Alternatives to hip replacement: The evidence for non-surgical treatments
Ross A. Hauser, MD., Danielle R. Steilen-Matias, MMS, PA-C
The evidence for alternatives to hip replacement
For someone in chronic pain, in this case, from degenerative hip disease, we know you will spend hours in front of a computer searching for information that you hope will help you. The times you are spending in front of your computer or on your phone searching are most likely the times when you are in a more acute painful situation. It is also likely that you have been given the recommendation for a hip replacement, or you are concerned you will soon be sent to surgery. That you are searching for options shows that you have a concern about this procedure.
If you are like others we have helped, you have reached a point of hoping for and discussing with your doctors “hip preservation,” a chance that your hip has not degenerated enough for hip replacement and that there is a realistic chance that you can save your hip from replacement surgery.
An Important point to remember when considering hip replacement surgery:
- Hip replacement is an elective procedure. This means that it is your choice to have it or not. For many people, even those with significant hip degeneration, if the hip still has a good range of motion, if walking is still doable for the most part with limited pain, if mobility has not yet been significantly altered, a hip replacement can be put off or in some cases be avoided altogether.
- Hip replacement can also be a very effective procedure for many people. People who have successful hip preplacement are usually the people who do not contact us. The people that contact us are the people for whom the results of their hip replacement did not meet expectations.
We hope this article will offer you some insights and answers in helping you understand, manage, and make decisions in regard to your chronic hip pain. Later in this article, we are going to present the evidence that many people can avoid hip replacement surgery with regenerative medicine injections. We are going to present realistic treatment outlines and discuss the regeneration of a diseased hip as opposed to replacing the hip.
Why do people consider a hip replacement? Should you?
We will often hear from people that they do not think they need a hip replacement, but they are on the waiting list anyway. Their stories go something like this:
The orthopedist keeps saying the same thing over and over, “bone on bone,” bone on bone.” I need a total hip replacement.
I have been on the waiting list for a hip replacement. All this time I have been on the waiting list I keep thinking to myself that I do not think I need this surgery. The orthopedist keeps saying the same thing over and over, “bone on bone,” bone on bone.” I need a total hip replacement. My job is physically demanding, yet I can do it. I am still walking a lot, its a little painful but I can do it. I am not even taking the prescriptions for anti-inflammatories or painkillers I have been given, I don’t think I need them. I do take vitamins, I am not sure if they help or not but I like taking them. My gut tells me I should not have this operation. I don’t need it.
There are several reasons why you are considering hip replacement. You may believe that hip replacement is the only way to:
- Get rid of the constant pain.
- Get back to normal everyday activities such as walking, getting in and out of a car, getting on and off the toilet.
- Regain independence and stop “being a burden.”
- Help you keep your job or your business because now you are getting to the point that you cannot work.
Another reason that you are now considering hip replacement is that you are getting inadequate pain relief from anti-inflammatory drugs, physical therapy, or walking supports.
You may have just returned from a follow-up visit to your orthopedic surgeon. Over time he/she may have been exploring conservative care options for you but now you have more pain and more hip instability following these treatments. Your hip may be making a lot of noise such as grinding, clicking, and popping as a signal to you that something is not right. It may give way on a staircase, getting out of your car may now be a challenge. Let’s explore how you got here.
- One course of treatment is conservative care treatment. This is usually a combination of painkillers, anti-inflammatory medications, physical therapy, hyaluronic acid injections, and cortisone injections. You may continue getting these treatments until such time as a hip replacement procedure is warranted.
- We have written extensively on these treatment options: Please see our articles:
- Exercise and physical therapy fail to restore muscle strength in hip osteoarthritis patients
- In this article, we will discuss why exercise and physical therapy fail to restore muscle strength in hip osteoarthritis patients.
- Hyaluronic acid vs platelet-rich plasma in the treatment of hip osteoarthritis
- We do not recommend viscosupplementation for hip osteoarthritis, this article provides supported research and clinical observation. It also shows success with PRP or platelet-rich plasma injections, a type of regenerative medicine treatment we utilize.
- Anti-inflammatory medications. (This is not something we recommend. Please see my article When NSAIDs make the pain worse. I explain why chronic non-steroidal anti-inflammatory drug (NSAIDs) usage can make the pain worse in the long term and accelerate the need for joint replacement.)
- Stronger pain medications. This particular recommendation has very little long-term appeal as it can make your situation worse. Please see our article, when Painkillers make the pain worse.
- Corticosteroids/cortisone or steroid injection. (This is also a treatment we do not recommend. Please see my article Alternative to cortisone shots, in which I examine new research that is providing more warnings that cortisone does not heal and, in fact, accelerates the deterioration of already damaged joints.
- Exercise and physical therapy fail to restore muscle strength in hip osteoarthritis patients
- We have written extensively on these treatment options: Please see our articles:
Your pain relief medications accelerated your hip damage and the need for hip replacement
On the surface, this statement may seem obvious. You can’t get pain relief so that is why you are considering a hip replacement. However, the longer you avoid treatment and try to self-manage, the worse you are making your hip. It is likely your pain relief medication ACCELERATED your need for hip replacement. For many people, this is difficult to understand.
What are we seeing in this image?
In this image we see a hip with “joint space,” and a hip that is bone on bone. The bone on bone hip has been treated in the past with cortisone injections and these injections are thought to have contributed to this patient’s accelerated hip degeneration.
Our research on why your hip was made worse by medications:
Here is a brief understanding:
- In our clinic, we see many patients with degenerative hip disease who received years of traditional care that include numerous cortisone injections that did not help long-term and as we have noted in Caring Medical research published in the Journal of Prolotherapy, cortisone accelerated cartilage degeneration. (1)
- Many of these patients also had prescriptions for NSAIDs which can quickly degenerate the hip’s articular cartilage. These findings were also published by our Caring Medical research team in the Journal of Prolotherapy. (2)
The irony, of course, is that conservative care treatments of traditional insurance-based medicine are supposed to help people avoid or delay the need for hip replacement. It actually accelerates the need.
