Point-Counterpoint: Is External Fixation With Beams Better Than Internal Fixation?

Yes.

These authors note that the use of intramedullary beams provides a simpler, more effective approach to correcting complex Charcot deformities and maintaining anatomic realignment.
By William Grant, DPM, FACFAS, Lisa Grant, DPM, and Gregory Bitto, DPM

Charcot arthropathy of the foot is a disorder with the potential for devastating complications, morbidity and limb loss. Presently, the underlying pathophysiology has no clinical/medicinal therapeutic treatment. Therefore, management ideally falls to the reconstructive foot and ankle surgeon.

With regard to Charcot reconstruction, surgeons have used several constructs in an attempt to address various pathologies in the Charcot patient. A review of the literature reveals several methods of fixation including but not limited to locking plates, plantar plates, intramedullary screw fixation, K-wire fixation, crossing screws and external fixation. Each surgical construct addresses a different component of the patient’s pathology.

For example, some surgeons have used locking plates to address the extensive bone pathology. A locking screw to plate construct obviates the need for an appropriate bicortical paradigm.^1-2 Similarly, intramedullary constructs attempt to reinforce the bone to prevent further collapse. Intramedullary screws in theory absorb tension and replace the abnormal/dysfunctional collagen. Regardless of the hardware you choose, it is important to recognize that unlike standard fracture repair, these implants will be paramount in deformity correction for the life of the correction. Even after remodeling, Charcot bone maintains an immature, woven state. For this reason, hardware choice is essential to ensure persistent repair.  

Experience has shown us that in many instances, the osteotomies of Charcot patients do not fuse but instead go on to pseudarthrosis. Therefore, the goal of Charcot reconstruction cannot simply be to achieve solid fusion although this is certainly a treatment goal.

Current Concepts With Beaming In Charcot Reconstruction
For the purposes of Charcot reconstruction, we simplify the realignment process by dividing the foot into two columns. The first column is the medial column, which includes the first metatarsocuneiform joint, the cuneiform-navicular joint and the talonavicular joint. The medial column is the dominant column in Charcot reconstruction. The second column in reference to Charcot diabetic foot reconstruction is the lateral column. The lateral column includes the third, fourth and fifth metatarsals and their articulation with the cuboid, the calcaneocuboid joint and calcaneus. As we previously stated, the medial column controls the lateral column with regard to Charcot. This means that even if the lateral column appears stable, it can collapse if the medial column fails. The result is frequently a dislocation of the cuboid and/or the fifth metatarsal base with ulceration and/or osteomyelitis.

Frequently, we see patients who have had a prior resection of the base of the fifth metatarsal for osteomyelitis from a diabetic foot ulcer. Often the result is a dislocation of the cuboid and the development of a new ulceration beneath the cuboid in a Charcot foot.

In our experience, the simplest approach to repairing complex deformities is to use intramedullary beaming. We divide the foot into medial and lateral columns, and stabilize both columns with Steinmann pins. One can place large diameter cannulated stainless steel screws along the Steinmann pins. If one takes the time to completely align the medial column, the senior author has found in his experience there is subsequently less pressure on the lateral column and a minimal chance of recurrence of the lateral ulceration.

There are other advantages to utilizing beams in Charcot patients. In addition to easier maintenance of anatomic realignment than other forms of internal fixation, beams were designed for the express purpose of maintaining two columns in a debilitating disease state. Since the surgeon places beams deep along the actual columns themselves, they do not necessarily need removal due to superficial wound dehiscence because they are buried in the actual bone.

There have been cases in which beams have not been completely successful. In our experience, beams fail most frequently when two factors occur. The first is insufficient correction of Meary’s angle along the medial column. This results in the collapse of the lateral column or the failure of the lateral column beam. Secondly, along the medial column, beam failure is typically associated with the use of an undersized beam or one that is made of titanium. A secondary cause of problems with beams is failing to place the beam through the talus and its midsection.

A Closer Look At The Disadvantages Of Plating Systems
It is now important to consider the alternative of plating systems. Plating is technically difficult and does not permit or in any way facilitate the anatomic reconstruction. Surgeons have to perform reconstruction separately, hold the correction with small K-wires and subsequently place the locking plates.

Locking plates introduce so much hardware into the diabetic foot that it becomes difficult to identify whether there is a non-union or an infection. When one uses locking plates, it appears that the goal is to produce a plantigrade foot. This is not necessarily a salvageable situation. Consider a renal-pancreatic transplant patient, who had a deep osteomyelitis hidden among all the hardware and severe pain in his posterior ankle. This was due to a surgeon fusing the hindfoot in plantarflexion despite the fact that the patient had a plantigrade foot.

