Category Archives: Hip pain

FDA Wants All Metal Hip Replacements Off The Market

Barry Meier writing in the New York Times reports the FDA wants to halt the sale of all metal hips which have been failing prematurely. An estimated 500,000 patients in the US have received the artificial hip.all-metal-hip-replacement

Under the FDA proposal, “makers of artificial hips with all-metal components would have to prove the devices were safe and effective before they could continue selling existing ones or obtain approval for new all-metal designs.” The action “is intended to close a loophole in the 1976 federal law under which medical devices were first regulated. It is the agency’s first use of powers that Congress granted to it last year to deal with medical devices, like all-metal hips, that have been in regulatory limbo for decades.”

Another complication of joint replacement.

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Joint replacement surgery associated with heart attack risk

Jim Morelli writing in Arthritis Today commented on a new study published in the Archives of Internal Medicine.

joint-replacement-surgery“We found that total hip and knee replacements substantially increase the risk of heart attack during the first two weeks, in particular in patients older than 60,” says lead study author Arief Lalmohamed, a researcher in the department of pharmaceutical sciences at Utrecht University in the Netherlands. “We learned from this study that we need to focus more on preventing cardiac outcomes following this major surgery.”

The study relied on national registry data on about 95,000 Danish patients who underwent total hip replacement or total knee replacement surgeries between 1998 and 2007. The average age of the hip patients was 72, while the average age of the knee patients was 67. The researchers found that during the two weeks immediately following each surgery, heart attack risk rose sharply – 25-fold for heart-attack-in-hospitalhip patients and 31-fold for knee patients, compared with similar people in the Danish registries who did not have these surgeries.

After two weeks, heart attack risk dropped dramatically – although the overall risk of heart attack after hip replacement surgery remained elevated for six weeks. Researchers also found that the association between hip and knee replacement surgeries and heart attack was strongest in those 80 years or older. They found no significantly increased risk in patients younger than 60.

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What can be done about osteoarthritis?

Osteoarthritis (OA) is the most common form of arthritis and affects approximately 28 million Americans.  While it has been viewed as a “wear and tear” phenomenon, it has become quite clear that it is a disease that is multifactorial in its development.

It is not a benign disease because, in addition to the pain, OA leads to functional disability.

The joint is a dynamic structure where anabolic (building) activities are counterbalanced by catabolic (destructive) activities.

With OA, the catabolic activities gradually overtake the anabolic ones. While there are attempts at repair, these attempts are dysfunctional , leading to the formation of bony spurs, called osteophytes.osteoarthritis-knee

There are three major risk factors for the development of osteoarthritis.  They are genetic (usually a family history is prominent), constitutional (obesity in the case of OA of the knee, and aging), and finally local components (injury and ligamentous laxity).

Cartilage consists of cells called chondrocytes that sit inside a “soup”, a matrix, which consists of collagen and proteoglycans.cartilage_1

The development of osteoarthritis starts with an initial injury to cartilage.

The injury may trigger an inflammatory response leading to the synthesis of cartilage matrix degrading enzymes, produced by chondrocytes. Over time, the catabolic activities override anabolic activities and abnormal repair mechanisms lead to the formation of osteophytes, while cartilage continues to degrade.

The treatment for osteoarthritis is primarily symptomatic.  Analgesics (pain nsaidsrelievers), non-steroidal-anti-inflammatory drugs (NSAIDS), weight loss, exercise, assistive devices such as wedge insoles, braces, canes, walkers, and such. Injection of glucocorticoids and viscosupplements (lubricants viscosupplementderived either from rooster combs or from bacteria) may also be helpful.

knee-joint-replacement-surgeryEventually patients will require surgery in the form of joint replacement. Joint replacement surgery has come a long way, but there are still concerns about them.  The first is the possibility of a surgical complication such as blood clot or infection.  The second issue is the finite lifespan of the prosthesis.  They usually last 10 to 15 years but this is a function of activity and joint replacement patients do have restrictions on their activity level.  Persistent pain due to particle induced inflammation can also be a problem.

Finally, the chance of faulty prosthetic devices such as the recent  Johnson & Johnson metal-on-metal hip debacle, makes the choice of total joint replacement less attractive.

Recent developments in stem cell technology may provide an alternative to joint replacement.

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The four types of stem cells that could be used for osteoarthritis treatment

stem-cellThere are four types of stem cells undergoing current study. They are embryonic SCs, allogeneic (donor) SCs, induced pluripotential adult SCs, and finally autologous SCs. Of these four, only two, donor SCs and autologous SCs have been used to treat arthritis so far.