The evidence for alternatives to hip replacement – addressing hip instability with regenerative medicine injections
- Note: Hip replacement may be the only option for people with advanced degenerative hip disease. This is where degeneration is so advanced that it has deformed the hip ball and socket and caused a “frozen” or “locked” hip situation, a lot of pain, and loss of quality of life. In our opinion, this is the only time hip replacement should be considered the number 1 option but it should also be the number 1 option when regenerative medicine injections are not considered a realistic option.
Whether you choose to have surgery or you are seeking not to have the surgery by using regenerative medicine injections, you need to function quickly and pain-free. There is a degree of urgency here because your hip will get worse and worse and at an accelerated rate. One of the first things that will happen if it has not already is that your hip will start causing you much more pain than your doctor or MRI shows. This is a critical time and we cover this patient problem in our article: Your hip hurts worse than your MRI is saying it should and your doctor doesn’t believe you. When you have more hip pain than an MRI is showing you should, your hip is sending signals to the brain that it is sinking.
Research: Did hip replacement patients really experience great improvements or did the doctors think the patients did and reported it as such?
For many people, hip replacement was a great success. In other instances, the doctors thought that the surgery was a great success. The patients themselves were not so sure.
This is a point of contention in the medical industry. First, people do get good results with hip replacements, especially those with significant osteoarthritis-caused deformities. But how good were the results for everybody? Researchers writing in the Public Library of Science health journal PLusOne (3) wrote that because there are many hip replacement component types and many techniques for surgical installation of these products, there is concern that medical research on the long-term effectiveness of the varying techniques is inconclusive due to poor reporting, missing data, or uncertainty in treatment estimates. In other words, doctors may have interpreted patient results as being much better than they actually were to support the use of a specific implant or specific technique.
These findings were supported by other researchers including a 2018 study published in the journal BMC Medical Research Methodology (4) which also found problems of accuracy in reporting patient success in hip replacement and suggested to doctors that results of the research that patients were happy with their hip replacements may not be as good as is being reported.
In a February 2020 study in the journal BioMed Central Musculoskeletal Disorders, (5) doctors reported that there may be under-reporting of adverse side effects in hip replacement. This is what these doctors said:
“Dislocation, periprosthetic fracture, and infection are serious complications of total hip replacement and which negatively impact on patients’ outcomes including satisfaction, quality of life, mental health and function. The accuracy with which patients report adverse events after surgery varies. The impact of patient self-reporting of adverse effects on patient-reported outcome measures (PROMs) after total hip replacement is yet to be investigated.”
Do people who have adverse effects but cannot be confirmed through medical testing really have adverse effects?
The doctors of this study then sought to determine the effect of confirmed and perceived adverse effects on patient-reported outcome measures after primary total hip replacement.
Here is the learning points of this research:
- Forty-one adverse effects were reported in a group of 417 patients (234 females), with 30 adverse effects reported by 3 months after surgery.
- Eleven (27 reported) infections, two (six reported) periprosthetic fractures, and two (eight reported) dislocations were confirmed.
- Those in the no adverse effects group reported significantly better outcomes than the reported adverse effects group.
- Patients who report adverse effects have worse outcomes than those who do not, regardless of whether the adverse effects can be confirmed by standard medical record review methods.
- The observed negative trends suggest that patient perception of adverse effects may influence the patient outcome in a similar way to those with confirmed adverse effects.
What are we to make of this? Do people who have adverse effects but cannot be confirmed through medical testing really have adverse effects? In our experience they do. Because it cannot be confirmed, does that mean it is not reported as an adverse effect? The bottom line here is that people are reporting adverse effects, are they being taken seriously?
Let’s move on now to solutions.
If the surgery was so successful why so many opioid users after surgery? More painkillers before surgery
Here is a November 2020 study published in The Journal of Arthroplasty (6).
- Patients awaiting total joint arthroplasty (replacement) have high rates of opioid use, and many continue to use opioid medications long term after surgery.
- The strongest risk factor for chronic postoperative opioid use was preoperative opioid use.
Recently many people who finally had a hip replacement had to wait for a very long-time to get it as we suffered through the global health crisis. During this time many people had to resort to prolonged opioid usage. It should be pointed out that this study was a three-year outcome. Even before the health crisis people were using opioids before surgery and this study shows that opioid use after surgery continued at a high rate.
The evidence for alternatives to hip replacement.
In this section we will discuss three regenerative medicine techniques and hip replacement:
- Treatment option: Prolotherapy injections. This is the injections of dextrose, a simple sugar that provokes a healing response in damaged soft tissue. This would include the hip ligaments, the hip tendon’s attachments that connect muscle to bone (the enthesis), and the hip cartilage.
- Treatment option: Platelet Rich Plasma injections (PRP Therapy). This is an injection treatment that uses your blood platelets. This treatment also works on soft tissue. We have an extensive article on Platelet Rich Plasma for treating Hip Osteoarthritis that goes deeper into this subject.
- Treatment option: Stem Cell Therapy. In our clinic:
- We use bone marrow-derived stem cells.
- We do not use this on every patient.
- Stem cell therapy utilizes cells from your own bone marrow to begin the regeneration process. This treatment is typically reserved for patients who have significant damage to their hips, but where there is a realistic expectation that the treatment will help the patient avoid a hip replacement.
- Treatment option: Hip replacement.
What do hip ligaments have to do with bone on bone- no cartilage in my hip?
If you fix my ligaments, can I avoid a hip replacement? There’s a good chance, yes.
Doctors who see patients with hip pain significant enough for a hip replacement recommendation soon or sometime in the future, tend to focus mainly on the bone-on-bone situation. It is very unlikely that you have seen an orthopedist who discussed anything but arthritis, joint space, cartilage, and bone on bone. Now think to yourself, when did anyone talk to you about your hip ligaments?
In the research below we are seeing that doctors are now accepting the fact that people do not wake up one morning with advancing bone on bone hip osteoarthritis. Something caused it. Bone on bone hip osteoarthritis is the end result of continued, prolonged, unrelenting hip joint erosion. What is causing this erosion? Now doctors are realizing that it is damaged, loose, hip ligaments.
