By Dr Raghuram Y.S. MD (Ay) & Dr Manasa, B.A.M.S
Avascular means lack of blood supply. Necrosis is death of cells in a tissue or organ, due to disease, injury or lack of blood supply. Avascular necrosis means ‘death of bone tissue’. It happens due to lack of blood supply. Avascular Necrosis is also abbreviated as AVN.
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What is the consequence
When there is lack of blood supply to the bone, small breaks can occur due to death of its tissue. Eventually it may lead to bone collapse.
When a bone breaks or joint gets dislocated, there can cause obstruction of blood flow to a part of bone. The disease usually affects the joints of the body. It may occur on one side or is bilateral (like afflicting both hips, both knee joints etc).
Read – Diseases Due To Pathological Bone Tissue – Asthi Pradoshaja Rogas
Osteonecrosis – osteo means bone, necrosis means death
Ischemic bone necrosis
Who is afflicted by AVN?
AVN is most commonly found to occur in people between 30-50 years age group. But it can affect anyone. Some references tell that most people suffering from AVN are between 20 and 50 years of age.
In many people there may not be any symptoms especially in the earlier stages of the disease.
Pain of AVN – In advanced conditions, the disease becomes worse. In this condition one may experience joint pain.
– At the beginning it might hurt only when you put pressure on the affected bone. Later the pain becomes constant.
– Joint hurts more when more weight is transferred onto the joint. The pain of AVN is also felt when one lies down.
– If there is collapse of bone and surrounding tissue the pain gets severe. In this condition one will not be able to use the joints. The range of movements too will get restricted.
– The time gap between the first symptoms of AVN i.e. pain and bone collapse may range from several months to more than one year.
Nature of the pain – The pain of AVN may be mild or severe in nature. It usually develops gradually.
Common seats of AVN – AVN most commonly occur in the hips. Other sites are shoulder, knee, hand and foot (ankles).
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When to consult the doctor?
– Joint pain is worse, persistent and intolerable
-feeling that your bone has been broken or joints dislocated
Reduction or interrupted blood supply to a bone is the main cause of avascular necrosis.
Causes of reduction in blood supply to the bone
1. Bone / Joint trauma – caused by –
– dislocation of joint
– damage to bone due to injury
– cancer treatments weaken bones and harm blood vessels since it involves radiation
AVN may affect 20% of people or more in whom hip dislocation takes place.
2. Deposits of fats in blood vessels – which eventually block the small blood vessels. This will reduce the blood flow to the bones and there will be death of bone tissue.
3. Impact of diseases – like sickle cell anemia and Gaucher’s disease may cause reduced blood flow to the bone causing death of bone tissue.
4. Arterial pathology / damage – blood clots, inflammation and damage to arteries can block blood flow to the bones causing AVN.
5. Use of steroids in higher doses for a longer time – 35% of non-traumatic AVN are said to be caused by long term use of steroids. They are believed to increase blood fat deposits leading to hampered blood flow to bones and joints.
6. Excessive consumption of alcohol – might lower blood supply to the bones by causing deposits of fat in the blood / blood vessels.
7. Treatments – radiation therapy for cancer, organ transplants
Note – The cause of disruption of blood supply to the bones is not known in about 25% of people suffering with AVN.
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Trauma – causes dislocation or fracture and consequent damage to the blood vessels therein. This will cause diminution in blood flow to bones leading to the death of bone tissue.
Excessive use of steroids and alcohol
Certain treatments – like radiation therapy, organ transplantation (mainly kidney) weaken the bones and also cause AVN. Long term use of high doses of Bisphosphonate for treatment of cancers might contribute to osteonecrosis of the jaw.
