|Year : 2019 | Volume
| Issue : 1 | Page : 66-69
Early results of clubfoot management by Joshi's external stabilizing system
Alok C Agrawal, Sharath Kowshik, Bikram Keshari Kar
Department of Orthopaedics, AIIMS, Raipur, Chhattisgarh, India
|Date of Web Publication||19-Aug-2019|
Dr. Alok C Agrawal
Department of Orthopaedics, AIIMS, Raipur, Chhattisgarh
Source of Support: None, Conflict of Interest: None
Introduction: With the use of Ponseti's technique, majority of children with clubfoot do not need operative treatment; however, some severe clubfoot including neglected, recurrent, and resistant forms cannot be managed by conservative methods and needs surgical intervention. The foot becomes rigid with soft tissue surgery, and bony operations can make the foot even more smaller. To avoid it, a simple alternative is to use joshi's external stabilising system (JESS) and distractor components which are used on the principle of controlled differential fractional distraction histogenesis. JESS distractors allow gradual distraction of contracted soft tissues and align all the joints of the foot so as to bring corrections of all aspects of deformity of the foot simultaneously. Purpose: To analyze the role of JESS fixator in correcting case of clubfoot in terms of cosmetic, functional, and anatomical outcome which were assessed by International Clubfoot Study Group (ICFSG) scores. Materials and Methods: Total of 6 Clubfoot underwent differential fractional distraction in AIIMS, Raipur. Patients were assessed preoperatively for morphology and functionality and radiologically by ICFSG score. Period of correction varied from 5 to 8 weeks. Once correction is obtained, then apparatus is locked in that position for the same period and later converted to cast in plantigrade for maintenance and followed up regularly. The results were analyzed with ICFSG score. Results: Excellent to good results were obtained in all the cases which were assessed by ICFSG score. There were only minor complications in patients. Conclusion: JESS frame is simple, versatile, and best suited for correcting clubfoot deformities which were neglected, resistant, and recurrent.
Keywords: Clubfoot, differential distraction, joshi's external stabilising system
|How to cite this article:|
Agrawal AC, Kowshik S, Kar BK. Early results of clubfoot management by Joshi's external stabilizing system. J Orthop Traumatol Rehabil 2019;11:66-9
|How to cite this URL:|
Agrawal AC, Kowshik S, Kar BK. Early results of clubfoot management by Joshi's external stabilizing system. J Orthop Traumatol Rehabil [serial online] 2019 [cited 2019 Nov 22];11:66-9. Available from: http://www.jotr.in/text.asp?2019/11/1/66/264726
| Introduction|| |
Congenital talipes equinovarus (CTEV) is one of the oldest and most common deformities affecting children. Its incidence is 1/1000 live births per year. CTEV vary in severity from mild to severe. Mild clubfoot though uncommon can be corrected easily with gentle manipulations. The moderate clubfoot is one where foot is supple, a transverse crease is absent, and the heel is easily definable. This constitutes the largest group which responds to gentle manipulation followed by application of corrective casts (Ponseti's Technique). With the use of Ponseti's technique, majority of children with clubfoot do not need operative treatment; however, some severe clubfoot including neglected, recurrent, and resistant forms cannot be managed by conservative methods and needs surgical intervention. Surgery for clubfoot in an infant has its own disadvantages. It is invasive and leads to scarring. The foot becomes rigid with soft tissue surgery, and bony operations can make the foot even more smaller. At times, a single foot may need repeated operations to correct all deformities. To avoid it, a simple alternative is to use Joshi External Stabilizer System (JESS) external fixator and distractor components which are used on the principle of controlled differential fractional distraction histogenesis. This is a percutaneous technique with minimal scarring. JESS distractors allow gradual distraction of contracted soft tissues and align all the joints of the foot so as to bring corrections of all aspects of deformity of the foot simultaneously.
We aimed to assess the efficacy of controlled differential distraction as a method of treatment in clubfoot (neglected, recurrent, and relapsed cases) from the results based on clinical and radiological findings evaluated as per International Clubfoot Study Group (ICFSG) scores.
| Materials and Methods|| |
This study included 6 clubfoot from Department of Orthopaedics, AIIMS, Raipur. The study was conducted between June 2018 and January 2019. The patients were between 2 and 5 years of age.
On admission of the patient, a thorough history was elicited from parents to reveal the duration and previous treatment. The patients were evaluated preoperatively using clinical and radiographic method by ICFSG.
Routine blood and urine investigations were performed. Following approval of fitness for surgery, the patients in this study were operated under general anesthesia with patient in the supine position. No tourniquet was used in this procedure.
