Bone Cement Tied to Rare Severe Hip Surgery Outcomes

Larry Hand

June 19, 2014

Bone cement use in hip hemiarthroplasty for fractured neck of femur may be associated with rare instances of perioperative death or severe harm, according to an article published online June 12 in BMJ Open.

Paul D. Rutter, PhD, from the Institute of Global Health Innovation, Imperial College London, United Kingdom, and colleagues analyzed data on cases of bone cement implantation syndrome (BCIS) reported to the National Reporting and Learning System (NRLS) between 2005 and 2012 for England and Wales.

The NRLS received 360 BCIS cases during that period, with 62 death or severe harm reports, amounting to 1 case for every 2900 hip hemiarthroplasties for fractured neck of femur. The NRLS received 39 other reports of death or severe harm for different hip operations or hip operations, with no type or indication listed in the reports. Patients in the reports ranged from 66 to 100 years old.

Of the 62 cases in this analysis, 41 patients died, 33 (80%) of whom died on the operating table. In most cases (55/62; 89%), acute deterioration occurred within approximately 3 minutes after cement insertion. Of the patients who lived, 14 were resuscitated from cardiac arrest and 7 from periarrest situations, all of which occurred immediately.

About 75% (46/62) of the deaths occurred after the National Patient Safety Agency issued guidance recommending surgeons use caution when applying cement and use "appropriate patient assessment, anaesthetic technique and surgical technique." However, the lack of direction to not use cement reflected a lack of available evidence and professional opinion on the practice, the researchers write.

Analyzing data in the NRLS, which covers 56 million people in the National Health Service, can help "detect patterns of rare but serious harm that may not be apparent to individual practitioners of hospitals, or indeed within formal trials," the researchers write.

Case reports suggest that BCIS is a "rare event," they add, and note that "[i]t might well be the case that cement provides a benefit to patients that outweighs the harm of BCIS."

They conclude, "Although rare, BCIS contributes to the total mortality associated with cemented hip hemiarthroplasty surgery."

Even Rarer

In the United States, it is "extremely rare, as cemented femoral components are not as commonly performed as in other countries such as the UK and Europe," Stuart B. Goodman, MD, PhD, an orthopedic surgeon at Stanford University Medical Center in Redwood City, California, and Robert L. and Mary Ellenburg Professor of Surgery at Stanford University, told Medscape Medical News.

He thinks the issue with this study is "pushing marrow contents under pressure from the femoral canal into the venous sinusoids and then into the lungs during [total hip replacement]."

He said diagnosing BCIS is straightforward: "During insertion of the cemented femoral component, there is a shattering of marrow contents into the lungs, causing immediate hypoxia, hypotension, and even arrhythmia sometimes."

He said surgeons can work to prevent it by meticulously cleaning the femoral canal before introducing bone cement, venting the femoral canal to keep pressures low, and slowly inserting the femoral component. Anesthesiologists can help to prevent by "keeping the patient well-hydrated and well-oxygenated."

This research was supported by the National Health Service England. The authors and Dr. Goodman have disclosed no relevant financial relationships.

BMJ Open. Published online June 12, 2014. Full text

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