Medical conditions which might contribute to AVN
– Sickle Cell Anemia
– SLE (Systemic Lupus Erythematosus)
– HIV / AIDS
– Gaucher’s disease
– Decompression sickness
– Radiation therapy / chemotherapy
– Autoimmune diseases
– Bone collapse
– Loss of bone shape
– Severe Arthritis
– Avoid or limit smoking and drinking alcohol
– Keep a control on cholesterol levels
– Avoid indiscriminate use of steroids in high dose and for longer time
Taking good rest – will help to slow down the damage to the joints and will help in their recovery. Alternatively one may use crutches.
Doing exercises in the right way – physical exercises should be done cautiously by taking the help of a doctor or expert therapist. This will help you to get the right moves. You can gradually try to regain good range of motion in your joints.
The doctor would examine your joints to elicit pain, tenderness and any other damage so as to make appropriate diagnosis. The range of motions may also be examined.
– X-rays – helps in finding out the bone changes which occur in AVN, in the later stages of the disease.
– MRI & CT Scan – help in finding out the early changes occurring in the bone indicating AVN.
– Bone Scan – helps in finding out the parts of bones that are injured or healing.
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More than half patients who suffer from AVN might need surgery within 3 years of diagnosis of the disease.
If bone collapse occurs in one of the joints, it is likely to happen sooner or later in the other joint also.
The outlook depends on the disease stage at the time of diagnosis and the presence of an underlying condition / disease.
The prognosis will be good if
– patient is over 50 years of age
– disease is at stage III or higher at the time of diagnosis
– there is death of more than 1/3 of the bone’s weight bearing area
– damage has gone past the bone end
– there is a long history of treatments with cortisone
The main goal of the treatment will be to prevent the further loss of bone tissue, to improve movements at the joint and ease pain in the joints. Effective treatment depends on the age of the patient, cause of AVN, stage of the disease, amount of damage to the bone & location of disease. If the disease is diagnosed earlier, the treatment may involve limiting the use of the affected joint and taking pain relieving medications.
Medicines and therapy – helps in easing the symptoms of early stages of AVN. They include –
1. NSAID – medicines such as ibuprofen, naproxen sodium etc – helps in relieving pain
2. Drugs used to treat osteoporosis
3. Drugs used for lowering cholesterol levels – They will reduce the cholesterol and fat from the blood. This would help in preventing the blockages in the blood vessels supplying the bones which may cause AVN.
4. Blood thinners – prevents clotting in the blood vessels supplying the bones. These are given even if AVN is caused by blood clots.
5. Rest – reducing physical activity or using crutches would help in keeping the body weight and stress off the joints and bones and slow down the damage.
6. Exercises – will help in maintaining and also improving the range of motions in the joints
7. Electrical stimulation – will help in replacing the damaged bone by enabling the body to grow new bone.
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Surgical procedures and other effective interventions
Core decompression – a part of the inner layer of bone is removed surgically. This procedure reduces pain, healthy bone tissue and blood vessels are produced.
Bone transplant (bone graft) – strengthens the bone area affected by AVN.
Bone reshaping (osteotomy) – from above or below a weight bearing joint, a wedge of bone is removed. This helps to shift the weight off the damaged bone.
Joint replacement – should be done when the diseased bone has collapsed or when other treatments are not yielding the desired results.
Regenerative medicine treatment – For treating early stage of avascular necrosis of the hip, bone marrow aspirate and concentration are appropriate. Stem cells are harvested from the bone marrow. The dead hip bone is removed and the stem cells are placed in its place. This will allow growth of new bone.
Electrical stimulation – will help in stimulating new bone growth.
