Jess

1. JOSHI’S EXTERNAL STABLISATION SYSTEM-(JESS) IN CTEV DR. K.S.V. Rao MBBS, D.Orth , DNB( Ortho)

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

3. Causes Of Relapse In Rx Of CTEV ------- Lack of rehabilitation exercises Rigid club foot associated with- arthrogryposis , aminiotic band syndrome, Menigomyelocele , spina bifida, spinal cord defects Unequal growth of muscles during growth spurts 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) S purious correction later manifests as relapse .

5. Residual Deformities Adduction & inversion of forefoot Equinus at ankle. Cavus & heel varus In-toeing ± 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 ) Calf atrophy Posterior displacement of the fibula Creases medial or posterior Curved lateral border Cavus Fixed equinus Navicular fixed to medial malleolus Os cacis fixed to tibia No mid tarsal mobility 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 Preexisting fibrosis Stiffness of the joints of the foot Hypoplastic anterior tibial vessels 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 Drop out of conservative treatment Recurrence after earlier surgical release Known resistant cases- severely contracted foot, AMC, Congenital band syndrome. Late presentation to treatment 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 The tibial hold The Metatarsal hold 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 Casting 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

36. 10/5/2009 Post STR rt-3/M

37. 28/10/2009

38. 18/4/2011 STR-dec2007( Sohar ) JESS-28/10/2009KH Tib AT-12/5/2010KH EXCELLENT RESULT

39. RESULTS

40. 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

41. 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 )

42. 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 .

43. Complications

44. 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

45. Older Children/Adults

46. 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

47. Is it Really a Different fixator ? The major differences between JESS fixator & Circular fixators Wires in JESS fixators are not tensioned but only pre-stressed, to prevent them from cutting through the soft bones. 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. .

48. JESS frame is superior to the Ilizarov fixator , because of its easier application, lighter weight, shorter learning curve, less inventory, and lower cost. The average time for fixator removal in patients treated by Ilizarov was 23.6 weeks, in Jess it was 13.6 weeks

49. Take Home Message INTERVENE EARLY “Soft tissues lead –bones follow”

50. Discussions Can Continue @ home!!

51. DR.RAO.K.S.V MBBS, d.Ortho DNB-Ortho