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Hip Surgery Results: Little Evidence the Procedure Works

POSTED ON IN Hip Latest News BY Chris Centeno

Hip Surgery Results

You would think that with the explosion of hip arthroscopy surgeries in the United States and worldwide that we would have excellent research supporting that the procedure is very successful for patients with hip impingement. You would, of course, be wrong. Despite the surgical melee, we don’t have a single high-quality study of excellent hip surgery results. The fact that a paper was just published describing a research study that is now being planned highlights this research void.

The Levels of Evidence for Surgical Procedures

First, I’m not a card-carrying and proselytizing member of the evidence-based-medicine mafia so prevalent in medicine today.  In fact, being a clinical provider responsible for the day-to-day outcome of the patients I treat and taking that responsibility seriously, I’m more of an empiricist, which means that I have no issues with relying on observational evidence that a procedure works. Why?

Oftentimes, waiting for the highest levels of evidence before treating a patient is not ethical. For example, if you observe that a procedure works and the calculus is correct (i.e., low risk and the possibility of high return), then waiting a decade until the evidence catches up while the patient suffers is not right. Having said that, a key part of that equation is always risk (i.e., how likely is it that the procedure will cause a horrible side effect?).

This has always been my problem with many surgical procedures. Unlike precise injections, which are inherently low risk, orthopedic surgery is inherently higher risk. Infections, nerve injuries, and damage caused by the surgery are real issues. In addition, for many hip arthroscopy surgeries, you’re rearranging the structural anatomy, which carries with it bigger risks of creating a lifetime of abnormal function. Hence, in my book, orthopedic surgery has a higher evidence burden to bear than any injection-based procedure. Interestingly, the entire specialty has some of the weakest evidence base of any medical specialty with very few common procedures having any high-level evidence of efficacy. Hip arthroscopy is certainly in this club of higher-risk, low-evidence procedures.

What Is the Evidence That We Should Be Operating on Hip Impingement at All?

Hip impingement means that there is an extra bone spur on the socket or the ball of the hip joint. Orthopedic surgeons believe that this can cause an impingement of the joint, leading to excessive wear and tear on hip cartilage and the fibrous lip around the socket (the labrum). However, does the evidence support or refute this view that has launched a million hip surgeries?

First, if this type of impingement or tear in the labrum was a common source of hip pain, we would expect that patients without hip pain wouldn’t have these findings and patients with hip pain would be the only patients who have them. Is this the case? No! In fact, many patients have these findings on hip MRI but have never experienced a day of hip pain.

In addition, there’s another really disconcerting fact about these surgeries. One of the most common bone spurs that’s removed is called a “pincer” deformity. This means that the socket of the hip grows an extra piece of bone that usually extends to the side of the joint. Surgeons love removing this because early studies showed that the spur was associated with patients who had hip arthritis. However, these studies just said that the two things were related to each other, but they didn’t say how. Recently, the largest study done on this issue showed that the relationship was that the spur formed to protect the joint and that patients who had it developed less arthritis over time. So instead of causing arthritis, it protected against it! Hence, removing the spur is the opposite of what should be done based on the research.

The New Study

The new research will finally answer whether this invasive surgery is worth the risk. For example, this statement from the abstract says it all: “The current evidence to support both surgical and conservative interventions for femoroacetabular impingement is based on low-level research.” So for the first time, hip impingement patients will be randomized to get either surgery or physical therapy. Will this study show that the procedure actually works? Well, the recent history of testing common orthopedic surgeries versus physical therapy haven’t been helpful to surgeons. For example, a recent study showed that the most common orthopedic surgery in developed countries, surgery for meniscus tears, was no better than physical therapy.

The upshot? It’s great to see this invasive procedure finally get researched to show whether or not it works. Maybe it produces excellent hip surgery results; maybe it doesn’t. In the meantime, we usually prefer to use less-invasive stem cell injections rather than surgery.

To find out if you might be a candidate for a Regenexx stem cell procedure, complete our Regenexx Procedure Candidate Form online.

    comments

    Dennis says

    Thanks for the interesting post. Have you had good success with stem cell injections for very active middle aged adults with FAI?

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    Chris Centeno says

    Dennis,
    Yes. Importantly in Hip FAI, finding and treating the instability that caused the FAI is as important as treating the FAI itself. Here is some additional information: http://www.regenexx.com/the-regenexx-procedures/hip-surgery/ And some studies: http://www.regenexx.com/hip-impingement-causes/ http://www.regenexx.com/hip-impingement-causes/ http://www.regenexx.com/what-is-hip-impingement-do-you-need-surgery/ If you are interested in finding out if you're a good candidate and speaking to one of our physicians about your case, please fill out the Regenexx Candidate form on the first link.

