E-ISSN:2456-3110

Case Report

Avascular Necrosis

Journal of Ayurveda and Integrated Medical Sciences

2023 Volume 8 Number 5 May
Publisherwww.maharshicharaka.in

An Ayurvedic approach for the management of Avascular Necrosis (AVN) - A Case Study

Gupta S.1*, Srivastava S.2
DOI: http://dx.doi.org/10.21760/jaims.8.5.46

1* Sakshi Gupta, Post Graduate Scholar, Department of Rog Nidan Evum Vikriti Vigyan, Pt. Khushilal Sharma Government (Auto.) Ayurveda College & Institute, Bhopal, Madhya Pradesh, India.

2 Sanjay Srivastava, Professor & HOD, Department of Rog Nidan Evum Vikriti Vigyan, Pt. Khushilal Sharma Government (Auto.) Ayurveda College & Institute, Bhopal, Madhya Pradesh, India.

Background - Avascular Necrosis (AVN) is a disease affecting bone due to temporary or permanent cessation of the blood supply which finally leads to the destruction of the joints. AVN is asymptomatic in the early stage but as the disease progress there is constant pain with decrease in the function of joints. AVN of femoral head is the most common type of among all AVN. On the basis of Dosha and Dushya Avascular Necrosis resembles with the Asthimajjagata Vata. Raktavaha Srotas, Asthivaha Srotas and Majjavaha Srotas are hampered in Asthimajjagata Vata. Case Report - This is the case of 56 year old female came to our hospital having complaints pain in B/L hip joints which radiates to both thigh region (Rt. > Lt.), morning stiffness more than 30 mintues, pain in groin region, difficulty in walking, sleep disturbed due to pain and indigestion. Aim and Objective - To evaluate the efficacy of various Panchakarma procedure especially Manjisthadi Majja Basti. Result - The therapy provided marked relief in pain and stiffness along with improvement in gait and difficulty in walking was reduced. Conclusion - AVN is a chronic degenerative disease which occurs when a blood flow to the bone is interrupted or reduced. On the basis of this case study, it can be concluded that Manjisthadi Majja Basti along with various Panchakarma procedure is effective in the management of AVN of femoral head.

Keywords: Avascular Necrosis, Asthimajjagata Vata, Manjisthadi Majja Basti

Corresponding Author How to Cite this Article To Browse
Sakshi Gupta, Post Graduate Scholar, Department of Rog Nidan Evum Vikriti Vigyan, Pt. Khushilal Sharma Government (Auto.) Ayurveda College & Institute, Bhopal, Madhya Pradesh, India.
Email: 		Sakshi Gupta, Sanjay Srivastava, An Ayurvedic approach for the management of Avascular Necrosis (AVN) - A Case Study. J Ayu Int Med Sci. 2023;8(5):265-270.
Available From
https://jaims.in/jaims/article/view/2489

Manuscript Received Review Round 1 Review Round 2 Review Round 3 Accepted
2023-03-23 2023-03-25 2023-04-01 2023-04-08 2023-04-15
Conflict of Interest Funding Ethical Approval Plagiarism X-checker Note
Nil Nil Yes 19%

© 2023by Sakshi Gupta, Sanjay Srivastavaand 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].

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Gupta S et al: An Ayurvedic approach for the management of Avascular Necrosis (AVN)

Introduction

Avascular necrosis (AVN) is a condition that occurs due to disruption and loss of blood supply to the bone which leads to cellular death of bone tissue, also known as osteo, aseptic, or ischemic bone necrosis. Several factors like trauma, genetic factors, metabolic factors, use of glucocorticoids, diseases that promotes hypercoagulable states are the etiological factors of AVN. [1] Avascular Necrosis (AVN) is a chronic and degenerative disease affecting bone due to temporary or permanent cessation of the blood supply causing the bone structure collapse, resulting in bone destruction, pain, and loss of joint function. Initially, patients are asymptomatic, but with the passage of time, AVN leads to joint destruction, requiring surgical intervention and in latter stages, total hip replacement (THR) is required.[2] It typically affects the epiphysis of long bones at weight-bearing joints. The upper arm, knee, and ankle joints are also affected in the case of AVN. Usually, men are more prone than women. Patient of AVN of femoral head is often having pain in hip or groin region radiating to buttocks, thigh or knees, exacerbated by heavy weight and sometimes often by coughing.[3] Factors like pain in lower limbs, alcohol history, hidden diseases, disease of lower limbs etc. may lead to the misdiagnosis of the AVN.[4] In early stages AVN is difficult to diagnose from clinical findings and plain radiograph so early MRI should be done to verify clinical suspicion.[5] On the basis of clinical presentation, AVN can be correlated with Asthikshaya, Asthimajjagata Vata, and Asthibhagna, out of these Asthimajjagata Vata is more similar to AVN by its pathogenesis and symptoms. The sign and symptoms of Asthimajjagata Vata are Bhedoasthiparvanam (breaking type of pain in bones), Sandhishoola (Joint pain), Mamsakshaya (muscular wasting), Balakshaya (weakness), Sandhishaithilyam (flaxity of joints), Aswapna Satatruka (sleeplessness due to continuous pain), Shiryantiva Cha Asthi-Dourbalyani (destruction of bony tissue causing generalized weakness).[6] Asthimajjagata Vata can be cured if treated in acute stage but it becomes difficult for the complete recovery in chronic stages. The present day modern modalities includes administration of anti-inflammatory analgesics, steroid therapy, arthroplasty, femoral head graft, hip compression, hip replacement, osteotomy, and physiotherapy; each of them is having its own limitations and

