Paget’s disease of the hip: Treatment

1 Nov
2011

Management of patients with Paget’s disease can be challeng­ing. The mainstay of treatment is to relieve pain and improve function. This often necessitates administration of nonsteroidal anti-inflammatory medications and other analgesics. In order to retard excessive osteoclastic activity bisphosphonate drugs may be administered. Joint arthroplasty for Paget’s patients with end-stage symptomatic arthritis may be indicated. Due to gross deformities osteotomy of the affected bone either as an isolated procedure or at the time of arthroplasty may be indicat­ed. When a subcapital or intracapsular hip fracture occurs in a pre-existing pagetoid bone, total hip arthroplasty may be indicated if acetabular bone is also affected.

Outcomes

Although few patients with Paget’s disease ever require surgi­cal therapy, successful surgical management of severe ortho­pedic complications has improved the quality of life for these patients. Total hip arthroplasty (THA) has consistently been re­ported to improve function for these patients. The optimal method of fixation of hip components against pagetoid bone has been debated in the past. Cemented total hip arthroplasty is reported to be a viable and accepted treat­ment modality for symptomatic coxarthritis of the hip in patients with Paget’s disease. However, a higher incidence of symptomatic and asymptomatic radiolucencies around the bone-cement interface of components placed against pagetoid bone has been documented with the possibility of increased rates of implant failure over an intermediate time frame postop­eratively discussed. Radiolucencies occurred in twenty of thirty-two acetabular components implanted against pagetoid bone in one series. Merkow et al. reported on twenty-one cemented hips that showed the need for two revi­sions (9.5%) at 5.2 years follow-up.

Previously McDonald et al. reported the results of ninety-one cemented total hip arthroplasties in eighty patients with significantly higher inci­dence of revision (fifteen per cent) in patients with Paget’s dis­ease compared to the unselected population receiving total hip arthroplasty during the same time period (p<0.001). Radi­ographic loosening of twenty-nine per cent, cup loosening of 13.5 per cent, and a fall off of good and excellent results to seventy-four per cent of the total in that same series, all point­ed to increasing problems with longer follow-up. Use of uncemented acetabular components during hip arthro­plasty has become the preferred method for the majority of hip arthroplasties, with reports of better survivorship and a lower loosening rate for uncemented acetabular components when compared to cemented alternatives. Concerns exist, however, regarding implantation of uncemented components against pagetoid bone, as it is not known whether the altered quality and morphology of bone adversely influences ingrowth into uncemented implants. Some surgeons, because of the un­derlying abnormal bone metabolism, refrain from placing an uncemented component in the hip. However, in recent years there have been reports showing excellent osseointegration of press fit components placed against pagetoid bone. The mid-term result of uncemented femoral and acetabular components in patients with Paget’s disease have been en­couraging. Paradoxically uncemented hip arthroplasty may be a better treatment option for patients with Paget’s dis­ease as sclerotic abnormal bone in these patients precludes optimal cement interdigitation. In one study intended cementing of hip components had to be abandoned in some patients be­cause of perceived inability to obtain good cement interdigita- tion and bonding.

Complications

Osteolysis following THA in Paget’s disease patients, thought to be related to the increased metabolic turnover though rare has been reported. But much more evidence has been reported reinforcing the concept that no rapid osteolysis has been found after cemented and uncemented primary or revision THA. Medication you can afford online pharmacy generic drugs

Patients with Paget’s disease are still at moderate risk for de­veloping heterotopic ossification (HO) after THA, compared to those at high risk like previous history of HO in either hip, bilat­eral hypertrophic osteoarthritis or posttraumatic arthritis. This is the basis for starting preventive measures (pre-op and post-op radiation and prophylactic drug regimens). Excessive bleeding during surgery is one of the most common complications related to Paget’s disease, which is attributed to hypervascularity of the bone, technical difficulty prolonging the procedure, and the need for additional procedures such as os­teotomy during the hip arthroplasty. In any case large amount of cross matched blood may need to be available for pagetoid patients undergoing surgical procedures. Other complications include nonunion of the trochanteric os­teotomy in the formerly used approach for THA, and high­er incidence of periprosthetic fractures around hip arthroplasty components.

Continuation of bone pain following joint arthroplasty, due to the presence of disease or coexistent deformity, pathological microfractures and on very rare instances malignant transfor­mation can also occur. Malignancy, mostly osteosarcoma, can develop in one percent of Paget’s patients. Transmission of Paget’s disease, during autologous bone grafting, from one location to another has also been described.

 

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