Treating hip pain and necrosis without core decompression

Prolotherapy Knee articular cartilage repair without surgery

Ross Hauser, MD

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, without blood flow the bone dies.

Before you read on, do you have a question about core decompression? Get help and information from our Caring Medical staff

Loss of blood flow to the hip is a leading cause of the hip degenerative disease and the need for hip replacement surgery. One treatment option in avoidance of total hip replacement is core decompression.

Core decompression

Core decompression is considering a “joint sparing” surgery. If it works, there can be an avoidance or delay of hip replacement. The core decompression surgical procedure involves drilling a hole(s) into the femoral head of the hip to relieve pressure in the bone and hopefully create new blood vessels to nourish the affected areas of the hip. The overall success of this treatment is unclear.

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, 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.

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.

Early necrosis deterioration and conversion to total hip replacement

University hospital researchers in China writing in the journal International Orthopaedics 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.(2)

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

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.

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.(4)

Doctors recommend incorporation of blood platelets and stem cells into core decompression

Another way, incorporate PRP Platelet Rich Plasma and Stem Cells into this surgical procedure.

In 2012 doctors in Spain publishing in Knee surgery, sports traumatology, arthroscopy wrote that:

CONCLUSIONS: Arthroscopic management of avascular necrosis of the femoral head is viable and has significant advantages (especially when PRP is added). (5)

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,(6) they cited the 2016 work of Greek and English researchers in the journal Acta Orthopaedica (7) 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.(8)

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

The use of stem cell therapy in bone necrosis is exciting. In the more than two decades 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. Probably no other diagnosis leads to a quicker joint replacement than “bone death.”

The diagnosis of avascular necrosis should not mean automatic joint replacement, nor should its diagnosis need to be a “life-altering situation” in many cases it can be managed with the comprehensive approach of dextrose Prolotherapy, Platelet Rich Plasma, and Stem Cell Therapy.


Caring Medical and Rehabilitation Services 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.(9 Read our research)


Supportive research: PRP and stem cells

In one case published in PM & R : the journal of injury, function, and rehabilitation 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.(10)

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.(11)

Application of ‘regenerative medicine’ has given a 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.(12)

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.”(13)

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

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.(15)

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.(16)

In an animal study, doctors examined stem cells for bone regrowth in the jaw bones 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.(17)

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

1 Olsen M, Lewis PM, Morrison Z, McKee MD, Waddell JP, Schemitsch EH. Total hip arthroplasty following failure of core decompression and tantalum rod implantation. Bone Joint J. 2016 Sep;98-B(9):1175-9. [Google Scholar]

2 Zhang X, Wang J, Xiao J, Shi Z. Early failures of porous tantalum osteonecrosis implants: a case series with retrieval analysis. Int Orthop. 2016 Sep;40(9):1827-34. [Google Scholar]

Classen T, Warwas S, Jäger M, Landgraeber S. Two-year follow-up after advanced core decompression. J Tissue Eng Regen Med. 2017 Apr;11(4):1308-1314. [Google Scholar]

4 Landgraeber S, Warwas S, Claßen T, Jäger M. Modifications to advanced Core decompression for treatment of Avascular necrosis of the femoral head. BMC musculoskeletal disorders. 2017 Dec;18(1):479. [Google Scholar]

5 Guadilla J, Fiz N, Andia I, Sánchez M. Arthroscopic management and platelet-rich plasma therapy for avascular necrosis of the hip. Knee Surg Sports Traumatol Arthrosc. 2012 Feb;20(2):393-8. doi: 10.1007/s00167-011-1587-9. [Google Scholar]

6 Calori GM, Mazza E, Colombo A, Mazzola S, Colombo M. Core decompression and biotechnologies in the treatment of avascular necrosis of the femoral head. EFORT Open Reviews. 2017;2(2):41-50. [Google Scholar]

7 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]

8 Samy AM. Management of osteonecrosis of the femoral head: A novel technique. Indian journal of orthopaedics. 2016 Jul;50(4):359. [Google Scholar]

9. Hauser R, Ostergaard S. Direct bone marrow injections for avascular necrosis of the talus: a case report. Journal of Prolotherapy. 2012;4:e891-e894.

10. 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]

11. Im GI. Stem Cells for Reutilization in Bone Regeneration. Journal of cellular biochemistry. 2015 Apr 1;116(4):487-93.  [Google Scholar]

12. 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]

13. 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]

14. 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]

15 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]

16 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]

17 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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