Treating Degenerative Hip Disease
- New research says PRP injections offer a significant clinical improvement in patients with hip osteoarthritis
- In another new study – stem cells can help repair diseased bone.
In new research surrounding Platelet Rich Plasma therapy, doctors evaluated the effectiveness of intra-articular platelet-rich plasma (PRP) injections in patients with hip osteoarthritis.
A total of 111 patients were randomly assigned to 3 groups and received 3 weekly injections of either
- PRP (44 patients),
- PRP + Hyaluronic Acid (31 patients),
- or Hyaluronic Acid (36 patients).
The idea behind hyaluronic acid injections is to protect the hip by injecting a lubricant. Please read our article on hyaluronic acid by Ross Hauser MD
- At all follow-ups, the PRP group had the lowest pain assessment scores Significant improvements were achieved in reducing pain and ameliorating quality of life and functional recovery.
Results indicated that intra-articular PRP injections offer a significant clinical improvement in patients with hip osteoarthritis without relevant side effects. The benefit was significantly more stable up to 12 months as compared with the other tested treatments. The addition of PRP + Hyaluronic Acid did not lead to a significant improvement in pain symptoms.1
In the second new study doctors found that the repair of subchondral bone (the bone on bone phenomena) lesions and damage with stem cells should be considered as the native stem cells in the hip positively respond to the repair stimulus during stem cell therapy.2
Ross Hauser, MD of Caring Medical discusses PRP and Stem Cell Injections for degenerative hip disease
Various stages of hip osteoarthritis
Hip joint pain and injury is one of the more difficult conditions to treat if a patient has let the condition progress for many years without treatment or mobility. One criterion that determines if a pain patient will do well with Prolotherapy is good range of motion in that particular joint.
It is a relatively common occurrence in our Prolotherapy practice to see patients under the age of 50 with premature osteoarthritis. Patients typically complain of significant hip and groin pain, especially with exercise.
There are many causes of premature osteoarthritis of the hip.
- Coxa Profunda (a condition of a deep hip socket – however it is also seen in many patients on MRI and scans who exhibit no symptoms).3
- Femoroacetabular Impingement
- Avascular Necrosis
- Hip Instability From Hip Ligament Injury
- Labral Tear
- Joint Dislocation
As hip degeneration increases, normal mechanical load will cuase worsening joint instability. Eventually articular cartilage breakdown and bony overgrowths called bone spurs, which are another common occurrence with osteoarthritis or degenerative arthritis will occur.Eventually the pain and hip range of motion will both deteriorate to the point where the patient ‘s activities are severely limited or stopped.
Prior to Hip Replacement – a patient may be recommended to the following procedures:
- Labral Debridement and Repair: Debridement refers to the removal of tissue via an arthroscopic blade, shaver, or ablator. The goal of debridement is to relieve pain by removing any torn or frayed labral tissue from the labrum.
In a new study hip range of motion and adduction strength (the lateral movement of the hip joint) were associated with weakened and damaged hip labral tears and considered to be important quality-of-life in patients with labral problems.4 This clearly indicates that patients want repair not tissue removal.
- Chondroplasty: The removal of damaged cartilage during surgery via shaving, cutting, scraping, laser, or burring away. The idea is that after the damaged cartilage is removed via chondroplasy, the body may recover the area with new cartilage.
- Microfracture: A surgical procedure whereby a “pick” is used to spike holes in damaged cartilage to promote bleeding and the migration of bone marrow cells to the joint surface. The idea is that the blood cells/bone marrow will heal the damaged cartilage. As aforementioned, microfracture is the only technique performed during this patient’s surgery that may be considered regenerative, in that the technique is applied in attempt grow new tissue. However, a much simpler, less risky and more cost effective treatment would be PRP and stem cells to stimulate the growth of new cartilage.
- Osteoplasty: The surgical alteration of bone.
- Synovectomy: The surgical removal of the entire or partial synovial membrane of a joint.
The case for stem cells as non-surgical repair of degenerative hip
In 2015, doctors announced their findings for long-term safety follow up in patients who received stem cell therapy in the knee, ankle, or hip for treatments of osteoarthritis.
Seventeen patients were followed through the end of the study. The patients received ONE bone-marrow stem cell injection to the affected joint. Patients were followed with clinical examinations, MRI and laboratory tests at 2, 6, 12, and 30 months post-transplantation.
The doctors concluded their findings as having observed no severe adverse events . . .
All patients exhibited therapeutic benefits such as increased walking distance, increased function, and reduced pain.
“Our study has shown that injection of MSCs (stem cells) in different osteoarthritis affected joints is safe and therapeutically beneficial.”5
In 2013 Caring Medical published research on seven patients who had hip, knee or ankle osteoarthritis and who received two to seven stem cell therapy treatments over a period of two to twelve months. Following treatments the seven patients all 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 symptom relief, and two additional patients achieved resumption of vigorous exercise.6
Hip Osteoarthritis in a Prolotherapy Patient
This is a case history or a patient who had a long history of pain in both hips. She had tried numerous treatments including chiropractic, cortisone injections, and even multiple Prolotherapy sessions at another clinic. Prolotherapy, or regenerative injection therapy, is an injection treatment used to heal and strengthen connective tissues such as ligaments, tendons and cartilage by causing an inflammatory response which draws the immune system to the area of injury. The patient had severe osteoarthritis in her hips and was looking for an alternative to total hip replacement when she was referred here. She decided to have a consult with us as she understood we specialize in difficult cases.
