Treating avascular necrosis of the femoral head without hip replacement. New evidence on non-surgical options
Ross Hauser, MD., Caring Medical Regenerative Medicine Clinics, Fort Myers, Florida
Danielle R. Steilen-Matias, MMS, PA-C., Caring Medical Regenerative Medicine Clinics, Oak Park, Illinois
David N. Woznica, MD., Caring Medical Regenerative Medicine Clinics, Oak Park, Illinois
Treating hip pain and necrosis – core decompression or non-surgical injection therapy?
Osteonecrosis (called avascular necrosis or aseptic necrosis) is a condition where the 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 undergoes wear and tear without the ability to repair the degenerative damage. 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, you 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 likely 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
Early in 2019, United States Army surgeons wrote of the “Low Rate of Return to Impact Activity Following Core Decompression for Femoral Head AVN in Military Servicemembers.” (1) This study was published in the journal Military Medicine. Here is what the army doctors wrote:
- A total of 29 active duty patients were examined (22 male, 7 female; average age 32.3 years).
- Seven patients of the 29 patients (24%) progressed to the need for total hip replacement and they were more likely to have bilateral (both hips) disease (86%) and be older (35.4 years versus 31.2 years).
- At the final follow-up, 86% of patients had significant hip-related activity restrictions, with only 6 of the 29 patients (21%) remaining on active military service.
- Military service members have a low likelihood of returning to preoperative physical function and running activities (13.7%).
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)(2) Which questioned the success of core decompression surgery. These are the learning points:
- Osteonecrosis is a multifactorial condition that can be caused by many things. This prevents surgeons from developing a single and standardized surgical treatment. (Bone loss/death can be caused by steroids (see the case history below), 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 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, (3) 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 (4) 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 (Left) Core decompression.
(Right) In this x-ray, the drill lines show the pathway of small drill holes used in a core decompression procedure.
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. (5)
- 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.(6)
Making core decompression work better – the use of stem cells and blood platelets during surgery?
In this section, we will talk about treatments that we offer at our clinics, Platelet Rich Plasma therapy and stem cell therapy that are sometimes used by surgeons during the decompression surgery to make the surgery work better. Let’s clarify and explain these treatment options.
- In our clinics, we do not perform surgery. The goal of our treatments is to help people avoid surgery by the regeneration of damaged ligament, tendon, cartilage, and bone through the use of various therapeutic and regenerative injections.
- In the many cases of patients presenting degenerative hip disease, we can help these patients alleviate pain and restore function with simple injections. These would be PRP (Platelet Rich Plasma), bone marrow-derived stem cell injections, and the base of our treatment program, simply dextrose or H3 Prolotherapy injections. We have more than a quarter century of experience and expertise in helping patients seek relief with our non-surgical options.
- We cannot help everyone with our treatments. Sometimes the hip is completely destroyed, such as in femoral head collapse, or large bone spurs have fused and locked the hip into a “rusted old joint,” that cannot be budged. Sometimes a hip replacement has to be recommended. We are hopeful that we see patients before they have reached this point of significant degeneration.
Surgeons are also looking into the incorporation of PRP Platelet Rich Plasma and Stem Cells into the decompression procedure.
- PRP is your concentrated blood platelets that offer concentrated healing factors.
- PRP treatment re-introduces your own concentrated blood platelets into the damaged joint. During the surgery, surgeons apply it to the femoral head in an attempt to facilitate healing.
- Your blood platelets contain growth and healing factors. When concentrated through simple centrifuging, your blood plasma becomes “rich” in healing factors, thus the name Platelet RICH plasma.
In 2012 doctors in Spain publishing in Knee Surgery, Sports Traumatology, Arthroscopy (7) 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 that offer 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 2018, German doctors wrote in the journal Der Orthopäde (The Orthopedist) (8) “therapies such as additive stem cells or platelet-rich plasma (PRP) combined with core decompression have yet to prove their efficacy.”
Bone Marrow-Derived Stem 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 that 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) and chondrocytes (cartilage cells), fibroblasts (ligament and tendon) and others when reintroduced into the body by injection.
In treatment without surgery, the bone marrow is taken from the iliac crest of the pelvic bone in a simple drawing procedure. The bone marrow is either centrifuged to create a bone marrow aspirate concentration which is injected into the problem hip, or the bone marrow is injected directly into the problem hip without the concentration. We have published research on both these methods and this is discussed below.
Use during surgery
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,(9) they cited the 2016 work of Greek and English researchers in the journal Acta Orthopaedica (10) 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.(11)
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.(12)
Here are their leaning points:
- 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 pre-collapse 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
- 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 a hip replacement.
- Core hip decompression with an 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.
- 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.
Can you avoid the surgery?
Bone marrow stem cells and PRP may be beneficial during surgery. How about the treatments without the surgery? 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 worked 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.