However, this discussion would be incomplete without mentioning the other types as well.

Embryonic SCs (ESCs) are derived from embryos and are pluripotential, meaning they can easily differentiate into any body tissue.

stem-cell-differentiationSelf-renewing cells were first extensively studied in mouse cancer models. These cells showed the ability to not only self-duplicate but to also differentiate into multiple types of tissue. Obviously, though, cells that are capable of self-duplication are also capable of becoming malignant.

Potential pitfalls associated with embryonic stem cells are the following:

• The ethical dilemma which has restricted the amount of government spending towards ESC research.

• The risk of malignancy associated with cells that have not completely differentiated yet and are as potent as ESCs.

• The theoretical problem with a graft versus host reaction. While immunosuppressive drugs can be used to mitigate the effects of this, these drugs are not without significant side effects.

There is actually a variant of embryonic stem cells, the fetal stem cell.  For more about this, here’s a video: http://youtu.be/vvklsJs86BI

The second type of SC is the induced pluripotential SC. In 2006, Japanese researchers used retroviruses to insert genes into mouse cells. They were able to take these adult mouse cells and cause them to revert back to a pluripotential embryonic state.

The identical technique was then applied to human skin cells. These “adult turned baby cells” are known as induced pluripotential stem cells (IPSCs). Therefore, it is technically possible to take any adult cell and make it function like an embryonic stem cell.

As one might expect, the primary concern is malignancy. How can these cells get controlled off once they start to multiply?

The third type of SC and one which has been used to treat arthritis in both animals as well as humans is the allogeneic or donor SC. These cells come from healthy donors. Advantages are that a tremendous number of SCs can be cultured. Downsides include the potential transmission of unknown genetic disorders as well as the possibility of infection.

The fourth and most commonly used type of SC in arthritis treatment are the autologous SCs or adult SCs. There are various techniques used to harvest these cells from the adult. Typically, they are obtained from bone marrow, fat, or blood, which is then concentrated to provide a maximum number of cells in the smallest possible volume.

Autologous SCs have the advantage of coming from the host – the patient. This helps avoid the consequences of rejection or graft versus host reaction which may occur with SCs that come from either embryos or donors.
These are multipotent, meaning they can be coaxed into becoming a limited number of different tissue types. This is one of the major differences between adult SCs and embryonic SCs (and induced pluripotential SCs).

For a great video about this topic: http://youtu.be/hky2KB1yrX4

Embryonic SCs and induced pluripotential SCs are pluripotent, meaning they can be converted into any type of tissue.

Nonetheless, the multipotent property of autologous (also known as “mesenchymal” SCs) is sufficient for them to be used to treat disorders involving connective tissue, such as blood, tendon, ligament, cartilage, bone, nerve, muscle, and liver.

These cells are programmed to zero in on areas of tissue injury to help with repair. While it is still not clear what the homing mechanism is, it is suspected that different types of chemical messengers are involved in “calling” mesenchymal SCs. These cells are capable of contributing to both repair as well as regeneration.

One danger is that some techniques using adult SCs involve the use of cell culture ex vivo, meaning outside the body. The possibility of contamination and infection is a concern. Also, when cultured for a lengthy period of time, these SCs may become unstable and the possibility of malignancy developing arises.

Finally, a major weakness of adult SCs is that they are restricted in their capacity to replicate and differentiate. In other words, they go through an aging process and have a limited life span. This is unlike embryonic SCs which have the capacity to multiply and divide forever.

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What can be done about trochanteric bursitis

Bursae are small sacs that contain minute amounts of fluid. They are located around most joints and are responsible for cushioning. When they become inflamed, the condition is referred to as “bursitis.”

One of the most common causes of hip pain is trochanteric bursitis. It is an affliction of middle-aged to elderly people and tends to affect women more often than men. Patients are often overweight.

hip-painThe primary symptom is aching pain located on the side of the hip at an area called the “greater trochanter”. The pain sometimes radiates down the side of the thigh.

The pain is aggravated by walking, climbing stairs, and lying on the affected side. The pain tends to come on gradually and can become so severe the patient has difficulty walking. In some cases, trauma plays a role and can cause a more acute onset of pain.

On examination, there is tenderness located over the lateral hip. The pain elicited by examination can be excruciating. Having the patient lift their leg laterally (to the side) can also bring out the pain. There may be a noticeable limp.

The condition is almost always accompanied by tendinopathy, meaning the tendons overlying the bursa are diseased or damaged. The two tendons that are most often affected are the gluteus minimus and gluteus medius.

Some conditions can predispose to trochanteric bursitis. These include scoliosis as well as leg length differences.

