Role of Joshi's external stabilisation system fixator in the management of idiopathic clubfoot

Journal of Orthopaedic Surgery, Dec 2003 by Suresh, S, Ahmed, A, Sharma, V K

ABSTRACT

Purpose. To explore the role of Joshi's external stabilisation system fixator in correcting cases of clubfoot peculiar to India, we studied cases of neglected clubfoot, dropout cases of plaster-of-paris cast treatment, or failed surgical procedures that had been followed for a minimum period of 2 years.

Methods. 26 children underwent 44 Joshi's external stabilisation system procedures at the Central Institute of Orthopaedics at the Safdarjung Hospital, New Delhi, between January 1998 and December 1999 for the conditions of interest. Three-dimensional correction was achieved by use of the distractor device.

Results. Excellent results were obtained in 77% of the cases, good results in 13%, and poor results in 9% of the cases. Complications in half of the cases were ,pintract infections, which eventually healed on an outpatient basis without any residual sequelae.

Conclusion. The Joshi's external stabilisation system frame is ideally suited for the child in whom clubfoot deformities remain uncorrected by plaster-of-paris casts and manipulation, as well as for recurrent clubfoot. Casting after complete correction not only protects the osteopenic bones while the pin-tracts heal, but also maintains correction and allows gradual weightbearing.

Key words: clubfoot; external fixator

INTRODUCTION

Despite the significant improvement in the quality of health care in India, many patients, especially those from rural areas, present in city hospitals with neglected or inadequately treated congenital orthopaedic problems that were not treated in infancy because of ignorance or lack of opportunity. 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. Many patients with these conditions are not suitable candidates for management by soft tissue release procedures. The discovery of principles of distraction histoneogenesis by Ilizarov,1 opened a new chapter in the management of complex deformities of limbs.2-4 While there is a wide variety of paediatric applications of the Ilizarov technique to correct lower extremity deformities,5-7 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 et al.8 devised a simple external fixator (Joshi's external stabilisation system [JESS]), in the early 1990s, which is especially useful for patients with small feet. In this study, we present a series of 44 feet in 26 patients of neglected clubfoot, dropout cases of POP cast treatment, or failed surgical procedures that had been followed up for a minimum period of 2 years by using the JESS fixators.

MATERIALS AND METHODS

This study was conducted at the Central Institute of Orthopaedics at the Safdarjung Hospital, New Delhi, India, between January 1998 and December 1999. 50 feet belonging to 30 patients aged between 10 months and 6 years were initially included in the study (mean age of patients, 2.8 years). Four patients (2 bilateral cases and 2 unilateral cases) were lost for follow-up, leaving 26 patients with 44 treated feet: 14 in girls and 30 in boys (Table 1). Only cases of non-treated clubfoot (n=20), dropout cases of POP cast treatment (n=22), and recurrent clubfoot after previous surgery (n=2) were included in this study. 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 instructions. Preoperative and postoperative clinical, radiological, and functional evaluations were performed using the Hospital for Joint Diseases Orthopaedic Institute functional rating system for clubfoot surgery.9 The fixator is available in 3 sizes: small (for children aged 1.5 years or younger), medium (for those aged between 1.5 and 3 years), and large (for those older than 3 years). The components of the fixator are shown in Fig. 1, and the surgical technique is shown in Fig. 2.

Postoperatively, the limb was elevated on a pillow to reduce the oedema. From postoperative day 3 onwards, medial distraction was started at the rate of 1 mm/d (4 x 0.25 turns per day) and lateral distraction at the rate of 0.5 mm/d (2 x 0.25 turns per day). Toes were passively manipulated at regular intervals. Patients were discharged on postoperative day 7, after having been taught proper distraction and care of the fixator. Patients were followed up at twice-weekly intervals until slight overcorrection was achieved. Distraction was stopped and the feet were maintained in the frame for 6 to 12 weeks in the fixator to allow tissues to adapt to the changed posture. Fixators were removed under anaesthesia, and another POP cast was fitted for 3 months, followed by pronator shoes as recommended by Joshi et al.,8 Galante et al.,10 and Oganesian and Istomina.11