As you might have noticed, I’ve started a new “Stem Cell Botched” series, the goal of which is to educate patients and physicians about the difference between high-quality, regenerative interventional orthopedics and just bad care with stem cells. So today let’s look at a patient who was diagnosed with hip avascular necrosis (AVN), or osteonecrosis, and how this patient had care that was below the standard of care using fat stem cells. First, let me define hip AVN.
AVN/osteonecrosis occurs when the blood supply to the bone is interrupted or obstructed causing the bone to die. Well, at least that’s the old conception. We now know that in many cases, the bone dies off because the stem cells in the bone that normally keep it healthy die off, become sick, or are too few in number to keep up with normal wear and tear.
Today I’m going to focus on AVN of the hip, but it can also occur in other areas, such as the knee, shoulder, and so on. It is a terrible disease that typically presents as hip pain at an early age and comes on quite suddenly. From there, the femoral head (the ball part of the ball-and-socket hip joint) dies quickly with bone collapse typically occurring within a few months to a year.
The traditional approach to AVN is commonly a surgery, such as a core decompression or hip replacement. With core decompression, a tunnel is drilled into the bone with the intention of “decompressing” the “high-pressure” area, which the surgeon may believe is causing the AVN. More recent research, as stated above, disputes the notion of how this surgery works, instead now focusing on bringing some local healthy stem cells to the area to properly maintain and heal the bone. Obviously, if there is nothing to “decompress,” an injection of stem cells will work just as well as a surgery. Hip replacement, of course, is a highly invasive surgery that involves replacing the hip joint with an artificial joint, and it is associated with many complications.
In 2016, I shared another trend I’d been encountering: fat stem cell treatments for hip AVN offered as either an infusion or as a blind injection (meaning without imaging guidance) into the hip joint. This leads us to the patient case I want to share with you today.
First, it’s important to understand that while we didn’t invent hip AVN bone marrow stem cell injections (that honor goes to Phillipe Hernigou of France), we’ve done hundreds of these since 2006, so we often get referrals from physicians to evaluate difficult issues. It’s also important to understand that the goal of my Botched Stem Cell series is to promote quality standards for stem cell therapies. With that being said, let’s take a look at a patient I evaluated this week.
The patient had developed hip pain while working out. He initially saw a physician and was diagnosed with mild to moderate AVN, at about stage 2. He was offered a hip replacement.
What’s bizarre about the recommendation for a hip replacement is that hip AVN is a disease that has been treated successfully with X-ray–guided bone marrow stem cell injections since the ’90s. So this is not a new technology, but despite that, it’s not done very much in the U.S. because surgeons prefer to do big invasive surgeries rather than stem cell injections. In addition, the big surgery is paid by insurance and the stem cell injection is not.
The patient, over the next year, then made the rounds with two physicians who blindly injected his hip joint with fat stem cell treatments. There are a few problems with these treatments, which are outlined in my exhibits below:
Blind injections (without imaging guidance): Injecting the hip joint blind is below the standard of care. There is no reason physicians should be performing blind injections in the hip or elsewhere. What’s the chance that they made it into his hip joint? Less than 50/50.
Why inject into the hip joint when the main problem isn’t usually in the joint, it’s in the bone? So injecting the joint (i.e., not in the bone) will do little to help the bone.
Using fat stem cells: We have three decades of data on AVN and bone marrow stem cells. Why in the world would you inject fat? It makes no sense; we have very little data that shows injecting fat into bones will help bones, but we have tons of data supporting bone marrow.
The patient eventually saw a physician who did inject bone marrow stem cells into the bone, and then he finally made his way to us. While he eventually got proper treatment, his first two treatments were a hip AVN stem cell scam with little chance of improving his condition. He lost valuable time, which is critical in a hip AVN case, and he may not completely heal now because of that lost time.
The upshot? It’s hard for patients to understand that a huge part of whether their stem cell procedure will be successful or fail has to do with getting the cells in the exact right spot! Hence, blindly injecting stem cells somewhere in the vicinity of the hip joint to treat a bone disease that must be precisely injected under real-time X-ray guidance is nonsense.
About the Author
Christopher J. Centeno, M.D. is an international expert and specialist in regenerative medicine and the clinical use of mesenchymal stem cells in orthopedics. He is board certified in physical medicine as well as rehabilitation and in pain management through The American Board of Physical Medicine and Rehabilitation.…