Total knee arthroplasty in Paget's disease: technical problems and results

Outcomes following Total Hip and Knee Arthroplasty in Patients Who Have Paget's Disease of Bone: A Systematic Review

BACKGROUND

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.

METHODS

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.

RESULTS

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.

CONCLUSION

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.

Do Patients with Paget's Disease Have Worse Outcomes following Primary Total Knee Arthroplasty?

Well-powered studies evaluating the effects of Paget's disease on patient outcomes following primary total knee arthroplasty (TKA) are limited. The objective of this study was to determine whether Paget's disease patients undergoing primary TKA have higher rates of complications. A query of an administrative database was performed identifying Paget's disease patients undergoing primary TKA as the study cohort. Patients who did not have Paget's disease served as a matching cohort. Study group patients were matched in a 1:5 ratio by age, sex, and comorbidities. The query yielded 34,284 patients in the study (n = 5,714) and matched (n = 28,570) cohorts. Outcomes analyzed included length of stay (LOS), costs of care, 90-day medical and surgical complications, and 2-year implant-related complications. Multivariate logistic regression analyses were used to calculate the odds ratios (ORs) of complications. Paget's disease patients undergoing primary TKA were found to have significantly longer in-hospital LOS (4 vs. 3 days, p < 0.0001). Study group patients incurred significantly higher 90-day episode-of-care costs ($15,124.55 vs. $14,610.01, p < 0.0001). Additionally, Paget's disease patients were found to have higher incidences and odds of medical/surgical (25.93 vs. 13.58%; OR: 1.64, p < 0.0001) and implant-related complications (8.97 vs. 5.02%; OR: 1.71, p < 0.0001). Specifically, Paget's disease patients were more likely to have periprosthetic fractures, mechanical loosening, and revision TKAs (p < 0.0001). This study demonstrated that Paget's disease was associated with longer in-hospital LOS, increased costs, and higher rates of complications. The study can be utilized by physicians to adequately educate patients with Paget's disease concerning potential complications following their primary TKA.

Shoulder Arthroplasty for Patients With Proximal Humeral Paget's Disease

Poorly controlled Paget's disease leads to excessive blood loss following total hip arthroplasty. The effect in shoulder arthroplasty is unknown. The authors reviewed 3 patients with Paget's disease involving the proximal humerus, comparing them with 17 patients with Paget's disease but no humeral involvement. The 3 patients had an estimated blood loss of 1400 mL, 1100 mL, and 350 mL, compared with an average of 280 mL in the control group. The first 2 cases required 4 units of packed red blood cells intraoperatively, and both were not managed with bisphosphonates. Paget's disease of the humerus leads to more intraoperative blood loss and higher blood transfusion requirements, particularly in cases not managed with bisphosphonates. [Orthopedics. 2021;44(4):e614-e619.].

Correction of tibial deformity in Paget's disease using the Taylor spatial frame

A 64-year-old man presented with a severe deformity of the tibia caused by Paget's disease and osteoarthritis of the ipsilateral knee. Total knee replacement required preliminary correction of the tibial deformity. This was successfully achieved by tibial osteotomy followed by distraction osteogenesis using the Taylor spatial frame. The subsequent knee replacement was successful, with no recurrence of deformity.

Surgical management of Paget's disease of bone

Paget's disease is a chronic nonmetabolic bone disorder that is characterized by increased bone resorption, bone formation, and remodeling. This unbalanced process may lead to osseous deformities, structural weakness, and altered joint biomechanics, all of which can make surgical reconstruction difficult. Although few patients with Paget's disease ever need surgical treatment, successful surgical management of orthopedic manifestations of the disease has improved the quality of life for these patients. Surgical options include corrective osteotomy for long bone deformity, fracture fixation, joint arthroplasty, spinal decompression, and tumor resection. Patients are at increased risk for surgical complications such as blood loss and heterotopic bone formation. Issues relating to the surgical management of patients with Paget's disease such as appropriate preoperative diagnosis, technical challenges of surgery, and strategies to improve the long-term outcome of surgical intervention are discussed.

Surgical manifestations of Paget's disease

Paget's disease is a chronic, nonmetabolic bone disorder characterized by increased bone resorption, bone formation, and remodeling. This unbalanced process may lead to osseous deformities, structural weakness, and altered joint biomechanics, all of which can make surgical reconstruction difficult. Although few patients with Paget's disease require surgical treatment, successful surgical management of severe orthopaedic complications has improved the quality of life for these patients. Surgical options include osteotomy to correct long-bone deformity and arthroplasty to restore altered joint mechanics. Patients are at increased risk for surgical complications, such as blood loss and heterotopic bone formation. Issues relating to the surgical management of patients with Paget's disease include appropriate preoperative diagnosis, technical challenges of surgery, and strategies to improve the long-term outcome of surgical intervention.

