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Regenerative Medicine Clinics


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Hip Replacement alternatives | Treatment after surgery


Ross.Hauser.MD

In this article Ross Hauser MD discusses hip replacement surgery alternatives as well as seeing the patient following hip replacement who had surgical complications. In the research below you will see that it is not only non-surgical doctors such as Prolotherapists, who are critical of unnecessary surgical procedures, but the surgeons themselves who question the validity of certain procedures after they see the outcome in their own patients.

Dr. Hauser will also discuss options that include Prolotherapy, Platelet Rich Plasma Therapy, and Stem Cell Therapy.


Osteonecrosis repair with bone marrow cell therapies: state of the clinical art

Cell-based therapies might aid in osteonecrosis bone damage repair by providing stem cells and other progenitor (originator) cells to potentially improve the local cellular environment in the affected hip. A review of 15 medical studies on osteonecrosis showed statistical improvement in patients treated with mesenchymal stem cells.1 What does this mean? It means that stem cell therapy provides the cells that start or “originate” the healing process that changes the hip joint from diseased state to healing – regenerative state.

Caring Medical Research

In our published research in Clinical Medicine Insights: Arthritis and Musculoskeletal Disorders, we showed that not only do stem cells regenerate tissue damage within the osteoarthritic joint, but used in combination with simple dextrose Prolotherapy injections, we were able to document repair and a return to hip stability.

In this case series, we describe our experience with a simple, cost-effective regenerative treatment using direct injection of  whole bone marrow (Stem Cell Therapy) into osteoarthritic joints in combination with hyperosmotic dextrose (Prolotherapy).

  • Seven patients with hip, knee or ankle osteoarthritis (OA) received two to seven treatments over a period of two to twelve months. Patient-reported assessments were collected in interviews and by questionnaire. All patients reported improvements with respect to pain, as well as gains in functionality and quality of life.
  • Three patients, including two whose progress under other therapy had plateaued or reversed, achieved complete or near-complete symptomatic relief, and two additional patients achieved resumption of vigorous exercise.

As far back as 2006, an article in Pain Physician Journal featured a case study of successful cartilage regeneration using stem cell therapy.2 This case involved a 64-year-old man with a 20-year history of hip pain. He was a candidate for hip replacement as his MRI showed severe degeneration, decreased joint space, bone spurs and cysts.

This man underwent a stem cell transfer in an effort to regenerate cartilage in his hip. Bone marrow was extracted from this patient, processed and injected into the affected hip. After the first stem cell treatment the patient reported some improvements in his hip although the MRI showed no change.

One month later a second treatment was performed and resulted in increased joint space and increased range of motion. The patient reported that he was able to stand for longer periods of time, enjoyed travel and recreation and was able to walk further and sit with less pain. The researchers concluded that this man did in fact have cartilage regeneration and that bone marrow therapies hold great promise for joint degeneration.

Since 2006 there has been more research in favor of using Stem Cell Therapy, yet Hip Replacement Surgery continues to be the “gold standard” in the medical community. Below is research for the use of and warnings of hip replacement surgery.


“All patients considering joint-preserving hip arthroscopy should be educated on the risk of total hip replacement after arthroscopy.”


Joint replacements can be avoided. Often patients seek a doctor’s opinion after having had a hip arthroscopy. While some have experienced temporary relief of pain and symptoms, others continue to experience the same problems following surgery. The unfavorable long-term results of joint arthroscopy should not be surprising. Removing tissue from joints may provide a temporary pain-relieving benefit, but long-term, the patient is left with a weaker joint, more susceptible to degeneration.

What is “joint-preserving hip arthroscopy?” In simple terms it is a surgery that will help prevent a total hip replacement. In an amazing statement in one research study, doctors said: The use of joint-preserving surgery of the hip has been largely abandoned since the introduction of total hip replacement. However, with the modification of such techniques as pelvic osteotomy (bone reshaping), and the introduction of intracapsular procedures such as surgical hip dislocation (a procedure where the ball-and-socket hip joint is surgically dislocated so that the natural hip joint can be repaired,) these techniques may be used to decelerate or even prevent progression to osteoarthritis.3

What is so amazing about this? Doctors are saying that the surgical alternative to hip replacement is surgery!

