Hip AVN stem cell treatment has been science fiction for many patients but we here at the Centeno-Schultz clinic have been pioneering this advanced procedure for years. RA is a patient that has benefited from an injection of his own stem cells which helped him to dodge the hip replacement bullet. He is now 58 years old seen and was first seen by us in April of 2009. In 2003 he had a fall on his hip while playing volleyball and was eventually diagnosed with avascular necrosis of the hip. By the time he was seen in our clinic he was an ARCO grade III with a large area of osteonecrosis in the head of the femur and flattening of the femoral head. He was only a fair candidate for being able to avoid a hip replacement with a stem cell injection due to this advanced grade of osteonecrosis (grade III means that the femoral head had begun to collapse). The patient had tried various treatments before being evaluated by our clinic and these had included chiropractic adjustments, acupuncture, and arthritis medication. Being an otherwise active man in his late fifties, he wasn’t thrilled about the prospect of undergoing a hip replacement. As a result we agreed to place his own cultured stem cells (Regenexx-C procedure) into the femoral bone lesion under x-ray guidance. Note that rather than an injection of the cells in his joint (an easier injection) that our advanced AVN procedure involved placing a needle into the bone lesion to deliver the stem cells. Now 2 1/2 years out from his procedure, he reports that he’s 70% improved and has yet to pull the trigger on a hip replacement. Even just delaying hip replacement by just a few years in these AVN patients (possibly longer term) may mean the difference between needing just one hip replacement versus needing to replace the worn-out prosthesis at a later and much more invasive second surgery. In addition, research has already shown that less advanced stem cell injection procedures can delay the need for a hip replacement as much as ten years. While we generally have more success with ARCO grade I and II osteonecrosis patients, we’re happy to hear this success story from a more severe grade III patient!

Troubling New York Times article this morning on how metal on metal hip replacement prostheses are causing patients to get sick and are wearing out only after a few years.  What’s also concerning is the staggering health care costs associated with caring for these sick patients and taking out their failed hip replacement parts for a second joint replacement. The article describes how we will all bear these high cots in one way or another. I’ve blogged before on metal on metal hip replacement surgeries, the most prominent example of which is “hip resurfacing“. These hip resurfacing problems include the production of wear particles that not only irritate the surrounding tissue, but also get into the bloodstream, exposing the patient to a variety of systemic illnesses. The article highlights a gentleman who has more than $400,000 in medical expenses related to the removal of metal hip and for the past 5 months has been left without a joint and is bedridden. Extrapolating from the number of patients in Europe who have needed their metal joints surgically removed and replaced, as many as tens of thousands of patients in the U.S. will need to have their metal hips prematurely removed. The companies that make these metal on metal joints are facing massive lawsuits that will likely break all records for medical device liability claims. The upshot? Don’t fall for “hip resurfacing” claims. The procedure is billed as “minimally invasive” when in fact it’s really just a mini hip replacement surgery using a prostheses that is metal on metal. In addition, the metal prostheses used will likely lead to wear particles which can make some patients very sick. We also don’t know the long-term consequences of metal ions in the blood stream, but I’d wager that it’s not a good thing.

Hip replacement pain after one year? ML is a 69 year old woman who we first evaluated in June and who now claims we have performed a “miracle”. I don’t know if I would use the same terms other than we were able to get to an accurate diagnosis of what was wrong. Prior to having a hip replacement, the patient had a long history of low back problems and had a failed back surgery. Her physical therapist thought her hip pain was coming from her SI joint, while her orthopedist thought it was her hip. The surgeon won and she eventually had a metal on metal hip replacement, which seemed to help her hip pain for a few months, but then it returned with a vengeance. So she had hip replacement pain after one year of trying to recover. Based on her lack of recovery, she was then told by another surgeon that she may need a low back fusion. At that point she ditched the whole concept of more surgery and began looking for answers. On her initial exam it seemed clear that either her hip pain was from the metal on metal wear particles caused by her prosthesis or was being caused by her low back and SI joint. We investigated all of this by first numbing up what was left of her hip joint under x-ray guidance. When this numbing block didn’t help we then tried her SI joint and SI joint ligaments, which helped her hip pain. We now had a diagnosis, her hip pain was coming not from her hip, but the SI joint. The SI joint is the area between the tailbone and the back of the hip. How can the SI joint cause hip pain? This is discussed in our practice’s book (Orthopedics 2.0) but briefly, most patients with SI joint pain have pain that they describe as the back of the hip and sometimes the groin. However most patients with hip joint pain describe it as in the groin area. Many times there’s no accurate way to tell which joint is causing the hip pain (the SI or hip joint) outside of taking a good history (she had a fall off a horse at a young age and landed on her SI joint and sacrum) and performing a numbing block of the hip and the SI joint to see which injection helps more. Because either joint could be causing hip pain, just looking at an x-ray of the hip and concluding that since it looks like it has arthritis it’s causing pain is a bad idea. So how did we help this patient? We injected her own blood platelets and stem cells into the SI joint and associated ligaments three times under x-ray guidance (Regenexx-SCP). Today she reports long-term pain relief for the first time in years. She’s reduced her pain medications significantly and is finely getting more active. She states that it’s a miracle, but it’s really just taking the time to tease through a correct diagnosis of the cause of her hip pain. The upshot? Even though you feel hip pain doesn’t mean it’s really coming from the hip joint! It could be your SI joint or even a pinched nerve in your back. Insist that a doctor numbs your hip under x-ray or ultrasound guidance to prove that your hip is causing most of the pain before they surgically remove the hip joint. If all of your pain doesn’t go away, then your pain isn’t coming from the hip joint!

