Bone Cement Implantation Syndrome (BCIS) is characterized by hypotension, hypoxia, and cardiopulmonary instability during the cementation process in arthroplasty. The pathophysiology of BCIS remains controversial, and reporting in the literature has been inconsistent. In 2009, Donaldson et al. proposed a classification system that stratifies BCIS severity into three grades. This systematic review and meta-analysis aims to evaluate the incidence, risk factors, perioperative outcomes, and prophylactic strategies for BCIS using the Donaldson criteria.

A systematic review was conducted in accordance with PRISMA guidelines, querying PubMed/MEDLINE, Embase, Web of Science, and Cochrane Library databases. Clinical studies investigating BCIS published in 2009-present using the Donaldson et al. 2009 criteria in primary unilateral total hip or hemiarthroplasty were included. The following data was extracted from included studies: patient characteristics, surgical details, BCIS incidence, risk factors evaluated, prophylactic measures employed, and perioperative complications/outcomes. Pooled incidence was calculated using a random-effects meta-analysis. Risk factors were evaluated using best-evidence synthesis and perioperative outcomes were evaluated using Grading of Recommendations, Assessment, Development and Evaluations (GRADE).

Seventeen studies comprising 2560 cases of BCIS met inclusion criteria. The overall pooled incidence of BCIS in the trauma setting was 29%, and 60% in oncologic settings. Grade 1 BCIS was most frequently reported; severe cases (Grades 2–3) were less common but associated with increased 30-day mortality. Advanced age, high ASA status, and oral anticoagulation were the most consistent risk factors, though evidence was generally limited due to reliance on observational data. Cement characteristics were poorly reported throughout included studies. Among prophylactic strategies, third-generation cementing techniques, femoral borehole creation, force-closed stem designs, and goal-directed anesthesia were associated with reduced BCIS incidence in single-study analyses.

BCIS is an underrecognized complication of cemented hip arthroplasty, primarily reported in trauma and oncologic settings. The findings of this review are most applicable to trauma settings (hemiarthroplasty for femoral neck fractures) and oncologic hip reconstruction. Extrapolation to elective primary THA for osteoarthritis should be made with caution, as only one included study addressed this population. High heterogeneity in pooled estimates of overall and grade 1 BCIS incidence should be interpreted in the context of institutional variation in surgical and anesthetic practices. Severe BCIS can lead to significant morbidity and mortality. Standardized definitions, improved reporting of cementation techniques, and prospective studies, especially RCTs using the Donaldson classification, are required to advance understanding and management of BCIS.

IIb; Systematic Review.