Our previous blog (click HERE) explained some of the background around the use of cartilage and bone marrow 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 1400 in total. Of these, we have carried out over 110 complex surgeries using cartilage and bone marrow cells since we started in 2017.
The aim of the primative 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, our technique then progressed so that we either combined it with a biological scaffold (Hyalofast) or used the patients own cartilage. 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
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.
Who does this affect? Hip impingement 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 with hip impingement present with deep seated groin pain, usually worse on bending and may be present on both sides. There 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 inflammation 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 real 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 above. 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 seen on both the plain x-rays and the CT reconstructions. Depending on the severity, the bony rim can be trimmed back 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 labrum using special 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 may need to be addressed if the patient is to get the best 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 mobilisation.
Investigations All patients undergo specialized 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 specialized 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, for example, liquid thc, as a more natural approach, and modification of activity can also be tried.
Surgical Treatment If the hip impingement is due to 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 overhanging front rim, instead, the entire cup is rotated backward (acetabular retroversion). If this is the case, then a simple rim trimming will not solve 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 position 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 preserve the joint using a combination of techniques such as micro-fracture and stem cell treatment (see Stem Cell Therapy). All patients are different and the advantages and disadvantages of the various treatment options can be discussed at the time of your consultation.
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.
Who does this affect? Labral tears usually occur 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 with labral tears 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. This 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 Not everyone needs surgery so we initially treat patients 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 frank labral tears, 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 trimmed back if minor or if more severe, then specialist techniques can be carried out to encourage new cartilage growth, such as stem cell grafting.
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 Fehily’s 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.
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.