The surgeon needs to place locking plates superficially beneath the skin and subcutaneous tissue over the bones of the foot. The foot is not a satisfactory place to use large plates. Wound dehiscence is common. If the wounds dehisce, then it is frequently necessary to remove the plates. This destroys the fixation and the possibility for the correction. Recently, we have seen colleagues who use beams but also use a locking plate over them. When this happens, surgeons introduce the same problems of standard locking plates into the beaming construct. That is to say that plates become highly susceptible to infection and loss of correction can occur.

In Conclusion
In our practice, we use external fixation in combination with internal beaming. The beams align the medial-lateral columns while the external fixation compresses the columns. Typically, the external fixator remains in place for 12 weeks. This also allows the wounds to heal with direct visualization. In our opinion, Charcot diabetic foot reconstruction is the ideal circumstance for utilizing external fixation. However, external fixation by itself cannot maintain the ideal alignment of the Charcot foot as well as beaming can. These two types of fixation work synergistically.  

Beaming is by no means an experimental process or one that is baseless. As physicians, we need to explore all options available to us in order to better serve our patients. Physicians have achieved excellent results by matching proper hardware with an understanding of the underlying anatomic disruptions and good surgical technique to create a favorable result for people facing a terrible illness.

William Grant, DPM, is a Fellow of the American College of Foot and Ankle Surgeons, and is board-certified by the American Board of Podiatric Surgery. He is an instructor in the Department of Surgery at Eastern Virginia Medical School and is in private practice in Virginia Beach, Va.

Lisa Grant, DPM, is a first-year resident at Western Pennsylvania Hospital in Pittsburgh.

Gregory Bitto, DPM, is a first-year resident at Southeast Michigan Surgical Hospital in Warren, Mich.

References

1.     Hardukewych GJ, Ricci W. Locked plating in orthopaedic trauma: a clinical update. J Am Acad Orthop Surg. 2008;16(6):347-55.
2.     Tejwani NC, Wolinsky P. The changing face of orthopaedic trauma: locked plating and minimally invasion techniques. Instr Course Lect. 2008; 57:3-9.

Editor’s note: For further reading, see “A Closer Look At Beaming The Columns In The Charcot Diabetic Foot” in the March 2014 issue of Podiatry Today, “Current Concepts With External Fixation And The Charcot Foot” in the October 2013 issue and “When Charcot Reconstructions Fail” in the December 2013 issue.

No.

Taking a look at the literature, these authors assert that in the absence of infection, the use of internal fixation can stabilize the neuropathic foot, maintain a plantigrade position and avoid the potential complications of external fixation.
By Jennifer L. Mulhern, DPM, AACFAS, Nicole M. Protzman, MS, and Stephen A. Brigido, DPM, FACFAS

The neuropathic foot can pose a considerable challenge to the foot and ankle surgeon. Given the loss of sensation, Charcot neuroarthropathy is often complicated by cellulitis, abscess, open ulcerations, osteomyelitis and/or peripheral vascular disease. The physician needs to consider and address all of these issues during treatment. The primary objective is to create a stable, plantigrade, braceable foot that allows the patient to continue community ambulation.^1-3

Surgical interventions include the use of internal fixation alone, external fixation alone or a combination of the two methods. While physicians have committed much time and dedication to developing algorithms for successful surgical outcomes, we believe that internal fixation, in the absence of osteomyelitis, can obtain and maintain a plantigrade foot with successful patient outcomes.

Comparing Internal Fixation Versus External Fixation
Although internal and external fixation have shown comparable fusion site stability, compression across the arthrodesis site is imperative to obtain bony union.⁴ In 2002, Berson and colleagues compared four different combinations of combined and solo fixation for ankle arthrodesis.⁵ The results revealed that a nail-mounted compression device was significantly better at maintaining compression in comparison with an external fixator. These findings suggest that intramedullary fixation increases compression across the arthrodesis site and may improve the rate of bony union.

