Mukharjee Regimen for AVN of

hip joint
Dr Aroop Mukharjee’s concepts about hip AVN and its reversal. His
theories about why his regimen works. The same regimen is also used
for treating Rheumatoid conditions with great success.

INTRODUCTION: three years ago from my close

friend Dr Arvind Diwakar Jain,
This chapter is a result of but did not have an opportunity
discussions between Dr Aroop of trying it. The reason was
Mukharjee and Dr L.Prakash, simple, I did not know what the
over two nights in Jaipur. I heard method was!
about Mukharjee method of
conservative management for However many young surgeons
AVN hips about regularly asked me if there was a
 way to avoid THR in the young DR AROOP MUKHERJEE:
patient with AVN. They all
wanted to know some form of Has done his medical graduation
medical management, which and post graduation from GSVM
would either delay, postpone or Medical college , KANPUR in the
avoid hip replacements in the yr 1981 and 1985. He then did his
very young. research fellowship of ICMR on
Orthopedic bracing using for
I referred a few surgeons to Dr fractures and other indications in
Mukharjee, who described his the same institute.
methods to them, and they gave
me such glowing reports of After that, he had further training
success by the medicines, that I in Hand surgery from Stanley
was impressed. I invited him to Medical College Chennai, under
share the secrets in the Jaipur Prof Venkataswami in 1989-90
conference in December, the He then went to UK for further
world’s rst conference on training and completed my M Ch
orthopaedics beyond books. ( o r t h ) f ro m L i v e r p o o l , a n d
When I heard his talk, I was very worked there till 1993 at Queens
impressed, and the sheer logic Medical centre at Nottingham and
was extremely convincing. And Pulvertaft Hand centre , Derby.
then he showed the X-rays of his Fazakerley Hospital in
patients, with clinical results. That Rheumatology department.
was the evidence I was waiting He came back to India and made
for, and in an instant I too became his own hand injury centre in the
a convert of his method. industrial town of Kanpur and
We spent three days together and served there till 2005, managing
discussed at length about his dif cult hand and arthritic
method, the logic, rationale, and problems.
dosages. Here I describe the He was invited to Max Hospital
original method, as well as my New Delhi, in the orthopaedic
suggestions and modi cations. In department to head the Hand
Mukharjee I found a scientist twin Surgery department, where he is
who spoke the same language as still working as a senior
myself and who was as crazy consultant .
about bones as Dr L.Prakash, a
rare breed indeed.
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 He has a special interest in is no different from the original
complicated reconstructive hand bone.
surgery and Rheumatology.
This is the premise under which
He has an experience of more the Mukharjee regimen works!
than 2.5 lakh patients of various
autoimmune musculoskeletal ISCHAEMIA, OCCLUSION
problems, travelling to him from AND NECROSIS:
all over the world and bringing Anatomists and pathologists,
them and maintaining them have always envisaged more
under remission. i n t e r e s t i n AV N t h a n a n
W H A T I S AVA S C U L A R orthopaedic surgeon or
NECROSIS? BONES VERSUS rheumatologist! Scaphoid, neck of
OTHER TISSUES: femur, lower tibia, medial femoral
condyle and lunate have always
Avascular necrosis, translated into interested an anatomist more than
simple English means “Death and a surgeon. Even today a
decay due to lack of blood pathological classi cation of AVN
supply”. AVN of the bone is just is a more precise indicator of
the same as myocardial infarct or prognosis than MRI or X-rays
a stroke. The blood supply to a based orthopaedic Ficat
particular organ gets occluded, classi cation.
the affected area dies. But unlike
cardiac, neural tissue, muscle or It is logical to assume that when
skin, a bone is a different structure blood supply to bone is
altogether. Every tissue except interrupted, the bone cells die.
bone is replaced by scar tissue or Here rather than brous tissue, it
inferior quality brous tissue. is replaced by fatty non bony
However bone is the only tissue tissue as shown in the pictures. As
which is replaced by normal bone, and when blood supply and
if a correct stimulus is given. oxygen to tissue is restored, all of
it converts to bone, as good and
If we break a bone and stretch it, pristine as its original form!
new bone can be created as shown
by Ilizarov methods. Increasing When the AVN happens in the
the blood supply and providing proximity of a weight bearing
precise mechanical stimulus joint, it would naturally collapse
makes bone appear and this bone and deform leading to mechanical
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wear and tear. And thus if we are
able to increase the blood supply
by any way, while protecting the
joint, it is logical to assume that
the avascular area will become
healthy bone again!

ANATOMICAL VARIATIONS
IN FEMORAL HEAD BLOOD
SUPPLY AND ITS RELATION
TO AVN.

Despite various causes for

“Idiopathic” AVN of hip, the
a c t u a l re a s o n i s t h e s a m e .
Synovitis with multiple
proliferation of synovial cells
causing oedema compressing
blood vessels and causing
thrombosis and ischemia!