As you know, we’re big advocates for the concept of the “hip bone’s connected to the back bone, and the leg bone’s connected to the knee bone…” We often see patients who have both hip and back pain and many assume that their back pain is a result of them walking funny due to pain. However, we have also frequently observed that fixing the low back in many of these patients often takes their hip pain away, especially if you catch them early in this cycle (before severe hip arthritis sets in). We often observe the same thing with low back and knee pain. Why? Some of the nerves in the low back can shoot pain to the hip. In addition, recent studies have started to show the inter-relationship between pain, nerves, and arthritis. A recent study supports this concept, finding that almost 50% of patients undergoing total hip replacement had low back pain. The rest of the study shows a complex inter-relationship between the hip and low back. For example, about 2/3′rds of patients had their back pain resolve after hip replacement surgery (which begs the question if 1/3 of these patients actually had their low back leading to most of their hip pain) and 20% had back pain develop after their hip replacement (which begs the question of if their hip pain was really a sentinel of their low back problem). The upshot? If you have low back and hip pain consider asking your doctor for a simple diagnostic test known as a “diagnostic block” of the hip. I would make sure the doctor that performs the block doesn’t use steroids as the high doses commonly used may make your back feel better even though the medications are being placed in your hip. In this procedure, the doctor will only numb the hip to ensure that all of your pain goes away. If all of your back and hip doesn’t go away, a doctor needs to take a closer look at your low back.

In a study out this month, smokers were at substantially increased risk of all sorts of complications after a knee or hip replacement. Researchers from the University of Alabama at Birmingham assessed the effects of cigarette smoking on 33,336 patients, 30 days after elective total hip or total knee replacement surgery. Smokers who have total knee or hip replacement surgeries are at a significant risk of 30-day postoperative complications and/or death at one year. But what really surprised us were these statistics: 53% greater chance of infection, 161% greater chance of stroke, 63% greater chance of 1-year mortality, 34% greater chance of pneumonia. We’ve blogged many times in the past that hip and knee replacement complications are legion, as these are big surgeries. As examples, consider that metal on metal hip resurfacing implants have been associated with everything from local irritation of the tissues to higher concentrations of toxic metal ions in the blood. Also the fact that pretty much every type of hip or knee replacement implant creates wear particles that end up in the blood stream. Also the fact that some patients have severe knee pain despite getting their knee replaced. We also know that age impacts knee and hip replacement complications, with the odds of perishing from a hip replacement 13 times higher for patients age 80 and over. In addition, heavier patients also do poorly after hip or knee replacement when compared to their lighter counterparts. The upshot? If you’re thinking of a knee or hip replacement, look at other biologic options. If you still want to get your hip or knee replaced and still smoke, consider quitting before pulling the trigger on the surgery.

We pride ourselves in discussing all aspects of the results of our hip stem cell therapy, so rather than an astounding success today I’d like to discuss a patient that had a time limited result. CS is a middle aged woman who has post-polio syndrome with severe hip arthritis. In fact, there wasn’t much left of the hip when she was first seen in clinic several years ago. She ultimately underwent several Regenexx-C stem cell procedures to treat her hip arthritis and she did well, reporting about 80% relief of her pain for about 2 years. She recently contacted us that because the pain was beginning to return. It’s likely she’ll need another treatment. So let’s explore what may have happened in this patient with a very weak lower body due to her illness and very severe hip arthritis. Did the stem cells magically grow her a new hip? No. We have seen MRI evidence in select patients with severe hip arthritis that using the Regenexx-C stem cell procedure did seem to establish a joint space where none existed before, but this was far from growing the patient a brand new hip. Why did the effects of the Regenexx-C stem cell procedure only last about two years? We’ve seen duration of effects lasting up to 4-5 years, but have no data beyond that at this point. There may be several reasons why this patient may have been a shorter term responder. One is that the hip arthritis is very severe. For the most part continued analysis of Regenexx-C patient outcomes show that knee and hip arthritis patients respond independent of severity-meaning patients with more severe arthritis seem to do as well as those less severe arthritis. However, this amount of severe arthritis due to the polio was more than we would usually encounter. Another reason for the shorter term response may be that the hip was severely unstable due to the weakness in the hip girdle muscles, so this is a hip with substantially more ongoing wear and tear than other hips. The upshot? Again, we pride ourselves in being frank with patients about what stem cells as a tool can or can’t deliver. In this case, while it’s great that we were able to give this patient two years of dramatic relief when she had few other hip surgery alternatives, it looks like she’ll need re-treatment of the hip

