JOSHI’S EXTERNAL STABLISATION SYSTEM-(JESS)

INCTEV

DR. IMRAN JANMBBS, DNB( Ortho)

Causes Of Relapse In Rx Of CTEV1. Errors in ctev correction methods in Ponseti2. Improper surgical intervension without

adequate conservative treatment3. Inadequate post operative care4. Non-compliant parents in post correction

regime

Causes Of Relapse In Rx Of CTEV-------

5. Lack of rehabilitation exercises6. Rigid club foot associated with-

arthrogryposis, aminiotic band syndrome, Menigomyelocele, spina bifida, spinal cord defects

7. Unequal growth of muscles during growth spurts

8. Defective or inadequate orthotic fittings

• Relapsed clubfoot is nothing more than an incompletely corrected feet.

-(Beatson and Pearson 1966, Evans 1961, Fripp and Shaw 1967, Kite 1972, Turco 1971)

• Spurious correction later manifests as relapse.

Residual Deformities

1. Adduction & inversion of forefoot

2. Equinus at ankle.3. Cavus & heel varus4. In-toeing ± 5. Problem – compounded by

secondary changes in skin/bone & joints fibrosis/stiffness

Basic Anatomic Derangement In Clubfoot

• Congenital subluxation of talo-calcaneo navicular joint

• Navicular & calcaneus displaced medially in relation to talus.

• Club foot- abnormal intertarsal relationship

• The shape of the tarsal bones is altered in accordance with the wolf’s law.

• Soft tissue contracture acquired in accordance with the law of Davis

“When ligaments and soft tissue are in lax state they will gradually shorten”

Clinical Assessment- (Caroll)1) Calf atrophy

2) Posterior displacement of the fibula

3) Creases medial or posterior

4) Curved lateral border

5) Cavus

6) Fixed equinus

7) Navicular fixed to medial malleolus

8) Os cacis fixed to tibia

9) No mid tarsal mobility

10)Fixed forefoot supination

**Each feature scores 1 point Worst feet would score 10 and a Normal well corrected foot score 0

Radiological Assessment

•Talo-calcaneal angle(AP) 15°-40

•Talo-calcaneal angle (lat stress) 25-40 °•Talo-calcaneal index > 40 °

•Tibio-calcaneal angle (stress lat) 5-15 °

nTC 25-40

nTC15-40

N 60-90

<15 Abn

OVERCORRECTED FEET

-to tide over the period till the child reaches age of 14 before triple arthodesis

Problems -RevisionRepeat surgical procedure –Challenging

1. Preexisting fibrosis

2. Stiffness of the joints of the foot

3. Hypoplastic anterior tibial vessels

4. Wound closure difficulties with skin necrosis.

Prof. Brij Bhushan Joshi (1928 – 2009)

JESSJoshi External Stablisation System• Developed by DR. B.B.JOSHI in Mumbai, India

• First Patient - operated in 1988

• Today - evolved into a verastile system with application in trauma, defects & deformities in upper and lower limb.

• JESS has a special application in the correction of resistant clubfoot .

Principle Of Jess• Basis of deformity correction - principle Of

FRACTIONAL DISTRACTION OF ILIZAROV (1980)

• Dr Joshi added the concept of DIFFERENTIAL DISTRACTION (1988)

• In differential distraction - concave side of deformity is distracted twice the rate of the convex side

• Prevents crushing of the tissues on the convex side, lengthens the limb and effectively corrects the deformity at the same time.

Indications1. Drop out of conservative treatment

2. Recurrence after earlier surgical release

3. Known resistant cases- severely contracted foot, AMC, Congenital band syndrome.

4. Late presentation to treatment

5. Adjunct to surgical treatment -for realignment of skeleton to minimise bone resection and shortening of the foot

The Goal Of TreatmentFoot that is –• Cosmetically acceptable• Pliable• Functional• Painless• Plantigrade• Fits into standard footwear• Spares the parent and the child from the

ordeal of frequent hospitalisation and years of treatment with casts and braces.

Components of JESS Fixator

Distractor Devices• The double hole• The fish mouth • The split block • The biaxial hinge

• Connecting rods- standard connecting rods in the small and medium set is 3 mm rod.

LINK JOINTS

• Link joints- different sizes-

• Medium size accommodates a -connecting rod upto 3 mm diameter in lower hole - a k wire of 1.2 to 3 mm diameter in upper hole.

• Universal link joint-independent locking system for each connecting rod and k wire Can hold rods up to 4 mm diameter

Operative Technique• GA-Supine• Pneumatic tourniquet is applied- not inflated• Neurovascular markings• Hand drill to pass k wires/power drill in older

children• 3 MAIN STEPS:

1.The insertion of k-wires2.The creation of holds3.The connection between the holds

Creations Of HoldsA. The tibial holdB. The Metatarsal holdC. The Calcaneal hold

THE CONNECTION BETWEEN HOLDS• The Tibio-metatarsal connection• The Calcaneo-Metatarsal connection• The Tibio-Calcaneal connection

TOE SLING ATTACHMENT-provides dynamic traction to prevent flexion of the toes as deformity gradually corrects

