postoperative stroke after hemiarthroplasty for femoral neck fracture: a report of 2 cases and review of literature

INTRODUCTION

Femoral neck fractures in the elderly comprise a significant number of orthopedic surgical cases at a major trauma center. These patients are immediately incapacitated, and surgical fixation can help increase mobility, restore independence, and reduce morbidity and mortality. However, operative treatment carries its own inherent risks including infections, deep vein thromboses, and intraoperative cardiovascular collapse. Cerebrovascular stroke is a relatively uncommon occurrence after hip fractures.

METHODS

We present 2 cases with unusual postoperative medical complication after cemented hip hemiarthroplasty for femoral neck fracture that will serve to illustrate an infrequent but very serious complication.

RESULTS

Case 1 was a 73-year-old man with a Garden IV femoral neck fracture who underwent a right hip unipolar cemented hemiarthroplasty under general anesthesia. After uneventful surgery, he developed neurological deficits, and a postoperative noncontrast head computed tomography showed a right medial thalamic infarct. Case 2 was an 82-year-old man with a Garden IV femoral neck fracture who underwent a right hip unipolar cemented hemiarthroplasty under general anesthesia. After uneventful surgery, the patient became hemodynamically unstable. A postoperative noncontrast head computed tomography showed a large evolving left middle cerebral artery stroke.

CONCLUSIONS

General anesthesia in the setting of decreased cardiac function (decreased ejection fraction and output) carries the risk for ischemic injury to the brain from decreased cerebral perfusion. Risk factors including advanced age, history of coronary artery disease, atherosclerotic disease, and atrial fibrillation increase the risk for perioperative stroke. Furthermore, it is known that during the cementing of implants, microemboli can be released, which must be considered in patients with preoperative heart disease. As a result, consideration of using a noncemented implant or cementing without pressurizing in this clinical scenario should be an important aspect of the preoperative plan in an at-risk patient. Further studies are needed that can elucidate a causal relationship.

Hemiarthroplasty of the hip with and without cement: a randomized clinical trial

BACKGROUND

Controversy exists regarding the use of cement for hemiarthroplasty to treat a displaced subcapital femoral neck fracture in elderly patients. The primary hypothesis of this study was that use of cement would provide better visual analog pain scores following this procedure in an elderly patient population.

METHODS

Elderly patients (at least seventy years of age) without severe cardiopulmonary compromise who presented to one institution with a displaced subcapital femoral neck fracture were offered inclusion in the study. One hundred and sixty patients (mean age, eighty-five years) with an acute displaced femoral neck fracture were randomly allocated to hemiarthroplasty with either a cemented Exeter or an uncemented Zweymüller Alloclassic component. Clinical and radiographic follow-up was performed for two years and the outcomes were recorded by a blinded assessor. The main clinical outcome measures were pain, mortality, mobility, complications, reoperations, and quality of life measured with use of validated instruments.

RESULTS

The mean visual analog pain score at rest did not differ significantly between the groups. The total number of complications was greater in the uncemented group (sixty-three compared with twenty-eight in the cemented group). Subsidence was significantly more common in the uncemented group (eighteen compared with one in the cemented group). Intraoperative or postoperative fracture was also significantly more common in the uncemented group (eighteen compared with one in the cemented group). The mortality rate did not differ significantly between the groups at any time point (thirty-five deaths in the uncemented group compared with thirty-two in the cemented group at two years). The Oxford hip score was significantly poorer in the uncemented group at six weeks (38.8 compared with 35.7 in the cemented group), and it was also poorer or similar at later follow-up time points although the differences were not significant. There was also a trend toward poorer mobility and greater dependence on walking aids in the cemented group. The postoperative Short Musculoskeletal Function Assessment and Mini-Mental State Examination scores did not differ significantly between the groups.

CONCLUSIONS

In elderly patients (seventy years or older) without severe cardiopulmonary compromise who were treated with hemiarthroplasty for a displaced femoral neck fracture, use of a cemented Exeter implant and use of an uncemented Alloclassic implant provided a comparable outcome with regard to pain. However, implant-related complication rates were significantly lower in the group treated with a cemented implant. Trends toward better function and better mobility in the cemented group were observed. These trends reached significance in particular functional scores at some postoperative time points.

LEVEL OF EVIDENCE

Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Pulmonary haemodynamics and right ventricular function during cemented hemiarthroplasty for femoral neck fracture

BACKGROUND

Bone cement implantation syndrome (BCIS) is characterised by hypoxia, hypotension and loss of consciousness occurring early after bone cementation. The haemodynamic perturbations during BCIS have not been extensively studied, particularly not in patients with femoral neck fracture. We evaluated the effects of cemented hemiarthroplasty, in these patients, on pulmonary haemodynamics, right ventricular performance, intrapulmonary shunting and physiological dead space.

METHODS

Fifteen patients undergoing cemented hemiarthroplasty because of femoral neck fracture were included. Surgery was performed under total intravenous anaesthesia in the lateral position. All patients were catheterised with a radial and pulmonary artery catheter, for continuous measurements of mean arterial pressure (MAP), pulmonary arterial pressure (PAP), cardiac output, mixed venous oxygen saturation, right ventricular end-diastolic volume (RVEDV) and right ventricular ejection fraction (RVEF). Haemodynamic measurements and blood gas analyses were performed after induction of anaesthesia, during surgical stimulation before and immediately after bone cementation and prosthesis insertion, 10 and 20 min after insertion and during skin closure.

RESULTS

After bone cementation and prosthesis insertion, MAP (-10%), cardiac index (-10%) and stroke volume index (-10%) decreased, while PAPs (10-15%) and the pulmonary vascular resistance index (45%) increased. RVEF decreased by 10-20%, while the RVEDV index increased by 10%. Pulmonary haemodynamic and RV variables changed progressively with time, while intra-pulmonary shunting and physiological dead space increased immediately after prosthesis insertion and then returned to baseline.

CONCLUSIONS

Cemented hemiarthroplasty in patients with femoral neck fracture causes a pronounced pulmonary vasoconstriction and an impairment of RV function accompanied by pulmonary ventilation/perfusion abnormalities.

Bone cement implantation syndrome

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. This article reviews the definition, incidence, clinical features, risk factors, aetiology, pathophysiology, risk reduction, and management of BCIS. It is possible to identify high risk groups of patients in which avoidable morbidity and mortality may be minimized by surgical selection for uncemented arthroplasty. Invasive anaesthetic monitoring should be considered during cemented arthroplasty in high risk patients.