AVASCULAR NECROSIS Presented by Dr Aparna Chapra ,PG Scholar, Department of Panchakarma, Panchakarma Sdmcah Hassan

1. AVASCULAR NECROSIS
PRESENTER
DR APARNA
2ND YEAR PG SCHOLAR
SDM COLLEGE OF
AYURVEDA, HASSAN
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2. CONTENTS
 INTRODUCTION
 PATHOPHYSIOLOGY
 AETIOLOGY
 PRESENTATION
 STAGING
 MANAGEMENT
 AYURVEDIC POINT OF VIEW AND MANAGEMENT
 CASE REPORT
 ARTICLE
 DISCUSSION
 CONCLUSION
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3. INTRODUCTION
 Avascular necrosis (AVN), also called as osteonecrosis, aseptic
necrosis, or ischemic bone necrosis.
 It is a condition that occurs when there is loss of blood to the bone.
Because bone is living tissue that requires blood, an interruption to
the blood supply causes bone to die. If not stopped, this process
eventually causes the bone to collapse.
 Avascular necrosis most commonly occurs in the hip. Other
common sites are the shoulder, knees, and ankles.
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4. CAUSES
 Acute trauma
 Steroid therapy
 Alcoholism
 Sickle cell anemia
 Collagen vascular disease (e.g. SLE)
 Gaucher’s disease
 Radiation therapy
 Metabolic diseases(hyperlipidemia, gout, renal failure)
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5. PATHOPHYSIOLOGY
 Vascular occlusion
 Altered lipid metabolism
 Intravascular coagulation
 Healing process
 Primary cell death
 Mechanical stress
5

6. CLINICAL FINDINGS
 Initial maybe unrevealing or asymptomatic
 Tenderness around affected joint
 Restricted and painful active and passive movements
 Neurologic deficit
 Joint deformity and swelling
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7. PRESENTATION - EXAMINATION
 Limp
 Antalgic gait
 Restricted ROM
 Tenderness around bone
 Joint deformity
 Muscle wasting
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8.  Crescent Sign
 Snowcapping
 Areas of lucency
 Flattening of joint surface
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9. Crescent Sign
9

10. Luscent areas
Flattening of joint
surface
10

11. Snowcapping
Luscent areas
Flattening
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12. ARCO STAGING
Stage Clinical and radiological findings
0 Asymptomatic, radiology normal, histological diagnosis
I +-symptoms, normal CT and X ray, early changes on MRI
II Symptomatic, bone density changes on X ray, diagnostic MRI findings
III Cresent sign. IIIa - <15% articular surface, IIIb 15 – 30%, IIIc >30%
IV Collapse of head IVa - <15% surface collapsed, IVb 15 – 30%. IVc
>30%
V OA – narrowed joint space, acetabular sclerosis, marginal osteophytes
VI Extensive destruction of joint and involved bone
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13. MANAGEMENT PRINCIPLES
The goals of treatment for AVN are to improve or ensure
function of the affected joint, stop the progression of bone
damage, and reduce pain.
The best treatment will depend on a number of factors,
including:
 age
 Stage of the disease
 Location and amount of bone damage
 Cause of AVN
13

14. Early stages (I & II):
 Bisphosphonates prevent collapse
 Unloading osteotomies
 Medullary decompression + bone grafting
Intermediate stage (III & IV):
 Realignment osteotomies, decompression
 Arthrodesis
Late stage (V & VI):
 Analgesia, activity modification
 Arthrodesis
 Arthroplasties
14