Solitary vessel supplied femoral

heads, i.e. those predominantly
dependant on posterior
retinacular vessels are at highest
risk. Those with good foveolar
supplies RARELY get AVN. Heads
with good anterior, posterior and Pathological appearance of
foveolar supply NEVER get AVN AVN femoral head
unless there is a very bad
subcapital fracture with total on posterior retinacular blood
disruption of blood supply as supply and these most often
shown in X-rays below. develop AVN.

Even untreated subcapital neck of Be it trauma, infection, arthritis or

femurs will unite in 14% of arthropathy, pressure on vessels,
population with good blood thrombosis, plaque and
s u p p l y. O n l y a b o u t 1 5 % constriction of blood supply is the
population are entirely dependant culprit! As per Mukharjee theory,
Femoral head blood supply has many individual
variations
 it is synovitis due to rapidly
proliferating synovial
in ammatory cells, that cause
tissue oedema, and constriction of
posterior retinacular vessels that
lead to their strangulation. And
thus develops AVN.

The so called idiopathic, post

partum, alcohol, or steroid
induced AVN is nothing else but
highly proliferative synovitis with
consequent avascularity in those
vulnerable hips which are only
supplied by posterior retinacular Dr. Yellapragada Subbarao!
vessels!

A n d t h i s b r i n g s u s t o D r. College. His father in law assisted

Yellapragada Subbarao! him with nances so he could
nally go to study in the US.
Dr. Yellapragada Subbarao!
He sailed for the US on October
Dr Subbarao was born in 26, 1922, and took admission in
Bhimavaram in Andhra Pradesh the Harvard School of Tropical
in the year 1895. During his early Medicine. After completing his
l i f e h e h a d t o f a c e s e v e re studies, he joined Harvard as a
hardships. After completing his Junior Faculty member. He left the
matriculation, he managed to get this job in 1940 and took up a
himself enrolled in Madras position with Lederle
Medical College. His education Laboratories.
there was supported by friends.
His rst tryst with success came
Although he did well in college, with the discovery of the Fiske-
his British professor granted him Subbarao method, which helped
only a lesser LMS degree instead estimate the amount of
of a full MBBS. He then became phosphorous in body uids and
interested in Ayurveda and took tissues.
up a job as Lecturer in Anatomy at
Dr. Lakshmipathi’s Ayurvedic This discovery was followed by a
long chain of achievements,
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 including the discovery of the achieve miracles by the
ATP molecule (which gives Mukharjee regimen, and “Aroop’s
energy to our body), and folic neutralisation theory” helps
Aureomycin, a rst of its kind to counteract the side effects of
antibiotic that was stronger than the drug with a combination of
both penicillin and streptomycin; low but effective doses, followed
it helped save millions of lives b y n e u t r a l i s a t i o n p ro d u c e s
around the world. He also helped wonders!
develop Methotrexate, one of the
rst chemotherapy agents that is Aroop’s folic neutralisation
still used widely. Humans were theory
not the only ones to bene t from Syonvitis, and rapidly
his research; Hetrazen, a drug proliferating synovial cells cause
used to treat brosis in animals, compression and strangulation of
was introduced by him too. He femoral head blood supply.
also
Methotrixate will inhibit these
spearheaded US medical research rapidly proliferating cells.
during World War II.
Methotrixate however is a very
Despite such an amazing track powerfully toxic drug with
record, Subbarao was relatively systemic effects, and as
hidden from the media eye. He methotrixate acts on mutant, or
didn’t win the Nobel Prize or rapidly neoplastic cells by
even an equivalent, and often interfering with folic acid
took the backseat in terms of metabolism and cycle, alternating
recognition. Often, when he his MTX with folic acid will
research was being published in neutralise its ill effects.
front of an audience, he would
have to be pushed by his Blood thinners like warfarin and
colleagues to go on stage and take aspirin with low dose steroids
a bow. will allow more of the drugs to
reach the site.
Subbarao succumbed to cardiac
arrest on the August 9, 1948. He Key words
was just 53 years of age.
• Creeping substitution.
It is the miracle drug
methotrixate, that helps us to
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• Avascular zone or necrotic • Removal of thrombosis and
zone. revascularisation in femoral
• Bone is the only tissue head may take about 2 years
which rejuvenates without time.
scar tissue. • Thrombosis is the most
• That means bone which is common complication in
dead today (avascular) will arthritis. 80-90% of lower
be living tomorrow and limbs show blood clots/
fully functional. t h ro m b o s i s i n d o p p l e r
• To achieve this, we prevent studies in all patients of
