Hip Pain

Hip osteoarthritis pain treatment options or hip replacement?

Over the years we have seen our fair share of people with a diagnosis of a bone-on-bone hips. The people we usually see have a lot of hip pain and instability which causes walking difficulties, balance difficulties and prevents these people from feeling stable on their feet. They also come into our office claiming that they have been told they only have one treatment option, hip replacement and that they should get on the list to get one. They are here in our office to ask, “Is hip replacement really my only option?”

Some people come in with a diagnosis of avascular necrosis. Some of these people have been told that the only way they will ever get pain relief is from a hip replacement. There are cases where the bone is very damaged and it has collapsed completely. The hip joint is now fused and the person cannot move or lift their leg. This person’s best option is probably joint replacement. But most people I see with avascular necrosis of the hip or shoulder don’t need a surgery. Sometimes they only need a little education to help them understand what is happening in their hip and that they can avoid the hip replacement.

Hip pain relief – are all hip replacement options being explored?

Someone who suffers constantly from pain and who does not want to learn to live with it may consider hip replacement as their only way to get back to a pain-free life and resumption of their normal activities. Others choose hip replacement because of concerns over losing their independence. This includes concerns over their ability to walk, drive, and perform daily and routine personal chores such as dressing, meal preparation, and hygiene. These same concerns are also brought up by people who do not want to have hip replacement. Hip replacement is a major surgery. The post-recovery rehab can put the person into these same situations that they were hoping to avoid, the inability to drive and be independent for weeks or months.

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.

I am going to explore some of the research surrounding stem cell therapy from bone marrow concentrate. At the end of this article I will recap our own Darrow Stem Cell Institute research published in the journal Clinical Medicine Insights Case Reports.

Recently a paper in the Journal of medical Internet research suggested (1) that the treatment of hip arthritis and hip injury, 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 however 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 arthritis, 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 arthritis regarding the many different treatment options available to them. How wide a gap? One study published in the journal Osteoarthritis Cartilage suggested 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)

Are the hip replacement surgeries as successful as the doctors think they are?

A recent study (27) discussed the “increasing numbers of systematic reviews on total knee arthroplasty and total hip arthroplasty (which) have been published in recent years, but their quality has been unclear.” What the researchers said were unclear were the study outcomes: “Clinicians should be judicious when applying the conclusions of the systematic reviews results to their own patients.” The surgery may not be as successful as we think.

Continued long term use of opioid medications after joint replacement

While many have successful surgeries, many, even those who had successful surgery, will continue to take opioids long afterwards. As reported in a June 2020 study (29) patients who were waiting for a total knee or hip replacement were shown to have higher rates of opioid usage and many continue to use opioid medications long term after surgery. One of the reasons people have hip replacement is so that they can get off medications. Many of these pre-surgical candidates are on “heavy” doses and it is effecting their quality of life. Unfortunately for some, what the researchers uncovered was was that people using opioids before the hip replacement were at strong risk for continued use after the hip replacement.

Continued use of painkillers following surgery, in the case of the above study, for a minimum of three years after the surgery does give the appearance of a successful hip replacement surgery.

The rush to hip replacement because of severe pain. But is the hip as bad as the pain?

A February 2022 study (23) suggests that people, or the brain, my perceive a much more painful hip than the MRI indicates. This is what the paper says: “Hip osteoarthritis is characterized by chronic pain, but there remains a mismatch between symptoms and radiological findings (the pain is worse than the MRI). Recently, brain connectivity (the brains understanding of body parts, like the hip for instance) has been implicated in the modulation of chronic peripheral pain, however its association with perceived pain in hip osteoarthritis is not understood.” To understand why some people felt more hip pain than the MRI revealed patients with hip osteoarthritis were asked to perform activities that the researchers suspected would cause them pain. What they found was “functional connections between brain regions associated with pain are altered in hip osteoarthritis patients, and several connections are modulated by performing painful activity.” In other words pain causes more pain. To remedy this, the hip needs to be made less painful.