A case of Paget's disease treated by distraction osteogenesis

Paget's disease is a localized bone disorder marked by increased turnover usually associated with a deformity of the affected bone. Distraction osteogenesis may be a useful method for correcting the deformity. A 57-year-old woman with Paget's disease had a 3 cm limb-length discrepancy with a 47 degrees procurvatum deformity of the ipsilateral femur. Distraction osteogenesis using a Taylor Spatial Frame was performed, leading to complete correction of the procurvatum deformity and limb-length discrepancy. After improvement of the limb-length discrepancy, the patient felt more comfortable than she had before surgery with less low back pain. This result suggests distraction osteogenesis may be appropriate for the treatment of some severe, complex deformities of the lower limbs in patients with Paget's disease.

Total knee arthroplasty in patients with Paget's disease of bone at the knee

The purpose of this study was to identify the technical difficulties, complications, and long-term outcome of total knee arthroplasty in patients with Paget's disease. Twenty consecutive patients (21 knees) with Paget's disease at the knee who underwent primary total knee arthroplasty were retrospectively reviewed. All arthroplasties employed cemented condylar implants. Two patients died at less than 2 years and one was lost to follow-up; the remaining 17 (18 knees) were followed for an average of 9 years. Mean Knee Society scores for pain and function improved from 41 and 36 points preoperatively to 87 and 67 points, respectively, postoperatively. One patient underwent femoral revision for aseptic loosening at 10 years. None developed substantial heterotopic ossifications or deep infection. Total knee arthroplasty in patients with Paget's disease can provide good clinical results with low revision rate and good implant durability, despite technical challenges.

Use of the Cusum technique for evaluation of a CT-based navigation system for total knee replacement

Most of the early failures of total knee replacements are related to technical flaws. Conventional ancillary devices achieve good alignment in the frontal plane in only an average of 75% of total knee replacements. Computer-assisted surgery may improve the technical quality of implantation surgery. The aim of our study was to evaluate the use of computer-assisted surgery using a quality control process. Seventy-eight total knee arthroplasties were done with a CT-based computer-assisted surgery system. The outcomes studied were alignment of the lower limb, implant positioning, and operative time. The target for alignment was 180 degrees +/- 3 degrees. Cusum analysis showed that the three outcomes were controlled during the study. The cusum test identified any existing outliers. Because few data were available at the beginning of this study regarding computer-assisted surgery for total knee replacement, a randomized study was not relevant. However, a control of the procedure was mandatory. The cusum technique allowed continuous evaluation of the performance of the new procedure, and is a useful tool in assessing new technology. The results of this study showed that it is possible to do a randomized study to determine if computer-assisted surgery can improve the technical result of total knee replacement.

Corrective osteotomy for deformity in Paget disease

BACKGROUND

Severe deformity resulting from Paget disease is not uncommon. Malalignment of the extremity may lead to intractable pain, mechanical overload of the neighboring joints, limitation of motion and function, and dysmorphic appearance. Although corrective osteotomy has been used to treat osseous deformities, the outcome of corrective osteotomy for long-bone deformities resulting from Paget disease remains largely unknown.

METHODS

The results after twenty-five corrective osteotomies (twenty-two patients), performed between 1975 and 1995, in sixteen tibiae, eight femora, and one radius were evaluated. There were thirteen men and nine women with a mean age of sixty-seven years. The indication for osteotomy was pain in twenty limbs, recurrent stress fractures in three, and limitation of function in two. A variety of osteotomies and fixation methods were used. Two patients underwent simultaneous total hip arthroplasty and proximal femoral osteotomy.

RESULTS

Twenty-three of twenty-five osteotomies healed with an average time to union of six months. Both nonunions were in patients who had been managed with intramedullary fixation. The time to union was significantly shorter in metaphyseal osteotomies fixed with plates than in diaphyseal osteotomies (p < 0.04). There was a substantial improvement in the deformities. Satisfaction was rated excellent or good by fourteen patients, fair by six, and poor by two. Complications included a pin-track infection in two patients, peroneal nerve palsy in one, and loss of fixation following external fixation in one. Disease activity, as measured by serum alkaline phosphatase level, and medical treatment with calcitonin and/or bisphosphonates did not have a significant impact on time to union.

CONCLUSIONS

Corrective osteotomy for the treatment of severe deformity in Paget disease can be challenging and yet rewarding. A higher prevalence of complications was observed following intramedullary nailing and external fixation. Fracture-healing seems to be particularly protracted in diaphyseal osteotomies.