The patient’s X-rays and physical exam confirmed severe osteoarthritis in both hips. In many cases dextrose Prolotherapy will eliminate all or most of the pain associated with this disease, however, severe cases are more difficult.
- One of the determining factors that points to the severity of the arthritis is the range-of-motion that remains in the joint. This patient had zero degrees of internal rotation and 25-30 degrees of external rotation, very limited.
New research entitled: “How Much Arthritis Is Too Much for Hip Arthroscopy” tries to grade at what point hip damage is too severe for hip arthroscopy and when the patient should be sent to full hip replacement.
- The researchers concluded: “Current evidence is insufficient to define a cutoff for how much arthritis is too much for hip arthroscopy.” 7
When we see an advanced case of osteoarthritis or a patient after normal Prolotherapy has not met their goals, we may suggest stem cell treatment for hip osteoarthritis. This is a procedure where the patient’s own bone marrow is extracted via a simple, fairly painless procedure from their shin bone, or tibia. Bone marrow contains stem cells, cells that differentiate, or change, into any other types of cells in the body, according to what is needed. This occurs naturally in the body, but the premise of Stem Cell Therapy is to inject the bone marrow containing stem cells right where it is needed. Prolotherapy is also done at the same time to help repair ligaments around the hip to stabilize them, as it is often joint instability that leads to uneven wear and tear of the cartilage.
- Following stem cell therapy from bone marrow, the patient reported 20% improvement after the first treatment, 70-80% improvement after the second, and has been cycling ten miles per day nearly every day.
Stem cells and progenitor cells from bone marrow have been shown to “revascularize” or make new blood vessels around an area of injury.8,9 Progenitor cells are similar to true stem cells in that they can replicate themselves, but only a limited number of times, unlike stem cells, which can do so indefinitely, given the right conditions. Stem cells have been shown in studies to differentiate into cartilage cells and are used to repair cartilage defects.10,11
The promising results with these studies and the clinical evidence at Caring Medical gives hope to those suffering with degenerative hip disease.
1 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 J Sports Med. 2016 Mar;44(3):664-71. doi: 10.1177/0363546515620383. Epub 2016 Jan 21.
2. Campbell TM, Churchman SM, Gomez A, McGonagle D, Conaghan PG, Ponchel F, Jones E. Mesenchymal stem cell alterations in bone marrow lesions in hip osteoarthritis. Arthritis Rheumatol. 2016 Feb 11. doi: 10.1002/art.39622. [Epub ahead of print]
3. Griffin JW, Hadeed MM, Werner BC, Diduch DR, Carson EW, Miller MD. Platelet-rich plasma in meniscal repair: does augmentation improve surgical outcomes? Clin Orthop Relat Res. 2015 May;473(5):1665-72. doi: 10.1007/s11999-015-4170-8. Epub 2015 Feb 6.
4. Kemp JL, Makdissi M, Schache AG, Finch CF, Pritchard MG, Crossley KM. Is quality of life following hip arthroscopy in patients with chondrolabral pathology associated with impairments in hip strength or range of motion? Knee Surg Sports Traumatol Arthrosc. 2015 Jul 3. [Epub ahead of print]
5. 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.
6. Hauser RA, Orlofsky A. Regenerative injection therapy with whole bone marrow aspirate for degenerative joint disease: a case series. Clin Med Insights Arthritis Musculoskelet Disord. 2013 Sep 4;6:65-72. doi: 10.4137/CMAMD.S10951. eCollection 2013.
7. Domb BG, Gui C, Lodhia P. How Much Arthritis Is Too Much for Hip Arthroscopy: A Systematic Review. Arthroscopy. 2014 Dec 25. pii: S0749-8063(14)00900-1. doi: 10.1016/j.arthro.2014.11.008. [Epub ahead of print]
8. Ashara T, et al. Bone marrow origin of endothelial progenitor cells responsible for postnatal vasculogenisis in physiological and pathological neovascularization. Circulation Research. 1999;85:221-228.
9. Hermann P, et al. Concentration of bone marrow total nucleated cells by a point-of-care device provides a high yield and preserves their functional ability. Cell Transplantation.2008;16:1059-1069.
10. Fortier L, et al. Concentrated bone marrow aspirate improves full-thickness cartilage repair with micro-fracture in the equine model.Journal of Bone and Joint Surgery Am. 2010;92:1927-1937.
11. Gobbi A, et al. One-step cartilage repair with bone marrow aspirate concentrated cells and collagen matrix in full-thickness knee cartilage lesions: results at 2-year follow-up.Cartilage.