Year :
2024
| Month :
June
| Volume :
18
| Issue :
6
| Page :
KD01 - KD4
Full Version
Ayurvedic Management of Avascular Necrosis of head of Femur: A Case Report
Published: June 1, 2024 | DOI: https://doi.org/10.7860/JCDR/2024/66768.19521
Tanika Yadav, Vaishali Kuchewar, Pankaj Yadav
1. Postgraduate Scholar, Department of Kayachikitsa, Mahatma Gandhi Ayurved College, Hospital and Research Centre, Salod (H), Datta Meghe Institute of Higher Education and Research (Deemed to be University), Wardha, Maharashtra, India.
2. Professor, Department of Kayachikitsa, Mahatma Gandhi Ayurved College, Hospital and Research Centre, Salod (H), Datta Meghe Institute of Higher Education and Research (Deemed to be University), Wardha, Maharashtra, India.
3. Postgraduate Scholar, Department of Kayachikitsa, Mahatma Gandhi Ayurveda College, Hospital and Research Centre, Salod (H), Datta Meghe Institute of Higher Education and Research (Deemed to be University), Wardha, Maharashtra, India.
Correspondence Address :
Ms. Tanika Yadav,
Postgraduate Scholar, Department of Kayachikitsa, Mahatma Gandhi Ayurved College, Hospital and Research Centre, Salod (H), Datta Meghe Institute of Higher Education and Research (Deemed to be University), Wardha-442001, Maharashtra, India.
E-mail: tanikaydv12@gmail.com
Abstract 
Avascular Necrosis (AVN) is a pathological condition characterised by a reduction in the blood supply to the subchondral bone, leading to the degenerative condition of the bone, marked by the death of cellular components of the bone. It is also known as osteonecrosis. The epiphysis of long bones at weight-bearing joints is typically affected. All of these conditions have a poor prognosis. In Ayurveda, it corresponds to Asthivahastrotodushtivikara (musculoskeletal disorder) as there is kshaya (necrosis) of asthi (bone) and Majja (bone marrow) dhatu (major structural components of the body). In modern medicine, AVN is managed by the use of corticosteroids and many surgical procedures such as drilling, insertion of prosthetics, or bone grafts. Therefore, Ayurveda provides a conservative line of treatment based on the principle of Asthi-majjagatkashaya (decalcification of bone) caused by abhighatajanyavataprakopa (trauma). A case of AVN with the right femoral head was treated with shaman (oral medications), Sodhana (bio-purification), and bruhmana (rejuvenation) procedures. The therapy provided significant improvements in pain and range of movement of the hip joint, based on the patient’s signs and symptoms before and after treatment. Conservative treatment can give outstanding results, improve the quality of life, halt disease progression, and help manage AVN by tissue regeneration without harmful effects.
Keywords
Asthi dhatu, Bruhmana, Kshaya, Musculoskeletal disorder, Sodhana
Case Report
A 36-year-old female reported to the outpatient department of Kayachikitsa with complaints of pain in the right hip joint, difficulty in walking, standing for long periods, sitting, and climbing stairs for one month. She had a history of a fall one month prior, after which she began experiencing mild pain in her right hip joint. After a few days, her pain gradually aggravated for which she consulted an orthopaedic surgeon who diagnosed her with AVN of the right femoral head with joint effusion based on Magnetic Resonance Imaging (MRI). She was advised for surgery but as she was not willing, she sought Ayurvedic management from this department. Clinical examination was done based on Ayurvedic parameters (Table/Fig 1),(Table/Fig 2).
She was a vegetarian with a normal appetite, and her bowel habits were normal, but her sleep was disturbed due to pain. On clinical examination, mild tenderness was noted in the right hip region, along with a decreased range of movement in the hip. Internal rotation of the hip joint was painful on the right-side. Investigations like Complete Blood Count (CBC) and blood sugar levels were within normal limits.
