J Orthop Sci DOI 10.1007/s00776-014-0691-3

ORIGINAL ARTICLE

Monitoring of blood pressure during total hip arthroplasty using the interface bioactive bone cement (IBBC) technique Hiroshi Fujita · Tomoo Okumura · Hiroaki Hara · Hiroshi Toda · Hideto Harada · Ryuuichi Nishimura · Tomohiro Tominaga 

Received: 28 July 2014 / Accepted: 18 December 2014 © The Japanese Orthopaedic Association 2015

Abstract  Background  Cement implantation syndrome, which is characterized by hypotension, hypoxemia, and cardiac arrhythmia or arrest, has been reported in the literature. The purpose of the present study was to monitor the blood pressure changes that occur after cementing during primary total hip arthroplasty (THA). Methods  The present study examined 178 cases in which 204 joints were treated with primary THA. Study subjects had a mean age at the time of surgery of 64.5 years (range 35–89). Under general anesthesia, both hip components were cemented in place using an anterolateral approach. After cementing, systolic arterial blood pressure was measured at 1-min intervals for 5 min and then again at 10 min. The maximum regulation ratio (MRR) was calculated as follows: (maximum change in blood pressure − blood pressure before cement application) divided by blood pressure before cement application. Results  No major complications, such as cardiac arrest, occurred in most cases; blood pressure increased until 4 mins on the acetabular side and until 2 min on the femoral side, and then gradually returned to the level observed prior H. Fujita (*) · T. Okumura · H. Harada · R. Nishimura · T. Tominaga  Department of Orthopedic Surgery, Institute for Joint Replacement, Kyoto Katsura Hospital, Yamada‑hirao‑cho 17, Nishikyo‑ku, Kyoto 615‑8256, Japan e-mail: [email protected] H. Hara  Department of Rehabilitation, Kyoto Katsura Hospital, Yamada‑hirao‑cho 17, Nishikyo‑ku, Kyoto 615‑8256, Japan H. Toda  Department of Anesthesiology, Kyoto Katsura Hospital, Yamada‑hirao‑cho 17, Nishikyo‑ku, Kyoto 615‑8256, Japan

to cement application. On the acetabular side, the mean MRR was 11.2 % [standard deviation (SD): 15.9; range −26 to −80], whereas it was 6.4 % (SD: 14.9; range −31 to −65) on the femoral side. Correlations were detected between MRR classification on the acetabular side and the subject’s age at the time of the operation or bleeding control status on the acetabular side. When bleeding control was judged as complete, the tendency for blood pressure to decrease was reduced. Conversely, when bleeding control was judged as good, blood pressure showed a greater tendency to decrease. Conclusion  In the present study, no episodes of major hypotension occurred. During THA involving the interface bioactive bone cement (IBBC) technique, when bleeding control on the acetabular side was judged as complete the tendency for blood pressure to decrease was reduced.

Introduction The longevity of cemented total hip arthroplasties (THA) has been improved by the introduction of modern cementing techniques including cement pressurization [1, 2]. On the other hand, cement pressurization can lead to cement implantation syndrome [3], which is characterized by hypotension, hypoxemia, and cardiac arrhythmia or arrest, and is caused by the pushing of intramedullary fat and marrow into the venous circulation system, which can lead to pulmonary embolization. To improve the longevity of THA, we use a combination of the interface bioactive bone cement (IBBC) technique [4–6] and other modern cementing techniques at our institution [7]. The main principle of this approach involves the smearing of hydroxyapatite (HA) granules on the dry bony surface followed by cement pressurization. We have used

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this approach in all recent primary THA procedures and have not experienced any episodes of major intraoperative hypotension. The purpose of the present study was to prospectively monitor blood pressure after cementing during consecutive primary THA procedures involving the IBBC and cement pressurization techniques. We hypothesized that after cementing, blood pressure would remain the same or be slightly decreased for a short period.

Materials and methods Consent was obtained from all patients prior to the start of the study according to our institutional regulations. Also, approval was obtained by the ethical committee of our institute (number 376). Between 2006 October and 2010 July, 204 hip joints belonging to 178 patients were subjected to primary cemented THA. The mean age of the patients at the time of the operation was 64.5 years (standard deviation, SD: 10.7; range 35–89), and the patients included 171 females (83.8 %) and 33 males (15.8 %) (Table 1). Coxarthrosis, a vascular necrosis of the femoral head, rheumatoid arthritis, femoral neck fractures, and dermatomyositis were seen in 180 (88.2 %), 13 (6.4 %), 8 (3.9 %), 2 (1.0 %), and