The diagnosis is suspected clinically and can be confirmed by magnetic resonance imaging (MRI). Another condition that can mimic this problem is sciatica.

The treatment initially can be conservative with stretching of the gluteus medius and gluteus minimus tendons as well as the iliotibial band, a long ligament that stretches from the greater trochanter of the hip down to the knee. Non-steroidal-anti-inflammatory drugs (NSAIDS) can provide symptomatic relief as can ice packs or moist heat.

Patients who are overweight should be counseled regarding weight loss.

In stubborn cases, ultrasound guided injections of glucocorticoid (“cortisone”) may be useful. These injections should be used sparingly because they may cause more tendon degeneration.

Patients who continue to have symptoms will require a procedure called ultrasound-guided percutaneous needle tenotomy accompanied by platelet-rich plasma (PRP).

The theory here is that using a small gauge needle to poke holes in the area of degeneration will induce an acute inflammatory response. This causes the release of active growth and healing factors from the platelets in the platelet-rich plasma. This procedure will lead to healing of the diseased bursa and adjacent tendons.

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Seven tips about stem cells for arthritis

 

A feature article appearing on ABC News (Newcomb “Stem Cell Treatments for Zoo Animals Hold Promise for Humans) underscored the interest that both scientists as well as lay people have in the new technology of using stem cells to repair and treat degenerative conditions.

“We just extract them, concentrate them, wash them and in the same setting readminster them. Inject them in your heart or your knees, wherever you need them,” Dr. Eckhard Alt told ABC Station KTRK-TV in Houston after treating an arthritic pig at the Houston Zoo.”

So… can this technology be applied to humans?

Here are seven tips about stem cells (SCs) for arthritis treatment you might want to know…

1. There are four types of SCs currently being studied. They are embryonic SCs, allogeneic (donor) SCs, induced pluripotential adult SCs, and finally autologous SCs. Of these four, only two, donor SCs and autologous SCs have been used in either animals or humans to treat arthritis. Here’s a video that gives the basics on stem cells :     http://youtu.be/a3iOGLx2elI

2. The SC that appears to generate the most interest is the autologous SC. This is the SC that is present in the patient and can be found in bone marrow, periosteum of bone, fat, and peripheral blood. Autologous SCs are referred to as “repair SCs” because these are the SCs that help with the healing process.

3. Arthritis occurs as a result of cartilage degeneration. Various attempts at inducing cartilage healing with SCs have met with mixed results. The results appear to be highly dependent upon the following factors: age of the patient, body mass index (BMI), extent of cartilage loss, and the technical expertise of the center performing the procedure.

4. The processing and administering of SCs for an arthritis problem is more than just getting SCs out and injecting them. There appears to be a need for some type of acute injury to help stimulate the stem cells to multiply and divide.

5. Possible complications of SC treatment can vary. They include the following: infection, rejection, graft versus host reaction, malignancy, and transmission of genetic disease.

6. The need for a cartilage restorative procedure is very evident since the only treatments available currently for osteoarthritis are palliative, meaning pain control only. This is not satisfactory.

7. In the proper hands autologous SC treatment can be successful. Early data indicating an improvement in cartilage thickness in the treatment of osteoarthritis of the knee has been published.

(Wei N, Beard S, Delauter S, Bitner C, Gillis R, Rau L, Miller C, Clark T. Guided Mesenchymal Stem Cell Layering Technique for Treatment of Osteoarthritis of the Knee. J Applied Res. 2011; 11: 44-48)

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Osteoarthritis… what is it?

Osteoarthritis (OA) is the most common joint disease.  It affects approximately 28 million Americans and tends to become more common with increasing age. It is a universal condition in people past the age of 70 although not everyone is symptomatic. It is a disease that affects articular cartilage, the gristle that caps the ends of long bones.cartilage_0

There are risk factors for the disease.  Increasing age, as mentioned earlier is one.  In addition, female gender, genetic predisposition, obesity, and trauma are the other important items.

The most frequent targets for OA to strike are the neck, low back, fingers, base of the thumb, knees, and hips.

Less commonly the ankles, shoulders, and elbows are involved.  In these areas, antecedent trauma appears to be the primary cause.

knee-arthritisOA is what is called, a focal disease.  What that means is that it doesn’t affect the whole joint.  It preferentially attacks certain areas within the joint.  An example would be the knee where the medial (inside) part of the joint cartilage-defectis affected far more often than the lateral (outside) part.

In the hip, the top part of the joint tends to become involved while the rest of the joint is relatively spared.  The same is true for other joints affected by OA.

