Over the years we have seen our fair share of hip bone on bone patients. These patients have pain, they have hip instability, and they have one option according to their doctor: Hip replacement. With that recommendation to surgery also comes the need to pain manage the patient until surgery day. Various medications, perhaps hyaluronic acid or cortisone injections will be recommended and prescribed.
Sometimes a patient, who is on the list for hip replacement and has a few weeks to go before the surgery will come into our office for a second opinion. Sometimes the patient comes in because the idea of surgery is making them nervous, sometimes the patient comes in at the request of a loved one or spouse or family member who are concerned about the surgery.
If you ask these people, who were on a waiting list for hip replacement, why are they getting a hip replacement they say, “my doctor told me to because I am bone on bone . . . I have no cartilage . . . nothing will fix it.”
A team of European researchers lead by Espen Andreas Brembo of the University College of Southeast Norway, published a study in the medical journal BMC Health Services Research to support the idea that patients be allowed to make their own informed choices about hip osteoarthritis treatments including the need for hip replacement: Hip replacement is an elective surgery, that means the patient elects to have the surgery or not. The doctor should support educating the patients in various treatment programs. This is not always the case in a medical system that always seems to find a surgical procedure at the end of the road.
The journey towards hip replacement
The researchers presented a table of what a patient may experience on this journey up until the time to make a decision on surgery. The time frame was broken up into 6 phases:
Phase 1 Hip pain begins and the patient gets a diagnosis of hip osteoarthritis
- Patient is upset and confused about the pain and expresses that “Something is wrong, what is this hip pain?”
- A typical patient response: “I had noticed this pain in my hips that persisted over a period of time. Then I told my (doctor) about this pain, and he referred me for an X-ray”
Phase 2 Hip pain symptoms increasingly interfere with physical functioning
- Patient asks: “My hip really bothers me, what can I do?”
- A typical patient response: “I haven’t taken any painkillers. I don’t want to […] I believe that if you take painkillers you’ll become worse and get more pain in the end.”
Phase 3 Symptoms significantly decreases quality of life (This is where surgery is discussed in earnest).
- Patient asks: “I can´t stand the pain, is it time for surgery?”
- A typical patient response: “I have to crawl up the stairs using the arms to push myself upwards.”
Phase 4 Orthopaedic evaluation and surgical decision-making
- Patient asks: “Will a hip replacement help me with my problems?”
- A typical patient response: “I have long been aware that I would need to replace the hip at some point, but I wanted to wait as long as possible.”
Phase 4a The timing of surgery
- Patient states: The doctor tells me that the timing is not right for me, what now?
- Patient states: “The doctor said that it (the joint) was worn out, but not enough to allow surgery. Then I just had to wait until it was bad enough.”
Phase 4b the waiting for surgery
- Patient states:I am waiting for surgery, what should I do?
- Patient states: “I have done exercises three times a week the last 3–4 months to prepare for the operation. It is important to strengthen the muscles to become best prepared for the period after surgery.”
Phase 4c The denial of surgery: Not medically fit, or don’t prefer surgery
- Patient states: What are my options if I am not receiving surgery?
- Patient states: I have come to a point to wonder whether surgery is a wise thing to do
Phase 5 The perioperative period What will happen at the hospital?
Phase 6 The recovery period What can I expect after having surgery?
The concluding statements of this article suggested something we see all time, “Patients with hip osteoarthritis are in great need of information both at the time of diagnosis and further throughout the disease development and care continuum. Lack of information may result in unnecessary and dysfunctional misconceptions, underuse of potentially helpful treatment options and uninformed decisions. Patients need continuous support from health professionals and their families in order to find and consider effective treatment strategies.”(1)
What we find in many patients that have already had hip replacement and are in our office looking for help with continued hip pain even after the replacement is that they didn’t know they could make choices. They may have felt pressured into having the surgery, they were told alternative treatments would not work, there were no other options.
My doctor said Hip replacement was my only choice
Research: when given time and educational materials to debate whether or not to proceed with hip replacement, patients decided on having less surgeries
A combined research team from the Universities of Montreal, Ottawa, Toronto, and Chicago concluded that: when given time and educational materials to debate whether or not to proceed with hip replacement, patients decided on having less surgeries.(2)
Research such as this makes clear that people with hip osteoarthritis are too often told only about hip replacement as a treatment, so they do not even know about the nonsurgical treatments available.
Conservative treatment modalities in osteoarthritis of hip or knee are underused, whereas the demand for surgery is rising substantially
The treatment of hip osteoarthritis, like other joint osteoarthritic problems, is redefining itself at a pace probably not seen seen the advent of hip replacement surgery. Yet despite the attention given to “biomedicines” ― treatments based on using the patient’s blood platelets and stem cells as a basis of rebuilding damaged bone and cartilage ― and the movement away from surgery by leading researchers, a new paper has been published that tries to explain the “rush to surgery” thinking.
Here is what researchers said:
“Conservative treatment modalities in osteoarthritis of hip or knee are underused, whereas the demand for surgery is rising substantially. To improve the use of conservative treatments, a more in-depth understanding of the reasons for patients’ treatment choice is required. This study identifies the reasons for choice of treatment in patients with hip or knee osteoarthritis:
Various treatment options were discussed: medication, exercise, physical therapy, injections, surgery, complementary and alternative treatment. Four key themes underlying the choice for or against a treatment were identified:
1) treatment characteristics: expectations about its effectiveness and risks, the degree to which it can be personalized to a patient’s needs and wishes, and the accessibility of a treatment;
2) personal investment: in terms of money and time;
3) personal circumstances: age, body weight, comorbidities and previous experience with a treatment; and
4) support and advice: from the patient’s social environment and healthcare providers.”(3)
The feeling is that hip replacement or arthroscopic surgery is readily available. There is an expectation that surgery fixes everything and improves general overall health. There is a lot of expectation. Yet other research says these expectations are not met, and this is clearly cause for concern.
