Joshis external stabilization support

"Fixation" is a process of stabilization important for anatomical study of biological tissue

External fixators offer a versatile method of correcting complex 3dimensional deformities of the foot such as clubfoot, more so in cases with rigid, deformed, previously operated feet that are scarred and in cases in which feet have big callosities, when chances of skin breakdown are quite high, such as following a soft tissue procedure. The Joshi External Stabilizing System (JESS) is a versatile, lightweight external fixator consisting of K wires, distractors, and connecting rods (both hinged and nonhinged) along with various link joints. JESS is a dynamic system that allows the lengthening of the contracted tissues via slow distraction, causing minimal surgical insult.

Introduction
Neglected cases of clubfoot that involve large callosities and skin problems, and dropout cases i.e. those who did not complete plaster-of-paris (POP) cast treatment that involve deformities provide considerable problems. neglected CTEV,
residual CTEV or recurrent CTEV usually present after one yr.of age. Many patients with these conditions

are not suitable candidates for management by soft tissue release procedures.

 Neglected clubfoot was defined as a case in which either no treatment course was taken or the patient dropped out of POP cast treatment and started walking on the deformed foot. Recurrent clubfoot was defined as a case in which deformity recurred after soft tissue release and deformity correction, either because the patient failed to return for follow-up or to follow postoperative instruction In elderly child of tissue release alone is often not sufficient for full correction.In patients with previous surgrical scars ,it is more difficult .

Illizarov vs JESS
While there is a wide variety of paediatric applications of the Ilizarov technique to correct lower extremity deformities,use of an Ilizarov fixator in patients younger than 6 years who have small feet presents considerable problems: the instrument is bulky and difficult to manage. On the basis of similar principles, Joshi devised a simple external fixator(Joshis external stabilisation system [JESS]),in the early 1990s, which is especially useful for patients with small feet. So fractional distraction by joshi external stabilization system is useful option to correct deformity.

 The JESS fixator is available in 3 sizes: 1)small (for children aged 1.5 years or younger), 2)medium(for those aged between 1.5 and 3 years), and 3)large(for those older than 3 years)

Components of the fixator: (1) distractors, tibio calcaneal; (2) distractors, Metatarso calcaneal; (3) knurled rods, various lengths; (4) Allen keys, large and small; (5) beta-clamps, add-on (fish-mouth type); (6) betaclamps; (7) Z rods; (8) L rods, large and small; and (9) K-wires, 1.8 mm and 2 mm.

 The major difference between the fixators that are used in JESS and circular fixators described by Ilizarov is that the wires in JESS fixators are not tensioned but only pre-stressed, to prevent them from cutting through the soft bones.Furthermost this fixator is an uncontrained device used soft tissue as hinge

Main indications: Dropout of conservative treatment Recurrence after earlier surgical release. Known resistant cases like AMC, streeter's syndrome Late presentation for treatment Adjunct to soft tissue, surgical procedure for realignment of skelton to minimize bone resection and shortening of the foot.

The principles of correction of foot deformity by soft tissue distraction

Fixation is applied separately to the tibia (two ring fixation block, four wires or equivalent fixation), the calcaneus(one half ring, two opposing olive wires), and the metatarsals (one five-eighths ring, two opposing olivewires).

 The tibial ring fixation block is connected to the heel half ring by two rods with a hinge at each end.By convention, these are called the inner and outer heel rods. As the equinus is corrected, the calcaneus moves through an arc in the sagittal plane.The hinges allow the rods to follow this movement without bending or, worse, causing anterior subluxation of the ankle. Anterior subluxation is made less likely by angling the heel rods posteriorly. The rods can be lengthened differentially,thus correcting hindfoot varus or valgus.

 The heel ring is connected to the forefoot ring by inner and outer foot rods, hinged at each end. Distraction of these corrects cavus and differential distraction will correct forefoot varus.

 The forefoot ring is connected to the tibial fixation block by one front rod attached to an outrigger, if the deformity is one of simple equinus or plantaris.Two front rods are used if there is pronation or, more commonly, supination. Differential pull corrects the deformity.This rod (or rods) is not pulled on immediately for fear of causing joint compression and damage to the articularcartilage. It is best to delay until the ankle and foot have been modestly distracted after10--14 days.

 The frame described above is called an Unconstrained Frame. The axes of correction are not constrained by the construction of the frame. The correction occurs around the bodys own hinges, the frame merely applies the forces required to achieve this. By contrast in a Constrained Frame the axis of correction is determined by a hinge axis built into the frame, which need not correspond to any given anatomical structure.Unconstrained frames are suitable for distraction of soft tissue contractures.Constrained frames are appropriatewhere it is necessary to move an osteotomy around a given axis.

 Since some recoil is expected after removal of the frame, the foot should be over-corrected by at least10deg, more in a recurrent or very stiff case. Once this position is achieved, the foot should be held in the frame for 46 weeks to gel in its new position. The frame is then removed, under general anaesthesia in children. The foot is measured for an ankle foot orthosis (AFO), and a cast is applied until such time as the AFO is ready. AFO be worn during the day for1year after the removal of the frame, as scar contracture is greatest during this phase of healing.

Operative steps (a) tibial K-wires lateromedial, (b) K-wires in position, (c) metatarsal K-wires, (d) calcaneal K-wires;(e) Z and L rods fixation, (f) distractor application, and (g) completed frame.

Soft tissue correction series. (A) Multiple previous surgeries with recurrence of all facets of CTEV deformity. (B) Near end of correction showing unconstrained frame employing toe slings. (C) Result 5 year spost correction with maintenance of plantigrade foot

Advantages
Possibility of imminent scarring due to conventional surgery was abolished, because of distraction histoneogenesis based on sound physiological principles. the JESS frame is superior to the Ilizarov fixator, because of its easier application, lighter weight, shorter learning curve, less inventory, and lower cost foot length was maintained; a soft, supple,and plantigrade foot was achieved; and substantial deformity correction was possible If performed at around 9mths of age the procedure enables the child to walk with a plantigrade foot by time child is in walking age gp

Complications
Pin tract infection:intractable infection,associated with wire loosening,settled after wire removal and repositioning to maintain the desired traction.most cases respond to antibiotics and intensive pin site care regimes Trasient clawing of toes :these occur whenever foot is bought out of equinus or is lengthened, unle preventive measures are taken.Deformity is ext at IP jt,and fl at MTP jt .If untreated lead to subluxation of MTP jts.

injudicious and unsupervised distraction:may lead to catastrophic results in the small developing foot.

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