# Delayed Ischemic Hepatocellular Injury Following Cemented Total Hip Arthroplasty: A Case Report Within the Spectrum of Bone Cement Implantation Syndrome

## TL;DR

An elderly woman developed severe but reversible liver and kidney failure after a hip surgery, possibly linked to temporary blood pressure and oxygen drops during the procedure.

## Contribution

This case report highlights a rare delayed hepatic manifestation within the spectrum of Bone Cement Implantation Syndrome.

## Key findings

- The patient experienced ischemic acute liver failure and acute kidney injury following cemented total hip arthroplasty.
- The clinical profile was consistent with ischemic hepatocellular injury due to systemic hypoperfusion.
- Complete recovery of liver, kidney, and neurological functions was achieved with intensive care management.

## Abstract

Bone cement implantation syndrome (BCIS) is classically associated with acute intraoperative cardiopulmonary disturbances during cemented arthroplasty. However, accumulating clinical observations suggest that its systemic manifestations may extend beyond the immediate peri-cementation period. Hepatic involvement remains rarely reported and is poorly characterized, particularly in frail elderly patients with limited physiological reserve. We report the case of an 82-year-old woman who developed severe but reversible ischemic acute liver failure with concomitant acute kidney injury following cemented total hip arthroplasty. A brief peri-cementation episode of hypotension and mild hypoxemia was followed, within the early postoperative period, by abrupt elevation of aminotransferases (AST 4980 IU/L; ALT 3120 IU/L), coagulopathy (INR ≥ 1.5), transient neurological alteration compatible with early hepatic encephalopathy, severe acute kidney injury, and new-onset atrial fibrillation. An extensive diagnostic evaluation excluded viral, autoimmune, toxic, biliary, vascular, infectious, and structural causes of liver injury. The clinical and biochemical profile was consistent with ischemic hepatocellular injury occurring in the context of systemic hypoperfusion. Management consisted of supportive intensive care focused on hemodynamic stabilization, respiratory support, rhythm control, metabolic management, and close laboratory monitoring, resulting in complete hepatic, renal, and neurological recovery. This case describes a rare presentation of ischemic acute liver failure with multiorgan involvement following cemented total hip arthroplasty. The temporal association with transient peri-cementation hypotension and hypoxemia suggests a possible delayed systemic manifestation within the spectrum of BCIS, even in the absence of overt intraoperative collapse. Although causality cannot be established, the clinical course underscores the importance of careful postoperative evaluation in vulnerable patients who experience perioperative hemodynamic disturbances.