Moreover, the use of external fixation introduces additional risk, particularly in this patient population. Complications specific to external fixation include pin tract infections and pin/wire failure. Clinicians typically address pin tract infections with outpatient antibiotic therapy but if these infections are unrecognized or undertreated, osteomyelitis can result in an area of previously unaffected bone.⁶ Broken wires and pins render the external fixation device unstable and therefore require an urgent surgical exchange or adjustment.⁶ Additionally, a return to the operating room is necessary in all cases for external fixator removal. As with any surgical procedure, one must consider the specific patient population. Recent evidence suggests that patients with diabetes are seven times more likely to develop wire complications than patients without diabetes.⁷ Therefore, when treating Charcot joints, intramedullary fixation appears to be the more viable choice.

Internal fixation, however, is not without complications. Fixation failure is always a risk.^6,8 Given the poor bone density of the Charcot foot and the inability of the tendons and ligaments to support the reconstruction, the internal device is subject to excess stress, increasing the likelihood of failure in this patient population.^8,9 If large incisions are necessary for internal fixation placement, there is a greater risk for wound healing complications.⁶ Particularly with intramedullary nails for hindfoot Charcot, infection of the implanted hardware can result in large bone losses and often amputation.¹⁰ In cases of non-union, dynamization or revision may be necessary to facilitate healing.^11,12

While complications are a possibility, the complication rate associated with internal fixation is relatively low, validating these devices as safe and effective in the treatment of Charcot arthropathy in the foot and ankle.

Obtaining Surgical Stabilization With Internal Fixation
The stage of the condition dictates surgical intervention. Although surgery is a topic of recent controversy for Charcot Eichenholtz stage 1, it is generally accepted that one should avoid surgery at this stage.¹³ Surgical stabilization with adequate fixation during this stage is often difficult to achieve due to the ongoing, active processes of Charcot breakdown.¹⁴ In Eichenholtz late stage 2 and stage 3 Charcot arthropathy, surgical stabilization can be effective.¹³

Sammarco recently introduced the term “superconstructs” to discuss the most advantageous fixation constructs for managing Charcot deformity.¹⁵ These constructs should adhere to the following tenets:
• Fixation and arthrodesis should extend beyond the zone of injury. This will include non-affected joints, improving the stability of implanted fixation.
• Resection allows for shortening of the extremity for adequate reduction of deformity and minimization of tension on the soft tissues.
• Utilize the strongest device allowed by the soft tissue envelope.
• Apply internal fixation that maximizes mechanical function.

When possible, employ minimal incision internal fixation to decrease the risk of wound healing complications. Examples of minimal incision fixation include intramedullary rods for either the ankle/hindfoot or the metatarsals (“beaming”) for stabilization with tarsal arthrodesis in the treatment of midfoot Charcot. However, the nature of the deformity and the need for joint resection often require larger incisions. In these situations, locking plates and screws can create a stable construct.

Combining plates and intramedullary fixation can significantly increase the strength of the reconstruction. Intramedullary beams are stress shielding devices and thus may limit stress both dorsally and plantarly along the metatarsal shaft, providing stabilization in the sagittal plane.³ Additionally, plate placement within the medullary canal and across multiple joints can provide stabilization in the transverse plane.³ Surgeons cannot control frontal plane rotation with beaming but the combination of beaming and plates can impart stability on the frontal plane for triplanar stabilization.³

Pertinent Insights On The Use Of Intramedullary Fixation
When “beaming” for the stabilization of midfoot Charcot, surgeons utilize minimal incisions while limiting periosteal dissection. One can perform wedge resection for deformity correction of the midfoot through two small incisions, one medial and one lateral, to allow for entry of an oscillating saw or a Gigli saw. In either instance, it is imperative to retract the dorsal neurovascular structures during resection. Following wedge resection, stabilize both the medial and lateral columns with beams.³ We recommend large diameter solid screws or fusion bolts with cannulated instrumentation. Percutaneous placement can be either retrograde or antegrade.¹⁶ Strategic placement of the small incisions can be particularly beneficial in the presence of ulceration.

When facing hindfoot Charcot breakdown, intramedullary fixation can help one perform a tibiotalocalcaneal arthrodesis with a retrograde nail. Surgeons can apply most retrograde nails and fixate them to impart compression across the arthrodesis sites. In situations involving the use of interpositional bone graft, one can lock the nail into a static position and later dynamize it. We agree with Woods and Burn that a straight nail in the hindfoot Charcot may be more appropriate due to potential talar destruction as well as the need to medialize the distal segment for extremity realignment.¹⁷ Small incisions overlying the ankle and subtalar joint can allow access for cartilage resection and percutaneous placement of locked screws.

