Postmortem Findings in Bone Cement Implantation Syndrome–Related Deaths

Abstract

Several mechanisms have been postulated as potentially involved in life-threatening complications during cemented surgery. In this study, we evaluated the role of anaphylaxis and pulmonary fat embolism in the pathophysiology of bone cement implantation syndrome in a series of fatal cases that underwent medicolegal investigations. Postmortem findings in these cases were compared with those obtained from individuals who died after other injuries and/or interventions and in which activated mast cells and pulmonary fat embolism were involved in the pathogenesis of death. Fifty subjects were selected including 6 individuals who had undergone cemented total hip arthroplasty and died intraoperatively, 32 subjects who died shortly after being involved in traffic accidents, 8 individuals who died shortly after the injection of contrast material, and 4 subjects who had undergone orthopedic surgery and died postoperatively. Massive pulmonary fat embolism was determined to be the cause of death in all the 6 subjects who died intraoperatively as well as the main cause of death in traffic-road victims with rapid respiratory function deterioration. Mast cell activation was identified exclusively in the group of subjects who died shortly after contrast material administration. Massive pulmonary fat embolism appears to be the most important factor responsible for severe cardiorespiratory function deterioration during cemented arthroplasty. Cardiac comorbidities can also significantly influence the severity of intraoperative complications, thus corroborating the hypothesis of a multifactorial model in the pathogenesis of bone cement implantation syndrome.

Temas transversais em saúde coletiva

“…Essa síndrome está relacionada a altos índices de morbimortalidade intraoperatória (SINGH et al, 2016). Froidmont et al (2014) realizaram um estudo post-mortem para avaliar o papel da embolia pulmonar e da anafilaxia na fisiopatologia da síndrome da implantação óssea do cimento. Foram analisados 50 indivíduos, desses 6 haviam se submetido a artroplastia total do quadril cimentada e falecidos durante o procedimento cirúrgico, 32 falaceram logo após se submeterem a um acidente de trânsito, 8 após a injeção de contraste e 4 foi a óbito no pós-operatório.…”

The role of bone cement for the development of intraoperative hypotension and hypoxia and its impact on mortality in hemiarthroplasty for femoral neck fractures

“…To our knowledge, this is the first study demonstrating the link between the use of bone cement, per se, with intraoperative hemodynamic and/or pulmonary instability and increased postoperative mortality. It has been suggested that the BCIS is caused by an increase in intra-medullary pressure caused by prosthesis insertion and cementation, which will force medullary content into the circulation causing lung embolization (de Froidmont et al 2014). This will, in turn, induce hypoxia, pulmonary vasoconstriction, and an increase in right ventricular (RV) afterload and eventually RV failure with systemic hypotension.…”

Grade III bone cement implantation syndrome in malignant lung cancer patient: a case report

“…Literature review hypothesize the multifactorial model of pathogenesis according to postmortem finding of patient succumbing to intraoperative mortality for the syndrome complex which shows massive pulmonary fat embolism as a major culprit along with mast cell activation [ 9 – 11 ]. Anaphylaxis with release of mediators [ 12 , 13 ] to monomer of bone cement, embolus [ 10 ] has also been proposed giving similar pictures as embolic model. There are also reports of patients requiring intensive care [ 14 ] and succumbing to death postoperatively [ 9 , 15 ] particularly in patients who were unstable in intraoperative periods.…”