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stem cells
Stem cells

Our previous blog (click HERE) explained some of the background around the use of stem cells and the current evidence. We felt it would be useful to provide an update on our experience. The Manchester Hip Clinic is a national centre for hip arthroscopy and we have carried out nearly 1300 in total. Of these, we have carried out nearly 60 surgeries using stem cells since we started in 2017.

The aim of the stem cells (which we harvest from the patients’ thigh bone and centrifuge to form Bone Marrow Aspirate Concentrate (BMAC)) is to regenerate damaged joint surface cartilage. When we first started, we simply combined it with Tisseal (a biological glue) and dripped it onto the damaged area (see previous blog). However, that does not give it structural stability, so more recently we have combined it with a biological scaffold (Chondrogide or Hyalofast). While it is a more challenging procedure to do, recent research has suggested that the use of these scaffolds leads to improved and longer lasting patient benefit.

Preparing the graft site
Preparing the graft site

The ideal candidate seems to be someone with localised areas of damage and with good quality surrounding joint surface (see image). If the damage is too extensive, then the graft is not supported and is more likely to fail. Older patients (>55) and those with damage on the ball of the hip seem to do badly so we tend to recommend robotic assisted hip replacements (click HERE) to them.

The recovery period after a “normal” hip arthroscopy is usually up to six months. For patients who have cartilage treatment, that recovery can take up to 12 months with more extensive physiotherapy needed. This increased recovery period is probably due to the level of damage present and the muscle wasting/inflammation that patients develop before surgery. A useful way to think about it is that the surgery is to correct the damage, the physiotherapy is to strengthen the muscles afterwards and then we often recommend Pilates/Yoga to maintain that improved core/hip girdle strength and flexibility. The surgery/stem cell treatments seem to improve patients by 85-90% on average so it is more about improving a damaged hip rather than an absolute cure. After recovery, we normally recommend patients switch to non-impact cardio-vascular exercise afterwards such as cycling, swimming, cross-training or spin. The small number of patients that have remained symptomatic after treatment, tend to carry out impact exercise such as road running, squash, impact gym work etc. If we see these patients and they really wish to continue these activities, we often recommend Mako robotic hip replacement (click HERE) rather than hip preserving surgery.



What is it?

Hip arthroscopy 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 micro-fracture or stem cell therapies.

Once the rest of the joint is inspected, the traction is released and access 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 minimise 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 160 of these procedures per year and over 1300 in total. 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.


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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