Jess
-
Upload
vasu-rao-kaza -
Category
Documents
-
view
7.906 -
download
1
Transcript of Jess
![Page 1: Jess](https://reader035.fdocuments.us/reader035/viewer/2022062513/554b8e5fb4c90561588b5879/html5/thumbnails/1.jpg)
JOSHI’S EXTERNAL STABLISATION SYSTEM-(JESS)
INCTEV
DR. K.S.V. RaoMBBS, D.Orth, DNB( Ortho)
![Page 2: Jess](https://reader035.fdocuments.us/reader035/viewer/2022062513/554b8e5fb4c90561588b5879/html5/thumbnails/2.jpg)
Causes Of Relapse In Rx Of CTEV
1. Errors in ctev correction methods in Ponseti
2. Improper surgical intervension without
adequate conservative treatment
3. Inadequate post operative care
4. Non-compliant parents in post correction
regime
![Page 3: Jess](https://reader035.fdocuments.us/reader035/viewer/2022062513/554b8e5fb4c90561588b5879/html5/thumbnails/3.jpg)
Causes Of Relapse In Rx Of CTEV-------
5. Lack of rehabilitation exercises6. Rigid club foot associated with-
arthrogryposis, aminiotic band syndrome, Menigomyelocele, spina bifida, spinal cord defects
7. Unequal growth of muscles during growth spurts
8. Defective or inadequate orthotic fittings
![Page 4: Jess](https://reader035.fdocuments.us/reader035/viewer/2022062513/554b8e5fb4c90561588b5879/html5/thumbnails/4.jpg)
• 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.
![Page 5: Jess](https://reader035.fdocuments.us/reader035/viewer/2022062513/554b8e5fb4c90561588b5879/html5/thumbnails/5.jpg)
Residual Deformities
1. Adduction & inversion of
forefoot
2. Equinus at ankle.
3. Cavus & heel varus
4. In-toeing ±
5. Problem – compounded by
secondary changes in
skin/bone & joints
fibrosis/stiffness
![Page 6: Jess](https://reader035.fdocuments.us/reader035/viewer/2022062513/554b8e5fb4c90561588b5879/html5/thumbnails/6.jpg)
Basic Anatomic Derangement In Clubfoot
• Congenital subluxation of talo-calcaneo navicular joint
• Navicular & calcaneus displaced medially in relation to talus.
![Page 7: Jess](https://reader035.fdocuments.us/reader035/viewer/2022062513/554b8e5fb4c90561588b5879/html5/thumbnails/7.jpg)
• 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”
![Page 8: Jess](https://reader035.fdocuments.us/reader035/viewer/2022062513/554b8e5fb4c90561588b5879/html5/thumbnails/8.jpg)
Clinical Assessment- (Caroll)1) Calf atrophy
2) Posterior displacement of the fibula
3) Creases medial or posterior
4) Curved lateral border
5) Cavus
6) Fixed equinus
7) Navicular fixed to medial malleolus
8) Os cacis fixed to tibia
9) No mid tarsal mobility
10)Fixed forefoot supination
**Each feature scores 1
point Worst feet would
score 10 and a Normal
well corrected foot score
0
![Page 9: Jess](https://reader035.fdocuments.us/reader035/viewer/2022062513/554b8e5fb4c90561588b5879/html5/thumbnails/9.jpg)
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 °
![Page 10: Jess](https://reader035.fdocuments.us/reader035/viewer/2022062513/554b8e5fb4c90561588b5879/html5/thumbnails/10.jpg)
nTC 25-40
nTC15-40
N 60-90
<15 Abn
![Page 11: Jess](https://reader035.fdocuments.us/reader035/viewer/2022062513/554b8e5fb4c90561588b5879/html5/thumbnails/11.jpg)
OVERCORRECTED FEET
![Page 12: Jess](https://reader035.fdocuments.us/reader035/viewer/2022062513/554b8e5fb4c90561588b5879/html5/thumbnails/12.jpg)
-to tide over the period till the child reaches age of 14 before triple arthodesis
![Page 13: Jess](https://reader035.fdocuments.us/reader035/viewer/2022062513/554b8e5fb4c90561588b5879/html5/thumbnails/13.jpg)
