Can ‘Beam’ Surgery Have An Impact For The Collapsed Charcot Foot?

I have been performing “beam” surgery for the treatment of the collapsed Charcot foot for about 18 months. If you are not familiar with this procedure, it involves reducing the deformity and percutaneously inserting a large diameter screw inside the bones of the medial column.

We insert a 6.5 mm screw through the first metatarsal head, the medial cuneiform, navicular and into the body of the talus. One can stabilize the lateral column with the screw running through the calcaneus, cuboid into the 4th metatarsal base. Surgeons can insert these screws from either a distal or proximal approach. Frequently, I also insert 4.0 mm screws percutaneously from the lateral aspect of the foot and crossing the Lisfranc’s joint for greater stability.

On several cases, I was able to perform closed reduction to correct the rocker bottom and abduction deformity of the foot. In those cases, one resects cartilage through small incisions over the joint with fluoroscopy guidance. If closed reduction is not successful, the surgeon may employ conventional exposure to wedge the joints for proper alignment.

Previously I have used external fixation or bone plates for fixation of the Charcot foot deformity. In my experience, this was not very successful. The external fixators either loosened or the wires broke before the fusion site healed. The plates and screws frequently displaced or broke, resulting in collapse of the foot.

This is not to say that the “beam” doesn't have complications. Every surgical procedure does. In our first twelve cases, two of the 6.5 mm medial column screws broke and one backed out through the posterior aspect of the talus. All three cases required additional surgery. Two of the revisional surgeries were minor and the third was more extensive. I find this an acceptable level of complications for such a high-risk condition.

This is actually an exciting procedure/fixation technique that yields very nice results for a serious foot problem that can easily result in amputation of the leg.

Will this procedure stand the test of time and become universally accepted? I think it will. Certainly, we need more outcome studies and strength analysis of the fixation. A prospective comparative study of external fixation, plantar plating and medial column beaming would be a good start to evaluating this technique.