This document discusses Dr. B.B. Joshi's External Stabilization System (JESS) for treating clubfoot, also known as congenital talipes equinovarus (CTEV). It provides details on the causes of clubfoot relapse, assessment methods, the basic anatomy derangements in clubfoot, and the principles and components of the JESS fixator system. The JESS system uses gradual distraction with differential rates to correct the deformity while preventing tissue damage. It has advantages over surgery or other external fixators in allowing correction without shortening and minimizing scarring.

1. JOSHI’S EXTERNAL STABLISATION SYSTEM-(JESS)INCTEVDR. K.S.V. RaoMBBS, D.Orth, DNB( Ortho)

2. Causes Of Relapse In Rx Of CTEVErrors in ctev correction methods in PonsetiImproper surgical intervension without adequate conservative treatmentInadequate post operative careNon-compliant parents in post correction regime

3. Causes Of Relapse In Rx Of CTEV-------Lack of rehabilitation exercisesRigid club foot associated with- arthrogryposis, aminiotic band syndrome, Menigomyelocele, spina bifida, spinal cord defects Unequal growth of muscles during growth spurtsDefective or inadequate orthotic fittings

4. 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.

5. Residual Deformities Adduction & inversion of forefootEquinus at ankle.Cavus & heel varusIn-toeing ±Problem – compounded by secondary changes in skin/bone & joints fibrosis/stiffness

6. Basic Anatomic Derangement In ClubfootCongenital subluxation of talo-calcaneonavicular joint

7. Navicular & calcaneus displaced medially in relation to talus.Club foot- abnormal intertarsal relationshipThe 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”

8. Clinical Assessment- (Caroll)Calf atrophyPosterior displacement of the fibulaCreases medial or posteriorCurved lateral borderCavusFixed equinusNavicular fixed to medial malleolusOs cacis fixed to tibiaNo mid tarsal mobilityFixed forefoot supination**Each feature scores 1 point Worst feet would score 10 and a Normal well corrected foot score 0

9. Radiological AssessmentTalo-calcaneal angle(AP) 15°-40

10. Talo-calcaneal angle (lat stress) 25-40 °

11. Talo-calcaneal index > 40 °

12. Tibio-calcaneal angle (stress lat) 5-15 °nTC25-40N 60-90<15 AbnnTC15-40

13. OVERCORRECTED FEET

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

15. Problems -RevisionRepeat surgical procedure –ChallengingPreexisting fibrosisStiffness of the joints of the foot Hypoplastic anterior tibial vesselsWound closure difficulties with skin necrosis.

16. Prof. BrijBhushan Joshi (1928 – 2009)

17. JESSJoshi External Stablisation SystemDeveloped by DR. B.B.JOSHI in Mumbai, IndiaFirst Patient - operated in 1988Today - 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 .

18. Principle Of JessBasis 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 sidePrevents crushing of the tissues on the convex side, lengthens the limb and effectively corrects the deformity at the same time.

19. IndicationsDrop out of conservative treatmentRecurrence after earlier surgical releaseKnown resistant cases- severely contracted foot, AMC, Congenital band syndrome.Late presentation to treatmentAdjunct to surgical treatment -for realignment of skeleton to minimise bone resection and shortening of the foot

20. The Goal Of TreatmentFoot that is – Cosmetically acceptable Pliable Functional PainlessPlantigrade Fits into standard footwear Spares the parent and the child from the ordeal of frequent hospitalisation and years of treatment with casts and braces.

21. Components of JESS Fixator

22. Distractor DevicesThe double holeThe fish mouth The split block The biaxial hinge Connecting rods- standard connecting rods in the small and medium set is 3 mm rod.

23. 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

24. Operative TechniqueGA-SupinePneumatic tourniquet is applied- not inflatedNeurovascular markingsHand drill to pass k wires/power drill in older children3 MAIN STEPS:1.The insertion of k-wires2.The creation of holds3.The connection between the holds

25. Creations Of HoldsThe tibial holdThe Metatarsal holdThe Calcaneal holdTHE CONNECTION BETWEEN HOLDSThe Tibio-metatarsal connection The Calcaneo-Metatarsal connection The Tibio-Calcaneal connectionTOE SLING ATTACHMENT-provides dynamic traction to prevent flexion of the toes as deformity gradually corrects

26. Application Of Tibial Wires

27. Application Of Transverse Calcaneal Wires

28. Application Of Metatarsal Wires

29. Application Of Axial Calcaneal Wire

30. Calaneo –Metatarsal DistractionCorrects forefoot adduction at mid tarsal & tarsometarsal joints

31. Realigns the head of talus with the navicular

32. Derotates the calcaneumEnd 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

33. The Tibio-calcaneal DistractionTC is carried out in 2 positionsDistractors are mounted between the inferior limbs of the tibial Z rods and post limb of the calcaneal-L rodDistractors lie parallel to the leg and just posterior to the transfixing calcaneal wires. This corrects varus of the hind foot and equinus

34. Once the varus is corrected-Tibiocalcanealdistractors are shifted posteriorly-Distraction in this position provides thrust to stretch the posterior structures and corrects hind foot equinus at the ankle and subtalar jointsEnd point –judged clinically (approx 4 weeks)Medial- 0.25 mm every 6 hoursLateral- 0.25 mm every 12 hours

35. Tibio-metatarsal ConnectionTibio-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 deformityRocker bottom –pseudo correction occurs if force dorsiflexion

36. Post Operative ManagementDISTRACTION SCHEDULE—3 rd day onwards360 clock wise in 4 fractions/180 in 2 fractions

37. Corrective period: 3-6 weeks.

38. Static period: 3-6 weeks

39. 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 assemblyCover the pin sites with a dry dressingEncash the whole frame with a thin layer of soft foam or cardboardChange dressing of pin tracks regularly

40. The Static Phase20 ° 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

41. Cases

56. 10/5/2009Post STR rt-3/M

57. 28/10/2009

58. STR-dec2007(Sohar)JESS-28/10/2009KHTib AT-12/5/2010KHEXCELLENT RESULT18/4/2011

61. RESULTS

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. 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

63. Khoula Experience1992-1998 Khoula hospital, paedortho unit treated 112 feet using JESS fixator to correct foot deformities.20 were excluded from study-polio, meningomyelocele, muscular dystrophy92 feet were recurrent/neglected club feet--72 feet (56 patients) were available for study14(19.4%) were neglected-no surgery42(80.6%) were recurrent clubfoot3 (8.3%) had limited soft tissue surgery at time of JESS application. (Heel cord lengthening, plantar fasciotomy, and tibialis post z plasty)

64. ResultsGOOD 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.

66. Complications

67. Orthotic DevicesSplints are fitted to maintain the corrected position over prolonged periodsThermoplastic splints are used-allows minor individual variations.Denis–browne splint with abduction bar –in non ambulatory childChild refered to physiotherapist for gait training and to strengthen weaker muscles to keep foot supple and aligned

68. Older Children/Adults

71. Advantages Of JessUse in Small foot