DOI: 10.

17354/SUR/2016/10
Original Article

Treatment of Buerger’s Disease by Bone Widening

by Ilizarov Technique

Satish Nesari1, Mahaboob Pasha2

1
Assistant Professor, Department of Orthopedics, Belgaum Institute of Medical Science, Belagavi, Karnataka, India,
2
House Surgeon, Department of Orthopaedics, Belgaum Institute of Medical Science, Belagavi, Karnataka, India

Abstract
Background: Thromboangiitis obliterans (TAO) is a chronic inflammatory arteritis affecting small/medium arteries, predominantly
of lower limbs. It is difficult to get good results with conservative treatment; response rates with surgical treatment options such
as sympathectomy are inconsistent. Other options such as omentopexy are costly and have high complication rates.
Materials and Methods: Patients diagnosed with TAO were treated using bone widening technique using Ilizarov external fixator
and results analyzed.
Results: We present our early experience in managing TAO by bone widening by Ilizarov method. Ilizarov technique gave
excellent results, as indicated by subsidence of pain (though gradual), increase in peripheral capillary oxygen saturation (>95%),
and increase in claudication distance (1-5 km).
Conclusion: A bone widening technique using Ilizarov method can be a good alternative in the treatment of Buerger’s disease.
It is excellent and cost-effective method.
Keywords: Bone widening, Buerger’s disease, Gangrene, Neohistogenesis

INTRODUCTION changes in the walls of arteries and veins which

may lead to thrombosis.

T hromboangiitis Obliterans (TAO), also known as

Buerger’s disease, is a progressive, inflammatory
reaction in the arterial wall with involvement of
Carl Friedlander, in 1876, first named it as “arteritis
obliterans.”7 3 years later, in 1879, Felix von Winiwarter,
neighboring vein and nerve, terminating in thrombosis came across a case of unusual obliteration of the arteries
of the artery.1-3 TAO is a more common in males. There and veins of the leg in a 57-year-old male patient, which
may be some hormonal influence which suggests sex he termed as endarteritis obliterans. 8 Leo Buerger,
distribution.3 TAO is a disease of male smokers. Though in 1908, gave the first pathological description and
very rare, it is also seen in females.4-6 called it “presenile spontaneous gangrene.”9 As the
acute histologic features in the arteries/veins were
Definite etiology for the disease is unknown but it is characterized by thrombosis and marked inflammatory
strongly associated with smoking (primarily), also from response, he called it TAO.
the use of smokeless tobacco. It is common in age group
Clinically, TAO presents as chronic ischemia (lower
of 20-40 years. Histologically, there are inflammatory
limb>upper limb). Usually, pain is the presenting
Access this article online complaint (claudication/rest pain). Associated features
like chronic ulcers/gangrene may be present. History of
Month of Submission : 11-2015 tobacco use (smoking/smokeless tobacco) is present.
Month of Peer Review : 12-2015
Month of Acceptance : 01-2016 Although there is no permanent cure as of now, cessation of
Month of Publishing : 02-2016 tobacco in any form should be the first step/most effective
www.surgeryijss.com
step10,11 in treatment and results in disease quiescence but

Corresponding Author: Dr. Satish Nesari, House no.308, Belgaum Institute of Medical Science Doctors (Group A) Quarters, Near Civil
Hospital OPD, Belgaum Institute of Medical Science, Belgaum - 590 001, Karnataka, India. Phone: +91-9448035954.
E-mail: Satish_nesari@rediffmail.com

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 Nesari and Pasha: Treatment of Buerger’s Disease by Ilizarov Technique