The patient who has a recommendation for hip replacement. What they are telling us?

The patient who has been recommended to hip replacement will tell us:

The thought of a hip replacement surgery terrifies me because I do not know if I will be able to resume all the activities I love.
I have to find another way. I own my own construction business, I cannot be take this time off to recover.
I had hip replacement on the left side, it worked, but I do not want to go through all that again.

Sometimes someone will come into the office at the request of a loved one or spouse or family member who are concerned about the surgery and what the general anesthesia and the toll of a demanding recovery time may do to their loved one. Sometimes a person will come in because they are the caregiver for their spouse or older parent and cannot take the time off for the surgery and recovery. Sometimes they cannot take the time off from work.

Balance Remains Impaired after Hip Replacement

A March 2022 study (26) examined the hoped for positive effects of hip replacement on patient balance. Overall, the evidence found suggested that balance is impaired immediately after surgery and, 4-12 months after surgery, it becomes better than preoperatively, although without reaching the level of healthy subjects. A strong level of evidence was found for hip resurfacing resulting in better balance restoration than total hip replacement, and for strength and ROM exercises after surgery positively influencing balance.

Do patients have side-effects or do they think they have side-effects.

A 2020 study (28) suggested that people who report side-effects after their hip replacement surgery or prone to have worse surgical outcomes. That is not the point of this study. This suggestion is is that patients who report side effects have worse outcomes whether they actually have side-effects that can be confirmed by standard medical record review methods or they think they are having side-effects. “The observed negative trends suggest that patient perception of adverse effects may influence patient outcome in a similar way to those with confirmed adverse effects.” In other words if you are not happy with the surgery, you will have a bad follow up.

If you combine the two studies you have doctors who think the surgery was more successful than the patients thought they.

Management and pain relief from hip arthritis

Medicine can offer many options for hip pain relief beyond drugs and medications. Research such as those studies above makes it clear that people with hip arthritis are too often told only about hip replacement as a treatment, so they do not even know about a nonsurgical arthritis treatment option that may be available beyond pain medication or “live with it.” Here is what researchers said in the journal Arthritis Care and Research (3): “Conservative treatment modalities in arthritis of hip or knee are underused, whereas the demand for surgery is rising substantially. To improve the use of conservative arthritis 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.”

ConZip, Ultram NSAIDs for hip osteoarthritis

In this section we will explore pain-medications.

An April 2022 study (24) reported the following: “The use of tramadol among osteoarthritis patients has been increasing rapidly around the world, but population-based studies on its safety profile among osteoarthritis patients are scarce. (The researchers here) sought to determine if tramadol use in osteoarthritis patients is associated with increased risks of all-cause mortality, cardiovascular diseases (CVD), venous thromboembolism (VTE), and hip fractures compared with commonly prescribed nonsteroidal anti-inflammatory drugs (NSAIDs) or codeine.”

Study summary

Overall, 100,358 OA patients were included (average age: 68 years, 63% females).
All-cause mortality was higher for tramadol compared to NSAIDs
For cardiovascular diseases (CVD), no differences were observed between tramadol and NSAIDs.
Tramadol had a higher risk of venous thromboembolism (VTE) compared to diclofenac.
Tramadol also had a higher risk of hip fractures compared to diclofenac and Cox-2 inhibitors.
Osteoarthritis patients initiating tramadol have an increased risk of mortality, venous thromboembolism, and hip fractures within one year compared with commonly prescribed NSAIDs, but not with codeine.

Treated with medication and then hip replacement or arthroscopic surgery and then poor health

The feeling is that when traditional pain-relief treatments and pain medications have run their course and no longer relieve hip pain, hip replacement or arthroscopic surgery is readily available as options to the patients. There is an expectation that surgery fixes everything and improves general overall health and physical well-being and most importantly provides pain relief. There is a lot of expectation. Yet other research says these expectations are not met, and this is clearly cause for concern as post-surgical medications use and drugs for pain relief may be needed after surgery.