If we can fix the hip ligaments there is a good chance we can help the patient avoid surgery.
What are we seeing in this image?
This illustration reveals to us the dynamic and often overlooked importance of the hip ligament complex in holding the pelvis and hips in proper alignment and stability. When any of these strong connective tissues are weakened or damaged, they will not hold the bones they connect in place. The degenerative hip disease occurs with an eventual grinding of the bones and the development of a bone-on-bone situation. Notice in this illustration you cannot see the ball and hip socket because they are covered in ligaments. In the case of this illustration, the pubofemoral ligaments and the iliofemoral ligaments cover the hip joint providing stability.
- The three main ligaments of the hip, the iliofemoral, pubofemoral, and ischiofemoral ligaments are very strong. They keep your hip stable.
- When these ligaments are not strong your hip becomes unstable.
When your hip is unstable it rips at the hip labrum and other supporting tissue. The ball starts to rub the socket the wrong way. This is what they call “wear and tear,” degeneration.
The next time your hip is causing you pain, think to yourself, my hip is being rubbed the wrong way.
The ligaments need to be saved to save your hip
Remarkable in their observations are recent studies that look at people who still had hip pain after hip replacement surgery. Since the bone-on-bone was alleviated by the hip replacement what could be causing the patient’s continued pain?
Doctors at Washington University in St. Louis School of Medicine suggest that it must be the hip ligaments. They write: “surgical management for hip disorders should preserve the soft tissue constraints (ligaments) in the hip when possible to maintain normal hip biomechanics.”(7)
“Hip capsular ligaments prevent excessive range of motion, may protect the joint against adverse edge loading and contribute to synovial fluid replenishment at the cartilage surfaces of the joint”
A study published in the Journal of Biomechanics (8) explained how important ligaments were to the hip and how to save a hip joint, you need to save the hip ligaments:
“Laboratory data indicate the hip capsular ligaments prevent excessive range of motion, may protect the joint against adverse edge loading, and contribute to synovial fluid replenishment at the cartilage surfaces of the joint. However, their repair after joint preserving (hip arthroscopy) or arthroplasty (hip replacement) surgery is not routine. (What the researchers are suggesting is that preserving and maintaining the ligaments during these surgical procedures are “not routine.” In other words, difficult and challenging.
Back to the study: “In order to restore their biomechanical function after hip surgery, the positions of the hip at which the ligaments engage together with their tensions when they engage is required. “(You need to put the hip back together with intact ligaments).
To suggest to doctors how to do this, the researchers did cadaver experiments. They took an intact left hip and ran it through various ranges of motions. They then recorded the ligaments in these various stages of motions with their elasticity and tensile or tension strength. In essence, the researchers were providing a manual on how the ligaments moved and where the greatest demands in the hip range of motion were. When the study was done, the researchers concluded to their fellow surgeons: “(This study) provide(s) a target for the restoration of normal capsular ligament tensions after joint preserving hip surgery. Ligament repair is technically demanding, particularly for arthroscopic procedures, but failing to restore their function may increase the risk of osteoarthritic degeneration.”
Research: Putting the ligaments back after they have been removed during hip replacement may help salvage a bad hip replacement
Here is an understanding of the idea, “you don’t know what you got until you don’t get it.”
In December 2020, surgeons writing in the medical journal Orthopaedics and Traumatology, Surgery and Research (9) discussed the problems of chronically dislocating hip replacements. Again, we do want to stress that many people have very successful hip replacement procedures, some people have very successful hip preplacement repair or revision surgeries. These are typically not the people we see at our center. We see people looking for help at the hip replacement procedures that have not fared well for them.
In this paper, the surgeons discuss the problems of recurrent dislocations of the patient’s total hip arthroplasty (replacement). For many people, this problem, as they note, can be repaired by going into the hip again and replacing the socket hardware or the cup with a “dual-mobility and constrained cup.” This hardware can limit the range of motion to prevent recurrent dislocations or your replacement from popping out of place. BUT, this hardware replacement may also fail in the case of hip abductor mechanism loss.
Hip abductor mechanism sacrifice and loss
We are going to quickly discuss hip abductor mechanism loss. While this is regard to hip replacement fixes, we are going to show just how important the hip ligaments are in building our opinion that treating the hip ligaments, non-surgically can reduce or eliminate the need for hip replacement in selected patients with hip osteoarthritis.
The hip abductor mechanism is your ability to lift your leg to the side. If you have hip abductor mechanism problems following a hip replacement, you will have pain on the outer side of the hip and limp a bit. In more severe cases, the muscles left in the hip after the surgery will atrophy, or worse, you will have muscle necrosis. The muscle is dying.
In the study above the surgeon researchers announced:
“For such complex situations, we developed an original artificial iliofemoral and ischiofemoral ligament reconstruction technique . . . The technique was implemented in 2 patients showing recurrent dislocation after total hip replacement, associating total femur replacement, and cemented constrained liner in a metal reinforcement ring. (Patient had a lot of problems following the initial hip replacement). In 1 of the 2 cases, the abductor mechanism had been entirely sacrificed. This simple and accessible salvage technique prevented the recurrence of dislocation at 12 months’ follow-up in these complex cases, previously subject to several episodes per year.”
They had to go back in and put the ligaments back
The good news here is that these surgeons have a way of helping complex hip replacement problems. In their paper, hip replacement dislocations occurred several times a year. What should be understood is that the fix these complex problems, they had to go back in and put the ligaments back. In this case, artificial ligaments.
Putting the muscles and ligaments back
Many people do well with hip replacement surgery. Some people do not. For some people the answer to fixing their failed hip replacement procedure, as we have just seen, is to put things back that may have been removed during the surgery. In this paper, it is the hip ligaments and muscles.
Also from 2020, surgeons writing in the Journal of Bone and Joint Surgery Reviews (10) discuss, “putting things back.”
“(Surgical) intervention for deficient hip abductor muscles may require muscle transfer or the use of synthetic materials, possibly with biologic (taking tissue from somewhere else) augmentation, to help stabilize the hip joint and prevent further dislocation following total hip arthroplasty (replacement).”
