The Incidence of Bone Cement Implantation Syndrome Grade 3 in Hip and Knee Arthroplasty: A Retrospective Multicenter Case Series.

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.