1 (0.5 %) hip joints, respectively. Most patients had secondary osteoarthritis due to dysplasia. Regarding co-morbidities, 128 (62.7 %), 47 (23.0 %), and 29 (14.2 %) of the patients were categorized into groups A, B, and C, respectively, according to Charnley’s classification. The patients’ mean height was 153.8 cm (SD: 8.0; range 134–175), and their mean body weight was 55.9 kg (SD: 9.9; range 35–88). As a result, their mean body mass index (BMI) was 23.6 kg/m2 (SD: 3.6; range 15.9–35.2). As for BMI distribution, 135 patients had a BMI of less than 24 kg/m2 (66.2 %), 64 had a BMI of 25–30 kg/m2 (31.4 %), and 5 patients had a BMI of over 31 kg/m2 (2.4 %). Antihypertensive drugs were administered in 87 cases (42.6 %). According to the American Society of Anesthesiologists(ASA) classification, the patients’ physical status [8] was categorized as class 1 in 47 cases (23.0 %), class 2 in 145 cases (71.1 %), and class 3 in 12 cases (5.9 %). Under general anesthesia and whilst the patient was in the lateral position, THA was performed via Dall’s anterolateral approach [9]. An intentional hypotension during the operation was not performed. On the acetabular side, after complete containment had been achieved through bulk bone grafting, pulsatile lavage followed by gauze packing were performed to obtain a dry bony surface during cement mixing. When the polymethyl

Table 1  Characteristics of the patients

Mean (SD) Age (year) Male sex (no.) (%) Diagnosis  Coxarthrosis  Avascular necrosis of the femoral head  Rheumatoid arthritis  Femoral neck fracture  Dermatomyositis Charnley category  A  B  C Height (cm) Body weight (kg) Body mass index (kg/m2)   31 Antihypertensive drug administered (no.) (%) ASA physical status  Class 1  Class 2  Class 3  Class 4

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Range (min–max)

64.5 (10.7)

Distribution (no.) (%)

35–89 33 (15.8) 180 (88.2) 13 (6.4) 8 (3.9) 2 (1.0) 1 (0.5) 128 (62.7) 47 (23.0) 29 (14.2)

153.8 (8.0) 55.9 (9.9 %) 23.6 (3.6)

134–175 35–88 15.9–35.0 135 (66.2) 64 (31.4) 5 (2.4) 87 (42.6) 47 (23.0) 145 (71.1) 12 (5.9) 0 (0.0)

Monitoring of blood pressure

methacrylate (PMMA) cement reached the dough stage, the gauze was removed and HA granules were smeared onto the acetabulum. Finally, the PMMA bone cement was pressurized, and then an all-polyethylene cup was fixed in place. On the femoral side, after complete containment had been achieved via distal bone grafting, pulsatile lavage followed by gauze packing were performed to obtain a dry bony surface during cement mixing. After HA granules were smeared into the femoral canal, the PMMA bone cement was pressurized and an Exeter stem (Stryker Orthopedics, Mahwah, NJ, USA) was fixed in place. A combination of the IBBC technique and other modern cementing techniques [4–7] were used in every case. The IBBC technique involves the smearing of HA granules onto the target bone just before the cementing procedure. The HA granules were manufactured by sintering at 1,200 °C and then sieved to obtain granules with diameters of 300–600 μm (Boneceram P G-2, Olympus Terumo Biomaterials Corp., Tokyo, Japan). Two grams of HA granules were smeared onto the inner surface of the prepared acetabular surface and femoral canal just before the application of cement. Surgical Simplex P radiopaque bone cement (Stryker Orthopedics, Mahwah, NJ, USA) was used in every case. Systolic and diastolic blood pressures were recorded at admission to the operating room, and a catheter was inserted into the radial artery to allow arterial blood pressure to be measured continuously. Systolic and diastolic arterial blood pressure during cementing acetabular and femoral components were monitored just before cement application, at 1-min intervals until 5 min, and then at 10 min after insertion of the cement. The regulation ratio (RR) was calculated as follows: (systolic blood pressure value recorded from 1 to 5 min and at 10 min after cement application – systolic blood pressure just before cement application) divided by systolic blood pressure just before cement application. The maximum regulation ratio (MRR) was defined as the RR of 1–5 min after cement application that exhibited the greatest difference (positive or negative). The subjects’ MRR were classified into the following three groups: group A (increased by more than 10 %), group B (changed by plus/minus below 10 %), and group C (decreased by more than 10 %). Bleeding control status just before the cementing procedure was categorized as complete, good, fair, or poor based on the proportion of the surface area of the reamed acetabulum or the visible inner surface of the femoral canal that was covered in blood; i.e., complete, good, fair, and poor were defined as less than 5, 5–25, 25–50, and 50–100 %, respectively. Bleeding control status was judged based on visual inspection by two doctors; i.e., an operator and an assistant. Then, during cement polymerization, when an

impression was fresh, a decision was made after discussion between two doctors. The operation duration, intraoperative infusion volume, and intraoperative blood loss were also recorded, as were preoperative complications, such as hypotension, hypoxemia, or cardiac arrhythmia or arrest, and any deaths that occurred within three months postoperatively. Inter-group MMR differences between the acetabular and femoral sides were analyzed using the Chi square goodness of fit test. Pearson correlations were calculated to extract factors associated with MRR classification. Correlations between the MRR classification and age at the time of the operation, hypertension, BMI, ASA physical status, hospitalization period, intraoperative infusion volume, intraoperative blood loss, and the bleeding control statuses of the acetabular and femoral sides were analyzed using the Chi square test. Then, the parameters that were found to be related to the MRR classification were examined using Fisher’s exact test, and then adjusted standardized residuals were calculated. Quantitative data were analyzed using one-way analysis of variance (ANOVA) followed by Tukey’s honestly significant difference (HSD) test. All statistical analyses were performed using the software SPSS version 11.0 J (SPSS, Japan Inc.). The significance level was set at p = 0.05.