AVN – Ayurveda Concept
Doshas and tissues involved in AVN
All the doshas – vata, pitta and kapha are involved in the causation of AVN at one or the other stage of the disease. Predominantly Vata dosha is involved.
a. Vata dosha and bone tissue have a resident – residence relationship. Vata is located in the bones. When vata increases the bone tissue decreases or gets damaged. Similar mechanism takes place in the manifestation of AVN. Therefore Vata is invariably involved in the causation of AVN.
b. Pitta may be indirectly involved in the pathogenesis. Pitta resides in the blood just like vata resides in bones. Since there is a lack of blood supply to the bones there cannot be high pitta in the joints. But high pitta might be causal for destruction of blood and channels (arteries and arterioles supplying the bone) carrying blood. When the blood vessels get damaged due to pitta and consequently depletion of blood supply to bones occurs, AVN is manifested.
c. Kapha too may be involved in the causation of AVN. Fat tissue is one of the seats of kapha. When kapha increases it will impair and imbalance fat tissue. The fat tissue too will increase and cause blocks in many channels of the body, including the blood carrying channels of the body. This will cause lack of blood supply to the bones causing AVN.
Different kinds of pathogenesis in AVN occur when one, two or all doshas are involved.
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a. Asthi Dhatu / Bone tissue – AVN is a disease related to bone tissue, death of bone tissue to be precise. Therefore bone tissue is invariably involved.
b. Rakta Dhatu / Blood tissue – Since this bone tissue death is caused due to deficit or lack of blood supply to the bone, the blood tissue is also involved.
c. Medo Dhatu / Fat tissue – Accumulation of bad fats in blood vessels cause AVN.
d. Majja Dhatu / Bone Marrow tissue – According to Ayurveda, bone marrow is located inside the bone and fills it. Destruction, death and depletion of bone tissue also affects bone marrow. Bone marrow tissue also forms the root of bones and joints of the body. Therefore when the bone marrow tissue gets depleted, the bones and joints which take origin from it too get weak, diseased, cracked and collapsed, as in AVN.
Note – The channels conveying the above said tissues are also contaminated and damaged in AVN.
Read – Diseases Due To Pathological Bone Tissue – Asthi Pradoshaja Rogas
a. Vata aggravating factors – foods, lifestyle and seasons favoring vata aggravation
b. Kapha and fat aggravating factors
c. Aggravating factors of blood tissue
d. Malnutrition – leading to depletion of tissues
e. Over-nutrition – leading to accumulation of kapha and fat in the body tissues and channels
f. Obstruction of channels leading to vata aggravation – further leading to bone damage, break-down and collapse
g. Contamination of channels carrying bones, bone marrow, fat and blood
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h. Diseases like
i. Sthoulya and medoroga – obesity and disorders of fat metabolism
j. Asthi-Majjagata Vata – Vata located in bones and bone marrow – osteopenia / osteoporosis
k. Agnimandya – deterioration of digestive fire
l. Ama in circulation
Traumatic and Non-traumatic AVN
Gross AVN can happen due to traumatic and non-traumatic causes. Even modern medicine has described this.
According to Ayurveda –
1. Traumatic causes – Seeing the symptoms of Asthi-Majjagata Vata these conditions can be considered as traumatic causes of AVN. Bhagna- trauma / fractures and dislocations also fall under this category.
2. Non-traumatic causes – The other etiological factors enlisted above fall under this category.
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One or the other form of the below mentioned pathogenesis will be involved in the causation of AVN.
Dhatu kshaya janya vata vriddhi (Vata increase caused due to tissue depletion) – Depletion of any tissue leads to increase of vata at the site of depletion of tissue. This rule holds well with depletion of bone tissue too. When due to lack of blood supply to the bone when the bone tissue gets depleted due to death of its cells, vata will increase in those regions of the bone tissue. This increase in Vata will lead to increase of Vata qualities in the bone like dryness, roughness, lightness, minuteness etc. this will eventually lead to damage and breakage of bone. Increase of vata will also cause pain in the joints and bones. When vata further increases, the bone tissue death will further increase and eventually lead to bone collapse. This explanation holds good in accordance with the pathogenesis explained in modern texts.
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Vata Vriddhi Janya Asthi Dhatu Kshaya (Bone death due to increase in Vata – Due to excessive consumption of vata aggravating etiological factors the bone tissue gets destroyed leading to AVN. On the other hand, the aggravated vata can also destroy the blood tissue and blood vessels and hamper blood supply to the bones. Among the causes of vata vitiation, excessive exercises, excessive fasting, falls and injuries, fractures, depletion of tissues are mentioned as important ones.
