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What are stem cells?
Stem cells are perhaps Nature’s best-kept secret. These cells, which are found in multicellular organisms, such as humans, not only have the ability to divide (mitosis) but also to form various structures such as cartilage, bone and many more. The process is called ‘differentiation’.

What types of stem cell are there?
There are two basic forms of stem cell – the embryonic stem cell and adult stem cell. Adult stem cells, which are also known as mesenchymal stem cells or MSCs are of great interest to researchers, scientists and surgeons alike. MSCs are free of the controversy that surrounds the embryonic stem cells and yet have the potential to form new tissues. At The Manchester Hip Clinic we use the MSCs. This gives us the ability to repair and regenerate tissues such as cartilage and bone more effectively.

MSCs can be found at various locations in the body, including bone marrow, adipose tissue (fat) and peripheral blood. We favour the use of marrow-based or peripheral blood stem cells.

Where do the cells come from that are used in stem cell therapy?
At The Manchester Hip Clinic the stem cells are harvested autologously – directly from the patients. Consequently, there is no risk of disease transmission, rejection or ethical controversy that can exist using cells from an unrelated donor. All of us have a supply of MSCs in various tissues and these can be harvested using specialised techniques.

Where can stem cells be used?
By their very nature, stem cells can be used in a variety of different situations to help in the repair and regeneration of damaged tissues and structures. In joint preservation, one role of stem cells is in the possible treatment of arthritis of the hip and knee joints. This can potentially be accomplished by regeneration of cartilage (gristle). In simple terms, the gristle on the joint surface is the barrier to arthritis. Once this layer is damaged, the joint is likely to progress to frank arthritis, which presents as pain, stiffness and loss of function. Stem cell therapy may be used in an attempt to encourage regeneration of this gristle layer. The procedure is designed to help preserve the natural hip and knee joints and perhaps to delay or prevent the need for more major operations such as replacement of the hip or knee joint.

Another area of particular interest for stem cell therapy in the hip and knee is to help with the regeneration of dead bone. In a condition called avascular necrosis, or AVN, there is death of a segment of the bone near the joint.  This can sometimes progress onwards to become severe arthritis.  Early reports of the use of stem cells to regenerate bone in AVN are encouraging.

There are many other reasons why stem cells might be used.  These techniques may be relevant to different patients and are employed as required.

What does the procedure involve?
The procedure is in the form of arthroscopy (keyhole surgery) of the hip. Patients often ask whether stem cell therapy involves surgery on two separate occasions.  For the techniques that we use, only a single operation is normally required. Most hip arthroscopy patients will have one night’s stay in hospital.  Once the patient is under anaesthestic, an aspirate of their blood and/or marrow is taken with a special needle. In order to harvest the stem cells, the aspirate is then processed in the operating theatre, while the patient is still asleep,. At the same time the keyhole operation (arthroscopy) is commenced to access the hip.  The surgeon uses specialist arthroscopy techniques to prepare the tissue bed so that it is ready to receive the stem cells.  The harvested stem cells, alongside a suitable scaffold, are then injected through the same keyholes that are routinely used for the arthroscopy.

What are the side effects?
Any surgical intervention carries a degree of risk however the surgical procedures used for stem cell therapy are the same as those for routine hip arthroscopy operations.  There is a theoretical risk of infection, but this is low and surgery is in any event covered by antibiotic treatment.  As for the stem cells, these are derived from the patient’s own blood or marrow, so there is no risk of rejection or disease transmission.

What is the evidence for stem cell therapy?
Stem cell therapy is a relatively new procedure.  However, it has created so much interest worldwide that extensive research has been taking place in this field. Animal and human studies have been published that have suggested a safe and favourable response to stem cell therapy in hips, knees and even ankles.  Our practice routinely collects data on all patients who undergo surgical treatment under our care; assessment questionnaires are periodically sent to those who have undergone surgery.  This is an invaluable source of information that helps us to inform our patients, publish in the literature, and to train others who are interested in the techniques we undertake.


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Hip Arthritis Who does this affect?

This condition occurs when there is degeneration in the hip causing damage to the joint surface (figures 1 and 2). There are numerous different causes but the most common is osteoarthritis and this is most often seen in the older patient. However, it can occur earlier due to abnormalities within the hip. This may be due to a previous injury, childhood hip disease, femero-acetabular impingement or problems with the blood supply to the hip.

Symptoms

Commonly, this causes groin pain often going down the thigh to the knee. The hip is stiff, and the patient walks with a limp. As the arthritis becomes more widespread and severe, the pain becomes more constant, it may occur at night and be associated with increasing stiffness, decreased mobility and activity.

