1. JOSHI’S EXTERNAL STABLISATION SYSTEM-(JESS)INCTEV 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) Spurious 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

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

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

11. Talo-calcaneal index > 40 °

13. OVERCORRECTED FEET

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

15. 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.

16. Prof. BrijBhushan Joshi (1928 – 2009)

17. 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 .

18. 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.

19. 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

20. 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.

21. Components of JESS Fixator

22. 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.

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 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

25. 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

26. Application Of Tibial Wires

27. Application Of Transverse Calcaneal Wires

28. Application Of Metatarsal Wires

29. Application Of Axial Calcaneal Wire

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 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

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 joints End point –judged clinically (approx 4 weeks) Medial- 0.25 mm every 6 hours Lateral- 0.25 mm every 12 hours

35. 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

37. Corrective period: 3-6 weeks.

38. Static period: 3-6 weeks

40. 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

41. Cases

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

57. 28/10/2009

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

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 Experience 1992-1998 Khoula hospital, paedortho 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)

64. 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.

66. Complications

67. 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

68. Older Children/Adults

72. Avoiding fibrous tissue formation & scarring due to conventional surgery due to distraction histogenesis

73. Absence of further shortening unlike bony procedures

74. Proper control of all components of corrections

75. Versatile and easy to learn system

77. JESS frame is superior to the Ilizarovfixator, 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

78. Take Home MessageINTERVENE EARLY “Soft tissues lead –bones follow”

79. Discussions Can Continue @ home!!

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