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 Table of Contents  
Year : 2020  |  Volume : 12  |  Issue : 1  |  Page : 53-57

Management of clubfoot in children above 5 years with differential distraction using joshi external stabilizing system

Department of Orthopaedics, AIIMS, Raipur, Chhattisgarh, India

Date of Submission13-Apr-2020
Date of Acceptance20-Apr-2020
Date of Web Publication26-Jun-2020

Correspondence Address:
Dr. Sharath Kowshik
Department of Orthopaedics, AIIMS, Raipur, Chhattisgarh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jotr.jotr_22_20

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Introduction: Ponsetti's technique is the recommended procedure for treating idiopathic clubfoot in children below the age of 2 years, and the same is also followed in some severe clubfoot deformities including neglected, recurrent and resistant forms who eventually may need surgical intervention. In children >5 years of age (children belonging to 5–10 years), open surgical procedures make the foot rigid with soft-tissue surgery, and bony operations can make the foot even smaller. Simultaneous correction of all aspects of deformity by differential distraction using external fixator rescues the foot from such complications. Joshi's external stabilizing system (JESS) can be used to gradually correct the deformities by differential distraction. In comparison to Ilizarov ring fixators, these are lighter in weight, shorter, cheaper, and have an easier application. Purpose: The purpose of this study is to analyze the role of JESS fixator in correcting cases of clubfoot in children >5 years in terms of morphological, functional, and radiological outcomes which were assessed using the International Clubfoot Study Group (ICFSG) scores. Materials and Methods: Five consecutive children with eight clubfoot >5 years underwent differential fractional distraction in our hospital. Period of correction varied from 6 to 8 weeks, including the distraction phase and static phase. Follow-up was done by application of cast in plantigrade position for double the duration of corrective distraction. Patients were assessed preoperatively and postoperatively at 6 months for morphology, functionality, and radiological correction by the ICFSG score. Results: Excellent to good results were obtained in all cases, which were assessed using ICFSG score, with only minor complications in patients. Conclusion: JESS frame is simple, versatile, and best suited for correcting clubfoot deformities, which were neglected, resistant and recurrent, and also with residual deformity, even in the children above the age of 5 years with advanced osteoarticular development and higher rigidity.

Keywords: International clubfoot study group, Joshi's external stabilizing system, neglected clubfoot

How to cite this article:
Agrawal AC, Kowshik S, Kar BK, Sakale HS. Management of clubfoot in children above 5 years with differential distraction using joshi external stabilizing system. J Orthop Traumatol Rehabil 2020;12:53-7

How to cite this URL:
Agrawal AC, Kowshik S, Kar BK, Sakale HS. Management of clubfoot in children above 5 years with differential distraction using joshi external stabilizing system. J Orthop Traumatol Rehabil [serial online] 2020 [cited 2020 Oct 22];12:53-7. Available from: https://www.jotr.in/text.asp?2020/12/1/53/287712

  Introduction Top

Clubfoot, one of the most common deformities affecting children with the incidence of 1 per 1000 live births per year, is characterized by the varus position of the foot, and equine adducted forefoot, which can be fixed or rigid of varying degrees. The most reliable treatment should be initiated within the 1st week of life with gentle manipulations followed by the application of corrective casts (Ponseti's Technique). With the use of Ponseti's technique, the majority of children with clubfoot do not need operative treatment; however, some patients who present at hospital in a later stage or neglect treatment at a point, including recurrent and resistant forms cannot be managed by conservative methods easily and needs surgical intervention.[1] The difficulty of the treatment in this group of patients is due to stiffness, ossification, and mature age of the joints. The foot becomes rigid with soft tissue surgery, and bony operations can make the foot even 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 stabiliser system (JESS) external fixator and distractor components, which are used on the principle of controlled differential fractional distraction histogenesis.[2] 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 to bring corrections of all aspects of deformity of the foot simultaneously.

The aim of this study was to present our experience in the management of clubfoot in children >5 years of age by using JESS distractors and their clinico-radiological evaluation as per the International Clubfoot Study Group (ICFSG) scores.[3]

  Materials and Methods Top

This study included eight consecutive clubfoot in children above the age of 5 years who presented to our hospital. The study was conducted between June 2018 and January 2020. The patients were between 5 and 10 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 the clinical and radiographic methods by ICFSG.[3]

Following approval of fitness for surgery and obtaining consent, the patients in this study were operated under general anesthesia with the patient in the supine position. No tourniquet was used in this procedure.

Insertion of K-wires

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. Followed by two transfixing wire was passed from the fifth to first metatarsal at the level of the neck and shaft and was made sure that all the metatarsals had been impaled by at least one of the wires. For calcaneum, 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.

Connecting the segmental hold

After attachment of Z and L rods on either side of tibial and metatarsal and calcaneal pins respectively, segmental holds are connected as below:

  • Calcaneo-metatarsal connection: A pair of appropriately sized distractors were attached to the calcaneal and metatarsal wires on either side of the foot for correction of adduction and supination
  • Tibio-calcaneal connection: Posterior limbs of the “Z” rods were attached to “L” rods of the calcaneal hold by distractors on either side for correction of varus deformity and lengthening
  • Tibio-metatarsal 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 for equinus correction by intermittent manual readjustment.

Gradual distraction

On the 3rd postoperative day, differential fractional calcaneo-metatarsal distraction and tibio-calcaneal distraction on the medial side was 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 and was discharged and 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.

Following the correction, the assembly was held in a 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.

