The concept of asthimajja vidradhi described in sushrut Samhita Nidana Sthana 9/34-38 & Chikitsasthana 16/39-43

  Asthimajja Vidradhi is tridoshaja (Vidradhi 6 types- vataja, pittaja, kaphaja, tridoshaja, Kshataja, raktaja)

Asthimajja vidradhi can be correlated with Osteomyelitis.

   Osteomyelitis of calcaneum is a condition progressive towards morbidity of the patient because of the chronicity and severe complication.      

  According to modern science, available treatment on calcaneum osteomyelitis is debridement, incision and drainage. But due to chronicity of disease there may be relapse of the infection. But Ayurveda offers us good treatment protocol on the basis of Ayurvedic principles related to pathophysiology of the disease and gives ray of hope to such patient.

   According to Ayurved, Vidradhi is classified as Bahyaa Vidradhi (external part of the body) and Antar Vidradhi (internal part of the body).

   Asthividradhi can be correlated with Birdie’s abscess or infective osteomyelitis. Chronic infective Osteomyelitis can be correlated with      Asthimajjagata Vidradhi.

   Acharya Charaka described that due to very early or acute suppuration by vitiated blood in abundance, it is called Vidradhi. There is more involvement of Raktdushti by which pus formation (Paka) takes place predominantly. The Doshas located around the Asthi or bone tissue, on getting vitiated will contaminate Twaka (skin), Rakta (blood), Mamsa (muscle), Meda (fat). Acharya Sushruta has given much importance to multidisciplinary management for all sorts of surgical wound. Treatment principle of Asthividradhi includes Snehana, Swedana and use of TiktaKashyam and Tiktasarpi.

       Brodie’s abscess is a sub- acute form of osteomyelitis, presenting as a collection of pus in bone, often with an insidious onset.

       Osteomyelitis is defined as an inflammatory and infective condition affecting the bone, which begins as an infection of the medullary cavity, rapidly involving the harversian systems, then extending to involve the periosteum of the affected area. The condition leads to gross morbidity to the patient, owing to its intricate progress, associated chronicity and severe complications. But Ayurveda offers us good treatment protocol on the basis of Ayurvedic principles related with pathophysiology of the disease and gives ray of hope to such patient.

        According to Ayurveda , Vidhradhi is classified as Bahya Vidradhi (external part of body) and

Antar Vidradhi (internal part of body)[1]. Asthividhradhi can be correlated with Brodie’s abscess or infective osteomylitis. As chronic infective Osteomylitis can be correlated with Asthimajjagata Vidhradhi or Dushta Vrana. Acharya Charaka described that due to very early or acute suppuration by vitiated blood in abundance, it is called Vidradhi. There is more involvement of Rakta Dushti and by this Rakta Dushti, pus formation (Paka) takes place predominantly. The doshas located around the Asthi or bone tissue, on getting vitiated will contaminate Twak (skin), Rakta (blood), Mamsa (muscle) and Meda (fat)[2].According to Sushruta, it is condition of Asthimajjanirodhana having discharge as Medoprabha Snigdha ,Shukla,Shita,Guru. Burning sensation is the prominent feature. He has given much importance to multidisciplinary management for the all sorts of surgical wounds. Treatment principle of Asthividhradhi includes Snehana, Swedana, Raktavasechana and use of Tikta Kashaya and Tiktasarpi

         However, he has specifically mentioned specific Strotoshodha, Raktaprasadkar drugs having capable for blood purification and enhancing microcirculation. The Mridu Virechana[4] Karma (therapeutic purgation) and Shamana Chikitsa had been planned for this case study. So general line of treatment for Asthimajjagata Vidhradhi or Dushta Vrana was adopted to treat this condition. The Shastiupkarma could rightly be explored in a novel way for the treatment of chronic osteomyelitis

PATHO-PHYSIOLOGY OF THE DISEASE (SAMPRAPTI GHATAKA OF ASTHI MAJJA VIDHRADHI )

Dosha- Kapha –pitta Pradhana Tridoshaja

Dushya- Rakta, Kandara, Asthi,Majja

Dosha Adhisthan- Asthi

Agni- Jatharagnijanya, Dhatvagnijanya

Strota- Rasa, Rakta, Asthi, Majjavaha,Purishavahas

Strotodusti- Sanga, Vimargamanam

Udbhavastana- Amashaya (Kapha, Pitta), Pakvashaya (Vata)

Adhisthan- The Adhisthana Was Asthi And Majja With Vata-Pitta- Kapha Predominance.