15. MANAGEMENT - CONSERVATIVE
 Offloading affected joints with use of crutches
 Immobilisation
 Analgesia
 Bisphosphonates to delay femoral head collapse
 Statins in patients on high dose corticosteroids – reduced
lipid deposition
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16. CORE DECOMPRESSION
 Indicated in ARCO I and II
 8 – 10 mm anterolateral core of bone
 Filled with bone graft (vascularised/non vascularised)
 Decompresses medullary cavity, reduces pain
 Cortical (osteoconductive) or cancellous(osteoinductive)
bone graft
 Vascularised graft may reverse necrosis
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17. REALIGNMENT OSTEOTOMY
 Indicated in ARCO III & IV
 Used to relocate necrotic area from weight bearing portion
of femoral head
 Angular osteotomies more common
 Multiple techniques for holding the fixation
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18. ARTHROPLASTY
 Indicated in ARCO IV onwards
 Main aim is pain reduction
 Young patients will need revision
 Higher failure rates than in OA
 Hemi arthroplasty an option
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19. AYURVEDIC POINT OF VIEW
 अध्यस्थिदन्तौ दन्तास्थिभेदशूलं वििर्णता|
के शलोमनखश्मश्रुदोषाश्चास्थिप्रदोषजााः||१६||
 रुक् पिणर्ां भ्रमो मूर्च्ाण दशणनं तमसथतिा|
अरुषां थिूलमूलानां पिणजानां च दशणनम्||१७||
मज्जप्रदोषात्, ...|१८|
 भेदोऽस्थिपिणर्ां सस्न्िशूलं मांसबलक्षयाः|
अथिप्नाः सन्तता रुक् च मज्जास्थिकु वपतेऽननले||३३||
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20. MANAGEMENT PRINCIPLES
 Rukshana
 Shodhana – (mrudu virechana, shodhana basti)
 Brumhana
 Bahirparimarjana chikitsaa
 Shamana drugs
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21. CASE REPORT
VITAL DATA
NAME : Mahesh
AGE : 33
SEX : Male
RELIGION : Hindu
MARITAL STAT : Married
OCCUPATION :
ADDRESS : Hoskote
D.O.A : 21/02/17
D.O.D :6/03/17
OP NO:094477
IP NO : 19585
21

22.  CHIEF COMPLAINTS:
Pain in left hip joint region since 3 months
 ASSOCIATED COMPLAINTS
Restricted movements of hip and thigh since 3 months
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23. PAST HISTORY
4 years back patient suffered from asthma . He
consulted an Ayurvedic doctor who gave him
kashayas prepared by the physician himself which he
used for one and half years.
FAMILY HISTORY
Nothing relevant
23

24. H/O PRESENT ILLNESS
 Patient was said to be apparently healthy before 3 months, he gradually
developed with pain in left hip region. For which he consulted his family
doctor who prescribed him with volini spray, tablets for a duration of 10
days and an injection for 3 days. He got temporary relief. After 1 month
he developed with the same complaints and consulted the same doctor
who changed the medications and prescribed ORS. On February 16th his
pain at hip region increased to an extent where he couldn’t walk without
support. Then he consulted Srinivas Nursing home at Hoskote, and they
suggested to take X-ray and MRI and suggested for surgical intervention.
On February 20th he consulted Vikram hospital in Bangalore for second
opinion and they also suggested for surgical intervention. As he was not
willing for surgical intervention he approached SDM hospital for further
treatment.
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25. VITAL SIGNS
Pulse : 74bpm.
B.P : 120/80 mmHg.
Temperature : Afebrile
Respiratory rate : 20 / minute
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26. LOCOMOTOR EXAMINATION
Examination Before Treatment
Forward bending
Backward bending
Lateral rotation Restricted
Knee angel of flexion
Hip angel of flexion
 Pain in left hip region during walking
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27. MRI report:
IMPRESSION
Avascular necrosis of left femoral head – stage 3 (Arlet
and Ficat’s staging)
27

28. Day Treatment
21/2/17 1.Sar parisheka with dhanyamla and DMQ
2.Gandharva hastadi taila 10 ml with warm milk
@evening
3. Yogaraja guggulu 2 tid (a/f)
4.Manjistadi lepa – left hip region
22/2/17 Same above
5.Churna basti
23/1/17 Same above
Basti - NB and AB
28

