Can Stem Cell Therapy Help a Bone on Bone Hip Waiting for Hip Replacement

Your hip is bone on bone. Can you avoid a hip replacement surgery?

Over the years we have seen our fair share of people with a diagnosis of a bone-on-bone hips. The people we usually see have a lot of hip pain and instability which causes walking difficulties, balance difficulties and prevents these people from feeling stable on their feet. They also come in claiming that they have been told they only have one treatment option. Hip replacement and that they should get on the list to get one. Often they will ask, “Is hip replacement really my only option?”

At this point they will describe their medical history. They will tell me that their hip has been bothering them for a long time, sometimes 10 years, maybe even 15 years. That is also the same amount of time that they have been getting medical treatments for it. It is easy to see why people would be this way for 10-15 years. They were probably too young to be considered for replacement and have now grown old enough to be considered a good candidate for surgery.

Over these 10 – 15 years these people have tried many treatments, pain medications, acupuncture, physical therapy, cortisone and others and every time they get an MRI their hip looks worse.

Generally speaking, if you have a good range of motion in that hip and can bend your knee upwards and point your knee out to the side, then we would expect a realistic expectation that stem cell therapy could help you.

“given time and educational materials to deliberate whether or not to proceed with hip replacement, more patients decide not to have surgery”

As I mentioned above, some people are told that hip replacement is their only option. For some people, it is their only option. Their hip maybe fused or stuck in place by bone spurs.

Some people come in with a diagnosis of avascular necrosis. Some of these people have been told that the only way they will ever get pain relief is from a hip replacement. There are cases where the bone is very damaged and it has collapsed completely. The hip joint is now fused and the person cannot move or lift their leg. This person will probably need a joint replacement. But most people I see with avascular necrosis of the hip or shoulder don’t need a surgery. Sometimes they only need a little education to help them understand what is happening in their hip and that they can avoid the hip replacement. There are many doctors like myself, who are upset that patients are not given the full story on hip replacement options and alternatives. Below is the opening sentence of a study published recently in the Journal of medical Internet research.(1)

• “Despite the availability of evidence‐based guidelines for conservative treatment of osteoarthritis, management of degenerated joints is often confined to the use of painkillers and the wait for eventual total joint replacement. This suggests a gap in knowledge for those with osteoarthritis regarding the many different treatment options available to them.”

How wide a gap? A recent study published in the journal Osteoarthritis and cartilage says that when given time and educational materials to deliberate whether or not to proceed with hip replacement, more patients decide not to have surgery.(2)

These findings should not be a surprise to you. In fact, after all, you are reading my article because you are exploring the possibility of avoiding a hip replacement for yourself or a loved one.

The patient who has a recommendation for hip replacement. What they are telling us?

The patient who has been recommended to hip replacement will tell us:

• The thought of a hip replacement surgery terrifies me because I do not know if I will be able to resume all the activities I love.
• I have to find another way. I own my own construction business, I cannot be take this time off to recover.
• I had hip replacement on the left side, it worked, but I do not want to go through all that again!

Sometimes someone will come into the office at the request of a loved one or spouse or family member who are concerned about the surgery and what the general anesthesia and the toll of a demanding recovery time may do to their loved one. Sometimes a person will come in because they are the caregiver for their spouse or older parent and cannot take the time off for the surgery and recovery. Sometimes they cannot take the time off from work.

Active, sports minded people being sent to hip replacement without suggestion of non-surgical options are finding options on their own. Stem cell therapy is one option

What I present here are not statistics but what people are telling us in the office. It is in agreement from what research tells us, people are being sent to hip replacement with no other choices offered. This is what these people said:

• I am a man who is 55 years old, I am in fantastic health. My orthopedists has diagnosed me with osteoarthritis in my right hip. He showed my my x-rays and he showed my an MRI and I get it. There is degenerative hip disease going on. I have lost some mobility and sometimes I have pain and discomfort. But I am just as active as I have always been. I’d like to avoid hip replacement if I can, because I am being managed until the hip gets bad enough to be replaced.I am looking for options
• I ran a marathon less than a year ago. Now I am a hip joint replacement candidate. I want to consider all my options.
• I have no cartilage in both hips, I need help, I am not on pain medications, but can’t work anymore. What are my options?

Can Stem Cell Therapy be effective in treating hip osteoarthritis and in helping you avoid a hip replacement surgery?

When a patient comes into our office with a more advanced arthritis and similar challenges as those demonstrated above, we perform a detailed examination and look at how much range of motion his/her hips have. If the hip can move left to right, back and forth that is a good indication that stem cell therapy can be effective. If the patient is as active as ever, that is usually a good sign that stem cells can help. If someone ran a marathon last year, that is a good indication that we can help.

“I am bone on bone.”

Someone 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. This is a person who is not sure that hip replacement is right for them or for their lifestyle. They tell us that the agreed to the surgery because, “it is the only way.” Or, because “I am bone on bone.”

