This document provides information on Dr. Imran Jan's Joshi's External Stabilization System (JESS) for the treatment of clubfoot, or congenital talipes equinovarus (CTEV). JESS uses the principles of fractional distraction developed by Ilizarov to gradually correct clubfoot deformities in multiple planes. It involves the insertion of wires and connecting rods under the skin to form fixation points in the tibia, calcaneus, and metatarsals. Graduated distraction between these points over weeks can fully correct clubfoot without surgery in many cases. Studies show JESS achieves excellent results in over 75% of CTEV cases.

1. JOSHI’S EXTERNAL
STABLISATION SYSTEM-
(JESS)
IN
CTEV
DR. IMRAN JAN
MBBS, DNB( Ortho)

2. Causes Of Relapse In Rx Of CTEV
1. Errors in ctev correction methods in Ponseti
2. Improper surgical intervension without adequate
conservative treatment
3. Inadequate post operative care
4. Non-compliant parents in post correction regime

3. Causes Of Relapse In Rx Of CTEV-------
5. Lack of rehabilitation exercises
6. 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

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
1. Adduction & inversion of forefoot
2. Equinus at ankle.
3. Cavus & heel varus
4. In-toeing ±
5. Problem – compounded by
secondary changes in skin/bone &
joints fibrosis/stiffness

6. Basic Anatomic Derangement In
Clubfoot
• Congenital subluxation
of talo-calcaneo
navicular joint
• Navicular & calcaneus
displaced medially in
relation to talus.

7. • 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”

8. 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

9. 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 °

10. nTC 25-40
nTC15-40
N 60-90
<15 Abn

11. OVERCORRECTED
FEET

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

13. Problems -Revision
Repeat 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.

14. Prof. Brij Bhushan Joshi (1928 – 2009)

15. JESS
Joshi 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 .

16. 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.

17. Indications
1. 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

18. The Goal Of Treatment
Foot 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.

19. Components of JESS Fixator

20. 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.

21. 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

22. 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-wires
2.The creation of holds
3.The connection between the holds

23. Creations Of Holds
A. The tibial hold
B. The Metatarsal hold
C. 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

24. Application Of Tibial Wires

25. Application Of Transverse
Calcaneal Wires

26. Application Of Metatarsal
Wires

27. Application Of Axial Calcaneal
Wire

28. 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

29. 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

30. • 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

31. 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

32. Post Operative Management
DISTRACTION 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
after complete correction not only protects
the osteopenic bones while the pin-tracts heal, but
also maintains correction and allows gradual
weightbearing.

33. • 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

34. 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

35. Cases

50. 10/5/2009
Post
STR
rt-
3/M

51. 28/10/2009

52. 18/4/2011
STR-dec2007(Sohar)
JESS-
28/10/2009KH
Tib AT-12/5/2010KH
EXCELLENT RESULT

55. RESULTS

56. • 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

57. 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)

58. 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.

60. Complications

61. 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

62. Older Children/Adults

65. 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

66. 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.

67. 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