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Nepal S, Jarusriwanna A, Unnanuntana A. Stress Fracture of the Femoral Shaft in Paget's Disease of Bone: A Case Report. J Bone Metab 2021; 28:171-178. [PMID: 34130369 PMCID: PMC8206614 DOI: 10.11005/jbm.2021.28.2.171] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Accepted: 04/19/2021] [Indexed: 11/12/2022] Open
Abstract
Paget’s disease of bone (PDB) is a progressive bone disorder characterized by increased osteoclast-mediated bone resorption and abnormal bone formation. Incomplete atypical femoral fracture, appearing radiographically as a stress fracture at the lateral aspect of the femur, is an uncommon low-trauma fracture frequently seen in association with long-term bisphosphonate therapy. We describe the case of a 61-year-old female patient with PDB who developed a stress fracture at the lateral femoral cortex after 5 doses of intravenous bisphosphonate. The conservative treatment plan included discontinuation of bisphosphonate, a continuation of calcium and vitamin D supplementation, and limited weight-bearing for 3 months. The patient’s pain level gradually improved after switching to the new treatment plan. At the latest follow-up, approximately 5 years after the initiation of conservative treatment, the patient remained pain-free, and her PDB was well-controlled. However, the fracture line was still visible on the most recent radiograph. Although it remains unclear whether a stress fracture at the lateral femoral cortex occurred due to bisphosphonate therapy or PDB, this case highlights the importance of careful evaluation of any lesion that appears in PDB patients receiving bisphosphonate therapy.
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Affiliation(s)
- Sarthak Nepal
- Department of Orthopaedic Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Atthakorn Jarusriwanna
- Department of Orthopaedics, Faculty of Medicine, Naresuan University, Phitsanulok, Thailand
| | - Aasis Unnanuntana
- Department of Orthopaedic Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
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Di Martino A, Coppola MAR, Bordini B, Stefanini N, Geraci G, Pilla F, Traina F, Faldini C. Clinical and radiological outcomes of total hip arthroplasty in patients affected by Paget's disease: a combined registry and single-institution retrospective observational study. J Orthop Traumatol 2021; 22:13. [PMID: 33733386 PMCID: PMC7969678 DOI: 10.1186/s10195-021-00574-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Accepted: 02/23/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Total hip arthroplasty (THA) in patients with Paget's disease can be associated with technical difficulties related to deformities and altered mechanical bone properties, and hypervascularity leads to significative intra-operative bleeding. The purpose of this registry and single-institution study was to investigate overall survival and causes of failure of THA in pagetic patients, together with an analysis of the clinical and radiological complications. MATERIAL AND METHODS Registry-based survival and complication analysis, type of fixation, intra- and post-operative complications, clinical (pharmacological history, blood transfusions, Harris hip score [HHS]) and radiographic (cup orientation, stem axial alignment, osteolysis around the cup and the stem and heterotopic ossification [HO]) data were reviewed. RESULTS In total, 66 patients (27 males and 39 females, mean age at surgery 71.1 years for males and 74.8 years for female) from the registry study presented a 10-year survival of 89.5%. In the institutional study, involving 26 patients (14 males and 12 females, 69 years average) and 29 THAs, hip function improved significantly. Average cup orientation was 40.5°, while varus stem alignment was 13.8%. In total, 52% of hips had heterotopic ossifications. Peri-acetabular osteolysis was in 13.8% of implants and in 45% of hips was found around the stem. Allogenic and autologous blood transfusion rate were 68.2% and 31.8%, respectively, with an average transfusion of 2 units of blood (range 1-6 units). HHS improved by an average of 34 points, with excellent result in 64.3% of patients. Two implants failed, one due to traumatic ceramic head fracture 64 months after surgery, and one due to mobilization of the cup on the second post-operative day. CONCLUSION THA surgery in Paget's patients is a safe procedure, and implant survival is only partly affected by bone remodelling and choice of fixation. The post-operative functional outcome is largely similar to that of other patients. Bleeding-related complications are the main complications; a careful pharmacological strategy should be recommended to decrease the risk of transfusions and of HO development. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Alberto Di Martino
- 1st Orthopaedic and Traumatologic Clinic, IRCCS Istituto Ortopedico Rizzoli, Via Pupilli, 1, 40136, Bologna, Italy.