Kapha and fat contaminating the channels of the body and causing blocks / Obesity and errors of fat metabolism as causal for AVN
a. Kapha and fat tissue have resident and residence relationship i.e. fat is one of the seats of kapha. Increased kapha causes pathological imbalance of fat tissue and increases it. This increased free circulating fat will accumulate in the blood vessels supplying to the bones and cause deprivation of blood supply. This will cause necrosis and death of bone tissue causing AVN.
b. This pathology can occur ‘independent of vitiation of kapha’. Fat increasing etiological factors will directly increase fat in the body subsequently leading to its accumulation in blood vessels supplying the bones causing lack of blood supply to the bones. This eventually leads to bone death causing AVN.
In the chapter of Medo Roga – disorders caused due to errors of fat metabolism, it is said that ‘when the channels of the body (including arteries) get obstructed by the fat the other tissues are not nourished (including bones)’.
Even in modern explanations of AVN, deposits of fat in blood vessels is said to be one of the causative factors.
Contamination of blood tissue – Among the signs and symptoms of contamination of blood tissue, vatarakta has been mentioned. In this condition there is combined vitiation of vata and blood leading to symptoms resembling AVN.
Read – Rakta Pradoshaja Rogas – When Blood Is Vitiated By Doshas
Malnutrition – When the tissues are not properly nourished with complete and balanced nutrition, it will cause depletion of tissues. This is true with bone tissue too. ‘Pain in the leg, thigh and sacral joint and in the small / big joints and bones’ is said to be one of the symptoms of ‘diseases caused due to deficit nutrition’. These are the sites of the body wherein pain is manifested in AVN.
Over-nutrition and subsequent obstruction in the channels of the body leading to vata increase – Over-nutrition will cause many disorders due to disturbed and imbalanced metabolism. Over-nutrition will also impose a burden on the stomach and intestines leading to indigestion and formation of ama. Less nutritive juices are formed and the tissues including bones are deprived of blood supply and nutrition. More kapha too will be formed in the system. Over nutrition will cause diseases like diabetes and obesity as mentioned by Master Charaka in chapter 23 of Sutra Sthana. Modern medicine too has mentioned these among causes of AVN.
Contamination of channels carrying –
– bones – cause destruction of bones – among the symptoms of diseases caused due to contamination of bones, bone pain and splitting pain and fracture have been mentioned
– bone marrow – causes destruction of bone marrow
– fat – causes obstruction in the blood vessels supplying the bone
– blood – causes lack of blood supply to the bones
Diseases with AVN like symptoms
Vatarakta – It is a disease caused by a vicious and pathological combination of vitiated vata and vitiated blood. They get aggravated independently by their own aggravating etiological factors or due to the common factors leading to aggravation of both vata and blood. They also will contaminate each other during the process of the pathogenesis of the disease. Symptoms resembling AVN are mentioned among the causes (trauma), premonitory symptoms and symptoms of vata predominant vatarakta. Symptoms of the disease manifesting both at superficial and deeper levels are almost similar to those of AVN.
Pandu – Anemia leads to lack of blood supply to the bones and joints. This leads to AVN.
Asthi-Majjagata Vata – is a condition in which vitiated vata is lodged and deep seated in bones and bone marrow. These are described under special disorders caused by vitiated vata i.e. in the context of vatavyadhi.
Symptoms of these conditions include –
– splitting pain in the bones and inter-phalangeal joints
– pain in the joints
– emaciation of muscles
– deterioration of strength
– constant pain
These symptoms too closely resemble AVN. Generally the Ayurveda doctors treat AVN in comparison to these conditions and the treatments are usually successful to a higher proportion.
These conditions are often compared to osteopenia and osteoporosis. Modern medicine too uses osteoporosis medicines in the treatment of AVN.
