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Year : 2013  |  Volume : 6  |  Issue : 3  |  Page : 274-280  

A clinical study of ligamentoaxis using an external fixator, modified frame in the management of a neglected, relapsed, resistant older congenital Talipes Equino varus child

1 Department of Orthopaedics, Shri Annasaheb Shinde Mhaishalkar Charitable Trust and Post Graduate Institute of Orthopaedics, Sangli, India
2 Department of Orthopedics, Padmashree Dr D Y Patil Medical College, Hospital and Research Centre, Dr D Y Patil Vidyapeeth, Pune, India

Date of Web Publication5-Jul-2013

Correspondence Address:
Ajit Shinde
Mhaishalkar Shinde Hospital, Civil Hospital Chowk, Dr. Abmedkar Road, Sangli, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0975-2870.114661

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Background: In an older, relapsed, recurrent, resistant Congenital Talipes Equino Varus (CTEV) child with previous surgical scar, soft tissue release alone is often not sufficient for full correction, particularly at above 2 years of age. Here controlled, fractional differential distraction with Joshi's external stabilization system is a useful option to correct all the deformities. It is a well-established modality but with complication rate of 30%, mainly related to pin loosening and infection leading to instability of frame. We aimed to study a method to increase stability of frame to reduce incidence of pin loosening, infection and to evaluate clinical and functional outcome of the modality along with modification. Materials and Methods: 117 children underwent Joshi's external stabilization system procedure. The principle of correction applied in this study was fractional distraction. Patients were evaluated by Catteral and Simons criteria. Results: Excellent results were obtained in 68.50% of cases, good results in 23.90%, and poor results in 7.60% of the cases. The complication rate reduced to 3% pin tract infections, which eventually healed with outpatient treatment. Conclusion: Fractional distraction method by using Joshi's External Stabilization System is an easy, simple, less invasive method, which corrects all the deformities in resistant, neglected, and relapsed cases of CTEV and modification of the frame we used proved to be beneficial. Teaching and awareness of parents regarding distraction schedule, stability of frame postoperative importance of wearing of corrected footwear for long period are important.

Keywords: Clubfoot, neglected, relapsed, resistant, with modified Joshi′s External Stabilization System

How to cite this article:
Shinde A, Kamble S, Shah S, Shinde R. A clinical study of ligamentoaxis using an external fixator, modified frame in the management of a neglected, relapsed, resistant older congenital Talipes Equino varus child. Med J DY Patil Univ 2013;6:274-80

How to cite this URL:
Shinde A, Kamble S, Shah S, Shinde R. A clinical study of ligamentoaxis using an external fixator, modified frame in the management of a neglected, relapsed, resistant older congenital Talipes Equino varus child. Med J DY Patil Univ [serial online] 2013 [cited 2021 Apr 20];6:274-80. Available from:

  Introduction Top

The neglected and recurrent club foot problem is compounded by additional secondary changes in skin, bones, and joints due to weight bearing in deformed position. [1] In the older child, issue of correction of deformities becomes more complicated by additional skin scar, fibrosis of previous surgery which need extensive soft tissue surgeries along with various boney osteomies and forcible manipulation. [2],[3] None of the procedures [4],[5],[6] can completely achieve the goal of functional, painless, and cosmetically acceptable complete plantigrade normal foot in such cases. This unsatisfactory situation prompted surgeons to seek a method which does not involve soft tissue trauma or bony resection.

Illizarov in 1960 [7],[8],[9] proposed the biologic law of tissue histiogenesis of bone, muscle, nerve, and skin occurring when the tissues are put to stretch gradually. But the fixators he used were constrained, bulky, using tensioned wires, needing enough strength in the bones to hold them and technically demanding. On the same principal Joshi [10] in 1990 developed a plain unconstrained simple, versatile, cheaper, and light fixator system with tremendous potential as an extension of the conservative method with osseous holds where wires used are prestressed and only soft tissue stretching is involved. The concept of controlled differential distraction prevents crushing of the tissues on the convex lateral side and limb lengthening along with correction deformity taking place gradually and effectively to achieve a supple foot.

This fixator [11],[12] has many theoretical advantages like avoiding fibrous tissue formation, prevention of further shortening of foot as against the bony procedures and proper control of all components of corrections, with actual lengthening and histioneogenesis of the soft tissues.

The aim of the present study was to observe the correction of all elements of deformities of foot with Joshi's external fixator, without compromising neurovascular status of the limb and with our modification of frame, avoid all possible complications to gain supple, cosmetically acceptable foot with durable corrections of deformities.

  Materials and Methods Top

This study was done at department of orthopedics and traumatology S.A.S.M.C.T.'s PG Institute Of Orthopaedics Mhaishalkar Shinde Orthopaedic Research Center and Accident Hospital, Sangli, Maharashtra, India during March 2008 to March 2012. A total of 117 cases of neglected, recurrent and relapsed CTEV were included in the study.