Investigations

X-rays of the hip to confirm the diagnosis are taken as standard. More complex scans such as CT or Magnetic Resonance may be needed to aid surgical planning.

Non-surgical Treatment

To begin with, simple measures are tried such as painkillers, weight loss and activity modification. Oral supplements such as glucosamine and chondroitin may benefit some patients, especially with early arthritis. Occasionally, steroid injections may be used to either confirm the source of the pain (e.g. if the patient also has back pain) or in those patients who are not fit for a joint replacement.


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Trancanteric Pain Symptoms
This is a relatively common condition that can cause significant pain on the outer aspect of the hip. It tends to be constant, often tender to touch and its intensity can vary over time.

Who does this affect?
The majority of patients are female, often in their forties or older. They may or may not have had surgery in the past and the true cause of the condition is unclear. It may be caused by a combination of tight fascia lata, inflammed trochanteric bursa (figure 1) and tendon tears. Occasionally, the lateral hip pain is secondary to a deeper hip joint problem such as hip impingement.

Investigations
X-rays of the hip are usually normal. Scans such as magnetic resonance scans can be useful to confirm the diagnosis as well as out-ruling any other pathology (figure 2).

Non-surgical Treatment
Physiotherapy (particularly working on core-stability and fascia lata stretching exercises), painkillers, anti-inflammatory drugs and localised high frequency ultrasound can all be useful. Podiatry and in-soles can correct foot position and relieve symptoms. Steroid injections into the area of maximal tenderness will usually make a significant difference but how long it lasts can vary from patient to patient. Professor Fehily would generally carry out between 2 or 3 injections before considering surgery.

Investigations
X-rays of the hip are usually normal. Scans such as magnetic resonance or ultrasound scans can be useful to confirm the diagnosis as well as out-ruling any other pathology (figure 2).

Non-surgical Treatment
Physiotherapy (particularly working on core-stability and fascia lata stretching exercises), painkillers, anti-inflammatory drugs and localised high frequency ultrasound can all be useful. Steroid injections into the area of maximal tenderness will usually make a significant difference (but how long it lasts can vary from patient to patient) and can make physiotherapy easier to carry out. Professor Fehily would generally carry out between 1 or 2 injections before considering surgery.

Surgical Treatment
If patients symptoms do not settle with conservative therapy, then surgery is recommended. Professor Fehilys’ procedure of choice is to do an open fascia lata release, plus a bursa excision or tendon repair if required. The options are best discussed at the time of your consultation. While this can be of great benefit to the patient, not all patients are cured. Roughly speaking, a third are cured, a third are better and a third have no benefit from surgery.



Who does this affect?
This is a relatively common condition in which there is a structural abnormality in either the femoral head (ball of the hip) or the pelvic cup. Normally, as the hip bends up, the bony cup and flexible cartilaginous rim (Labrum) sit into the concave femoral neck.

However, some patients have either a bump on their femoral head (cam impingement) or an over-hanging cup (pincer impingement) and this causes damage to the labrum and eventually the joint surface.

Symptoms
Patients present with deep seated groin pain, usually worse on bending and may be present on both sides. They may be an associated deep click, which can be either due to a torn rim cartilage, or more commonly, an inflamed tendon running over the front of the hip (Psoas Tendon). If the condition has been present for some time, there may also be inflammation of the tissues surrounding the hip such as the outer hip (trochanteric bursitis), the groin muscles (adductor tendonitis) or infammation of tendons in front of the hip (sartorius tendonitis). Eventually, as the damage continues, the patient may begin to develop more arthritic symptoms such as a dull ache in the groin and increasing stiffness. Hip-related pain is not always felt directly over the groin, it may also be felt on the outer aspect of the thigh, the buttock or traveling down the leg. Occasionally, the pain you do feel in the hip may actually be the result a problem in your back, a hernia or other diagnoses.

Causes
Hip impingement is caused by bony abnormalities on the acetabular or pelvic rim, the femoral head (ball of the hip) or a combination of the two. Using a combination of plain x-rays and CT scans with 3-D reconstructions, it is possible to very accurately identify where the abnormality is and what needs to be removed at the time of surgery. The routine use of 3D CT has made a significant difference to the success of the surgery and the eventual outcome for the patient.

Pure CAM deformity
In a CAM deformity, there is an abnormal bump at the junction between the head/ball of the femur and the neck. This is evident on the image below. This area can be accessed from within the joint and shaving carried out using a small burr until the appropriate shape has been created.

