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Surgical treatment of complications of Paget’s disease
Bone Vol. 24, No. 5, Supplement May 1999:51S–53S
CLINICAL ASPECTS: ABSTRACTS
mmol/L, the mean percent decrease in AP was 68% (to 32% of baseline). The mean time to the AP baseline was 9 months (Table 1).
Surgical Treatment of Complications of Paget’s Disease J. KENWRIGHT Nuffield Department of Orthopaedics, Oxford University, Oxford, UK
Table 1. Treatment responses
In many countries, Paget’s disease is extremely common, and patients in whom complications have developed frequently present to orthopedic clinics, both general and specialist. General problems for operative treatment. In Paget’s disease, the bone can be excessively soft, or hard, and this can cause problems with internal fixation. Complex deformities cause further problems for planning internal fixation. Excess vascularity of bone can cause serious bleeding. General perioperative and postoperative management. It is important to treat patients with antiresorption agents 1 month before operation. These are of no value if given immediately before operation. Postoperative medication may delay union of fractures. Immobilization can lead to hypercalcemia. Fractures. When the results for osteotomies and diaphyseal fractures were reviewed, it was seen that delayed union is common. Furthermore: (i) intracapsular fractures at the neck of the femur do not heal well and require prosthetic replacement; and (ii) subtrochanteric fractures in the femur are often associated with delayed union, and deformity makes open reduction and internal fixation difficult. Deformity. There are strong indications for correction of deformity if there is repeated fissure fracture and if the deformity is close to a joint in which there is early osteoarthritis (i.e., the knee joint). Degenerative arthritis. Degenerative arthritis is common at the hip and knee joint and joint replacement may be needed; surgical problems may occur due to the deformity of the shaft of the femur and due to protrusio acetabulum. Localization of the cause of pain in and around the joints can be helped by diagnostic injection of local anesthetic. The spine. Spinal stenosis is common; surgical results may be disappointing and persistent medical treatment may be more effective. Malignant change in Paget’s disease of bone is very rare; the prognosis for this condition is still very poor.
Disease
F/M ratio
n
Origin
Paget’s PHPT Both
0.49 2.37 2.75
163 7406 30
WA Literature This series
KEY: F, female; M, male; PHPT, primary hyperparathyroidism; WA, Western Australia. The gender distribution resembles that of pure PHPT. The prevalence of PHPT in PD is 2.2%– 6.0%. In our series, 73% were women .60 years of age. In population studies in patients .60 years of age, 3% of women and 1% of men had PHPT. Thus, the prevalence rates of PHPT in PD and in the elderly population are similar.
Conclusions The evidence strongly favors a chance association of two common diseases. Neck exploration should be considered in those with symptomatic PD and CaC .2.70, to reduce bone turnover. Antiresorptive drugs should be avoided for at least 6 months postoperatively. Address for correspondence and reprints: D. H. Gutteridge, Sir Charles Gairdner Hospital, Nedlands WA 6009, Australia. PII S8756-3282(99)00051-4
Long-Term Follow-up of Paget’s Disease: Progression Despite Medical Treatment A. J. PHILLIPS, R. SMITH, and S. E. VIPOND Departments of Radiology and Metabolism, Nuffield Orthopaedic Centre, Oxford, UK
Address for correspondence: Professor John Kenwright, Nuffield Department of Orthopaedics, Headington, Oxford University, Oxford OX3 7LD, UK. PII S8756-3282(99)00049-6
The indications for treatment of Paget’s disease and the expected outcome are based largely on short-term experience and early biochemical response. The individual response to bisphosphonates varies considerably. Early studies have demonstrated that a single course of etidronate could produce prolonged remission. Further experience shows that the skeletal changes of Paget’s disease often progress regardless of treatment. From a large group of patients with Paget’s disease, nine initially treated with etidronate and calcitonin, and subsequently with clodronate and pamidronate, were followed for up to 20 years. Temporary biochemical response was followed by progressive skeletal deformity in eight subjects. Complications included basilar invagination with ventricular block (one patient) and increasing spinal cord compression (two patients). Despite intensive antipagetic treatment the plasma alkaline phosphatase remained above normal. In these patients, treatment of Paget’s disease was incomplete. It has yet to be shown that newer potent bisphosphonates and a more aggressive treatment protocol can prevent deformity and complications in the long term.
Paget’s Disease With Primary Hyperparathyroidism: Gender Distribution in 30 Cases, and Prediction of Skeletal Response to Parathyroidectomy in 18 D. H. GUTTERIDGE,1,2 H. E. GRUBER,3 D. G. KERMODE,1 and G. K. WORTH1 1 Sir Charles Gairdner Hospital, Nedlands, WA, Australia 2 University of Western Australia, Nedlands, WA, Australia 3 Carolinas Medical Center, Charlotte, NC, USA Introduction Paget’s disease (PD) and primary hyperparathyroidism (PHPT) are both common diseases—the former is most common in men, the second in women. The effect of PHPT, and its surgical correction, on the severity of PD is poorly documented. We report 30 cases with both disorders, 19 of whom had neck explorations, and examine the gender distribution and population prevalence of patients with each disorder, and with both.
Address for correspondence and reprints: Dr. A. J. Phillips, Department of Radiology, Nuffield Orthopaedic Centre, Headington, Oxford OX3 7LD, UK. PII S8756-3282(99)00052-6
Results We found a significant correlation between the degree of postparathyroidectomy (PTx) fall in plasma alkaline phosphatase (AP) and both the preoperative pl. corrected calcium (CaC) (p , 0.01) and ionized calcium (p , 0.05). All patients except one had a post-PTx decrease in AP. For those seven patients with CaC .3.0 © 1999 by Elsevier Science Inc. All rights reserved.
