Recently a paper suggested that the treatment of hip osteoarthritis, like those of other joint osteoarthritic problems, is redefining itself at a pace probably not seen since the advent of hip replacement surgery. Some doctors are upset that patients are not given the full story on hip replacement options and alternatives. Despite the availability of evidence-based guidelines
for conservative treatment of osteoarthritis, management of degenerated joints is often confined to the use of painkillers and the wait for eventual total joint replacement. This suggests a gap in knowledge for those with osteoarthritis regarding the many different treatment options available to them.(1)
How wide a gap? One study says that when given time and educational materials to deliberate whether or not to proceed with hip replacement, more patients decide not to have surgery.(2)
Research such as this makes clear that people with hip osteoarthritis are too often told only about hip replacement as a treatment, so they do not even know about the nonsurgical treatments available. Here is what researchers said: “Conservative treatment modalities in osteoarthritis of hip or knee are underused, whereas the demand for surgery is rising substantially. To improve the use of conservative treatments, a more in-depth understanding of the reasons for patients’ treatment choice is required. This study identifies the reasons for choice of treatment in patients with hip or knee osteoarthritis.
Various treatment options were discussed: medication, exercise, physical therapy, injections, surgery, complementary and alternative treatment. Four key themes underlying the choice for or against a treatment were identified:
- treatment characteristics: expectations about its effectiveness and risks, the degree to which it can be personalized to a patient’s needs and wishes, and the accessibility of a treatment;
- personal investment: in terms of money and time;
- personal circumstances: age, body weight, comorbidities and previous experience with a treatment; and
- support and advice: from the patient’s social environment and healthcare providers.” (3)
The feeling is that hip replacement or arthroscopic surgery is readily available. There is an expectation that surgery fixes everything and improves general overall health. There is a lot of expectation. Yet other research says these expectations are not met, and this is clearly cause for concern.
Presenting alternatives to hip replacement surgery is an important function in the patient–doctor relationship, as suggested in this recent study:
“Arthroscopic surgery is commonly performed in the knee, shoulder, elbow, and hip. However, the role it plays in the management of osteoarthritis is controversial. Routine arthroscopic
management of osteoarthritis was once common, but this practice has been recently scrutinized. Although some believe that there is no role for arthroscopic treatment in the management
of osteoarthritis, it may be appropriate and beneficial in certain situations. The clinical success of such treatment may be rooted in appropriate patient selection and adherence to a
specific surgical technique. Arthroscopy may serve as an effective and less invasive option than traditional methods of managing osteoarthritis.”(4)
In other words, as controversial and unproven as arthroscopic surgery is, it may still be better than hip replacement. Far better than both as a first option, in my opinion, are the biomedicine
treatments of Bone Marrow Aspirate Stem Cell Therapy and Platelet-Rich Plasma (PRP) Therapy.
Treating Hip Osteoarthritis
Can Bone Marrow Aspirate Stem Cell Therapy and Platelet-Rich Plasma Therapy be effective in treating hip osteoarthritis and in helping you avoid a hip replacement surgery? The answer in many cases is yes. However, success is dependent on a physical examination and a practice of best diagnosis. The hip is a tricky and complex area filled with many pain generator suspects.
Diagnosing Hip Pain
In February 2012, research was presented at the American Orthopaedic Society for Sports Medicine’s (AOSSM) Specialty Day meeting suggesting that when doctors treat people with hip pain, “Physicians should not replace clinical observation with the use of magnetic resonance images (MRI).” The research stated that when MRIs were performed on volunteers without hip pain, 73% showed abnormal findings.
Abnormal findings = surgical procedure.
This simple equation is well documented in the medical literature. Medical journals are filled with studies suggesting that while MRI is frequently used to diagnose conditions affecting the hip, its effectiveness in determining hip pain is not as valuable as a physical examination. And MRIs are not cost effective.(5)
In the medical journal Pain Physician, doctors agreed, and they offered a commentary that warned physicians that the true causes of hip pain can be easily overlooked and misdiagnosed because of the MRI.(6)
Misdiagnosed hip pain can lead to back surgery
Not only might you get a hip replacement you may not need, you may in addition suffer a back surgery you don’t need. Doctors have noted that the symptoms of hip pain and spinal stenosis leg pain can be very similar, with only subtle differences in both history and clinical examinations. Spinal stenosis is classically diagnosed in patients with leg pain that occurs during standing or walking and is relieved when the individual sits down. This is a clinical diagnosis that doctors say can only be confirmed by MRI.
