Caring Medical - Where the world comes for ProlotherapyTreating hip pain and necrosis: Can your hip be saved with core decompression or injection therapy?

Ross Hauser, MD  | Caring Medical Regenerative Medicine Clinics, Fort Myers, Florida
David N. Woznica, MD | Caring Medical Regenerative Medicine Clinics, Oak Park, Illinois
Katherine L. Worsnick, MPAS, PA-C  | Caring Medical Regenerative Medicine Clinics, Fort Myers, Florida
Danielle R. Steilen-Matias, MMS, PA-C | Caring Medical Regenerative Medicine Clinics, Oak Park, Illinois

Treating hip pain and necrosis Can your hip be saved with core decompression or injection therapy?

Osteonecrosis (called avascular necrosis or aseptic necrosis) is a condition where blood supply to the bone is impeded or disrupted. Bone needs circulating blood to regenerate and repair itself so you can have pain free, healthy joint motion. Loss of blood flow to the hip is a leading cause of the hip degenerative disease and the need for hip replacement surgery. Without blood flow, the bone under goes wear and tear without repair. Eventually your bone dies, the femoral head (the ball) of the hip joint collapses, and in essence your hip dies with it.

To avoid this outcome, especially in patients who are deemed too young for total hip replacement, one treatment option that your doctors may have discussed with you in treating your avascular necrosis is core decompression surgery.

If you are reading this page it is likely that you have already received the recommendation to go ahead with a core decompression surgery. You may even feel that you got some good news in that your femoral head has not collapsed yet and you do not need a hip replacement. The recommendation to core decompression, while still a major surgery, has its appeal. There is a chance that the core decompression surgery will save your hip, your will not need a much larger hip replacement surgery in the near future, and more importantly, you can have restored function and a lot less pain, faster. Or so is the belief.

If you are reading this page you have been researching and you have found some things that may offer you some concern about this procedure.

  • People are talking about significant pain after the core decompression surgery, lasting 1 – 2 months.
  • People are talking extensive rehabilitation 3 – 6 months
  • People are talking regrets about having the surgery
  • People are talking about having to get the hip replacement anyway. Having the core decompression first made the hip replacement a much more complicated procedure.

Please note that people have core decompression surgery and do very well with it. Some do not. If you are reading this page, you are concerned about the problems that post-surgery patients had, or worse, you are one of those post-surgical people who have more pain after the procedure and are waiting for a hip replacement and your doctors are trying to figure out how to do it. You may be reading our article because you are too looking for options. Below we will present some options.

Core decompression – the surgery – bringing blood back to the bone

Core decompression is considering a “joint sparing” surgery. If it works, a hip replacement can be avoided or delayed. The core decompression surgical procedure involves drilling a hole(s) into the femoral head of the hip to relieve pressure (from bone edema / swelling) in the bone and hopefully create new blood vessels to nourish the affected areas of the hip. The hope is that the new blood circulation will help with bone rebuilding.

According to surgeons who perform this procedure: The overall success of this treatment is unclear.

The failure of core decompression to provide long-term relief has been a challenge for hip surgeons

In August 2018, doctors at the Institute of Orthopedics and Traumatology at the University of San Paulo in Brazil published their findings in  (The Brazilian Journal of Orthopedics).(1) These are the learning points:

  • Osteonecrosis is a multifactorial condition that can be caused by many things. This prevents surgeons from developing single and standardized surgical treatment. (Bone loss/death can be caused by steroids, hormone replacement therapy, joint instability).
  • This condition continues to be underdiagnosed in its initial phase; if an early diagnosis is made, decompression is a possible treatment option. If the diagnosis is made in advanced stages, with established femoral head collapse, the indicated treatment is a total hip replacement.

The surgeon/researchers point out that their study was aimed at analyzing the characteristics of patients who underwent decompression in the last two years; all procedures were performed in the same way (guidewire placement in the femoral neck with fluoroscopic aid and drilling with a cannulated burr in the necrotic area).

Drilling relieved pressure and pain

  • The authors believe that the symptoms may be related to the presence of bone edema, which was observed in all cases submitted to the procedure. A significant improvement of the patients’ early symptoms was observed in 83.3% of decompressed hips.

Pain relief did not last long

  • In scoring patients pain symptoms, preoperative and postoperative pain did not present statistically significant alterations after six months, which indicates that the decompression treatment improves the early pain symptomatology, but does not alter the disease prognosis or the subsequent recommendation to hip replacement.

