A Plethora of Complications from Paget Disease.

Abstract

In and of itself, Paget disease can be a challenging condition for patients to live with and for orthopaedists to treat. Moreover, as this edition of “Case Connections” illustrates, this mysterious bone-remodeling anomaly can trigger additional orthopaedic complications, including fractures and advanced arthritis. This month’s cases also illustrate that orthopaedic surgery in a zone of pagetic bone can be especially tricky, due in part to the apparent potential of Paget disease to “spread.” Total hip arthroplasty (THA) is one viable approach to treating Paget disease of the hip, but in the March 11, 2015, JBJS Case Connector, Amundsen et al. reported on a case in which the onset of Paget disease soon after THA led to stem loosening that necessitated revision. The seventy-seven-year-old man in this case had two years previously undergone a left THA for posttraumatic arthritis that included a cementless stem, cobalt-chromium head, and polyethylene liner. Radiographs made six months after the arthroplasty showed normal bone morphology, and the patient was symptom-free for the subsequent twelve months. Eighteen months after the procedure, however, he began experiencing hip pain and noticed a mass on the proximal aspect of the right tibia. Left hip radiographs showed femoral component subsidence with cortical thickening and expansion of the greater trochanteric region. Radiographs of the right tibia showed a mixed lytic and sclerotic lesion of the anterior cortex, characteristic of mixed-phase Paget disease. Upon physical exam, surgeons noted a 10-cm × 3-cm firm, nontender mass over the proximal tibial crest, and a bone scan showed areas of increased activity in the proximal half of the left femur …