Assessment Criteria
1) The pain was assessed using the Visual Analogue Scale (VAS) (1), which scored an eight. The Straight Leg Raising (SLR) test was positive. After abduction of the hip joint up to her total capacity, the distance from the right toe to the left toe (Table/Fig 3) was 53 cm with pain.
2) Internal rotation of the right hip joint was painful up to 60° and external rotation of the right hip joint was also painful up to 60°.
Timeline of Treatment
She was diagnosed as a case of Asthi-Majja-gata Vata and was treated according to Ayurveda treatment principles for five months. Medicines and Basti (medicated enema) treatment were administered for Strotoshodhan (detoxification of body channels) to improve local blood circulation and nourish the Asthi Dhatu (bone) (2). According to Acharya Vagbhata, in Asthi Kshaya, Basti containing Ksheer (milk), Ghrita (clarified butter), and Tikta Rasa (bitter taste) should be administered (3).
As per above principle, Shaman chikitsa (oral medication) was given for one month while the patient was admitted to the ward. She got mild relief in symptoms. Upon discharge, she was advised oral medication for three months along with Pathya Sevana (healthy regime) (Table/Fig 4).
Shodhana Basti (medicated enema) was given in the form of Manjisthadikwathbasti (therapeutic enema) in a Yoga Basti schedule for 10 days. Shastishalipindsweda (red rice sudation) was given as Brumhanachikitsa (Rejuvenation) for 10 days (Table/Fig 5).
Observation
Clinically, there was a significant improvement in symptoms such as pain and tenderness. The range of motion of the right hip joint showed significant improvement (Table/Fig 6). But there were no significant changes observed in the MRI report.
Follow-up and Outcome
After 10 days of the Yoga Basti plan, the patient got mild relief in symptoms. She was able to sit in a squat position, and the SLR test increased from 60 to 80°. After follow-up of three months, she got complete relief. Her pain score became zero, she achieved complete flexion and abduction of the leg without pain, and internal and external rotation became painless (Table/Fig 7). Currently, the patient is off treatment and is keeping well.
Discussion
The AVN is a pathological condition caused by an interruption of subchondral blood supply, which results in degenerative bone condition characterised by the death of cellular components of the bone (4). It is also known as osteonecrosis, aseptic necrosis, or ischaemic bone necrosis (5). Typically, the epiphysis of long bones at weight-bearing joints is affected. Common sites of AVN include the femoral heads, humeral head, and knee joints it can affect both the bone and surrounding structures. The aetiology can be traumatic or non traumatic. Non traumatic AVN is caused by the blockage of blood vessels due to intravesicular or outer compression of blood vessels, limiting blood flow to the femoral head (6). Traumatic AVN is caused by an injury that disrupts blood supply. The most typical type of bone necrosis is AVN of the femur head, manifesting as a radiolucent band with demineralisation of unaffected bone in the fibrous zone and mottled area. The main issue is reduced blood flow to the bone or malnutrition of the bone. The femoral head portion has very little arteries that nourish it, making it more vulnerable to injury and eventual femur disintegration (6). AVN can be caused by the use of systemic steroids, certain inflammatory diseases like vasculitis, systemic lupus erythematosus, smoking, sickle cell disease, coagulopathy, infections like Human Immunodeficiency Virus (HIV), tuberculosis, and meningococcal infection (7). It mainly affects people in the age group of 30 to 50 years. Epidemiological data from the United States estimate the prevalence of AVN of the hip joint in the general population to be around 300,000 to 600,000 cases in the early 2000s, with about 10,000 to 20,000 new cases occurring every year (8).
