(Dhatukshyajanya) W.S.R. to Avascular Necrosis

Patient name: A. B. C.
Sex: Male
Age: 29 years
Business: Advocate
Desha: Anupdesha
Cast: Hindu
Saratva: Mansasar
Prukriti: Kaphavatanubandhi
D.O.A. – January 17, 2012
D.O.D. – March 12, 2012

Present Complaints:

Patient came in our hospital i.e. Seth R. V. Ayurved Hospital, Sion on January 17, 2012 with following complaints

UbhayaVankshansadhiGraha (Bil. hip joint stiffness) with Sashulakriya (pain and restricted movements); Ubhayapadachimchimayana (Tinglimnumbness) since 4 month.

Past History:

Radiation therapy for malignant soft tissue neoplasm of perennial region before 4 ½ month and also taking same medicine for that but temporary relief is there but now all the symptoms are exaggerated and even he could not walk also for same distance on a plane surface.

Family History: Nad

Radiological Investigations:

MRI Of BIL Hip Joints on dated November 30, 2011
S/O Bilateral AVN of femoral head with irregular articular surface of left femoral head. Moderate effusion of both hip joints.

MR of BIL Hip Joints on dated February 15, 2012

S/O Extensive bilateral AVN of femoral head with extension edema in neck, intertrochanteric region and visualized upper shaft. Osteoarthritic changes in femoral shaft.

MRI of BIL Hip Joints on dated March 15, 2012

S/O There is no AVN changes in bilateral hip joints. Both hip joints are normal mineralization.

Asthtavidh Parikshan:

Shabda: Spastha
Sparsh: Normal
Druka: Normal
Aakruti: Madhyam
Nadi: 76/min Regular
Mala: Normal
Mutra: Normal
Jivha: Nirama
Bhar: 80 Kg.

Samanya Parikshan:

Nadi: 76/min
BP: 110/70 mm of Hg
Aaharshakti: Normal
Nidra: Normal

Strotasa Parikshana:

Ashtimazzavaha Stritasa:

UbhayaVankshansadhiGraha (Bil. hip joint stiffness) with Sashulakriya (pain and restricted movements); Ubhayapadachimchimayana (Tingling numbness)

Sandhiparikshan:

                                                            RT                            LT

SLRT                                                  200                              300
Abduction movement                          200                              300
Adduction movement                          200                              300

All the movements of bilateral hip joints are very painful. Other Strotasa are normal.

Nidan Panchak :

Hetu:

Aahar: Ruksha, Tiktakatu rasa pradhan; irregular diet habit; Viruddhaaaharsevan.
Vihar: Prolong standing, Regularly traveling for 2-3 hrs. Bike riding.
Manas: Chinta, Bhaya.
Agantuj: Radiation therapy.

Purvarupa:

UbhayaVankshanasandhishula.

Rup:

UbhayaVankshansadhiGraha (Bil. hip joint stiffness) with Sashulakriya (pain and restricted movements), Ubhayapadachimchimayana (Tingling numbness)

Samprapti

1)  Hetusevan
2) Vitiation of Vata dosha
3) Rukshata, Parushata, Kharata of Ashti-mazzavahastrotasa
4) Vayupurana at Riktastrotasai. e Vankshansandhi
5) VankshansandhigataVatavyadhi (Dhatukshyajanya) i. e AVN of femoral head

Upashaya:  Due to local Oliation and Hot fomentation.
Unupashaya: Due to hetusevan and Apathyasevan i.e. prolong standing and traveling.
Rogamarg: Abhayantar
Adhisthan: Asthi-Mazzavahastrotas
Hetu: Apatarnajanya
Avastha: Navavastha

Vyadhi Vyevocheda (Differential Diagnosis)

1) MargaavarodhajanyaSandhigatavata
2) Vatarakta (Gambhiravastha)
3) Rakta-avruttavata

Chikitsa Vaishishtey:

