E-ISSN:2456-3110

Case Report

Avascular Necrosis

Journal of Ayurveda and Integrated Medical Sciences

2022 Volume 7 Number 1 Jan-Feb
Publisherwww.maharshicharaka.in

Ayurveda Management of Avascular Necrosis of Femoral Head - A Case Study

Behera S.1*, Divya K.2
DOI:

1* Satyajit Behera, Post Graduate Scholar, Department of Kayachikitsa, All India Institute of Ayurveda, New Delhi, India.

2 Kajaria Divya, Assistant Professor, Department of Kayachikitsa, All India Institute of Ayurveda, New Delhi, India.

Introduction: Avascular necrosis (AVN) of femoral head is the collapse of femoral head subsequent top transient or permanent loss of blood supply to femoral head. It can be correlated with Asthi-Majjagata Vata. A 24 yrs old male, with complaints of severe pain in the left side hip joint along with right hip joint associated with restricted movements of bilateral hip joints aggravated since 7 months was treated with Krimighna Vasti followed by Manjisthadi Ksheera Vasti. Aim and Objective: To evaluate the efficacy of Krimighna Vasti and Manjisthadi Ksheera Vasti in the management of avascular necrosis of femoral head. Methodology: Krimighna Vasti for a period of 3 days followed by Manjisthadi Ksheera Vasti was given as Niruha Vasti and a combination of Gugulu Tiktaka Ghrita (60ml) and Pinda Taila (60ml) was given as Anuvasan Vasti in Yoga Vasti pattern for a period of 8 days. Results and Discussion: Patient was not able to walk without support with restricted movement and limping was able to walk with mild pain. And the patient also had acute bronchitis feature having symptoms of recurrent nonproductive cough, mild fever, headache on auscultation there was crepitation in bilateral lungs field and x-ray finding suggestive of prominent broncho vascular margin that is also diminished. Ksheera Vasti possibly aided in strengthening of subchondral bone of the femoral head. As it is a Brimhana Vasti the patient also get relieve in symptoms of bronchitis.

Keywords: Avascular necrosis (AVN) of femoral head, Asthi-Majjagata vata, Krimighna Vasti, Manjisthadi Ksheera Vasti, Pinda Taila

Corresponding Author How to Cite this Article To Browse
Satyajit Behera, Post Graduate Scholar, Department of Kayachikitsa, All India Institute of Ayurveda, New Delhi, , India.
Email: 		Satyajit Behera, Kajaria Divya, Ayurveda Management of Avascular Necrosis of Femoral Head - A Case Study. J Ayu Int Med Sci. 2022;7(1):434-439.
Available From
https://jaims.in/jaims/article/view/1644

Manuscript Received Review Round 1 Review Round 2 Review Round 3 Accepted
2022-01-25 2022-01-27 2022-02-03 2022-02-10 2022-02-17
Conflict of Interest Funding Ethical Approval Plagiarism X-checker Note
Nil Nil Yes 19%

© 2022by Satyajit Behera, Kajaria Divyaand Published by Maharshi Charaka Ayurveda Organization. This is an Open Access article licensed under a Creative Commons Attribution 4.0 International License https://creativecommons.org/licenses/by/4.0/ unported [CC BY 4.0].

Journal of Ayurveda and Integrated Medical Sciences 2022;7(1)434
Behera S. et al: Ayurveda Management of Avascular Necrosis of Femoral Head - A Case Study

Introduction

Avascular necrosis (AVN), is osteonecrosis (dead bone) and is also called Osteochondritis Dissecans/Chandler's Disease in young adults with 60% of the cases being bilateral. This condition is one of the most challenging problems faced by orthopedic surgeons.

The objectives of the treatment include the preservation of structure, function and relief from pain.[1]

Many surgical procedures such as drilling, insertion of bone grafts, modified Whitman or Colonna reconstruction and insertion of prosthesis are carried out to remedy this condition.

According to Ayurveda, AVN of femoral head can be correlated to Asthi-Majjagata Vata due to presence of pain in Shakthi and Sandhi Shula (deep pain in groin; often referred to ipsilateral buttock and knee), limited range of motion of hip joint, Teevra Balakshaya, Asthi saushirya, satata ruja (continuous pain) and Asvapna (insomnia due to persistent[2]

Case Report

A twenty-four year old male, approached the outpatient door of Kayachikitsa, All India institute of Ayurved with complaints of pain in bilateral hip joint, restricted movement of both hip joints since one year and aggravated since 7 months, along with recurrent dry cough. Seven years back he had history of intestinal tuberculosis for which he had taken anti tubercular drugs for 6months. He also had history of encephalitis one year back. One year back, he experienced sudden sense of pain in the left hip joint along with weakness in the bilateral hip joint while climbing stairs then he consulted to orthopedician and advised to do x-ray which shows subchondral sclerosis of left hip joint then he was advised to do MRI, MRI finding shows changes of Avascular Necrosis (AVN) in left femoral head (stage III) and right femoral head (stage II). Moderate left synovial effusion.