Pain relief did not last long despite new techniques and innovated solutions

The researchers noted that the failure of core decompression to provide long-term relief has been a challenge for hip surgeons, who have used new techniques associated with core decompression, such as the use of vascularized or non vascularized grafts, stem cell injection, shock wave therapy, and anticoagulant drugs. Moreover, various techniques have been described using different types of drills and number of drillings. The results have been similar, with initial symptom improvement that does not influence disease progression.

The failure of core decompression presents a challenge for hip surgeons in converting the hip to total hip replacement

In this section, we will present the research from the surgeons themselves in the challenges they face with a hip that has already had and failed core compression.

There is a problem with the rods and the metal debris in the hip they may cause.

A research team from Canada and the United Kingdom issued troubling findings in patients where core decompression failed and a subsequent total hip replacement was required.

The doctors, writing in the Bone and Joint Journal, (2) looked at core decompression and insertion of a tantalum rod into the hip joint for stabilization. The doctors were concerned that there may be a high failure rate associated with this procedure and examined failed tantalum rod insertion patients and their move to and subsequent hip replacement outcomes.

  • They found that in the short term, tantalum rod implantation does not adversely affect subsequent total joint replacement surgery. However, patients show a high rate of retained tantalum debris on postoperative radiographs and thus there is an unknown risk of accelerated articular cartilage wear necessitating longer-term study.

Common sense should tell us floating metallic debris in the hip is not optimum and reminds many of the metal on metal hip replacement recalls.

University hospital researchers in China writing in the journal International Orthopaedics (3) shared their equal concerns: “Porous tantalum osteonecrosis implants have been used in femoral head necrosis for several years, while the clinical outcomes were mixed. As a joint-preserving surgery, early necrosis deterioration and conversion to total hip replacement failed our expectation.”

What concerned the Chinese researchers was that the deterioration of early failed tantalum implant exceeds the nature of osteonecrosis progression. In other words, the implant caused accelerated hip degeneration.

They note that it was not the failure of the implant mechanical support, but rather the results of the drill that compromised the bone and led to early failure of porous tantalum osteonecrosis implants.

In other words, the concerns of the Chinese researchers was how fast the surgery failed and caused stress fractures in the bone it was designed to preserve.

 

American Academy of Orthopaedic Surgeons Illustration of Core decompression. (Right) In this x-ray, the drill lines show the pathway of small drill holes used in a core decompression procedure.

American Academy of Orthopaedic Surgeons Illustration of (Left) Core decompression.
(Right) In this x-ray, the drill lines show the pathway of small drill holes used in a core decompression procedure.

Porous tantalum osteonecrosis implants

Porous tantalum osteonecrosis implants

Making core decompression work better – a better drill?

Doctors in Germany examined “Advanced Core Decompression,” a new option that tries to remove the necrotic (dead) tissue in patients with osteonecrosis of the femoral head in a minimally invasive way by the use of a percutaneous expandable reamer (a drill) and refilling with a resorbable and osteoinductive bone-graft substitute.

Simply, a better drill and filling the drill holes with bone grafts. The better idea did not work out. This examination appeared in the April 2017 issue of the  Journal of Tissue Engineering and Regenerative Medicine. (4)

  • Seventy-two hips of sixty patients with a mean follow-up of 29 months after Advanced Core Decompression were examined.
  • The femoral heads collapsed in 24 cases (33%).
  • Analysis of the survival rates with regard to defect size revealed that the largest defects had a significantly higher rate of femoral head collapse than the smaller defects.

A later study from 2017 suggested that patients would have better success if their own bone graft, as opposed to donor bone, was used. As reported in the journal BioMed Central Musculoskeletal Disorders, in 75.9% the treatment was successful with no collapse of the femoral head or conversion to a total hip replacement.(5)

Making core decompression work better – the use of stem cells and blood platelets during surgery?

Surgeons are also looking into the incorporation of PRP Platelet Rich Plasma and Stem Cells into this surgical procedure. We noted above, that according to studies, this has not worked out that well in preventing conversion to total hip replacement. But other studies suggest these addon or adjunct surgical treatments may be of great benefit. So which is it?