Presenting alternatives to hip replacement surgery is an important function in the patient–doctor relationship, as suggested in this recent study published in The Journal of the American Academy of Orthopaedic Surgeons: (4)

“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.”

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 including Bone Marrow Aspirate and Platelet-Rich Plasma (PRP) Therapy. These are non-surgical options for pain relief.

Diagnosing Hip Pain and arthritis – MRI or physical examination

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 for determining pain or arthritis problems. MRIs are also not cost effective.(5) MRI is one of the main causes of continued hip pain after surgery.

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) This is why an extensive physical examination should be part of the diagnostic process.

Misdiagnosed hip pain can lead to back surgery – patient and doctor over reliance on MRI

We see many people with hip and back pain. Some have been told that they need a hip replacement, some have been told that they need a spinal fusion. Many of been told that they should consider both surgeries. Now these people are trying to decide between one or the other surgery and exploring options to help them avoid one or the other surgery, even both. The problem for some of these people is that they may get a back surgery for a hip problem and a hip surgery for a back problem. Doctors have noted that the symptoms of hip arthritis pain and spinal stenosis leg pain can be very similar, with only subtle differences in both history and clinical physical 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. MRI causes more problems. When the hip arthritis 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 arthritis pain remained.

This article should provide a cautionary note for patients who insist that the MRI is providing the evidence needed to end their arthritis 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) This causes obvious concern.

Bone Defects and Bone Death can this only be treated with hip replacement or medication?

For some patients, bone defects in the hip represent a great physical 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 arthritis 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 interruption of the blood supply) of the femoral head presents a new and exciting remedial procedure that medicine is looking into. 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 Health in Hip Replacement

The physical healing of hip arthritis 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 arthritis 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) This may lead the patient into life-long use of medications and drugs.

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?

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 physical activity and what sports you can play and at what level – what is the health of your hip?

In the Journal of Bone and Joint Surgery, surgeons warn about sports: “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)

Doctor, 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.

Treating Hip Osteoarthritis Injection Therapy

Can Bone Marrow Aspirate injections and Platelet-Rich Plasma Therapy be effective in treating hip arthritis 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 beyond arthritis. The causes of hip pain can be many this is why an extensive physical examination should be part of the diagnostic process.

A March 2022 study (25) examined the use of hip injections. The paper writes:

“Hip injection for osteoarthritis are in vogue nowadays. Corticosteroids and hyaluronic acid gel are the two most common agents injected into the hip. Off late, platelet-rich plasma (PRP), mesenchymal stem cell (MSC), bone marrow aspirate concentrate (BMAC), local anesthetic agents, non-steroidal anti-inflammatory drugs (NSAIDs) and their different combinations have also been injected in hips to provide desired pain relief. . .

. . . Intraarticular corticosteroids are effective in providing the desired pain relief in the osteoarthritis hip, but repeated injections should be avoided and the interval between hip injection and hip arthroplasty must be kept for more than three months.

Chondrotoxic effects of local anesthetic agents is a concern. Although national guidelines do not favor the use of hyaluronic acid for hip osteoarthritis, numerous publications have favored its usage for a moderate grade of osteoarthritis. The PRP, mesenchymal stem cell (MSC), and bone marrow aspirate concentrate (BMAC) are treatment options with great potential; however, currently, the evidence is conflicting on their role in hip osteoarthritis.”

Research on corticosteroids

A February 2020 paper (22) suggested that corticosteroid injections had significant efficacy on both immediate and delayed pain relief until 12 weeks after injection, though the injections effectiveness decreased over time. In addition, based on the current evidence, the longer than 12 weeks follow-up data of efficacy are still rarely reported. Previous research failed to demonstrate significant outcomes on pain reduction at both immediate and delayed intervals up to six months after injection. The researchers noted that they found these results surprising in that they had hypothesized the corticosteroid would be more effective.