A Closer Look At Plate Fixation
The use of locking plate constructs can be beneficial in both the midfoot deformity and the hindfoot deformity. Plantar plating adheres to traditional guidelines, whereby surgeons secure plates, when possible, to the tension side of the bone. This technique can maintain stabilization at a greater load and has proven superior to screw fixation.¹⁸ Plating can effectively address subluxations/dislocations within the midfoot where beaming may prove more challenging. Plating also allows the surgeon to formally prepare each involved joint and selectively perform arthrodesis on only the affected joints. Additionally, plate fixation, particularly on the medial column, creates an extremely rigid construct when one utilizes long locking screws to traverse the midfoot from medial to lateral. Therefore, medial and lateral plating with long length locking screws can stabilize the entire midfoot region.

Posterior blade plate fixation was the initial fixaton of choice in tibio-talocalcaneal arthrodesis. Over time, however, it became clear that posterior blade fixation was fraught with complications. The pendulum has therefore shifted to the use of intramedullary fixation. Be that as it may, improved locking plate fixation options have developed, which has led to an increase in plate fixation for tibiotalocalcaneal fusions. These hardware options include locking and interfragmentary slots that allow rigid fixation across the arthrodesis site. Surgeons can apply plates posterior, anterior or medial depending on the deformity correction necessary and avoidance of compromised soft tissues.

Nevertheless, application of plates in both the midfoot and hindfoot scenarios requires larger incisions, which can prove problematic for healing. Although one can place screws alone percutaneously, we do not advocate this technique in the hindfoot Charcot situation.

What The Clinical Research Reveals
Surgeons have used intramedullary devices to treat a wide spectrum of Charcot-related deformities throughout the foot and ankle.^10-12,19 Following Lisfranc joint dislocation secondary to Charcot neuroarthropathy, the use of plantar plating has successfully stabilized the midfoot.¹⁹ Assal and Stern achieved successful deformity reduction in patients with diabetic neuropathy and midfoot Charcot arthropathy by employing intramedullary beaming with and without plate fixation.¹² In patients with severe hindfoot Charcot, several authors have achieved a high rate of limb salvage with intramedullary nailing.^10,11 Several reports throughout the literature support the use of intramedullary devices in the treatment of Charcot arthropathy.^10-12,19

Although there has been success with various intramedullary devices, researchers have explored if one construct is superior to another.^20,21 In 2010, Lee and colleagues conducted a cadaveric investigation to compare the load to failure and fatigue associated with a posterior blade plate and an intramedullary nail.²¹ Their results indicate that fixation with an intramedullary nail exhibits greater construct stiffness in comparison with blade plate fixation.²¹

In a subsequent report, Pope and colleagues conducted a comparative investigation to evaluate plantar plating and intramedullary screws for midfoot arthrodesis.²⁰ The study found that the two constructs display a similar load to failure and stiffness, supporting the use of either plantar plating or intramedullary screws.²⁰ Collectively, these results suggest that intramedullary nailing may provide superior fixation and improve outcomes.²¹

In Conclusion
Management of midfoot and hindfoot Charcot neuroarthropathy can present a considerable challenge. Although several options can provide successful patient outcomes, in the absence of infection, researchers have shown that internal fixation alone creates a stable, plantigrade, braceable foot without the need for external fixation removal surgery. Moreover, internal fixation negates risks associated with the application of external fixators. As such, the solitary use of internal fixation has support throughout the literature. If the surgeon applies internal fixation appropriately, it can provide a “superconstruct,” which can stabilize the neuropathic foot and permit community ambulation with a relatively low complication rate.

Dr. Mulhern is a Fellow of Foot and Ankle Reconstruction at Coordinated Health in Bethlehem, Pa. She is an Associate of the American College of Foot and Ankle Surgeons.

Ms. Protzman is a Research Associate at Coordinated Health in Allentown, Pa.

Dr. Brigido is the Fellowship Director of Foot and Ankle Reconstruction at Coordinated Health in Bethlehem, Pa. He is a Fellow of the American College of Foot and Ankle Surgeons.