- Department of Biomedical and Neuromotor Science-DIBINEM, University of Bologna, Bologna, Italy.
| | | | - Barbara Bordini
- Laboratorio Di Tecnologia Medica, IRCCS Istituto Ortopedico Rizzoli, Via di Barbiano, 1/10, 40136, Bologna, Italy
| | - Niccolò Stefanini
- 1st Orthopaedic and Traumatologic Clinic, IRCCS Istituto Ortopedico Rizzoli, Via Pupilli, 1, 40136, Bologna, Italy
| | - Giuseppe Geraci
- 1st Orthopaedic and Traumatologic Clinic, IRCCS Istituto Ortopedico Rizzoli, Via Pupilli, 1, 40136, Bologna, Italy
| | - Federico Pilla
- 1st Orthopaedic and Traumatologic Clinic, IRCCS Istituto Ortopedico Rizzoli, Via Pupilli, 1, 40136, Bologna, Italy
| | - Francesco Traina
- Department of Biomedical and Neuromotor Science-DIBINEM, University of Bologna, Bologna, Italy
- Orthopaedic-Traumatology and Prosthetic Surgery and Revisions of Hip and Knee Implants, IRCCS Istituto Ortopedico Rizzoli, Via Pupilli, 1, 40136, Bologna, Italy
- University of Messina, Messina, Italy
| | - Cesare Faldini
- 1st Orthopaedic and Traumatologic Clinic, IRCCS Istituto Ortopedico Rizzoli, Via Pupilli, 1, 40136, Bologna, Italy
- Department of Biomedical and Neuromotor Science-DIBINEM, University of Bologna, Bologna, Italy
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Fuentes-Calvo I, Usategui-Martín R, Calero-Paniagua I, Moledo-Pouso C, García-Ortiz L, Pino-Montes JD, González-Sarmiento R, Martínez-Salgado C. Influence Of Angiogenic Mediators And Bone Remodelling In Paget´s Disease Of Bone. Int J Med Sci 2018; 15:1210-1216. [PMID: 30123059 PMCID: PMC6097267 DOI: 10.7150/ijms.26580] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Accepted: 07/02/2018] [Indexed: 01/06/2023] Open
Abstract
Paget´s disease of bone (PDB) is characterized by increased bone resorption followed by an excessive compensatory bone formation, with an abnormal bone structure with altered mechanical properties. Pagetic bone also has a higher vascularization and marrow fibrosis. Despite of pagetic bone being a highly vascularized tissue, there are no studies on the plasma levels of angiogenic mediators in the different states of the disease; moreover, the effect of PDB treatment on plasma levels of these angiogenic mediators is not very well known. The aim of this study was to analyse plasma levels of cytokines implicated in the increased bone turnover (OPG, RANKL, sclerostin) and hypervascularization (VEGF, PGF, ENG) observed in PDB and their evolution and response to zoledronic acid treatment in 70 PDB patients, 29 with an active disease measured by plasma alkaline phosphatase (ALP). Plasma ALP concentration was higher in active PDB than in inactive PDB patients, whereas there were no differences in OPG, RANKL, sclerostin, VEGF, PGF and ENG plasma levels between active and inactive PDB patients. ALP decreased at 3 and 12 months after zoledronic acid treatment. RANKL levels were reduced and sclerostin levels were increased after 12 months of treatment. PGF levels were lower 12 months after zoledronic acid treatment, whereas there were no differences in plasma VEGF and ENG after zoledronic acid treatment. Summarizing, zoledronic acid treatment is associated to decreases in plasma levels of ALP, RANKL, sclerostin and P1GF in active PDB patients. This treatment may reduce bone turnover and might reduce the pathological vascularisation typical of pagetic bone.
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Affiliation(s)
- Isabel Fuentes-Calvo
- Translational Research on Renal and Cardiovascular Diseases (TRECARD), Department of Physiology and Pharmacology, University of Salamanca, Salamanca, Spain.,Institute of Biomedical Research of Salamanca (IBSAL), Salamanca, Spain
| | - Ricardo Usategui-Martín
- Institute of Biomedical Research of Salamanca (IBSAL), Salamanca, Spain.,Molecular Medicine Unit, Department of Medicine, University of Salamanca and Institute of Molecular and Cellular Biology of Cancer (IBMCC), University of Salamanca-CSIC, Salamanca, Spain
| | | | - Cristina Moledo-Pouso
- Translational Research on Renal and Cardiovascular Diseases (TRECARD), Department of Physiology and Pharmacology, University of Salamanca, Salamanca, Spain
| | - Luis García-Ortiz
- Institute of Biomedical Research of Salamanca (IBSAL), Salamanca, Spain.,Research Unit, Primary Care Centre of La Alamedilla, Salamanca, Spain
| | - Javier Del Pino-Montes
- Institute of Biomedical Research of Salamanca (IBSAL), Salamanca, Spain.,Metabolic Bone Unit, University Hospital of Salamanca, Spain
| | - Rogelio González-Sarmiento
- Institute of Biomedical Research of Salamanca (IBSAL), Salamanca, Spain.,Molecular Medicine Unit, Department of Medicine, University of Salamanca and Institute of Molecular and Cellular Biology of Cancer (IBMCC), University of Salamanca-CSIC, Salamanca, Spain
| | - Carlos Martínez-Salgado