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    Kim says

    Hello,

    I have been putting hip replacement surgery off for years, I'm a 51 year old female. But the pain is getting to the point I cannot take it much longer. Also, my right leg is now noticeably shorter than my left, since I have been putting more pressure on that side to compensate for the pain. I was also told years ago, that I would need the right hip replaced as well at some point in time.

    I know it's a lot to ask, but is there anyway now, since my body is uneven, that Regenexx could possibly work for me? or is it more likely that I will need surgery to correct the damage already done to both sides.

    Thanks for your time,
    Kim.

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    Chris Centeno says

    Kim,
    I'd venture to guess that the cause and effect is the other way around, that the shorter leg (which may be more pronounced now) caused the hip problem, as even a difference of 1cm can cause these issues. There is definitely a possibility that we can help. If you fill out and submit the Regenexx Candidate form here: http://www.regenexx.com/the-regenexx-procedures/hip-surgery/ that will set up a chat with one of our physicians in which they will read your MRI, take a history, ask and answer questions and be able to let you know based on their experience and the largest stem cell registry in the world full of outcome data, whether you would be a good, fair, or poor Candidate

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    Judith Farrell says

    My husband's hip was totally eaten away and he had a wonderful surgery, can now walk without pain, the doctors were great, his recovery was easy and the cut was small and surgery went great. I do not agree with this article and It might scare people who need a hip replacement, I personally would have it done if I needed it, the secret is get a very good doctor and hospital and good after care. Check out options and try to have it done from the front instead of the side, smaller cut and less recovery time.

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    Chris Centeno says

    Judith,
    We're very happy to hear that your husband's hip replacement went so well! The Anterior Approach is a much better surgical procedure. Joint replacement will always be necessary in some cases and when one is necessary, we're the first to tell our patients The problem is that in America today, conservatively at least 1/3 of joint replacements have no medical basis. Given the cardiovascular, pulmonary, chronic pain, metal toxicity and early revision risks of the procedure, our point is...try everything else first. http://www.regenexx.com/the-regenexx-procedures/hip-surgery/ This says knee but applies to all joints:http://www.regenexx.com/knee-replacement-questions/

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    Leah Stein says

    I am also 51, with advanced degeneration in my left hip, a labrum tear and I am trying to avoid surgery. I am a fair candidate for stem cell success which means 50/50 chance of improvement. If I can generate the funds, I would like to try the stem cell approach. In the meantime, however, I have found GREAT improvement with Egoscue Method. I was unable to walk of do any daily activities without pain. Now, I am pain-free unless I overdo it and exert myself extensively. I am certain that I am prolonging the health of my hip, and also, further and further away from surgery. Check it out: Egoscue.com. Whether or not you decide to try the stem cell or surgical approach - I believe that Egoscue exercises will offer great benefit. This has been my experience.

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    Chris Centeno says

    Leah,
    We are big proponents of Egoscue, very happy it's helping! Most conservative things first...

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    Chuck says

    Okay, so here's the biz. My name is Chuck. I'm 34 years old. I have bilateral labral tears in my hips, osteophyte growth on both femoral heads and some formation of subchondral cysts. I went to an orthopedist to get a professional opinion on what to do and he said the cartilage was so worn down that I was running bone on bone in both hips. He told me that I need to have both hips replaced. The thing is, I don't feel like I need to have them replaced. The pain got the worst when I was around 240 lbs a little over a month ago. I'm down to 210 and losing. I went through my first PRP treatment 2 weeks ago for both hips and my pain now is greatly decreased. I can't tell if it's from the weight loss of the PRP. Probably both. Anyhow my orthopedist told me that it doesn't matter how much PRP or Stem Cell therapy I get because the amount of cartilage in my hips is so low it wouldn''t do any good. I don't feel any grinding. It doesn't feel like bone on bone. I really don't think I am at the point that I need any hip replacement. I am getting a second opinion next Thursday. I guess my question is, because the cartilage is so thin or by my orthopedist's words "non-existent" will Stem Cell therapy or PRP do any good on regrowth of the cartilage in my hips where it is worn down? I would think that arthroscopy would take care of the bone growth but I'm no doctor. I get I may need new hips one day but I don't want to get new hips and in 20 years, have to go through it again. I hope you all get great results. Cheers!

