right hip pain , incidental finding of right tibia osteolysis
A male patient, 75 years of age came to our hospital complaining of right hip pain. He had a history of an intacapsular fracture of his right hip five years ago, which had been treated with a Thompson hemiarthroplasty. The pain in the hip of the patient was attributed either to infection of the hemiarthroplasty or to protrusion of the head of the prosthesis into the acetabulum. In order to clarify the cause of the patient’s pain and proceed to the appropriate treatment, a number of laboratory and imaging tests were performed. The bone scintigraphy demonstrated only an immediate accumulation of radionuclide in a wedge-shaped pattern in his right tibia. This appearance, which has been likened to a “blade of grass” or “flame”, is typical of Paget’s disease and corresponds to an osteolytic area during the active phase of the disease (fig1). Following the finding of the bone scintigraphy, an X- ray of the tibia was performed, where a V- shaped radiolucent area clearly demarcated from the adjacent bone and typical of the disease was demonstrated (fig 2). Various X-rays were taken in different parts of the body (skull, pelvis, spine, long tubular bones) but no other part of the body showed involvement in the disease which was compatible with the scintigraphy findings as well. It was concluded that the patient suffered from monostotic Paget’s disease, which is a rare pattern of the disease and was incidentally found in this case.
Paget’s disease (osteitis deformans) is common in middle-aged and elderly persons affecting 3% of the population over the age of 40 years. The precise cause of the disease is still unknown, though many suggestions have been made including inflammatory, neoplastic and viral causes. The viral cause especially a paramyxovirus of the measles group has been strongly supported recently. Paget’s disease is a combination of osteoclastic and osteoblastic activity that accounts for marked elevation of the rate of bone turnover, with succeeding waves of bone destruction and bone formation. In many patients the disorder is diagnosed first as an incidental finding on radiographs obtained for unrelated purposes. On occasion the disease is manifested with severe symptoms and signs such as skeletal, neuromuscular and cardiovascular complications. Namely, the most important complications of Paget’s disease are fractures, neurologic deficits, articular problems or neoplasms. Paget’s disease has a predilection for the axial skeleton particularly the pelvis, sacrum, lumbar spine and skull. Abnormalities of the axial skeleton or the proximal part of the femur are present in approximately 75-80% of the cases, while monostotic Paget’s disease is a pattern evident in only 10-35% of cases. In tubular bones osteolysis begins almost invariably in the subchondral regions of the epiphysis and extend subsequently into the metaphysis and diaphysis, but only exceptionally is Paget’s disease apparent in the diaphysis without involvement of the epiphysis. When present, this latter feature typically occurs in the tibia as a V- or wedge-shaped radiolucent area that has been likened to a blade of grass or flame. In conclusion, Paget’s disease can involve any part of the human skeleton and the diagnosis is generally based on radiographic findings. Even when the disease is confined to one bone – monostotic – which is a rare condition and may be more difficult to diagnose, there are characteristic radiologic findings, which are generally observed and allow an accurate diagnosis and differentiation from other conditions.
Monostotic Paget's disease
1. From the bone scan images, an area of abnormally increased radiotracer uptake is visible in the right tibia, suggesting locally active bone metabolism.
2. The X-ray shows a distinct zone of bone destruction coexisting with new bone formation in the diaphysis of the right tibia, presenting a “blade-like” or “flame-shaped” radiolucent band that extends near the distal articular surface of the tibia. Cortical thickening and uneven bone density are also observed.
3. Overall, the lesion exhibits both bone destruction and repair with an irregular shape, featuring areas of focal cortical thickening. This differs from typical degenerative changes or simple bone destruction.
Considering the patient’s age, clinical presentation (right hip pain but the tibial lesion was found incidentally), and X-ray and bone scan results indicating a “blade-like” or “flame-shaped” pattern of concurrent bone destruction and new bone formation, along with the common locations and histological characteristics of Paget’s disease, the most likely diagnosis is Paget’s disease (monostotic type).
If there is still uncertainty, tests such as serum alkaline phosphatase (ALP), other bone metabolism studies, or, if necessary, a pathological biopsy can be performed for further clarification.
1. Medication:
- Bisphosphonates (e.g., alendronate) are the first-line treatment for Paget’s disease. They help reduce the high bone turnover in the affected regions, alleviate pain, and prevent deformities.
- If significant pain or joint symptoms are present, appropriate use of analgesics or nonsteroidal anti-inflammatory drugs (NSAIDs) can provide pain relief.
2. Surgical Treatment:
- For patients with severe bone deformities, pathological fractures, or joint dysfunction, surgical intervention (such as deformity correction or joint replacement) may be necessary to restore function.
- In this case, only the tibia is involved and the lesion was found incidentally. If there is no severe pain or significant structural alteration, no immediate surgical intervention is required, and conservative management can be pursued.
3. Rehabilitation and Exercise Prescription:
- Gradual Progression Principle: Depending on the patient’s joint and skeletal condition, begin with mild weight-bearing exercises, such as short-distance walking on a flat surface with crutch support or static standing training, to ensure stability.
- Frequency: Perform rehabilitation training 3–5 times per week. During daily activities, moderate walking can be included, with rest according to pain and fatigue.
- Intensity: Start at a low intensity (e.g., 10 minutes of slow walking), avoiding strenuous exercise and high-impact activities (such as running or jumping) to prevent fractures or excessive stress.
- Duration: Each session should last about 15–20 minutes at first, gradually extending to over 30 minutes as tolerated.
- Modality: Focus on gentle walking on flat surfaces, mild lower limb strengthening exercises, and active joint movements in seated or supine positions.
- Progression: After initial adaptation, simple lower limb strength training (e.g., quadriceps contraction, leg raises) can be introduced, or partial weight-bearing exercises in water under professional guidance.
- If the patient has compromised cardiopulmonary function or fragile bones, blood pressure, heart rate, and pain levels should be closely monitored, and exercise intensity and type should be adjusted in a timely manner.
This report is based on the provided imaging and clinical information and is for reference only. It does not replace in-person consultation or formal medical advice from a professional physician. If you have any questions or if symptoms worsen, please seek medical attention promptly for further evaluation.
Monostotic Paget's disease
