OTSR - 2026-03-19 - Journal Article; Review
Bone cement implantation syndrome following cemented hip arthroplasty for traumatic and oncologic indications: A systematic review and meta-analysis of incidence, risk factors, and outcomes.
MacElroy D, Park A, Rajkovic C, Shatkin M, Hayden BL
Topics
Key Takeaway
Pooled BCIS incidence is 29% in trauma (hemiarthroplasty) and 60% in oncologic cemented hip arthroplasty, with severe grades (2–3) associated with increased 30-day mortality.
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Summary
This PRISMA-compliant systematic review and meta-analysis evaluated BCIS incidence, risk factors, and prophylaxis in cemented primary unilateral THA and hemiarthroplasty using the Donaldson 2009 classification. Random-effects pooling of 17 studies (n=2,560) yielded a 29% BCIS incidence in trauma and 60% in oncologic settings; Grade 1 predominated, but Grades 2–3 carried elevated 30-day mortality. Advanced age, high ASA class, and oral anticoagulation were the most consistent risk factors; third-generation cementing techniques, femoral borehole creation, and goal-directed anesthesia showed incidence reduction in single-study analyses only.
Key Limitation
Only one included study addressed elective primary THA for osteoarthritis, making findings non-generalizable to the largest cemented arthroplasty population and limiting applicability of risk factor data beyond trauma and oncologic indications.
Original Abstract
BACKGROUND
Bone Cement Implantation Syndrome (BCIS) is characterized by hypotension, hypoxia, and cardiopulmonary instability during the cementation process in arthroplasty. The pathophysiology of BCIS remains controversial, and reporting in the literature has been inconsistent. In 2009, Donaldson et al. proposed a classification system that stratifies BCIS severity into three grades. This systematic review and meta-analysis aims to evaluate the incidence, risk factors, perioperative outcomes, and prophylactic strategies for BCIS using the Donaldson criteria.
PATIENTS AND METHODS
A systematic review was conducted in accordance with PRISMA guidelines, querying PubMed/MEDLINE, Embase, Web of Science, and Cochrane Library databases. Clinical studies investigating BCIS published in 2009-present using the Donaldson et al. 2009 criteria in primary unilateral total hip or hemiarthroplasty were included. The following data was extracted from included studies: patient characteristics, surgical details, BCIS incidence, risk factors evaluated, prophylactic measures employed, and perioperative complications/outcomes. Pooled incidence was calculated using a random-effects meta-analysis. Risk factors were evaluated using best-evidence synthesis and perioperative outcomes were evaluated using Grading of Recommendations, Assessment, Development and Evaluations (GRADE).
RESULTS
Seventeen studies comprising 2560 cases of BCIS met inclusion criteria. The overall pooled incidence of BCIS in the trauma setting was 29%, and 60% in oncologic settings. Grade 1 BCIS was most frequently reported; severe cases (Grades 2-3) were less common but associated with increased 30-day mortality. Advanced age, high ASA status, and oral anticoagulation were the most consistent risk factors, though evidence was generally limited due to reliance on observational data. Cement characteristics were poorly reported throughout included studies. Among prophylactic strategies, third-generation cementing techniques, femoral borehole creation, force-closed stem designs, and goal-directed anesthesia were associated with reduced BCIS incidence in single-study analyses.
DISCUSSION
BCIS is an underrecognized complication of cemented hip arthroplasty, primarily reported in trauma and oncologic settings. The findings of this review are most applicable to trauma settings (hemiarthroplasty for femoral neck fractures) and oncologic hip reconstruction. Extrapolation to elective primary THA for osteoarthritis should be made with caution, as only one included study addressed this population. High heterogeneity in pooled estimates of overall and grade 1 BCIS incidence should be interpreted in the context of institutional variation in surgical and anesthetic practices. Severe BCIS can lead to significant morbidity and mortality. Standardized definitions, improved reporting of cementation techniques, and prospective studies, especially RCTs using the Donaldson classification, are required to advance understanding and management of BCIS.
LEVEL OF EVIDENCE
IIb; Systematic Review.