Problems -Revision
Repeat surgical procedure –Challenging
1. Preexisting fibrosis
2. Stiffness of the joints of the foot
3. Hypoplastic anterior tibial vessels
4. Wound closure difficulties with skin necrosis.
![Page 14: Jess](https://reader035.fdocuments.us/reader035/viewer/2022062513/554b8e5fb4c90561588b5879/html5/thumbnails/14.jpg)
Prof. Brij Bhushan Joshi (1928 – 2009)
![Page 15: Jess](https://reader035.fdocuments.us/reader035/viewer/2022062513/554b8e5fb4c90561588b5879/html5/thumbnails/15.jpg)
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 .
![Page 16: Jess](https://reader035.fdocuments.us/reader035/viewer/2022062513/554b8e5fb4c90561588b5879/html5/thumbnails/16.jpg)
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.
![Page 17: Jess](https://reader035.fdocuments.us/reader035/viewer/2022062513/554b8e5fb4c90561588b5879/html5/thumbnails/17.jpg)
Indications1. Drop out of conservative treatment
2. Recurrence after earlier surgical release
3. Known resistant cases- severely contracted foot, AMC, Congenital band syndrome.
4. Late presentation to treatment
5. Adjunct to surgical treatment -for realignment of skeleton to minimise bone resection and shortening of the foot
![Page 18: Jess](https://reader035.fdocuments.us/reader035/viewer/2022062513/554b8e5fb4c90561588b5879/html5/thumbnails/18.jpg)
The Goal Of TreatmentFoot 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.
![Page 19: Jess](https://reader035.fdocuments.us/reader035/viewer/2022062513/554b8e5fb4c90561588b5879/html5/thumbnails/19.jpg)
Components of JESS Fixator
![Page 20: Jess](https://reader035.fdocuments.us/reader035/viewer/2022062513/554b8e5fb4c90561588b5879/html5/thumbnails/20.jpg)
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.
![Page 21: Jess](https://reader035.fdocuments.us/reader035/viewer/2022062513/554b8e5fb4c90561588b5879/html5/thumbnails/21.jpg)
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
![Page 22: Jess](https://reader035.fdocuments.us/reader035/viewer/2022062513/554b8e5fb4c90561588b5879/html5/thumbnails/22.jpg)
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-wires2.The creation of holds3.The connection between the holds
![Page 23: Jess](https://reader035.fdocuments.us/reader035/viewer/2022062513/554b8e5fb4c90561588b5879/html5/thumbnails/23.jpg)
Creations Of HoldsA. The tibial holdB. The Metatarsal holdC. 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
![Page 24: Jess](https://reader035.fdocuments.us/reader035/viewer/2022062513/554b8e5fb4c90561588b5879/html5/thumbnails/24.jpg)
Application Of Tibial Wires
![Page 25: Jess](https://reader035.fdocuments.us/reader035/viewer/2022062513/554b8e5fb4c90561588b5879/html5/thumbnails/25.jpg)
Application Of Transverse Calcaneal Wires
![Page 26: Jess](https://reader035.fdocuments.us/reader035/viewer/2022062513/554b8e5fb4c90561588b5879/html5/thumbnails/26.jpg)
Application Of Metatarsal Wires
![Page 27: Jess](https://reader035.fdocuments.us/reader035/viewer/2022062513/554b8e5fb4c90561588b5879/html5/thumbnails/27.jpg)
Application Of Axial Calcaneal Wire
![Page 28: Jess](https://reader035.fdocuments.us/reader035/viewer/2022062513/554b8e5fb4c90561588b5879/html5/thumbnails/28.jpg)
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
![Page 29: Jess](https://reader035.fdocuments.us/reader035/viewer/2022062513/554b8e5fb4c90561588b5879/html5/thumbnails/29.jpg)
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
![Page 30: Jess](https://reader035.fdocuments.us/reader035/viewer/2022062513/554b8e5fb4c90561588b5879/html5/thumbnails/30.jpg)
• 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
![Page 31: Jess](https://reader035.fdocuments.us/reader035/viewer/2022062513/554b8e5fb4c90561588b5879/html5/thumbnails/31.jpg)
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
![Page 32: Jess](https://reader035.fdocuments.us/reader035/viewer/2022062513/554b8e5fb4c90561588b5879/html5/thumbnails/32.jpg)
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.
