Treating hip pain and necrosis without core decompression
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.
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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 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.
- 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.(1)
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 (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
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.
- 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.(3)
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
In 2012 doctors in Spain publishing in Knee surgery, sports traumatology, arthroscopy wrote that:
- Patients with grade I or grade IIA avascular necrosis of the hip are treated by core decompression performed by drilling under fluoroscopic guidance.
- Liquid platelet-rich plasma (PRP) is delivered through a trocar, saturating the necrotic area.
- In more severe conditions, the necrotic bone is decompressed and debrided, 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). (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)
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)
- 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 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.
- 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).(14)
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)
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
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