New Treatments for Hips and Knees

[Pat Walter]

One of our members wanted to have a place to discuss the new treatments that are being developed.  Most of them are very expensive as I understand and many have not worked well.  However, hip resurfacing was new once.

I am happy to have people post information and links about developements being tested.  I just don't want perspective patients to think there is a much better solution than hip resurfacing at this time.

Lets share information and try to be polite with our, I am sure, interesting discussions.

One interesting website shared with me is

http://www.westcoastorthopedics.com/index.php/services-2/#tab-1-2-cartilage-restoration

Another is

http://cytonics.com/

I am sure there are more and invite members to share them with us.

Pat

[blinky]

I tried stem cell injections before resurfacing. On one hip, the worse side, I enjoyed about six weeks of marked improvement. No difference on the better hip.


Last spring my left hip was going downhill rapidly. I cast about for some solution. My sports med guy had suggested artificial synovial fluid a few years prior, and I wondered if there was something else, or if that procedure, new back then, had become widely accepted.  I googled "running hip arthritis" and it took me to stories of runners and triathletes who had tried stem cells and enjoyed some benefit. I was surprised because I thought any workable technology was a good five ten years in the future.


I was even more surprised to find that I could get the injections not just on the coasts at some speciality place, but here in Texas. Several ortho offices offered stem cell injections, including my doctor.


I went back to him and asked what my options were. He said to forget about artificial synovial fluid, still not approved for hips, but if I wanted to try something nonsurgical, to think about stem cells. He gave me a quick run down on what his office offered vs others, the cost (2k a shot), handed me a few published studies, warned me that I was pretty messed up and was unlikely to see much if any benefit, and told me to go think about it. He also offered to make an appointment with a surgeon, just to talk. As noted above, I tried the injections. (I am old and financially comfortable enough to be able to exhaust my nonsurgical remedies.)


The version of stem cells I got? Amniotic mixed with PRP. No anti-inflammatory drugs for one week before or after, no impact sports for a week after. The radiologist numbed the area with lidocaine. It didn't hurt, but the hip joint felt unpleasantly full by the time the whole injection was put in. I drove myself home. In the hip that enjoyed benefits, the effect was pretty quick. MY ROM was much better. It peaked at about four weeks, then faded.


FWIW last week I interviewed a biomedical engineer who has a patent on a scaffolding for stem cells to be used for cartilage or bone. If only we had the stem cells to put on it!


(The google search that led me to stem cells also led me here.)

[Pat Walter]

Thanks for sharing blinky.  I guess everything is new at some point and we hope new treatments will work eventually.

Glad you found your way here.

Pat

[Saf57]

This could be promising, read about it here:http://www.israel21c.org/cartilage-regeneration-on-the-way-for-knees-and-osteoarthritis/

[brianflanagan]

Hi,


I am continuing this topic as it was mentioned stem cells interest.


In my other topic, I've indicated that I've been through 7 sessions of MBST (magnetic therapy to help bone and cartilage to regegenerate). You can read about it here :
http://surfacehippy.info/hiptalk/index.php/topic,6031.0.html


Results were very good but only for 3 weeks.
Now it is a little bit better than previously.


Dr John George said that because there was some good results, he would like to go with stem cells treatment before going through hip resurfacing.
He mentioned that I still have cartilage, that's why he would like to try to work on this.


Is it really possible to regenerate cartilage with stem cells ?!


I have read different things about stem cells.
Do you know if there are some possible bad effects or risks ?


Have you heard about real improvements because of stem cells therapy ?


Thank you very much

[suncag]

Hi,


    I have tried quite a few non-surgical things to postpone HR for my left hip which has moderate to severe osteoarthritis.  The most effective thing I tried was Hyaluronic Acid injections.  Also known as "Rooster Juice." The exact brand name is "Supartz."  I did 3 injections, 3 weeks apart 3 years ago and was pleasantly shocked at how well it worked.  Results showed up 5 weeks after the 1st injection.  It allowed me to play tennis again and lasted just short of a year.  Supartz is basically "Viscosupplementation" which gives you a temporary foam-like cartilage replacement.  It provides the shock absorption and the lubrication aspects of synovial fluid. Worked great.  So I did a 2nd round the next year of 3 injections and good results again.  I did it one more time a 3rd year in a row and at that point I think it no longer worked. 