Patients with other congenital anomalies like meningomylocele, spina bifida arthrogryposis, cerebral palsy, and other neuromuscular disorders are excluded.


The standard JESS frame was applied to all patients (using hand drill with slow rpm and taking proper stab incisions) which included two tibial transverse k-wires connected by L/Z rods (in some older patients we passed three tibial transverse k-wires). Two transverse and one axial calcaneal wires, three metatarsal wires (first wire anchoring minimum fifth and first metatarsals, second and third half k-wires from either side engaging three metatarsals each so that the third metatarsal has engaging half pins from either side through it). The application of JESS fram is illustrated in [Figure 1], [Figure 2] and [Figure 3].
Figure 1: Application of JESS (anterior view)

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Figure 2: Application of JESS (oblique view)

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Figure 3: Application of JESS (inferior view)

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Our Modification for Increasing Stability

Two anteroposterior (vertical) k wires - first above the upper tibial transverse K-wire (avoiding tibial tuberosity) and second below the second transverse tibial k-wire - were passed taking care of posterior structures. Both were connected by link joints and rod and in turn connected to anterior limbs of L/Z rods of tibia as shown in [Figure 1]. Because of this modification in severely deformed feet during correction loosening of K-wires was tremendously decreased.

The fixation calcaneal axial wire was reinforced by one more transverse rod connected to L rods of transverse calcaneal wires, so as to increase stability of axial k-wire as shown in [Figure 2].

Distraction schedule was, as standard, started on the third to fifth day. Since beginning parents were taught and asked to do distraction. At the end of each day they were made to check the link joints and make tight if needed. Every patient was given Allen key with him at home. They were asked to visit OPD every 15 days (on average as most of the patients were not ready for hospitalization during distraction period).

The deformities were corrected in sequence. Fore-foot adduction and cavus were fully corrected first by differential distraction of medial and lateral rod of foot frame. This was followed by full correction of varus of the heel by distraction of rod on medial side. After this the equinus was corrected by distraction of the poterior rod. The rate of distraction was at 1 mm per day.

In severe and resistant cases, adduction of the fore-foot and cavus were corrected by plantar fasciotomy and abductor hallucis release, capsulotomy of the talo-navicular and naviculo-cunieform joints with k-wire fixation. Severe equinus was corrected by Z-plasty of the tendo-achillis tendon before applying the JESS frame for full and final correction by the distraction method.

Correction of deformities was checked clinically as well as radiologically as and when needed. Manipulation of frame was done periodically without exerting pressure.

The time taken for correction by distraction varied from patient to patient (6-12 weeks with an average of 7 weeks). The frame was further retained for 1 1 / 2 months in static phase. After removal of the fixator 1 month below knee cast in maximum corrected position, the patient was allowed to bear weight on limb and walk. Again plaster boot cast was given twice, each for 15 days with maximum correction. The patient was asked to do all the activities with the plaster boot on. Then proper shoe ware was given and checked at every follow-up for its fitting.

Postoperatively after the removal of the fixator, the taloclcaneal index was measured.

Deformity was assessed using CARROL's [13] clinical criteria.

X-rays taken were (1) Antero Posterior and Lateral X-ray Plantigrade and Weight Bearing, (2) Forced planter Flexion AP, (3) Forced Dorsi flexion Lateral and different angles were measured. [14],[15]

Patients were advised follow-up every 2 months for the first six months, then every 6 months for 1 year and then yearly for 3 years.

The results were quantified according to Simon's criteria [16] as shown in [Table 1].
Table 1: Simon's criteria

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Radiologically the talocalcaneal angle in stress or weight bearing anterio-posterior (AP) and lateral views was taken as more than 15° to call a result to be satisfactory.

  Results Top

Age and Gender Distribution of Cases Yearwise

This is shown in [Table 2]. More male patients were brought for the corrective procedure than females. Similarly, right-sided operations were more than left-sided operations [Table 3].
Table 2: Age and gender of patients yearwise

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Table 3: Side of feet operated upon

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Out of 117 patients (136 feet), 38 (32.47%) patients were relapsed cases and 79 (67.52%) patients were neglected cases.

Out of 38 relapsed patients, 11 (28.94%) were failure of conservative management and 27 (71.06%) were failure of surgical management.

Almost every patient had varying degree of foot edema in the initial days, which subsided with elevation of foot.

Pin loosening was very much decreased because of modified fixation of the frame. Also parents were keeping watch on the fixator tightness daily.

Finger contractures were also reduced tremendously as since second day physiotherapy of toes was started. At the time of each distraction, parents were advised to do toe movements passively. Finger slings were given to every patient.

The pain during distraction was managed by analgesics.

