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Worst case scenario

Cement Implantation syndrome during a hip hemiarthroplasty

An 85 year old lady wast brought to the operating theatre for a left hip hemiarthroplasty following a displaced intracapsular neck of femur fracture.

Their admission AMTS was 3/10 and they had been consented using a Form 4 (patients lacking capacity). A 'Do Not Attempt Cardiopulmonary Resuscitation' form had been completed pre-operatively with their next of kin.

The surgeons were 2 experienced SpRs. The consultant was in the hospital but not in the operating theatre.

During cementation the patient developed ventricular tachycardia and lost their cardiac output.


Everything happened by the book:

- The anaesthetist gave the order to press the emergency buzzer

- Within seconds the wound was closed using skin clips

- A large Ioban dressing was place over the wound

- The patient was turned to a supine position and CPR was commenced

- Cardiac output was temporarily

- Ultimately the event was unsurvivable but prompt action bought enough time for the patient's family to attend (in theatre)

- A team debrief was conducted and the decision was made to stand down the theatre

Learning points:

Bone Cement Implantation Syndrome is a rare but potentially fatal complication of any procedure involving Orthopaedic cement. A total of 26 deaths had been reported when cement was used during hemiarthroplasty between October 2003 and October 2008.

There are certain steps which can be taken to mitigate against this risk:

1) Patient risk factors: Increasing age and comorbidities make patients more susceptible to this complication. Surgeons and anaesthetists should be aware of this and specifically incorporate it into their pre-operativce briefing.

2) Surgical factors: Thorough lavage of the medullary cavity is mandatory. Consider placing a suction catheter to reduce pressure at the cement/marrow vessel interface during cementation. Pressurisation should be appropriate to the surgical scenario; often this means no or very little pressure.

3) Team factors: Communication is key. The surgeon should provide the Anaesthetic team with sufficient warning prior to - and upon - cementation.

The decision to perform CPR on a patient with a DNACPR form should ideally be discussed well before the situation arises. If the Surgeon and Anaesthetist agree, it is reasonable to attempt CRP whilst seeking to correct reversible causes.


Timperley et al. 2009. Mitigating surgical risk in patients undergoing hip arthroplasty for fractures of the proximal femur. Available here


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