- Direct repair of the abductor mechanism at the greater trochanter can be used in patients who present with hip instability for less than 15 months following hip replacement
- Augmentation of soft tissue with acellular dermal allografts (from a cadaver) can be considered for patients with abductor avulsion (muscles and tendons that have pulled off the bone) that require posterior capsular reconstruction.
- You can use the Achilles tendon and the heel bone from a cadaver for patients who have undergone multiple prior revision surgeries, who have experienced failure of nonoperative management, and who have tissue inadequacy in the posterior wall of the hip joint.
- The gluteus maximus tendon transfer is indicated in patients with chronic abductor tears, limited or loss of function in the gluteus medius and minimus, and a fully functioning gluteus maximus.
- Vastus lateralis transfer may benefit patients with a history of multiple revision procedures, a large separation between the gluteus medius tendon and the proximal part of the femur, and the ability to observe the postoperative protocol of splinting for 6 weeks.
- Synthetic ligament prostheses can be used in patients with recurrent posterior dislocations in the setting of normal components.
That is putting back a lot of stuff.
Your painful wobbly hip needs help
To recap, osteoarthritis is a progressive disorder involving joint instability and joint destruction. Instability causes your hip to be rubbed the wrong way and when that happens, this rubbing or destructive abnormal joint motion leads to chronic hip pain and a possible diagnosis of:
- Trochanteric tendonitis or bursitis
- Please see our article Greater trochanteric pain syndrome. Greater trochanteric pain syndrome begins with minor damage to the hip joint tissue, primarily the ligaments, and ends with destructive abnormal joint motion (hip instability) that leads to inflammation and eventual problems of degenerative hip disease.
- Pelvic floor dysfunction.
- Ischiofemoral impingement, please see our article if you have severe buttock pain along with tenderness on the ischial tuberosity (the sit bones).
- Iliopsoas bursitis, an inflammation of the bursa that sits under the iliopsoas muscle of the hip.
- Myofascial pain syndrome of the tensor fascia lata. This is a pain on the outside of the hip that originates with the tiny muscle on the outside of the pain that causes a lot of pain.
- Gluteal muscle tears and strain, The gluteal muscle is a buttock muscle.
As well as ligament sprains of the hip.
Research: We know the hip ligaments are important, they may be more important than we think.
As mentioned above, when you first go to a doctor with hip pain, it is rare for the doctor to acknowledge that your problem may be from the ligaments. The reason? Ligaments are not cartilage and they are not bone. It is easier to describe to someone that they have “bone on bone” than joint instability causing a premature arthritis condition.
Doctors not knowing or understanding the hip ligaments and their role in hip stability are slowly recognizing ligaments as a major problem in the treatment of hip pain. Listen to what a team of German surgeons at the Department of Orthopedics at the University of Leipzig has recently published in the health journal PLusOne.(11)
- We know that hip ligaments contribute to hip stability.
- We do not know how ligament damage affects men and women differently or how ligaments affect inside, outside, front, or back hip pain.
- We do not know clearly know how ligaments interact with other tissues stabilizing the pelvis and hip joint, as research is scant.
Here is the concluding statement of the paper abstract:
- “Comparison of the mechanical data of the hip joint ligaments indicates that their role may likely exceed a function as a mechanical stabilizer.”
Again, the realization that limited range of motion and/or pain with motion may not be solely caused by a bone-on-bone situation has lead doctors to further understand the relationship of the hip ligaments to pain and limited range of motion and in our research in the Journal of Prolotherapy, we showed that treating weakened ligaments helped patients avoid hip replacement surgery and increase hip function.
Non-surgical repair of the ligaments could be the crucial first step in hip surgery avoidance
We are going to continue to see in the research that doctors are unclear of the extent of the importance of the hip ligaments in stabilizing and repairing hip problems and that a missed opportunity, the non-surgical repair of the ligaments that could be the crucial first step in hip surgery avoidance, is not being suggested to patients.
Understanding hip ligaments lead to non-surgical options
This was pointed out in research from 2007 in the medical journal Arthroscopy, (12) which obviously specializes in surgical technique, here doctors wrote that doctors who understand the hip ligaments could offer non-surgical options for hip pain. They highlighted that the ischiofemoral ligament, iliofemoral ligament, pubofemoral ligament, iliofemoral ligament, all control internal rotation in flexion and extension. Understanding the independent functions of the hip ligaments, therefore, are essential in determining nonsurgical options.
This research and that of another recent study points out what has been obvious to many Prolotherapy doctors over the years. You can’t save the hip (prevent hip replacement) without saving and repairing the hip ligaments.
Here is a summary of that research that appeared in the Journal of Biomechanics. (13)
- Hip ligaments prevent an excessive range of motion and contribute to synovial fluid replenishment (the natural lubrication process of joints) at the cartilage surfaces of the joint that prevents friction and wear and tear.
- However, the repair of ligaments after joint preserving or arthroplasty surgery is not routine. (Which may lead to hip revision surgery).
- In order to restore their biomechanical function after hip surgery, you need to restore the hip ligaments to their normal tension.
- Surgical ligament repair is technically demanding, particularly for arthroscopic procedures, but failing to restore their function may increase the risk of osteoarthritic degeneration.
Orthopedic surgeons are at an exciting crossroads in medicine
A February 2021 paper in the journal International orthopaedics (14) offers this opinion on the future of surgery: “Orthopedic surgeons are at an exciting crossroads in medicine, where hip biologic therapies are evolving and increasingly available. Time tested interventions such as arthroplasty have shown good results and still have a major role to play but newer, regenerative approaches have the potential to effectively delay or reduce the requirement for such invasive procedures.”
Strengthening and repairing ligaments with Comprehensive Prolotherapy injection
So now we have reached a point where we will discuss the alternative to treatments you have been trying for years without effectiveness. We will now turn to Prolotherapy injections.
In this video for athletes and active patients, a demonstration of the type of Comprehensive Prolotherapy offered at Caring Medical is shown.
- This should also be seen as a demonstration of how Prolotherapy can help get the worker back to the job, and the hip osteoarthritis patient back to mobility. In the video, the patient is comfortable in receiving these injections.
