Bone cement implantation syndrome induced by antibiotic-loaded bone cement covering the infected bone surface: A case report

Introduction and importance: Bone cement implantation syndrome (BCIS) typically occurs during bone cementation and prosthesis insertion. Almost all of the models used to explain BCIS are based on studies related to hip arthroplasty. BCIS induced by bone cement implantation in superficial wounds has not been reported. Case presentation: We report the case of a 37-year-old man with chronic osteomyelitis of the left tibia (Cierny - Mader type II), who developed BCIS after covering the infected bone surface with antibiotic-loaded bone cement. BCIS presented as acute massive pulmonary exudation and hypoxemia. Early application of awake prone positioning effectively improved oxygenation and lung injury, and prevented the need for a more advanced means of respiratory support. The patient was discharged without any clinical complications on postoperative day 15. Clinical discussion: We assessed the cause of acute respiratory events in this patient using Naranjo Adverse Drug Reaction Probability Scale, and BCIS was finally considered. Despite the lack of "driving force" (e.g., increased intramedullary pressure), the bone cement monomer may be absorbed into circulation through the wound surface due to its penetrability. Subsequent immune-mediated amplification resulted in pulmonary exudation and hypoxemia. As a pathophysiologically change-oriented strategy, effective drainage after awake prone positioning significantly improved clinical outcomes. Conclusion: Bone cement monomer absorbed through the wound should be of concern, and pathophysiological change-oriented management should be emphasized in BCIS.