The evidence for alternatives to hip replacement
Why are you being recommended to hip replacement?
There are several reasons why your doctor may recommend hip replacement surgery. Recently, the American Academy of Orthopaedic Surgeons published general criteria which included the following reasons:
- Hip pain that limits everyday activities such as walking or bending
- Hip pain that continues while resting, either day or night
- Stiffness in a hip that limits the ability to move or lift the leg
- Inadequate pain relief from anti-inflammatory drugs, physical therapy, or walking supports.
Inadequate pain relief causes 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 getting a hip replacement. However, under the surface, it was the pain relief medication that ACCELERATED you need for hip replacement. For many people, this is difficult to understand.
- In our office, 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 I have noted in my 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 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. Hip replacement does help people whose degenerative hip disease that has deformed the hip ball and socket. In our opinion, this is the only time hip replacement should be considered the number 1 option.
Did hip replacement patients experience great improvements or did the doctors think the patients did and reported it as such?
This is a point of contention in the medical industry. First, people do get good results with hip replacement, 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 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?(3)
The evidence for alternatives to hip replacement – stem cells and Prolotherapy injections
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.(4)
In this case series, we describe our experience with a simple, cost-effective regenerative treatment using 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.(5) This case involved a 64-year-old man with a 20-year history of hip pain. He was a candidate for 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.
Are you a Prolotherapy stem cell candidate?
One criterion that determines if a pain patient will do well with Prolotherapy and stem cells is a good range of motion in the hip.
It is a relatively common occurrence in our practice to see patients under the age of 50 with premature osteoarthritis being “managed” until they were “ready” for the hip replacement.
In our research published in the Journal of Prolotherapy we sought to show how Prolotherapy could provide high levels of patient satisfaction while avoiding the path to hip replacement surgery. Here is what was reported:
- We examined sixty-one patients, representing 94 hips, who had been in pain an average of 63 months.
- We treated these patients quarterly with Prolotherapy. Included in this patient group was twenty patients who were told by their doctors that there were no other treatment options for their pain and eight patients who were told by their doctor that surgery was their only option.
Results: In these 94 hips,
- 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.(6)
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
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.
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 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
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.
Recent research entitled: “How Much Arthritis Is Too Much for Hip Arthroscopy” tries to grade at what point hip damage is too severe for hip arthroscopy and when the patient should be sent to full hip replacement.
- The researchers concluded: “Current evidence is insufficient to define a cutoff for how much arthritis is too much for hip arthroscopy.” (7)
Comprehensive PRP Prolotherapy and Stem Cell Prolotherapy
Above we briefly touched on bone marrow aspirate or stem cell therapy and PRP or Platelet Rich Plasma therapy as part of the comprehensive Prolotherapy program, we will discuss stem cell treatments a little further here in relation to this patient’s case history. 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 (8), 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 (9) and Orthopaedic Arthroscopic Surgery International, Bioresearch Foundation, in Milan, Italy publishing in the journal Cartilage (10).
- 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.”(11)
- 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.”(12)
- 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.(13)
If you have questions and would like to discuss your hip pain issues with our staff you can get help and information from us.
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 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]
5 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]
6 Hauser R, Hauser M. 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]
7. Domb BG, Gui C, Lodhia P. How Much Arthritis Is Too Much for Hip Arthroscopy: A Systematic Review. Arthroscopy. 2014 Dec 25. pii: S0749-8063(14)00900-1. doi: 10.1016/j.arthro.2014.11.008. [Google Scholar]
8 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]
9 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]
10 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]
11 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]
12 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]
13 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]