does not reverse the disease. Various medical (platelet tibial, dorsalis pedis were not palpable, though femoral
inhibitors, vasodilators, anticoagulants, thrombolytic arterial pulsations were palpable. Peripheral capillary
therapy, clofibrate, etc.), surgical (thrombolytic therapy, oxygen saturation by pulse oximetry was not recordable.
bypass grafts, lumbar sympathectomy, omental transfer, Three out of five patients had gangrene of great toe for
etc.), and other modalities (spinal cord stimulation and which amputation (guillotine method) of great toe was
therapeutic angiogenesis) have been tried with limited done followed by bone widening by Ilizarov technique.
success. As the disease progresses, amputations may One patient had involvement of upper limb in addition
eventually be required. Periosteal stripping,12 cell therapy, with chronic ischemic features in the left hand and
vascular gene therapy,13 osteotrepanation14 are newer gangrene of left index finger/thumb. Radial/ulnar
modalities in the treatment. artery pulsations were not palpable. He had segmental
narrowing and occlusion of the brachial artery, ulnar and
GA Ilizarov has studied effect of tension stress on genesis radial arteries which were operated by vascular surgeon
and growth of tissues in canine tibiae and found that before presenting to us. After surgery, there was some
corticotomy and distraction of fragments increased improvement in pain but later as the symptoms worsened,
blood supply to the limb and led to osteogenesis and the patient was advised for above elbow amputation.
neo-histogenesis.15,16 Ilizarov technique was tried prior to amputation. As
there was considerable improvement in signs/symptoms,
Buerger’s disease can be effectively managed using amputation was avoided.
the principles of distraction osteogenesis to promote
angiogenesis. Ilizarov’s method of distraction osteogenesis Postoperatively, weight bearing was allowed soon after
increases vascularity of the ischemic limb, thereby operation. Most of the patients were able to walk at about
preventing subsequent amputations at a higher level. 7 days post-surgery.
However, it needs considerable skill and expertise and has
a long learning curve. Although distraction osteogenesis All the patients were followed up for >2 years (mean =
is shown to promote angiogenesis, using this technique 2 years 9 months).
as a treatment modality has been reported by only a few.
In the last follow-up, all the patients are able to walk for
We report here our experience in treating five patients >1.5 km and they resumed to their duties.
diagnosed to have Buerger’s disease (TAO) using bone
widening technique using Ilizarov external fixation Technique: Corticotomy was performed on the
technique. anteromedial surface of tibia (ulna in case of upper limb
TAO). Percutaneous multiple small vertical incisions were
MATERIALS AND METHODS taken. The longitudinal osteotomy was made on the
anteromedial surface of the tibia using 5 mm osteotomes.
A total of five patients diagnosed with TAO and treated This results in a small fragment of tibia (about 12-15 cm
using bone widening technique using Ilizarov external long), in the posteromedial area which is distracted
fixator were studied from March 2012 until September apart horizontally using crossed plain wires. Osteotomy
2015. fragment was fixed with cross wire technique.

History of heavy smoking (20-40 beedis/day, for Post-operative care: Regular dressings were done to
>25 years) since early age was present in all cases. All prevent pin tract infection. Physiotherapy was advised
patients had severe rest pain. All patients had Grade IV postoperatively. After a period of 7-day, distraction
ischemia as per Rutherford classification and Stage IV was started. The rate of distraction being 0.25 mm,
disease as per Leriche-Fontaine classification. Other 4 times day. Total distraction was 2-2.5 cm consolidation
possible causes of ischemia such as atherosclerosis, period was about 10 weeks. External fixator time was
Raynaud’s phenomenon were excluded before the about 12 weeks. Post-operative radiographs were taken
diagnosis of TAO was made. Relevant Investigations every 6 weeks until frame is removed.
such as color Doppler and MR angiography was done
whenever indicated. All patients had received some Patients were discharged after 10 days. Ilizarov apparatus
or the other pharmacological treatment with limited removed after about 12 weeks (Figures 1-8).
success.
RESULTS
Mean age was 43 years. Four patients had lower limb
involvement (chronic ischemic features with non- Improvement in symptoms was gradual, pain relief (rest
healing ulcer). In three patients, popliteal, posterior pain) seen after 2 weeks following treatment.

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 Nesari and Pasha: Treatment of Buerger’s Disease by Ilizarov Technique

Figure 1: Upper limb thromboangiitis obliterans Figure 4: Healed osteotomy site post removal (12 weeks) of
Ilizarov fixator

Figure 2: upper limb thromboangiitis obliterans operated using

Ilizarov fixator Figure 5: Osteotomy fragment fixed using crossed wire
technique and Ilizarov fixator

Figure 3: Osteotomy fragment fixed using crossed wire Figure 6: Healed osteotomy site post removal (12 weeks) of
technique and Ilizarov fixator Ilizarov fixator

In all patients, the severity of pain got reduced and changes in skin improved. By the time fixator was
dramatic improvement in claudication distance. Ischemic removed, ulcer showed signs of healing.