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    Chris Centeno says

    Chuck,
    No one should be considering bi-lateral hip replacement at 34 if there are other options. Orthopedics is very different paradigm than Regenerative Interventional Orthopedics. Orthopedic surgeons do surgery, we work to repair joints through injections of your own stem cells and platelets. The field of Orthopedics is singularly focused on structure, but structural issues are often not the cause of pain, which is why surgically repairing structure often does not resolve the pain. These will explain further: http://www.regenexx.com/osteoarthritis-pain-not-related-to-structure-again/ the pain. http://www.regenexx.com/stem-cell-cartilage-regeneration/ http://www.regenexx.com/knee-replacement-questions/ http://www.regenexx.com/helping-a-college-athlete-avoid-hip-labrum-surgery/ The Osteophytes, or bone spurs are caused by instability, so the question is which came first, the chicken or the egg? http://www.regenexx.com/bone-spur-pain/ We'd be glad to take a look at the MRI's which resulted in conclusion that you need bilateral hip replacements, take a history and chat by phone to establish if you're a candidate for our Procedures. The Regenexx Candidate form is on this page: http://www.regenexx.com/the-regenexx-procedures/hip-surgery/ Please let us know if we can be of further assistance.

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    Zalak Kataria says

    I disagree about lot of things said about evidence based medicine and use of observational data; it is unethical to charge patients to essentially participate in a treatment which is under investigation rather than standard of care; this is like taking advantage of patients desperation and ignorance which is rampant in economically developing world eg India; but I can't believe that such thing is going on in USA! Patented technology does not mean that there is enough clinical data to offer treatment to general patients and charge them for the same! When regulators catch up with this practice hopefully things will be streamlined.

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    Chris Centeno says

    Zalak,
    There is more peer reviewed published research studies that these procedures work than the surgeries they replace. And, unfortunately there are many doctors who are offering stem cell procedures as a new found business opportunity without the appropriate knowledge and experience. We do all we can to educate the public as to know what to look for and what questions to ask. Regenexx, however, was the first to use stem cells for orthopedic application in the USA, is the most studied stem cell procedure in the world, does ongoing research in our university style research lab to continually improve outcome based on our patent registry outcome data (the largest in the world) and has published 33% of the world's research on the use of bone marrow stem cells for Orthopedic use. We agree with you in regards to clinics and doctors offering stem cell therapy who are not qualified, don't have the experience they claim, and are not properly trained, as there are few things as tragic as "stealing hope". This will take you to several pages of articles on same: http://www.regenexx.com/?s=stem+cell+clinics Read through the website, and check out the research and clinical trials sections: http://www.regenexx.com.

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    Julie says

    Last November I had the Regenexx SD procedure done to my right hip. It is AMAZING! Prior to having my stems cells injected I was loosing my ability to walk. Anyone who has this debilitating pain knows the feeling. The pain gets into your head and never leaves. Two months post procedure I can walk, run, exercise, even sweat and feel nothing in my hip. The pain is gone from my joint and head.

    For reference, I just turned 50 and in good shape. I think it's correct to say that this procedu should be done sooner rather than later because you need all those stem cells. It's better to put off the surgery, but not this procedure.

    To the previous comment, what's unethical is that this procedure is not covered by insurance!!!! And keep in mind that hip surgeries cost money too. If I went outside a network to choose the best surgeon, than the cost would be about the same as the procedure -- maybe more.

    I am very grateful to all who have made this treatment possible and available.

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    Chris Centeno says

    Julie,
    Wonderful to hear of your good results...thank you for sharing them with us! Hope you don't mind the quote, as it is an important point made eloquently:
    "For reference, I just turned 50 and in good shape. I think it’s correct to say that this procedure should be done sooner rather than later because you need all those stem cells. It’s better to put off the surgery, but not this procedure."

    The point is, successful or not successful, surgery can't be undone, and with conservatively 1/3 of joint replacements in the US being done with no medical basis...all conservative and less invasive treatment needs to be tried first.

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    Annette Brunken says

    Last October, December 2015 I had both same day and then the cultured stem cell injections in the Caymans. Regretfully the pain continues to worsen. I wonder what I should be doing to improve chances of improvement and for how long do I hold out hope?

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    Chris Centeno says

    Annette,
    Everyone heals differently and I want to make sure you're communicating with your doctor. Can we be of any assistance in helping you reach him? That said, general post treatment advice that may or may not apply in your case would be to avoid NSAIDs, take the Advanced Stem Cell Support Formula, follow instructions re any medications and on activity/physical therapy. Please do let us know if we can help with that, Annette.

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    James Keyes says

    I am 80 year old male. Always active, years running several miles every morning and recovering from a decade of knee pain with 2 partal knee replacements.
    Had stem cell injections in both knees and shoulder (torn rotator cuff) on January 13, 2016, followed by PRP.
    On February 24, 2016, I'm pain free and beginning to walk well again.
    Don't let anyone tell you that this procedure doesn't work when you don't have any cartilage left.

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    About the Author

    Chris Centeno

    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.…

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