 

Pure PINCER deformity
In a PINCER deformity, there is an overhanging cup. This can be visualized on both the plain x-rays and the CT reconstructions. Depending on the severity, the bony rim can either be resected leaving the soft cartilaginous rim in place (peri-labral rim recession), if it is a mild deformity or in more severe cases, by removing it, shaving back the bony rim and then reattaching the cartilagenous labrum using highly specialized bony anchors.

Mixed CAM/PINCER deformity
In the majority of patients, there is a combination of CAM and PINCER impingement. In these cases both sides must be addressed if the patient is to get an optimal result. This can often be achieved by doing a peri-labral rim recession and a femoral head reshaping, thereby leaving the labrum in place and allowing for early mobilization.

Investigations
All patients undergo specialised x-rays of the hip as well as more complex scans such as CT and Magnetic Resonance Arthrography (MRA). These scans are used to confirm the soft-tissue damage and to accurately map out the bony deformity. This is very important when planning the surgery.

Non-surgical Treatment
Professor Fehily has designed a specialised hip rehabilitation program. This was done in conjunction with his specialist hip physiotherapists. This was initially developed for patients following key-hole hip surgery but it is now being used for general hip rehabilitation.  Other therapies such as painkillers, anti-inflammatory drugs and modification of activity can also be tried.

Surgical Treatment
If there is an underlying bony abnormality and physiotherapy has not cured the pain then surgery is recommended. The aim is to correct the bony deformity before there is irreversible joint damage. This is usually done by hip arthroscopy (keyhole surgery) where the deformity is shaved back via 2 or 3 small incisions. Occasionally some patients with pincer impingement do not simply have an over hanging front rim, instead the entire cup is rotated backwards (acetabular retroversion). If this is the case, then a simple rim trimming will not resolve the problem and by decreasing the amount of head coverage, may actually speed up the onset of arthritis. These cases may need more significant pelvic surgery to alter the postion of the cup (peri-acetabular osteotomy).

Hip arthroscopy is highly specialised and technically difficult surgery but can achieve excellent results if carried out correctly and on the right patient. Based on Professor Fehilys own experience and that of the wider orthopaedic community, certain patients do not do well from hip arthroscopy e.g. patients with significant hip arthritis, patients with severe childhood hip disease (hip dysplasia) or patients with inflammatory hip disease (e.g. rheumatoid arthritis).  Occasionally, the bony deformity may be so large that an adequate bony reshaping is not possible using key-hole surgical techniques. In those cases the operation is done using an open technique. In some cases, the damage caused to the joint by the impingement may be so severe that the only reliable option is a joint replacement. However, if at all possible we will try to presume the joint using a combination of techniques such as microfracture and stem cell treatment. All patients are different and the advantages and disadvantages of the various treatment options can be discussed at the time of your consultation.



Who does this affect?
This injury usually occurs in patients who have femero-acetabular impingement. These patients have either an abnormal bump on their femoral neck or an overhanging pelvic cup. In both these cases, the soft cartilaginous cup rim (labrum) gets damaged (figure 1) as the hip bends up. Initially the rim is simply peeled back but eventually it becomes torn and occasionally shredded. Patients are typically younger and very active, often taking part in sports such as running, kick-boxing, mountain biking and horse riding. Occasionally it can occur due to a severe and traumatic injury e.g. hip dislocation while playing rugby.

Symptoms
Patients present with deep sharp groin pain, which may only occur on full hip bending. They may or may not be an associated deep click, which can be either due to the torn labrum, or more commonly, an inflamed tendon running over the front of the hip. If the condition has been present for some time, there may also be inflammation of the tissues surrounding the hip such as the outer hip (trochanteric bursitis), the groin muscles (adductor tendonitis) or infammation of tendons in front of the hip (sartorius tendonitis).

Investigations
All patients undergo specialised x-rays of the hip as well as more complex scans such as CT and Magnetic Resonance Arthrography (MRA). The MR arthrogram involves injecting dye into the hip joint prior to the scan. The allows identification of the torn cartilage. CT scans are used to accurately map out the bony deformity. This is very important when planning the surgery.

Non-surgical Treatment
If patients are unfit for surgery they can be treated with physiotherapy, painkillers, anti-inflammatory drugs and modification of activity. However, if they have a proven labral tear and physiotherapy has not cured their symptoms, then it is recommended that they undergo key-hole hip surgery (hip arthroscopy) first to address both the torn cartilage and bony abnormality, then undergo our specialist rehabilitation afterwards. A patient who has a painful hip and a proven tear is unlikely to settle without surgical intervention.