Roga Marga- Madhyama

Vyadhi Swabhav- Chirkala

MANAGENT OF ASTHIMAJJA VIDRADHI

-         Panchtikta gugglu, Amrita guggul, Triphala guggul, Lakshadi guggul

-         Sanjeevani vati

-         Svarga bhasma, Vnga bhasma, Rasa manikya

-         Jatyadi ghruta/ Jatyadi Taila

-         For Asthi shrav- Shatavari Guda, Dhatradi Ghrita

In Ayurveda, osteomyelitis is correlated with Dustha Vrana or Asthi-vidradhi. The Vrana more than a week called Dushta Vrana which fail to heal for a long period and result into chronic wound (Dheergha Kalanubandhi Dushta). As the experts of the wounds recommend Virechana (Mrudu Virechana) in wounds vitiated by predominant Vata and Pitta Dosha and which are chronic

Among Bahya chikitsa

Sarvanga Snehana with Dhanwantar Oil[8] increases blood circulation, relieves edema and pain, increases ROM .Local massage with Dhanvantara Oil reduces edema and congestion which results in relief in pain and

tenderness. It controls the vitiated the Vata Dosha by removing Margaavarodh and reduces Vedana (throbbing pain) and Shotha (swelling).

Local Dhara over left ankle joint with Dhanavatara oil to increase vascularity.

Punarnavadi Lepa over left ankle joint

Due to application of Punaranavadi lepa swelling was reduced and blackish discoloration also reduced due to above mentioned drugs having properties Shothhara and Raktaprasadakar

Aabhyanar Chikitsa

Main aim of treatment is

• To reduce vascular insufficiency by adequate drainage, increases revascularization to local soft

tissues, obliteration of dead space, wound protection(dushta vrana and vidhradhi chikitsa) –shothahara and pachana

• to arrest its spread and repair the damage it has caused (kha viagynyhara chikitsa )

Combination OF Suvarna Samirpannaga Rasa,GuduchiSatva,Sukshma Triphala powder with Asthimajjapachaka Choorna ,Kaishorguggulu fulfils the above aim by

Decreasing the bacterial load, removes dead necrotic tissues, and gives a chance for the host immune system to arrest infection

• eliminating Doshas but also helps in removing the impurities of Rakta Dhatu, decreasing Strotorodha which augments the blood circulation and nutrition and formation of healthy granulation tissue(resolving in bone cavity with healing of bone ).

• Vatakaphahar of this combination helpful in regression of inflammation and avoid further necrosis and reduce ischemia, indirectly helpful for rejuvenation of bone.

Suvarna Samirpannga Rasa-In this kalpa, Gandhka is Rakashudhhikara and increases vascularuty.Hartala,Manashila are Raktapraadaka in nature and are generally used in Kustha.

Suvarna Samirpannga Rasa generally use in weakness of Snayu, Sandhigata Vata,Sannipataja condition,  allergic rhinitis., vitiated and stagnated Kapha, Mandagni ,Dhatugata Dosha. It is the best medicine use in Sannipataja condition. Suvarna Samirpannga Rasa acts effectively in Asthishosha, Janghasthi Vedana[.

Due to its properties such as Vyavayi, Vikasi (Loosening/dispersibility) and Sookshma(Minuteness),Tikshna(Sharpness), Ushna(Hotness) and Vikashi, it spreads in all minute channels ,decreases obstruction in channels and quickly reach up to cellular level where the nexus of toxins with tissues exists. In order to break down the complicated nexus, the Ushna property of drug soften the chemical bonds of the toxins. There after they are broken down by Teekshna property, into smaller and relatively less harmful molecules which can be removed out of the cell accelerates the wound healing process. Suvarna Samirpannaga Rasa which have action such Vatakaphahar which also helpful in regression of inflammation and avoid further necrosis and reduce ischemia, indirectly helpful for rejuvenation of bone.

Sukshma Triphala Powder:- Uttam Rechaka,Dipana,Pachana,Rakta Shodhaka. It penetrates at deep channels and acts as antiseptic and antibiotic. Best use in septic tonsillitis and follicular tonsillitis which are caused due to staphylococcus infection.

Guduchi satva:-It is acts as possessing detoxifying property,

inflammatory, hematogenic in nature. It is best Rasayana, Pittashamana and rejuvenation of bone tissue and immunomodulator. Helps in formation of red cells. It improves body defense mechanism and liver function. It has Yogavahi property which augments the effect of Suvarna Samirpannaga Rasa. It improves the Dhatu Upachaya (metabolism of the tissues) and acts as a rejuvenator of the body.

Combination OF Suvarna Samirpannaga Rasa,Guduchi Satva,Sukshma Triphala powder with Asthimajjapachaka Choorna ,Kaishorguggulu not only eliminates Doshas but also helps in removing the impurities of Rakta Dhatu, decreasing Strotorodha which augments the blood circulation and nutrition and formation of healthy granulation tissue(resolving in bone cavity with healing of bon ).