structural collapse of bone arthritis which may cause or
which is avascular. may not cause pulmonary
• Av a s c u l a r i t y i s d u e t o embolism. So all patients are
t h r o m b o s i s o f a r t e r y, kept in LMWH in THR/
arterioles, capillary, veins in TKR.
the Haversian system. • Principles of treatment in
• Because of the rich collateral AVN.
and interconnectivity of • Start anti-arthritis treatment
Haversian systems, AVN is (without pain killers/
not a usual occurrence. NSAIDS) in AVN.
• Areas of solitary blood • Add blood thinners to
supply suffer from AVN. increase blood permeability
• 1/3 rd of the population has to the peripheral areas of
solitary blood supply in the bone necrotic zone.
femoral head and 20% • Continue Anti-arthritic
population has solitary treatment (Low dose
dorsal blood supply in DMARDS) or Mukharjee’s
lunate.
 Regime which is safe in long
term use.
• Still; monster blood test and Principles of therapy
other parameters to ensure
To start medication to control auto
patient safety. Immune reaction leading to
• Monitor Xray pelvis AP and decreasing levels of toxics like
PG1, PG2, TNF2, Cytokynes and
in 30 degrees hip exion AP prevent degeneration and tissue
to check skeletal integrity of breakdown. Control acidity and
the femoral dome and ISN G1 irritability for better
absorption of DMARDS.
every two months.
Give DMARDS, not all of them
• Avoid smoking/ alcohol
daily, but 2 drugs alternative rays.
intake, weight gain in order
S i n c e M e t h y l P re d n i s o l o n e
to increase possibility of
(steroid) is given in small doses
collapse of avascular zone regularly hence supplement
(Dietary restrictions). vitamin A ( Becadexamine) to
reduce the oxidative stress
• Intermittent attacks of pain produced by steroid.
is possibility (after
Supplement Vitamin B12 as
remission) which can be antibodies against
managed by rest and low Neurotransmitters are produced
in Arthritis.
dose steroid along with
regular intake of Add Blood thinner (Acetron/
Warfarin) to allow more blood
Mukharjee’s Regime. perfusion with medication, to
• Any surgical intervention disease affected area and promote
will increase the intensity of creeping substitution. Keep the
level of vitamin D nearly 100
arthritis and joint mum/ml to promote maximum
replacement is not a long bone healing
term solution in young
individuals.
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Supplement easily digestible bio- 4) Ta b s u l f a s a l a z i n e 1 g m
protiens to encourage quick
alternate day
healing and repair
5) Tab Lefunamide 20 mg
Supplement probiotics (4 billion
alternate day
spores) every day to promote
protein absorption from the gut 6) Cap Probiotic (3 billion
(which is in amed most of the spores) alternate day
time)
After Dinner
High protein diet is essential for 1) Tab Calcium Citrate 1gm 1
the protein matrix of bony tissue,
and vitamin D and B complex are tab daily
essential helpers! 2) T a b v i t a m i n E w i t h
Fasting Levocarnitine 1 tab daily
1) Tab Folic Acid 5mg on 3) Tab Methyl Prednisolone
Mon/Wed/Fri • 4 mg daily * 1 month
2) Tab Methotrexate 2.5mg on • 2 mg daily * 2 month
Tue/Thu/Sat
3) Cap Vitamin D 6000 units Add: Tab Warfarm 2 mg daily
on sunday (fasting) daily (except Sunday)
4) Tab pantoprazole 40mg in AVN cases
daily
BLOOD THINNERS:
After Lunch
Warfarin2 mg daily fasting 6 days
1) Capsule Vitamin A 5000
a week, except Sunday for two
units alternate day months or till pain disappears.
2) Capsule Vitamin B 1500 mg Monitor PT every week. Then
aspirin 75 mg daily after dinner
alternate day
six days a week.
3) Tab Hydroxychloroquine
Mederol to be tapered. 2 mg bd
400 mg alternate day for 15 days, 2 mg bd for 30 days, 2
mg daily thereafter.
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Protein supplementation: How long to continue treatment?

6 egg whites, Protinules, or Whey Creatinine Uric acid Lipid

protein, 125 grams per day every
day TSH

Until complete revascularisation Until complete revascularisation

of the head, which may take up to of the head, which may take up to
24 months depending on the size 24 months depending on the size
of the area affected and the degree of the area affected and the degree
of AVN. of AVN.

As no NSAID is added, pain relief As no NSAID is added, pain relief

is the best indicator for success of is the best indicator for success of
treatment! treatment! Examples are given on
the subsequent pages
Examples are given on the
subsequent pages

Before beginning treatment :

CBC phosphatase SGPT Alkaline

PT/APTT ESR Sugar(F) Hb A1C
USG whole Abdomen To See

1. Fatly Liver

2. Renal Calculus

3. IBs

MRI Pelvis

◦ Every 6 months
Example 1 Feb 2015
Example 1 September 2016
Example 1 clinical picture
Example 2 MRI sequence and nal clinical
picture
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Example 3 Sequential progress. Dates on lms,
with clinical pictures
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