In 2012 doctors in Spain publishing in Knee surgery, sports traumatology, arthroscopy (6) wrote:

  • Patients with grade I or grade II avascular necrosis of the hip are treated by core decompression performed by drilling under fluoroscopic guidance.
  • Liquid platelet-rich plasma (PRP) (your concentrated blood platelets which offers concentrated healing factors) is delivered through a trocar, saturating the necrotic area.
  • In more severe conditions, the necrotic bone is decompressed and debrided (removed), through a cortical window at the head-neck junction. A composite graft made of autologous bone and PRP is delivered through the core decompression track.
  • Fibrin membranes are applied to enhance healing of the head-neck window and arthroscopic portals. Platelet-rich plasma is infiltrated in the central compartment.

CONCLUSIONS: Arthroscopic management of avascular necrosis of the femoral head is viable and has significant advantages (especially when PRP is added).

This is not a widespread adapted procedure. It is what is called in medicine a “novel approach,” meaning new, unusual, not regular procedure. This research was hardly followed up.

In 2017 Doctors at the University of Milan also examined the role of bone marrow aspirate during core decompression surgery. In their study in the medical journal Efort Open Reviews,(7) they cited the 2016 work of Greek and English researchers in the journal Acta Orthopaedica (8) showing that the application of autologous bone marrow concentrate in combination with core decompression is superior to core decompression treatment alone, as it was found to markedly decelerate the progression of the disease to the stage of femoral head collapse. This procedure also limited the need for total hip replacement, particularly when employed in the early (pre-collapse) stages of avascular necrosis of the femoral head.

In 2016 Dr. Ahmed M Samy of the Department of Orthopedics, Tanta University, Egypt wrote in the Indian Journal of Orthopaedics that  mesenchymal stem cells and platelet rich plasma (PRP) have been used as an adjunct to core decompression to improve clinical success in the treatment of precollapse hips.(9)

Mayo Clinic findings on using PRP and stem cells during the core decompression surgery – corticosteroid-induced osteonecrosis

In February 2018, doctors at the Mayo Clinic reported on their findings in patients who underwent core decompression for steroid induced bone loss who had bone marrow aspirate stem cells and  platelet rich plasma introduced into the bone during the surgery. The research was published in the journal Clinical orthopaedics and related research.(10)

Here are their leaning points:

Study participants

  • Twenty-two patients (35 hips; 11 men and 11 women – 13 people had both hips involved)) with corticosteroid-induced osteonecrosis who met study inclusion criteria were enrolled
  • All patients had precollapse osteonecrosis, rated either University of Pennsylvania Stage 1 (4 of the hips) or Stage 2 (35 hips).
  • Average patient age 43 years old, average patient was overweight

Study observations

  • At 3 years – 84% of the hips did not go unto hip replacement
  • Two patients (four hips) underwent a second decompression and MSC injection for persistent pain without signs of radiographic collapse.
  • All patients with suffered femoral head collapse underwent hip replacement.
  • Core hip decompression with injection of concentrated bone marrow plus PRP improved pain and function in mo0re than 90% of hips in this series were without collapse at a minimum of 2 years.

Conclusions:

  • The results of this study should be taken in light of certain limitations. Because this study only includes patients with corticosteroid-induced bone necrosis, results may not be translatable to patients with bone necrosis secondary to an alternative risk factor.
  • Furthermore, there is no comparison to patients undergoing decompression alone.

Bone marrow stem cells and PRP may be beneficial during surgery. How about the treatments without the surgery?


Direct bone marrow aspiration (stem cells), treating avascular necrosis without core decompression 

Using stem cells taken from a patient’s bone marrow is becoming a therapy of interest due to the potential of these mesenchymal stem cells to differentiate into other types of cells such as bone and cartilage. In the more than 26 years experience we have working with patients in varying degrees of osteoarthritis, nothing sounds more terminal and ominous than the patient being told by another doctor that their bone is dying or they have necrosis, dead bone cells.

Bone Marrow is the liquid spongy-type tissue found in the hallow (interior) of bones. It is primarily a fatty tissue that houses stem cells which are responsible for the formation of other cells. These mesenchymal stem cells (MSC), also called marrow stromal cells, can differentiate (change) into a variety of cell types including osteoblasts (bone cells)chondrocytes (cartilage cells), myocytes (muscle cells), adipocytes (fat), fibroblasts (ligament and tendon) and others when reintroduced into the body by injection. Bone marrow also contains hematopoietic stem cells that give rise to the white and red blood cells and platelets.

