1,2 PG Department of Panchkarma, Institute for Ayurved Studies and Research, Shri Krishna Ayush University, Kurukshetra (Haryana).
3. Department of Research and Innovation, Shri Krishna Ayush University , Kurukshetra (Haryana).
Avascular necrosis of hip joint occurs due to disruption of blood supply of head of the femur .Osteonecrosis follow a pathway where apoptosis of osteoblasts & osteocytes occurs. Treatment for avascular necrosis of hip joint are available in modern science include some risky surgical procedures such as core decompression, insertion of bone grafts or prosthetics, total hip arthroplasty.All these procedures are costly with the poor prognosis. Ayurveda approach gives an understanding of its causes (hetu), pathogenesis (samprapti), and treatment planning (chikitsa). Here, a case of grade 2 and grade 3 AVN diagnosed as per modern medical science is being presented, which was treated with Ayurvedic medicines and panchkarma therapy. The patient’s condition was assessed based on the symptoms of asthimajjagat vata along with standard objective parameters such as x-ray and MRI of pelvis . Significant improvement was noted in this case in classical signs and symptoms as well as in modern objective parameters. This case gives a focus on the prognosis and treatment approach of AVN through Ayurvedic point of view.
Avascular necrosis or osteonecrosis is a degenerative bone condition characterised by the death of the cellular components of the bone due to an interruption of blood supply. It majorly effects the epiphysis of long bones, mainly at the weight bearing joints. Thus the most common site for AVN are the femoral head of hip joint , knee joint , talus of the ankle joint , humeral head of the shoulder joint. The femoral head of the hip joint is the most common site overall. Avascular necrosis of femoral head categorised in two classes -traumatic or atraumatic ,eventually both the causes leads to the ischemia of the femoral head and osteonecrosis of the osteocytes. Common classifications that map the phases of osteonecrosis of hip joint are : Ficat and Arlet and Steinberg classifications . Here in this case study we will discuss about Ficat grade 3 and Ficat grade 2 avascular necrosis of the left and right hip joint respectively. Symptoms of avascular necrosis of hip joint includes pain in hip and groin area, stiffness in hip joint, pain and stiffness in thigh region ,limping gait. In modern science in early cases with subchondral lucency nonoperative treatment like pain control, physiotherapy, modification in daily activity may be done however many patients ultimately need a total hip arthroplasty. Therefore, there is a need to understand this disease from the other system of medicines. Symptoms mentioned in AVN can be correlated with the lakshana of Asthimajjagata vata. Internal regimen (Panchatikta ghrita gugglu) and Panchtikta ksheer basti is used in management of Asthimajjagata vata because tikta rasa is indicated in asthi and majja dushti vikara in charaka samhita. Basti is the best method in treatment of vitiated vata vikara. Hence the overall treatment is working on vitiated vata vikara in asthi & majja dhatu.
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Table 1. Prognosis can be made according to the severity of conditions mentioned in Asthimajjagata vata.
Samprapti Ghataka:
Dosha – VataPredominant
Dushya – Rakta, Asthi, Majja
Srotasa – Asthimajjawaha
Srotodushti – Sanga
Adhistana – Kati, Vankshan, Uru pradesha
Agni – Agnimandhya
Sadhyasadhyata – Kastsadhya
CASE STUDY:
A 36?year?old male named Shiv Kumar, diagnosed case of bilateral femoral avascular necrosis since 1 year came to the Out Patient Department (OPD) of Panchkarma department of Institute for Ayurved Studies & Research Hospital, Shri Krishna AYUSH University for possibility of management for his condition. The patient presented with symptoms like pain in bilateral hip region and groin area, stiffness in hip joint, pain and stiffness in thigh region, limping gait, disturbed sleep. 2 years ago the patient was fine with normal gait. Then gradually he started to develop pain in groin region during abduction and internal rotation of the hip joint and morning stiffness was present. He had taken allopathic medicine and got symptomatic relief. After sometime he again started pain in groin and hip region .This time there was stiffness in hip joint almost all over the day and there was restricted movement of the hip joint. Both joints were involved but left side was more affected. He had gone in allopathic hospital and diagnosed with AVN of Hip joint B/L . Patient had taken treatment for months but there was only mild relief. Pain was consistent and stiffness was increased .Walking and climbing on stairs were making the pain worsen. There was limping in gait. Pain was persist even at rest. The patient advised for replacement of the hip joint. But he was not willing for any surgical procedure. Then patient came in OPD of Panchkarma department of Institute for Ayurved Studies &Research Hospital with the above complaints.The diagnosis was made on the basis of Asthimajjagat vata lakshana ,lab reports, radiological findings which was Kashtasadhaya to manage.
MEDICAL HISTORY
There was no history of hypertension.
B.P was 116/74 mmHg
There was no history of DM or any metabolic disorder.
PERSONAL HISTORY
Prakriti- Kaphaj
Sara- Mamas sara
Samhanana- Madhayam
Satva-Madhyam
Apetite- Good
Bowel- Regular
Bladder- Normal
Sleep- Sound sleep
Patient was non alcoholic & there was no history of smoking.
Patient was vegetarian by diet.
