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SHORT RESEARCH
Short term results of Correction of CTEV with JESS Distractor
Anwar Marthya.H*,Arun. B**

* Lecturer
** Post Graduate Student, Dept. of Orthopaedics, MCH, Calicut

Address for Correspondence

Dr Anwar Marthya
Lecturer in  Orthopaedics, 
Medical College Hospital, Calicut 8,
Kerala, India

ABSTRACT

Background: Many patients come to the orthopaedic department with neglected CTEV, residual CTEV or recurrent CTEV. They usually present after one year of age. In a elderly child, soft tissue release alone is often not suffiecient for full correction. Ina patient with previous surgical scar, it is all the more difficult. So fractional distraction with Joshi's external stabilisation system is a useful option to correct the deformity in such patients. We aimed to study the short term follow up of 41 patients with 16 bilateral cases treated with Joshi's external stabilisation system at the department of orthopaedics, medical college, Calicut; regarding the cosmetic, fuctional and anatomical outcome.
Methods: 41 patients with 16 bilateral cases in whom, Joshi's external stabilisation system was done at the department of Orthopaedics, Calicut medical college, during the period of 1994-2002; followed up for an average period of three and half years. Patients were selected irrespective of sex, but patients with non-idiopathic club foot was not included in this study. The principle of correction applied in this study was fractional distraction.
Results: 33.3% of patients in this study had undergone various surgical procedures previously including posteromedial surgical release. 66.7% had undergone, conservative treatment, which included serial casting, one child had neglected CTEV. The severity assessed in these cases were 5 and above in 666.7% of children. Children with less severe deformity had lesser distraction period. 59.7% had excellent and good results.
Conclusion: Fractional distraction with JESS is an easy method and it is simple and easy to understand. The parents learn the distraction technique easily and were usually complaint. Adequate static period is necessary for maintaining full correction. Once the external fixator is removed , protective splints are a must to maintain the correction. The procedure is less invasive and the results are good irrespective of the severity of the deformity.



J.Orthopaedics 2004;1(1)e3


Introduction: 
The basic deformity in clubfoot is a congenital subluxation of Talocalcaneal-navicular joint. But the correction of abnormal tarsal relationship is resisted by pathological contracture of soft tissues. A lasting correction is obtained when the correction is complete and reduction is maintained long enough for the tarsal bones to remold and form a stable articulation(1). Many one and two staged operations have been described to correct all components of the deformity. Some surgical procedures are piecemeal operations intended to correct one specific component of the deformity(2). Soft tissue release operations, though produce good results in most of the cases, may reduce motion of the foot and ankle(3). Extensive soft tissue release operations have resulted in over correction of the deformity(4,5). JESS works on the principles of soft tissue distraction, maintenance of tarsal relations and correcting all the deformities simultaneously. As the procedure does not include any incision and acute correction of the deformity, dreaded skin complications, which are so common in other modalities of treatment is less likely to occur.


Aim of the Study:

Continuous and adequate conservative treatment usually results in satisfactory complete correction of CTEV in most of the cases, in children of all age groups. Most failures occur from inadequate treatment(6), negligent parents interrupting regular continuous treatment or resistant form of clubfoot. This study aims to find out the indications and operative feasibility at various age groups with different grades of deformity. The study evaluates complications and management of complications. The study also intends to assess the final outcome of this technique of treatment. 


Patients and Methods:

A prospective study of fractional distraction using JESS distractors for Idiopathic congenital club foot was conducted on 41 patients during the period 1994-2002. The cases broadly came under 3 categories.
1. Rigid foot not responding to serial manipulation and casting.
2. Recurrent cases after earlier surgical failures.
3. Neglected, late presenting cases.
Non Idiopathic club foots were not included in this study. All the cases were clinically assessed for associated anomalies clinically and in indicated cases with X-rays of Lumbosacral spine and X ray pelvis, to rule out spina bifida and congenital dysplasia of Hip. The child and parents were informed about the procedure, giving opportunity to discuss with other patients undergoing the same treatment and with photographs. The importance of pin track care and strict regular follow up is stressed in the preoperative planning. 