CH is a 51 year old ex-power lifter who was seen in May of last year because he was seeking a hip surgery alternative. His MRI showed severe arthritis and he was considered less than a fair candidate. He knew that as an avid long-distance hiker his chances of returning to this level of high activity if he pursued a hip replacement were not good. In addition, if he instead went with a hip resurfacing and returned to a high activity level, the wear particles from the metal on metal prosthesis may cause other problems. As a result, he agreed to try using his own stem cells to see if we could use his “original equipment” to get him back to hiking. The patient had three stem cell injection procedures under exacting image guidance into his hip-the first was a Regenexx-C in July of 2010 and the second and third were Regenexx-SD procedures in August and November 2010.

“I am happy to report on my progress following Regenexx C/SD on my hip.  Prior to treatment, my last backpacking trip was January, 2009.  Since then, I went through the stages of semi-immobility with osteoarthritis.  Last weekend I went on my first  Post-Regenexx backpacking trip of 32 miles in two days in Great Smoky Mountain National Park.  This represents long daily mileage for advanced hikers in this terrain.  Although I was apprehensive about trying such a long distance on my first trip out, I did fine.  Just a few small blisters on my toes and sore muscles the day after I got back.  I had a great time!

Thanks so much for your dedication and continued work in advancing the Regenexx procedures.  I promote it every chance I have.”

Again, CH’s treatment was more than just placing magic stem cells somewhere in the vicinity of the hip joint, but involved key aspects of Orthopedics 2.0 philosophy. For example, CH had significant myofascial tightness around the hip muscles leading to abnormal wear on the joint. This had to be addressed before we would treat his hip with stem cells. In addition, like many patients with hip arthritis, he had irritated nerves in his low back. His back hadn’t been addressed because his hip arthritis looked so bad on imaging. This low back issue had to be treated as it was causing significant weakness in the hip girdle muscles and thus leading to a “sloppy hip” which could no longer protect the joint. The upshot? We wish CH many more miles hiking on the trails of life. Do all of our hip patients get these same results? No, like any surgical hip procedure, our stem cell injection procedure has a failure and success rate.

We’ve been re-analyzing Regenexx-C data for a scientific publication and came across some interesting observations. We’ve traditionally reported that hip arthritis patients tended to respond less often than knee arthritis patients to our cultured stem cell injections. However, when we take out patients with the bone disease avascular necrosis (AVN, also called osteonecrosis), a different picture emerges. AVN  is a disease where the bone in the ball of the hip joint is dying off and the arthritis is not caused by usual wear and tear forces, but usually by this bone death. While we’ve had great success in treating ARCO grade 1 and 2 AVN patients, we usually get grade 3′s and 4′s who want to try the procedure, as those patients are usually facing a hip replacement with many more possible complications than the average patient with hip arthritis. These later stage AVN patients were in our initial hip arthritis data we reported because they also have arthritis. When we remove them from that hip data at the one year mark, we see what we have above (see graph). Initially it looks like the hip arthritis patients are reporting a slightly greater amount of relief than the knee arthritis patients. However, the drop-out rate (the number of patients we couldn’t contact to obtain outcome information) is higher in the hip group than the knee group. To us, this likely still means that the patient’s with hip arthritis are not doing as well as the knee group. This is because more seem to have moved onto other treatments and as a result, are no longer answering outcome questionnaire requests. However, this data also shows that hip patients without AVN tend to do better with stem cell injections than those with AVN. We’ve been working on improvements in the procedures used to accurately place stem cells into the hip to provide maximum benefit, so hopefully the next time we look at this data the hips will be doing as well as the knees. The upshot? We spend many hours pouring through our standardized outcome questionnaires making sure what we do is helping patients and making sure that we can reasonably set expectations for any stem cell based procedure.