Insertion of K-wires
- Tibial: Two parallel transfixing wires were passed in the tibia about 2.5 cm below and lateral to the tibial tuberosity, perpendicular to the longitudinal axis. The length of the middle segment of the Z' bar was marked below the first wire. The second wire was passed parallel to the first wire at this level
- Metatarsal: Two transfixing wire was passed from the fifth to first metatarsal at the level of the neck and shaft. It was made sure that all the metatarsals had been impaled by at least one of the wires
- Calcaneal: Two transfixing parallel wires were passed into the tuber of the calcaneum from the medial side. The axial calcaneal wire was passed posterior to anterior just distal to the insertion of the Achilles tendon in the longitudinal axis of the calcaneum.
Attachment of “Z” and “L” rods
- Tibial attachment: The tibial wires were attached to the middle segment of the “Z” rods by link joints on the medial and lateral aspects. One connecting rod was used to span the anterior limbs of “Z” rod and another to span the posterior limbs
- Metatarsal attachment: Two small “L” rods were attached to the metatarsal wires on the medial and lateral aspect of the foot
- Calcaneal attachment: Two large “L” rods were attached to the transfixing calcaneal wires on either side of the heel. Behind the foot, these rods were connected to each other by a connecting rod to which the axial calcaneal wire was clamped.
Connecting the segmental hold
- Calcaneometatarsal connection: A pair of appropriately sized distractors were attached to the calcaneal and metatarsal wires on either side of the foot
- Tibiocalcaneal connection: Posterior limbs of the “Z” rods were attached to “L” rods of the calcaneal hold by a distraction on either side. Distractors were attached near the transfixing pins
- Tibiometatarsal connection: The anterior limbs of the “Z” rods were connected by a pair of rods to the small “L” rods anterior to the attachment of the metatarsal wires.
Sterile dressing was applied to the pin tract sites, and a foot plate was applied to prevent clawing of the toes. Distal pulsations (dorsalis pedis and posterior tibial arteries) were checked manually using a pulse oximeter. Capillary filling time was noted. The dressings were changed daily during the hospital stay for a week with betadine lotion. Pin sites were covered with dry gauze, and the patients were advised to report immediately if there was any discharge from the pin tracts.
On the 3rd postoperative day, differential fractional calcaneometatarsal distraction and tibiocalcaneal distraction on the medial side were started at twice the rate than that on the lateral side (medial – 0.5 mm every 12 h; lateral – 0.25 mm every 12 h). The above explained distraction was very clearly demonstrated to the patient's attender and supervised for 2 days. 7 days following the surgery, the patient was fit enough to be discharged and was advised for a regular follow-up at weekly intervals for 6 weeks to look for a progressive correction of the deformity, persistent edema, rule out pin tract infections, and tighten the loosened link joints and monthly for 3 months and biannually.
Following the correction, the assembly was held in the static position for the same period to allow soft tissue maturation in the elongation position. Single-stage removal of the whole assembly was done under mild sedation and a well-molded below-knee plaster cast was applied in maximum correction for double the period took for achieving correction.
Full correction of forefoot adduction, varus, and equinus was achieved usually at the end of 6 weeks. For all patients, CTEV corrective shoes were advised for 5 years to maintain correction and prevent recurrence.
Postoperatively, patient was evaluated using ICFSG score, where results were classified as excellent (0–5), good (5–15), fair (16–30), and poor (>30) at follow-up intervals of 3 and 6 months. The parents care and compliance played an important role in the success of this procedure.
| Results|| |
The present study comprised of a total of six clubfeet in three patients. Male:female ratio was 2:1. All cases were having bilateral deformities. The mean duration in frame was 48 days; maximum 60 days and minimum 42 days. The fixators were kept in static phase for a same time period that required for deformity correction. Plaster cast to hold the correction was maintained for 6–8 weeks.
The mean follow-up was 7.3 months. All six feet were graded as poor at presentation. At the latest follow-up, the ICFSG score was excellent in 5 feet and good in 1 feet [Table 1]. The mean preoperative ICFSG score was 41.8 (39–46) and at the latest follow-up was 4.8 (4–7). This difference was statistically significant with P value of 0.027 using the Wilcoxon signed-rank test. A plantigrade foot was accomplished in all patients at the end of the treatment as in [Figure 1] and [Figure 2].
|Figure 1: 3-year-old bilateral neglected clubfoot. Preoperative, foot with JESS distractor and after removal|
Click here to view
|Figure 2: 5-year old bilateral neglected clubfoot. Preoperative, foot with JESS distractor and after removal|
Click here to view
| Discussion|| |
External fixators are a versatile method of correcting complex three-dimensional deformities of the foot such as clubfoot. The basic principle of external fixation (JESS) in this study was the same as advocated by Ilizarov. Physiological tension and stress applied to the tissue stimulates histogenesis of tissues, while controlled differential distraction gradually corrects the deformities and realigns the bones. JESS fixators are also lighter in weight, shorter, cheaper, and have an easier application than Ilizarov's fixators. The results of our study employing JESS proved to be better than the outcome of the study of Ilizarov's fixator conducted by Fernando where only 58.3% of cases showed excellent results 3 and the study conducted by Bradish and Noor where only 47% of cases were successful.