29. Day Treatment
24/2/17 Same above
25/2/17 1.Sar abyanga with murivenna taila followed by sar
parisheka with dhanyamla and DMQ
2.Tiktaka ksheera basti
3.Remaining treatment same
26/1/17
27/2/17
28/2/17
Same above
Same treatment
1.Sar abyanga with MN taila followed by sthanika
parisheka with KB taila
2. Remaining same treatment
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30. Day Treatment
1/3/17
2/3/17
3/3/17
4/3/17
Same above
5/3/17 1.Mustadi yapana basti
2.Remaining treatment same
6/3/17
7/3/17
Same above
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31. DISCHARGE MEDICINES
1.Gandha 10 drops with milk @ night
2.Murivenna taila for (E/A)
3.Guggulu tikta kashaya
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32. ARTICLE
MANAGEMENT OF AVASCULAR NECROSIS THROUGH
AYURVEDA –A CASE STUDY
Vaishali Kuchewar
CASE REPORT:
A 55 years old patient brought to Kayachikitsa OPD of Mahatma
Gandhi Ayurved College Hospital & Research Centre, Salod, with the
complaints of severe pain in both hips radiating to thighs. He was not
able to walk, sit or even lie on either of the side. He felt comfortable
comparatively in supine position. On history taking, he had mild pain
in both hip joints. Transient relief was found with conventional
treatments. Thereafter his condition gradually worsened and he
developed inability to walk without support..
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33. MRI of both hips showed osteonecrosis of the femoral head, stage
III C. He was advised surgical intervention but patient was not
willing so he opted for Ayurvedic treatmentAs he had severe pain,
Tab Diclofenac sodium 100mg once a day after dinner was given for
first three days to make patient comfortable for Ayurvedic
procedures. Management was done on the basis of three components
of Rasayan chikitsa i.e. Rasa (nutrition), Agni (digestion&
metabolism) and Strotus
(Microchannels).
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34. Following procedures and medicines were advised.
 mruduSnehan(lightmassage) with Ksheerbala taila &
Swedan(foementation) with Nirgudi patra potali at lumber, hip
region & thighs was done - For 21days
 Panchatikta ksheera basti (medicatedenema) For 21days
 pranayam(Anuloma-viloma) – daily
 Gandharva haritaki – for 5 days10 gms at night with luke warm
water.
 Kaishor guggulu for 21 days5oo mg twice a day after meals
 Sarivadyasava - For 21 days20 ml twice a day after meals
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35.  Tab. Me-cal (Dhootpapeshwar) From first day For 21 days 1tab
twice a day
 Shiva gutika – From first day For 21 days 500 mg twice a day with
luke warm
Water after meals.
On discharge
 Kaishor guggul One month 5oo mg twice a day after meals.
 Sarivadyasava –One month 20 ml twice a day after meals.
 Tab. Me-cal (Dhootpapeshwar) One month 1tab twice a day
 Shiva gutika –One month 500 mg twice a day with luke warm
water after meals
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36.  After completion of treatment, he was advised only local
application of Ksheerbala taila & Nirgundi patra potali swedan.
He was also advised some light exercise like movements of hip
joints in supine position & rest.
 Outcome: Pain and range of movements were assessed. Pain is
assessed by using visual analog scale (VAS), where “0” is no
pain and “10” is severe pain. Range of movements assessed
subjectively. On the day of admission, pain graded as “9” on
VAS. After 5 days of treatment, pain reduced to grade 8.
Gradually the pain was reduced & it was graded as ‘2’. Range of
movements - he had significant improvement in range of
movement. After one year, MRI of both hip showed same stage
of avascular necrosis
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37. DISCUSSION
 Patient of AVN can be treated with rūkṣaṇa followed by śodhana
and bṛhmaṇa line of treatment.
 Ācāryas while explaining the dhātupāka avasthā (metabolism
process) clearly explained the importance of agni which is
singularly responsible for the formation of the dhātus. Thus,
correction of agni should be done by administration
of dīpana and pācana dravyas and the process of dhātu pāka must be
strengthened, the doṣas must be balanced and metabolic toxins must
be eliminated from the dhātus through pañcakarma.
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38.  As the pre-operative process, ācāryas have
prescribed “bṛhmyāṃstu mṛdu langhayet” which means the
usage of rūkṣaṇa for better bṛhmaṇa (rejuvenation)
 Basti is one among the pañcakarmas which clearly shows its
efficacy in chronic conditions due to its therapeutic effect
especially in its brimhana action . Therefore in AVN like
conditions this can prove to be a better modality of treatment,
as AVN represents gambhīra asthi dhātu involvement.
 In asthigatavāta tikta rasa auṣadhi (medicines with bitter taste)
are beneficial. However Anuvāsana (oil enema) can be
administered with the use of a tikta ghṛta
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39. CONCLUSION
 Ayurveda maintain the health in cellular level. In
ayurvedic prospective there is wide scope for management
in GambhirVyadhi.
 The AVN is considered as surgical disease and there is no
any positive conservative management in other system of
medicine.
 Conservative management of Avascular Necrosis
throughAyurvedic principle provides significant relief on
the basis of symptomlogy.
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40. THANK YOU
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