In this video, you also see that the injections are not only targeted at the center of the joint, as in PRP injections but also around the joint. What this does is address joint instability by treating the ligaments of the peri-articular or “outside” hip region.
Caring Medical published its research in 2009 (15) where we looked at 61 patients, 33 of them had hip pain in both hips. Twenty of these patients were told that there were no treatment options available to them, with eight being recommended to surgery as their “only hope,” for hip pain alleviation.
Of the 94 hips treated in the 61 patients:
- 89% experienced more than 50% of pain relief with Prolotherapy;
- more than 84% showed improvements in walking and exercise ability, anxiety, depression, and overall disability;
- 54% were able to completely stop taking pain medications.
Patients who had Pain, Crunching Sensation, Stiffness.
In our study, we asked patients to rate their pain, crunching sensation, and stiffness on a scale of 1 to 10.
- A score of 1 being no pain/crunching/stiffness and 10 being severe crippling pain/crunching/stiffness.
- The 61, representing 94 hips had an average:
- A score of 7.0/10 for pain
- A score of 2.0 for crunching sensation
- A score of 4.4 for stiffness
- Before: Score of 7.0/10 for pain. After: Score of 2.4/10 for pain
- Before: Score of 2.0 for crunching sensation. After: Score of 2.4/10 for crunching sensation
- Before: Score of 4.4 for stiffness. After: Score of 2.0/10 for crunching sensation.
- It should be pointed out that 54% of these people had a starting pain level of eight or greater, while only 5% had a starting pain level of three or less,
whereas after Prolotherapy only 2% had a pain level of eight or greater while 77% had a pain level of three or less.
Patients who had issues with Range of Motion
In our study, we asked patients to rate their pain, crunching sensation, and stiffness on a scale of 1 to 7.
- A score of 1 being no motion,
- 2 through 5 were fractions of normal motion,
- 6 was normal motion, and 7 was excessive motion.
- Before: The average starting range of motion was 4.3 and the ending range of motion was 5.1.
- Before Prolotherapy, 30% had very limited motion (49% or less of normal motion), this decreased to only five percent after Prolotherapy.
- Prior to Prolotherapy, only 36% had 75% or greater of the normal range of motion but this improved to 75% after Prolotherapy.
Pain Medication Utilization.
- Sixty percent of the patients discontinued pain medications altogether after Prolotherapy.
- In all, 75% of patients on medications at the start of Prolotherapy were able to decrease them by 75% or more after Prolotherapy.
- None of the patients had to increase pain medication usage after stopping Prolotherapy.
- Before Prolotherapy, the average patient was taking 1.1 pain medications but this decreased to 0.3 medications after Prolotherapy.
- Before Prolotherapy, 23% of patients were on two or more pain medications, but this decreased to 2% after Prolotherapy.
- Sixty-nine percent of patients using additional pain management therapies before Prolotherapy were able to decrease them by 75% or more after treatment
- Before Prolotherapy, 59% of patients experienced compromised walking ability, but this decreased to 39% after Prolotherapy.
- Specifically, 38% could walk three blocks or less before Prolotherapy, but this decreased to 10% after Prolotherapy.
- While 27% of patients could walk less than one block before Prolotherapy, all could walk greater than that distance after Prolotherapy.
Exercise and Athletic Ability.
- In regard to exercise or athletic ability prior to Prolotherapy
- 30% reported totally compromised ability (couldn’t do any athletics),
- seven percent ranked it as severely compromised (less than 10 minutes),
- 23% ranked it as very compromised (less than 30 minutes) and
- a total of 84% ranked it as at least somewhat compromised.
- After treatments: 80% of patients were able to do 30 or more minutes of exercise with 40% not being compromised at all.
- 40% reported an overall disability of at least 50% (could only do about half of the tasks they wanted to).
- This decreased to 11% after Prolotherapy.
- Sixty-seven percent noted they had at least a 25% overall disability prior to treatments and this decreased to 24% after.
- Before receiving Prolotherapy, five of the patients were dependent on someone for activities of daily living (dressing self and additional general self-care).
- All five regained complete independence after Prolotherapy.
- Before Prolotherapy, 11% considered themselves completely disabled in regards to their work situation, but this decreased to seven percent after Prolotherapy.
We concluded this research study with these observations:
The results of this retrospective, uncontrolled, observational study, show that Prolotherapy helps decrease pain and improve the quality of life of patients with chronic hip pain.
Decreases in pain and stiffness and improvements in range of motion reached statistical significance even in patients whose medical doctors said there were no other treatment options for their hip pain or that surgery was their only option.
- Ninety-five percent of patients stated their pain was better after Prolotherapy.
- Over 70% said the improvements in their pain, crunching, and stiffness since their last Prolotherapy session have very much continued (75% or greater).
- Eighty-nine percent of patients stated Prolotherapy relieved them of at least 50% of their pain.
- Fifty-nine percent received greater than 75% pain relief. Only two patients had less than 25% of their pain relieved with Prolotherapy.
A February 2020 study published in the journal Medical Science Monitor (16) looked at patients who developed osteoarthritis as a result of developmental dysplasia of the hip, (the socket of the hip joint being too shallow). This is a major cause of hip pain and disability.
According to the researchers, “the aim of the study was to compare the effectiveness of prolotherapy injections versus exercise protocol for the treatment of developmental dysplasia of the hip.”
- There were 46 hips of 41 patients who had osteoarthritis secondary to developmental dysplasia of the hip included in this study.
- Patients were divided into 2 groups:
- 20 treated with prolotherapy and
- 21 treated with exercise.
- Clinical outcomes were evaluated with a visual analog scale for pain (VAS) and Harris hip score (HHS) at baseline, 3 weeks, 3 months, 6 months, and a minimum of 1-year follow-up.
- At the start of the study, no differences in pain and function were noted. Then treatments began.
- Dextrose Prolotherapy injection recipients outperformed exercise controls for VAS pain change score at 6 months and 12 months and for HHS function scores at 6 months and 12 months.