However, in one paper, researchers showed that in as many as 50% of elderly patients, MRI gave a false positive diagnosis of spinal stenosis. Those MRI results might prompt a surgeon to perform spinal surgery. When the hip symptoms persist and remain undetected, it is even possible that a second unnecessary back surgery could be performed. The following paper reported on patients who had MRI scans and multiple epidural injections and were subjected to repeat back surgeries, all while continuing to complain of their leg pain—the source of which was hip pathology.(7)
This is why some patients continue to experience hip pain after elective hip replacement surgery. One research study advised doctors to look for pain originating from different sources not directly linked to the replacement hardware, as something else must have been the problem.(8) This revelation comes a little late. I see patients who were misdiagnosed and their pain generators overlooked. They have hip pain and an MRI in their chart showing a herniated disc in the lower back. After they had back surgery, the hip pain remained.
This article should provide a cautionary note for patients who insist that the MRI is providing the evidence needed to end their pain. In one study of patients who received a hip replacement, researchers noted postoperative complications occurring in almost 20% of the patients. Dislocation was the most common complication, followed by wound infection.(9)
Included in those worries are fresh concerns about the amount of bone loss in the first surgery and the ability to perform a successful revision or future replacement surgery to replace worn-out hardware.(10)
Bone Defects and Bone Death
For some patients, bone defects in the hip represent a great challenge. When the protective cartilage wears away on the “ball” of the hip joint (the femoral head), there can be direct contact with the pelvic acetabulum (part of the pelvis bone in which the femur is seated). For some patients with advanced osteoarthritis or avascular necrosis (bone death) there may be the crunching and grinding of bone on bone.
FIXING THE FEMORAL HEAD MEANS REPLACEMENT
The most-used procedure does not fix the femoral head, instead replacing it (hip replacement) through amputation of the head of the femur and addition of prosthesis (total hip arthroplasty). Since not everyone is suitable for or wants to have the procedure, researchers are exploring ways to fix the femoral head before it becomes unstable or collapses and requires artificial joint replacement.
One method is to patch the bone defects—this is autologous bone grafting. Some of the bone is cut into a patch in the hope that it will take root and grow. However, the amount of bone available for grafting is quite limited as case histories point out.(11)
Regenerating the bone is an appealing remedy, leading researchers to look at bone marrow stem cells, using one’s own stem cells to heal bone defects. In recent research doctors suggested stem cells. The injection of stem cells into the joint can initiate the healing environment in the affected hip, including the regrowth of bone in cases of osteonecrosis (bone death).(12)
The use of stem cells for the treatment of avascular necrosis (bone death due to interuption of the blood supply) of the femoral head presents a new and exciting remedial procedure. In pre-clinical studies, the use of stem cells uniformly demonstrates improvements in osteogenesis (bone growth) and angiogenesis (blood vessel formation). In clinical studies, groups treated with stem cells have shown significant improvements in patient-reported outcomes.(13)
The Importance of Bone in Hip Replacement
The healing of hip osteoarthritis can be complex and complicated, especially if complex and complicated treatments are employed. Once failed surgery exacerbates the matter, it is even more difficult to remedy the hip, especially as the patient ages. The incidence of osteoarthritis is constantly advancing with increased longevity. Aging also leads to an increasing number of patients with osteoporosis (decreased bone mass) who “need” hip replacement for osteoarthritis. Osteoporosis has three major potential complications in total hip arthroplasty: perioperative (that is, near
the time of the surgery) fracture, an increased risk of periprosthetic fracture (fracture of bones near the implant), and late aseptic loosening (loosening of hip replacement components). A study examining the effects of osteoporosis on total hip replacement procedure outcome highlights the importance of an adequate study of calciumphosphorus metabolism in patients who are candidates for hip surgery, as well as the need to start a suitable therapy to recover the bone mass before surgery. Poor bone quality of the hip joint is an important risk factor limiting the durability and longevity of the hip replacement.(14)
However, if we are prepping the patient for hip replacement by strengthening the bone to hold the artificial devices, why not regrow the bone and cartilage and repair the tissue with the goal of avoiding surgery?