- Translational Research on Renal and Cardiovascular Diseases (TRECARD), Department of Physiology and Pharmacology, University of Salamanca, Salamanca, Spain.,Institute of Biomedical Research of Salamanca (IBSAL), Salamanca, Spain.,Institute of Health Sciences Studies of Castilla y Leon (IECSCYL), Research Unit, University Hospital of Salamanca, Salamanca, Spain
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Numan MS, Amiable N, Brown JP, Michou L. Paget's disease of bone: an osteoimmunological disorder? DRUG DESIGN DEVELOPMENT AND THERAPY 2015; 9:4695-707. [PMID: 26316708 PMCID: PMC4544727 DOI: 10.2147/dddt.s88845] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Osteoimmunology represents a large area of research resulting from the cross talk between bone and immune systems. Many cytokines and signaling cascades are involved in the field of osteoimmunology, originating from various cell types. The RANK/receptor activator of nuclear factor Kappa-B ligand (RANKL)/osteoprotegerin (OPG) signaling has a pivotal role in osteoimmunology, in addition to proinflammatory cytokines such as tumor necrosis factor-α, interleukin (IL)-1, IL-6, and IL-17. Clinically, osteoimmunological disorders, such as rheumatoid arthritis, osteoporosis, and periodontitis, should be classified according to their pattern of osteoimmunological serum biomarkers. Paget’s disease of bone is a common metabolic bone disorder, resulting from an excessively increased bone resorption coupled with aberrant bone formation. With the exception of the cellular responses to measles virus nucleocapsid protein and the interferon-gamma signature, the exact role of the immune system in Paget’s disease of bone is not well understood. The cytokine profiles, such as the increased levels of IL-6 and the interferon-gamma signature observed in this disease, are also very similar to those observed in other osteoimmunological disorders. As a potential osteoimmunological disorder, the treatment of Paget’s disease of bone may also benefit from progress made in targeted therapies, in particular for receptor activator of nuclear factor Kappa-B ligand and IL-6 signaling inhibition.
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Affiliation(s)
- Mohamed S Numan
- CHU de Québec Research Centre, CHU de Québec-Université Laval, Quebec City, QC, Canada ; Division of Rheumatology, Department of Medicine, CHU de Québec-Université Laval, Quebec City, QC, Canada
| | - Nathalie Amiable
- CHU de Québec Research Centre, CHU de Québec-Université Laval, Quebec City, QC, Canada
| | - Jacques P Brown
- CHU de Québec Research Centre, CHU de Québec-Université Laval, Quebec City, QC, Canada ; Division of Rheumatology, Department of Medicine, CHU de Québec-Université Laval, Quebec City, QC, Canada ; Department of Rheumatology, CHU de Québec-Université Laval, Quebec City, QC, Canada
| | - Laëtitia Michou
- CHU de Québec Research Centre, CHU de Québec-Université Laval, Quebec City, QC, Canada ; Division of Rheumatology, Department of Medicine, CHU de Québec-Université Laval, Quebec City, QC, Canada ; Department of Rheumatology, CHU de Québec-Université Laval, Quebec City, QC, Canada
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Numan MS, Brown JP, Michou L. Impact of air pollutants on oxidative stress in common autophagy-mediated aging diseases. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2015; 12:2289-305. [PMID: 25690002 PMCID: PMC4344726 DOI: 10.3390/ijerph120202289] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/22/2014] [Revised: 01/13/2015] [Accepted: 02/11/2015] [Indexed: 12/11/2022]
Abstract
Atmospheric pollution-induced cellular oxidative stress is probably one of the pathogenic mechanisms involved in most of the common autophagy-mediated aging diseases, including neurodegenerative diseases such as amyotrophic lateral sclerosis (ALS), Alzheimer's, disease, as well as Paget's disease of bone with or without frontotemporal dementia and inclusion body myopathy. Oxidative stress has serious damaging effects on the cellular contents: DNA, RNA, cellular proteins, and cellular organelles. Autophagy has a pivotal role in recycling these damaged non-functional organelles and misfolded or unfolded proteins. In this paper, we highlight, through a narrative review of the literature, that when autophagy processes are impaired during aging, in presence of cumulative air pollution-induced cellular oxidative stress and due to a direct effect on air pollutant, autophagy-mediated aging diseases may occur.
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Affiliation(s)
- Mohamed Saber Numan
- Department of Endocrinology and Nephrology, Centre Hospitalier Universitaire de Québec Research Centre, Québec, QC, G1V 4G2, Canada.
- Division of Rheumatology, Department of Medicine, University Laval, Québec, QC, G1V 4G2, Canada.
| | - Jacques P Brown
- Department of Endocrinology and Nephrology, Centre Hospitalier Universitaire de Québec Research Centre, Québec, QC, G1V 4G2, Canada.
