Marc Darrow MD,JD

Your hip is bone on bone. Can you avoid a hip replacement surgery?

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.

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.

Below is the opening sentence of a study published recently in the Journal of medical Internet research.(1)

  • “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.”

How wide a gap? A recent study published in the journal Osteoarthritis and cartilage 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)

These findings should not be a surprise to you. In fact, after all, you are reading my article because you are exploring the possibility of avoiding a hip replacement for yourself or a loved one.

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

A recent study (3) 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.

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

A 2020 study (4) 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.

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.

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 (5) 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.

Active, sports minded people being sent to hip replacement without suggestion of non-surgical options are finding options on their own. Stem cell therapy is one option

What I present here are not statistics but what people are telling us in the office. It is in agreement from what research tells us, people are being sent to hip replacement with no other choices offered. This is what these people said:

  • I am a man who is 55 years old, I am in fantastic health. My orthopedists has diagnosed me with osteoarthritis in my right hip. He showed my my x-rays and he showed my an MRI and I get it. There is degenerative hip disease going on. I have lost some mobility and sometimes I have pain and discomfort. But I am just as active as I have always been. I’d like to avoid hip replacement if I can, because I am being managed until the hip gets bad enough to be replaced. I am looking for options
  • I ran a marathon less than a year ago. Now I am a hip joint replacement candidate. I want to consider all my options.
  • I have no cartilage in both hips, I need help, I am not on pain medications, but can’t work anymore. What are my options?

The research in support of stem cell therapy for hip osteoarthritis and “bone on bone.”

Since not everyone is suitable for or wants to have hip replacement, 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 with the hopes it takes root and grows. However, the amount of bone for grafting is quite limited.(6)

Regenerating the bone is an appealing remedy, leading researchers to look at Stem Cell Therapy, using one’s own stem cells to heal bone defects. In recent research doctors suggested that stem cells injected into the joint can initiate the healing environment in the affected hip including the regrowth of bone in cases of osteocronosis (bone death).(7)

Most recently, December 2020 (8) a study published in the Orthopaedic journal of sports medicine examined 16 patients diagnosed with symptomatic hip osteoarthritis who elected to undergo a single bone marrow concentrate (stem cell) injection as treatment for their hip pain.

  • A total of 18 hips from 16 patients (7 male and 9 female) (average age, almost 58 years old; mean body mass index on average slightly overweight) were followed.
  • Significant improvements were observed in pain with activity and without activity
  • No serious adverse events were reported from the bone marrow concentrate harvest or injection procedure.

Conclusion: “A single bone marrow concentrate (stem cell) injection can significantly improve subjective pain and function scores up to 6 months in patients with symptomatic hip osteoarthritis.

  • In recent research doctors at Toronto Western Hospital suggested that stem cells injected into the joint can initiate the healing environment in a degenerated hip including the regrowth of bone in cases of osteocronosis (bone death).(9)
  • Doctors at the Mayo Clinic write that 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 show significant improvements in patient reported outcomes.) (10)
  • Researchers in France led by Philippe Hernigou of the Department of Orthopaedic Surgery, University Paris East shows that despite advanced hip disease, bone marrow derived stem cell therapy can repair bone damage in hip osteonecrosis for the long-term. In one study, the researchers treated 189 hips in 116 patients with bone marrow concentrate and had a follow-up of 5 to 10 years. Satisfactory results were achieved in the majority of patients according to improvement of the (pain) hip score, radiographic assessment and the avoidance of hip replacement.(11)
  • 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. (12)

A closer look at Bone Marrow Aspirate Concentrate

An April 2021 paper (13) 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 stuyd 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.”

Why don’t the stem cells in the upper thigh bone of the hip repair the damage to the bone they live in?

Researchers in France again led by Philippe Hernigou of the Department of Orthopaedic Surgery, University Paris East have some answers in their recent 2017 study.[14]

The French team suggests that the relationships between native bone marrow and the degenerating hip complex cause vast changes in the native stem cells. This is the degenerative joint disease process, changing the joint from healthy to diseased and compromising the stem cells present in the hip.

  • The degenerative process creates fatty marrow that inhibit healing.
  • Abnormalities of the osteogenic stem cells are also present in the bone marrow of some of these patients which could be caused by injury, disease or past steroid injections.

Because of this diseased hip environment, blood flow is restricted and this may be a predisposing factor for osteonecrosis since changes in bone marrow and bone remodeling (repair) are linked.

  • The situation is bone cells are dying and the “stronger” bone cells are being suffocated by lack of blood flow caused by dying bone cells.
  • This causes insufficient bone remodeling because of the small number of progenitor (stem) cells present in the femoral head in these patients.
  • Although both research and clinical studies have shown that dead bone may be replaced by living bone, the osteogenic potential for repair is low in osteonecrosis. This is why people are recommended to hip replacement.

