Fukui Kiyokazu, Kaneuji Ayumi, Yonezawa Katsutaka, Shioya Akihiro, Ichiseki Toru, Kawahara Norio
Department of Orthopedic Surgery, Kanazawa Medical University, Japan.
Department of Orthopedic Surgery, Kanazawa Medical University, Japan.
Int J Surg Case Rep. 2020;76:5-10. doi: 10.1016/j.ijscr.2020.09.101. Epub 2020 Sep 21.
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.
骨佩吉特病（PDB）是一种局限性慢性骨病，其病因显然并非遗传，常因偶然的影像学检查而被诊断出来。该疾病的特征包括骨骼变形、血管增生以及结构脆弱，还有关节生物力学的改变。大多数PDB病例可通过影像学检查结果轻松诊断，但单骨型病例可能存在问题，需要进行侵入性检查。
一名70岁女性因原发性全髋关节置换术后21年未诊断出的PDB导致孤立性髋臼翻修髋关节置换术早期灾难性失败而接受再次翻修手术。为确定早期失败的发病机制，我们对右侧髂嵴进行了骨活检。组织病理学检查结果显示为PDB特征性的骨镶嵌模式。在计划进行的再次翻修手术前，我们使用地诺单抗治疗PDB，直至患者血清碱性磷酸酶（ALP）水平恢复正常。地诺单抗治疗两个月后，我们使用结构性同种异体骨和Kerboull型增强装置进行了再次翻修髋关节置换术。
PDB诊断延误与骨盆骨的快速破坏有关。术前使用抗佩吉特病药物可降低植入物松动的风险，可能有必要采取此措施以降低该风险。
对于关节置换失败的患者，术前进行抗佩吉特病药物的审慎评估是必要的，以降低PDB活动度，并有可能降低植入物松动的风险。本文提供了一些在翻修手术前检查中降低此类风险的步骤。