The research in support of stem cell therapy for hip osteoarthritis and “bone on bone.”

• In recent research doctors at Toronto Western Hospital suggested that stem cells injected into the joint can initiate the healing environment in a degenerated hip including the regrowth of bone in cases of osteocronosis (bone death).(3)
• Doctors at the Mayo Clinic write that 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.) (4)
• 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 bone marrow concentrate 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.(5)
• Doctors in Argentina and Seton Hall University in New Jersey combined to suggest that in their research in patients receiving bone marrow aspirate intra-articular injections for the treatment of early knee or hip osteoarthritis were found to be safe and demonstrated satisfactory results in 63.2% of patients. It should be pointed out that this was a single injection treatment. (6)

Stem cell therapy injections in the treatment of Avascular Necosis

A July 2020 (7) questioned whether core decompression of the femoral neck was necessary for all patients considering the procedures inconsistent results. It is interesting to note the suggestion of this and other research that this procedure can optimized by injecting autologous stem cells into the necrotic zone (the damaged area). Injecting autologous stem cells have demonstrated long-term results in the early stages of the disease, where the femoral head has not yet lost its sphericity. This study adds: “The now proven long-term efficacy as well as the safety of this technique (stem cell injections) make it the method of choice for treating young patients detected at the sub-radiological stage by MRI.”

PRP helps reverse steroid induced dame to femoral head.

Let’s look at a study from August 2020.(8) In this paper. the researchers examined the problem of steroid-associated necrosis of the femoral head. This problem is one, they point out, of the most common and difficult to treat chronic diseases with increasing incidence.

• The typical pathological changes of steroid-associated necrosis of the femoral head include decreased osteogenic differentiation (the ability of native stem cells to initiate repair).
• This animal study conducted on Dewey rats investigated the effects and potential mechanisms of Platelet-rich plasma (PRP) on steroid-associated necrosis of the femoral head.
• PRP treatment significantly increased the hemorheological indexes and serum levels of bone gla-protein (BGP) and vascular endothelial growth factor (VEGF), while decreased the levels of triglyceride (TG) and total cholesterol (TC). (In other words, increased circulation to the hip brought more healing factors and removed harmful fat deposits that could impair healing).
• Testing indicated that bone trabecular microstructure and bone mineral density were significantly improved after PRP treatment.
• In summary, for the first time, PRP was demonstrated to prevent the development of steroid-associated necrosis of the femoral head through stimulating bone formation and vascularization as well as retarding adipogenesis.

What does Darrow Stem Cell Institute research say about hip osteoarthritis and treatment with bone marrow derived stem cells? Here are four patient cases we published in Clinical medicine insights. Case reports.

In research from our Stem Cell Institute, we suggested that the use of mesenchymal (connective tissue) stem cells from bone marrow concentrate improved quality of life for patients with hip osteoarthritis. Here are our 4 case studies.(9)

Case 1
The first patient is a 75-year-old woman with a 10-year history of progressive right hip pain. She had consulted with two orthopedic surgeons, each of whom recommended total hip replacement as her only option. Magnetic resonance imaging (MRI) of the right hip showed severe osteoarthritis with extensive bone spurs and near-complete obliteration of the joint space. (Bone on bone). The patient experienced the most pain when sitting for extended periods of time. She had tried massage therapy and anti-inflammatory gel for pain relief; however, her resting and active pain were each 6 out of 10.

• The patient underwent 4 bone marrow concentrate stem cell treatments over a 49-day period, and her symptoms improved with treatment.
• After the second treatment, the patient reported a 40% improvement, with more joint flexibility.
• At the follow-up after the fourth treatment, the patient noted a 60% total overall improvement with active and resting pain levels of 2/10.
• Her functionality score also increased to 37/40. At the final follow-up, the patient reported that she was sleeping better and that she had avoided a total hip replacement.

Case 2
The second patient was a 61-year-old man who had chronic hip pain for two years. His pain was most pronounced while standing or with intensive exercise. The patient had undergone chiropractic adjustments, cupping, and physical therapy for pain relief, but his symptoms returned within 1 week of each treatment. Radiographic assessment of the right hip demonstrated severe osteoarthritis. At baseline, the patient reported a resting pain of 1/10 and an active pain of 7/10. His functionality score was 28/40.

• The patient underwent 4 bone marrow concentrate stem cell treatments during a 42-day period.
• After the first bone marrow concentrate stem cell treatment, he reported an 80% total overall improvement, with no resting pain.
• At the follow-up after the fourth treatment, the patient reported only infrequent, mild pain (0/10 at rest and 2/10 with activity).
• Following treatment, he was able to resume exercise and an active lifestyle.
• His functionality score was 37/40 and reported that he had 94% total overall improvement.