The newest thing I tried was 8 weeks ago.  Stem cells harvested from my love handles.  Had high hopes for this but 8 weeks out I would have to say there was zero improvement.  Had it done at Emory Sports clinic.  Dr. thinks it did not work either.  Some say you have to wait 3 to 6 months, but  Dr. thinks whatever you get in first 6 weeks is indicative of result.  He offered a PRP booster but thought it probably would not help much.  Had to pay $3k for stem cells and it's $800 for PRP if I do it.


The most exciting new thing I've heard about is this "polyurathane sleeve":
https://www.medica-tradefair.com/cgi-bin/md_medica/lib/pub/tt.cgi/Hip_joint_sleeve_versus_endoprosthesis.html?oid=84518&lang=2&ticket=g_u_e_s_t


Still trying to figure out if Andy Murray got this sleeve or a true Hip Resurfacing.


Question for everyone:  not being a naysayer, as I believe HR is way to go.  But as a 52-year old active guy, I am worried about what I do when the HR prosthesis fails in 10-15 years?  I may not be playing tennis then, but I would like to be able to run and play with my grandchildren then.  Don't really want to ever get a THR.  So my question to everyone who went ahead with HR at a young age is "if you knew that you would outlive the HR prosthetic, what was/is your thinking/plan for what to do when it fails?


Thanks,
Chris

[MattJersey]

Andy Murray almost certainly had some sort of arthroscopy, not a joint replacement or a sleeve.


His surgeon doesn't do resurfacing or sleeves, and I am willing to wager a month's wages he hasn't had a THR.

[suncag]

Well in his interviews Andy used the word "sleeve" himself and I think arhtroscopic surgery is usually not employed for osteoarthritis because it does not address the fundamental issue which is cartilage loss.

[John C]

Hi suncag. I wanted to take a shot at answering your question about what to do "when the HR prosthesis fails in 10-15 years". My answer is that I truly do not expect it to fail in 10 or 30 years. Dr Gross has told me that he expects my resurfacings to last a lifetime, and his statistics to bear that out as being likely. For the type of hip that I have, I believe that his statistics only go out about 12 years for the prosthesis and technique that he is currently using, but it is showing around a 98% survival rate at 12 years, with a failure curve that virtually flattens out after about 2 years. In other words, if you make it past the first couple of years, his statistics show almost no failures out to 12 years. Mr McMinn shows similar long term results going out 15 years, and there is nothing we know of yet that would indicate a reason that graph would change.
With the old THR using the previous generation of poly, 10 to 15 years was a realistic expectation, especially if a person was young and active. However, Dr Gross and others feel that current resurfacing done by a top surgeon has eliminated those failure mechanisms, so there is no need to expect a 10 to 15 year failure. Obviously if you are part of the 1 or 2% that does fail, the statistics do not help much, but if you are trying to plan ahead for what is likely, they are certainly useful.
For the second part of your question, if I had expected a failure in 10 to 15 years, I think that I would have followed the old protocol to wait and live with the pain until you are over 70 and very inactive before getting a replacement. I got my first resurfacing ten years ago when I was 56, and have pushed it hard every day ever since through skiing every day all winter, and playing tennis, surfing, and windsurfing every day all summer. I just had my other hip resurfaced 6 weeks ago, and I am planning on pushing both of them hard until I drop dead, which will hopefully be more than 10-15 years away.
I will attempt to attach a graph showing Dr Gross's results, but it only goes out to 2016, so you need to add two more years of the same results to see where we are today. http://www.grossortho.com/patient-education/latest-results  Note - Patricia Walter added corrected url

[John C]

Sorry, the link looks like it may not have worked, If not, here is another try, or just go to his web site and look under recent results.  South Carolina Joint Replacement Center - Hip Resurfacing & Knee Repl

[Pat Walter]

Hi John
This is the clickable url     http://www.grossortho.com/patient-education/latest-results
Pat

[suncag]

Thanks so much, John, for taking the time to write that comprehensive response.  I am pretty much decided on having my HR with Dr. Gross.  He has always been great to me since the first time I called him to discuss 3 years ago and when I went to meet him in person last May he was also great.  Both he and Nancy. Not that I am picking him due to proximity, but it is a nice benefit that I live only 3 hours away from his facility.  When I shared my concerns with him about longevity of the device, he stated that he has HR's out there that are 18 years and going strong (so maybe closer to 20 now).  His data is very strong, supporting his excellence as a surgeon. 


Pat - I appreciate your chiming in to the discussion as well with the link.  After thinking on HR and tracking it for past couple of years, I still feel it is the best option for me, given that I want to be able to maintain an active lifestyle (tennis, skiing, daily hiking with my wife, basketball, daily workouts, etc.).  My wife and I have always walked anywhere from 2 to 6 miles a day.  Lately, I'm not able to hang in there any more for the duration on the walks because the hip joint fatigues more quickly now.