Why have the surgery if you are trying to avoid a surgery especially when research shows, stem cells and prolotherapy can repair bone and the natural hip joint without the risks.

Why do doctors warn patients that the joint sparing surgery may complicate the eventual hip replacement?

In this research 4, doctors looked at 96 patients over the age of 50 who had “joint-preserving hip arthroscopy.”

  • Of the 96 patients, 31 went on to have total hip replacement. That’s approximately one in three patients who had “joint-preserving” surgery that led to replacing the joint.

But the numbers are not what this research was all about. The research sought to predict who would need the hip replacement after the arthroscopy – and the best predictions came after radiographic evidence. If there was joint space of 2 mm or less (meaning the cartilage had worn down) 80% of those patients would need total hip replacement. It is therefore all about the joint space.



There are several reasons why your doctor may recommend hip replacement surgery. Recently, the American Academy of Orthopaedic Surgeons published general criteria which included the following reasons:

  • Hip pain that limits everyday activities, such as walking or bending
  • Hip pain that continues while resting, either day or night
  • Stiffness in a hip that limits the ability to move or lift the leg
  • Inadequate pain relief from anti-inflammatory drugs, physical therapy, or walking supports

The difficulty in diagnosing hip pain accurately and unnecessary or wrong site surgery


Research suggests that doctors must differentiate between radiating pain from the lumbar spine to the hip – and – pain originating from the hip itself. Physicians are warned that without making this connection patients may be subjected to hip replacement for back pain and back surgery for hip pain with neither surgery addressing the patients true cause of pain and leading to “Failed Surgery Syndrome.”

  • The research concludes: “…(There is) evidence for an association between hip pain and disk space narrowing at disk level L1/L2 and L2/L3. In case of uncertainty of the cause of hip pain, evaluation of lumbar radiographs may help to identify those hip pain patients who might have pain arising from the lumbar spine.”5

Recently other research said the opposite. They say that the incorrect diagnosis of spinal stenosis in patients with primary hip arthritis can lead to devastating consequences, especially if this leads to inappropriate spinal surgery, repeated spinal surgery and costly testing. In this research, doctors in South Africa examined the high prevalence of wrong site operations. 6


“Physicians should not replace clinical observation with the use of magnetic resonance images (MRI).”


The above statement,7 and similar research suggests that reliance on MRI in the determining of the need for hip replacement can lead to unnecessary surgery. In instances when hip or lumbar pain is difficult to pinpoint or diagnose, physicians should be aware that hip ligament and tendon problems are in play. In a physical examination, a physician palpates the junction points of ligaments and bones and tendons to muscle in the patient looking for an exact site of injury and his/her ability at reproducing the pain. This can help both patient and doctor determine the more probable cause of the patient’s discomfort.


Types of Hip Replacement To Consider


In the latest research doctors acknowledge that there are many different types of hip replacement to consider as there are evolvements in the design, fixation methods, size, and bearing surface of implants for total hip replacement. One problem with so many options and different replacement parts, is the need to determine the best combinations of implants. What worried the doctors was that while short-term benefits were apparent for many patients – the effectiveness of the hip replacement in the long-term is of great concern.

The reason? Medical research is inconclusive due to poor reporting, missing data, or uncertainty in treatment estimates.(Were the patients experiencing the great improvements or did they doctors think the patients were having great improvement).8


Minimally Invasive Total Hip Replacement Options


Minimally Invasive Total Hip replacement offers some benefit, but not as much benefit as the patient expects. In new reserch doctors says that neither pre-operative education nor mini-invasive surgery reduces the time to reach complete functional independence. Mini-invasive surgery significantly reduces blood loss and the need for morphine consumption.9

Visible muscle damage occurred in most hips during minimally invasive anterior supine intermuscular hip arthroplasty (replacement). The clinical importance of this muscle damage requires further study, because some evidence suggests earlier restoration of gait and need of walking aids with this method of hip replacement despite this damage. Surgeons performing this approach can expect more difficulty and as a result possibly more damage to the muscle in patients who are men and have more body weight or Body Mass Index (BMI).10