Presenting alternatives to hip replacement surgery is an important function in the patient–doctor relationship, as suggested in this recent study:
“Arthroscopic surgery is commonly performed in the knee, shoulder, elbow, and hip. However, the role it plays in the management of osteoarthritis is controversial. Routine arthroscopic management of osteoarthritis was once common, but this practice has been recently scrutinized. Although some believe that there is no role for arthroscopic treatment in the management of osteoarthritis, it may be appropriate and beneficial in certain situations. The clinical success of such treatment may be rooted in appropriate patient selection and adherence to a specific surgical technique. Arthroscopy may serve as an effective and less invasive option than traditional methods of managing osteoarthritis.”(4)
In other words, as controversial and unproven as arthroscopic surgery is, it may still be better than hip replacement.
Can Stem Cell Therapy and Platelet-Rich Plasma Therapy be effective in treating hip osteoarthritis and in helping you avoid a hip replacement surgery? The answer in many cases is yes.
When the protective cartilage wears away on the “ball” of the hip joint (the femoral head) there can be direct contact with the pelvic acetabulum (the socket). For some patients with advanced osteoarthritis or avascular necrosis (bone death) there may be the crunching and grinding of bone on bone.
The most-used procedure does not fix the femoral head, it replaces it (hip replacement) by amputation of the head of the femur and prosthesis (total hip arthroplasty). Since not everyone is suitable for or wants to have the procedure, researchers are exploring ways to fix the femoral head before it becomes unstable or collapses, and requires artificial joint replacement.
One method is to patch the bone defects – this is autologous bone grafting. Some of the bone is cut into a patch with the hopes it takes root and grows. However, the amount of bone for grafting is quite limited.(5)
Regenerating the bone is an appealing remedy, leading researchers to look at Stem Cell Therapy, using one’s own stem cells to heal bone defects. In recent research doctors suggested that stem cells injected into the joint can initiate the healing environment in the affected hip including the regrowth of bone in cases of osteocronosis (bone death).5
In pre-clinical studies, the use of stem cells uniformly demonstrates improvements in osteogenesis (bone growth) and angiogenesis (blood vessel formation). In clinical studies, groups treated with stem cells show significant improvements in patient reported outcomes.) (6)
Studies on bone marrow derived stem cells and hip osteoarthritis
Researchers in France led by Philippe Hernigou of the Department of Orthopaedic Surgery, University Paris East shows that despite advanced hip disease, bone marrow derived stem cell therapy can repair bone damage in hip osteonecrosis for the long-term. In one study, the researchers treated 189 hips in 116 patients with autologous BMCs and had a follow-up of 5 to 10 years. Satisfactory results were achieved in the majority of patients according to improvement of the (pain) hip score, radiographic assessment and the avoidance of hip replacement.(7)
These findings have been supported by other recent research in which investigators speculated that not only could stem cell therapy repair bone damage in hip osteonecrosis, but it could halt the disease acceleration by changing the cellular joint environment to one of healing. In pre-clinical studies, the use of stem cells uniformly demonstrated improvements in osteogenesis (bone fragility) and angiogenesis (blood vessel formation).
Ask Dr. Darrow about your hip pain
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1 Brembo EA, Kapstad H, Eide T, Månsson L, Van Dulmen S, Eide H. Patient information and emotional needs across the hip osteoarthritis continuum: a qualitative study. BMC Health Services Research. 2016;16:88. doi:10.1186/s12913-016-1342-5.
2. Anderson PA, Giori NJ, Lavernia CJ, Villa JM, Greenwald AS. Update on Biomaterials. Instr Course Lect. 2016;65:449-66.
3 Selten EM, Vriezekolk JE, Geenen R, van der Laan WH, van der Meulen-Dilling RG, Nijhof MW, Schers HJ, van den Ende CH. Reasons for treatment choices in knee and hip osteoarthritis: A qualitative study. Arthritis Care Res. (Hoboken). 2016 Jan 27. doi: 10.1002/acr.22841
4 Pitta M, Davis W, Argintar EH. Arthroscopic Management of Osteoarthritis. J Am Acad Orthop Surg. 2016 Feb;24(2):74-82. doi: 10.5435/JAAOS-D-14-00258.
5. Lau RL, Perruccio AV, Evans HM, Mahomed SR, Mahomed NN, Gandhi R. Stem cell therapy for the treatment of early stage avascular necrosis of the femoral head: a systematic review. BMC Musculoskelet Disord. 2014 May 16;15:156. doi: 10.1186/1471-2474-15-156.
6. Houdek MT, Wyles CC, Martin JR, Sierra RJ. Stem cell treatment for avascular necrosis of the femoral head: current perspectives. Stem Cells Cloning. 2014 Apr 9;7:65-70. eCollection 2014.
7 Hernigou P, Beaujean F. Treatment of osteonecrosis with autologous bone marrow grafting. Clinical Orthopaedics and Related Research®. 2002 Dec 1;405:14-23.
8. Lau RL, Perruccio AV, Evans HM, Mahomed SR, Mahomed NN, Gandhi R. Stem cell therapy for the treatment of early stage avascular necrosis of the femoral head: a systematic review. BMC Musculoskelet Disord. 2014 May 16;15:156. doi: 10.1186/1471-2474-15-156. PUBMED ABSTRACT
9. Houdek MT, Wyles CC, Martin JR, Sierra RJ. Stem cell treatment for avascular necrosis of the femoral head: current perspectives. Stem Cells Cloning. 2014 Apr 9;7:65-70. eCollection 2014. PUBMED ABSTRACT