Application Of Tibial Wires

Application Of Transverse Calcaneal Wires

Application Of Metatarsal Wires

Application Of Axial Calcaneal Wire

Calaneo –Metatarsal Distraction Corrects forefoot adduction at mid tarsal &

tarsometarsal joints

Realigns the head of talus with the navicular

Derotates the calcaneum

End point-Clinical and radiological correction of forefoot deformities(approx 2-4 weeks)

Medial- 0.25 mm every 6 hours Lateral- 0.25 mm every 12 hours

The Tibio-calcaneal Distraction TC is carried out in 2 positions

• Distractors are mounted between the inferior limbs of the tibial Z rods and post limb of the calcaneal-L rod

• Distractors lie parallel to the leg and just posterior to the transfixing calcaneal wires. This corrects varus of the hind foot and equinus

• Once the varus is corrected

• -Tibio calcaneal distractors are shifted posteriorly

• -Distraction in this position provides thrust to stretch the posterior structures and corrects hind foot equinus at the ankle and subtalar joints

• End point –judged clinically (approx 4 weeks)

Medial- 0.25 mm every 6 hours Lateral- 0.25 mm every 12 hours

Tibio-metatarsal Connection• Tibio-metatrsal connection is static.

• Keeps anterior part of the ankle and subtalar joint open while the heel equinus is being corrected

• Weekly adjustment needed to reduce excessive tension by loosening the clamps.

• Dorsiflexion of the ankle joint achieved gradually after correction of the other components of the deformity

• Rocker bottom –pseudo correction occurs if force dorsiflexion

Post Operative ManagementDISTRACTION SCHEDULE—3 rd day onwards

360 clock wise in 4 fractions/180 in 2 fractions

Corrective period: 3-6 weeks.

Static period: 3-6 weeks

Casting after complete correction not only

protects the osteopenic bones while the pin-tracts

heal, but also maintains correction and allows

gradual weightbearing.

• Care of the assembly

• Cover the pin sites with a dry dressing

• Encash the whole frame with a thin layer of soft foam or cardboard

• Change dressing of pin tracks regularly

The Static Phase• 20 ° of dorsiflexion necessary to avoid

recurrence and to permit squatting.

• Following correction - assembly held in a static position for 3 to 6 wks to allow soft tissue maturation in the elongated position.

• Static phase should be twice the period of distraction

Cases

10/5/2009Post STR

rt-3/M

28/10/2009

18/4/2011

STR-dec2007(Sohar)

JESS-28/10/2009KHTib AT-12/5/2010KHEXCELLENT RESULT

RESULTS

• In 2003 S. Suresh et all treated 26 children with ctev

44 Joshi's external stabilization system procedure at

the Safdarjung Hospital, New Delhi between Jan 1998

and Dec 1999.

• Three dimensional corrections were achieved by use

of the distracter device.

• Excellent results were obtained in 77% of cases, good

results in 13% and poor results in 9% of the cases.

S.SURESH et al – Role Of JESS In The Management Of Idiopathic Club feet, journal Of Orthopaedic Surgery. 2003: 11(2):194-200

Khoula Experience• 1992-1998 Khoula hospital, paed ortho unit

treated 112 feet using JESS fixator to correct foot deformities.

• 20 were excluded from study-polio, meningomyelocele, muscular dystrophy

• 92 feet were recurrent/neglected club feet--72 feet (56 patients) were available for study

• 14(19.4%) were neglected-no surgery• 42(80.6%) were recurrent clubfoot• 3 (8.3%) had limited soft tissue surgery at time

of JESS application. (Heel cord lengthening, plantar fasciotomy, and tibialis post z plasty)

Results• GOOD result- 58 feet(80.5%)

• FAIR result- 10 feet(13.9%)

• POOR result-4 feet(5.6%)—needed reapplication

of JESS to correct the deformity prior to triple

arthrodesis.

• None of our patients showed correction to a

normal range of talocalcaneal angle radiologically.

Complications

Orthotic Devices• Splints are fitted to maintain the corrected

position over prolonged periods• Thermoplastic splints are used-allows minor

individual variations.• Denis–browne splint with abduction bar –in non

ambulatory child• Child refered to physiotherapist for gait training

and to strengthen weaker muscles to keep foot supple and aligned

Older Children/Adults

Advantages Of Jess Use in Small foot

Avoiding fibrous tissue formation & scarring due to

conventional surgery due to distraction histogenesis

Absence of further shortening unlike bony procedures

Proper control of all components of corrections

Versatile and easy to learn system

The technique of gradual distraction allows

neohistogenesis of soft tissue as well as bone

Is it Really a Different fixator?The major differences between JESS fixator & Circular fixators

1. Wires in JESS fixators are not tensioned but only pre-stressed, to prevent them from cutting through the soft bones.

2. Clubfoot is a multiplanar, multiapical deformity. It is very difficult to plan the location of an external hinge for deformity correction. JESS frame is an unconstrained device, using soft tissues as a hinge and relies on correction at the natural joints.

3. .

3. JESS frame is superior to the Ilizarov fixator, because of its easier application, lighter weight, shorter learning curve, less inventory, and lower cost.

4. The average time for fixator removal in patients treated by Ilizarov was 23.6 weeks, in Jess it was 13.6 weeks