All the cases were assessed preoperatively with 
1. Clinical assessment for severity of the club foot.
2. Pre operative photograph.
3. Preoperative X-ray of foot- Antero posterior and lateral view(7,8).
4. Pre anaesthetic check up.
In preoperative clinical assessment (Caroll) the details evaluated are(4,9):
1. Calf atrophy
2. Posterior displacement of the fibula
3. Creases- medial or posterior
4. Curved lateral border of the foot
5. Cavus 
6. Fixed equinus
7. Navicular fixed to the medial malleolus
8. Os calcis fixed to the Tibia
9. Fixed forefoot supination.


Each feature scores one point when present and no point when absent. Thus the worst foot having all the features would score 10 points and a normal as well as corrected foot would score 0 points.


Very simple routine instrumentation will suffice for the procedure. Hand drill, T-Handle are used for introduction of Kirschner Wires. The basic component forming the heart of the JESS system is the link joint. Kwire drilled through the bone is assembled to the system of connecting rod through link joint. Link joint connect the K wire and connecting rod at right angles. The link joint is locked in place by a recessed hexagonal nut.


Connecting rods of various lengths of smooth rods and angled rod are used, in younger children 3.0mm and older children 4.0mm connecting rods are used. Z rods used to construct the Tibial segment of frame is available in predetermined sizes to suit various age groups. L shaped rods of 2 sizes are necessary for metatarsal segment and calcaneal segment of the frame.


The standard JESS distraction device is used(11). It has a threaded rod on which is mounted a static block and a translating block. Each block has 2 holes for passage of K wire or a connecting rod. The length of the outer border of the foot is measured for ascertaining the length of distractor used for the foot. The length of the leg is measured to select the size of the Tibiocalcaneal distractor and Tibio-metatarsal connecting rod.


The Tibial K wires are passed first. 2 K wires should be parallel and the distance between the 2 K wires is determined by the length of the Z rod. Metatarsal K wires are introduced using T handle, for continuous feed back regarding the position of the K wire in the foot. One transfixing wire is passed from the firth to the first Metatarsal engaging fifth and first metatarsal at the neck. No attempt is made to impale all the metatarsals and thereby flattening the transverse arch of the foot. 2 separate wires, one from medial and other from lateral aspect are introduced parallel and proximal to the first wire. These two wires engage two or three metatrsals on their respective side at the level of the proximal shaft. Calcaneal K wires are introduced using T handle. The position of the posterior Tibial Artery is palpated and two transfixing K wires are passed into the Calcaneum from the medial side taking care not to injure the artery. These wires are perpendicular to the long axis of the Calcaneum. The distance between the two wires should be the distance between the holes in the blocks of distractror to be used. The axial calcaneal wire is passed posterior to anterior. By abducting the hip, externally rotating the limb, the foot can be positioned to expose the heel. The point of entry is; just distal to the insertion fo the Achilles tendon. The wire is directed medially and distally, towards the varus and equinus of the Calcaneum. The wire should be in the long axis of the Calcaneum.


The connecting rods and distractors and assembled. The plantar limbs of the L rods provide a slot for the foot plate attachment. This plate supports the foot and toes and prevent flexion contractures of the toes during distraction phase due to the relatve in elasticity of the flexor tendons. 


Distraction Schedule:

Calcaneo metatarsal distraction corrects forefoot adduction at midtarsal and tarsometatarsal joints. This also realigns the head of the Talus with the Navicular and derotates the Calcaneum. Placement of a distractor on the lateral column of the foot will prevent a wedge compression of the bones and cartilages if only medial distractor is used. It will also help to unlock the tight Calcaneo cuboid joint. This connection is static. It keeps anterior part of the ankle joint and subtalar joints open, while the heel equinus is being corrected. 
Dorsiflexion of the ankle joint is achieved gradually after correction of all other components of the deformity. 20-30 of dorsiflexion is necessary to avoid recurrences and to permit squatting.


Following the achievement of correction the foot has to be maintained with the assembly till the soft tissues remould and mature in the elongated position. It is generally preferred that the period of static phase should be twice the period of distraction. Positioning the foot in evertion for a few days before the removal of the frame will help in reducing recurrence. This is achieved by evertion bar. 


Complications:

Edema of the Leg, Flexion contracture of the toes, Loosening of link joints, jamming of the distractors, linear skin necrosis, heel ulcer, rocker bottom foot and under correction are the common complications. These complications can be avoided by closely adhering to the suggested protocol.