My feeling is that HR will be very successful in the short term, my concern is really about 2 things in the long term:


1) One is the topic of this thread - how long will this solution really last and what's the plan to keep me on my feet if/when it does fail - even if that is 15 or 30 years out.  (I'm only 52 and and hoping and planning on living more than 15 or 20 more years so I can enjoy active things with my grandkids too). 


2) The second is my concern about possible dangerous longterm effects (cancer, necrosis, etc.) that could occur not only from metal ions but from having metal drilled into the bone after a long period of time.  are there any cases (and if so, how prevalent or rare) of HR patients getting bone cancer or other serious unintended consequences from the foreign material?


You've been so kind to offer your thoughts.  Any other thoughts or info you could provide on this would be very helpful.


Thanks so much,
Chris

[blinky]

I'll offer a few opinions, too.


1) No one knows how long your HR will last. You can look at data from the doctors who track results and you can review the anecdotes we offer, but that is the best you can do. The data only goes out about fifteen years but you can find a few early recipients of HR from 20plus years ago who still have their fake hips. 


The device itself should last for decades. Its adherence to your bone is the issue; aseptic loosening, or coming loose from the bone, is the limiter, as I understand it. This is the limiter for THR, too.


If my HR fails, I will try to get it fixed and if that won't work, revise to a THR. My biggest concern is finding a doctor who will know how to work with HR ten-fifteen-twenty years from now since the experienced docs are aging and the technique is more niche-y. If the new ceramic HRs work well, I hope the number of HR docs will rise and there will be new, young docs added.


When I decided to have surgery I told myself that I would likely get ten-fifteen years of my HR. That is what the data led me to believe (unless I was in the unlucky 2%). That would be ten-ffiteen years of running, hiking, jumping, dancing, stretching and take me to age 63-68. I could live with that. And I might get more years and/or my device might outlive me.


2) Other potential dangers. There just isn't any evidence of those. I haven't thought about these in a while, but I don't remember seeing any studies showing cancer or necrosis. You can generalize and look for studies where people (and animals) have metal plates and screws put in, not just metal hip joints.


There are cases in which too many metal ions build up, more than your body can clear, but those cases are increasingly rare since about 2012. Read thru the old Yahoo hip resurfacing sites and you can see the initial excitement about HR and people fighting to get in clinical trials because HR is so much better than THR. Then you see a sharp decline in enthusiasm as there is a wave of defectively designed prosthesis issues and doctors who make mistakes. In around 2012 doctors realize there is an optimal angle at which the ace tabular cup can be put in, one that avoids metal ion issues. Today the defective devices are off the market, the less skilled doctors have stopped doing HR, and the doctors who still operate know about the safe cup angle so the metal ion issue is pretty much gone.


If the idea of metal joints still disturbs you, get one Dr Pritchett's non metal joints or try to get into a clinical trial for one of the new ceramic joints.


The bottom line for me was that after weighing the risks and the benefits, HR was the way to go. I could live with the risks and was willing to take them for the potential benefits.


Best of luck.


Dr Gross bilat
11-15

[suncag]

Thanks so much for sharing your thought process with me, Blinky! Very valuable insight.  Regarding the new ceramic joints,  are you referring to the H1 ceramic hip in clinical trials at Imperial in London?


https://www.imperial.ac.uk/news/184706/new-resurfacing-implant-could-lead-better/


Also, any thoughts on the "sleeve" approach?


 https://www.medica-tradefair.com/cgi-bin/md_medica/lib/pub/tt.cgi/Hip_joint_sleeve_versus_endoprosthesis.html?oid=84518&lang=2&ticket=g_u_e_s_t


Thanks so much!
Chris

[blinky]

Yes, I think that is the ceramic device. There may be more than one coming out.


I don't know much about the sleeve. I first heard about it here in connection with speculation about Andy Murray's hip surgery.


How bad is your hip? If you wait too long, you could miss the window for getting HR---if you wait too long you might not have enough femoral head left to resurface. (Says the woman who almost waited too long.) If you aren't in a dire situation, do take time to interview several doctors, HR docs and THR docs. Investigate some of these newer techniques and see what it would take to get a ceramic hip or a sleeve. Take your time and be comfortable with whatever choice you make. Heck, even if the situation is fairly urgent, get several medical opinions and get comfortable with your choice.

