Cementless Hip Arthroplasty in Paget's Disease at Medium-Term Follow-Up (Average of 6.7 Years)

doi:10.1016/j.arth.2006.09.010

The Journal of Arthroplasty

Volume 22, Issue 5, August 2007, Pages 692-696

https://doi.org/10.1016/j.arth.2006.09.010 Get rights and content

Abstract

We performed 33 cementless total hip arthroplasties for arthritis in 27 patients with an established diagnosis of Paget's disease on the acetabular or femoral side of the hip. There were 3 revisions. One stem for aseptic loosening at 55 months, and 2 stems after periprosthetic fractures at 9 and 70 months. Twenty-three cases were available for follow-up at an average of 6.7 years (range, 2-14 years). Harris hip score improved from 56/100 preoperatively (16-98/100) to 90/100 postoperatively (78-100/100). All surviving components were radiographically bone ingrown. Based on our findings, it appears that a cementless total hip arthroplasty can have a good outcome in Paget's disease.

Section snippets

Materials and Methods

We reviewed patients who had a primary hip arthroplasty, from February 1988 to June 2003, under the care of the 2 senior authors where there was an established diagnosis of Paget's disease. A total of 33 cases in 27 patients were identified.

Pattern of pagetic involvement was 23 femora involved and 24 acetabuli, with both areas involved in 14 cases. A total of 71% of prosthetic components were implanted into pagetic bone. Average age at surgery was 75 years (range, 63-85 years). Fifty-six

Results

Of the 27 patients (33 hips), 2 patients (2 hips) were lost to follow-up despite repeated attempts to contact them. In addition, one woman of 80 years of age filled in a clinical self-assessment questionnaire for her hip and had no pain or limitations from her hip. She refused radiographs, as she did not think it was worthwhile. Four patients (5 hips) died before the minimum 2-year follow-up due to reasons unrelated to their surgery. The high death rate reflects the advanced age of the

Discussion

Of the 33 acetabuli inserted, 30 were hydroxyapatite coated and 24 were implanted into radiographically pagetic bone. There was no case of acetabular loosening clinically or radiographically giving a strong endorsement for their use. This backs up earlier smaller studies [5], [6], [7], the largest of which [6] gave similar results in 19 acetabuli in pagetic bone. This must be contrasted with the results of cemented acetabular components. A study from the Mayo Clinic [2] reviewed 91 cases of

Acknowledgments

The authors acknowledge Sharon Wales and Lyn McDonald for their assistance with collection of data.