- Division of Rheumatology, Department of Medicine, University Laval, Québec, QC, G1V 4G2, Canada.
- Department of Rheumatology, Centre Hospitalier Universitaire de Québec, Québec, QC, G1V 4G2, Canada.
| | - Laëtitia Michou
- Department of Endocrinology and Nephrology, Centre Hospitalier Universitaire de Québec Research Centre, Québec, QC, G1V 4G2, Canada.
- Division of Rheumatology, Department of Medicine, University Laval, Québec, QC, G1V 4G2, Canada.
- Department of Rheumatology, Centre Hospitalier Universitaire de Québec, Québec, QC, G1V 4G2, Canada.
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Guay-Bélanger S, Picard S, Gagnon E, Morissette J, Siris ES, Orcel P, Brown JP, Michou L. Detection of SQSTM1/P392L post-zygotic mutations in Paget's disease of bone. Hum Genet 2014; 134:53-65. [PMID: 25241215 PMCID: PMC4282700 DOI: 10.1007/s00439-014-1488-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2014] [Accepted: 09/10/2014] [Indexed: 01/30/2023]
Abstract
Paget’s disease of bone (PDB) is transmitted, in one-third of cases, in an autosomal dominant mode of inheritance with incomplete penetrance. The SQSTM1/P392L germinal mutation is the most common mutation associated with PDB. Given the focal nature of PDB, one team of investigators showed that SQSTM1/P392L somatic mutations could occur in pagetic bone lesions in the absence of germinal mutations detectable in the peripheral blood. The objectives of this study were to develop a reliable method to detect SQSTM1/P392L post-zygotic mutations, by optimizing a polymerase chain reaction (PCR)-clamping method reported to be effective in detecting post-zygotic mutations in peripheral blood from patients with fibrous dysplasia; and to evaluate the frequency of this post-zygotic mutation in PDB patients. We used a locked nucleic acid (LNA) specifically designed for the SQSTM1/P392L mutation, which blocks the wild-type allele amplification during the PCR. DNA from 376 pagetic patients and 297 controls, all without any SQSTM1/P392L germinal mutation, was analyzed. We found that 4.8 % of PDB patients and 1.4 % of controls were carriers of this post-zygotic mutation [p = 0.013, OR 3.68 (1.23; 11.00)]. PDB patient carriers of a post-zygotic mutation had a lower number of affected bones and Renier’s index than patients carrying a germinal mutation, suggesting a lower disease extension. We also demonstrated that this post-zygotic mutation was restricted to the monocytic lineage. These results confirmed that LNA PCR clamping is effective for the detection of SQSTM1/P392L post-zygotic mutations, which may occur in patients with PDB.
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Affiliation(s)
- Sabrina Guay-Bélanger
- CHU de Québec Research Centre, Rhumatologie-R4774, CHU de Québec, 2705 boulevard Laurier, Québec, QC, G1V 4G2, Canada
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Abstract
Paget disease of bone (PDB) is a chronic progressive disease of the bone of uncertain etiology, characterized initially by an increase in bone resorption, followed by a disorganized and excessive formation of bone, leading to pain, fractures, and deformities. It can manifest as a monostotic or polyostotic disease. The prevalence of PDB is common in the Anglo-Saxon population, but relatively rare in India. The disease is often asymptomatic and commonly seen in an aging population. The diagnosis of the disease is mostly based on radiological examination and on biochemical markers of bone turnover. Markedly elevated serum alkaline phosphatase (SAP) is a constant feature while calcium and phosphate levels are typically within normal limits. It is being successfully treated by biphosphonates, a group of anti-resorptive drugs, thereby decreasing the morbidity and mortality associated with the disease. We report a classic case of PDB with craniofacial involvement resulting in Leontiasis Ossea (lion like face), cotton wool appearance of the skull and elevated SAP.
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Affiliation(s)
- Y Uday Shankar
- Department of Oral Medicine and Radiology, G. Pulla Reddy Dental College and Hospital, Kurnool, Andhra Pradesh, India
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Abstract
Bisphosphonates (BPs) are synthetic analogues of pyrophosphate. They inhibit bone resorption and are therefore widely used in disorders where there are increases or disruptions in bone resorption. This includes postmenopausal osteoporosis, glucocorticoid-induced osteoporosis, Paget's disease of bone, and malignancy-related bone loss. To best understand the clinical application of BPs, an understanding of their pharmacokinetics and pharmacodynamics is important. This review describes the structure, pharmacology and mode of action of BPs, focusing on their role in clinical practice. Controversies and side effects surrounding their use will also be discussed.
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Affiliation(s)
- Geeta Hampson
- Osteoporosis Screening Unit, Guy's Hospital, London, UK ; Department of Chemical Pathology, St Thomas' Hospital, London, UK
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