Results No major complications, such as cardiac arrest, occurred during the study period. In addition, no preoperative complications, such as hypotension, hypoxemia, or cardiac arrhythmia or arrest, occurred. Furthermore, there were no cases in which the intravenous injection of vasopressor drugs or an increase in the fluid transfusion speed was necessary. None of the patients died within three postoperative months. The mean hospitalization period, operation duration, intraoperative infusion volume, and intraoperative blood loss were 25 days (SD: 9.5; range 11–84), 160.8 min (SD: 34.2; range 115–378), 2,256 ml (SD: 490; range 105– 3,700), and 307 ml (SD: 143; range: 41–769), respectively (Table 2). Bleeding control on the acetabular side was judged to be complete in 179 joints (87.7 %), good in 23 joints (11.3 %), fair in 2 joints (1.0 %), and poor in 0 joints (0 %), whereas on the femoral side, bleeding control was judged as complete in 169 joints (82.8 %), good in 34 joints (16.7 %), fair in 1 joint (0.5 %), and poor in 0 joints (0 %). The mean systolic and diastolic blood pressures recorded at admission to the operating room were 132.5 mmHg (SD: 24.3; range 90–251) and 75.3 mmHg (SD: 13.3; range 46–122), respectively (Table 3), whereas those recorded

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H. Fujita et al. Table 2  Hospital stay and operative data

Mean (SD) Hospitalization period Operation duration (min) Intraoperative infusion volume (ml) Intraoperative blood loss (ml) Bleeding control of the acetabular side  Complete  Good  Fair  Poor Bleeding control of the femoral side  Complete  Good  Fair

25 (9.5) 160.8 (34.2) 2,256 (490) 307 (143)

Range (min–max)

Distribution (no.) (%)

11–84 115–378 1,050–3,700 41–769 179 (87.7) 23 (11.3) 2 (1.0) 0 (0.0) 169 (82.8) 34 (16.7) 1 (0.5)

 Poor

0 (0.0)

Table 3  Blood pressure data

Systolic blood pressure at patient’s admission to the operating room (mmHg) Diastolic blood pressure at patient’s admission to the operating room (mmHg) Systolic blood pressure just before cement insertion to the acetabulum (mmHg) Diastolic blood pressure just before cement insertion to the acetabulum Systolic blood pressure just before cement insertion to the femoral canal Diastolic blood pressure just before cement insertion to the femoral canal MRR of the acetabular side  Group A (increased more than 11 %)  Group B (±10 %)  Group C (decreased less than −11 %) MRR of the femoral side  Group A (increased more than 11 %)  Group B (±10 %)  Group C (decreased less than −11 %)

just before application of cement to the acetabulum were 101.1 mmHg (SD: 13.9; range 70–147) and 57.0 mmHg (SD: 9.7; range 30–87), respectively. In addition, the mean systolic and diastolic blood pressures obtained just before insertion of cement into the femoral canal were 100.1 mmHg (SD: 13.6; range 77–165) and 56.8 mmHg (SD: 9.3; range 36–84), respectively. In most cases, blood pressure increased until 4 min after cement application on the acetabular side and until 2 min after cement application on the femoral side, and then gradually returned to the level seen before the application of cement by 10 min. On the acetabular side, the mean MRR was 11.2 % (SD: 15.9; range −26 to 80). Groups A, B, and C contained 108 joints (52.9 %), 78 joints (38.2 %), and 18 joints (8.8 %), respectively (Fig. 1a), and the proportions of joints that

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Mean (SD)

Range (min–max)

132.5 (24.3) 75.3 (13.3) 101.1 (13.9) 57.0 (9.7) 100.1 (13.6) 56.8 (9.3) 11.2 (15.9)  %

90–251 46–122 70–147 30–87 77–165 36–84 −26 to 80

6.4 (14.9)  % −31 to 65

Distribution (no.) (%)

108 (52.9) 78 (38.2) 18 (8.8) 74 (36.3) 104 (51.0) 26 (12.7)

belonged to each group differed significantly (Chi square goodness-of-fit = 61.7, df = 2, p 

Monitoring of blood pressure during total hip arthroplasty using the interface bioactive bone cement (IBBC) technique.

Cement implantation syndrome, which is characterized by hypotension, hypoxemia, and cardiac arrhythmia or arrest, has been reported in the literature...
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