Postoperative assessment yielded results that were comparable to those of other external fixator systems of Oganesian and Istomina (75.7% good results). Our study seemed to show comparable results to those of Marthya and Arun (59.7% excellent and good results) and Shrivatsava et al. (40% excellent results). In the study by Suresh et al. of 44 feet treated by JESS, there were 77% excellent, 13% good, 0% fair, and 9% poor results.
Of 6 feet, two feet with superficial pin tract infections were treated with regular sterile dry dressings and oral antibiotics for a week which eventually subsided. One foot with flexion contracture of toes may have occurred due to relative inelasticity of the flexor tendons. Skin necrosis was found in one foot which was due to the rapid rate of correction. In this case, the distraction was stopped and reversed until tension relieved. The distraction was continued after a few days under supervision.
| Conclusion|| |
The goal of any clubfoot surgery is to obtain a cosmetically acceptable, pliable, functional, painless, and plantigrade foot, and to spare the parent and the child from the ordeal of frequent hospitalization and years of treatment with casts and braces. The best treatment for clubfoot that does not respond to conventional treatment remains controversial. The procedure used in the current study holds promise for fulfilling the above-mentioned goals. This procedure is ideally suited for children in whom the clubfoot deformities remain uncorrected by POP casts and manipulation, as well as for recurrent clubfoot.
Functional distraction using JESS apparatus is an easy method, which does not require any sophisticated instrumentation and minimal image intensifier. Parents learn the distraction technique easily and comply with the procedure. Pin tracts should be cared meticulously. An adequate period of static phase is necessary before removal of the apparatus. Strict postoperative management and follow-up are mandatory. Differential distraction technique gives good result in children, but results are excellent in younger children and those who have not undergone any previous operative procedure. All cases of CTEV are not amenable to this technique; only those cases which are neglected, recurrent, and POP drop out cases should be operated. In relatively mild and moderate varieties of clubfoot, probably traditional soft tissue surgery still holds good. Motivated and compliant parents were a pivotal factor on which the success of the study depended. Although the technique has many advantages, one should not forget that injudicious and unsupervised distraction may lead to catastrophic results in the small developing foot. Long-term studies (10 years) are required to accurately assess the functional outcome of treatment of clubfoot by JESS.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Cummings RJ, Lovell WW. Operative treatment of congenital idiopathic club foot. J Bone Joint Surg Am 1988;70:1108-12.
Joshi BB. Correction of Congenital Talipes Equino Varus (CTEV) by Controlled Differential Fractional Distraction Using Joshi's External Stabilization System (JESS). 1st
ed. Mumbai, India: JESS Research and Development Centre; 2001. p. 1-53.
Bensahel H, Kuo K, Duhaime M. Outcome evaluation of the treatment of clubfoot. The international language of clubfoot. J Pediatr Orthop 2003;12B:269-71.
Bradish CF, Noor S. The ilizarov method in the management of relapsed club feet. J Bone Joint Surg Br 2000;82:387-91.
Oganesian OV, Istomina IS. Talipes equinocavovarus deformities corrected with the aid of a hinged-distraction apparatus. Clin Orthop Relat Res 1991;266:42.
Marthya AH, Arun B. Short term results of results of correction of CTEV with JESS distractor. J Orthop 2004;1:e3.
Shrivatsava S, Das R, Shukla J, Shrivatsava N. Our experience with JESS in the management of CTEV. Indian J Orthop 2000;34:88-91.
Suresh S, Ahmed A, Sharma VK. Role of Joshi's external stabilisation system fixator in the management of idiopathic clubfoot. J Orthop Surg (Hong Kong) 2003;11:194-201.
M. Joshi CN. Joshi's external stablization system (JESS) application for correction of resistant club-foot. Internet J Orthop Surg 2009;18:1.
McKay DW. New concept of and approach to clubfoot treatment: Section II – Correction of the clubfoot. J Pediatr Orthop 1983;3:10-21.
[Figure 1], [Figure 2]