AYURVEDIC INSIGHTS OF AVASCULAR NECROSIS OF FEMORAL HEAD

Avascular necrosis of the femur head (AVNFH) is a debilitating disease caused due to the use of alcohol, steroids, following trauma or unclear (idiopathic) etiology, affecting mostly the middle aged population. Clinically AVNFH is associated with impaired blood supply to the femoral head resulting in bone necrosis and collapse.In Ayurveda, there is no direct reference of disease resembling to Avascular necrosis of femoral head, hence it can be understand on the basis of Vikaraprakriti of disease caused by vitiation of Dosa , Adhisthana (abodesite) and Hetu (causes of vitiation of Dosa ). In the present study an effort has been made to understand AVN on the ground of Ayurveda.


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Other conditions associated with non traumatic AVN include: 1. Gaucher disease, an inherited metabolic disorder in which harmful quantities of a fatty substance accumulate in the organs 2. Sickel cell disease 3. Pancreatitis, inflammation of the pancreas 4. HIV infection 5. Radiation therapy or chemotherapy 6..Autoimmune diseases 7. Decompression sickness, a condition that occurs when the body is subjected to a sudden reduction in surrounding pressure, causing the formation of gas bubbles in the blood.

Symptoms of Avascular Necrosis
In its early stages, AVN typically cause no symptoms; however, as the disease progresses it becomes painful. At first, you may experience pain when you put pressure on the affected bone. Then, pain may become more constant. If the disease progresses and the bone and surrounding joint collapse, you may experience severe pain that interferes with your ability to use your joint. The time between the first symptoms and collapse of the bone may range from several months to more than a year. 2

Pathogenesis
The pathogenesis of osteonecrosis is an area of controversy. Most experts believe that it is the result of the combined erects of genetic predisposition, metabolic factors and local factors, affecting blood supply, such as vascular damage, increased inter osseous pressure, and mechanical stresses. The mechanism responsible for the osseous infarction is fat embolism and intravascular flat globules are often found in resected femoral heads in idiopathic necrosis. It probably begins by and interruption of the blood circulation within the bone, subsequently the adjacent area becomes hyperaemic, resulting in de-mineralizationin trabecular thinning and later incollapse. 3 Treatment Treatment has been facilitated by using a widely accepted international classification system, effective earlier diagnosis using MRI and more aggressive surgical management. No universally satisfactory therapy has been developed, even for early disease. It is essential that AVN of the femoral head is diagnosed early because delayingthis disease by joint preserving measures have a much better prognosis and because the results of joint replacement are poorer in young individuals. 4

Ayurvedic View
There is no direct reference available in our literature which corresponds to AVN of femoral head. But with the help of Hetu, Dosha and Dhatu involvement we can make Samprapti of the disease. Hetu plays an significant role in the pathogenesis of any disease. Various factors liable for vitiation of Vata and Pitta, along with the factors guilty for vitiation of Asthivaha and Majjavaha Srotas are responsible for pathogenesis of AVN. Astangahridaya describes the factors responsible for provocation of Vata and Pitta. 5 Due to vitiation of Vata Dosha there is Dushti of Vyanavayu which is responsible for normal circulation of blood through vessels results in improper flow of blood through bone tissues which causes Toda, Ruka, Sausirya, Vataprakopaka Laksanas. Pitta Dosha Dushti is responsible for Rakta Dushti due to Ashrayaashrayibhava 6 and its Updhatu Sira which causes impaired vascular supply resulting in Kotha (osteonecrosis) of Asthidhatu.
Similarly, dietary factors such as intake of Abhisyandi and incompetent foods (Virudhaahara) that are responsible for Majjavahasrotodusti 7 , indirectly provokes Vata due to Srotoavrodha produced by Ama formation resulting in impaired work of Vyanavayu. Indulgence in unwholesomedietary and lifestyle factors cause vitiation of Asthivahasrotas; for e.g., overexercise, concussionand violent flexion directly leads to provocation of Vata, resulting in Asthiksaya. 8 which produce symptoms like Asthitoda and Asthishoolala prominently appears in AVN also. In later stage of AVN, if not treated earlier, there is an involvement of Majja in which symptoms of Majjaksaya like Asthisausirya (osteoporosis), Siryantaivacasthini (eleterioration of bone ) and Durbalaasthi (weakness of bone) appear causing death of bone tissue and collapse of bone.
Acharya Dalhan has mentioned that Purishdhara kala and Asthidhara kala are one and the same. 9 Hence causative factors responsible for vitiation of Purishvahasrotas also guilty for producing pathogenesis of Asthikshaya. The causative factors for vitiation of Purisavahasrotas are suppression of natural urges like defecation, excessive eating, 53 overeating during indigestion, weak digestive power and thin body constitution. Suppression of urge of defecation leads to Udavarta and ultimately to provocation of Vata. 10
l. Nidanaparivarjana: -The person suffering from AVN must avoid excess in etiological factors which provok Vata, Pitta, along with Asthivaha, Majjavaha and Purishavahasrotas and also some psychic factors such as· worry, fear, grief, anger, etc. Hence the physician should not recommend Tiksna drugs. Excessive biopurification and injury to vital organs should also be prohibited along with opposing treatment, as they lead to Asthiksaya.