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JOSHI’S EXTERNAL STABLISATION SYSTEM-(JESS)INCTEV<br />DR. K.S.V. Rao<br />MBBS, D.Orth, DNB( Ortho)<br />
Causes Of Relapse In Rx Of CTEV<br />Errors in  ctev correction  methods in Ponseti<br />Improper surgical intervension wi...
Causes Of Relapse In Rx Of CTEV-------<br />Lack of rehabilitation exercises<br />Rigid club foot associated with- arthrog...
Relapsed clubfoot is nothing more than an incompletely corrected feet.<br />-(Beatson and Pearson 1966, Evans 1961, Fripp ...
Residual Deformities <br />Adduction & inversion of forefoot<br />Equinus at ankle.<br />Cavus & heel varus<br />In-toeing...
Basic Anatomic Derangement In Clubfoot<br /><ul><li>Congenital subluxation of talo-calcaneonavicular joint
Navicular & calcaneus displaced medially in relation to  talus.</li></li></ul><li>Club foot- abnormal intertarsal relation...
Clinical Assessment- (Caroll)<br />Calf atrophy<br />Posterior displacement of the fibula<br />Creases medial or posterior...
Radiological Assessment<br /><ul><li>Talo-calcaneal angle(AP) 15°-40
Talo-calcaneal angle (lat stress) 25-40 °
Talo-calcaneal index > 40 °
Tibio-calcaneal angle (stress lat) 5-15 °</li></li></ul><li>nTC25-40<br />N 60-90<br /><15 Abn<br />nTC15-40<br />
OVERCORRECTED FEET<br />
 -to tide over the period till the child reaches  age of 14 before triple arthodesis<br />
Problems  -Revision<br />Repeat surgical procedure –Challenging<br />Preexisting fibrosis<br />Stiffness of the joints of ...
Prof. BrijBhushan Joshi  (1928 –  2009)<br />
JESSJoshi External Stablisation System<br />Developed by  DR. B.B.JOSHI in Mumbai, India<br />First Patient - operated  in...
Principle Of Jess<br />Basis of  deformity correction - principle Of FRACTIONAL DISTRACTION OF ILIZAROV (1980)<br />Dr Jos...
Indications<br />Drop out of  conservative treatment<br />Recurrence after earlier surgical release<br />Known resistant c...
The Goal Of Treatment<br />Foot that is –<br /> Cosmetically acceptable<br /> Pliable<br /> Functional<br /> Painless<br /...
Components of JESS Fixator<br />
Distractor Devices<br />The double hole<br />The fish mouth <br />The split block <br />The biaxial hinge <br />Connecting...
LINK JOINTS <br />Link joints- different sizes-<br />Medium size accommodates a                               -connecting ...
Operative Technique<br />GA-Supine<br />Pneumatic tourniquet is applied- not inflated<br />Neurovascular markings<br />Han...
Creations Of Holds<br />The tibial hold<br />The Metatarsal hold<br />The Calcaneal hold<br />THE CONNECTION BETWEEN HOLDS...
Application Of Tibial Wires<br />
Application Of Transverse Calcaneal Wires<br />
Application Of Metatarsal Wires<br />
Application Of Axial Calcaneal Wire<br />
Calaneo –Metatarsal Distraction<br /><ul><li>Corrects forefoot adduction at mid tarsal & tarsometarsal joints
Realigns the head of talus with the navicular
Derotates the calcaneum</li></ul>End point-Clinical and radiological correction of forefoot deformities(approx 2-4 weeks)<...
The Tibio-calcaneal Distraction<br />TC is carried out in 2 positions<br />Distractors are mounted  between the inferior l...
Once the varus is corrected<br />-Tibiocalcanealdistractors are shifted posteriorly<br />-Distraction in this position pro...
Tibio-metatarsal Connection<br />Tibio-metatrsal connection is static.<br />Keeps anterior part of the ankle and subtalar ...
Post Operative Management<br />DISTRACTION SCHEDULE—3 rd day onwards<br /><ul><li>360  clock wise in 4 fractions/180 in 2 ...
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 cor...
The Static Phase<br />20 ° of dorsiflexion  necessary to avoid recurrence and to permit squatting.<br />Following correcti...
