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Introduction

Avascular necrosis (AVN) of the femoral head, also known as osteonecrosis of the femoral head, is a progressive and debilitating disorder characterized by compromised blood supply to the femoral head, resulting in death of osteocytes and bone marrow components. The condition eventually leads to structural collapse of the femoral head and degenerative arthritis of the hip joint if not managed appropriately.([i]) AVN most commonly affects individuals in the third to fifth decades of life and is considered one of the major causes of hip disability in young adults.([ii]) The pathogenesis of AVN involves interruption or reduction of the vascular supply to the femoral head due to various etiological factors such as trauma, prolonged corticosteroid therapy, alcoholism, metabolic disorders, or idiopathic causes. The resulting ischemia leads to bone necrosis, subchondral fracture, and progressive collapse of the femoral head.([iii]) Magnetic resonance imaging (MRI) is considered the most sensitive and reliable modality for early detection and staging of AVN, allowing accurate evaluation of the extent of necrosis and structural integrity of the femoral head.([iv])

Management of AVN depends on the stage of the disease. In early stages, conservative measures including pharmacotherapy and restricted weight bearing are attempted, whereas advanced stages often require surgical interventions such as core decompression, osteotomy, or total hip arthroplasty.([v]) However, surgical procedures are associated with economic burden and long-term complications, particularly in young patients, making joint-preserving strategies an area of growing clinical interest.

From an Ayurvedic perspective, the clinical presentation of AVN of the femoral head can be correlated with Asthi-Majjagata Vata, wherein vitiated Vata Dosha affects the Asthi and Majja Dhatu, leading to degeneration, pain, and impairment of joint function.([vi]) Classical Ayurvedic texts emphasize the role of Basti Karma as the principal therapeutic modality for disorders predominantly caused by Vata Dosha, as it helps in systemic regulation of Vata and provides nourishment to the Asthi Dhatu.

Considering the progressive nature of AVN and the need for effective conservative management, the present case report aims to evaluate the clinical and radiological outcome of Ayurvedic management in a patient with bilateral avascular necrosis of the femoral head over a two-year follow-up period.

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[iii] Shah KN, Racine J, Jones LC, Aaron RK. Pathophysiology and risk factors for osteonecrosis. Curr Rev Musculoskelet Med. 2015;8:201–209.

[iv] Mitchell DG, Rao VM, Dalinka MK, Spritzer CE, Axel L, Kressel HY. MRI of osteonecrosis of the femoral head. AJR Am J Roentgenol. 1987;148:1215–1220.

[v] Lieberman JR, Berry DJ, Mont MA. Osteonecrosis of the hip: management in the twenty-first century. J Bone Joint Surg Am. 2002;84:834–853.

[vi] Agnivesha, Charaka samhita of Acharya Charaka, Dridhabala krit,  edited by Acharya Vidyadhara Shukla, Prof. Ravidatta Tripathi Charak Samhita, Vaidyamanorama Hindi commentary, Sutrasthana, Chapter 28, Verse 16, Delhi: Chaukhamba Sanskrit pratisthan; p. 430.

Materials and Methods

This is a single case study conducted in the Department of Panchakarma. A 33-year-old female patient (UHID-32285) presented with complaints of severe pain in both hip joints, difficulty in walking, inability to perform floor activities, and antalgic gait since approximately three years. The patient had no history of trauma, steroid intake, or systemic illness.

Clinical Examination

On examination at September 2024, the patient exhibited restricted movements at both hip joints with significant pain (Visual Analogue Scale [VAS] score: 6/10). Gait was antalgic. General and systemic examination revealed no significant abnormalities.

From an Ayurvedic perspective, the condition was assessed as Asthi-Majjagata Vata. The patient had Madhyama Agni, Krura Koshtha, unsatisfactory bowel habits, and normal sleep pattern.

Diagnostic Assessment

Baseline magnetic resonance imaging (MRI) of pelvis with both hip joints (dated 13/07/2024) revealed bilateral avascular necrosis of the femoral head with Ficat and Arlet Stage III changes and approximately 70–80% involvement of both femoral heads along with joint effusion.

Therapeutic Intervention

The patient underwent two courses of Panchatikta Ksheera Yoga Basti in a Yoga Basti pattern during hospitalization.