The study concluded: “To our best knowledge, this study is the first regarding the effects of an injection method in the treatment of osteoarthritis secondary to developmental dysplasia of the hip. According to our study, Prolotherapy is superior to exercises. Prolotherapy could provide significant improvement for clinical outcomes in developmental dysplasia of the hip and might delay surgery.
Is Prolotherapy the right treatment for your hip pain and instability?
When we receive hip x-rays from prospective patients via email, they provide a good assessment of how many Prolotherapy treatments might be needed to achieve the patient’s goals. The best assessment would be a physical examination in the office.
- Rating a hip Prolotherapy Candidate: We will rate the potential hip pain patient on a sliding scale of being a very good Prolotherapy candidate to a very poor one. In a very good candidate’s x-ray, the ball of the femur will be round, fitting nicely into the socket in the pelvis, with good spacing between these two bones. This space is the cartilage that cushions and allows the femur to rotate freely within the socket.
- Prolotherapy prognosis for hip patients: The prognosis ranking is lowered from very good to good, to questionable to guarded to poor, based on the following criterion:
1. Amount of joint space or cartilage that remains.
2. The presence or absence of bone spurs (osteophytes), and their locations
3. The shape of the femoral head itself. In very poor candidates, the hip does not even look like a hip anymore; the ball is flattened or egg-shaped and does not fit into the socket as well. Once the damage is this extensive, the patient will likely need a recommendation for total hip replacement.
This is best explained with a visual presentation. In the video below you will see a patient that was recommended for a hip replacement but was actually a better candidate for Prolotherapy.
Are you a Prolotherapy candidate?
What are we seeing in this image? The x-ray of someone considered a good candidate.
In this image, we see a patient with problems with bone spurs. Is this person a good candidate for Prolotherapy? This person has some mild osteoarthritis in his right hip he also has a bone spur in this image it is depicted by the arrow. Even though the patient has good joint space, far from being bone on bone, the bone spur was limiting his range of motion. We can help this patient as a good candidate for Prolotherapy but he is not an excellent candidate for Prolotherapy because of the bone spur.
Assessing the patient’s realistic success of treatment
When we receive hip x-rays on discs or film from prospective patients, they provide an estimated prognosis, which is their best assessment of how many treatments might be needed to achieve the patient’s goals. This is more difficult to assess when we do not have the opportunity to examine the patient in person.
- Rating a hip Prolotherapy Candidate: We will rate the potential hip pain patient on a sliding scale of being a very good Prolotherapy candidate to a very poor one.
- In a very good candidate’s x-ray, the ball of the femur will be round, fitting nicely into the socket in the pelvis, with good spacing between these two bones. This space is the cartilage that cushions and allows the femur to rotate freely within the socket.
- The prognosis ranking is lowered from:
- very good to good,
- questionable to guarded,
Based on the following criterion:
- Amount of joint space or cartilage the patient shows.
- The presence or absence of bone spurs (osteophytes), and their locations
- The shape of the femoral head itself
What are we seeing in this image?
In very poor candidates, the hip does not even look like a hip anymore; the ball is flattened or egg-shaped and does not fit into the socket as well. Once the damage is so extensive, the patient will need a recommendation for total hip replacement.
In this image, we show a patient who would not be a good candidate for Prolotherapy treatment. We have to be realistic about who we can help with Prolotherapy and who we can’t help. In this patient’s x-ray, we see hip damage that would tell us that this is a very poor candidate for treatment and cannot have a realistic expectation that we can be successful with them. This patient has severe osteoarthritis and degeneration of his right hip. He has lost all joint space and has developed bone spurs throughout the joint. He has a severely limited range of motion and was unable to flex the hip to 90 degrees or internally rotate his hip at all. He is not a good candidate for Prolotherapy.
What are we seeing in this image?
In this image, we see an x-ray of a severely degenerated hip. No cartilage remains (arrow) in this left hip joint. This is the classic bone-on-bone degeneration where the hip is or will soon be frozen and locked in place making mobility and function challenging. In someone like this hip replacement would be recommended.
What are we seeing in this image?
In this image we see an x-ray showing pubic symphysis and significant hip joint destruction. In realistically assessing this person’s hip, it was deemed that the hip was “too far gone.” In the x-ray, both of this person’s hips are shown for a good comparison of what hip can realistically be helped with regenerative medicine injections and which hip can’t. In this image, the left hip has mild osteoarthritis. The right hip doesn’t even look like a hip anymore. The formerly round femur head (the ball) is now collapsed. This is a hip that would be best served with a hip replacement.
Also in this x-ray image, we see the patient suffers from Public symphysis diastasis. The two halves of his pelvis are pulling apart from each other. We suggested that this person would probably get 70% pain relief from his hip replacement and that Prolotherapy could help get him closer to 100% by addressing the Public symphysis diastasis.
We recently saw a patient whose hip looked just like we described above. The physical exam proved limited external and internal rotation, and the x-ray the patient brought confirmed bone spurs.
It was these extensive osteophytes that were preventing the full range of motion in that patient’s hip. Bone spurs do not always preclude someone from doing well with Prolotherapy, however, much depends on the extent, size, and location of the spurs. Unfortunately, we had to refer this particular patient for hip replacement, but he went into it with full knowledge of the extent of his degenerative joint disease and the confidence that a conservative care clinic had recommended it.
This case shows that a second opinion from a non-surgical viewpoint can provide the patient with a level of confidence that a hip replacement is really warranted in their situation. The message of this article is to receive a second opinion on your hip replacement recommendation from a doctor who specializes in non-surgical approaches like Prolotherapy. Many times the vast majority of our patients are able to eliminate their painful joint conditions without surgery.
A discussion on advanced hip osteoarthritis – When do we use PRP or stem cell therapy? When we don’t.
This article is limited to three regenerative medicine techniques that are designed to address the problems of hip degeneration by trying to restore ligament structure and addressing thinning cartilage.
Here is a patient story:
I was diagnosed with severe bilateral hip replacement. Both hips, I was told, would eventually need to be replaced. As I have a family history of joint replacement that did not go too well I started searching for options and alternatives to the hip replacements.