Research on Platelet-Rich Plasma Therapy 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 physical 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)

A closer look at Bone Marrow Aspirate Concentrate

An April 2021 paper (30) examined how bone marrow stem cell therapy or whole bone marrow aspirate concentrate (BMAC) works to repair damage in an osteoarthritic hip.

“Potentially, these (stem cells from bone marrow aspirate concentrate) are able to provide a direct cell source for repair. (The injected cells themselves become building blocks to fill lesions). In addition, (the stem cells) may have a significant paracrine (advanced cell to cell communication) effect, releasing and delivering a myriad of cytokines and growth factors to orchestrate tissue repair processes.

The use of BMAC has been suggested to restore joint harmony (changing the joint environment from breakdown to regenerative) and minimize further chondral deterioration. As I just mentioned above, stem cells injected into the joint can initiate a healing environment.

One advantage of this orthobiologic is that MSCs are ideal for the chondrolabral junction, since these cells are able to differentiate into both fibrocartilage (this is the very tough cartilage found at the insertion or attachment points where ligaments and tendons attach themselves to the bone) and hyaline-like tissue products. (The stem cells morph into the different types of cartilage).

The study authors noted: “The results of BMAC in bone, cartilage and tendon injuries are encouraging. . . The use of BMAC especially in the early stages of hip diseases resulted in positive results for pain and function, and could represent a promising contemporary treatment strategy.”

Bone marrow concentrate injection treatment improves short-term outcomes in patients suffering from hip osteoarthritis

A December 2020 paper (31) suggested that bone marrow concentrate injection treatment improves short-term outcomes in patients suffering from hip osteoarthritis.

In this study a total of 24 patients diagnosed with symptomatic hip osteoarthritis elected to undergo a single bone marrow concentrate injection to see if the injection would help their hip pain. A total of 18 hips from 16 patients (7 male and 9 female) (average age, 58 mean body mass index, about 26 or a little overweight) were used in the final analysis.

Significant improvements were observed in pain scores with activity and without activity over 6 months. At 6 months, all patients maintained their improvements and did not return to preprocedure status.
Conclusion: A single bone marrow concentrate injection can significantly improve subjective pain and function scores up to 6 months in patients with symptomatic hip osteoarthritis. Further studies are warranted to evaluate osteoarthritis treatment against other therapeutics in a larger sample size and compare the biological signature profiles that may be responsible for the therapeutic effect.
Doctors in Argentina and Seton Hall University in New Jersey combined to suggest that in their research in patients receiving bone marrow aspirate intra-articular injections for the treatment of early knee or hip osteoarthritis were found to be safe and demonstrated satisfactory results in 63.2% of patients. It should be pointed out that this was a single injection treatment. (32)