Symptoms of the condition consist of pain that is aggravated by use and relieved by rest.  Also, there is short term stiffness with inactivity. This is called “gelling.” Night time pain is also a common feature. Another common lament is crunching of the joint with movement.  This is called “crepitus.”

On exam the rheumatologist will often spot swelling due to the formation of bone spurs, called “osteophytes.”  There can be tenderness of the joint, pain with movement, swelling due to fluid accumulation, and muscle wasting around the joint.

In advanced cases, there is clear deformity and sometimes evidence of instability.

Laboratory tests are usually normal.  Imaging studies can help with the diagnosis.  Magnetic resonance imaging will pick up early changes.  X-ray findings also can help with the diagnosis.  The problem is that if x-ray changes are evident, then the disease has progressed substantially.  The primary changes seen on x-ray are narrowing of the joint, bone spurs, and changes in the bone underlying the cartilage.

Joint fluid, if present, should be aspirated.  The joint fluid is typically viscous, translucent, and has fewer than 200 white blood cells per cubic milliliter.  Occasionally the white blood cell count will be higher if a patient has a particularly inflammatory form of osteoarthritis. This is the conundrum of OA.  While the old thinking was that the condition was primarily a mechanical disease, it has become quite clear that OA has a significant inflammatory component as well.

What has been a perplexing question is, “What causes pain in OA of the knee?”  Cartilage has no blood vessels nor does it have nerves.  So the topic of pain mechanism in osteoarthritis has been the subject of intense interest.knee

There are a number of potential suspects.  For example, when osteophytes (bone spurs) develop, they can lift the periosteum (the thin top layer of the bone).  Periosteum is rich in nerve fibers and certainly can be a source of pain.

It has been noted that blood vessels in bone underlying osteoarthritic cartilage can become engorged and this may elevate the pressure inside the bone which could also, theoretically, cause pain.

The lining of the joint (synovium) becomes inflamed in OA.  Pain fibers are located within the joint capsule and these inflammatory processes could irritate them.

The joint capsule can contract or shrink leading to irritation of nerve fibers located within the capsule.

By the same token, if fluid builds up within the joint, it can stretch the joint capsule again leading to stimulation of pain fibers.

As mentioned earlier, there are two small pieces of fibrocartilage located within the knee.  These pieces of fibrocartilage (menisci) have a rich blood and nerve supply where they attach to the joint capsule.  OA often leads to tearing of these menisci. This can cause damage to the capsular attachment leading to pain.

Spasm of the muscles surrounding the knee can also lead to pain.

Finally, there is increasing interest in the role of the central nervous system- the brain- in causing the pain of knee OA.  Recent studies showing the effectiveness of drugs like Cymbalta, a drug originally prescribed for depression, but also showing beneficial effects on pain relief in patients with OA, led to FDA approval for this indication in 2011.

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Iliopsoas bursitis… an underdiagnosed cause of hip pain

Bursitis is a term that describes inflammation of a bursa- the small sacks that surround joints.

One of the more common conditions that causes pain in the front of the hip is iliopsoas bursitis. This is particularly common in active people who exercise regularly.

The iliopsoas muscle originates from the inside of the pelvis as well as the lumbar spine. This muscle inserts onto a small bony ridge on the upper femur (upper leg bone).

The iliopsoas bursa is a small fluid filled sac that lies just behind the iliopsoas muscle and in front of the hip joint. Its purpose is to provide cushioning for the hip joint as well as to ensure proper gliding of the tendons adjacent to it.

As with many types of bursae, inflammation can affect the iliopsoas bursa. When this occurs, the patient will experience pain in the groin as well as the front of the thigh. The pain is aggravated by flexing (bending)  the hip. Activities such as walking, running, and climbing stairs can be painful.hip-flexor

Sometimes patients may hold their leg with the hip slightly bent and the foot turned out in order to minimize discomfort. Patients may also have a limp.

On examination, there is tenderness when pressure is placed directly over the front of the hip. In severe cases, the bursa may be swollen.

While overactivity or trauma may be the most common cause of this type of bursitis, arthritis can also lead to iliopsoas bursitis.

Between 15 to 20% of the time, the bursa communicates with the hip joint. In situations like this, it is sometimes difficult to differentiate whether the discomfort is coming from the bursa versus the joint.

The diagnosis is suspected by taking a careful history and doing a careful physical examination. The clinical impression can be confirmed by either magnetic resonance imaging or diagnostic ultrasound.

The treatment for this condition is usually conservative to start with. Non-steroidal anti-inflammatory drugs and physical therapy may be helpful.

Ice may also be palliative.