Case 3
The third patient was a 76-year-old man who had a 7-year history of chronic hip pain. He previously underwent a left hip replacement but reported that the recovery had been challenging. Furthermore, he did not want a second hip replacement that had been recommended by his surgeon. The MRI of the right hip showed moderate to severe osteoarthritis with articular surface irregularity. The patient had physical therapy and massage but his pain had progressed. He underwent 4 bone marrow concentrate stem cell treatments over a 54-day period. At baseline, his resting pain was 4/10, active pain was 5/10, and functionality score was 33/40.

• After the second treatment, the patient reported a 50% total overall improvement with increased hip flexibility and range of motion.
• At the follow-up after the fourth treatment, the patient reported a 65% total overall improvement with a resting pain of 1/10 and active pain of 2/10.
• Following treatment, his functionality score was 37/40, and he was able to walk long distances with no pain and enjoyed a significantly improved quality of life.

Case 4
The fourth patient was a 56-year-old man who had a 2-year history of chronic hip pain resulting from his physically demanding career as a contractor. The patient reported that his pain was worsening and limiting his everyday activity. He had an epidural injection with no pain relief. A radiograph of his right hip showed mild osteoarthritis. His resting pain was 2/10, active pain was 5/10, and functionality score was 17/40 at baseline.

• The patient underwent 4 bone marrow concentrate stem cell treatments over a 146-day period.
• The patient experienced minor, incremental improvements following each of the first 3 treatments (overall improvement, 30%). He reported improved ability to perform daily activities with less pain during the course of those 3 treatments. After 40 days of the fourth treatment, the patient reported a 70% total overall improvement. His resting and active pain were 1/10, and his functionality score increased to 30/40.

Based on these results we were able to demonstrate that receiving multiple bone marrow concentrate stem cell injections within a short time period may provide an effective hip cartilage repair. While this is a short-term outcome study, we have seen many patients with long-term results.

The treatment in this study is explained in the video below.

A study from December 2018 (9) examined Bone marrow aspirate concentrate in the treatment of early knee and hip osteoarthritis. In 19 patients (16 female and 3 male), totaling 25 joints (10 knees, 15 hips), treated with intra-articular Bone marrow aspirate concentrate for early osteoarthritis found a satisfaction rate of 63.2%. Two patients were converted to total hip replacement at 8 months after Bone marrow aspirate injection.

It is important that proper patient selection is involved. Not everyone will benefit and success rates would be higher with better candidate selection. Are you a good candidate? Ask me.

1. Umapathy H, Bennell K, Dickson C, Dobson F, Fransen M, Jones G, Hunter DJ. The web‐based osteoarthritis management resource my Joint pain improves quality of care: a quasi‐experimental study. J Med Internet Res.2015 Jul 7;17(7):e167. doi: 10.2196/jmir.4376.
2. Stacey D, Taljaard M, Dervin G, Tugwell P, O’Connor AM, Pomey MP, Boland L, Beach S, Meltzer D, Hawker G. Impact of patient decision aids on appropriate and timely access to hip or knee arthroplasty for osteoarthritis: a randomized controlled trial. Osteoarthritis Cartilage. 2016 Jan;24(1):99‐107. doi: 10.1016/j.joca.2015.07.024. Epub 2015 Aug 4.
3. 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.
4. 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.
   
5. Hernigou P, Beaujean F. Treatment of osteonecrosis with autologous bone marrow grafting. Clinical Orthopaedics and Related Research®. 2002 Dec 1;405:14-23.
6. Rodriguez-Fontan F, Piuzzi NS, Kraeutler MJ, Pascual-Garrido C. Early Clinical Outcomes of Intraarticular Injections of Bone Marrow Aspirate Concentrate for the Treatment of Early Osteoarthritis of the Hip and Knee: A Cohort Study. PM&R. 2018 May 29.
7. Massin P. Treatments of avascular osteonecrosis of the hip: Current treatments [published online ahead of print, 2020 Jul 8]. Morphologie. 2020;S1286-0115(20)30051-5. doi:10.1016/j.morpho.2020.06.003
8. Xu HH, Li SM, Fang L, et al. Platelet-rich plasma promotes bone formation, restrains adipogenesis and accelerates vascularization to relieve steroids-induced osteonecrosis of the femoral head [published online ahead of print, 2020 Aug 24]. Platelets. 2020;1-10. doi:10.1080/09537104.2020.1810221
9. Darrow M, Shaw B, Darrow B, Wisz S. Short-Term Outcomes of Treatment of Hip Osteoarthritis With 4 Bone Marrow Concentrate Injections: A Case Series. Clinical Medicine Insights Case Reports. 2018;11:1179547618791574. doi:10.1177/1179547618791574.
10. Rodriguez-Fontan F, Piuzzi NS, Kraeutler MJ, Pascual-Garrido C. Early clinical outcomes of intra-articular injections of bone marrow aspirate concentrate for the treatment of early osteoarthritis of the hip and knee: a cohort study. PM&R. 2018 Dec 1;10(12):1353-9.