Is Bone Cement Implantation Syndrome Actually Caused by Cement? A Systematic Review of the Literature Using the Bradford-Hill Criteria.
Systematic Review
Debate surrounding the use of cemented femoral components in hip arthroplasty persists. A proposed risk of cement fixation is bone cement implantation syndrome (BCIS), a phenomenon characterized by intraoperative hypotension, hypoxia, and/or cardiovascular collapse. The purpose of this study was to analyze the literature to determine if enough evidence exists to support a causal relationship between cement and BCIS./r/nA systematic review of articles on BCIS published from 2010 to 2023 was performed. Using the Bradford-Hill criteria, a set of nine epidemiological principles were developed to evaluate the relationship between exposure and outcome, and two reviewers independently reviewed the articles and determined the level of support for each criterion and the overall cement-BCIS relationship./r/nBased on 52 eligible articles, there was little to no support for five criteria: strength of association, specificity, dose-response relationship, coherence, and experiment. There was moderate support for temporality and plausibility and strong support for consistency and analogy. Although intraoperative hypotension, hypoxia, and/or cardiovascular collapse may manifest during cemented surgeries, their occurrence is not exclusive to cement utilization and can be attributed to multiple other potential causes. Furthermore, the diagnosis and timeline of BCIS are highly ambiguous, and the clinical relevance of nonfatal BCIS is unclear./r/nThere appears to be insufficient evidence to conclusively establish a causal link between cement and BCIS. Orthopaedic surgeons and anesthesiologists should exercise caution when attributing intraoperative complications solely to cement usage and consider alternative explanations. The term “BCIS’ itself may be a misnomer, as this phenomenon may occur in the absence of cement. Until there is stronger evidence to establish a causal link between cement use and BCIS, avoidance of BCIS does not appear to be a strong argument against cementation.