Despite these challenges, Dr. Hernigou cited his earlier research where 189 hips in 116 patients were treated with bone marrow stem cells drawn from their own iliac crest bone at the top of the pelvis.

  • Satisfactory results were achieved in the majority of patients according to improvement in various pain scores and the patient’s ability to avoid hip replacement noted at follow ups 5 to 10 years AFTER treatment.

Stem cell therapy injections in the treatment of Avascular Necrosis

A July 2020 (15) questioned whether core decompression of the femoral neck was necessary for all patients considering the procedures inconsistent results. It is interesting to note the suggestion of this and other research that this procedure can optimized by injecting autologous stem cells into the necrotic zone (the damaged area). Injecting autologous stem cells have demonstrated long-term results in the early stages of the disease, where the femoral head has not yet lost its sphericity. This study adds: “The now proven long-term efficacy as well as the safety of this technique (stem cell injections) make it the method of choice for treating young patients detected at the sub-radiological stage by MRI.”

Four patient cases we peer-review published in Clinical medicine insights. Case reports.

In research from our Stem Cell Institute, we suggested that the use of mesenchymal (connective tissue) stem cells from bone marrow concentrate improved quality of life for patients with hip osteoarthritis. Here are our 4 case studies.(16)

Case 1
The first patient is a 75-year-old woman with a 10-year history of progressive right hip pain. She had consulted with two orthopedic surgeons, each of whom recommended total hip replacement as her only option. Magnetic resonance imaging (MRI) of the right hip showed severe osteoarthritis with extensive bone spurs and near-complete obliteration of the joint space. (Bone on bone). The patient experienced the most pain when sitting for extended periods of time. She had tried massage therapy and anti-inflammatory gel for pain relief; however, her resting and active pain were each 6 out of 10.

  • The patient underwent 4 bone marrow concentrate stem cell treatments over a 49-day period, and her symptoms improved with treatment.
  • After the second treatment, the patient reported a 40% improvement, with more joint flexibility.
  • At the follow-up after the fourth treatment, the patient noted a 60% total overall improvement with active and resting pain levels of 2/10.
  • Her functionality score also increased to 37/40. At the final follow-up, the patient reported that she was sleeping better and that she had avoided a total hip replacement.

Case 2
The second patient was a 61-year-old man who had chronic hip pain for two years. His pain was most pronounced while standing or with intensive exercise. The patient had undergone chiropractic adjustments, cupping, and physical therapy for pain relief, but his symptoms returned within 1 week of each treatment. Radiographic assessment of the right hip demonstrated severe osteoarthritis. At baseline, the patient reported a resting pain of 1/10 and an active pain of 7/10. His functionality score was 28/40.

  • The patient underwent 4 bone marrow concentrate stem cell treatments during a 42-day period.
  • After the first bone marrow concentrate stem cell treatment, he reported an 80% total overall improvement, with no resting pain.
  • At the follow-up after the fourth treatment, the patient reported only infrequent, mild pain (0/10 at rest and 2/10 with activity).
  • Following treatment, he was able to resume exercise and an active lifestyle.
  • His functionality score was 37/40 and reported that he had 94% total overall improvement.

Case 3
The third patient was a 76-year-old man who had a 7-year history of chronic hip pain. He previously underwent a left hip replacement but reported that the recovery had been challenging. Furthermore, he did not want a second hip replacement that had been recommended by his surgeon. The MRI of the right hip showed moderate to severe osteoarthritis with articular surface irregularity. The patient had physical therapy and massage but his pain had progressed. He underwent 4 bone marrow concentrate stem cell treatments over a 54-day period. At baseline, his resting pain was 4/10, active pain was 5/10, and functionality score was 33/40.

  • After the second treatment, the patient reported a 50% total overall improvement with increased hip flexibility and range of motion.
  • At the follow-up after the fourth treatment, the patient reported a 65% total overall improvement with a resting pain of 1/10 and active pain of 2/10.
  • Following treatment, his functionality score was 37/40, and he was able to walk long distances with no pain and enjoyed a significantly improved quality of life.

Case 4
The fourth patient was a 56-year-old man who had a 2-year history of chronic hip pain resulting from his physically demanding career as a contractor. The patient reported that his pain was worsening and limiting his everyday activity. He had an epidural injection with no pain relief. A radiograph of his right hip showed mild osteoarthritis. His resting pain was 2/10, active pain was 5/10, and functionality score was 17/40 at baseline.