![Page 33: Jess](https://reader035.fdocuments.us/reader035/viewer/2022062513/554b8e5fb4c90561588b5879/html5/thumbnails/33.jpg)
• 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
![Page 34: Jess](https://reader035.fdocuments.us/reader035/viewer/2022062513/554b8e5fb4c90561588b5879/html5/thumbnails/34.jpg)
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
![Page 35: Jess](https://reader035.fdocuments.us/reader035/viewer/2022062513/554b8e5fb4c90561588b5879/html5/thumbnails/35.jpg)
Cases
![Page 36: Jess](https://reader035.fdocuments.us/reader035/viewer/2022062513/554b8e5fb4c90561588b5879/html5/thumbnails/36.jpg)
![Page 37: Jess](https://reader035.fdocuments.us/reader035/viewer/2022062513/554b8e5fb4c90561588b5879/html5/thumbnails/37.jpg)
![Page 38: Jess](https://reader035.fdocuments.us/reader035/viewer/2022062513/554b8e5fb4c90561588b5879/html5/thumbnails/38.jpg)
![Page 39: Jess](https://reader035.fdocuments.us/reader035/viewer/2022062513/554b8e5fb4c90561588b5879/html5/thumbnails/39.jpg)
![Page 40: Jess](https://reader035.fdocuments.us/reader035/viewer/2022062513/554b8e5fb4c90561588b5879/html5/thumbnails/40.jpg)
![Page 41: Jess](https://reader035.fdocuments.us/reader035/viewer/2022062513/554b8e5fb4c90561588b5879/html5/thumbnails/41.jpg)
![Page 42: Jess](https://reader035.fdocuments.us/reader035/viewer/2022062513/554b8e5fb4c90561588b5879/html5/thumbnails/42.jpg)
![Page 43: Jess](https://reader035.fdocuments.us/reader035/viewer/2022062513/554b8e5fb4c90561588b5879/html5/thumbnails/43.jpg)
![Page 44: Jess](https://reader035.fdocuments.us/reader035/viewer/2022062513/554b8e5fb4c90561588b5879/html5/thumbnails/44.jpg)
![Page 45: Jess](https://reader035.fdocuments.us/reader035/viewer/2022062513/554b8e5fb4c90561588b5879/html5/thumbnails/45.jpg)
![Page 46: Jess](https://reader035.fdocuments.us/reader035/viewer/2022062513/554b8e5fb4c90561588b5879/html5/thumbnails/46.jpg)
![Page 47: Jess](https://reader035.fdocuments.us/reader035/viewer/2022062513/554b8e5fb4c90561588b5879/html5/thumbnails/47.jpg)
![Page 48: Jess](https://reader035.fdocuments.us/reader035/viewer/2022062513/554b8e5fb4c90561588b5879/html5/thumbnails/48.jpg)
![Page 49: Jess](https://reader035.fdocuments.us/reader035/viewer/2022062513/554b8e5fb4c90561588b5879/html5/thumbnails/49.jpg)
![Page 50: Jess](https://reader035.fdocuments.us/reader035/viewer/2022062513/554b8e5fb4c90561588b5879/html5/thumbnails/50.jpg)
10/5/2009Post STR
rt-3/M
![Page 51: Jess](https://reader035.fdocuments.us/reader035/viewer/2022062513/554b8e5fb4c90561588b5879/html5/thumbnails/51.jpg)
28/10/2009
![Page 52: Jess](https://reader035.fdocuments.us/reader035/viewer/2022062513/554b8e5fb4c90561588b5879/html5/thumbnails/52.jpg)
18/4/2011
STR-dec2007(Sohar)
JESS-28/10/2009KHTib AT-12/5/2010KHEXCELLENT RESULT
![Page 53: Jess](https://reader035.fdocuments.us/reader035/viewer/2022062513/554b8e5fb4c90561588b5879/html5/thumbnails/53.jpg)
![Page 54: Jess](https://reader035.fdocuments.us/reader035/viewer/2022062513/554b8e5fb4c90561588b5879/html5/thumbnails/54.jpg)
![Page 55: Jess](https://reader035.fdocuments.us/reader035/viewer/2022062513/554b8e5fb4c90561588b5879/html5/thumbnails/55.jpg)
RESULTS
![Page 56: Jess](https://reader035.fdocuments.us/reader035/viewer/2022062513/554b8e5fb4c90561588b5879/html5/thumbnails/56.jpg)
• 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
![Page 57: Jess](https://reader035.fdocuments.us/reader035/viewer/2022062513/554b8e5fb4c90561588b5879/html5/thumbnails/57.jpg)
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)
![Page 58: Jess](https://reader035.fdocuments.us/reader035/viewer/2022062513/554b8e5fb4c90561588b5879/html5/thumbnails/58.jpg)
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.