they have serious side effects like loss of memory, weight gain, gastrointestinal disturbance, habit forming nature and dermatological diseases like psoriasis, eczema, contact dermatitis and SLE.[7] Since all the surgical treatments are cost worthy and having poor prognosis on AVN an effort is made to evaluate the efficacy of Manjisthadi Majja Basti Karma in the management of the AVN of femoral head.

Case Report

A 56-year-old female patient came to the OPD of Pt. Khushilal Sharma Govt. Ayurveda Institute, Bhopal having complaints pain in B/L hip joints which radiates to both thigh region (Rt. > Lt.), morning stiffness more than 30 minutes, pain in groin region, pain during prolonged sitting, difficulty in walking, restricted movement of both lower limb, sleeplessness due to pain and indigestion. The patient was well before 10 months then gradually pain start in right hip joint with stiffness which radiates in lower limb then after 2 months her condition become worsened and felt pain in left hip joint too. The pain aggravates during prolonged sitting on the chair or any other activity. The pain was so severe so her gait has been changed. Moreover, her day-to-day activities were also hampered due to pain and stiffness. The patient had received allopathic treatment (analgesic and physiotherapy) for 5-6 months but did not get satisfactory relief. Thus, she approached further for Ayurvedic management.

Table 1: History of Patient

SN History Details of the patient
1. Past history Patient suffering from covid in April 2021
2. Family history No, any important family history
3. Personal history Diet - Pure Vegetarian Addiction - No Krur Kostha, taking Alpa Aahar, Avara Jaran Shakti, doing Yoga and exercise daily Sleeplessness

Local Examination

1. Tenderness present in bilateral hip region and groin region (R > L)

2. Swelling (mild) - over bilateral hip joint.

3. Significant loss in the range of movement.

4. Gait - Trendelenburg sign positive.

5. Painful internal and external rotation.

6. Involuntary Movement - Absent


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Table 2: O/E Ashtavidha Pariksha

Nadi Vata Kaphaj
Mutra Prakrut
Mala Kathina
Jivha Saam
Shabdha Spastha
Sparsha Samasheetoshna
Drik Prakrut
Aakriti Madhyam

Table 3: Samprapti Ghatak

Dosha Vata - Kapha
Dushya Rakta, Sira, Asthi, Majja, Sandhi
Srotas Raktavaha, Asthivaha, Majjavaha
Srotodushti Sang
Rogamarg Marmaasthisandhi
Adhishthan Asthi-Sandhi
Udhabhavasthan Aam- Pakwashaya
Vyakta Sthan Asthi-Sandhi

Investigation

Table 4: Blood investigation dated December 08, 2021

1. Hb% 11.6 g/dl
2. ESR 31 mm/hr
3. RBS 107 mg/dl
4. Blood Urea 26.6 mg/dl
5. Serum Creatinine 0.73
6. Serum Calcium 9.2 mg/dl
7. Vitamin D 29.9 ng/dl

MRI - MRI scan (15/12/2021) revealed early stage of Grade III AVN on left side and Grade II

AVN on right side of femoral head.

jaims_2489_01.JPG


Assessment Criteria

The range of the movement of the hip joint i.e., Adduction, Abduction, Flexion, Extension, Internal rotation, External rotation was measured.

[Table No. 8] Assessment was done on the basis of subjective parameters. [Table No.5] Assessment was done on the basis of subjective criteria, signs and symptoms. Pain and morning stiffness was markedly reduced after Karma Basti course.

After completion of two rounds of Karma Basti patient was able to walk without any difficulty, leg raising from 30° to 60° and trendlenberg sign was improved.