Surgical Treatment
The treatment of choice is hip arthroscopy. This allows access to both the true hip joint itself and the front of the femoral head where the bony abnormality is often located. Most patients do not have a frank tear, rather the labrum is peeled back from the acetabular rim. In those patients where there is a gross tear, there is good evidence to show that patients do better long term if the tear is repaired. Occasionally the labrum is frayed and is simply debrided back until it is stable. Once that is carried out, the rest of the joint surfaces are inspected and treated as required. If the joint surface is damaged, it can be debrided back if minor or if more severe, then specialist techniques can be carried out to encourage new cartilage growth (microfracture and stem cell transplantation).

If there is an underlying bony abnormality on either the femoral head or the bony pelvic cup, then that is also addressed at this stage. This is technically difficult surgery but can achieve excellent results if carried out correctly and on the right patient. Based on Professor Fehilys own experience and that of the wider orthopaedic community, certain patients do not do well from hip arthroscopy e.g. patients with significant hip arthritis, patients with severe childhood hip disease (hip dysplasia) or patients with inflammatory hip disease (e.g. rheumatoid arthritis). Occasionally, the bony deformity may be so large that an adequate bony reshaping is not possible using key-hole surgical techniques. In these cases the operation is done using an open technique and the labral tear can be addressed at the same time. In some cases, the damage caused to the joint by the impingement may be so severe that the only reliable option is a joint replacement. However, all patients are different and advantages and disadvantages of the various treatment options can be discussed at the time of your consultation with Professor Fehily.


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Who does this affect?

hip and groin pain can be a relatively common condition in active people of all ages and can be caused by a variety of problems.

This condition can include inflamed areas on the side of the hip, soft tissue problems around or in the hip joint, bony catching (impingement) in the hip and early arthritis. Hip-related pain can be felt in a number of areas although the groin crease is the most reliable. It may also be felt in the buttock, the outer aspect of the hip or even over the front of the knee. The pain you do feel in the hip may actually be the result a problem in your back, a hernia or other diagnoses.

A good physical examination will often provide invaluable information as to the true cause of the pain. X-rays of the hip are usual but specialised investigations such as ultrasound, Computerised Tomography (CT) and Magnetic Resonance (MRI) scans are often used for complex cases.

Non-surgical Treatment

Specialised physiotherapy, painkillers, anti-inflammatory drugs, localised injections and modification of activity can be tried.

Surgical Treatment

Depending on the cause, surgery is becoming more and more widely used. Options include hip arthroscopy (keyhole surgery), open debridement or hip replacement. The options are best discussed with Professor Fehily at the time of your consultation.


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As patients who have had a hip replacement age, there is a decrease in the strength of their bones and an increase in the risk of fracture around the hip replacement (peri-prosthetic fracture).

By their nature, these are sudden injuries, although patients may have had discomfort prior to the injury. The treatment depends on whether the implant is loose or not. If the implant is well fixed then the fractures can be reduced and held with specialised plates. A small percentage will have an underlying infection, which would have contributed to their fracture in the first place.

If the implants are loose, then they must be removed along with all the cement. The fracture is then reduced, fixed and a long stem implant introduced. Rehabilitation is similar to that of revision for loosening and most patients remain partially weight-bearing for up to 3 months until the fracture is healed.


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As hip replacements age, the components will wear and the hip will lose its’ initial soft-tissue tension. This combined with a general increase in tissue laxity can lead to episodes of dislocation. The risks of dislocation are greatest during the early post-operative period when the tissues are still healing and later at 5-7 years. Treatment of early dislocation is usually conservative, so long as the components are correctly positioned. However, patients who dislocate after many years tend to continue to do so and often require revision.

In these cases, the cup is usually removed and replaced with an implant that will allow a larger head. Using a large head gives greater stability and long-term function.

The stem is usually changed. This is done so that the head can be changed and the offset (distance from the centre of the head to the attachment of the abductor muscles) increased. Rather then remove the original implant and all the cement (which carries significant risks), it is possible to use mini-stems which can be cemented into the space left by the old implant.

Once this is done, the patient can usually weight-bear fully but should follow standard hip precautions until the tissues have healed and stability restored.



What is it?

This is an innovative procedure that allows access to the hip joint using minimally invasive surgical techniques. It has been carried out episodically for some years, but in its current form has only been practiced over the last 5 to 10 years. It was pioneered by surgeons in the UK, Australia and the US and since then the indications have rapidly expanded. Initially it was used to remove loose bodies, take tissue samples and to investigate joint pain. However, since the concept of impingement has become clearer, it has been used to reshape both the pelvic cup (acetabular) rim and the femoral head/neck.