References

1 Umapathy H, Bennell K, Dickson C, Dobson F, Fransen M, Jones G, Hunter DJ. The web-based osteoarthritis management resource my joint pain improves quality of care: a quasi-experimental study. Journal of Medical Internet Research. 2015;17(7):e167.
2 Stacey D, Taljaard M, Dervin G, Tugwell P, O’Connor AM, Pomey MP, Boland L, Beach S, Meltzer D, Hawker G. Impact of patient decision aids on appropriate and timely access to hip or knee arthroplasty for osteoarthritis: a randomized controlled trial. Osteoarthritis Cartilage. 2016 Jan;24(1):99-107.
3 Selten EM, Vriezekolk JE, Geenen R, van der Laan WH, van der Meulen-Dilling RG, Nijhof MW, Schers HJ, van den Ende CH. Reasons for treatment choices in knee and hip osteoarthritis: A qualitative study. Arthritis Care Res. (Hoboken). 2016 Jan 27.
4 Pitta M, Davis W, Argintar EH. Arthroscopic Management of Osteoarthritis. J Am Acad Orthop Surg. 2016 Feb;24(2):74-82. doi: 10.5435/JAAOS-D-14-00258.
5 Keeney JA, Nunley RM, Adelani M, Mall N. Magnetic resonance imaging of the hip: poor cost utility for treatment of adult patients with hip pain. Clin Orthop Relat Res. 2014 Mar;472(3):787-92.
6 Tasoglu O, Sirzai H, Onat SS, Ozgirgin N. Is hip originated pain misdiagnosed? Pain Physician. 2015 Mar-Apr;18(2):E259-60.
7 van Zyl AA. Misdiagnosis of hip pain could lead to unnecessary spinal surgery. SA Orthop J (Pretoria). 2010; 9(4)
8 Ferrata P, Carta S, Fortina M, Scipio D, Riva A, Di Giacinto S. Painful hip arthroplasty: definition. Clin Cases Miner Bone Metab. 2011 May;8(2):19-22.
9 Abbas K, Murtaza G, Umer M, Rashid H, Qadir I. Complications of total hip replacement. J Coll Physicians Surg Pak. 2012 Sep;22(9):575-8.
10 Panegrossi G, Ceretti M, Papalia M, Casella F, Favetti F, Falez F. Bone loss management in total knee revision surgery. Int Orthop. 2014 Jan 10
11 Hernigou P, Flouzat-Lachaniette CH, Delambre J, Poignard A, Allain J, Chevallier N, Rouard H. Osteonecrosis repair with bone marrow cell therapies: state of the clinical art. Bone. 2014 Jul 10. pii: S8756-3282(14)00257-9.
12 Lau RL, Perruccio AV, Evans HM, Mahomed SR, Mahomed NN, Gandhi R. Stem Cell Therapy for the treatment of early stage avascular necrosis of the femoral head: a systematic review. BMC Musculoskelet Disord. 2014 May 16;15:156.
13 Houdek MT, Wyles CC, Martin JR, Sierra RJ. Stem cell treatment for avascular necrosis of the femoral head: current perspectives. Stem Cells Cloning. 2014 Apr 9;7:65-70. eCollection 2014.
14 Bottai V, Dell’Osso G, Celli F, Bugelli G1, Cazzella N, Cei E, Guido G, Giannotti S. Total hip replacement in osteoarthritis: the role of bone metabolism and its complications. Clin Cases Miner Bone Metab. 2015 Sep-Dec;12(3):247-50.
15. Civinini R, Nistri L, Martini C, Redl B, Ristori G, Innocenti M. Growth factors in the treatment of early osteoarthritis. Cli. Cases Miner Bone Metab. 2013 Jan;10(1):26-9. doi: 10.11138/ccmbm/2013.10.1.026.
16 Sánchez M, Guadilla J, Fiz N, Andia I. Ultrasound-guided platelet-rich plasma injections for the treatment of osteoarthritis of the hip. Rheumatology (Oxford). 2012 Jan;51(1):144-50.
17 Dallari D, Stagni C, Rani N, Sabbioni G, Pelotti P, Torricelli P, Tschon M, Giavaresi G. Ultrasound-guided injection of platelet-rich plasma and hyaluronic acid, separately and in combination, for hip osteoarthritis: a randomized controlled study. Am. Sports Med. 2016 Jan 21.