Cases<br />
10/5/2009<br />Post STR rt-3/M<br />
28/10/2009<br />
STR-dec2007(Sohar)<br />JESS-28/10/2009KH<br />Tib AT-12/5/2010KH<br />EXCELLENT RESULT<br />18/4/2011<br />
RESULTS<br />
In 2003 S. Suresh et all treated 26 children with ctev 44 Joshi's external stabilization system procedure at the Safdarjun...
Khoula Experience<br />1992-1998  Khoula hospital, paedortho unit treated 112 feet using JESS fixator to correct foot defo...
Results<br />GOOD result- 58 feet(80.5%)<br />FAIR result- 10 feet(13.9%)<br />POOR result-4 feet(5.6%)—needed reapplicati...
Complications<br />
Orthotic Devices<br />Splints are fitted to maintain the corrected position over prolonged periods<br />Thermoplastic spli...
Older Children/Adults<br />
Advantages Of Jess<br /><ul><li>Use in Small foot
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Jess

  1. 1. JOSHI’S EXTERNAL STABLISATION SYSTEM-(JESS)INCTEV<br />DR. K.S.V. Rao<br />MBBS, D.Orth, DNB( Ortho)<br />
  2. 2. Causes Of Relapse In Rx Of CTEV<br />Errors in ctev correction methods in Ponseti<br />Improper surgical intervension without adequate conservative treatment<br />Inadequate post operative care<br />Non-compliant parents in post correction regime<br />
  3. 3. Causes Of Relapse In Rx Of CTEV-------<br />Lack of rehabilitation exercises<br />Rigid club foot associated with- arthrogryposis, aminiotic band syndrome, Menigomyelocele, spina bifida, spinal cord defects <br />Unequal growth of muscles during growth spurts<br />Defective or inadequate orthotic fittings<br />
  4. 4. Relapsed clubfoot is nothing more than an incompletely corrected feet.<br />-(Beatson and Pearson 1966, Evans 1961, Fripp and Shaw 1967, Kite 1972, Turco 1971)<br />Spurious correction later manifests as relapse.<br />
  5. 5. Residual Deformities <br />Adduction & inversion of forefoot<br />Equinus at ankle.<br />Cavus & heel varus<br />In-toeing ±<br />Problem – compounded by secondary changes in skin/bone & joints fibrosis/stiffness<br />
  6. 6. Basic Anatomic Derangement In Clubfoot<br /><ul><li>Congenital subluxation of talo-calcaneonavicular joint
  7. 7. Navicular & calcaneus displaced medially in relation to talus.</li></li></ul><li>Club foot- abnormal intertarsal relationship<br />The shape of the tarsal bones is altered in accordance with the wolf’s law. <br />Soft tissue contracture acquired in accordance with the law of Davis <br />“When ligaments and soft tissue are in lax state they will gradually shorten”<br />
  8. 8. Clinical Assessment- (Caroll)<br />Calf atrophy<br />Posterior displacement of the fibula<br />Creases medial or posterior<br />Curved lateral border<br />Cavus<br />Fixed equinus<br />Navicular fixed to medial malleolus<br />Os cacis fixed to tibia<br />No mid tarsal mobility<br />Fixed forefoot supination<br />**Each feature scores 1 point Worst feet would score 10 and a Normal well corrected foot score 0<br />
  9. 9. Radiological Assessment<br /><ul><li>Talo-calcaneal angle(AP) 15°-40
  10. 10. Talo-calcaneal angle (lat stress) 25-40 °
  11. 11. Talo-calcaneal index > 40 °
  12. 12. Tibio-calcaneal angle (stress lat) 5-15 °</li></li></ul><li>nTC25-40<br />N 60-90<br /><15 Abn<br />nTC15-40<br />
  13. 13. OVERCORRECTED FEET<br />
  14. 14. -to tide over the period till the child reaches age of 14 before triple arthodesis<br />
  15. 15. Problems -Revision<br />Repeat surgical procedure –Challenging<br />Preexisting fibrosis<br />Stiffness of the joints of the foot <br />Hypoplastic anterior tibial vessels<br />Wound closure difficulties with skin necrosis.<br />
  16. 16. Prof. BrijBhushan Joshi (1928 – 2009)<br />
  17. 17. JESSJoshi External Stablisation System<br />Developed by DR. B.B.JOSHI in Mumbai, India<br />First Patient - operated in 1988<br />Today - evolved into a verastile system with application in trauma, defects & deformities in upper and lower limb.<br />JESS has a special application in the correction of resistant clubfoot .<br />