We had two cases of mid-foot breakage in the initial period managed conservatively.

Preoperative photo and X-rays of a typical case are shown in [Figure 4], [Figure 5], [Figure 6] and [Figure 7]. The postoperative results after 2 years follow-up and X-rays are shown in [Figure 8], [Figure 9], [Figure 10], [Figure 11] and [Figure 12].
Figure 4: Preoperative picture (posterior view)

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Figure 5: Preoperative X-ray (anterior posterior view)

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Figure 6: Preoperative X-ray (lateral view)

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Figure 7: Preoperative picture (anterior view)

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Figure 8: Postoperative picture (lateral view)

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Figure 9: Postoperative picture (posterior view)

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Figure 10: Postoperative picture (anterior view)

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Figure 11: Postoperative x-ray (lateral view)

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Figure 12: Postoperative X-ray (anterior posterior view)

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Radiological findings: The talocalcaneal index was measured both preoperatively and postoperatively. The findings are shown in [Table 4].
Table 4: Talocalcaneal index preoperatively and postoperatively

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None of the patients showed correction to a normal range of AP talocalcaneal angles radiologically.

Equinus at the ankle: The mean precorrection equinus deformity was 59°. Postoperatively 106 (77.77%) feet showed well-corrected mobile ankle joints. The postoperative range of motion at the ankle was on average 40° with 25° plantar flexion and 15° of dorsiflexion. 28 (20.58%) patients showed mild degree of equinus remaining, though the feet were supple and range of movement was good and in 2 (1.47%) patients equinus remaining was more than 15° and needed reapplication of frame.

Fore foot varus was assessed clinically and radiologically. The mean precorrection adduction deformity was 26°. The mean post correction abduction achieved was 3°. Postoperatively 21 (15.44%) feet showed remnant of varus deformity of less than 10° which were flexible and managed with footwear and 3 (2.20%) needed surgical intervention in whom remnant of deformity was rigid.

The mean precorrection heel varus deformity was 39° while the mean postcorrection value was 4°. All patients had a good correction of heel varus except in 20 (14.70%) patients in whom up to 10° varus deformity was remaining.

Postoperative clinico radiolgical results were satisfactory in 125 (92.4%) of the cases, out of which 68.5% showed excellent results and 23.9% showed good results. In 11 (7.6%) cases the results were unsatisfactory

In few of our cases (where the T-N joint was not fixed with k-wire), we encountered mild degree of Rocker bottom foot, detected only radiologically but not clinically, with no functional disability.

No residual deformity after completions of distraction treatment was observed.

  Discussion Top

The institute is having a charitable trust through which it actively participates in many social activities one of which is the free school health program. During this program we observed that even up to school going age, 70-80% children have not received any specific management for club foot from orthopedic consultant because of poverty and illiteracy. In our study the incidence of older neglected children was high with very severe deformities with rigidity, adaptive changes of skin, bone, joints. The JESS fixator corrected most of the deformities (equinus, varus, and adduction) in the hind, mid- and forefoot even in the most of the neglected and recurrent clubfoot. No other procedure corrected all the deformities in all parts of the foot in a single procedure except triple arthrodesis, which is a salvage procedure and can only be done after maturity with stiffness, while by this methodology the feet were supple, mobile, and cosmetically acceptable so much so that they could accept normal footwear.

This fixator can be reapplied to correct the deformity if it recurred till the patients reach maturity when bony surgery can be done to stabilize the foot.

In our series satisfactory results were 92% while Turco in 1979 had 83% satisfactory results according to his own criteria. [4]

Thus our results are comparable to these series. The results of the present series can be discussed under the following headings.

In our series, operations performed were in the age group 3-16 years. It was observed that younger the patient the better the result.

Pin site infection [17] are common to all external fixators. In this study it was observed that modification of frame worked and pin track loosening, infection rate was reduced to 3% as against many other studies where it was 30% but one has to follow basic things like proper skin stabs for K wire passage/use of sterile equipments/slow drilling (use hand drill)/proper cleaning of pin sites, and avoiding deposition of crust at the site.

We taught older patients or parents to take care of pins themselves daily to avoid scab formation and provided them dressing material and antiseptics for keeping the pins clean. This decreased the rate of infection tremendously.

Also making link joints tight was taught to active parents. This decreased the loosening complication rate. We gave Allen key to each patient and asked them to check tightness once daily.

We observed that it took a longer period for distraction compared to other series as our patients were not hospitalized during the whole period of distraction. But surprisingly without hospitalization with proper care of frame stability and pin site infections the complication rate was decreased tremendously.

We did not find many differences in the end results of those patients who remained in the hospital throughout the period of distraction expect for the duration required. But we took real efforts to teach the parents and making them to bring the child for follow-up regularly, readmitting as and when needed.

