HIP ARTHROPLASTY IN PAGET'S DISEASE OF BONE: A CURRENT LITERATURE REVIEW, CLINICAL CONSIDERATIONS, AND THERAPEUTIC RECOMMENDATIONS

Abstract

HIP ARTHROPLASTY IN PAGET'S DISEASE OF BONE: A CURRENT LITERATURE REVIEW, CLINICAL CONSIDERATIONS, AND THERAPEUTIC RECOMMENDATIONS

ARTROPLASTIA DE CADERA EN LA ENFERMEDAD ÓSEA DE PAGET: REVISIÓN DE LITERATURA

Introduction

Paget’s Disease of Bone (PDB) is the second most common metabolic bone disorder after osteoporosis, affecting up to 5% of individuals over 80 years old. It is characterized by excessive bone remodeling due to increased osteoclastic and osteoblastic activity, resulting in weakened, disorganized, and hypervascularized bone prone to fractures and deformities. Although the etiology remains uncertain, genetic mutations—particularly in the SQSTM1 gene—and viral infections (e.g., measles virus) have been implicated. PDB most frequently involves the pelvis, femur, spine, skull, and tibia, and may be monostotic or polyostotic. While 20–25% of patients remain asymptomatic, others experience pain, deformities (e.g., coxa vara, acetabular protrusion), and fractures. Serum alkaline phosphatase (ALP) is the most reliable biochemical marker for diagnosis and monitoring. Hip involvement is common and often leads to secondary osteoarthritis, for which total hip arthroplasty (THA) becomes necessary. However, altered bone quality, deformities, and hypervascularity pose surgical challenges, especially regarding implant selection and fixation.

Objective

To evaluate recent evidence on clinical outcomes, complications, and implant performance in patients with Paget’s disease undergoing total hip arthroplasty (THA) or revision THA, with a focus on comparing cemented and uncemented components.

Methodology

A systematic literature search was conducted in February 2024 across databases including PubMed, Scopus, Cochrane, Embase, and Google Scholar, targeting studies published between January 2020 and January 2024. Search terms included: “Paget’s Disease of Bone,” “Total Hip Arthroplasty,” and “Revision Hip Arthroplasty.” Inclusion criteria were clinical studies in English or Spanish reporting THA outcomes in skeletally mature PDB patients. Exclusion criteria included studies on joints other than the hip, narrative reviews, and non-peer-reviewed sources. Clinical outcomes recorded included complication rates, implant type, revision surgery, and Harris Hip Score (HHS).

Results

Five relevant studies were included. Large cohort data (e.g., Arif et al., n=4211) reported higher medical complication rates (UTIs, VTEs, respiratory issues) and a revision rate of 4.4% over 7 years, with mean HHS of 85.2. Case reports (D’Ambrosi, Giaretta) and small series (Di Martino, Makaram) demonstrated lower complication rates and high functional recovery (mean HHS 82–90), but had limited follow-up and sample size. Cemented implants showed higher rates of aseptic loosening, particularly in the presence of elevated ALP. Non-cemented implants were associated with better long-term fixation, though technical difficulties remain due to sclerotic and deformed bone. Heterotopic ossification (HO) was reported in up to 51.7% of cases. Bisphosphonate therapy prior to surgery reduced intraoperative bleeding and may enhance implant survival.

Conclusions

Total hip arthroplasty significantly improves pain and function in patients with Paget’s disease but poses technical and biological challenges. Careful preoperative planning, imaging, control of disease activity (e.g., with bisphosphonates), and long-term follow-up are essential. Non-cemented implants may offer superior outcomes; though individualized approaches are recommended. High rates of heterotopic ossification necessitate prophylaxis. More large-scale, long-term comparative studies are needed to optimize surgical strategies and implant selection in this unique patient population.