  18. 18. Principle Of Jess<br />Basis of deformity correction - principle Of FRACTIONAL DISTRACTION OF ILIZAROV (1980)<br />Dr Joshi added the concept of DIFFERENTIAL DISTRACTION (1988)<br />In differential distraction - concave side of deformity is distracted twice the rate of the convex side<br />Prevents crushing of the tissues on the convex side, lengthens the limb and effectively corrects the deformity at the same time.<br />
  19. 19. Indications<br />Drop out of conservative treatment<br />Recurrence after earlier surgical release<br />Known resistant cases- severely contracted foot, AMC, Congenital band syndrome.<br />Late presentation to treatment<br />Adjunct to surgical treatment -for realignment of skeleton to minimise bone resection and shortening of the foot<br />
  20. 20. The Goal Of Treatment<br />Foot that is –<br /> Cosmetically acceptable<br /> Pliable<br /> Functional<br /> Painless<br />Plantigrade<br /> Fits into standard footwear<br /> Spares the parent and the child from the ordeal of frequent hospitalisation and years of treatment with casts and braces.<br />
  21. 21. Components of JESS Fixator<br />
  22. 22. Distractor Devices<br />The double hole<br />The fish mouth <br />The split block <br />The biaxial hinge <br />Connecting rods- standard connecting rods in the small and medium set is 3 mm rod.<br />
  23. 23. LINK JOINTS <br />Link joints- different sizes-<br />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.<br />Universal link joint-independent locking system for each connecting rod and k wire Can hold rods up to 4 mm diameter<br />
  24. 24. Operative Technique<br />GA-Supine<br />Pneumatic tourniquet is applied- not inflated<br />Neurovascular markings<br />Hand drill to pass k wires/power drill in older children<br />3 MAIN STEPS:<br />1.The insertion of k-wires<br />2.The creation of holds<br />3.The connection between the holds<br />
  25. 25. Creations Of Holds<br />The tibial hold<br />The Metatarsal hold<br />The Calcaneal hold<br />THE CONNECTION BETWEEN HOLDS<br />The Tibio-metatarsal connection<br /> The Calcaneo-Metatarsal connection<br /> The Tibio-Calcaneal connection<br />TOE SLING ATTACHMENT-provides dynamic traction to prevent flexion of the toes as deformity gradually corrects<br />
  26. 26. Application Of Tibial Wires<br />
  27. 27. Application Of Transverse Calcaneal Wires<br />
  28. 28. Application Of Metatarsal Wires<br />
  29. 29. Application Of Axial Calcaneal Wire<br />
  30. 30. Calaneo –Metatarsal Distraction<br /><ul><li>Corrects forefoot adduction at mid tarsal & tarsometarsal joints
  31. 31. Realigns the head of talus with the navicular
  32. 32. Derotates the calcaneum</li></ul>End point-Clinical and radiological correction of forefoot deformities(approx 2-4 weeks)<br />Medial- 0.25 mm every 6 hours<br /> Lateral- 0.25 mm every 12 hours<br />
  33. 33. The Tibio-calcaneal Distraction<br />TC is carried out in 2 positions<br />Distractors are mounted between the inferior limbs of the tibial Z rods and post limb of the calcaneal-L rod<br />Distractors lie parallel to the leg and just posterior to the transfixing calcaneal wires. This corrects varus of the hind foot and equinus<br />
  34. 34. Once the varus is corrected<br />-Tibiocalcanealdistractors are shifted posteriorly<br />-Distraction in this position provides thrust to stretch the posterior structures and corrects hind foot equinus at the ankle and subtalar joints<br />End point –judged clinically (approx 4 weeks)<br />Medial- 0.25 mm every 6 hours<br />Lateral- 0.25 mm every 12 hours<br />
  35. 35. Tibio-metatarsal Connection<br />Tibio-metatrsal connection is static.<br />Keeps anterior part of the ankle and subtalar joint open while the heel equinus is being corrected <br />Weekly adjustment needed to reduce excessive tension by loosening the clamps.<br />Dorsiflexion of the ankle joint achieved gradually after correction of the other components of the deformity<br />Rocker bottom –pseudo correction occurs if force dorsiflexion<br />
  36. 36. Post Operative Management<br />DISTRACTION SCHEDULE—3 rd day onwards<br /><ul><li>360 clock wise in 4 fractions/180 in 2 fractions
  37. 37. Corrective period: 3-6 weeks.