  • The patient underwent 4 bone marrow concentrate stem cell treatments over a 146-day period.
  • The patient experienced minor, incremental improvements following each of the first 3 treatments (overall improvement, 30%). He reported improved ability to perform daily activities with less pain during the course of those 3 treatments. After 40 days of the fourth treatment, the patient reported a 70% total overall improvement. His resting and active pain were 1/10, and his functionality score increased to 30/40.

Based on these results we were able to demonstrate that receiving multiple bone marrow concentrate stem cell injections within a short time period may provide an effective hip cartilage repair. While this is a short-term outcome study, we have seen many patients with long-term results.

The treatment in this study is explained in the video below.

Hip injections using Bone marrow stem cells

Platelet-rich plasma, hyaluronic acid, corticosteroid

I am often asked to compare the different injection treatments to stem cell therapy. At our office we use PRP injections as well as stem cells. PRP treatments involve collecting a small amount of your blood and spinning it in a centrifuge to separate the platelets from the red cells. The collected platelets are then injected back into the injured area to stimulate healing and regeneration.

A January 2020 (17) study examined 11 randomized controlled trials with a total of 1,060 patients in comparing the clinical outcomes of four intra-articular injection treatments:

  • Platelet-rich plasma, (which we use)
    Hyaluronic acid, (which we don’t use)
  • Corticosteroid, (which we don’t use)
  • and hyaluronic acid plus platelet-rich plasma (which we don’t use) in patients with hip osteoarthritis.

What the researchers found was that corticosteroid injections to provide the short term. PRP, they suggested provided pain relief for up to 6 months

In February 2021 doctors at the Mayo Clinic suggested (18) that therapies such as PRP and stem cells are at an “exciting crossroads in medicine, where hip biologic therapies are evolving and (are) increasingly available.”

We have been offering regenerative joint injections for over two decades. We have been fortunate to have helped many patients with their hip pain. Can stem cell therapy help you? Use the form below and tell us about your situation.

Do you have questions? Ask Dr. Darrow

For more information on PRP injections, see this article:

Treatment of Hip Osteoarthritis with Platelet-Rich Plasma Injections

 

A leading provider of stem cell therapy, platelet rich plasma and prolotherapy
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PHONE: (800) 300-9300 or 310-231-7000

Stem cell and PRP injections for musculoskeletal conditions are not FDA approved. We do not treat disease. We do not offer IV treatments. There are no guarantees that this treatment will help you. Prior to our treatment, seek advice from your medical physician. Neither Dr. Darrow, nor any associate, offer medical advice from this transmission. This information is offered for educational purposes only. The transmission of this information does not create a physician-patient relationship between you and Dr. Darrow or any associate. We do not guarantee the accuracy, completeness, usefulness or adequacy of any resource, information, product, or process available from this transmission. We cannot be responsible for the receipt of your email since spam filters and servers often block their receipt. If you have a medical issue, please call our office. If you have a medical emergency, please call 911.

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. J Med Internet Res.2015 Jul 7;17(7):e167. doi: 10.2196/jmir.4376.
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. doi: 10.1016/j.joca.2015.07.024. Epub 2015 Aug 4.
3 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.
4 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.
5 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
6 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. doi: 10.1016/j.bone.2014.04.034. [Epub ahead of print]
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. doi: 10.1186/1471-2474-15-156.
8 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.
9 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. doi: 10.1186/1471-2474-15-156.
10 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.
11 Hernigou P, Beaujean F. Treatment of osteonecrosis with autologous bone marrow grafting. Clinical Orthopaedics and Related Research®. 2002 Dec 1;405:14-23.
12 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.
13 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.
14 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. doi: 10.1016/j.bone.2014.04.034. [Epub ahead of print]
15 Massin P. Treatments of avascular osteonecrosis of the hip: Current treatments [published online ahead of print, 2020 Jul 8]. Morphologie. 2020;S1286-0115(20)30051-5. doi:10.1016/j.morpho.2020.06.003
16 Darrow M, Shaw B, Darrow B, Wisz S. Short-Term Outcomes of Treatment of Hip Osteoarthritis With 4 Bone Marrow Concentrate Injections: A Case Series. Clinical Medicine Insights Case Reports. 2018;11:1179547618791574. doi:10.1177/1179547618791574. —
17 Zhao Z, Ma JX, Ma XL. Different Intra-articular Injections as Therapy for Hip Osteoarthritis: A Systematic Review and Network Meta-analysis [published online ahead of print, 2020 Jan 6]. Arthroscopy. 2020;S0749-8063(19)30885-0.
18 Gül D, Orsçelik A, Akpancar S. Treatment of Osteoarthritis Secondary to Developmental Dysplasia of the Hip with Prolotherapy Injection versus a Supervised Progressive Exercise ControlMed Sci Monit. 2020;26:e919166. Published 2020 Feb 11. doi:10.12659/MSM.919166

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