E-ISSN:2456-3110

Case Report

Avascular Necrosis

Journal of Ayurveda and Integrated Medical Sciences

2023 Volume 8 Number 7 July
Publisherwww.maharshicharaka.in

Ayurvedic management of Avascular Necrosis of Femoral Head - A Case Study

S. Ashtankar H.1*, Wasnik (Thatere) V.2, S. Jain S.3
DOI: http://dx.doi.org/10.21760/jaims.8.7.33

1* Harshada S. Ashtankar, Post Graduate Scholar, Department of Swasthvritta and Yoga, Government Ayurveda College and Hospital, Nagpur, Maharashtra, India.

2 Vidya Wasnik (Thatere), Associate Professor, Department of Swasthvritta and Yoga, Government Ayurveda College and Hospital, Nagpur, Maharashtra, India.

3 Sumeeta S. Jain, Professor and HOD, Department of Swasthvritta and Yoga, Government Ayurveda College and Hospital, Nagpur, Maharashtra, India.

Osteonecrosis is a degenerative bone condition characterized by the death of cellular components of the bone secondary to an interruption of the subchondral blood supply. Also known as avascular necrosis. Avascular necrosis can be correlated to Asthi Majja Gata Vata and / or Asthi Dhatu Kshaya manifesting symptoms like Bhedo Asthi Parvanam (breaking type of pain in bones and joints), Sandhi Shula (joint pain), Mamsakshaya (muscular wasting), Balakshaya (weakness), Aswapna Santataruk (disturbed sleep due to continuous pain) and Sandhi Shaithilyam (afflicted joints) with Shiryanti Iva Cha Asthini Durbalani (destruction of bony tissue causing generalized weakness), Pratata Vata Rogini (other aggravated features of Vata). A wide range of treatment modalities have been mentioned in Ayurveda that are effective in such manifestations. A case of AVN with bilateral femoral head was treated with Shodhan followed by Brimhan. For Shodhan Jaladhauti, Bashpa Swedan, Vaitaran Basti and Manjhishthadi Niruha Basti was planned and Shashtishali Pinda Sweda and Panchatikta Kshir Basti were given along with internal medication. Patient was observed for symptomatic improvements based on the assessment done by the Harris Hip Score and the range of movement of the hip joint before and after treatment. The therapy provided marked relief in pain with improvement in gait and improved quality of life. Ayurvedic management provides significant relief and improves the quality of life.

Keywords: Avascular Necrosis, Asthi Majja Gata Vata, Ayurveda

Corresponding Author How to Cite this Article To Browse
Harshada S. Ashtankar, Post Graduate Scholar, Department of Swasthvritta and Yoga, Government Ayurveda College and Hospital, Nagpur, Maharashtra, India.
Email: 		Harshada S. Ashtankar, Vidya Wasnik (Thatere), Sumeeta S. Jain, Ayurvedic management of Avascular Necrosis of Femoral Head - A Case Study. J Ayu Int Med Sci. 2023;8(7):174-180.
Available From
https://jaims.in/jaims/article/view/2618

Manuscript Received Review Round 1 Review Round 2 Review Round 3 Accepted
2023-05-25 2023-05-27 2023-06-03 2023-06-10 2023-06-17
Conflict of Interest Funding Ethical Approval Plagiarism X-checker Note
Nil Nil Yes 19%

© 2023by Harshada S. Ashtankar, Vidya Wasnik (Thatere), Sumeeta S. Jainand 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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Introduction

Osteonecrosis is a degenerative bone condition characterized by the death of cellular components of the bone secondary to an interruption of the subchondral blood supply. Also known as avascular necrosis, it typically affects the epiphysis of long bones at weight-bearing joints. The most common sites for AVN are the femoral head, knee, talus, and humeral head. The hip is the most common location overall. Advanced disease may result in subchondral collapse, which threatens the viability of the joint involved.

