Degenerative Hip Disease | Comprehensive Prolotherapy Alternatives to Hip Replacement
Hip joint pain and injury is one of the more difficult conditions to treat if a patient has let the condition progress for many years without treatment or mobility. Yet, the top reason why patients with hip pain are referred to our office is to avoid a hip replacement surgery that is the consequence of non-treatment, lack of mobility, and/or ineffective treatment.
- If you have question about hip replacement alternatives, you can get help and information from our Caring Medical staff
Many of these patients 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 in the Journal of Prolotherapy.(2)
Clearly traditional insurance based medicine, especially orthopedic surgeons, have not determined how to stop degenerative arthritis from occurring in hip joints. The frequent and constant threat of a hip replacement often sends patients looking for referrals outside the surgical arena.
In the research below you will read about doctors who are critical of unnecessary hip procedures and the surgeons themselves who are questioning the validity of certain hip procedures following outcomes in their own patients.
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.
What is common to all four of these issues? Your hip is unstable, degenerating, and the bone and the whole joint for that matter is dying. Your hip is dying because of the breakdown of your cartilage, bone, and the connective supportive tissue including the powerful ligaments and tendons.
Diagnostic Terms for a dying hip and recommendation for Hip Replacement
What does it mean when the doctor says you have Hip Osteonecrosis or avascular necrosis or aseptic necrosis?
Necrosis means death. All three mean that the blood supply to the bone in the hip has been disrupted or interrupted and the bone can not repair or remodel itself. Without the constant repair that our bones perform on themselves to keep themselves strong and healthy – they die. When bone dies the joint suffers through degenerative disease.
What caused your hip bones to lose blood flow?
- Degenerative hip arthritis
- Hip Injury
- Glucocorticoids – too many steroid injections for hip pain, as mentioned at the onset of this article.
When a patient comes into our office and we perform an examination and take their medical history we will find they have been treated with:
- painkillers – which may have made their pain worse
- NSAIDs non-steroidal anti-inflammatory drugs – which may have made their pain worse as well as mentioned at the onset of this article
- anti-depressant medications
- steroid shots – cortisone which made their condition much worse as mentioned at the onset of this article
- trigger point injections into the muscles to break up spasms
- muscle strengthening exercises, weight loss, rest, massage therapy, manipulation, orthotics, and
- surgical treatments
Prior to Hip Replacement – a patient may be recommended to the following procedures:
There are many causes of premature osteoarthritis of the hip that may lead to arthroscopic hip surgery
- Coxa Profunda (a condition of a deep hip socket – however it is also seen in many patients on MRI and scans who exhibit no symptoms).
- Femoroacetabular Impingement
- Avascular Necrosis
- Hip Instability From Hip Ligament Injury
- Labral Tear
- Joint Dislocation
- Labral Debridement and Repair: Debridement refers to the removal of tissue via an arthroscopic blade, shaver, or ablator. The goal of debridement is to relieve pain by removing any torn or frayed labral tissue from the labrum.
In a recent study published in the journal Knee surgery, sports traumatology, arthroscopy. hip range of motion and adduction strength (the lateral movement of the hip joint) were associated with weakened and damaged hip labral tears and considered to be important quality-of-life in patients with labral problems.(3) This clearly indicates that patients want repair not tissue removal.
- Chondroplasty: The removal of damaged cartilage during surgery via shaving, cutting, scraping, laser, or burring away. The idea is that after the damaged cartilage is removed via chondroplasy, the body may recover the area with new cartilage.
- Microfracture: A surgical procedure whereby a “pick” is used to spike holes in damaged cartilage to promote bleeding and the migration of bone marrow cells to the joint surface. The idea is that the blood cells/bone marrow will heal the damaged cartilage. As aforementioned, microfracture is the only technique performed during this patient’s surgery that may be considered regenerative, in that the technique is applied in attempt grow new tissue. However, a much simpler, less risky and more cost effective treatment would be PRP and stem cells to stimulate the growth of new cartilage.
- Osteoplasty: The surgical alteration of bone.
- Synovectomy: The surgical removal of the entire or partial synovial membrane of a joint.
The effectiveness of the hip replacement in the long-term is of great concern
In research doctors acknowledge that there are many different types of hip replacement to consider as there are evolvements in the design, fixation methods, size, and bearing surface of implants for total hip replacement. One problem with so many options and different replacement parts, is the need to determine the best combinations of implants. What worried the doctors was that while short-term benefits were apparent for many patients – the effectiveness of the hip replacement in the long-term is of great concern.
The reason? Medical research is inconclusive due to poor reporting, missing data, or uncertainty in treatment estimates.(Were the patients experiencing the great improvements or did they doctors think the patients were having great improvement).(4)
Please see the companion article and research on our site Understanding hip replacement complications before the surgery.
Can Hip Osteonecrosis or avascular necrosis or aseptic necrosis be treated without hip replacement?
Cell-based therapies, such as Platelet Rich Plasma therapy for hip osteoarthritis, stem cell therapy which is discussed in the video above, may aid in osteonecrosis bone damage repair by providing stem cells and other progenitor cells to potentially improve the local cellular environment in the affected hip.
- 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.”(5)
- 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.”(6)
- 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.(7)
The promising results with these studies and the clinical evidence at Caring Medical provides evidence of hip replacement options to those suffering with degenerative hip disease.
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 a return to hip stability.(8)
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.(9) 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.
Prolotherapy as a realistic alternatives to Hip Replacement Surgery
One criterion that determines if a pain patient will do well with Prolotherapy is good range of motion in in the hip.
It is a relatively common occurrence in our Prolotherapy 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.(10)
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 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 get 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 points 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.” (11)
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 (12), 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 (13) and Orthopaedic Arthroscopic Surgery International, Bioresearch Foundation, in Milan, Italy publishing in the journal Cartilage (14).
Questions about hip replacement alternatives, email for help and information
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