In clinical observations at Caring Medical and Rehabilitation Services CMRS great benefit is seen in injecting bone marrow directly after extracting it.

The theory is that the number of stem cells is not as important as how long they live in their natural environment. In other words, when the bone marrow is directly injected, the source of stem cells is fresh and has great potential for healing. We also believe that the body knows best – it can use these immature cells to regenerate all injured tissues in the joint.

Caring Medical Research: Avascular Necrosis Case Report of Direct Bone Marrow Injections and Prolotherapy Treatment

Writing in the Journal of Prolotherapy, we documented the first case report of using direct bone marrow aspiration into areas of pain in a patient with avascular necrosis of the talus that does not involve core decompression. In this particular case, the bone marrow aspirate was injected into the tibiotalar and subtalar joints. The surrounding painful and injured ligaments on the lateral and medial sides of the ankle were also treated with Prolotherapy. Treating avascular necrosis with bone marrow stem cells is definitely a viable and successful treatment option to explore prior to surgery.(11 Read our research)


Supportive research: PRP and stem cells

In one case published in PM & R: the journal of injury, function, and rehabilitation (12) PRP was found very effective for advanced-stage degenerative AVN of the hip, with the patient demonstrating significant functional improvements and the ultimate outcome of being able to avoid surgery.

stem cell therapy in bone necrosis

An April 2015 study in the Journal of Cellular Biochemistry reported exciting news about stem cell therapy as a new modality of treatment in bone lesions that could not be treated with autologous bone grafting. However, while successful results were reported from individual studies, the paper said more studies were needed to validate stem cell therapy injections, an established treatment for bone regeneration.(13)

  • Since the time of that paper, validation has come from dozens of papers. Doctors writing in the European review for medical and pharmacological sciences had this to say over a seemingly new weapon surgeons could use to make surgery more successful.

Application of ‘regenerative medicine’ has given new hope to surgeons for the treatment of several chronic diseases and disorders including severe orthopedic conditions. There are a myriad of orthopedic conditions and injuries that presently have limited therapeutic treatments and could benefit from new developing therapies in regenerative medicine with the help of stem cell therapy.(14)

In other research, doctors confirmed that stem cell therapy for bone regeneration worked outside of surgery.

This was acknowledged in November 2015: Military university researchers in China reviewing the use of mesenchymal stem cells in the medical journal Biological research say:

“Bone is a unique tissue which could regenerate completely after injury rather than heal itself with a scar. Compared with other tissues the difference is that, during bone repairing and regeneration, after the inflammatory phase the mesenchymal stem cells (MSCs) are recruited to the injury site and differentiate into either chondroblasts (cartilage) or osteoblasts (bone) precursors, leading to bone repairing and regeneration. With this multilineage potentiality (the ability to change), the MSCs are probably used to cure bone injury and other woundings in the near future.”(15)

These findings are among the many research papers of the last two years that support the idea of bone regeneration in necrosis patients.

  • Medical university researchers in Serbia wrote in the journal International Orthopaedics found that a combination of adipose-derived mesenchymal stem cells and Platelet Rich Plasma regenerated bone mineral matrix in an animal model (regrew bone).(16)

A study published in the Journal of Orthopaedic surgery and research found that Fat (adipose) based MSC and PRP stimulated the articular extracellular matrix and reduced damaging inflammation in dogs with osteoarthritis.(17)

Researchers publishing in the publication Cell journal examined the use of Distraction osteogenesis – large volume expanded bone growth needed for limb lengthening. They tested bone growth using either a combination of stem cells and Platelet Rich Plasma Therapy or Platelet Rich Plasma Therapy alone. They found the combination of stem cell therapy and platelet rich plasma therapy provided superior results for accelerated bone growth.(18)

In an animal study, doctors examined stem cells for bone regrowth in the jawbones of rats who had bisphosphonate-related osteonecrosis (Bisphosphonates, when administered intravenously for the treatment of cancer, have been associated with osteonecrosis of the jaw). Publishing in the Journal of cranio-maxillofacial surgery, they found adipose-derived mesenchymal stem cells provided significant bone regrowth.(19)

Summary

The standard treatments for AVN seemingly lead to a singular destiny – joint replacement. But are there realistic options? Case studies started to appear in the medical literature which explores Platelet Rich Plasma and Stem Cell Therapy as possible solutions to bone death.