Indukanta ghrita;Used as Anupana for above mentioned herbomineral combination. It is best Strotoshodhaka,Yogavahi and Dipana, Pachana as well as immunomodulator

In Vidhradhi, Anupana should be Gomutra or Ghrita

Kaishor gugguglu: It increases vascularity, useful in Vata and Rakta Dushtijanya Vikara,Vrana,Vatarakta. It is a drug of choice in Vatarakta in which obstruction in blood vessels is main pathology more keeping this in view it was used

Asthimajja pachaka choorna (Guduchi +Musta +amalaki )

Guduchi-Antiinflammatory, Immunomodulator, hepatoprotective,antioxidant. Aquous extract have as best phagocytic index

Musta-As it is Kapha Pitthara,Dipana and Pachana and scrapping properties. Best use in Rakta Vikara,Visarpa

Aamlaki- Antiinflammatory, anti microbial activity, antioxidant hepatoprotective in nature

Over all combination acts as best Strotoshodhaka for Asthi and Majja Dhatu, increases vascularity and formation of osteoclast and speedy recovery of bony lesion.

Aarogyavardhini Vati Uttam Pachana ,Dipana,Sharirstrotoshodhana,Malashudhhikara,Balya for Yakruta and Pliha. It is excellent in Malavarodha,Dushta Vrana, predominance of Vatapitta, conditions of Rakta and Mansadushti

Phalatrikadi Qwath Best for Virechana in vitiation of Rakta and in liver impairment

Avipattikar powder- Excellent for Virechana in Paittika condition, Jatharagni Dipana[28]. It is for Mrudu Virechana which is remedy for Vatavyadhi

Most of the above mentioned medicines are specifically mentioned for Asthi Sandhigata Vikara due to its Tikta Rasa help to reach Asthi, Sandhi because Tikta Rasa is having predominance of Vayu and Akasha Mahabhuta. Hence, it has got affinity toward the body elements like Asthi which has same Mahabhautika Tattva (subtle constituents of matter). Due to its Sukshma Guna may help to open fresh blood supply and because of Tikta Rasa may reduce the Kleda and Kotha and by virtue of Snigdha Guna and Balya and Brimhana action nourishes the Asthi and Sandhi along with Raktaprasadkar property which induces revascularization and thus helps in the Samprāpti Vighaṭana (breaking down of pathology) of the Ashti Majja Vidhradhi.

To establish structural stability-use of dhatuposhaka chikitsa (asthi and majja ,rasa and raktadhatu)

Lakshadi guggulu

It is excellent medicine for bone disorders, trauma, erosions in bone, pain in bone, bone fracture. Lakshadi guggulu having property of Bhagna Sandhana, Vedanahara having property of Vata pitta Shamaka, Jeevniya, Sandhaniya, Rasayana, Balya. Repair process triggered by necrotic bone which includes osteoclasts, osteoblasts, histiocytes and vascular elements. There will be new bone formation over the dead bone and forms a thick layer on the dead bone which prevents revascularization of the dead/necrotic bone.

• Kaishor gugguglu: It increases vascularity, useful in Vata and Rakta Dushtijanya Vikara,Vrana,Vatarakta

• Asthimajja pachaka choorna (Guduchi +Musta +amalaki )-acts as best Strotoshodhaka for Asthi and Majja Dhatu, increases vascularity and formation of osteoclast and speedy recovery of bony lesion.

• Most of the above mentioned medicines are specifically mentioned for Asthi Sandhigata Vikara due to its Tikta Rasa has got affinity to reach Asthi, Sandhi

• Due to its Sukshma Guna may help to open fresh blood supply and because of Tikta Rasa may reduce the Kleda and Kotha and by virtue of Snigdha Guna and Balya and Brimhana action nourishes the Asthi and Sandhi along with Raktaprasadkar property which induces revascularization and thus helps in the Samprāpti Vighaṭana (breaking down of pathology) of the Ashti Majja Vidhradhi.

• All drugs which were used have the capabilities to address all the manifestations of Vidhradhi. Biofilms are typically composed of cells embedded in a highly hydrated polysaccharide matrix with nucleic acids and proteins throughout. These biofilms are associated with the refractory nature of chronic infections such as osteomyelitis[31]

• The reason for the reduced ability of antimicrobial agents to eradicate these infections is due to the reduced antibiotic penetration and the very slow growth rate and differential upregulation of stress response genes by cells within the biofilm.

A good result was obtained in this case. Results obtained in this case demonstrate that management of chronic infective Osteomylitis with Ayurvedic treatment and may offer a good approach to manage the condition clinically as well as radio logically. This approach may be useful for clinical practices and further studies on treating chronic osteomylitis.

SANSAMAN CHIKITSA PATRA

(Sub-Acute Osteomyelitis/Brodie abscess, Depends upon severity)

1.      Svarnbasant malti rasa 125mg + Guduchi satva 500mg + Praval panchamrita 62.5mg + Rasamanikya 62.5mg (twice with honey)

2.    Panchtikta ghrita guggul (1 twice with L.W. water)

3.    Lakshadi guggul (1 twice with L.W. water)

4.    Ksharsuthra packing

5.     Drainage and dressing with jatyadi ghrita