Therefore, early recognition and treatment of osteonecrosis are essential.[1]

There are limited studies on the epidemiology of femoral head osteonecrosis in Indian population. ONFH in the North Indian patients is a disease of young individuals with male predominance. Steroid intake is most commonly observed in these patients followed by idiopathic, chronic alcohol consumption, and trauma.[2]

Treatment of AVN Hip depends on the extent of injury involved and is usually non-operative e like restricted weight bearing, using pharmacological agents like lipid-lowering drugs, anticoagulants, vasodilators, and bisphosphonates. While the operative options involve various processes like core decompression best used for Grade 1 and Grade 2 AVN hip and newer modalities which include vascularized free-fibula grafting, total hip resurfacing, and the total hip arthroplasty which is most effective in reducing pain and preferable for young patients.[3]

Avascular necrosis can be correlated to Asthi Majja Gata Vata and / or Asthi Dhatu Kshaya manifesting symptoms like Bhedo Asthi Parvanam (breaking type of pain in bones and joints), Sandhi Shula (joint pain), Mamsakshaya (muscular wasting), Balakshaya (weakness), Aswapna Santataruk (disturbed sleep due to continuous pain) and Sandhi shaithilyam (afflicted joints) with Shiryanti Iva Cha Asthini Durbalani (destruction of bony tissue causing generalized weakness), Pratata Vata Rogini (other aggravated features of vata) etc.[4]

Wide range of treatment modalities have been mentioned in Ayurveda that are effective in such manifestations.


Case Report

A 37-year-old male patient visited OPD of Swasthvrutta, Government Ayurveda College, Nagpur with chief complaints of Bilateral hip joint pain with restricted movement in the left leg, Difficulty in Walking with limping gait, unable sit in crossed legged position, Pain in calf muscles since 1 year.

Past History: Patient gradually gained weight from four to five years before the above symptoms appear. One year ago, symptoms like mild pain and stiffness in left gluteal region occur then it increases gradually with restricted movement of left leg and after four to five months pain and stiffness started in right gluteal region, difficulty in walking and sitting. He was limping to the left side while walking. Pain and stiffness are more in monsoon and cold climate. He took allopathy medicines for the same, but couldn’t get relief. So, for further treatment, he came to Swasthrakshan OPD at Government Ayurveda College, Nagpur

Personal History

Habit - Drinking Alcohol, Tobacco chewing

Diet - Mixed diet (non-veg 3-4 times, eggs daily)

Bowel - regular

Sleep - Disturbed

Dosha Dushya Lakshan: The predominant Dosha in the disease is Vata in association with Kapha. Avarana of Kapha and Meda over Vata may also be considered to play an important role in the manifestation of symptoms like stiffness and restricted movement of the hip joint in the patient.

Examination of Patients

Table 1: Astavidha Pariksha (Eight Fold Examination)

1. Nadi (pulse) 76/min, regular
2. Mutra (urine) Samyaka
3. Mala (stool) Regular
4. Jihva (tongue) Saam
5. Shabda (sound) Spashta
6. Sparsha (touch) Anushnasheeta
7. Drik (eye) Spashta
8. Aakriti (built) Sthool

Physical examination: Range of motion of the left hip was severely limited and painful in all ranges, with the difference in length of both lower limbs i.e., left limb was found smaller than


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right lower limb by 1.8 cm so the patient is bent down on the left side during walking. There was no muscle atrophy. The straight leg raise test of the left leg is positive and the right leg is negative. The range of motion of both knee joints was full and painless. Neurological testing of lower limb reflexes is normal.

Investigation MRI: Ficat and Arlet stage II and Mitchelle class A osteonecrosis of bilateral femoral heads. Diffuse marrow edema involving both femoral heads, neck, and acetabulum.

Bilateral mild hip joint effusion.

Assessment Criteria: Range of movement of the hip joint i.e., Abduction, Adduction, Extension, Flexion, Internal rotation, and External rotation was measured by Goniometer. Visual Analogue Scale (VAS) is used for pain & Harris Hip Score.