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Outcomes following Total Hip and Knee Arthroplasty in Patients Who Have Paget's Disease of Bone: A Systematic Review
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Patients who have Paget's Disease more frequently require total hip arthroplasty (THA) and total knee arthroplasty (TKA) than matched controls. However, controversy remains regarding their outcome. We aimed to evaluate the literature regarding outcomes following THA and TKA in patients who have Paget's Disease.
MEDLINE, EMBASE and Cochrane databases were searched for all articles evaluating outcomes following THA and TKA in patients who have Paget’s Disease. Quality of included studies was assessed using the Newcastle-Ottawa Scale.
A total of 19 articles (published between 1976 and 2022) were included, comprising 58,695 patients (48,766 controls and 10,018 patients who have Pagets Disease), from 209 potentially relevant titles. Patients with Paget's Disease have a pooled mortality of 32.5% at a mean of 7.8 years (range, 0.1 to 20) following THA and 31.0% at a mean of 8.5 years (range, 2 to 20) following TKA, with a pooled revision rate of 4.4% at 7.2 years (range, 0 to 20) following THA and 2.2% at 7.4 years (range, 2 to 20) following TKA. Renal and respiratory complications, as well as heterotopic ossification and surgical-site infection were the most common post-operative complications.
There is marked heterogeneity in outcome reporting of studies assessing arthroplasty in patients who have Paget’s Disease, with studies of low to moderate quality. Patients with Paget's Disease undergoing THA and TKA appear to have similar implant longevity as their unaffected counterparts. However, they appear to have an increased risk of medical and surgical complications and may have a higher mortality risk from their procedure.
Paget's Disease in Primary Total Hip Arthroplasty Is Associated With Greater In-Hospital Lengths of Stay, Costs, and Complications
2021, Journal of Arthroplasty
Citation Excerpt :
Wegrzyn et al [13] found that 22 of 39 THAs formed heterotopic ossification, but 19 of the cases were Brooker grade [36] 1 or 2. Lusty et al [8] evaluated 33 THAs and found that 12 formed heterotopic bone but 11 were Brooker grade 1 or 2. It is plausible that in our study only more severe cases of heterotopic ossification were coded.
There are few well-powered studies investigating the association of Paget’s disease of bone on patients undergoing primary total hip arthroplasty (THA). This study utilized a nationwide database to determine whether Paget’s patients undergoing primary THA are associated with higher rates of (1) lengths of stay (LOS); (2) costs; and (3) complications (medical/surgical and implant-related).
Using International Classification of Diseases, Ninth Revision and Current Procedural Terminology codes, Paget’s patients undergoing primary THA were identified and matched to non-Paget’s patients in a 1:5 ratio by age, sex, and comorbidities utilizing the PearlDiver database. This resulted in 21,714 patients in Paget’s (n = 3619) and non-Paget’s (n = 18,095) cohorts. Outcomes assessed included LOS, episode-of-care costs, medical/surgical complications, and implant-related complications. A P value less than .003 was considered statistically significant.
Compared to the matched cohort, Paget’s patients undergoing primary THA had significantly longer LOS (P < .0001), higher 90-day total global episode-of-care costs (P < .0001), higher 90-day medical and surgical complications (P < .0001), and higher implant-related complications (P < .0001).
We found that Paget’s was associated with higher rates of LOS, costs, and complications. Although there was an association found, the risk appears reasonably low compared to the matched cohort. The study can be utilized by orthopedic professionals to counsel and educate these patients of potential complications which may occur following their procedure.
Catastrophic failure of cup revision hip arthroplasty due to undiagnosed Paget disease of bone: A case report
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Paget's disease of bone (PDB) is a localized chronic osteopathy, apparently not genetic in origin, and frequently diagnosed from incidental radiographic images. The disease is characterized by deformation, hypervascularity, and structural weakness of the bone and by changes in joint biomechanics. Most cases of PDB can be easily diagnosed from radiographic findings, but monostotic cases may be problematic and require invasive procedures.
A 70-year-old woman had re-revision surgery for early catastrophic failure of an isolated cup revision hip arthroplasty because of undiagnosed PDB 21 years after the primary total hip arthroplasty. To identify the pathomechanism of early failure, we performed bone biopsy on the right iliac crest. Histopathological findings showed a mosaic pattern in the bone characteristic of PDB. Prior to the planned re-revision surgery, we treated the PDB with denosumab until the patient’s serum level of alkaline phosphatase (ALP) was within the normal limits. Two months after denosumab treatment, we performed re-revision hip arthroplasty using a structural allograft and a Kerboull-type reinforcement device.
The delay in correct diagnosis of PDB was associated with the rapid destruction of pelvic bone. The preoperative use of antipagetic medication could decrease the risk of implant loosening and may be warranted to mitigate that risk.
In patients with a failed arthroplasty, thoughtful evaluation is warranted for preoperative antipagetic medication in order to reduce PDB activity and potentially decrease the risk of implant loosening. This paper offers some steps for such risk reduction in the workup before revision surgery.
Paget's disease of bone
2018, Orthopaedics and Trauma
Citation Excerpt :
This may be one of the reasons why the results of cemented THA in patients with PDB are poorer.51 Conversely, the increased bone turnover in PDB is thought to predispose to failure of osseointegration and early aseptic loosening.54 Marked deformity of the proximal femur may require implantation of a custom-made stem or a femoral osteotomy to enable adequate femoral component alignment and fixation.21,55,56
Paget's disease of bone is a bone modelling disorder, characterized by skeletal deformity. Although the aetiology is largely unknown, environmental and genetic theories have been proposed. Serum alkaline phosphatase and plain radiographs remain the most commonly utilised investigations for diagnosis, and allow monitoring of the disease process. Second-generation bisphosphonates continue to be the mainstay of treatment, but surgical intervention may be required to treat complications including fracture, deformity and arthritis. This article reviews the epidemiology, aetiology, clinical features, investigations and treatment, including both medical and novel surgical options.
Paget Disease of Bone
2015, Orthopedic Clinics of North America

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Original ArticleCementless Hip Arthroplasty in Paget's Disease at Medium-Term Follow-Up (Average of 6.7 Years)

Abstract

Section snippets

Materials and Methods

Results

Discussion

Acknowledgments

J Arthroplasty

Total hip arthroplasty in Paget's disease of the hip

J Bone Joint Surg Am

Total hip arthroplasty in Paget's disease. A follow-up note

J Bone Joint Surg Am

Total arthroplasty in Paget's disease of the hip. A clinical review and review of the literature

Clin Orthop Relat Res

Charnley low-friction arthroplasty for Paget's disease of the hip

J Arthroplasty

Outcome of uncemented hip arthroplasty components in patients with Paget's disease

Clin Orthop Relat Res

Hydroxyapatite-coated total hip replacement in Paget's disease: 20 patients followed for 4-8 years

Acta Orthop Scand

Clinical and radiographic evaluation of total hip replacement. A standard system of terminology for reporting results

J Bone Joint Surg Am

Original Article
Cementless Hip Arthroplasty in Paget's Disease at Medium-Term Follow-Up (Average of 6.7 Years)