Research on Stem Cells and Platelet-Rich Plasma for Hip Repair
Platelet-rich plasma (PRP), obtained by withdrawing the patient’s blood and concentrating the platelets, represents a safe, economical, easy to prepare, and easy to inject source of growth factors.
Platelets contain numerous growth factors, and a large number of them have specific activity in cartilage regeneration. PRP is able to significantly reduce pain and improve joint function.(15)
A study done in 2012 examined patient safety and symptomatic changes among 40 patients receiving Platelet-Rich Plasma (PRP) Therapy for osteoarthritis of the hip. In the study, each joint received three injections of PRP, administered once a week. The primary end point was meaningful pain relief, which was described as a reduction in pain intensity of at least 30% at six months post-treatment.
Secondary end points included reduction in the level of disability of at least 30% and the percentage of positive responders—that is, the number of patients who achieved a greater than 30% reduction in pain and disability.
The results were statistically significant reductions in pain and improvement in function as reported at seven weeks and again at six months.
- Twenty-three patients (58%) reported a clinically relevant reduction of pain (45%).
- Sixteen (40%) of these patients were classified as excellent responders and showed an early pain reduction at six or seven weeks that was sustained at 6 months, accompanied by a parallel
reduction of disability. (16)
From a January 2016 paper: “Results indicated that intra-articular PRP injections offer a significant clinical improvement in patients with hip osteoarthritis without relevant side effects.”(17)
In other research, doctors followed patients who received Stem Cell Therapy for hip, knee, or ankle osteoarthritis and documented such therapeutic benefits as increased walking distance, increased function, and reduced pain.(18)
Patient Expectations Following Hip Resurfacing
Many times a patient will come into our office with a stack of MRIs, a post-surgical report, and a promise that they were told that they could resume their running after a hip resurfacing procedure. Unfortunately for them, the surgery did not meet their expectations. Recently published research in the American Journal of Sports Medicine, says “Running is possible after hip resurfacing, and runners can even return to some level of competition, but this short follow-up series of hip resurfacing in athletes should be interpreted with caution regarding implant survival.”(19)
Lessen Your Expectations as to What Sports You Can Play and at What Level
In the Journal of Bone and Joint Surgery, surgeons warn: “High levels of sporting activities can be detrimental to the long-term success of hip resurfacing devices, independently from other risk factors. Patients seeking hip resurfacing are usually young and should limit their involvement in sports to levels that the implant construct will be able to tolerate.”(20)
What is the Difference Between Hip Resurfacing and Hip Replacement?
Hip resurfacing is not hip replacement. In hip resurfacing the head of the femur is capped (after being trimmed) with a smooth metal covering. The damaged bone and cartilage within the socket is removed and replaced with a metal cup, similar to that in a total hip replacement.
In total hip replacement, not only is the head of the femur replaced, but also the socket in the pelvis (acetabulum). One of the main selling points for hip resurfacing is that it leaves more bone so a hip replacement can be performed later.
I see hip resurfacing as one hip surgery setting up another. Surgery in my opinion should always be the last option.
Is Hip Resurfacing Really a Less Invasive Technique?
According to surgeons, hip resurfacing is more difficult to perform and requires a larger incision than typical hip replacement. This increases the risk of complications. For an athlete or a worker whose profession is physically demanding,or any other patient, this can mean unexpected down time and costs.
Does Hip Resurfacing Keep a Younger Patient Active?
Another main selling feature for hip resurfacing as opposed to hip replacement is that studies have shown that it allows the patient to remain more active. However, it is for a limited amount of time. Hip resurfacing has an unknown life span. Thereafter, hip replacement is often necessary.
There can be more issues in relation to the soft tissue needed to stabilize the hip: Doctors in the medical journal Radiographics suggest: “Surgical management for hip disorders should preserve the soft tissue constraints in the hip when possible to maintain normal hip biomechanics.” (21)
This is exactly why we see so many patients after hip surgery. It is too often that the soft tissue that holds the tendons to the bone, or the ligaments that hold the bones to the bones, are compromised. Strengthened ligaments and tendons help hold the hip joint in its proper place, causing less grinding and less bone-on-bone. Restored collagen can help rebuild the cartilage between the pelvis and thighbone, cushioning and relieving the bone-on-bone condition. This is when a consultation for Stem Cell Therapy and Platelet-Rich Plasma Therapy should be considered—and hopefully prior to rather than after surgery: once a prosthesis has been implanted, it is too late to regenerate tissue.