VAS Pain Score - In VAS Score “0” denotes No Pain and “10” denotes Worst pain

Table 2: Treatment

SN Drug Dose Time Duration
1. Guduchyadi Yoga 3 gm with lukewarm water Before food 30 Days
2. Kaishor Guggul 500mg After food BD 30 Days
3. Brihat Manjishthadi Kashay 15 ml After food BD 30 Days
4. Laghu Panchmool Siddha Kshir 50 ml Before Food BD 30 Days
5. Gandharvaharitaki Churna 3gm HS 30 Days

Table 3

SN Procedure Ingredients Quantity Duration
1. Dhouti Saindhav Jala with Saidhav Q.S 1 day
2. Bashpa Sweda Nirgundi Kwath Q.S 3 days
3. Vaitaran Basti Saindhav, Guda, Amlika, Taila, Gomutra 10 gm, 20 gm, 40gm, 40 ml, 160 ml 3 day
4. Pinda Sweda Godugdha and Shashtik Shali   12 day
5. Yoga Basti Manjishthadi Niruha Basti Anuvasan Basti Sahachar Tail Niruha Basti   7 day
6. Panchatikta Ksheer Basti Saindhav, Madhu, Amruta, Nimba, Patol, Vasa, Kantakari, Ghruta, Cowmilk, Water 20ml, 5gm, 3gm, 3gm, 3gm, 3gm, 3gm, 40ml, 120ml, 480ml 15 day

Pathya and Apathya

Pathya: Warm water, easily digestible food, Mudga Dal Khichadi, Puran Godhuma, Dhanyaamla, Laja, Jowar Roti, Ghrita, Dugdha.

Apathya: Diwaswapna, Ativyayam, Abhishyanada Ahara, exposure to cold air (AC, Cooler), maintaining one posture for a longer duration, jerky movement, lifting weights.

Observation and Results

Paim was assessed using a Pain VAS Score from 0 to 10. VAS was 3 in right leg before treatment and it came down to 0 after treatment. In left leg it was 8 and it became 1 after treatment. Body weight was reduced from 89 to 85 kg.

Improvement in the Range of Movement of the Hip Joint is shown in table (5). There was marked improvement in flexion, extension, adduction, abduction, internal rotation, and external rotation of hip rotation after completion of Shashtishali Pinda Sweda and Basti.

Table 4: Harris Hip Score before and after treatment

SN Criteria Assessment Right Leg Left Leg
1. Pain None/ignores (44 points) Slight, occasional, no compromise in activity (40 points) Mild, no effect on ordinary activity, pain after activity, uses aspirin (30 points) Moderate, tolerable, makes concessions, occasional codeine (20 points) Marked, serious limitations (10 points) Totally disabled (0 points) 30 44 20 30
2. Function: Gait Limp None (11 points) Slight (8 points) Moderate (5 points) Severe (0 points) Unable to walk (0 points) 11 11 5 8
    Support None (11 points) 11 11 11 11
    Cane, long walks (7 points) Cane, full time (5 points) Crutch (4 points) 2 canes (2 points) 2 crutches (1 points) Unable to walk (0 points)        
    Distance Walked - Unlimited (11 points) 6 blocks (8 points) 2-3 blocks (5 points) Indoors only (2 points) Bed and chair (0 points) 11 11 8 11
  Functional Activities: Stairs Normally (4 points) Normally with banister (2) Any method (1 points) Not able (0 points) 2 2 2 2
    Squatting With ease (4 points) With difficulty (2 points) Unable (0 points) 0 2 0 2
    Sitting cross legged with ease (5 points) with difficulty (3 points) Unable (0 points) 3 5 0 3
    Public Transportation Able to enter public transportation (1 points) Unable to use public transportation (0 points) 1 1 1 1
  Hip range of motion (Clinician assessed) Flexion (max 140°) Abduction (max 40°) Adduction (max 40°) External rotation (max 40°) Internal rotation (max 40°)        
  Range of Motion Scale 211 - 300 (5) 161 - 210 (4) 101 - 160 (3) 61 - 100 (2) 31 - 60 (1) 0 - 30 (0) 3 4 2 3
  Absence of deformity (Clinician assessed) Less than 30 ° fixed flexion contracture - Yes/No Less than 10 ° fixed abduction - Yes/No Less than 10 ° fixed internal rotation in extension Less than 3.2 cm limb length discrepancy - Yes/No If all 4 Yes (4) If less than 4 No (0) 0 0 0 0
  Total 100 72 (Fair) 91 (Excellent) 49 (Poor) 71 (Fair)