Table 5: Grading of subjective parameters 

SN Symptom Criteria Grade
 1. Pain No pain while walking 0
Mild Pain while walking 1
Moderate Pain while walking 2
Severe pain while walking 3
2. Stiffness No stiffness 0
Stiffness for 10 - 30 min 1
Stiffness for 30 - 60 min 2
Stiffness for more than 1 hr 3
3. Movement of joints Normal 0
Mildly restricted 1
Moderately restricted 2
Severely restricted 3
4. Radiating pain Pain never radiates 0
Occasionally radiating 1
Mostly radiating 2
Radiating all the time 3
5. Gait Unchanged 0
Occasionally changed 1
Walk with support 2
Unable to walk 3
 6.   Sleep Normal 0
Occasionally disturbed 1
Frequently disturbed 2
Unable to sleep due to pain 3

Treatment Plan

This diagnosed case of Avascular necrosis of the femoral head was admitted to the female general ward of Pt. K.L.S. Govt. Ayurveda Hospital, Bhopal with IPD no. 2022808 and undergo the following procedures.




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Table 6: Panchakarma Therapy

SN Date Procedure Drugs used Quantity Days
1. 10/03/22 -16/03/22 Udhwartan Triphala Churna - 07 days
2. 10/03/22 -16/03/22 Vashpa Sweda Dashmool Kwatha - 07 days along with Udavartana
3. 17/03/22 -26/03/22 Sarvang Patra Pinda Sweda Eranda Patra, Nirgundi Patra, Shigru Patra, Ark Patra, Lemon, Harida, Coconut etc. - Next 10 day
4. 17/03/22 -26/03/22 Pishinchil Ksheerbala Tail + Vatashamak Tail - Next 10 days
5. 17/03/22 -31/03/22 B/L Vankshan Basti Vatashamak Tail - 15 days
6. 06/04/22 -09/04/22 Sarvang Patra Pinda Sweda Same as above - 4 days
7. 10/04/22 -13/04/22 Pishinchil Same as above   4 days
8. 15/03/22 -13/04/22 Manjisthadi Majja Basti (Karma Basti) Anuvasana basti Guggul Tikta Ghrit Majja Sehcharadi Tail Satpushpa Saindhav Niruha Basti Manjisthadi Kwatha Majja Guggul Tikta Ghrit Madhu     Satpushpa Saindhav   40 ml 40 ml 50 ml 20 gm 5 gm   150 ml 40ml 40 ml 40 ml 20 gm 5 gm 30 days     Anuvasan Basti - 18     Niruha Basti - 12

Table 7: Assessment before and after treatment

Symptoms Before treatment After 16 days of t/t After 30 days of t/t
Pain 3 2 1
Radiating pain 3 1 0
Stiffness 2 1 0
Movement of joints 2 1 1
Gait 2 1 1
Sleep 3 1 0
Trendelenberg Sign Positive Improved Improved

Table 8: Observation in Range of Movement of Hip Joint             

Range of Movement   Before Treatment After Treatment
Abduction (30°-50°) Right Leg 20 40
Left Leg 30 50
Adduction (20°-50°) Right Leg 20 25
Left Leg 30 40
Flexion (110°-120°) Right Leg 90 100
Left Leg 100 120
Extension (10°-15°) Right Leg 10 10
Left Leg 10 15
Internal rotation (30°- 40°) Right Leg 10 20
Left Leg 20 30
External Rotation (40°-60°) Right Leg 20 20
Left Leg 40 50


Discussion

Avascular necrosis is cellular death of bone components due to interruption of blood supply causing collapse of the bone, resulting in pain, loss of joint function and finally damage of the joint.[8] Avascular necrosis is usually of traumatic and non-traumatic causes. Some non-traumatic AVN are found to be associated with corticosteroid usage, alcoholism, infections, storage disorders, coagulation defects and some autoimmune disease.[9] According to Ayurvedic point of view, there is no direct mention of avascular necrosis but on the basis of clinical presentation, there is predominance of Vata Dosha and Vikruti (vitiation) of Asthi Dhatu. In AVN of femoral head, the blood (Rakta Dhatu) supply to the femoral head is decreased due to Margavrodha (occlusion of blood vessels) or Abhighata (trauma), and ultimately leads to necrosis. Margavrodha and Abhighata both are also responsible to aggravation of Vata Dosha and increase in Vata Dosha finally resulting into loss of Asthi Dhatu. In advance stage, due to continuous imbalance of Vata Dosha (due to necrosis), it is further responsible for vitiation of Pitta and Kapha Dosha also. So, here Basti is a choice of treatment for AVN, in all Panchakarma procedures, because Basti is the first line of treatment for Vata Dosha[10] and is also beneficial in the imbalance of Pitta, Kapha and Rakta Dosha.[11] Here the Avascular necrosis of femoral head on the basis of sign, symptoms, Dosha and Dushya is treated on the line of Asthimajjagata Vata Vikara. Snehan and Swedan is also considered as the line of treatment of Vata Vyadhi.[12] Snehan either internal or external is indicated for the disorder of Asthimajjagata Vata.[13] Swedan helps in reducing the heaviness and stiffness.[14] Rakta, Asthi and Majja are the main involved Dhatus in AVN. In Asthimajjagata Vata patient Manjisthadi Majja Basti (processed with bone marrow) was planned as Manjishthadi Kwatha is Tikta, Katu Rasa Pradhana and Ushna Virya which is Tridoshahara and Raktaprasadaka and Majja helps strengthen Majja Dhatu which in turn nourishes Asthi Dhatu. The ingredients of these Basti include Tikta rasa, Katu Vipaka, Ushna Virya, etc. They all combinedly enhance the properties of Majja and helps in balancing the aggravated Vata Dosha and favours normal functioning of Dhatvagni facilitating increased nutrition to the Asthi Dhatu, also Tikta Rasa has Srotoshodhan properties which help to clear the Srotosanga.


