Dangers with cementation under low-viscosity state: Cement arterio-venogram and bone cement implantation syndrome

Abstract

Cement arterio-venogram is a rare event with cement extrusion into femoral nutrient vessels. In literature it is known to be benign with no significant clinical sequelae. It is postulated that it is due to high cement implantation pressure, that results in optimal cement filling quality. All previously reported cases were female patients, and it is thought to be a female only phenomenon due to the relatively narrow femoral canal leading to higher pressures during cementation. In this case series we report 3 cases different to existing literature. All 3 patients showed a cement arterio-venogram together with bone cement implantation syndrome and hypotension intraoperatively. It was also observed that during implantation the cement was of low viscosity. We postulate low cement viscosity during implantation with pressurization is also a contributing factor to these phenomena. This case series also demonstrates the first 2 male cases, showing this the even can occur in males too. The cement arteriovenogram is located at 41%-42% femur length which is within the 'third sixth' of the length of the femur. Good cementation techniques and prevention is also highlighted in this report.

Keywords: BCIS; Cement; Cement arterio-venogram; Hip fracture; Low viscosity.

Fig. 1

A, B Pre operative X-ray of case 1, anteroposterior and lateral respectively C, D, post operative X-ray of case 1, anteroposterior and lateral respectively. Both C and D showed features of venous filling including valvular constrictions, tortuous course, larger calibre. The leakage is in posteromedial direction.

Fig. 2

Post operative axial CT of Case 1. It illustrates the venous filling features and posteromedial direction of leakage.

Fig. 3

A, B. Pre operative X-ray of case 2, anteroposterior and lateral respectively C, D post operative X-ray of case 2, anteroposterior and lateral respectively. Both C and D showed features of arterial filling including small calibre, straight course, valveless. The leakage is in posteromedial direction.

Fig. 4

A, B. post operative axial CT of Case 2 C. Post operation coronal CT of Case 2. It illustrates the arterial filling features and posteromedial direction of leakage. D shows the extensive cement defect around the stem.

Fig. 5

A, B Pre operative X-ray of Case 3 anteroposterior and lateral respectively C, D post operative X-ray of Case 3, anteroposterior and lateral respectively.