Clinical Findings: General examination showed no pallor, icterus, cyanosis, clubbing, lymphadenopathy, edema, His vital signs are within limits. Range of motion was restricted to varying degrees with tenderness in both hip joints. Personal history revealed irregular bowel & bladder movement with reduced appetite and disturbed sleep.

Assessment Criteria

Harris Hip score[3] (Table 1), Visual Analogue scale[4] (Table 2), Depression Anxiety Scale [5](Table 3)

Table 1: Harris Hip Score[3]

<70 70-79 80-89 90-100
Poor Fair Good                                                                       Excellent

Table 2: V.A.S - Visual Analogue Scale[4]

0 2 4 6 8 10
No Hurt Hurts Little Bit Hurts Little More Hurts Even More Hurts Whole Lot Hurts Worst

Table 3: Depression Anxiety Stress Scale Interpretation

  Depression Anxiety Stress
Normal 0-9    0-7   0-14
Mild 10-13    8-9  15-18
Moderate 14-20   10-14  19-25
Severe 21-27   15-19  26-33
Extreme Severe 28+     20+   34+

Therapeutic interventions

Patient was advised to take Amrutottara Kashaya 30 ml BD, Hingwastaka Churna 3gm BD, Haritaki Churna 3gm BD for Deepana and Pachana effects (Table 4).

As Poorvakarma to Vasti therapy; Then Sarvanga Abhyanga with Pinda Taila and Sarvanga Swedana with Dashamool Kwatha was done for 3 days along with Krimighna Vasti then Yoga Vasti is continued where  Manjisthadi Ksheera Vasti was given as Niruha and Gugulu Tiktaka Ghrita (60ml) + Pinda Taila (60ml) was given as Anuvasana for eight days (Table 5).

Patient was advised for Yoga Vasti with following ingredients (Table 6).

Table 4: Shamana Chikitsa 

Medicines Dosages Remarks
Amrutottara Kashaya 30ml BD before food For 3 days
Hingwastaka Churna 3gm BD before food -
Haritaki Churna 3gm BD after food -

Table 5: Shodhana Chikitsa

Sarvanga Abhyanga with Pinda Taila followed by Sarvanga Swedana with Dashamool Kwatha + Krimighna Vasti
Karma Vasti - Anuvasana vasti with Gugulu Tiktaka Ghrita 60ml and Pinda Taila 60ml Niruha Vasti with Manjisthadi Ksheera Vasti and Gugulu Tiktaka Ghrita 80ml


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Behera S. et al: Ayurveda Management of Avascular Necrosis of Femoral Head - A Case Study

Table 6: Niruha Vasti ingredients

Niruha Vasti ingredients Dose
Makshika (honey) 80ml
Saindhava Lavana 10gm
Gugulu Tiktaka Ghrita 80ml
Kalka - Shatapuspa, Manjistha 10gm each
Kwatha - Manjisthadi Kwatha 150 ml
Gokshira (Cow milk) 200ml

Table 7: Krimighna Vasti ingredients

Krimighna Vasti ingredients Dose
Makshika(honey) 80ml
Saindhava Lavana 10gm
Tila Taila 80ml
Kalka - Vindanga, Pippali 10gm each
Kwatha - Vidanga, Triphala, Musta, Shigru 150 ml

Table 8: Yoga Vasti Schedule

Vasti Given Time Return Time Retention Time
Anuvasana 11am 1pm 2hrs
Anuvasana 12pm 2pm 2hrs
Niruha 12.30pm 12.45pm 15min
Anuvasana 3pm 5pm 2hrs
Niruha 2pm 2.15pm 15min
Anuvasana 11am 1pm 2hrs
Niruha 12pm 12.15pm 15min
Anuvasana 3pm  5pm 2hrs

Results

Subjective and objective parameters of Harris hip score were used to evaluate the outcome of interventions in each hip joint separately (Table 9 and Table 10). There was noticeable change in the range of motion in bilateral hip joints. The quality of life in terms of daily activities improved significantly by 21 days of treatment. Patient who was not able to walk without support with restricted movement and limping was able to walk with mild pain. And the patient also had acute bronchitis feature having symptoms of recurrent nonproductive cough, mild fever, headache on auscultation there was crepitation in bilateral lungs field and x-ray finding suggestive of prominent broncho vascular margin that is also diminished.

Discussion

As the patient was having constipated bowel since 1 month along with reduced appetite which clearly signifies presence of ama in his body, so in order to combat such condition Amapachana & Agnideepana

was done with Amrutottar Kashaya & Hingwastak Churna, Haritaki Churna, for Mala Shuddhi as well as Srota Sodhana Krimighna Vasti was given for 3 days as Raktavaha Srotarodha is the prime cause leading to Asthi and Majjadhatu Kshaya, in this patient the main complaints are pain in bilateral hip joint along with severe restricted movement of both hip joints which clearly indicated involvement of Vata Dosa. So, Basti was planned. According to Vagbhata, Basti prepared with Ksheera, Ghrita, & Tikta Rasa Dravya is ideal for Asthisankshaya.[6] Gugulu Tiktaka Ghrita is selected as Sneha Dravya in Niruha Vasti as well as in Anuvasana Basti as it is indicated in Sandhi Asthimajja Gata Vata.[7] 