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The Majja nourishes Asthi by means of its Purana (filling) and Snehan properties and pacifies vitiated Vata in Asthi. In this, Basti Guggultiktaka Ghrita was used as a Sneha and Tikta Dravyas are having Tikta Rasa, Ushana Virya and Madhura and Kaṭu Vipaka favour normal functioning of Dhatwagni (metabolic stage), facilitating increased nutrition to the Asthi Dhatu (bony tissue). Thus, it pacifies Vata; improves the Dhatu Upachaya (metabolism of the tissues) and acts as a rejuvenator of the body and overall, this Basti helps in body metabolism.

Conclusion

Manjisthadi Majja Basti (Karma Basti) along with Udhwartan, Vaspha Sweda, Sarvang Patra Pinda Sweda, Pishinchal shows remarkable symptomatic relief in the features of avascular necrosis of femoral head. This case indicates that when treatment is done in accordance with Ayurveda guidelines avascular necrosis can be effectively managed and patient’s quality of life can be enhanced. This result needs to be studied in more numbers of populations for better assessment.

Reference

1. Robert S Weinstein, Erin A Hogan, Michael J Borrelli, Serguei Liachenko, Charles A O’Brien, Stavros C Manolagas; (2017) The Pathophysiological Sequence of Glucocorticoid-Induced Osteonecrosis of the Femoral Head in Male Mice, Endocrinology, Volume 158, Issue 11, Pages 3817–3831, [PubMed]

2. http:/ /emedicine.medscape.com/article/ 386808, updated: Aug 1, 2008.

3. Orban HB, Cristescu V, Dragusanu M. (2009) Avascular necrosis of the femoral head. MAEDICA-a Journal of Clinical Medicine. 1;4(1):26-34.

4. Chen ZW et al (2017), Study on the risk factors for the misdiagnosis of femoral head osteonecrosis. Zhongguo

5. Bohndorf K, Roth A. (2018) Imaging and classification of avascular femoral head necrosis. Orthopade. 47(9):729-734 [Pubmed]

6. Acharya YT, editor, Shri Chakrapanidatta, commentator, Agnivesha, Charaka Samhita, Chikitsasthana; Vatavyadhichikitsa Adhyaya, 28/33, Chaukhamba Surbharti Prakashan, Varanasi, 2014; page 617.

7. Epstien NN, Tuffanelli DL, Epstein JH. Avascular Bone Necrosis: A Complication of Long Term Corticosteroid Therapy. Arch Dermatol. 1965; 92: 170–80p. (PubMed)

8. Tofferi JK, Gilliland W (2008) Avascular Necrosis. Available via eMedicine. Accessed 18 Sep 2018.

9. Assouline-Dayan Y, Chang C, Greenspan A, Shoenfeld Y, Gershwin ME. (2002) Pathogenesis and natural history of osteonecrosis. Semin Arthritis Rheum. 32(2):94–124. [PubMed]

10. Bhahmanand Triphathi, editor. Astangharadyam. Sutra Sthana, Chapter 1, Verse no. 25–26. 2007 Edn. Delhi: Chaukambha Pratishthan; 2007; 20p.

11. Kaviraaj Ambikadutta Shastri, editor. Susruta Samhita. Chikitsa Sathana, Chapter 35, Verse no. 6. 2012 Edn. Varanasi: Chaukambha Sanskrit Series Publication; 2012; 189p.

12. Harish Chandra Singh Kushwaha, editor (2009) Charaka Samhita. 28th Adhyaya 75-78th shloka Chikitsasthana. 1st ed. Varanasi: Chaukhambha Sanskri Sansthan; reprinted 2018. p. 745.

13. Harish Chandra Singh Kushwaha, editor (2009) Charaka Samhita. 28th Adhyaya 93rd shloka Chikitsasthana. 1st ed. Varanasi: Chaukhambha Sanskri Sansthan; reprinted 2018. p. 749.

14. Harish Chandra Singh Kushwaha, editor. (2009) Charaka Samhita. 28th Adhyaya 80th shloka Chikitsasthana. 1st ed. Varanasi: Chaukhambha Sanskri Sansthan; reprinted 2018. p. 746


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