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Harris Hip Score was done before and after treatment. Significant improvement was found in Harris Hip Score from 72 (fair) to 91 (excellent) in right leg and 49 (poor) to 71 (fair) in left leg shown in table (4).

Harris hip scoring

<70 - Poor result, 70-79 - Fair result, 80-89 - Good result

>90 - Excellent result

Table 5: Range of Movement of Hip Joint

Range of Movement   Before Treatment (In degree) After Treatment (In degree)
Abduction Right Leg 15 20
Left Leg 10 15
Adduction Right Leg 15 25
  Left Leg 15 20
Flexion Right Leg 70 70
Left Leg 70 40
Extension Right Leg 10 15
Left Leg 8 10
Internal Rotation Right Leg 20 30
Left Leg 5 15
External Rotation Right Leg 15 20
Left Leg 20 25

A straight leg rise test was done before and after treatment. Due to stiffness and pain, pt was unable to lift his left leg above 20 degrees but after treatment, it was up to 80 degrees as shown in table (6)

Table 6: Straight Leg Raise Test

  Before Treatment (In Degree) After Treatment (In Degree)
Right Leg 90 90
Left Leg 20 80

Discussion

Prakriti of patient was Kaphavataj and there is increase in weight due to lack of physical work BMI is 26. Jaaladhouti Shudhikriya (voluntarily induced vomiting) is done for cleaning of Digestive tract and remove toxins from the body. It expels the vitiated Dosha and removes blockages from the body and purifies all the Chakras.[5]

In this disease, there is a predominant of Vata Dosha along with Avaran of Kapha and Meda Dosha due to the appearance of symptoms like stiffness and limited hip joint movement.

Vaitaran Basti and Bashpa Sweda with Nirgundi Kwath are advised for three days for Shodhan and removal of Stambha. The Lavan-Amla-Sneha-Gomutra Yukta Vaitaran Basti Is Laghu, Ruksha, Ushna, Tikshna and the majority of drugs are having mainly Vata Kapha Shamak action, owing to this property antagonism to Kapha and Ama. It reduces the symptoms like Shula, Stambha, Samkoch, Shoth associated with this disease.[6]

AVN of the hip joint develops basically due to obstruction of small vessels supplying to the femoral head leading to the gradual development of necrosis due to reduced vascular supply. Thus, Raktavaha Sroto Rodh becomes the prime cause leading to Asthi Dhatu Kshaya in hip joint. For this Majishthadi Niruha Basti Was given along with Sahachar Tail Anuvasan Basti. Manjishthati Kwath is Tikta, Katu Rasa Pradhana, and Ushna Virya which acts as Raktaprasadana and Tridoshhara.[7]

There is Asthikshaya in AVN and for Brumhan of Asthi Dhatu Snigdha, Shoshak and Kharatwa Guna are needed this quality is getting if Tikta Rasatmak Dravya processed with Sneha and milk. Panchatikta Ksheer Basti is given for Asthimajjagata Vata and Asthikshay in condition like AVN.[8]

Internal medicine along with Panchkarma therapy was given. Guduchyadi Yoga contains Guduchi, Musta and Triphala which pacify the Vata and Kapha Dosha by its property like Katu Kashaya Rasa and Ushna Virya. It is Amapachak and Medohar.[9] Bruhat Manjishthadi Kashaya and Kaishor Guggulu are drugs on Vatarakta in which Obstruction in blood vessels is the main cause. So, in condition like AVN it may help in improve blood circulation of the head of femur.