Pain and complications after hip replacement


In this section we will discuss issues of hip replacement complications. Metal-on-metal total hip replacements have shown a number of adverse effects 11. Some recipients of these hip replacements have complained of severe pain and immobility after tiny metal fragments have chipped off and damaged surrounding tissue. As a result, many who receive metal-on-metal hip replacements have elevated blood levels of chromium and cobalt, two metals used in these hip replacements.12 

There has also been a greater need for revision surgery, a procedure where surgeons must re-open the hip for repair.13 Another hip arthritis treatment is hip resurfacing. Instead of completely replacing the hip joint, metal “caps” are placed on the articular surfaces of the femur and pelvic socket. Numerous reports continue to pour in about the adverse effects of metal-on-metal hip replacements. We’ve written before about the dangers of hip replacements and the complications associated with all-metal hip replacements. Recent articles are further revealing the trouble with metal-on-metal hip replacements. 14

Because of these complications, the metal-on-metal hip replacement has all but been abandoned

Loosening, instability, dislocation, infection

A new study from doctors in Spain sought to determine the impact of each cause of revision surgery in total hip arthroplasty during the period 2009-2013.They looked at 127  patients who had hip replacement revision surgery.

  • The most common cause of “rescue surgery” was aseptic loosening in 38 (30%) followed by instability in 30 (24%).
  • Age is a very influential factor in relation to longevity of primary arthroplasty. Complications were higher in when the primary hip replacement is implanted in older patients.15

An international team of researchers found that there are no clear answers in preventing dislocation of the new hip joint. The cause of dislocation is multifactorial, re-establishing the anatomic center of rotation, balancing soft tissues and avoidance of impingement around the hip are important considerations.16

One to 15 hip surgeries because of infection

Doctors in the United Kingdom reported on patients who had between 1 and 15 revision operations after their primary joint replacement. They found that these patients spent great amounts of time immobilized between and waiting on their next surgery and that this caused further health problems.17

Groin Pain after hip replacement

The  prevalence of groin pain after conventional total hip replacement ranges from 0.4% to 18.3% and activity-limiting thigh pain is still an existing problem linked to the femoral component of uncemented hip replacement in up to 1.9% to 40.9% of cases in some series.18 The complexity of hip and groin pain are discussed further in my article: Groin Pain Treatments.

 


Assessing the patient’s post treatment success – Surgery


The decision to go to any joint replacement is a big one. In medicine, a great deal of emphasis is placed on scores to help clinicians decide before a joint replacement who had the best chance for surgical success. A recent study looked at the “Oxford” scoring system of over 3000 patients who had a hip or knee replacement. The purpose of the study was to help doctors identify and prioritize those patients who had best chance of success. At the end of the study the doctors found that pre-operative Oxford scores have no predictive accuracy in distinguishing satisfied from dissatisfied patients. Further, Oxford hip and knee scores have no predictive accuracy in relation to post-operative patient satisfaction. This evidence does not support their current use in prioritising (sp) access to care.19,20


Fall Risks after hip replacement


Japanese researchers examined the fall risk in patients following hip replacement. They found an increased risk for falls and fall-induced injuries mostly associated with medication and shorter postoperative duration.20


Alternatives to Hip Replacement Surgery



 Stem Cell Therapy for Chronic Hip Pain


We are discovering study after study that proves the benefit of bone marrow in treating chronic pain. In our experience, we have seen excellent results using bone marrow as a proliferant for healing.  Stem cell injection therapy is just one treatment option that we offer sports injuries, chronic pain and arthritis of the hip.


Are you a candidate for Prolotherapy, Platelet Rich Plasma Therapy, or Stem Cell Therapy?


In our research published in the Journal of Prolotherapy we sought to show how Prolotherapy could provide high levels of patient satisfaction while avoiding hip surgery. Here is what was reported:

      • We examined sixty-one patients, representing 94 hips, who had been in pain an average of 63 months.
      • We treated these patients quarterly with Prolotherapy. Included in this patient group was twenty patients who were told by their doctors that there were no other treatment options for their pain and eight patients who were told by their doctor that surgery was their only option.

