The influence of bone cement and American Society of Anesthesiologists (ASA) class on cardiovascular status during bipolar hemiarthroplasty for displaced femoral-neck fracture: A multicenter, prospective, case-control study

Background: Little is known about how bone cement and American Society of Anesthesiologists (ASA) classification influence the cardiovascular system in elderly patients with femoral-neck fractures treated with cemented hemiarthroplasty. Therefore, we performed a case-control study to investigate these questions and compared the following: ≥ ASA III with ≤ ASA II patients who underwent cemented hemiarthroplasty; and cemented with cementless hemiarthroplasty in ≥ ASA III patients. Hypothesis: ASA classification influences the cardiovascular system during cemented hemiarthroplasty and bone cement influences intraoperative blood pressure [IBP] in patients rated ≥ ASA III. Materials and methods: This multicenter, prospective study included patients with acute displaced femoral-neck fractures. Baseline data, medical history, anesthesia, FiO₂, vasopressor use, femoral component, IBP, SpO₂, and complications were evaluated. Of 200 patients, 100 were cemented (mean age, 77 ± 10 years), and 100 were cementless (mean age, 78 ± 9 years). Cemented hemiarthroplasty employed a third-generation technique (plugging, irrigating, drying and filling the canal with cement under pressurization). Results: Systolic blood pressure (SBP) decreased significantly during cementing, versus pre-rasping in ≤ ASA II patients (from 117.9 ± 24.5 [range, 65–199] to 106.9 ± 20.3 [range, 59–172]; p = 0.007), in ≥ ASA III patients (from 129.5 ± 21.0 [range, 90–169] to 110.4 ± 17.9 [range, 79–157]; p = 0.006), and post-stem-insertion, versus pre-rasping in ≤ ASA II patients (from 117.9 ± 24.5 [range, 65–199] to 103.9 ± 20.7 [range, 53–178]; p = 0.0004), and in ≥ ASA III patients (from 129.5 ± 21.0 [range, 90–169] to 111.2 ± 24.6 [range, 70–156]; p = 0.009). In ≥ ASA III patients, SBP decreased significantly during cementing or rasping, versus pre-rasping in cemented patients (from 129.5 ± 21.0 [range, 90–169] to 110.4 ± 17.9 [range, 79–157]; p = 0.006), in cementless patients (from 115.0 ± 17.7 [range, 85–150] to 100.7 ± 15.7 [range, 75–142]; p = 0.004), and post-stem-insertion, versus pre-rasping in cemented patients (from 129.5 ± 21.0 [range, 90–169] to 111.2 ± SD [range]; p = 0.009), and in cementless patients (from 115.0 ± 17.7 [range, 85–150] to 89.4 ± 17.5 [range, 58–140]; p < 0.0001). There were no lethal complications. Conclusions: This study indicate a similar hemodynamic change intraoperatively between ≤ ASA II patients and ≥ ASA III patients in the cemented group, and between patients with cemented and cementless hemiarthroplasty in the ≥ ASA III patients. With modern hemiarthroplasty techniques, bone cement might be as safe as cementless techniques in elderly, ≥ ASA III patients. Level of evidence: III, multicenter case-control cohort study.