First admission: 11/11/2024 to 19/11/2024
Second admission: 18/12/2025 to 25/12/2025

During hospitalization, the following procedures were administered:

Table:1 Chronological Treatment Protocol with Dosage and Procedures

Summary of Therapeutic Approach

The treatment protocol consisted of repeated administration of Panchatikta Ksheera Yoga Basti in a Yoga Basti schedule, supported by Matra Basti, external therapies, and individualized oral medications. The intervention was planned to target Vata Dosha and promote nourishment of Asthi Dhatu, thereby aiming at disease stabilization and joint preservation.

1. Outcome Measures

The outcomes were assessed based on:

1. Pain intensity using Visual Analogue Scale (VAS)
2. Gait assessment (antalgic to normal walking)
3. Functional ability (walking and floor activities)
4. Range of motion at hip joint
5. Radiological assessment using MRI (Ficat staging and percentage involvement)

Follow-up assessments were performed at regular intervals, including post-first admission, post-second admission, and at two-year follow-up.

Assessment of Clinical and Radiological Outcomes

Table 2: Clinical Outcome Assessment

Table 3: Radiological Outcome Assessment (MRI Comparison)

Summary of Outcome

The patient demonstrated significant clinical improvement in terms of pain reduction, gait normalization, and functional ability following Ayurvedic intervention. Radiological comparison demonstrated stabilization of disease progression with partial regression in the left femoral head, where the stage improved from Ficat stage III to stage II along with reduction in the necrotic area. The absence of joint effusion and preservation of articular cartilage further indicate maintenance of joint integrity, suggesting a potential joint-preserving effect of the Ayurvedic intervention.

Discussion

Avascular necrosis (AVN) of the femoral head is a multifactorial disorder characterized by compromised microcirculation leading to ischemia, osteocyte death, and subsequent structural collapse. In recent years, an increased incidence of AVN has been observed following COVID-19 infection and corticosteroid exposure, suggesting a possible role of microvascular thrombosis and endothelial dysfunction in its pathogenesis. ([i]) The present case, although idiopathic in presentation, may be understood in the broader context of altered vascular dynamics and bone metabolism.

From an Ayurvedic perspective, the clinical presentation of AVN closely resembles Asthi-Majjagata Vata, wherein aggravated Vata Dosha localizes in Asthi and Majja Dhatu, resulting in pain (Shoola), restriction of movement, and progressive degeneration. The chronicity of symptoms and involvement of deeper Dhatus indicate a state of Dhatu Kshaya and Vata Prakopa, necessitating Brimhana and Vatahara line of management.

First Phase of Treatment (November 2024)

During the first hospitalization, Panchatikta Ksheera Yoga Basti was administered in a Yoga Basti schedule. Basti Karma is considered the prime modality for managing Vata Dosha, as described in classical Ayurvedic texts. The selection of Panchatikta Ksheera Yoga is particularly significant in Asthi Pradoshaja Vikara, as indicated by Acharya Charaka. ([ii])

The Tikta Rasa dominant drugs possess Vayu and Akasha Mahabhuta predominance, ([iii]) facilitating deep tissue penetration and channel cleansing (Srotoshodhana). However, when processed with Ksheera (milk) and Ghrita, which are Snigdha and Brimhana in nature, the formulation acquires dual action—both detoxifying and nourishing. This combination is especially relevant for Asthi Dhatu, which is also predominantly composed of Prithvi and Vayu Mahabhuta. Thus, Panchatikta Ksheera Basti provides a synergistic effect by correcting Vata Dosha and promoting regeneration of bone tissue.

The observed clinical improvement after the first course, including reduction in pain and improvement in gait and range of motion, may be attributed to improved microcirculation, reduction in inflammation, and enhanced nourishment of Asthi-Majja Dhatu.

Intervening Phase (Matra Basti and Oral Medication)

Following the first hospitalization, Matra Basti with Asthishrinkhala Ghrita was administered for one month. Asthishrinkhala (Cissus quadrangularis) is well-documented for its osteogenic and fracture-healing properties, promoting osteoblastic activity and enhancing bone mineralization. ([iv]) The lipid-based medium (Ghrita) facilitates better bioavailability and deeper tissue penetration.