Results: In these 94 hips,

      • 89% experienced more than 50% of pain relief with Prolotherapy; more than 84% showed improvements in walking and exercise ability, anxiety, depression and overall disability; 54% were able to completely stop taking pain medications.21

  Assessing the patient’s post treatment success


When we receive hip x-rays on discs or film from prospective patients, they provide an estimated prognosis, which is their best assessment of how many Prolotherapy treatments might be needed to achieve the patient’s goals.This is more difficult to assess when they do not have the opportunity to examine the patient in person, but they are able to give a good estimate based on the information provided.

      • Rating a hip Prolotherapy Candidate: We will rate the potential hip pain patient on a sliding scale of being a very good Prolotherapy candidate to a very poor one. In a very good candidate’s x-ray, the ball of the femur will be round, fitting nicely into the socket in the pelvis, with good spacing between these two bones. This space is the cartilage that cushions and allows the femur to rotate freely within the socket.
      • Prolotherapy prognosis for hip patients: The prognosis ranking is lowered from very good to good, to questionable to guarded to poor, based on the following criterion:

1. Amount of joint space or cartilage that remains (See cartilage repair).

2. The presence or absence of bone spurs (osteophytes), and their locations

3. The shape of the femoral head itself In very poor candidates, the hip does not even look like a hip anymore; the ball is flattened or egg-shaped and does not fit into the socket as well. Once the damage is so extensive, the patient will need a recommendation total hip replacement.

We recently saw a patient whose hip looked just like we described above. The physical exam proved limited external and internal rotation, and the x-ray the patient brought confirmed bone spurs, also called osteophytes. It was these extensive osteophytes that were preventing the full range of motion in that patient’s hip. Bone spurs do not always preclude someone from doing well with Prolotherapy, however, much depends on the extent, size and location of the spurs. Unfortunately we had to refer this particular patient for hip replacement, but he went into it with full knowledge of the extent of his degenerative joint disease and the confidence that a conservative care clinic had recommended it.

This case shows that a second opinion from a non-surgical viewpoint can provide the patient a level of confidence that a hip replacement is really warranted in their situation. The message of this article is get a second opinion on your hip replacement recommendation from a doctor who specializes in non-surgical approaches like Prolotherapy. Many times the vast majority of our patients are able to eliminate their painful joint conditions without surgery.