  38. 38. Static period: 3-6 weeks
  39. 39. Casting after complete correction not only protects the osteopenic bones while the pin-tracts heal, but also maintains correction and allows gradual weightbearing.</li></li></ul><li>Care of the assembly<br />Cover the pin sites with a dry dressing<br />Encash the whole frame with a thin layer of soft foam or cardboard<br />Change dressing of pin tracks regularly<br />
  40. 40. The Static Phase<br />20 ° of dorsiflexion necessary to avoid recurrence and to permit squatting.<br />Following correction - assembly held in a static position for 3 to 6 wks to allow soft tissue maturation in the elongated position.<br />Static phase should be twice the period of distraction<br />
  41. 41. Cases<br />
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  56. 56. 10/5/2009<br />Post STR rt-3/M<br />
  57. 57. 28/10/2009<br />
  58. 58. STR-dec2007(Sohar)<br />JESS-28/10/2009KH<br />Tib AT-12/5/2010KH<br />EXCELLENT RESULT<br />18/4/2011<br />
  59. 59.
  60. 60.
  61. 61. RESULTS<br />
  62. 62. 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.<br /> Three dimensional corrections were achieved by use of the distracter device.<br /> Excellent results were obtained in 77% of cases, good results in 13% and poor results in 9% of the cases.<br />S.SURESH et al – Role Of JESS In The Management Of Idiopathic Club feet, journal Of Orthopaedic Surgery. 2003: 11(2):194-200<br />
  63. 63. Khoula Experience<br />1992-1998 Khoula hospital, paedortho unit treated 112 feet using JESS fixator to correct foot deformities.<br />20 were excluded from study-polio, meningomyelocele, muscular dystrophy<br />92 feet were recurrent/neglected club feet--72 feet (56 patients) were available for study<br />14(19.4%) were neglected-no surgery<br />42(80.6%) were recurrent clubfoot<br />3 (8.3%) had limited soft tissue surgery at time of JESS application. (Heel cord lengthening, plantar fasciotomy, and tibialis post z plasty)<br />
  64. 64. Results<br />GOOD result- 58 feet(80.5%)<br />FAIR result- 10 feet(13.9%)<br />POOR result-4 feet(5.6%)—needed reapplication of JESS to correct the deformity prior to triple arthrodesis.<br />None of our patients showed correction to a normal range of talocalcaneal angle radiologically.<br />
  65. 65.
  66. 66. Complications<br />
  67. 67. Orthotic Devices<br />Splints are fitted to maintain the corrected position over prolonged periods<br />Thermoplastic splints are used-allows minor individual variations.<br />Denis–browne splint with abduction bar –in non ambulatory child<br />Child refered to physiotherapist for gait training and to strengthen weaker muscles to keep foot supple and aligned<br />
  68. 68. Older Children/Adults<br />
  69. 69.
  70. 70.
  71. 71. Advantages Of Jess<br /><ul><li>Use in Small foot
  72. 72. Avoiding fibrous tissue formation & scarring due to conventional surgery due to distraction histogenesis
  73. 73. Absence of further shortening unlike bony procedures
  74. 74. Proper control of all components of corrections
  75. 75. Versatile and easy to learn system
  76. 76. The technique of gradual distraction allows neohistogenesis of soft tissue as well as bone</li></li></ul><li>Is it Really a Different fixator?<br />The major differences between JESS fixator & Circular fixators<br />Wires in JESS fixators are not tensioned but only pre-stressed, to prevent them from cutting through the soft bones.<br />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.<br />.<br />
  77. 77. JESS frame is superior to the Ilizarovfixator, because of its easier application, lighter weight, shorter learning curve, less inventory, and lower cost. <br />The average time for fixator removal in patients treated by Ilizarov was 23.6 weeks, in Jess it was 13.6 weeks<br />
  78. 78. Take Home MessageINTERVENE EARLY<br />“Soft tissues lead –bones follow”<br />
  79. 79. Discussions Can Continue @ home!! <br />
  80. 80. DR.RAO.K.S.V<br />MBBS, d.Ortho DNB-Ortho<br />

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