Read – Gata Vata: Vitiated Vata Seated In Tissues, Visceral organs
Agnimandya – deterioration of digestive fire / capacity – Balance of digestive fire in the gut is very important to have a balance of the fires in all the tissues. The gut fire controls the balance of all the fires in the body including the tissue fires, the fire in the bones in this instance. Balance of the fire in the bones is very important for the bone to convert the nutrients available to it through circulation into components which nurture the bone tissue. When the gut fire gets weak, it will not be able to digest the food properly. Hence deficit nutrients reach all tissues. The blood tissue is nourished in a lesser proportion. There is deficit formation of blood. According to Ayurveda the tissues are formed one after the other, from the nutrition and support they get from their precursor tissues. So, bone tissue is formed after blood. The bones get deficit blood. The bones are as such getting less nutrition. To top it off, the blood circulation is also hampered. This sets up a stage for manifestation of AVN. On the other hand, the imbalance of gut fire will also cause an imbalance of bone tissue fire. The bones will not be able to properly utilize and convert the nutrition they get into the components suitable for their functioning, development and sustenance. This also leads to AVN.
Ama in circulation – Deficit digestive fire and resultant indigestion of food will lead to the formation of a toxic byproduct of bad digestion called ama. When this ama is put into circulation it blocks the blood vessels (and also other channels). This leads to deficit or lack of blood supply to the bones causing AVN.
Bhagna – Trauma leads to blood loss and lack of blood supply to the bones and joints. Trauma also includes fractures and dislocations.
Vata balancing measures – Since vata increase causes bone and joint death and destruction either directly or by causing destruction of tissues, mainly blood tissue leading to reduced blood flow to the bones all vata balancing measures including therapies, medicines and lifestyle changes shall be adopted, when the other doshas are not associated with vata.
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Kapha balancing measures – Since kapha increases leads to abnormal increase of the tissues in which it resides – especially fat tissue, the accumulation of which in the blood vessels deprives the bone of nutrition – leading to bone death, kapha balancing measures should be adopted.
Deepana – Medicines for kindling the digestive fire and bringing the digestive capacity to balance should be preferred at the beginning of the treatment. These medicines will also help in strengthening the fires so that it produces the best essence of nutritive juices by properly and completely digesting the foods we take. This is important in the treatment of AVN because the tissues, mainly bones and blood tissue are destroyed due to deficit nutrition and they need to be compensated for. When diagnosed early, these may help in further deterioration of tissues and revert the condition. They will also help in strengthening the tissue fires of bones, bone marrow and blood tissue and help them utilize the nutrition which reaches them to optimum levels. The kindled fire will also help in destroying the excessive fat accumulated in the blood vessels.
Pachana / Ama Pachana – Ama is also formed due to bad digestion in the stomach due to weak digestive fire. This ama when put into circulation will cause blocks in the channels of the body and deprive nutrition to the bones leading to AVN. Ama digesting medicines and measures should be used to destroy ama and open up the channels in the earlier stages of digestion. Fasting and drying therapies also digest ama.
Rukshana – means drying therapies. This is very essential and comes into play when kapha, ama or fat is involved in the pathogenesis of AVN. Ayurveda has advised to administer drying therapies before administering strengthening / nourishing (bulk promoting) treatments. These therapies will help in removing the obstruction in the channels including the blood vessels and will also cause compactness of the body parts, including bones. They also remove accumulation of fat in the channels. Carminatives / digestive fire kindling medicines, & ama digesting medicines also act like drying therapies. External therapies like herbal powder massage, showering with sour fermented medicinal fluids or drying decoctions work as drying therapies.
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Role of Panchakarma
Snehana – Oral consumption of medicated fats in small and metered doses or as preparation for cleansing therapies works good for AVN. Medicated fats i.e. oil, ghee, muscle fats and marrow – combination of two, three or all of these is good for vata, vata disorders and bone disorders including treatment of AVN.