LAB REPORTS
Hb – 10.2 gm/dL
BSL-R – 129.8 mg/Dl
RADIOGRAPHIC FINDINGS
There was mild flattening of the femoral head with evidence of subchondral fracture. Mild synovial collection is seen in left hip joint. Mild marrow edema was seen in the head and neck region of femur -imaging features were suggestive of likely representing stage 3 necrosis.
The imaging features of right femoral head likely representing stage 2 avascular necrosis.
PHYSICAL EXAMINATIONS
Physical examination were done to rule out the disease.
Flexion of the hip joint- 3/5
Extension of the hip joint- 2/5
Abduction of the hip joint-2/5
Internal and External rotation of the hip joint-2/5
SLR Test- can’t be performed accurately due to severe pain in hip joint
Patrick Test - +ve
Gait- Antalgic gait
Planter reflex- Mild Diminished B/L
Therapeutic focus & Management:
In this case, Bahya chikitsa as Patrapotali savedna with Dhanwantar oil, Kati basti with mahanarayana oil and Abhyantara chikitsa as Panchatikta ksheer basti with internal medication like Panchatikta ghrita guggul , Giloy satva ,Kukkutandtawak Bhasma ,Praval pishtiwere given.
ASSESSMENT & RESULT :
The patient’s condition was assessed in every 30 days after completing successful planning of Panchatikta ksheer basti. Significant improvement was noted in Vankshana Sandhi shool . The patient did not need to get any painkiller during this period. Internal medication were continued for 6 months. After that an X-ray was repeated. Visualised bones under the X-ray appeared normal. There was no evidence of any obvious fracture seen on the radiograph. There was no dislocation seen. The articular margins and the joints spaces were normal. There was no sign of any obvious necrosis seen.
Table 2: Before and after treatment comparison and assessment
Table 3: FICAT Classification of Osteonecrosis of hip joint
BT: Before treatment; AT: After treatment; LT: Left; RT: Right; B/L: Bilateral
Table 4: Before and after treatment comparison and assessment:
LAKSHANA according Classical text (grading was done as per Ayurveda parameter)
*Separate grading was adopted for the symptoms.
BT: Before treatment; AT: After treatment; acc: according;
Table 5: Changes observed in range of Hip joint movements before and after treatment
DISCUSSION:
The term Asthimajjagat vata refers to vatavyadhi in which predominently dosha is vata vitiated in asthi and majja dhatu & control over agni is lost at asthi dhatu site due to which there is dhatukshaya occurs in asthi and majja dhatu which leads to necrosis of asthi dhatu.This is dhaupaka awastha. Prithvi mahabhuta is decreased in asthi dhatu which leads in asthisarahinata. Panchtikta ghrit gugglu has Anti-inflammatory action. It reduces pain, and swelling in inflammatory conditions. It helps to purify the blood from toxins. It May boost bone mineral density and slow down bone degeneration . Thus it is a drug of choice in AVN Kukutandtawak Bhasma primarily works to balance kapha and vata doshas. It's a good source of calcium and aids in improving bone density by enhancing the Khara guna (strength and hardness) of bones. Giloy Satva helps to eliminate aama dosha from the body, increase Khara guna in bones. It has raktaprasadaka property & also act as catalyst for other drugs.
Patra Pinda Swedana is generally indicated in Vata Kaphaja conditions, owing to the properties of ingredients used. Patra Pinda Swedana being a Snigdha sweda pacifies morbid Vata. Patra Pinda Swedana was done with Nirgundi Patra. Leaves of the Nirgundi plant have analgesic, anti-bacterial and anti-inflammatory properties. It also possesses anti-histaminic properties and is muscle relaxant.Nirgundi Patra Pinda Swedana owing to the anti-inflammatory action, Snigdha and Ushna Guna of the materials used to subsides the inflammation, pacifies morbid Vata and Kapha Dosha, thus reducing pain and stiffness.
Ksheera Bastiserves dual function, i.e., Niruha and Anuvasana; hence, it acts as Shodhana as well as Snehana. Ksheera Basti relieves the Margavarodha and produces Brimhana effect . Panchatikta Ghrita is dominant of Tikta Rasa and Ushna Virya. Tikta Rasa increases the Dhatvagni (metabolic stage). As Dhatvagni increase, nutrition of all the Dhatus will be increased. As a result, Asthi Dhatu and Majja Dhatu may get stable, and Asthi Dhatu and Majja Dhatu Kshaya will be decreased. Ksheera possesses Snigdha, Brimhana, Balya, and Sandhaneeya property and hence used for Dhatuposhana purpose.
CONCLUSION:
The above?mentioned case study shows that the symptoms of AVN of hip joint can be successfully treated in accordance with the basic principles of Ayurveda. Apart from that, this case helps to make the proper prognosis. This study can support in further research of the treatment of AVN with the help of Ayurveda principles.
SOURCE OF REPORT:
Department of Panchkarma, Institute for Ayurved Studies and Research, Faculty of Ayurved, Shri Krishna AYUSH University, Kurushetra, 136118, Haryana.
REFERENCES
Raja Singla , Narender Kumar , Prerna Sharma , Management of Avascular Necrosis Through Ayuveda: A Case Study, Int. J. of Pharm. Sci., 2024, Vol 2, Issue 8, 3301-3306. https://doi.org/10.5281/zenodo.13337160
10.5281/zenodo.13337160
