Avascular necrosis and Hip Arthritis treated with Stem Cells

Revision Knee Surgery

Dr. Marc Darrow

A new paper says that while most bone defects heal spontaneously, defects caused by major trauma/malignant tumor and osteonecrosis of femoral head in young adults pose a great challenge in treatment.

While the golden standard in treating bone defects is autologous bone grafting, available bone for grafting is quite limited in an individual. To solve the dilemma, stem cell therapy has been tried as a new treatment in bone where grafting will not be effective. While successful results were reported from individual studies, stem cell therapy is still not an established treatment modality for bone regeneration and needs further assessment. 1 One of the things being assessed is the suggestion that stem cells injected into the joint can jump start the healing environment in the affected hip including a regrowth of bone in the situation of necrosis and osteocronosis.2

The use of stem cells for the treatment of avascular necrosis of the femoral head presents a new exciting level of study.

In pre-clinical studies, the use of stem cells uniformly demonstrated improvements in osteogenesis (bone fragility) and angiogenesis (blood vessel formation), yet source of implanted stem cells were variable (Stem cells can be drawn from bone marrow and fat). In clinical studies, groups treated with stem cells showed significant improvements in patient reported outcomes; however hip survivorship was not affected perhaps effected by discrepancies regarding dose of stem cell, bone disease severity and other factors.3

Often patients will ask us about the success rate of various treatments. Sometimes they come with their own research like that above that says stem cells work but there are too many variables to be considered. This goes along with other research that shows PRP and Stem Cell Therapy can help regrow bone especially in  halting the progression of Avascular necrosis of the femoral head, and subsequently the preventing of young patients from undergoing total hip arthroplasty.

Mayo Clinic

A diagnosis of Avascular necrosis

A diagnosis of Avascular necrosis (bone death) in the hip usually means a recommendation to hip replacement surgery. In a published case study doctors treated a patient with Platelet Rich Plasma. The patient demonstrated significant functional improvements after PRP without the need for further treatment except for physical therapy.4

In the above cited citation from the most current research, doctors are finding that stem cell therapy can also be as effective.5

Is Stem Cell Therapy and PRP therapy treatments for hip osteoarthritis a better option than replacement surgery?

In one study of patients who received a hip replacement, researchers noted postoperative complications occurring in almost 20% of patients; with dislocation being most common complication followed by wound infection.4

With doctors finding good results with PRP and patients recently hearing the news stories of faulty hip replacements, why not consider PRP first?

Research in the British Medical Journal cited the alarmingly high number of failed hip replacements.Here is what the research says:

“Revision rates— (that is) how likely it is that a patient will need an operation to replace a prosthesis—for hip replacements are by far the highest overall for metal on metal (so called because the head and the lining of the cup are both made of metal) hip devices…the highest failure rates involved the now recalled articular surface replacement (ASR) total hip implant made by DePuy. Of those patients who received the device six years ago 29% have since had it replaced…”6

Another problem is correctly identifying if the pain the patient has is actually coming from the hip

The “hip” could be the back of the pelvis where the iliolumbar ligament attaches to the L4 and L5 vertebrae, The “hip” can also be the greater trochanteric bursa, where there is a lump on the side of the femur (the thigh bone). Or “the hip” may be the thick fascia that attaches the quadraceps muscle on the front of the thigh to the pelvis, The “hip” may actually be the hip joint or the ligaments that hold the hip in place in the pelvis (in the acetabulum).

In this video Dr. Darrow explains PRP therapy for hip osteoarthritis

Sometimes it is a herniated disc that can refer pain to the area of the hip, or a mixture of some, or all of the above, depending on the patient’s condition.

Unjustified surgery

Research presented at the 2012 American Orthopaedic Society for Sports Medicine’s (AOSSM) Specialty Day meeting suggested that when doctors treat people with hip pain, physicians should not replace clinical observation with the use of magnetic resonance images (MRI).” They cited that when MRIs were performed on volunteers WITHOUT hip pain – 73% showed abnormal finds.7 This may lead to unjustified surgery.

PRP therapy for hip osteoarthritis

Platelet Rich Plasma Therapy is part of a group of treatments that come under the term “regenerative medicine”. Regenerative medicine is the science that studies the regeneration of biological tissues obtained through use of cells. In regards to the growth factors in platelet-rich plasma or PRP, obtained from a withdrawal of the patient’s blood, concentrating the platelets, represents a safe, economical, easy to prepare and easy to apply source of growth factors.

Numerous growth factors are in fact within the platelets and in particular a large number of them have a specific activity on cartilage regeneration. PRP is able to significantly reduce pain and improve joint function.6

Research looked to assess the safety and symptomatic changes in 40 patients receiving platelet-rich plasma (PRP) to osteoarthritis of the hip.

In the research, each joint received three injections of PRP, which were administered once a week. The primary end point was meaningful pain relief, which was described as a reduction in pain intensity of at least 30% at 6-months post-treatment.

Secondary end points included changes in the level of disability of at least 30% and the percentage of positive responders, i.e. the number of patients that achieved a >30% reduction in pain and disability.

Results. Statistically significant reductions for pain and improved function were reported at 7 weeks and 6 months.

Twenty-three (57.5%) patients reported a clinically relevant reduction of pain (45%), Sixteen (40%) of these patients were classified as excellent responders who showed an early pain reduction at 6-7 weeks, which was sustained at 6 months, and a parallel reduction of disability.8

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2. 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. 2014 Jul 10. pii: S8756-3282(14)00257-9. doi: 10.1016/j.bone.2014.04.034. [Epub ahead of print]

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 Abbas K, Murtaza G, Umer M, Rashid H, Qadir I. Complications of total hip replacement. J Coll Physicians Surg Pak. 2012 Sep;22(9):575-8.

6. Revision rates for metal on metal hip joints are double that of other materials. BMJ 2011; 343 doi: 10.1136/bmj.d5977

7. Treatment for Hip Conditions Should Not Rest Solely on MRI Scans. AOSSM February 11, 2012.

8. Civinini R, Nistri L, Martini C, Redl B, Ristori G, Innocenti M. Growth factors in the treatment of early osteoarthritis. Clin Cases Miner Bone Metab. 2013 Jan;10(1):26-9. doi: 10.11138/ccmbm/2013.10.1.026.

9. Sánchez M, Guadilla J, Fiz N, Andia I. Ultrasound-guided platelet-rich plasma injections for the treatment of osteoarthritis of the hip. Rheumatology (Oxford). 2012 Jan;51(1):144-50. Epub 2011 Nov 10.