In Ayurveda, there is no direct reference to AVN as a specific ailment. It may correspond to Asthi-majja-gata-vata (musculoskeletal disorder), elucidated under Vatavyadhi. Its symptoms include Bhedoasthiparvanam (bone-breaking pain), Sandhi Shula (joint pain), Mamsakshaya (muscle wasting), Balakshaya (weakness), Aswapna Santataruka (disturbed sleep due to continuous pain), Sandhi Shaithilyam (loosening of joints), and Shiryantiva Cha Asthi nidurbalani (generalised weakness due to destruction of bony tissue) (9). Asthi-majja-vahastrotodushti (musculoskeletal disorder) may occur due to abhighata (trauma) or margavrodha (obstruction), resulting in bone necrosis. In modern medicine, AVN is managed by the use of corticosteroids many surgical procedures such as drilling, insertion of prosthetics, or bone grafts. These procedures are costly and often have a poor prognosis. Therefore, a conservative treatment approach was chosen based on the principle of Asthi-majja-gata-kashaya (decalcification of bone) caused due to abhighatajanya-vata-prakopa (trauma). It was considered that there is an involvement of Vata dosha, asthi-majja dhatu vikriti, and raktavaha-strotodushti. This case of AVN in the right femoral head was treated with shaman (oral medications), Sodhana (bio-purification), and bruhmana (rejuvenation) procedures (10).
Chaturvedi A et al., conducted a study on AVN in which Shodhan and Shaman Chikitsa was given (10) but no Brumhaniya Chikitsa was used to give strengthen the bones, which is a unique aspect of this study. In present case, there was a history of a fall considered as traumatic aetiology, due to trauma, the patient started experiencing pain in the hip joint. Therefore, this case was treated based on the classical principles of Ayurveda, considering the Kashya of Asthi Dhatu, Brumhaniya Therapy, and Rasayana Therapy. Strotoavarodha (microchannel blockages), Ayurveda, can be used to explain pathogenesis due to the lack of blood flow to the hip joint or the head of the femur. Ayurveda claims that this condition is similar to Asthi-majja-gata-vata (AVN). Joint pain may gradually worsen, limiting one’s range of motion. The first line of treatment for Vata Dosha, (the regulating functional element responsible for movement and cognition) the dosha responsible for movement and digestion, is “Basti” (medicated enema). Additionally, it is explained for Rakta, (the body’s blood-regulatory functional factor) Kapha Dosha, and Pitta (the factor in charge of regulating body temperature and metabolic activity) (11). Along with Srotoshodhana (detoxification), Dosha Vilyana (releasing of toxins) takes place, which aids in reducing Margavarana of Vata. It enters the minute pathways of Srotasas (channels), hence pacifying Vata Dosha. The qualities of Ushna (hot), Ruksha (dry), and Tikshna (strong) serve to appease Sheeta (cold) and Snigdha (soothing) of Kapha (12). Keeping the above Ayurvedic principles in mind, the following treatment was planned and significant results were shown in this case. The patient’s quality of life improved, and she was able to perform her daily chores without any discomfort. Pain and tenderness disappeared, and the range of motion of the right hip joint also improved after treatment. However, there was no significant improvement shown in the X-ray and MRI reports.