[John C]

Hi suncag. I would issue a note of caution about the sleeve, just from my perspective. My concern is that the sleeve is a fairly soft material in comparison to something like metal or ceramic. Until there is data going out at least 10 years, I would question the longevity of the material both in terms of wear and in terms of the seam, and what the affects would be from the wear debris if there is a lot. I realize that they have done durability test with simulators, but history has proven that these do not tell the whole story about what is going to happen in a human body. One of the things that we have learned over the years, is that the larger the head, the more wear you can expect. A good history lesson in this is to look at the first resurfacings done back in the 70s using metal heads, and poly cups like they were using in THRs at the time. The whole thing was mostly a disaster with what I remember as being well over 50% failure rates by 10 years. No one saw this coming, and they were sure it was going to be a big success. They did a few metal on metal resurfacings back at about the same time, and many of those have survived well, which eventually lead to Mr McMinn developing the BHR. Dr Pritchett is a great source of studies on those early resurfacings if you want to look into what happened.
I think that the new H1 ceramic design out of London looks like a more promising option. For myself, I just could not wait the five years that it would take to get minimal data published. Many doctors, especially surgeons, will tell you that nothing is more dangerous in medicine than an exciting new discovery that has not yet had the years of data to uncover its hidden flaws.
Congratulations on the amount of homework you are doing before moving forward, and best of luck in whatever you decide to do.

[suncag]

Thanks again, John.  You make great points.  Regarding BHR vs. Biomet, I asked Dr. Gross why he uses Biomet instead and I think, aside from his being an investigator on it and having contributed to its evolution, he prefers it because it is cementless whereas the BHR is cemented.  Is that accurate with your understanding?


Thanks,
Chris

[John C]

Yes, I believe that is accurate. My understanding is that the designs of the Biomet and the BHR are very similar other than the cement issue in the femoral cap. Dr Gross's process over the years has been to study any potential failure mechanisms in hip replacements, and then to look for solutions. Obviously the biggest step was making his focus on resurfacing which he saw as a solution to the high failure rate seen in THRs among young active patients. Other steps were determining solutions for some of the failures seen in the early days of resurfacing such as femoral next fractures which have been addressed through taking care to avoid notching of the femoral neck during surgery as well as modifying activity during post-op months. Metal ion issues were addressed through a detailed study he published outlining ideal cup angles for each cup size. As the idea of resurfacings potentially lasting a lifetime became more likely, he believed that any cement used rather than relying on bone ingrowth had the possibility of being an eventual failure mechanism, so he teamed up with Biomet to develop a cementless femoral cap to go along with the cementless cups that were already the standard for major brands. One other concern he had with using cement were potential thermal affects on the bone and blood supply in the femoral head as the cement heats up as it cures. So far the thin cement mantle used in the BHR has not proved to be a common failure mechanism, but I believe Dr Gross still feels that by relying entirely on bone ingrowth without having any cement as an intermediary layer gives the best chance for a lifetime survival of a prosthesis, which makes sense to me. For myself, I really prefer the idea that my bone is actually interwoven into both parts of the prostheses, rather than just being cemented to the prosthesis on the femoral side.

[chuckm]

The BHR has long history of changes before it took its final form in the 90's. Mr. McMinn says that one thing he never considered changing was the cemented femoral component because it wasn't one of the reasons for failure.

Still, Dr. Gross theorized that over time the cemented femoral component could become an issue and fail over time. And so he began his development of the non-cement femoral component. His device is performing very well.


But Dr. Gross was wrong about the BHR and the cemented femoral component because it isn't failing, even 20 years later. And that is because there is no cement "mantle" between the bone and component. The component is hammered all the way down to the bone pressing all the cement into the bone, so it is directly metal to bone.

Early versions of cemented components maintained a mantle or layer of cement between the bone and the component. That is what began to fail because of the stress on it.

As it stands now, cemented vs non-cemented there is no advantage.

Chuckm

[suncag]

Thank you, John C (again) and Chuck M. 


Very valuable discourse.  John C - I feel the same way you do and share your preference for cementless.  For what it is worth, I had two vertebrae in my neck fused way back in 1997 due to a missing disc and subsequent disc herniation.  the common practice at that time was to take bone from he patient's hip and put it in place of the missing disc and then screw it together to hold it in place while he bone fused.  My surgeon was pretty advanced and used a vertebrae from a cadaver, fused it in between my two vertebrae and did not use any hardware.  It fused together in 6 weeks time and my neck's been great ever since.