We provide very simple thick cloth wrapping which (which is reusable) with simple belts to each patient according to their sizes to be wrapped around frame during traveling and during sleeping at home. Making k-wire ends blunt by applying sticking plast was done by parents themselves. This reduces frame loosening by getting adhered to cloths.

We Faced the Only Problem During Treatment

To judge the fineness of correction at the completion of deformity correction, for the end-point, through the frame is a tedious job. Checking with the help of X-ray is also difficult through the frame and chances of under correction are present. Hence doing slightly more lengthening is always good.

  Conclusion Top

In older patients with bony deformities along with soft tissue contractures that the JESS fixator has proved to be extremely useful. While evaluating the results one should always keep in mind that we are dealing with difficult problems of previously operated (many of them with multiple surgeries) recurrent and or rigid and neglected severely deformed feet.

Assessment was done on clinical outcome. X-ray was not included as criteria for assessment of the results, since none of our patients had full anatomical reduction of Talocalcanoeonavicular joint or restitution of normal range of A.P. and lateral Talocalcaneal angle but had satisfactory clinical outcome with the feet that were supple, mobile, and cosmetically good and which would accept normal footwear.

JESS modality working on the principle of gradual differential distraction along with our modification of the frame produces better results with less morbidity and low complications rate, than conservative and operative management for the older neglected severely deformed, relapsed, recurrent, and resistant cases.

  References Top

1.Carroll NC, McMurtry R, Leete SF. The pathoanatomy of congenital clubfoot. Orthop Clin North Am 1978;9:225-32.  Back to cited text no. 1
2.Dobbs MB, Nunley R, Schoenecker PL. Long-term follow-up of patients with clubfeet treated with extensive soft-tissue release. J Bone Joint Surg Am 2006;88:986-96.  Back to cited text no. 2
3.Ponseti IV, Smoley EN. Congenital clubfoot the results of treatment. J Bone Joint Surg 1963;45:134-41.  Back to cited text no. 3
4.Turco VJ. Surgical correction of the resistant club foot. One-stage posteromedial release with internal fixation: A preliminary report. J Bone Joint Surg Am 1971;53:477-97.  Back to cited text no. 4
5.Khan SA, Kumar A. Ponseti's manipulation in neglected clubfoot in children more than 7 years of age: A prospective evaluation of 25 feet with long-term follow-up. J Pediatr Orthop B 2010;19:385-9.  Back to cited text no. 5
6.Spiegel DA, Shrestha OP, Sitoula P, Rajbhandary T, Bijukachhe B, Banskota AK. Ponseti method for untreated idiopathic clubfeet in Nepalese patients from 1 to 6 years of age. Clin Orthop Relat Res 2009;467:1164-70.  Back to cited text no. 6
7.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. 7
8.Wallander H, Hansson G, Tjernstrom B. Correction of persistent clubfoot deformities with the Ilizarov external fixator. Experience in 10 previously operated feet followed for 2-5 years. Acta Orthop Scand 1996;67:283-7.  Back to cited text no. 8
9.Ferreira RC, Costa MT, Frizzo GG, Santin RA. Correction of severe recurrent clubfoot using a simplified setting of the Ilizarov device. Foot Ankle Int 2007;28:557-68.  Back to cited text no. 9
10.Joshi BB, Laud NS, Warrier S, Kanaji BG, Joshi AP, Dabake H. Treatment of CTEV by Joshi's External Stabilization System (JESS). In: Kulkarni GS, editor. Textbook of Orthopaedics and Trauma. 1 st ed. New Delhi: Jaypee Brothers Medical Publishers; 1999.  Back to cited text no. 10
11.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. 11
12.Anwar MH, Arun B. Short term results of Correction of CTEV with JESS Distractor. J Orthopaedics 2004;1:e3.  Back to cited text no. 12
13.Correll J, Forth A. Correction of severe clubfoot by Ilizarov method. J Foot Ankle Surg 2003;2:27-32.  Back to cited text no. 13
14.Morcuende JA, Dolan LA, Dietz FR, Ponseti IV. Radical reduction in the rate of extensive corrective surgery for clubfoot using the ponseti method. Pediatrics 2004;113:376-80.  Back to cited text no. 14
15.Radler C, Manner HM, Suda R, Burghardt R, Herzenberg JE, Ganger R, et al. Radiographic evaluation of idiopathic clubfeet under going Ponseti treatment. J Bone Joint Surg Am 2007;89:1177-83.  Back to cited text no. 15
16.Simons GW. Complete subtalar release in club feet. Part II-Comparison with less extensive procedures. J Bone Joint Surg Am 1985;67:1056-65.  Back to cited text no. 16
17.Atar D, Lehman WB, Grant AD. Complications in clubfoot surgery. Orthop Rev 1991;20:233-9.  Back to cited text no. 17


  [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], [Table 2], [Table 3], [Table 4]

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