Concomitantly, oral Ayurvedic medications, including formulations such as Lakshadi Guggulu, were prescribed based on symptomatic variations. Lakshadi Guggulu has been reported to possess bone-healing, anti-inflammatory, and anabolic effects on bone tissue, thereby contributing to structural stability and prevention of further degeneration. ([v])

Second Phase of Treatment (December 2025)

A second course of Panchatikta Ksheera Yoga Basti was administered to reinforce the therapeutic effect. Repeated administration of Basti is known to provide sustained regulation of Vata Dosha and continuous nourishment of Dhatus. By this stage, the patient demonstrated significant clinical improvement, including minimal pain, near-normal gait, and excellent range of motion.

Radiological Improvement

The follow-up MRI findings demonstrated reduction in the extent of femoral head involvement and regression of Ficat stage from III to II on the left side, indicating partial reversal of disease progression. The absence of joint effusion and preservation of articular cartilage further support the hypothesis that Ayurvedic intervention may contribute to stabilization of the disease and prevention of joint collapse.

The probable mechanism underlying this improvement may include enhanced vascularity, reduction in intraosseous pressure, and stimulation of reparative processes within the bone tissue, mediated through Basti Karma and osteo-protective herbal formulations.

[i] Sulewski A, Kowalczyk B, B?aszczyk M. Osteonecrosis in COVID-19 patients: a systematic review. J Clin Med. 2022;11(21):6410.

[ii] Agnivesha, Charaka samhita of Acharya Charaka, Dridhabala krit,  edited by Acharya Vidyadhara Shukla, Prof. Ravidatta Tripathi Charak Samhita, Vaidyamanorama Hindi commentary, Sutrasthana, Chapter 28, Verse 27, Delhi: Chaukhamba Sanskrit pratisthan; p. 431.

[iii] Maharsi Sushruta Virachita Susruta Samhita, Ayurveda Tatvasandipika Hindi vyakhya by Kaviraj Dr. Ambikadatta Shastri, SutraSthana, Chapter 42, Verse 3, Varanasi: Chaukhambha Sanskrit sansthan; 2014.

[iv] Stohs SJ, Ray SD. A review of the safety and efficacy of Cissus quadrangularis. Phytother Res. 2013;27(7):951–956.

[v] Sharma S, Kulkarni SK, Chopra K. Effect of Lakshadi Guggulu on fracture healing: experimental study. Indian J Pharmacol. 2010;42(3):140–144.

Intercurrent Event: Stress Fracture

The occurrence of stress fracture in the right femoral neck following a slip and fall represents a secondary traumatic event rather than progression of the primary pathology. In AVN, the structural integrity of bone remains compromised due to necrosis, predisposing it to fractures even with minor trauma. The conservative management with rest and subsequent reduction in pain further supports this interpretation.

Overall Interpretation

The chronological improvement observed in this case—from significant pain and restricted mobility to functional restoration and radiological stabilization—suggests a beneficial role of Ayurvedic management in AVN. The integrative approach involving Basti Karma, Brimhana therapy, and osteogenic herbal formulations appears to address both the symptomatic and structural aspects of the disease.

Thus, the present case highlights the potential of Ayurveda in altering the natural course of AVN by targeting the underlying Dosha-Dhatu imbalance and promoting joint preservation.

Conclusion

This case demonstrates that structured Ayurvedic management, including Panchatikta Ksheera Yoga Basti and supportive therapies, may result in significant clinical improvement and radiological stabilization in bilateral avascular necrosis of the femoral head. Over a two-year follow-up, reduction in pain, improvement in function, and partial regression in disease severity were observed, along with preservation of joint integrity. These findings suggest a potential role of Ayurveda in joint preservation and highlight the need for further systematic studies to validate these outcomes.

Acknowledgements

The authors express their sincere gratitude to the patient for her cooperation and consent to share the clinical details for academic and publication purposes. The authors also acknowledge the support of the Department of Panchakarma and Department of Dravyaguna, MACH for providing the necessary clinical facilities and guidance during the course of treatment. No external financial support or sponsorship was received for this study.

Conflict of Interest

The authors declare that there are no conflicts of interest regarding the publication of this case report.