Investigations

Prior to surgery, all patients undergo specific x-rays of the hip as well as more complex scans such as CT and Magnetic Resonance Arthrography (MRA). These scans are used to confirm the soft-tissue damage and to accurately map out the bony deformity. This is very important when planning the surgery.

Each patient undergoes a general anaesthetic and the procedure takes approximately 1.5 to 2 hours to carry out. The patient is on their side and traction is placed on the leg. This distracts the hip and allows access to the joint. Using a combination of hollow needles and tubes, a camera is inserted into the joint.

Once there both the cartilaginous labrum and the joint surface cartilage are assessed. If the labrum is torn, it is repaired if possible as there is good evidence in the orthopaedic literature that this has a significant effect on long-term outcome. Occasionally the quality of the torn labrum is too poor for repair so it is debrided. If there is a defect in the joint surface cartilage then it is either debrided back or treated with specialised techniques such as microfracture.

Once the rest of the joint is inspected, the traction is released andaccess is made to the outer part of the hip joint. Once there, the abnormal bump is identified and removed using an arthroscopic shaver until it no longer catches.

Following the surgery, the patient undergoes a specialist hip rehabilitation program. This works on restoring range of movement and core stability. The patient initially remains partial weight bearing for between one and four weeks, depending on the surgery carried out, patients either go home on the day of surgery or the following day and are followed up by a dedicated therapist. They are reviewed in out-patients at six weeks and six months where their progress is carefully monitored.

Patient recovery can vary significantly following the operation. Most will return to normal day to day activities by six weeks, however, functional activity will continue to improve between six and nine months following the surgery. Occasionally, a small group of patients will remain uncomfortable following surgery and in these patients, a steroid injection into the hip joint can be very useful.

Compared to open surgery, the risks of hip arthroscopy are far less.There is a small risk of infection, blood clots, temporary nerve injury and groin bruising. Patients are routinely given antibiotics and a blood thinning drug to minimize some of these risks.

The outcome of hip arthroscopy is good, so long as the appropriate procedure is carried out. Professor Fehily has pioneered the use of 3D CT scans to accurately map out each patients bony deformity which then allows bespoke surgery, tailored to each individual patient. All patients undergo functional scoring both pre and post surgery and are then followed up long-term. A prospective database is kept of all patients and this has allowed us to identify who does and does not benefit from this surgery. On the whole, the majority of patients are significantly better following this procedure and this benefit is maintained into the long-term.

Professor Fehily carries out over 100 of these procedures per year in both the NHS and Independent sector. He is one of the highest volume surgeons for this procedure in the UK. He is an Honorary Professor at Salford University on soft-tissue hip problems, teaches physicians and physiotherapists about hip arthroscopy and is a regular member of faculty on both national and international courses teaching these advanced techniques to orthopaedic surgeons.



When a patient has severe arthritis and painkillers no longer effectively control the symptoms, Hip Replacements are advised. This has the benefit of relieving the pain and allowing the patient to return to a near normal level of activity.

In simple terms, the ball of the hip is removed and the thigh bone is prepared before the metal stem is inserted. The pelvic cup is then prepared and the artificial cup is inserted and held using either bone cement or an artificial coating that bonds directly to the surrounding bone surface.

There are different forms of hip replacement and each one has a role to play depending on the patients age and activity level. Younger (<70) and more active patients, will have implants where the cup liner and the ball of the hip will be made of ceramic, which is very smooth, hard wearing and produces less wear debris then traditional implants. Older patients are better suited with cemented cups made of newer forms of plastic which are also wear resistant. The risks and benefits of each type will be discussed at the time of your consultation.

In general, a hip replacement is a safe and reliable operation. The vast majority of patients are either pain free following the surgery or have a significant improvement in their symptoms, returning to a level of activity that has not been possible for some time.

Approximately, 5% of patients will develop a post-operative complication. The most important of these are deep infection, hip dislocation, leg lengthening, nerve and blood vessel injury and blood clots. In patients with a ceramic implant, there is a small risk of Squeak and ceramic fracture. Great care is taken to minimize these risks including the use of antibiotics and blood thinning drugs around the time of the operation.

Patients tend to remain in hospital for between 3 and 5 days. During this time they undergo intensive physiotherapy, which continues after their discharge home. Patients are reviewed by Professor Fehily in out-patients six later and at this point, they can fully return to their normal activities.


The Manchester Hip Clinic is committed to helping all kinds of people with hip problems to be free from pain and often to resume near-normal levels of physical activity – even those who may have thought that such relief would never be possible.

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