Cap Ksheerbala is an excellent medicine for rejuvenation that fortifies the bones and joints, specifically calming the Vata and Pitta doshas (13). Shiv Gutika contains Shilajatu (Asphaltum Punjabianum) as its main content, helping to strengthen the bones by increasing the uptake of minerals like calcium, magnesium, and phosphate into the tissues of the bones and muscles. It reduces the risk of bone fragility and fractures. Humic acid, a key component, greatly reduces blood lipids, preventing fat deposits in the blood arteries and heart vessel obstruction. The reference for Shiv Gutika comes in the Shilajatu Prakarana of the Chakradutt book, where Lord Shiva revealed this Rasayana to Lord Ganesha, hence the name Shiv Gutika (14). Panchtikta Ghrita Guggulu has a Katu (pungent) and Tikta (bitter) taste, is Laghu (easy to digest), Rooksha (dry), Vishada (brings clarity), Sukshma (microscopic), Sara (brings movement), Katu (pungent), Vipaka (post-digestive effect), and hot in potency. Guggulu, on the other hand, has Lekhana (scraping and clearing the channels) properties, balances Tridoshas, and increases digestive power. It is extremely helpful in treating diseases like Asthikashaya and Asthi-Majjagat Vata (musculoskeletal disorders) as it serves as a “Srotoshodhak” (purifying agent) (15). Mahamanjisthadi Kwath is an Ayurvedic supplement that helps purify the blood, effectively maintaining Pitta vitiation and balancing Vata and Kapha doshas (16). Tab Me-cal is a unique blend of calcium, magnesium, strontium, and protein with Kukkutandtwak (eggshell) as its main content, stimulating chondrocyte differentiation and cartilage growth. It reduces pain, osteoresorption, and increases bone density in cases of osteoporosis and senile osteoporosis (17). Tab Hadjod (Cissus quadrangularisaids) speeds up the healing of fractures by lowering pain, oedema, and fracture mobility (18). Amalaki Rasayana, made from Embilica officinalis, includes all Rasas (tastes) except Lavana Rasa (salty taste), Laghu (light), Ruksha (dry) gunas qualities, Madhura (sweet) Vipaka (post-digestion effect), and Sheeta (cooling) Virya (effect). Rasayana is a form of Swathsyaurjaskara Bheshaja (rejuvenating medicine) that works to improve health by boosting immunity and treating ailments. Rasayana aims for achieving great Rasa and other Dhatus, long life, youthfulness, memory, immunity, intelligence, strength of body organs, and intelligence (19).
Lakshadi Guggulu: Due to its anti-inflammatory characteristics, Guggulu (Commiphora wightii) has properties such as Shothahara (anti-inflammatory) and Bhagna Sandhanakara (fracture mending), while Laksha (Lacifer Lacca) has properties such as Bhagnasandhana (bone healing) and Vranaropaka (wound healing). Additionally, Guggulu preparation eases discomfort by pacifying vitiated Vata dosha.
Guduchi Ghan Vati: Guduchi (Tinospora cordifolia) has a bitter flavour, light (Laghu), and unctuousness (Snigdha) qualities, which aid in boosting digestive capacity and acting as an anti-inflammatory, giving muscles power and relieving joint and muscle discomfort.
Snehan (body massage): Massage is said to help both Vata and Kapha dosha, as described by Acharya Sushrut in Chikitsa Sthana. Oil massage aids in pacifying the Doshas because Asthikshaya is mostly due to the predominance of Vata and Kapha Doshas.
Swedan (sudation therapy): Shastishali (red rice)+Ashwagandha (Withania somnifera) powder+Panchatikta Ghrita+milk Pinda Sweda. It is a type of Brimhana (bulk-promoting), Vatahara, and Balya (strengthening) Sweda. By virtue of its contents, including Godugdha (cow’s milk) and Shashtikashali, it provides nourishment to nervous tissues and gives muscles power. Following the administration of therapeutic heat, vasodilation occurs, which improves blood circulation and aids in the removal of waste materials. Anabolism increases as tissue gets the nourishment and oxygen. Sudation can alleviate tension and increase the range of motion by reducing stiffness and increasing tissue elasticity. The Shashtikashali Pinda Sweda technique increases tissue strength, resulting in more fluid motions (20).
Matra Basti (unctuous enema) is considered the best treatment mentioned in Chikitsa for Vata Rogais Basti. The major component of Kshir Bala Tail is Bala (Sida cordifolia) which is a strong neuroprotective herb that soothes pain and muscle stiffness, making it highly beneficial in Asthikshaya. Acharya Charak mentioned that ‘in diseases of Asthi, Basti should be given using Tikta Rasatmaka Aushadhi Dravya (bitter-tasting medicine) along with Ghrut (clarified butter) and Ksheer (milk) that is Saghrit Tikta Ksheer Basti.’ Tikta Rasa (bitter taste) is predominantly composed of the physical elements Vayu (air) and Akash (ether/space). It contains Tikta Rasa Pradhan Dravyas, a substance with Prithvimahabhuta (earth physical element), which aids in the growth and nourishing of bones. It has been shown to be helpful in Asthikshaya (bone decalcification) since it is snigdha (soothing), balya (strengthening), and brumhan (increasing bulk) (21).
