Bone Cement Implantation Syndrome | BCIS

Definition

  • Hypoxia, hypotension, arrhythmia or loss of consciousness during or soon after cementation
  • Most often seen with cemented hemiarthroplasty for hip fracture

Pathophysiology

  • Raised intramedullary pressure forces marrow fat, air, cement and bone debris into the venous system
  • Embolic load causes pulmonary vasoconstriction, raised pulmonary vascular resistance and right ventricular failure
  • Mediator release including histamine and complement adds vasodilatation and bronchoconstriction

Classification

  • Donaldson grade 1 is moderate hypoxia (SpO2 under 94 percent) or a fall in systolic pressure over 20 percent
  • Grade 2 is severe hypoxia (SpO2 under 88 percent), a fall in systolic pressure over 40 percent or unexpected loss of consciousness
  • Grade 3 is cardiovascular collapse needing CPR

Risk Factors

  • ASA grade 3 or 4, cardiopulmonary disease and pulmonary hypertension
  • Pathological fracture and malignancy
  • Osteoporosis and long cemented stems
  • Hip fracture hemiarthroplasty in frail patients

Prevention

  • Brief the anaesthetist before cementing
  • Increase FiO2 and keep the patient euvolaemic
  • Wash and dry the canal, use a distal plug and a retrograde cement gun
  • Avoid pressurisation in high risk patients and consider an uncemented stem

Management

  • Stop cementing and give 100 percent oxygen
  • Fluid resuscitation and a vasopressor such as noradrenaline or metaraminol
  • Inotropic support and echocardiography if collapse persists
  • Start CPR for arrest and continue until the embolic load clears

Registry Data

Reviewed by Professor Phong Tran, Head of Orthopaedic Surgery, Western Health. Last updated 15 October 2026.