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Osteologie 2023; 32(01): 33-41
DOI: 10.1055/a-2010-7244
Review

Chirurgische Interventionen beim Morbus Paget

Surgical Interventions in Paget Disease
Andreas Kurth
1   Zentrum für Orthopädie und Unfallchirurgie Marienhaus Klinikum Mainz, Mainz, Germany
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Zusammenfassung

Die orthopädisch – chirurgische Behandlung von Patienten mit einem Morbus Paget stellt eine Herausforderung dar.

In der modernen orthopädischen Chirurgie stehen adäquate Verfahren zur Verfügung, um – korrekt eingesetzt – dem Patienten eine deutliche Reduktion seiner Beschwerden zu ermöglichen und die Lebensqualität zu verbessern. Die Hauptkomplikationen sind pathologische Frakturen, Deformitäten der befallenen Knochen und die frühzeitige Entwicklung einer sekundären Arthrose großer Gelenke.

Für den Operateur zu beachten, dass dieses Patientengut mit einem erhöhten Risiko für intra- und postoperative Komplikationen einhergeht. Um die Komplikationsraten weitgehend zu minimieren bedarf es einer sorgfältigen präoperativen Planung mit Überprüfung des aktuellen Status der Grunderkrankung und möglicher präoperativer medikamentöser Intervention mittels Bisphosphonaten (evidenzbasiert Zoledronat 5 mg) zur Normalisierung des Knochenstoffwechsels. Auch muss eine umfassende klinische und radiologische Diagnostik durchgeführt werden, um mögliche Mitbeteiligungen angrenzender Skelettabschnitte frühzeitig zu erkennen und Operationen und Implantate planen zu können.

Intraoperativ sind die Schwierigkeiten gekennzeichnet durch die erhöhte Vaskularisierung des betroffenen Knochens und die deutlich veränderte Knochenstruktur. Einem vermehrten Blutverlust kann durch eine rechtzeitig eingeleitete Bisphosphonat-Therapie wahrscheinlich vorgebeugt werden. Wegen des oft gleichzeitig vorliegenden sklerotischen und osteolytischen Knochens ist die Verwendung geeigneten Instrumentarien und besondere Sorgfalt bei der Implantation von Osteosynthesematerial und Endoprothesen geboten. Eine maligne Entartung sollte bei ausgeprägter Schmerzsymptomatik und Weichteilschwellung bis zu ihrem Ausschluss in Betracht gezogen werden und eine weitere Diagnostik eingeleitet werden.

Abstract

The orthopedic-surgical treatment of patients with Paget's disease is a challenge.

In modern orthopedic surgery, adequate procedures are available to enable the patient – correctly applied – to significantly reduce his or her complaints and improve the quality of life. The main complications are pathological fractures, deformities of the affected bones and the early development of secondary arthrosis.

For the surgeon to consider, this patient population is associated with an increased risk of intraoperative and postoperative complications. In order to minimize complication rates to a large extent, careful preoperative planning with review of the current status of the underlying disease and possible preoperative drug intervention using bisphosphonates (evidence-based zoledronate 5 mg) to normalize bone metabolism is required. Comprehensive clinical and radiological diagnostics must also be performed to identify possible involvement of adjacent skeletal segments early and to plan surgery and implants.

Intraoperative difficulties are characterized by the increased vascularization of the affected bone and the significantly altered bone structure. Increased blood loss can probably be prevented by timely initiation of bisphosphonate therapy. Because of the often concomitant presence of sclerotic and osteolytic bone, the use of appropriate instrumentation and special care in the implantation of osteosynthesis materials and endoprostheses is required. Malignant transformation should be considered until ruled out in cases of increaded pain symptoms and soft tissue swelling, and further diagnostics should be initiated.

Schlüsselwörter

Morbus Paget - Therapie - Chirurgische Versorgung

Key words

Pagets Disease - Treatment - Surgical Management


Publication History

Received: 04 November 2022

Accepted: 09 January 2023

Article published online:
28 February 2023

© 2023. Thieme. All rights reserved.

Georg Thieme Verlag KG
Rüdigerstraße 14, 70469 Stuttgart, Germany

 

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