Key result
Severe grade 3 BCIS occurs in ~0.08% of hip arthroplasties but carries ~68% mortality.
Why the study?
The true incidence rates of bone cement implantation syndrome grade 3 during hip and knee arthroplasty and associated clinical characteristics and outcomes remain uncertain.
Observational (n=65,151)
Yes
BCIS grade 3 is a rare but highly lethal complication primarily observed in elderly patients undergoing hemiarthroplasty for femoral neck fractures, occurring even without cement use.
BCIS grade 3 warrants vigilance in elderly hip hemiarthroplasty; leaves open optimal prevention strategies.
Background: Cardiac arrest during hip or knee arthroplasty (KA) represents the most severe manifestation of bone cement implantation syndrome (BCIS). However, true incidence rates remain uncertain, and data on clinical characteristics and outcomes are limited. The aim of this study was to determine the incidence of BCIS grade 3 in hip and KA and to describe associated clinical characteristics and mortality. Methods: This retrospective multicenter case series included all hip and KA procedures performed at 4 Dutch hospitals. Potential cases were identified through database queries. Medical records were manually reviewed to confirm BCIS grade 3, defined as cardiovascular collapse requiring cardiopulmonary resuscitation occurring from joint manipulation through skin closure. Results: No cases of BCIS grade 3 occurred during 25,914 knee arthroplasties. Among 39,237 hip procedures, 31 patients experienced BCIS grade 3 (0.08%), of which 27 cases occurred during hemiarthroplasty for femoral neck fracture (FNF). The mean age of patients with BCIS grade 3 was 86.2 ± 7.7 years; 71.0% were female, 93.5% underwent acute surgery for FNF, 87.1% involved cemented procedures, and perioperative mortality was 67.7%. Conclusion: BCIS grade 3 is rare but highly lethal, occurring predominantly during hemiarthroplasty for FNF in elderly patients. Individualized risk assessment and informed consent are essential when managing FNF in high-risk patients. Level of Evidence: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Brokke et al. (2026) conducted an observational in Hip and knee arthroplasty (n=65,151). Hip and knee arthroplasty was evaluated on Incidence of Bone Cement Implantation Syndrome (BCIS) grade 3 during hip arthroplasty. BCIS grade 3 occurred in 0.08% of hip arthroplasties and 0% of knee arthroplasties, presenting as a rare but highly lethal complication with 67.7% perioperative mortality.
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