In our own clinical experience, we have seen similar results in patients who were given two options only – bilateral core decompression surgery or bilateral total hip replacement surgery. Patients should have been given the non-surgical option.

Do you have a question about core decompression? Get help and information from our Caring Medical staff

Prolotherapy Specialists core decompression

Danielle Steilen-Matias, PA-C | Katherine Worsnick, PA-C | Ross Hauser, MD | David Woznica, MD

1 Miyahara HD, Rosa BB, Hirata FY, Gurgel HD, Ejnisman L, Vicente JR. What is the role of core decompression in the early stages of osteonecrosis of the femoral head? Evaluation of the surgical result by functional score and radiological follow-up. Revista brasileira de ortopedia. 2018 Oct;53(5):537-42. [Google Scholar]
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8 Papakostidis C, Tosounidis TH, Jones E, Giannoudis PV. The role of “cell therapy” in osteonecrosis of the femoral head. Acta Orthop. 2015 Jul 29:1-7. [Google Scholar]
9 Samy AM. Management of osteonecrosis of the femoral head: A novel technique. Indian journal of orthopaedics. 2016 Jul;50(4):359. [Google Scholar]
10 Houdek MT, Wyles CC, Collins MS, Howe BM, Terzic A, Behfar A, Sierra RJ. Stem cells combined with platelet-rich plasma effectively treat corticosteroid-induced osteonecrosis of the hip: A prospective study. Clinical Orthopaedics and Related Research®. 2018 Feb 1;476(2):388-97. [Google Scholar]
11. Hauser R, Ostergaard S. Direct bone marrow injections for avascular necrosis of the talus: a case report. Journal of Prolotherapy. 2012;4:e891-e894.
12 Ibrahim V, Dowling H. Platelet-rich plasma as a nonsurgical treatment option for osteonecrosis. PM R. 2012 Dec;4(12):1015-9. doi: 10.1016/j.pmrj.2012.07.009.  [Google Scholar]
13 Im GI. Stem Cells for Reutilization in Bone Regeneration. Journal of cellular biochemistry. 2015 Apr 1;116(4):487-93.  [Google Scholar]
14 Li Y1, Tang J, Hu Y, Peng YH, Wang JW. A study of autologous stem cells therapy assisted regeneration of cartilage in avascular bone necrosis. Eur Rev Med Pharmacol Sci. 2015 Oct;19(20):3833-7. [Google Scholar]
15 Shao J, Zhang W, Yang T. Using mesenchymal stem cells as a therapy for bone regeneration and repairing. Biol Res. 2015 Nov 3;48(1):62. doi: 10.1186/s40659-015-0053-4.  [Google Scholar]
16 Cvetković VJ, Najdanović JG, Vukelić-Nikolić MĐ, Stojanović S, Najman SJ. Osteogenic potential of in vitro osteo-induced adipose-derived mesenchymal stem cells combined with platelet-rich plasma in an ectopic model. Int Orthop. 2015 Aug 1.  [Google Scholar]
17 Yun S, Ku SK, Kwon YS. Adipose-derived mesenchymal stem cells and platelet-rich plasma synergistically ameliorate the surgical-induced osteoarthritis in Beagle dogs. J Orthop Surg Res. 2016 Jan 15;11(1):9. doi: 10.1186/s13018-016-0342-9.  [Google Scholar]
18 Dehghan MM, Baghaban Eslaminejad M, Motallebizadeh N, Ashrafi Halan J, Tagiyar L, Soroori S, Nikmahzar A, Pedram M, Shahverdi A, Kazemi Mehrjerdi H, Izadi S. Transplantation of Autologous Bone Marrow Mesenchymal Stem Cells with Platelet-Rich Plasma Accelerate Distraction Osteogenesis in A Canine Model. Cell J. 2015 Summer;17(2):243-52. Epub 2015 Jul 11.  [Google Scholar]
19 Barba-Recreo P, Georgiev-Hristov T, Bravo-Burguillos ER, Abarrategi A, Burgueño M, García-Arranz M. Adipose-derived stem cells and platelet-rich plasma for preventive treatment of bisphosphonate-related osteonecrosis of the jaw in a murine model. Journal of Cranio-Maxillofacial Surgery. 2015 Sep 30;43(7):1161-8.  [Google Scholar]

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