Post Operative Assesssment(10):
 

 


Discussion:

This prospective study of treatment of idiopathic club foot with jess distractor was done in 41 patients, of which 16 children had bilateral deformity. 33.3% of the children in this study group had undergone various surgical treatment including Tendoachillis lengthening, posterior release and posteromedial release. Other 66.7% children had undergone only conservative treatment. One child aged 9 years had not undergone any treatment before. Severity assessment (Caroll) in these cases were 5 and above. 66.7% of the children were above score 7.


Irrespective of severity and age group all the children have undergone the same protocol of surgery and post operative management. Children with less severe deformity needed lesser period of distraction, where as moderate deformity of scores needed longer time of distraction.


54.4% of the children developed pin tract infection. In one case there were radiological changes of osteolmyelitis in Tibia and Calcaneum which was treated with parentral antibiotics and achieved healed status. Edema of the leg was also a major problem. 49.1% of children had obvious edma. Edema in most of the cases subsided with elevation of the limb. In the cases of moderate edema, the distraction is delayed for a few days until the edema is subsided. Those cases which had edema showed increased incidence of pin tract infection.
We have discarded using foot plate after initial 4 cases. All of them developed severed pain at the heel and tip of the toes. One of them developed a pressure ulcer over the heel. Flexion deformity of the toes occurred in most of the cases, but responded to passive stretching by the parents. Loosening of link joints are seen in 49.1% of the cases.
Skin necrosis was seen in 4 cases , reversing the distraction for a few days solved the problem. This was developed due to intial correction tried to achieve at the time of application of the apparatus. Initial correction was tried in this case due to difficulty in alaigning the distractor in the rigid club foot due to sever deformity. We have not used swivel distractors sofar, which would be a better option in these cases.


Assessement of results showed excellent and good results in 59.7% of cases, Functional, cosmetic and radiological criteria were used for assessment.
Though all the children had achieved full correction clinically at the time of removal of the apparatus, the difference was in the static period. We could not maintain static period of double the time of distraction in most of the cases due to pin track infection and non-compliance from the parents.


We could not find any correlation between the severity of the clubfoot and end result, but strong correlation was present in children who strictly follow the distraction static phase protocol and the final outcome.


Conclusion:

Functonal distraction using JESS apparatus is an easy method, which does not require any sophisticated instrumentation or image intensification. Parents learn the distraction technique easily and comply with the procedure. Pin tracks should be cared meticulously. Adequate period of static phase is necessary before removal of the appartus. Strict post operative management and follow up is mandatory.
As the procedure does not involve any open surgery, chances of scaring and skin complication are very unlikely. Surgical feasibility and tolerance to fixator is same for all age groups. Distraction system gives good results irrespective of the severity of the deformity.
The assessment of results reveals that many acceptable results still leave much to be desired, this stimulate us to elevate our goals and strive to attain the ideal of a near normal foot.


Reference:

1. Blek. E E: Congenital club foot Pathomechanics, radiographic analysis and results of surgical treatment, clinical orthopaedics and related research No 125 June 1977
2. Tachdijian M O. Peadiatric Orthopaedics 2nd Edition, W. B Saunders company, 2428-2557, 1990.
3. Vincent J Turco : Clubfoot Churchill Livingston
4. Caroll N. C. Mc Murtky R and Leete S.F: The pathoanatomy of congenital clubfoot, Orthopedic clinics of North America 9:2255.
5. Evans D. Relapsed clubfoot, JBJS 43 B 1961
6. Mc Kay DW: New concepts of and approach to club foot teatment, Principles and morbid anatomy J Peadiatric Orthopaedics, 2:347 1982
7. Huggo Adams Keim, Gordon W Ritchie: Weight bearing roentgenograms in the evaluation of foot deformities. CORR No 70 May June 1970
8. Milton E Ashby: Roentgenographic assessment of soft tissue medial release operations in club foot deformity, CORR No 90 Jan Feb 1973
9. Grill F and Franke J: The Ilizarov distractor for the correction of relapsed or neglecvted clubfoot. JBJS 69 B 593, 1987.
10. Dan Atar, Wellace B Lehman, Alfred D Gra
nt, Allen Strongwater: Functional rating system for evaluating the results of club foot surgery Orthopedic Review Vol I No. 2 1991
11. Joshi BB, Laud NS, Warrier SS : Operative manual of treatment of CTEV by JESS 

 This is a peer reviewed paper 

Please cite as :
Anwar MH,Arun B.Short term results of Correction of CTEV with JESS Distractor
J.Orthopaedics 2004;1(1)e3

URL: http://www.jortho.org/2004/1/1/e3  

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