Niruhabasti (decoction enema) consists of a Decoction of Dashmool Bharad (20 gm), Guduchi (Tinospora cordifolia) powder (10 gm), Kalka (paste) of Manjistha (Rubia cordifolia) powder (30 gm), Arjun (Terminalia arjuna) powder (20 gm), Saindhava (rock salt) (10 gm), honey (30 mL), and Sahachar oil (50 mL) for effective illness control, bone strengthening, healing, and to prevent relapse. The therapy provided significant improvements in pain and the range of movement of the hip joint.
Based on the patient’s signs and symptoms before and after treatment, symptomatic improvement was seen. Conservative treatment gave outstanding results and improved the quality of life.
Conclusion
Panchkarma therapy may be an alternative for AVN management without surgical intervention. Through Ayurveda, early diagnosis can be made, increasing the likelihood of a better prognosis.
Reference
|
| | 1. | Delgado DA, Lambert BS, Boutris N, McCulloch PC, Robbins AB, Moreno MR, et al. Validation of digital visual analog scale pain scoring with a traditional paper-based visual analog scale in adults. J Am Acad Orthop Surg Glob Res Rev. 2018;2(3):e088. Doi: 10.5435/JAAOSGlobal-D-17-00088. PMID: 30211382; PMCID: PMC6132313.
[ CrossRef] [ PubMed] | | 2. | Agnivesha, “Charaka Samhit”, revised by Charaka and Dridhbala with “Ayurveda Deepika” commentary, by Chakrapanidatta YadavajiTrikamaji Vd, editor. Acharya. Varanasi: Chaukhambha Surabharati Publications-221001 [reprint] 2002, Sutrasthana 28/27.
| | 3. | Vagbhata, Ashthanga Hridaya with Sarvaanga Sundara of Arunadatta and AAyurvedarasaayana of Hemadri-Dr. Anna Moreshwar Kunte and Krishna Ramachandra Shastri reprint of 6th edt. 1935 ChoukambaSurabhaaratiPrakashana Euro J Mol Clin Med. ISSN 2515-8260 Volume 07, Issue 11, 2020 8716 Varanasi Su.11/31.
| | 4. | Matthews AH, Davis DD, Fish MJ, Stitson D. Avascular necrosis. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan. 2023 Aug 28.
| | 5. | Kabra D, Jena S, Bhatted SK, Dharmarajan P. Healing avascular necrosis of femoral head: An Ayurvedic journey. Int J Health Sci Res. 2020;10(11):22-27.
| | 6. | Thomas A, Giri RV. Ayurvedic management of avascular necrosis of femoral head-a case study. J Ayu Int Sci. 2022;7(5):150-52.
| | 7. | Mont MA, Hungerford DS. Non-traumatic avascular necrosis of the femoral head. J Bone Joint Surg Am. 1995;77(3):459-74. Doi: 10.2106/00004623- 199503000-00018, PMID 7890797.
[ CrossRef] [ PubMed] | | 8. | Petek D, Hannouche D, Suva D. Osteonecrosis of the femoral head: Pathophysiology and current concepts of treatment. EFORT Open Rev. 2019;4(3):85-97. Doi: 10.1302/2058-5241.4.180036. PMID: 30993010; PMCID: PMC6440301.
[ CrossRef] [ PubMed] | | 9. | Acharya YT, editor. ShriChakrapanidatta, commentator, Agnivesha, Charka Samhita, Chikitsasthana; VatavyadhichikitsaAdhyaya. Vols. 28/33. Varanasi: Chaukhamba Surbharati Prakashan. 2014; pp. 617.
| | 10. | Chaturvedi A, Kumar MA, Lohith BA, Praveen BS, Swathi C. Role of Ayurveda in the conservative management of avascular necrosis of the femoral head: A case study. Anc Sci Life. 2016;35(3):173-75. Doi: 10.4103/0257-7941.179865, PMID 27143802, PMCID PMC4850778.
