A 68-year-old man with Paget disease of the left proximal femur has severe secondary hip osteoarthritis requiring total hip replacement. Preoperative planning should include measurement of serum alkaline phosphatase and, when disease activity is high, administration of:
- A Teriparatide for six weeks before surgery
- B Denosumab to suppress osteoclast-mediated remodeling
- C A bisphosphonate such as zoledronic acid to reduce disease activity ✓
- D Calcitonin continued indefinitely after arthroplasty
Correct answer: C. A bisphosphonate such as zoledronic acid to reduce disease activity
Explanation
Serum alkaline phosphatase reflects osteoblastic activity and is used to gauge pagetic activity. Suppressing active disease with a potent bisphosphonate such as zoledronic acid before arthroplasty reduces intraoperative bleeding from hypervascular pagetic bone and lowers the risk of postoperative heterotopic ossification and loosening. Teriparatide is contraindicated in Paget disease because it stimulates osteoclastic turnover.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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