51S
8756-3282/99/$20.00
CLINICAL ASPECTS: ABSTRACTS
mmol/L, the mean percent decrease in AP was 68% (to 32% of baseline). The mean time to the AP baseline was 9 months (Table 1).
Surgical Treatment of Complications of Paget’s Disease J. KENWRIGHT Nuffield Department of Orthopaedics, Oxford University, Oxford, UK
Table 1. Treatment responses
In many countries, Paget’s disease is extremely common, and patients in whom complications have developed frequently present to orthopedic clinics, both general and specialist. General problems for operative treatment. In Paget’s disease, the bone can be excessively soft, or hard, and this can cause problems with internal fixation. Complex deformities cause further problems for planning internal fixation. Excess vascularity of bone can cause serious bleeding. General perioperative and postoperative management. It is important to treat patients with antiresorption agents 1 month before operation. These are of no value if given immediately before operation. Postoperative medication may delay union of fractures. Immobilization can lead to hypercalcemia. Fractures. When the results for osteotomies and diaphyseal fractures were reviewed, it was seen that delayed union is common. Furthermore: (i) intracapsular fractures at the neck of the femur do not heal well and require prosthetic replacement; and (ii) subtrochanteric fractures in the femur are often associated with delayed union, and deformity makes open reduction and internal fixation difficult. Deformity. There are strong indications for correction of deformity if there is repeated fissure fracture and if the deformity is close to a joint in which there is early osteoarthritis (i.e., the knee joint). Degenerative arthritis. Degenerative arthritis is common at the hip and knee joint and joint replacement may be needed; surgical problems may occur due to the deformity of the shaft of the femur and due to protrusio acetabulum. Localization of the cause of pain in and around the joints can be helped by diagnostic injection of local anesthetic. The spine. Spinal stenosis is common; surgical results may be disappointing and persistent medical treatment may be more effective. Malignant change in Paget’s disease of bone is very rare; the prognosis for this condition is still very poor.
Disease
F/M ratio
n
Origin
Paget’s PHPT Both
0.49 2.37 2.75
163 7406 30
WA Literature This series
KEY: F, female; M, male; PHPT, primary hyperparathyroidism; WA, Western Australia. The gender distribution resembles that of pure PHPT. The prevalence of PHPT in PD is 2.2%– 6.0%. In our series, 73% were women .60 years of age. In population studies in patients .60 years of age, 3% of women and 1% of men had PHPT. Thus, the prevalence rates of PHPT in PD and in the elderly population are similar.
Conclusions The evidence strongly favors a chance association of two common diseases. Neck exploration should be considered in those with symptomatic PD and CaC .2.70, to reduce bone turnover. Antiresorptive drugs should be avoided for at least 6 months postoperatively. Address for correspondence and reprints: D. H. Gutteridge, Sir Charles Gairdner Hospital, Nedlands WA 6009, Australia. PII S8756-3282(99)00051-4
Long-Term Follow-up of Paget’s Disease: Progression Despite Medical Treatment A. J. PHILLIPS, R. SMITH, and S. E. VIPOND Departments of Radiology and Metabolism, Nuffield Orthopaedic Centre, Oxford, UK
Address for correspondence: Professor John Kenwright, Nuffield Department of Orthopaedics, Headington, Oxford University, Oxford OX3 7LD, UK. PII S8756-3282(99)00049-6
The indications for treatment of Paget’s disease and the expected outcome are based largely on short-term experience and early biochemical response. The individual response to bisphosphonates varies considerably. Early studies have demonstrated that a single course of etidronate could produce prolonged remission. Further experience shows that the skeletal changes of Paget’s disease often progress regardless of treatment. From a large group of patients with Paget’s disease, nine initially treated with etidronate and calcitonin, and subsequently with clodronate and pamidronate, were followed for up to 20 years. Temporary biochemical response was followed by progressive skeletal deformity in eight subjects. Complications included basilar invagination with ventricular block (one patient) and increasing spinal cord compression (two patients). Despite intensive antipagetic treatment the plasma alkaline phosphatase remained above normal. In these patients, treatment of Paget’s disease was incomplete. It has yet to be shown that newer potent bisphosphonates and a more aggressive treatment protocol can prevent deformity and complications in the long term.
Paget’s Disease With Primary Hyperparathyroidism: Gender Distribution in 30 Cases, and Prediction of Skeletal Response to Parathyroidectomy in 18 D. H. GUTTERIDGE,1,2 H. E. GRUBER,3 D. G. KERMODE,1 and G. K. WORTH1 1 Sir Charles Gairdner Hospital, Nedlands, WA, Australia 2 University of Western Australia, Nedlands, WA, Australia 3 Carolinas Medical Center, Charlotte, NC, USA Introduction Paget’s disease (PD) and primary hyperparathyroidism (PHPT) are both common diseases—the former is most common in men, the second in women. The effect of PHPT, and its surgical correction, on the severity of PD is poorly documented. We report 30 cases with both disorders, 19 of whom had neck explorations, and examine the gender distribution and population prevalence of patients with each disorder, and with both.
Address for correspondence and reprints: Dr. A. J. Phillips, Department of Radiology, Nuffield Orthopaedic Centre, Headington, Oxford OX3 7LD, UK. PII S8756-3282(99)00052-6
Results We found a significant correlation between the degree of postparathyroidectomy (PTx) fall in plasma alkaline phosphatase (AP) and both the preoperative pl. corrected calcium (CaC) (p , 0.01) and ionized calcium (p , 0.05). All patients except one had a post-PTx decrease in AP. For those seven patients with CaC .3.0 © 1999 by Elsevier Science Inc. All rights reserved.
51S
8756-3282/99/$20.00