![Page 59: Jess](https://reader035.fdocuments.us/reader035/viewer/2022062513/554b8e5fb4c90561588b5879/html5/thumbnails/59.jpg)
![Page 60: Jess](https://reader035.fdocuments.us/reader035/viewer/2022062513/554b8e5fb4c90561588b5879/html5/thumbnails/60.jpg)
Complications
![Page 61: Jess](https://reader035.fdocuments.us/reader035/viewer/2022062513/554b8e5fb4c90561588b5879/html5/thumbnails/61.jpg)
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
![Page 62: Jess](https://reader035.fdocuments.us/reader035/viewer/2022062513/554b8e5fb4c90561588b5879/html5/thumbnails/62.jpg)
Older Children/Adults
![Page 63: Jess](https://reader035.fdocuments.us/reader035/viewer/2022062513/554b8e5fb4c90561588b5879/html5/thumbnails/63.jpg)
![Page 64: Jess](https://reader035.fdocuments.us/reader035/viewer/2022062513/554b8e5fb4c90561588b5879/html5/thumbnails/64.jpg)
![Page 65: Jess](https://reader035.fdocuments.us/reader035/viewer/2022062513/554b8e5fb4c90561588b5879/html5/thumbnails/65.jpg)
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
![Page 66: Jess](https://reader035.fdocuments.us/reader035/viewer/2022062513/554b8e5fb4c90561588b5879/html5/thumbnails/66.jpg)
Is it Really a Different fixator?The major differences between JESS fixator
& Circular fixators
1. Wires in JESS fixators are not tensioned but
only pre-stressed, to prevent them from
cutting through the soft bones.
2. 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.
3. .
![Page 67: Jess](https://reader035.fdocuments.us/reader035/viewer/2022062513/554b8e5fb4c90561588b5879/html5/thumbnails/67.jpg)
3. JESS frame is superior to the Ilizarov fixator,
because of its easier application, lighter
weight, shorter learning curve, less inventory,
and lower cost.
4. The average time for fixator removal in
patients treated by Ilizarov was 23.6 weeks, in
Jess it was 13.6 weeks
![Page 68: Jess](https://reader035.fdocuments.us/reader035/viewer/2022062513/554b8e5fb4c90561588b5879/html5/thumbnails/68.jpg)
Take Home MessageINTERVENE EARLY
“Soft tissues lead –bones follow”
![Page 69: Jess](https://reader035.fdocuments.us/reader035/viewer/2022062513/554b8e5fb4c90561588b5879/html5/thumbnails/69.jpg)
Discussions Can Continue @ home!!
![Page 70: Jess](https://reader035.fdocuments.us/reader035/viewer/2022062513/554b8e5fb4c90561588b5879/html5/thumbnails/70.jpg)
DR.RAO.K.S.VMBBS, d.Ortho DNB-Ortho
![Page 71: Jess](https://reader035.fdocuments.us/reader035/viewer/2022062513/554b8e5fb4c90561588b5879/html5/thumbnails/71.jpg)