Virechana / therapeutic purgation – It helps in cleansing the obstructed channels and improving blood circulation to the bones. Vatavyadhi and Vatarakta according to Ayurveda can cause pathogenesis of AVN. In both these conditions purgation has been mentioned. Destruction of blood is caused due to obstruction of blood vessels due to contamination of blood and blood carrying channels for which purgation is the best remedy.
Vasti / therapeutic enemas – Enemas are the best treatments for vitiated vata, vata disorders, vatarakta, disorders of blood and also those of pitta and kapha. Since they are best for vata, they are also best therapies for bone related disorders and disorders caused due to contamination of blood carrying channels. Oil enemas and decoction enemas are combined for effective results. Enemas prepared with milk processed with vata alleviating herbs and milk is very effective in treating the bone and bone marrow lesions. This is effective therapy for those suffering from AVN.
– Herbal oil massages and sudation – helps in lubricating and strengthening the bones and joints, combats vata, relieves pain and discomfort. Sudation combats vata, relaxes the muscles and soft tissues around the bones and joints, brings lightness and makes joints flexible.
– Pichu / local lubrication – A swab or small cloth piece soaked in medicated oil, kept in contact with afflicted joint and left in place by wrapping a bandage around it.
– Sthanika Vasti – Oil pooling around the afflicted oil will help in relieving pain and improving movements.
Other local therapies
– Dhanyamla Dhara – stream pouring / showering the joint / limb with medicated sour fermented liquids. This helps in conditions wherein ama and kapha are associated with the disease, and when there is inflammation.
– Udwarthana – herbal powder massage is also used to relieve ama and kapha, to cleanse the blocks in the channels of the body and also to remove accumulation of fat.
– Sneha Dhara – stream pouring / showering the joint and afflicted limb with medicated oil. This is preferable when only vata is aggravated and there is no association of ama or kapha.
– Patra Pinda Sweda – leaf bolus sudation
– Shashtika Shali Pinda Sweda – rice bolus sudation – for nourishing the joints, to strengthen them, to relive pain and vata and improve movements
– Lepa – application of pastes of herbs which mitigate vata and relieve pain and also which improve circulation to the joints.
– Upanaha – Vata mitigating poultices
Other principles of treatment of AVN
1. AVN can also circumstantially be treated on the lines of –
– Treatment of contamination of channels carrying bone tissue
– Treatment of contamination of channels carrying blood tissue
– Treatment of contamination of channels carrying fat tissue
– Treatment of contamination of channels carrying bone marrow tissue
– Treatment of contamination of bone tissue
– Treatment of depletion of bone / blood tissue
2. AVN can also be treated on the lines of treating –
– Vata increase
– Asthimajjagata Vata – Vata lodged in bones and bone marrow
– Vatavyadhi – special vata disorders
– Vatarakta – disease caused by combined vitiation of vata and blood tissue
– Pandu Roga – anemia
– Bhagna – fractures / trauma
Brimhana – nourishing / bulk promoting treatments
Balya – strengthening treatment
Rasayana – tissue rejuvenators / immunity enhancing medicines / immune-modulators
Rakta Prasadana – medicines which enhance blood supply
Kashaya rasa – astringent tasting herbs and recipes prepared with them – astringent taste has property of increasing compactness which is very much needed in the treatment of AVN. It helps to reduce kapha, to prevent deposition of fat and enhance blood circulation. Example – milk processed and prepared with Arjuna – Terminalia arjuna serves this purpose on oral consumption.
Balancing nutrition – AVN can occur due to both under and over nutrition. These conditions should be identified and the nutrition levels of the patient should be balanced.
– Dashamula Kashaya
– Mahamanjishtadi Kashaya
– Guggulutiktaka Kashaya
– Ashtavarga Kashaya
– Mahayogaraja Guggulu
– Kaishora Guggulu
– Panchatikta Ghrta Guggulu
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