A) Aushadhi Chikitsa

1) Kaishor Guggulu 500mg TDS : Has Vatahara, Raktaprasadan, Strotoshodhan properties.
2) Sanshamanivati 500mg TDS: Due to tiktarasapradhan it is sukshmastrogami and also act as rasayanadravya.
3) Bramhivati 500mg HS: Act as manavikshobhahara i.e. calming effect because patient is very anxious about his illness.
4) Suvarna Sameerpannag RAS 125mg BBF: It is Sukshmastrotogami and Balya
5) Arjun Churna 500mg + Punarnava Churna 500mg + Daruharidra Churna 500mg + Manjistha Churna 500mg TDS with Luke worm water. They are Raktaprasadak and because its Raktaprasadak nature they act as SukshmaRaktavahiSiraprasadaka(small blood capillaries)
6) Shatavari 1gm + Ashvagandha 1gm + Bala Churna 1gm TDS with Milk. They have Balya and Raktaprasadak therefore help for cartilage regeneration at the site of AVN.
7) Inj. Zoledronic acid (4mg) IV infusion over in 20 min single does.  It is a Bisphosphonate are a class of drugs that prevent the loss of bone mass, inhibit the digestion of bone by encouraging osteoclasts to undergo apoptosis or cell death, there by slowing bone loss.

B) Panchakarma Chikitsa:

1) SarvangSnehana with Tilataila: It helps for oilation of body and stabilizes the vitiated vata dosha and nourishes the Asthidhatu.
2) Petisweda: Due to hot fomentation Ghrahata, Kriyakshtata and Chimchimayana of joint get minimizes and improve the restricted movements.
3) VankshanasandhiPichudharan with Balataila: Local snehan and swedan it minimizes ghrhata.
4) Pizinchil: In this procedure both snehan and swedan done simulteniosly.
5) Yogabastikram – 8 basti - Pakwashayashodhan and snehan and act as Vatahara.
6) TiktakshiraBasti for 15 days - Because of Tiktarasdravyapradhanya it is Sukshmastrotogami and a Asthi-Mazzadhatvaagnideepan and help to formation of healthy Asthimazzadhatu.
7) MahasnehaBasti : for 30 days - ( Mahatiktakghrut 20 ml + Balataila 20 ml + Mansaras 50 ml + Arjunchurna 10 gm + Musthachurna 10 gm + Milk 250 ml). It helps for Asthi and Mazzadhatuposhan.
8) Jalokaavacharana : 15 times at the site of AVN region over both hip joints. It helps for to maintain blood circulation at the site of AVN.

Evaluation of Improvement:

Day 1st (January 17, 2012)
C/O Vankshanasandhigraha with sashulakriya and Ubhayapadachimchimayana
All the movements of bilateral hip joints are very painful and he can’t able walk same steps on plane surface.

On January 18, 2012
C/O Vankshanasandhigraha with sashulakriya and Ubhayapadachimchimayanareduced by 10%.
All the movements of bilateral hip joints are less painful and he can able to walk same steps on plane surface and also walk on 10 – 15 stairs up and down.

On (February 15, 2012)
C/O Vankshanasandhigraha with sashulakriya and Ubhayapadachimchimayanareduced by 40%.
All the movements of bilateral hip joints are less painful and he can able to walk same steps on plane surface and also walk on 25- 30 stairs up and down.

On (March 1, 2012)
C/O Vankshanasandhigraha with sashulakriya and Ubhayapadachimchimayanareduced by 60%.
All the movements of bilateral hip joints are less painful and he can able to walk same steps on plane surface and also walk on 90 - 100 stairs up and down.

On (March 12, 2012):
C/O Vankshanasandhigraha with sashulakriya and Ubhayapadachimchimayanareduced by 80%.
All the movements of bilateral hip joints are less painful and he can able to walk same steps on plane surface and also walk on 90 - 100 stairs up and down.

Table Shows Improvement in Movement of Hip Joint:

Date Straight Leg Raising Test (Degree) Abduction Movement (Degree) Adduction Movement (Degree)

                               RT   LT   RT   LT   RT   LT

January 17, 2012     20   30    20    30    20   30
January 30, 2012     30   40    40    40    40   40
February 15, 2012   40   40    40    40    40   40
March 1, 2012         60   60    50    50    50   50
March 12, 2012       70   70    60    60    60   60

Patient was discharged on March 12, 2012 with considerable improvement. At time of  discharged he can walk on plane as well as irregular surface without any kind of restricted movements or pain of the both hip joints. After discharged from hospital patient give regular follow up on OPD basis on every 15 days of interval with free from all symptoms of hip joints.