18 Emadedin M, Ghorbani Liastani M, Fazeli R, Mohseni F, et al. Long-term follow-up of intra-articular injection of autologous mesenchymal stem cells in patients with knee, ankle, or hip osteoarthritis. Arch Iran Med. 2015 Jun;18(6):336-44. doi: 015186/AIM.003.
19 Fouilleron N, Wavreille G, Endjah N, et al. Running activity after hip resurfacing arthroplasty: a prospective study. Am J Sports Med. 2012 Apr;40(4):889-94. doi:
20 Le Duff MJ, Amstutz HC. The relationship of sporting activity and implant survivorship after hip resurfacing. J Bone Joint Surg Am. 2012 May 16;94(10):911-8.
21 Smith MV, Costic RS, Allaire R, Schilling PL, Sekiya JK. A biomechanical analysis of the soft tissue and osseous constraints of the hip joint. Knee Surg Sports Traumatol Arthrosc. 2012 Oct 30.
22 Zhong HM, Zhao GF, Lin T, Zhang XX, Li XY, Lin JF, Zhao SQ, Pan ZJ. Intra-articular steroid injection for patients with hip osteoarthritis: a systematic review and meta-analysis. BioMed Research International. 2020 Feb 24;2020.
23 Railton P, Delaney AJ, Goodyear BG, Matyas J, Lama S, Sutherland GR, Powell JN. Altered activity of pain processing brain regions in association with hip osteoarthritis. Scientific Reports. 2022 Feb 18;12(1):1-9.
24 Li L, Marozoff S, Lu N, Xie H, Kopec JA, Cibere J, Esdaile JM, Aviña-Zubieta JA. Association of tramadol with all-cause mortality, cardiovascular diseases, venous thromboembolism, and hip fractures among patients with osteoarthritis: a population-based study. Arthritis Research & Therapy. 2022 Dec;24(1):1-6.
25 Rampal S, Jaiman A, Tokgöz MA, Arumugam G, Sivananthan S, Singh RS, Zazali SB, Mohaddes M. A review of the efficacy of intraarticular hip injection for patients with hip osteoarthritis: To inject or not to inject in hip osteoarthritis?. Joint Diseases and Related Surgery. 2022 Mar 28;33(1):255-62.
26 Di Laura Frattura G, Bordoni V, Feltri P, Fusco A, Candrian C, Filardo G. Balance Remains Impaired after Hip Arthroplasty: A Systematic Review and Best Evidence Synthesis. Diagnostics. 2022 Mar 11;12(3):684.
27 Wu X, Sun H, Zhou X, Wang J, Li J. Quality assessment of systematic reviews on total hip or knee arthroplasty using mod-AMSTAR. BMC Med Res Methodol. 2018 Mar 16;18(1):30. doi: 10.1186/s12874-018-0488-8. PMID: 29548276; PMCID: PMC5857117.
28 Carpenter CV, Wylde V, Moore AJ, Sayers A, Blom AW, Whitehouse MR. Perceived occurrence of an adverse event affects patient-reported outcomes after total hip replacement. BMC Musculoskeletal Disorders. 2020 Dec;21(1):1-8.
29 Pryymachenko Y, Wilson RA, Abbott JH, Dowsey MM, Choong PFM. Risk Factors for Chronic Opioid Use Following Hip and Knee Arthroplasty: Evidence from New Zealand Population Data [published online ahead of print, 2020 Jun 27]. J Arthroplasty. 2020;S0883-5403(20)30684-7. doi:10.1016/j.arth.2020.06.040
30 Kruel AV, Ribeiro LL, Gusmão PD, Huber SC, Lana JF. Orthobiologics in the treatment of hip disorders. World journal of stem cells. 2021 Apr 26;13(4):304.
31 Whitney KE, Briggs KK, Chamness C, Bolia IK, Huard J, Philippon MJ, Evans TA. Bone Marrow Concentrate Injection Treatment Improves Short-term Outcomes in Symptomatic Hip Osteoarthritis Patients: A Pilot Study. Orthopaedic Journal of Sports Medicine. 2020 Dec 9;8(12):2325967120966162.
32 Rodriguez-Fontan F, Piuzzi NS, Kraeutler MJ, Pascual-Garrido C. Early Clinical Outcomes of Intraarticular Injections of Bone Marrow Aspirate Concentrate for the Treatment of Early Osteoarthritis of the Hip and Knee: A Cohort Study. PM&R. 2018 May 29.