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
When we first began publishing research on our results with bone marrow injections, we were able to show a patient case history of the repair of avascular necrosis of the talus (the large bone of the ankle. Later and documented below, we showed the results in cases of advanced hip degeneration.
Back to the ankle patient briefly and 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 did 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.(13 Read our research)
In our research published medical journal Clinical Medicine Insights Arthritis and Musculoskeletal Disorders (14), Ross Hauser, MD we documented the following cases of advancing hip osteoarthritis.
Patient case: A 76-year-old female
A 76-year-old female came into our office with pain in both hips that had plagued her the last 3-4 years. Her left hip pain being more significant than the right. She was unable to walk more than a mile without significant pain. The patient had received a recommendation for hip replacement. X-rays revealed moderate to severe degenerative changes in both hips.
The patient received seven bone marrow/dextrose H3 Prolotherapy treatments to each hip over a period of 12 months and adhered to a program of daily bicycle exercise.
- She reported incremental improvements in pain and function at each visit. At the final visit, the patient reported significant gains since the onset of treatment with respect to the range of motion, resumption of exercise, reduced crepitus, and reduction of pain medication use by two thirds. She reported her overall improvement as 90%.
Patient case: – A 56-year-old female presented with pain in bilateral knees and right hip.
- Right hip pain had been intermittent for 16 years, but instability and continuous pain began six months before her visit.
- The hip pain prevented sleep on the affected side, bicycle exercise had ceased for more than a year, and walking exercise was limited to three miles.
- MRI with a previous physician showed a labral tear. The patient was diagnosed with hip osteoarthritis and labral tear, and bilateral knee osteoarthritis.
- The patient received bone marrow/dextrose treatment at six visits with 8–10 week intervals.
- At visits 1 and 2, the right knee and right hip were treated with tibial whole bone marrow.
- At visits 3 and 4, both knees and right hip were treated with tibial whole bone marrow.
- The patient reported modest (20%–35%) overall improvement following these treatments.
- At the final two visits, bilateral knees and right hip were treated with iliac whole bone marrow injection. During the treatment period, the left hip was also treated for pain resulting from a flexor injury incurred following visit 1.
- Two months after visit 6, the patient reported 65%–95% overall improvement for the three joints. She is able to walk for two hours, no longer has disturbed sleep, and has been able to resume bicycle exercise with minimal discomfort. The patient still experiences intermittent soreness in a small region in the medial aspect of the right patella.
Patient case: A 63-year-old male presented with bilateral hip pain.
- Pain intensity was 6/10 with a frequency of 50%.
- The patient received five bilateral treatments with dextrose H3 prolotherapy over a period of 5 months.
- During this period, the patient reported overall improvement of 50%; however, this reduced to 30%–40% at the conclusion of the treatment period, at which time pain intensity was 6/10 with a frequency of 30%.
- Crepitus, previously absent, was now marked. At this point, the patient began a series of two whole bone marrow/dextrose treatments two months apart.
- At the time of the second treatment, pain intensity was 5/10. Crepitus was reduced.
- Specific pain manifestations previously noted, including ischial tuberosity pain and lateral hip pain, had abated, and the patient reported being able to walk without a cane for the first time in years.
- Two months after the second whole bone marrow/dextrose treatment, pain intensity was 1/10 with a frequency of 10%. Crepitus was absent and the patient reported walking without a limp and no longer needing a cane.
In this research we concluded:
“We have explored whole bone marrow injection in combination with dextrose prolotherapy as a cost-effective approach with potentially broad application for osteoarthritis. . .Our initial experience has been encouraging, as all patients experienced significant gains in treatment periods of 2–12 months without adverse events.
Additionally, five of seven patients experienced strong functional improvement and/or complete or near-complete pain relief. Patients uniformly expressed satisfaction with outcomes in interviews.
Five patients reported receiving a previous recommendation for joint replacement, and at final interview, none believed replacement would be needed.
Supportive research: PRP and stem cells
Clearly, we are not the only researchers showing success with bone marrow stem cell treatments or PRP treatments outside of surgery.
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. (15.)
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.(16)
- 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 that 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.(17)
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 that 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.”(18)
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).(19)
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.(20)
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.(21)
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.(22)
Research supporting the use of dextrose Prolotherapy injections alone
In the June 2019 issue of the journal Alternative therapies in health and medicine (23), doctors discussed a case history of a patient who had developed Avascular necrosis of the femoral head from long-time and uncontrolled glucocorticoid use. In the treatment of the case, the doctors used prolotherapy injections. After the sixth session of prolotherapy injections, the patient was able to do daily activities as the same as the previous physical and effort capacity. The doctors noted that: “We obtained successful outcomes in terms of patient satisfaction and clinical and radiological parameters with prolotherapy injections. Prolotherapy may be useful as an easily applicable and satisfying auxiliary method for the treatment of Avascular necrosis of the femoral head.”
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 H3 Prolotherapy, 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
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