1. 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. 2015 Jan;70:102-9. doi: 10.1016/j.bone.2014.04.034. Epub 2014 Jul 10.
2.
Centeno CJ, Kisiday J, Freeman M, Schultz JR. Partial Regeneration of the Human Hip Via Autologous Bone Marrow Nucleated Cell Transfer: A Case Study. Pain Physician. 2006;9:253-256. Regenexx study
3. Leunig M, Ganz R. The evolution and concepts of joint-preserving surgery of the hip.Bone Joint J. 2014 Jan;96-B(1):5-18. doi: 10.1302/0301-620X.96B1.32823. Review.
4. Philippon MJ, Briggs KK, Carlisle JC, Patterson DC. Joint Space Predicts THA After Hip Arthroscopy in Patients 50 Years and Older. Clin Orthop Relat Res. 2013 Jan 5. [Epub ahead of print]
5 de Schepper EI, Damen J, Bos PK, Hofman A, Koes BW, Bierma-Zeinstra SM.Disk degeneration of the upper lumbar disks is associated with hip pain. Eur Spine J. 2012 Nov 8. [Epub ahead of print]
6. van Zyl A, Misdiagnosis of hip pain could lead to unnecessary spinal surgery, SA orthop. j. vol.9 no.4 Pretoria 2010
7. from the Treatment for Hip Conditions Should Not Rest Solely on MRI Scans. AOSSM February 11, 2012.
8. Tsertsvadze A, Grove A, Freeman K, Court R, Johnson S, Connock M, Clarke A, Sutcliffe P. Total hip replacement for the treatment of end stage arthritis of the hip: a systematic review and meta-analysis. PLoS One. 2014 Jul 8;9(7):e99804. doi: 10.1371/journal.pone.0099804. eCollection 2014.
9. Biau DJ, Porcher R, Roren A, Babinet A, Rosencher N, Chevret S, Poiraudeau S, Anract P. Neither pre-operative education or a minimally invasive procedure have any influence on the recovery time after total hip replacement. Int Orthop. 2015 May 15. [Epub ahead of print]
10. Frye BM, Berend KR, Lombardi AV Jr, Morris MJ, Adams JB. Do sex and BMI predict or does stem design prevent muscle damage in anterior supine minimally invasive THA? Clin Orthop Relat Res. 2015 Feb;473(2):632-8. doi: 10.1007/s11999-014-3991-1.
11. Beswick AD, Wylde V, Gooberman-Hill R, Blom A, Dieppe P. What proportion of patients report long-term pain after total hip or knee replacement for osteoarthritis? A systematic review of prospective studies in unselected patients. BMJ Open. 2012 Feb 22;2(1):e000435.Print 2012.
11. Bates, C. Hope, J. Toxic metal hip implants ‘could affect thousands more people than PIP breast scandal’.News article Daily Mail UK
12. Van Raay JJ. Metal-on-Metal Total Hip Arthroplasty: Known and Unknown Side Effects. Orthopedics. 2012: 35 (6).
13 Lhotka, C., Szekeres, T., Steffan, I., Zhuber, K. and  Zweym BCllerK. (2003), Four-year study of cobalt and chromium blood levels in patients managed with two different metal-on-metal total
14. Isherwood J, Dean B, Pandit H. Documenting informed consent in elective hip replacement surgery: a simple change in practice. Br J Hosp Med (Lond). 2013 Apr;74(4):224-7.
15. Capón-García D, López-Pardo A, Alves-Pérez MT. Causes for revision surgery in total hip replacement. A retrospective epidemiological analysis. Rev Esp Cir Ortop Traumatol. 2016 Mar 1. pii: S1888-4415(16)00004-7. doi: 10.1016/j.recot.2016.01.002. [Epub ahead of print] English, Spanish.
16. Timperley AJ, Biau D, Chew D, Whitehouse SL. Dislocation after total hip replacement – there is no such thing as a safe zone for socket placement with the posterior approach. Hip Int. 2016 Mar 23;26(2):121-7. doi: 10.5301/hipint.5000318. Epub 2016 Feb 5.
17. Beard D, Carr AJ, Dawson J, Fitzpatrick R, Field RE. Assessing patients for joint replacement: can pre-operative Oxford hip and knee scores be used to predict patient satisfaction following joint replacement surgery and to guide patient selection? J Bone Joint Surg Br. 2011 Dec;93(12):1660-4. doi: 10.1302/0301-620X.93B12.27046.
18. Forster-Horvath C, Egloff C, Valderrabano V, Nowakowski AM. The painful primary hip replacement – review of the literature. Swiss Med Wkly. 2014 Oct 8;144:w13974. doi: 10.4414/smw.2014.13974. eCollection 2014.
19. Moore AJ, Blom AW, Whitehouse MR, Gooberman-Hill R. Deep prosthetic joint infection: a qualitative study of the impact on patients and their experiences of revision surgery. BMJ Open. 2015 Dec 7;5(12):e009495. doi: 10.1136/bmjopen-2015-009495.
20. Matharu GS, McBryde CW, Robb CA, Pynsent PB. An analysis of Oxford hip and knee scores following primary hip and knee replacement performed at a specialist centre. Bone Joint J. 2014 Jul;96-B(7):928-35. doi: 10.1302/0301-620X.96B7.32479.
20. Ikutomo H, Nagai K, Nakagawa N, Masuhara K. Falls in patients after total hip arthroplasty in Japan. J Orthop Sci. 2015 Mar 24. [Epub ahead of print]
21. Hauser R, Hauser M. A retrospective study on Hackett-Hemwall dextrose Prolotherapy for chronic hip pain at an outpatient charity clinic in rural Illinois. Journal of Prolotherapy. 2009;2:76-88.

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