I decided to try stem cell therapy. I had a single stem cell injection, this was donated umbilical cord stem cells mixed with Platelet Rich Plasma. This seemed to work until I started to develop a new pain on the outside of my hip. This pain radiated into my groin area and as I was getting extensive physical therapy I thought that I had overdone it. The pain got much worse and I went to see my surgeon who said that I had developed bursitis. I was immediately told that I needed a cortisone injection.
I want to avoid hip replacement. I went to my chiropractor who told me to avoid the hip replacements as long as I can but my chiropractor does not understand how difficult it is for me to get in and out of a car.
This is a clear example of how stem cell therapy will not work
Here is a situation where one treatment of stem cell therapy was tried and then the patient developed other problems leading to hip bursitis. This is a clear example of why stem cell therapy will not work. The patient had an injection to patch holes in the hip cartilage. The patient did not have a treatment that addressed hip instability and damaged or weakened hip ligaments that lead to hip instability. While the temporary patch helped, it did not resolve the underlying problems of their hip instability and degenerative conditions. The patient went back to their surgeon for a cortisone injection and recommendation to more quickly proceed with the hip replacement.
A case where stem cell therapy could help
As we mentioned earlier in this article, we do not use stem cell therapy on every patient. While this treatment is presented as leading and cutting edge, we have found of the years of offering stem cell therapy, that it is not needed in many cases. In some cases, however, it is. Here is one such case.
This is a case history of 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. 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. We will continue this case after a few explanatory notes.
- One of the determining factors that point 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.
When we see an advanced case of osteoarthritis or a patient after normal Prolotherapy has not met their goals, we may suggest PRP or stem cell treatment for hip osteoarthritis. Stem cell therapy 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, our case history 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. This highway of new vessels, attested to by research from Tufts University School of Medicine (17), brings the healing elements to the site of injury. 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. This was demonstrated in research from Cornell University published in the Journal of Bone and Joint Surgery (18) and Orthopaedic Arthroscopic Surgery International, Bioresearch Foundation, in Milan, Italy publishing in the journal Cartilage (19).
- Stem cells, blood platelets, and progenitor cells (stromal cells) from bone marrow have been shown to “revascularize” or make new blood vessels around an area of injury. This was documented in research from the Rizzoli Orthopedic Institute in Italy who wrote in the American Journal of Sports Medicine: “Results indicated that intra-articular PRP injections offer a significant clinical improvement in patients with hip osteoarthritis without relevant side effects.”(20)
- The use of stem cells and stroma cells for manipulating native stem cells to “remobilize,” and renew their healing capability in the dying femoral head of the thigh bone of the degenerated hip was suggested by British and Canadian researchers who wrote in the journal Arthritis and Rheumatology“subchondral bone MSC (stem cell) manipulation may be an osteoarthritis treatment target.”(21)
- A review of 15 medical studies prepared by researchers at Paris University East and published in the medical journal Bone on osteonecrosis showed statistical improvement in patients treated with mesenchymal stem cells. (22)
Stem Cells in combination with Prolotherapy
In our published research in Clinical Medicine Insights: Arthritis and Musculoskeletal Disorders, we showed that not only do stem cells regenerate tissue damage within the osteoarthritic joint, but used in combination with Prolotherapy injections, we were able to document repair and hip stability. (23)
In this case series, we describe our experience with a simple, cost-effective regenerative treatment using the direct injection of whole bone marrow (Stem Cell Therapy) into osteoarthritic joints in combination with hyperosmotic dextrose (Prolotherapy).
- Seven patients with hip, knee, or ankle osteoarthritis received two to seven treatments over a period of two to twelve months. Patient-reported assessments were collected in interviews and by questionnaire. All patients 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 symptomatic relief, and two additional patients achieved resumption of vigorous exercise.
As far back as 2006, an article in Pain Physician Journal featured a case study of successful cartilage regeneration using stem cell therapy. (24) This case involved a 64-year-old man with a 20-year history of hip pain. He was a candidate for a hip replacement as his MRI showed severe degeneration, decreased joint space, bone spurs, and cysts.
This man underwent a stem cell transfer in an effort to regenerate cartilage in his hip. Bone marrow was extracted from this patient, processed, and injected into the affected hip. After the first stem cell treatment, the patient reported some improvements in his hip although the MRI showed no change.
One month later a second treatment was performed and resulted in increased joint space and increased range of motion. The patient reported that he was able to stand for longer periods of time, enjoyed travel and recreation, and was able to walk further and sit with less pain. The researchers concluded that this man did, in fact, have cartilage regeneration and that bone marrow therapies hold great promise for joint degeneration.
Can our treatments work for you?
In the video below Ross Hauser, MD demonstrates a screening process to help patients determine if our treatments may be helpful.
Three patients are used to demonstrate:
- Who is a very good candidate for our Prolotherapy, PRP, or stem cell treatments?
- Who is a good candidate for our Prolotherapy, PRP, or stem cell treatments?
- Who is a poor candidate for our Prolotherapy, PRP, or stem cell treatments and these people should consider hip replacement surgery?
The first patient’s examination begins at 3:35
- This patient had been recommended for hip replacement. She was considered a very good candidate for treatment.
- Has good external rotation of the hip
- Has cartilage
- Minimal bone spurring
The second patient’s examination at 5:15
- This patient had been recommended for hip replacement. He was considered a good candidate for treatment.
- The patient has a lot of cartilage wear. The “ball,” of the hip joint still looks like a “ball” on an x-ray
- 6:10 patient’s range of motion limitations is discussed.
The third patient’s examination at 8:10
- This patient had been recommended for hip replacement. He was considered a POOR candidate for treatment.
- At 8:30 an x-ray of the hip shows advanced degeneration, the joint is basically destroyed. The hip is totally fused with no range of motion. This patient was advised to have a hip replacement.