Laghu Panchmools Siddha Kshira plays an important role in osteonecrosis.[10] Gandharva Haritaki Churna is a mild laxative and acts as Koshtaamayghna and Strotoshodhak.[11]

In this case, Shodhan and Brimhan treatment modalities were planned. For Shodhan Jaladhauti, Bashpa Swedan, Vaitaran Basti and Manjhishthadi Niruha Basti was planned and Shashtishali Pinda Sweda and Panchatikta Kshir Basti were given along with internal medication.

Along with Medicine strengthening exercises to hip, knee and ankle and range of motion exercise in supine and standing were advised


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to enhance muscle strength and increase the range of motion of the hip joint. Pathya and Apathya were advised during and after the treatment.

Shaman medicine was prescribed for a month after discharge from IPD. Trayodashanga Guggulu 500 mg twice a day, Bruhat Manjishthadi Kwath 15 ml BD, Balaashwagandha Kshirpaka for a month along with Pathyaapthya and exercise. During follow up there was mild pain in left hip joint during excessive walking or physical work but no further deterioration in the symptoms was observed.

Conclusion

Progression of the osteonecrosis includes destruction of joint which leads to persistent pain and debilitation. In this case, Ayurvedic management shows improvement in Harris Hip Score and improves quality of life. Range of movement of the hip joint is also increased with the improvement in gait and marked relief in pain.

There is a need to aware people about the ayurvedic management of AVN to stop the further progression of the disease and conduct such studies on a larger number of samples to draw definite conclusion.

Reference

1. Matthews AH, Davis DD, Fish MJ, et al. Avascular Necrosis. [Updated 2022 Nov 14]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm. nih.gov/books/NBK537007/

2. Vardhan H, Tripathy SK, Sen RK, Aggarwal S, Goyal T. Epidemiological Profile of Femoral Head Osteonecrosis in the North Indian Population. Indian J Orthop. 2018 Mar- Apr;52(2):140-146. doi: 10.4103/ortho.IJOrtho _292_16. PMID: 29576641; PMCID: PMC5858207.

3. Pancham Prasad & Parvinder Singh Sandhu. An Epidemiological Study of Diagnosed Avascular Necrosis of Hip Joint (AVN Hip) Cases and Exploring the Etiology and Treatment Offered in Patients Coming to Dr. Hardas Singh Orthopedic Hospital and Superspeciality Research Centre, Circular Road, Amritsar, Punjab, Sch Acad J Biosci, Nov, 2020; 8(11): 344- 349.


4. Kashinatha shastri, editor. Charaka samhita of Agnivesha, Chikitsa sthana, Vatavyadhi Chikitsa, chapter 28, verse 33, Chaukhambha Sanskrit Sansthan; Varanasi: reprint 2007. p. 196.

5. Sarasvati SN. Gherand Samhita. Yoga Publication Trust, Munger, Bihar, India.2012, p. 64, v. 38-39.

6. Mukherjee A, Dwivedi OP, Dr. jain J,Khuje SMR, Efficacy of Vaitaran Basti with respective to Ayurveda, Journal of DrugDelivery and Therapeutics.2018;8(6-s):246-250

7. Shastri Pandith Parashurama, editor. Sarangdhara Samhita of Sarangdhara, Madhyamakhanda, Kwath Kalpana, second chapter, verse 136. 5th ed. Varanasi: Chaukambha Orientalia; 2002.p.162.

8. Kashinatha shastri, editor. Charaka samhita of Agnivesha, Sutra Sthana, Vividhsheetapitiya adhyay chapter 28, verse 27, Chaukhambha Sanskrit Sansthan; Varanasi: reprint 2007. p.573.

9. Yogratnakar edited by Laxmipathi Shastri, Medoroga Chikitsa, Verse 99/6 Published by Choukhamba Sanskrit. 1999, p. 284

10. Rao P. Sahastrayoga, Kshirpaka yoga prakaran, verse 5/12 published by Chaukhamba Publications, 2019 p. 239.

11. Kureshi M., Kedar N., Important Aushadhi Yoga used in ano-rectal disorders in clinical practice – a review. 2021;10(10):2227-8179.


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