Overcorrection of deformities of 5°–10° was achieved usually at the end of 6 weeks. For all patients, congenital talipes equinovarus corrective shoes were advised for 5 years to maintain correction and prevent a 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.

  Results Top

The present study comprised a total of eight clubfeet in five patients. With almost equal male: female incidence, three cases had bilateral deformities. The mean duration in the frame was 50.4 days; maximum 74 days and minimum 40 days. The fixator was maintained in a static phase for a minimum of same the time required for the distraction of deformity wherever possible. Plaster cast to hold the correction was maintained for 6–8 weeks.

The mean age of the five patients was 7.2 years, ranging between 5 and 10 years old. From the 8 feet included in the study, all the patients were at their first presentation for orthopedic/surgical correction. The mean follow-up was 7.3 months, as listed in [Table 1]. All eight feet were graded as poor at presentation. At the latest follow-up, the ICFSG score was excellent in 6 feet and good in 2 feet. The mean preoperative ICFSG score was 40.7 (30–45) and at the latest follow-up 5.8 (4–7). This difference was statistically significant with P = 0.001 using the Wilcoxon signed-rank test. A plantigrade foot was accomplished in all patients at the end of the treatment as shown in [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12] in four cases.
Table 1: The preoperative and postoperative scores of respective patients with their age, sex, and duration of treatment and follow-up

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Figure 1: Preoperative image of 8-year-old male clubfoot

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Figure 2: Preoperative image of 8-year-old male clubfoot in squatting position

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Figure 3: Postcorrection image of 8-year-old male clubfoot

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Figure 4: Postcorrection image of 8-year-old male clubfoot in squatting showing adequate dorsiflexion

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Figure 5: Preoperative image of 7-year-old male clubfoot showing severe varus

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Figure 6: Preoperative image of 7-year-old male clubfoot in squatting

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Figure 7: After correction image of 7-year-old male clubfoot

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Figure 8: After correction image of 7-year-old male clubfoot in squatting position after equinus correct

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Figure 9: Preoperative image of 6-year-old female neglected clubfoot in standing

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Figure 10: Preoperative image of 6-year-old female clubfoot in supine

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Figure 11: Preoperative image of 6-year-old female clubfoot in prone

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Figure 12: After correction image of 6-year-old female clubfoot

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  Discussion Top

Clubfoot is difficult to be managed by traditional methods, especially in children after walking age, due to advanced ossification and maturation of the osteoarticular system. The frontline plan comes the release of the hind- and medial-plantar areas of the foot or surgeries on foot- and tibia bones, which lasts longer and has far more modest results compared to when treated in their infancy, and also makes the foot rigid with of rough painful postoperative scars. Better to avoid these complications, differential distraction by JESS fixators can bring the simultaneous correction of all the aspects of the deformity. 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 stimulate 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 fixators.[9] 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 and the study conducted by Bradish and Noor where only 47% of cases were successful.[4]

Results from our postoperative assessment were comparable to those of other external fixator systems of Oganesian and Istomina (75.7% good results).[5] Our study seemed to show comparable results to those of Marthya and Arun (59.7% excellent and good results)[6] and Shrivatsava et al. (40% excellent results).[7] 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.[8] Also, in short term study by Agrawal et al. in 2019, 83.3% of excellent results were achieved, and 16.6% were of good results using JESS.[10]

  Conclusion Top

We consider that in the correction of congenital recurrent and neglected clubfoot in children above 5 years of age against scar soft tissue and anatomical abnormalities of the skeletal system, closed distraction treatment by JESS is a method of choice since it carries an acceptable rate of success comparable to surgical release and serial casting. This method obviates the need for open extended releases, carries a low risk for major complications, and corrects the anatomic and radiographic anomalies as well as improves the function. Postoperative bracing and close follow-up are mandatory to detect early recurrences and prevent significant relapses. Long-term studies (10 years) are required to accurately assess the functional outcome of the treatment of clubfoot by JESS.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Cummings J, Lovel WW. Current concept operative treatment of congenital idiopathic club foot. J Bone Joint Surg 1988;70:1108.  Back to cited text no. 1
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: Joshi's External Stabilization System Research and Development Centre; 2001. p. 1-53.  Back to cited text no. 2
Bensahel H, Kuo K, Duhaime M. Outcome evaluation of the treatment of clubfoot. The international language of clubfoot. J Pediatr Orthop 2003;12:269-71.  Back to cited text no. 3
Bradish CF, Noor S. The Ilizarov method in the management of relapsed club feet. J Bone Joint Surg Br 2000;82:387-91.  Back to cited text no. 4
Oganesian OV, Istomina IS. Talipes equinocavovarus deformities corrected with the aid of a hinged-distraction apparatus. Clin Orthop Relat Res 1991;(266):42-50.  Back to cited text no. 5
Marthya AH, Arun B. Short term results of results of correction of CTEV with JESS distractor. J Orthop 2004;1:e3.  Back to cited text no. 6
Shrivatsava S, Das R, Shukla J, Shrivatsava N. Our experience with JESS in the management of CTEV. Indian J Orthop 2000;34:88-91.  Back to cited text no. 7
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.  Back to cited text no. 8
CN M. Joshi's External Stablization System (JESS) Application For Correction Of Resistant Club-Foot. The Internet Journal of Orthopedic Surgery. 2009 Volume 18 Number 1.  Back to cited text no. 9
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.  Back to cited text no. 10
  [Full text]  


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12]

  [Table 1]


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