If you have questions about hip pain Get help and information from our Caring Medical Staff
1 Hauser R. The deterioration of articular cartilage in osteoarthritis by corticosteroid injections. Journal of Prolotherapy. 2009;2:107-23. [Google Scholar]
2 Hauser R. The acceleration of articular cartilage degeneration in osteoarthritis by nonsteroidal anti-inflammatory drugs. Journal of Prolotherapy. 2010;(2)1:305-322. [Google Scholar]
3 Tsertsvadze A, Grove A, Freeman K, et al. Total Hip Replacement for the Treatment of End Stage Arthritis of the Hip: A Systematic Review and Meta-Analysis. Zintzaras E, ed. PLoS ONE. 2014;9(7):e99804. doi:10.1371/journal.pone.0099804. [Google Scholar]
4 Wu X, Sun H, Zhou X, Wang J, Li J. Quality assessment of systematic reviews on total hip or knee arthroplasty using mod-AMSTAR. BMC medical research methodology. 2018 Dec;18(1):30. [Google Scholar]
5 Carpenter CV, Wylde V, Moore AJ, Sayers A, Blom AW, Whitehouse MR. Perceived occurrence of an adverse event affects patient-reported outcomes after total hip replacement. BMC Musculoskeletal Disorders. 2020 Dec;21(1):1-8. [Google Scholar]
6 Pryymachenko Y, Wilson RA, Abbott JH, Dowsey MM, Choong PFM. Risk Factors for Chronic Opioid Use Following Hip and Knee Arthroplasty: Evidence from New Zealand Population Data [published online ahead of print, 2020 Jun 27]. J Arthroplasty. 2020;S0883-5403(20)30684-7. doi:10.1016/j.arth.2020.06.040
7 Smith MV, Costic RS, Allaire R, Schilling PL, Sekiya JK. A biomechanical analysis of the soft tissue and osseous constraints of the hip joint. Knee Surgery, Sports Traumatology, Arthroscopy. 2014 Apr 1;22(4):946-52. [Google Scholar]
8 van Arkel RJ, Amis AA, Jeffers JR. The envelope of passive motion allowed by the capsular ligaments of the hip. Journal of biomechanics. 2015 Nov 5;48(14):3803-9. [Google Scholar]
9 Sarrazin J, Dartus J, Martinot P, Galmiche R, Migaud H, Putman S. Salvage reconstruction of hip ligaments using absorbable material to treat recurrent instability of revision THA without abductor mechanism. Orthop Traumatol Surg Res. 2020 Dec 12:102783. doi: 10.1016/j.otsr.2020.102783. Epub ahead of print. PMID: 33321229.
10 Elbuluk AM, Coxe FR, Schimizzi GV, Ranawat AS, Bostrom MP, Sierra RJ, Sculco PK. Abductor Deficiency-Induced Recurrent Instability After Total Hip Arthroplasty. JBJS reviews. 2020 Jan 1;8(1):e0164. [Google Scholar]
11 Pieroh P, Schneider S, Lingslebe U, Sichting F, Wolfskämpf T, Josten C, Böhme J, Hammer N, Steinke H. The Stress-Strain Data of the Hip Capsule Ligaments Are Gender and Side Independent Suggesting a Smaller Contribution to Passive Stiffness. PLoS One. 2016 Sep 29;11(9):e0163306. PMID: 27685452. [Google Scholar]
12 Martin HD, Savage A, Braly BA, Palmer IJ, Beall DP, Kelly B. The function of the hip capsular ligaments: a quantitative report. Arthroscopy. 2008 Feb 1;24(2):188-95. [Google Scholar]
13 Van Arkel RJ, Amis AA, Jeffers JRT. The envelope of passive motion allowed by the capsular ligaments of the hip. Journal of Biomechanics. 2015;48(14):3803-3809. [Google Scholar]
14 Hevesi M, Jacob G, Shimomura K, Ando W, Nakamura N, Krych AJ. Current hip cartilage regeneration/repair modalities: a scoping review of biologics and surgery. International Orthopaedics. 2020 Sep 10:1-5. [Google Scholar]
15 Hauser RA, Hauser MA. A Retrospective Study on Hackett-Hemwall Dextrose Prolotherapy for Chronic Hip Pain at an Outpatient Charity Clinic in Rural Illinois. Journal of Prolotherapy. 2009;2:76-88. [Google Scholar]
16 Gül D, Orsçelik A, Akpancar S. Treatment of Osteoarthritis Secondary to Developmental Dysplasia of the Hip with Prolotherapy Injection versus a Supervised Progressive Exercise Control. Med Sci Monit. 2020;26:e919166. Published 2020 Feb 11. doi:10.12659/MSM.919166 [Google Scholar]
17 Asahara T, Masuda H, Takahashi T, Kalka C, Pastore C, Silver M, Kearne M, Magner M, Isner JM. Bone marrow origin of endothelial progenitor cells responsible for postnatal vasculogenesis in physiological and pathological neovascularization. Circulation research. 1999 Aug 6;85(3):221-8. [Google Scholar]
18 Fortier LA, Potter HG, Rickey EJ, Schnabel LV, Foo LF, Chong LR, Stokol T, Cheetham J, Nixon AJ. Concentrated bone marrow aspirate improves full-thickness cartilage repair compared with microfracture in the equine model. The Journal of Bone & Joint Surgery. 2010 Aug 18;92(10):1927-37. [Google Scholar]
19 Gobbi A, Karnatzikos G, Scotti C, Mahajan V, Mazzucco L, Grigolo B. 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. 2011;2(3):286-299. doi:10.1177/1947603510392023. [Google Scholar]
20 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. [Google Scholar]
21 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. [Google Scholar]
22 Hernigou P, Flouzat-Lachaniette CH, Delambre J, Poignard A, Allain J, Chevallier N, Rouard H. Osteonecrosis repair with bone marrow cell therapies: state of the clinical art. Bone. 2015 Jan;70:102-9. doi: 10.1016/j.bone.2014.04.034. Epub 2014 Jul 10. [Google Scholar]
23 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. [Google Scholar]
24 Centeno CJ, Kisiday J, Freeman M, Schultz JR. Partial Regeneration of the Human Hip Via Autologous Bone Marrow Nucleated Cell Transfer: A Case Study. Pain Physician. 2006;9:253-256. [Google Scholar]
This article was updated April 10, 2021