References

1. Zgonis T, Roukis TS, Lamm BM. Charcot foot and ankle reconstruction: current thinking and surgical approaches. Clin Podiatr Med Surg. 2007; 24(3):505-17, ix.
2. Lamm BM, Siddiqui NA, Nair AK, LaPorta G. Intramedullary foot fixation for midfoot Charcot neuroarthropathy. J Foot Ankle Surg. 2012; 51(4):531-6.
3. Crim BE, Lowery NJ, Wukich DK. Internal fixation techniques for midfoot charcot neuroarthropathy in patients with diabetes. Clin Podiatr Med Surg. 2011; 28(4):673-85.
4. Fragomen AT, Meyers KN, Davis N, Shu H, Wright T, Rozbruch SR. A biomechanical comparison of micromotion after ankle fusion using 2 fixation techniques: intramedullary arthrodesis nail or Ilizarov external fixator. Foot Ankle Int. 2008; 29(3):334-41.
5. Berson L, McGarvey WC, Clanton TO. Evaluation of compression in intramedullary hindfoot arthrodesis. Foot Ankle Int. 2002; 23(11):992-5.
6. Lamm BM, Gottlieb HD, Paley D. A two-stage percutaneous approach to charcot diabetic foot reconstruction. J Foot Ankle Surg. 2010; 49(6):517-22.
7. Wukich DK, Belczyk RJ, Burns PR, Frykberg RG. Complications encountered with circular ring fixation in persons with diabetes mellitus. Foot Ankle Int. 2008; 29(10):994-1000.
8. Grant WP, Garcia-Lavin S, Sabo R. Beaming the columns for Charcot diabetic foot reconstruction: a retrospective analysis. J Foot Ankle Surg. 2011; 50(2):182-9.
9. La Fontaine J, Shibuya N, Sampson HW, Valderrama P. Trabecular quality and cellular characteristics of normal, diabetic, and charcot bone. J Foot Ankle Surg. 2011; 50(6):648-53.
10. Caravaggi C, Cimmino M, Caruso S, Dalla Noce S. Intramedullary compressive nail fixation for the treatment of severe Charcot deformity of the ankle and rear foot. J Foot Ankle Surg. 2006; 45(1):20-4.
11. Siebachmeyer M, Boddu K, Bilal A, Hester TW, Hardwick T, Fox TP, Edmonds M, Kavarthapu V. Outcome of one-stage correction of deformities of the ankle and hindfoot and fusion in Charcot neuroarthropathy using a retrograde intramedullary hindfoot arthrodesis nail. Bone Joint J. 2015; 97-B(1):76-82.
12. Assal M, Stern R. Realignment and extended fusion with use of medial column screw for midfoot deformities secondary to diabetic neuropathy. J Bone Joint Surg Am. 2009; 91(4):812-20.
13. Eichenholtz SN. Charcot Joints. Charles C. Thomas, Springfield, IL, 1966, pp. 3-8.
14. Wukich DK, Sung W. Charcot arthropathy of the foot and ankle: modern concepts and management review. J Diabetes Complications. 2009; 23(6):409-26
15. Sammarco VJ. Superconstructs in the treatment of Charcot foot deformity: plantar plating, locked plating and axial screw fixation. Foot Ankle Clin. 2009; 14(3):393-407.
16. Sammarco VJ, Sammarco GJ, Walker EW Jr, Guiao RP. Midtarsal arthrodesis in the treatment of Charcot midfoot arthropathy. Surgical technique. J Bone Joint Surg Am. 2010; 92(Suppl 1 Pt 1):1-19.
17. Woods JB, Burns PR. Advances in intramedullary nail fixation in foot and ankle surgery. Clin Podiatr Med Surg. 2011; 28(4):633-48.
18. Marks RM, Parks BG, Schon LC. Midfoot fusion technique for neuroarthropathic feet: biomechanical analysis and rationale. Foot Ankle Int. 1998; 19(8):507-10.
19. Garchar D, DiDomenico LA, Klaue K. Reconstruction of Lisfranc joint dislocations secondary to charcot neuroarthropathy using a plantar plate. J Foot Ankle Surg. 2013; 52(3):295-7.
20. Pope EJ, Takemoto RC, Kummer FJ, Mroczek KJ. Midfoot fusion: a biomechanical comparison of plantar plating vs intramedullary screws. Foot Ankle Int. 2013; 34(3):409-13.
21. Lee AT, Sundberg EB, Lindsey DP, Harris AH, Chou LB. Biomechanical comparison of blade plate and intramedullary nail fixation for tibiocalcaneal arthrodesis. Foot Ankle Int. 2010; 31(2):164-71.

For further reading, see “When Should You Operate On The Charcot Foot?” in the March 2015 issue of Podiatry Today, “Assessing The Talectomy For Charcot Ankle Deformity” in the March 2015 issue or “Emerging Evidence On Treatment Of The Diabetic Charcot Foot” in the March 2012 issue.