Table 9: Harris Hip Score of Left Hip Joint

Parameters Before treatment After 21 days of treatment Follow up after 15 days
Pain Marked pain; serious limitation of activities Moderate pain; but makes concessions to pain, sometimes obstruct activities Mild pain, no effect on average activities
Distance walked 3 minutes 10 minutes 20 minutes
Activities: shoes, socks Fitting with difficulty Able to use Able to use
Public transportation (bus) Unable to use Able to use Able to use
Support Walk with support Walk without support Without support
Limp moderate  slight slight
Stairs Unable to climb Able to climb with difficulty Able to climb with ease
Sitting Able to sit with difficulty Can sit with slight difficulty No difficulty during sitting
Range of motion at hip joint (in total degrees)
Flexion 55-65 65-70 70-75
Abduction 10-15 10-15 15-20
Adduction 5-10 5-10 10-15
External Rotation 5-10 5-10 10-15
Harris hip score 39.7 63.9 73.2

For Anuvasana Basti Pinda Taila was used along with Gugulutiktaka Ghrita as Pinda Taila is indicated in Vatarakta having painful condition. The regeneration phase of AVN includes destruction of subchondral bone supporting the joint cartilage (Subchondral fracture) & condensation of the cancellous bone located at the core of the femoral head. In the light of new researches proving Basti is having effect of stimulation of sympathetic nervous system in angiogenesis[8] which results in proper


Journal of Ayurveda and Integrated Medical Sciences 2022;7(1)436
Behera S. et al: Ayurveda Management of Avascular Necrosis of Femoral Head - A Case Study

vascularization as well as improves the circulation at the site of the necrosis causing neovascularization of the femoral head.

Table 10: Harris Hip Score of Right Hip Joint

Parameters Before treatment After 21 days of treatment Follow up after 15 days
Pain Moderate pain Mild pain Mild pain
Distance walked 3minutes 10 minutes 20 minutes
Activities: shoes, socks Fitting with difficulty Able to use Able to use
Public transportation (bus) Unable to use Able to use Able to use
Support Walk with support Walk without support Without support
Limp moderate  slight slight
Stairs Unable to climb Able to climb with difficulty Able to climb with ease
Sitting Able to sit with difficulty Can sit with slight difficulty No difficulty during sitting
Range of motion at hip joint(in total degrees)
Flexion 40-45 45-55 55-65
Abduction 0-5 0-5 5-10
Adduction 0-5 0-5 5-10
External Rotation 5-10 5-10 5-10
Harris hip score 28.7 52.9 70.5


jaims_1644_01.JPG


Table 11: Assessment of Results

Scales Before Treatment After Treatment Follow Up after 15 Days
Harris Hip Score of Left 39.7 63.9 73.2
Harris Hip Score of Right 28.7 52.9 70.5
Visual Analogue scale 8 6 4
Depression 18 16 12
Anxiety 9 6 6
Stress 8 6 6

jaims_1644_02.JPGjaims_1644_03.JPGFigure 1: Before Treatment

jaims_1644_04.JPG


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Behera S. et al: Ayurveda Management of Avascular Necrosis of Femoral Head - A Case Study

jaims_1644_05.JPGFigure 2: After Treatment

Conclusion

Thus, the above medications and procedures can able to address the manifestation of Avascular necrosis. The current study provides a way for more clinical trial to evaluate the effect of Tikta Ksheera Vasti in the management of avascular necrosis (AVN). A good result has been obtained in this case. Informed consent was taken from the patient for this case report, this approach may be useful for clinical practices and further studies on treating post Avascular necrosis (AVN).

Reference

  1. Kadlimatti SM, Subbanagouda PG, Sanakal AI, Deshpande M. Ayurvedic management of avascular necrosis of the femoral head - A preliminary study. 2008; 29:154–60.
  2. Vagbhata, Ashtanga Hridayam, Nidanasthana, Vatavyadhi Nidanam, CHaukhamba Orientalia, Varanasi. In: Murthy KR, editor. 7th ed.2013.p.150.
  3. Söderman P, Malchau H. Is the Harris hip score system useful to study the outcome of total hip replacement?. Clinical Orthopaedics and Related Research (1976-2007). 2001 Mar 1,384:189-97.
  4. de Nies F, Fidler MW. Visual analog scale for the assessment of total hip arthroplasty.1997 jun1;12 (4):416-9.
  5. Balapala KR, Indla D. Depression, Anxiety and Stress among Health Science Students
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  2. Vagbhata, Ashtanga Hridayam, Sutrasthana, Doshadivij-naniyam, Chaukhamba Orientalia, Varanasi. In: Murthy KR editor. 7th ed.2013.p.161.
  3. Kunte AM, Navre Shastri KR, Vaidya HP, editors. 21st Adhyaya Chikitsasthana 58 61 shloka. Astanga Hradaya. Sanskrit commentary. Varanasi: Krishnadas Academy. p. 726.
  4. Hondermarck H, Jobling P. The sympathetic nervous system drives tumor angiogenesis. Trends in cancer. 2018 Feb 1;4(2) 93-4.

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