Category Archives: Pain in the hip

Stem Cells And Scaffolds For the Treatment Of Osteoarthritis

Osteoarthritis is the most common form of arthritis affecting more than 20 million Americans.  It is a disease of articular (joint) cartilage.

Normal cartilage  consists of a matrix constructed of a mixture of proteins,  sugars (proteoglycans), water, and collagen. Inside this matrix sit chondrocytes, cells that actually manufacture the matrix they sit in.

Under normal situation, cartilage is capable of withstanding both compressive forces as well as shear forces.  It deforms when loads are placed on it and then  expands to its normal contour once the load has been removed.

When cartilage is damaged as a result of trauma, injury, or other means, a change occurs in cartilage.  Chondrocytes produce destructive enzymes; the underlying bone deforms,  and the lining of the joint, the synovium, produces cytokines, protein messengers that stimulate inflammation.

The end result is wearing away of cartilage accompanied by chronic inflammation, and deformity related to abnormal mechanics of the joint.

To date, the treatment of osteoarthritis has been largely symptomatic using non-steroidal anti-inflammatory drugs (NSAIDS), physical therapy, and joint injections of either corticosteroid or hyaluronic acid.

The rapid development of stem cell science has shown promise as a treatment that may restore joint integrity by regenerating cartilage.

A caveat: The proper application of stem cells is not merely injecting stem cells into a joint and hoping for the best.

Multiple attempts by various laboratories have searched for a method of introducing stem cells along with a scaffold to enable stem cell multiplication and growth in an organized fashion that will best stimulate cartilage regeneration. A whole new branch of basic science, termed “tissue engineering” has been used to describe these ventures.

An excellent review of the current state of the science was published by the Harvard Stem Cell Institute.

(Willerth SM, Sakiyama-Elbert SE. Combining stem cells and biomaterial scaffolds for constructing tissues and cell delivery.)

The authors reviewed the literature regarding types of scaffold materials that had been studied.

These included natural biomaterials such as collagen, fibrin, silk, sugars, algae cell walls, hyaluronan, and chitin as well as synthetic platforms such as various polymers, peptides, and ceramics.

These scaffolds are generally “seeded” with growth factors that stimulate stem cell multiplication and division while protecting the stem cells in the hostile environment of the arthritic joint.

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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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Lumbar spinal stenosis: the masquerader

One of the most common problems encountered by rheumatologists is lumbar spinal-stenosisspinal stenosis.  This is a condition where arthritis and disc disease in the low back narrows the central canal that the spinal cord occupies.  As a result there is pressure placed on the spinal cord leading to many confusing symptoms.

Typically occurring in people past the age of 65, most will have back pain that radiates into the buttocks and upper thighs. The pain is worse with standing and walking and relieved by sitting.  Patients will often exhibit a waddling gait and have an abnormal sensory exam during the physical.

MRI scanning can help confirm the diagnosis.  Typically, the exam will show mri-spinal-stenosisarthritis in the facet joints, bulging of the intervertebral discs, and enlargement of the ligamentum flavum, the thick ligament that runs lengthwise down the spinal canal.

Other conditions can make the diagnosis difficult.  These include osteoarthritis of the hip, mechanical back pain, hip bursitis, and vascular narrowing.  The latter also causes aching in the legs with walking. The difference can be made by having the patient ride a bike.  With vascular claudication, the pain will return.  With spinal stenosis, the pain will not.

Treatment is highly dependent on the individual patient. While exercise and non-steroidal anti-inflammatory drugs may relieve some symptoms, they are difficult for many older patients with spinal stenosis to tolerate.  Epidural injections of steroids sometimes are helpful.  Many patients will require decompression surgery.

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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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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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