[ CrossRef] [ PubMed] | | 11. | Agnivesa C, Drdhabala C. Ayurvedadipika commentary of Cakrapanidatta, Vatashonita ChikitsaAdhayaya, Chikitsasthana, chapter 29, verse 88. In: Vaidya YadavjiTrikamji A, editor. Varanasi: ChaukhambhaSurbharatiPrakashan. 2016; pp.631.
| | 12. | Gauttam J, Jamir A, Verma P, Dharmarajan P, Bhatted S. Management of Asthi- MajjagataVata w.s.r. to Avascular Necrosis (AVN) of femoral head stage 3 by panchakarma-a case study. Int J Ayurveda Pharm Res. 2019;7(8):21-28.
| | 13. | Paradakar HS, editor. Ver. 45. Reprint ed. Varanasi: ChaowkhambaKrishandas Academy; 2006. Ashtangahridaya of Vagbhata, ChikitsaSthana; Ch. 22; pp. 732. [Google Scholar] [Ref list].
| | 14. | Mahadar SP, Jamdade YA. A review on the Rasayanas (Rejuvenatives) from Chakradatta and market survey for the availability of rasayana drugs and formulations. Int J Ayu Pharm Res. 2022;10(2):115-19. Available from: https:// ijapr.in/index.php/ijapr/article/view/2293.
[ CrossRef] | | 15. | Arundatta and Hemadri commentaries on Astangahrudyam of Vagbhata, Chikitsasthana, VatavyadhiChikitsa 21/58-61, ChaukhambhaSubharatiPrakashan; Varanasi: Edition 2014. pp. 726.
| | 16. | Samhita S, Tripathi B. ChaukhambaSurbhartiPrakashan; Varanasi. 2007; 488-53.
| | 17. | Patil SS. A review on kukkutandatwakbhasma. World J Adv Res Rev. 2023;17(1):564-66. Available from: https://doi.org/10.30574/wjarr.2023.17.1. 0084/.
[ CrossRef] | | 18. | Brahmkshatriya HR, Shah KA, Ananthkumar GB, Brahmkshatriya MH. Clinical evaluation of cissus quadrangularis as osteogenic agent in maxillofacial fracture: A pilot study. Ayu. 2015;36(2):169-73. Doi: 10.4103/0974-8520.175542. PMID: 27011718; PMCID: PMC4784127.
[ CrossRef] [ PubMed] | | 19. | Shastri PK. Charak Samhita Chikitsasthana-1/1, shlok no.13, Vidyotini Hindi Commentory by Pandit Kashinath Shastri. Varanasi: Chaukhamba Sanskrit series office; 1956.
| | 20. | Kumar V, Sonu A. case study on the effect of Shashtik Shali Pinda Sweda and Mahamasha Taila Nasya Karma in the management of Ekanga Vata with Mamsakshayaw.s.r. Demyelination of nerve, WJPP. 2022;6(10):1291-96.
| | 21. | Kumar S, Mangal G. Effect of tiktaksheera basti in the management of asthimajjagata vata with special reference to avascular necrosis of femoral head. Int J Scientific Res. 2022;11(1-2):1-2. Doi: 10.36106/ijsr/5405085. [ CrossRef] |
DOI: 10.7860/JCDR/2024/66768.19521
Date of Submission: Jul 28, 2023
Date of Peer Review: Oct 21, 2023
Date of Acceptance: Apr 06, 2024
Date of Publishing: Jun 01, 2024
AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. Yes
PLAGIARISM CHECKING METHODS:
• Plagiarism X-checker: Jul 28, 2023
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• iThenticate Software: Apr 05, 2024 (14%)
ETYMOLOGY: Author Origin
EMENDATIONS: 8
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