More Hip Problems that May Confuse the Diagnosis
Piriformis syndrome may cause pain in the buttocks, lower back, or down the leg. The piriformis muscle is in the buttocks, attaches to the pelvis and greater trochanter, and helps rotate the leg outward. The sciatic nerve is just beneath it. Occasionally the nerve is impinged beneath the piriformis muscle. When the muscle contracts, it pushes on the nerve, which causes the pain and its radiation down the leg. I rarely see true piriformis syndrome. Typically, the pain is at the enthesis of the piriformis or other buttocks muscles to the bone, and PRP usually heals that with one to three treatments.
GREATER TROCHANTERIC BURSITIS AND ISCHIAL BURSITIS
The areas around the hip are covered with and protected by several bursal fluid filled sacs. Each bursa produces lubricating fluid and functions to reduce pressure and friction around the muscles and ligaments over bone. These bursae can become irritated from injury, excessive pressure, and overuse. Inflammation of a bursa is called bursitis. More often this diagnosis is actually a tendinitis or tendinosis. Nevertheless, PRP is usually the correct treatment. Certainly not steroids, like cortisone, which deteriorate the tissue, and can make it worse later.
There is normally a small amount of synovial fluid contained in the hip joint that allows the cartilage on the bones to slide on each other. An excess of this fluid, often caused by overuse or arthritis, can cause pressure and pain in the joint. The fluid comes from synovial tissue surrounding the joint.
I use an ultrasound to visualize the joint, and if an effusion is present, I numb the area and aspirate the fluid. At the same time, platelet rich plasma or stem cells can be injected through the same needle.
Effusions are removed to reduce the joint pressure and to eliminate dilution of the regenerating cells from the patient’s body.
HIP TENDINITIS OR TEARS
Tendinitis occurs when a muscle is overused and pulls on the tendon that attaches it to the bone. In the hip, tendons perform an important role by keeping strong muscles attached to the femur (thighbone) as the legs move. One kind of tendinitis that occurs as a result of overuse is called iliacus tendinitis or iliopsoas tendinitis. The iliac muscle, which starts at the hip bone, and the psoas muscle, which starts in your lower spine, are used when lifting the leg toward the chest. They come together in a tendon at the top of the femur, and that is the point where tendinitis occurs. The problems of the hip can often be treated with Stem Cell Therapy and Platelet-Rich Plasma Therapy. In order to determine if you are a good candidate for this type of procedure, you need to be fully
evaluated by a physician who has significant experience with hip pain.
TERRIBLE SIDE EFFECTS
Unfortunately, too many patients come to me after a hip replacement or other “elective” surgery. The most recent disaster is happening to a very old friend of mine. He is 65 years old, and had both hips replaced for osteoarthritis a few years ago. I previously told him not to do the surgeries and that he really didn’t need them. We had dinner last week, and he told me of an “odd” situation that occurs around his surgical scars. Occasionally, the scar and surrounding tissue becomes red and swollen. None of his doctors can figure out why. Allergy to the prosthetic metal, plastic, or glue inside his body? I didn’t pay much attention since it didn’t sound that bad. He sent me photos of a recent out-break. The area of redness and swelling was about four inches by eight inches. I told him to go directly to the ER since it looked like an infection. He was told by the ER doc that he didn’t know what to do, and that my friend should see a dermatologist.
Unfortunately, no derm was available for several days in the rural area where my friend lives. I am on pins and needles waiting for the diagnosis, if anyone can figure it out. My guess is that my friend will have to have his prostheses removed and replaced with another material, with the hope that the “allergy” will not return. To me the skin looked so inflamed that if no infection was present, it certainly could occur anytime. I have not told him yet what I am thinking, and am glad this book will not be published for him to read for a couple more months.
I’m not going to implant you with terrible stories of what I have seen after surgeries on many different parts of the body. Since the time I became involved in surgery in 1989, I have seen more bad outcomes than I care to remember. And let me make it clear that I respect surgeons for the difficult and complex work that they do. To me, they are the masters of medicine. Not many of us are willing to bear such standards and responsibilities. However, I must say that in my humble opinion, most elective surgeries should not be done. The risks are just too high.
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