Aspiration of fluid from the bursa and simultaneous injection of  glucocorticoid using ultrasound guidance can be curative. On rare occasion, the bursitis may return. If the bursitis does recur, aspiration followed by needle fenestration and injection with platelet rich plasma (PRP) may be effective.

If the bursitis recurs repeatedly, surgery may be required.

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PRP Treatment For Tendinitis And Arthritis

To help heal damaged tissue, both athletes and non-athletes alike – particularly those in the Baby Boomer generation- have been attracted to the use of platelet-rich plasma (PRP) therapy. PRP is made by obtaining a specimen of a patient’s blood (usually 60 cc’s) and centrifuging it to isolate the platelets, (cells responsible for clotting), in a small volume of plasma.

prp_0This concentration of platelets is then injected, using ultrasound guidance, into the site of the patient’s injury. The theory surrounding PRP is that growth and healing factors, stored in small packets located inside platelets, accelerate tissue recovery.

Tendonitis, or more accurately, tendinopathy, is a universal soft tissue injury problem and is a common affliction of both athletes as well as Baby Boomers.

These tendon injuries tend to become chronic, and are due to microscopic tearing of the tendon with formation of scar tissue. These tendinopathies heal poorly because they are usually located in “watershed” areas, regions where there is as relatively poor blood supply. An example would be the Achilles tendon. Since poor blood supply restricts the ability of nutrients as well as  healing or growth factors to get to the area, the application of PRP fixes that problem.

So theory aside, what has the data shown?

A number of studies conducted on the effectiveness of PRP have come up with mixed results.  Some studies have shown benefit while others have not.

So why the discrepancy and does PRP really work?

Some investigators have argued that the placebo effect accounts for the success of PRP since it is a dramatic procedure involving a needle.

Another explanation is that the process of needling a tendon cause irritation and bleeding and this is known to help healing by attracting growth factors in the blood.

Another factor that might suggest a discrepancy in the results of studies is the difference in the rehabilitation program.  For optimal results following a PRP procedure, a patient requires rest, modification of activity level and a specifically designed rehabilitation program with stretching and strengthening. The rest is important for the first few days since a significant amount of pain is experienced by many patients following PRP.

A patient is considered a candidate for PRP if they have either failed at least two to three months of other therapies or have a significant tendon or ligament issue that needs immediate attention.

Usually patients respond to one treatment but may require at least one more.  Patients rarely require three.

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Is it arthritis, tendonitis, or bursitis?

When a patient complains of pain in a joint, the arthritis specialist needs to figure out the exact location of the pain source.  Is it due to something happening within the joint itself or is it due to adjacent structures such as the bone, ligaments, tendon, or bursa. Another possibility is that the pain could be referred meaning that the site that is causing the pain is not where the pain is.

hip-painAn example of this latter situation is osteoarthritis of the hip that often causes pain in the knee.  Also, a pinched nerve in the low back can also cause pain in the leg.

Arthritis pain is often accompanied by stiffness in the joint, pain with use, reduced range of motion, and occasionally swelling due to inflammation or fluid accumulation. The joint can be stiff after inactivity.  For example, patients with osteoarthritis or rheumatoid arthritis will often get stiff if they sit for a long time.  They can then loosen up by moving around.

Patients with an arthritic condition involving a joint have the “quartet” of arthritis: swelling, heat, redness, and pain.knee-arthritis

The presence of fluid inside the joint (called an “effusion”) can help establish the diagnosis.

Bone pain is most often due to fracture but may also occur due to infection (this is called “osteomyelitis”), or irritation of the bone surface, the periosteum.  Periosteal problems can occur as a result of malignancy or conditions such as Paget’s disease of bone, an unusual metabolic disease that causes bone deformity as well as bone pain.

Patients with tendonitis or bursitis usually have localized pain. Pain is aggravated by activity and relieved by rest. Getting a detailed history can provide clues to recent overuse that could be the trigger for the problem. Knowledge of anatomy can often pinpoint the source.  Physical examination is critical because certain maneuvers can provoke or reproduce the pain thereby narrowing the diagnostic focus.rub-hands

With bursitis, if there is significant inflammation, there will be swelling as well as pain and redness localized to the affected bursa.

Sometimes, though, it is difficult to separate a tendon issue from a bursal issue because the structures lie in such close proximity.  Examples would be tendonitis/bursitis involving the shoulder or hip where this problem can be a difficult one to differentiate.  Occasionally both the tendons and bursae can be affected.

Ligament problems are almost always due to trauma and the history as well as physical examination can establish the diagnosis.  Confirmatory imaging studies such as magnetic resonance imaging and diagnostic ultrasound can be helpful here.

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