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 Nesari and Pasha: Treatment of Buerger’s Disease by Ilizarov Technique

The disease is more prevalent in middle east and asia.18

Though definite etiology is unknown the possible
etiologies include/attributed to the use of tobacco,
genetic predisposition, autonomic over activity,
autoimmune etiology.3 Pain is typical of intermittent
claudication which progresses to rest pain. Gradually,
postural color changes appear, followed by trophic
changes and eventually ulceration and gangrene of one
or more digit; finally of the entire foot and hand requiring
amputation. As the disease progresses pain becomes
intense and may be even present at rest (rest pain).
Rest pain is so intense that patient cannot sleep, some
amelioration may be achieved by placing the affected
limb in dependent position.3,17

Signs suggestive of chronic tissue ischemia are present.

The most frequent finding is the absence of posterior
tibial and dorsalis pedis pulses in the feet. Absence of
posterior tibial pulse when bilateral is highly suggestive of
the disease. In the upper extremity, the radial pulse may
be absent and when bilateral is suggestive of disease.3
Recurrent superficial thrombophlebitis is a characteristic
feature of the disease.18 Migratory superficial phlebitis
may be present in up to 16% of patients, thus indicating
Figure 7: Full weight bearing 5 days after surgery a systemic inflammatory response. 17 Some of the
characteristic angiographic findings include - disease
confinement to distal circulation, the occlusions
are segmental and show skip lesions with extensive
collateralization (corkscrew collaterals).17

Conservative treatment comprises cessation of

smoking/tobacco use. But only 43-70% of cases manage
to give up smoking. 19 Vasodilators, anti-coagulants,
dextran, phenylbutazone, steroids, prostaglandin therapy
have been tried with questionable vaue.3 The role of
sympathectomy is doubtful3,17-18 and has got aspecific
role in alleviating pain. About 50% of patients are
significantly benefitted from sympathectomy.3 Although
Figure 8: Post Ilizarov (upper limb thromboangiitis obliterans) sympathectomy is shown to promote ulcer healing and
picture showing pulse oximetry parameters provides short-term pain relief in some patients with
Buerger’s disease, no long-term benefits have been
Oxygen saturation measured using pulse oximeter was confirmed. 20 Re-vascularizing options are limited. 17
>95% (Figure 8) at the time of fixator removal. The Arterial reconstruction is difficult because of the distal
patient is able to walk bearing full weight in few days nature of the disease; amputation is the only way out
after surgery (Figure 7). when gangrene develops.3
All the patients now are able to walk >1.5 km with no Distraction osteogenesis is a surgical technique used to
pain. All patients resumed to their duties/jobs. reconstruct skeletal deformities and lengthen the bones.
A corticotomy is used to fracture the bone into two
DISCUSSION segments, and the two segments are gradually moved
apart during which new bone forms in the gap.21,22
TAO, also known as Buerger’s disease/pre-senile gangrene, Intact medullary blood supply, preservation of soft
is a progressive, segmental, non-atherosclerotic, tissue envelope, mainly the periosteum and stability of
inflammatory, vaso-occlusive disease (thrombosis) of fixator are the most important factors for success of bone
small/medium sized arteries and/or thrombophlebitis of distraction.23,24 Distraction rate must be gradual to achieve
superficial or deep veins and Raynaud’s syndrome.1-2,17 optimal results. Too slow distraction rate would result in

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 Nesari and Pasha: Treatment of Buerger’s Disease by Ilizarov Technique

early bone consolidation whereas rapid distraction may method. It can avoid amputations at a higher level and
result in fibrous union.25 provides relief of symptoms, may halt/retard disease
progression when accompanied by cessation of tobacco
Treatment of TAO in our study is based on the principle use in any form.
of law of tension stress by prof. Ilizarov which states
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