Treatment options for torn cartilage, bone marrow lesions, and more.
Some patients may experience hip issues including catching, locking, or instability to the hip. If this is happening at least two or more times per week, and your doctor can find a reproducible reason for this condition, such as a labral tear, and may recommend a minimally invasive and outpatient procedure to treat the condition.
Normally, an MRI (Magnetic Resonance Imaging) of your hip is ordered to determine this condition, but it is not always needed. An MRI may also be ordered to look for a condition which may lie underneath the surface of your joint. This is known as a Subchondral Bone Marrow Lesion (abbreviated BML). The bone marrow lesion is sometimes referred to as Subchondral Fracturing, which is an older and less accurate term. The bone marrow under your cartilage may react and become inflamed, causing a deep pain in the hip. Another condition of the hip called Avascular Necrosis (AVN) can cause a loss of blood supply to areas of the hip next to the joint. This is a self-limiting condition potentially causing collapse of the bone and the joint surface. Treating just the surface cartilage of your hip may have little effect on this condition.
These are all conditions which can be treated effectively with a minimally invasive procedure such as an arthroscopy.
If you have had an MRI performed in the past 6-12 months, this may help the surgeon to make a decision. If not, you may require this test; however, as mentioned above, not all patients require an MRI.
If an arthroscopic procedure is recommended, there are different types of procedures which can be done alone or in combination to help the outcome of your hip. Each one will be explained below. The exact risks, benefits, indications, contraindications, potential complications, expectations, and limitations of each procedure are discussed privately with the surgeon with ample time to ask questions.
This is a procedure normally used for the hip joint, but can technically be performed on any joint. This is used to treat areas of bone where blood supply has been compromised or damaged. The lack of blood supply causes the bone under the sensitive cartilage to die and collapse; the joint can also collapse and become dysfunctional. If this condition is caught early enough, the area of damaged bone can be salvaged and restored through regenerative medicine using a minimally invasive surgical technique. The area of damage in the bone is mapped out after an MRI identifies the exact area and severity of the damage. During the procedure, the patient is placed on a specially designed table which allows a circular type of an x-ray device to view the hip from different angles. A small 1 cm incision is made over the side of the hip, and a small guide-wire is now passed up through the bone to the exact area of damage in the hip. A small drill is passed over this wire to ream out the damaged bone, and is then washed out while new blood flow is stimulated to enter into area. High quality bone marrow cells are taken from the pelvis, which include the important mesenchymal stem cells, platelet rich plasma (PRP) and platelet poor plasma (PPP) - a combination which helps expedite the healing process. Once good blood flow is observed, the BMC with the PRP and PPP is now slowly injected to fill in all the damaged area with healing cells. Over time, these cells will help attract new cells into the damaged area. Additional healing cells are injected within the hip joint to help prevent the cartilage from dying and collapsing, and a small suture is placed over the outer side of the hip. The patient must protect this area from excessive pressure, and is encouraged to limit weight bearing to 25% or less of their total body weight. (Normally, this is just enough weight to crush a potato chip under the flat portion of the foot.) Gradual weight bearing is allowed after the first follow up visit over the next 3-4 weeks. Patients must avoid running, or any excessive pressure across the joint for 3 months.
This is a condition where the area underneath your cartilage becomes very inflamed causing the bone supporting the cartilage to swell and, at times, begin to collapse. This may be reported as a fracture or break in the bone, but this is not true with every patient.
The cause of this intense bodily response still not fully understood; however, entering into this area with a special needle and stimulating new blood flow can help correct the problem. Adding in natural growth factors, plasma proteins, and even mesenchymal stem cells can aide in the healing process. Additional bone grafting material may be necessary in some rare cases. This condition is called a bone marrow lesion, or BML, and is diagnosed mainly through a properly performed MRI. The exact location of these BML’s are mapped out for precise treatment and confirmed with a special x-ray device on a specially designed table used to allow the surgeon to see the hip from different angles. A small incision over the side of the hip and a guide wire is then placed up into the area of the bone marrow lesion (BML). Bone marrow is taken from the pelvis during the surgery while under an anesthetic. This marrow is processed into two distinct products: the Bone Marrow Concentrate (BMC), some Platelet Rich Plasma (PRP) and other important Plasma Proteins, in addition to the Platelet Poor Plasma, which contains even more important plasma proteins. A specially designed bone needle is directed into the BML over the guide wire. Once the needle is within the BML, high pressure suction is used to stimulate a change in the marrow pressure and the stimulation of blood flow into the area. Once there is good blood flow seen, the BMC with the PRP, PP and PPP is now slowly injected to fill in all the damaged area with these healing cells. The needle is removed and the small incisions are closed normally with a single suture. Patients are asked to maintain limited weight bearing on this knee until their follow up appointment; this normally means that the patient should use crutches or a walker, and only place enough weight on that foot to crush a potato chip (about 25% or less your total body weight). Slow progression of weight bearing is allowed after the first visit in about 7-10 days.
The hip is a ball and socket joint, and the socket portion of this joint helps keep the ball portion stable through a tough cartilage ring called a labrum. Sometimes, this ring becomes torn. This is normally not due to a single traumatic event, but rather through multiple smaller and repetitive traumas such ballet dancing or soccer. However, one doesn’t need to be an athlete in order to tear this cartilage; in fact, the majority of patients with a labral tear have never played sports. The labrum may tear when subjected to fairly normal activities. Some patients have an abnormally shaped pelvis or hip joint which causes pinching of the labrum. Other patients develop bumps around their hip joint, causing chronic pinching and tearing. Still other patients develop the tear for no known reason at all! A labral tear is diagnosed by a combination of a history of pain and instability of the hip in specific positions, radiographic findings, physical exam tests, and magnetic resonance imaging (MRI) findings. Once a tear is diagnosed by a combination of the above, a plan for treatment can be designed. Some labral tears simply require careful observation, or routine physical therapy. However, others may require surgical treatment. If surgery is recommended, it can normally be done through a minimally invasive outpatient procedure called arthroscopy. During the procedure, the patient is placed onto a specially designed table and an x-ray device is utilized to see the hip from different angles during the surgery. Gentle traction is placed on the hip joint to allow the instruments into the joint. If there are spurs causing the labrum to tear, they are removed, and any rough spots on the hip joint are also smoothed out. The torn labrum is identified, and a decision is made to either repair this with specially designed and slowly dissolvable anchor sutures, or to remove the damaged portions of the labrum. The hip joint is washed out and the small incisions are normally closed with simple sutures. Bone marrow is taken from the pelvis during the surgery while under an anesthetic. This is processed into two distinct products: one is the Bone Marrow Concentrate (BMC), which contains the mesenchymal stem cells along with some Platelet Rich Plasma (PRP) and other important is Plasma Proteins. The other product is Platelet Poor Plasma, or General Fluid Concentrate (GFC), which also contains even more important healing plasma proteins. The combination of all these regenerative components can be injected into the hip to help with the arthritic conditions of the hip as well as expedite the healing process and prevent further tears of the labrum. The patient goes home the same day, and must remain partially weight-bearing until the first follow up visit with the surgeon. Physical therapy begins immediately, and it normally takes about six weeks for the patient to fully recover.
The procedures above are designed to help with mechanical problems of the joint, or damaged bone near the joint, so that the healing properties of the stem cells, platelet rich plasma and plasma proteins can work properly and allow restoration of joint function. These procedures do not guarantee a positive result; however, they provide a logical solution to problematic joint. It is highly suggested and required that you have a personal discussion with your surgeon regarding the risks, benefits, potential complications, expectations, and limitations of these procedures so any questions and concerns can be answered completely before committing to surgery.