Journal of Foot and Ankle Surgery (Asia-Pacific)
Volume 11 | Issue 01 | Year 2024

Inadvertent Metatarsal Lengthening and Hallux Valgus Associated with JESS in a Case of AMC: A Rare and Unreported Complication

Ashok N Johari1, Rashid Anjum2

1Department of Orthopedics, Children’s Orthopedic Centre, Mumbai, Maharashtra, India

2Department of Orthopedics, All India Institute of Medical Sciences (AIIMS), Jammu, Jammu and Kashmir, India

Corresponding Author: Rashid Anjum, Department of Orthopedics, All India Institute of Medical Sciences (AIIMS), Jammu, Jammu and Kashmir, India, Phone: 9419422770, e-mail:

Received: 03 March 2023; Accepted: 06 April 2023; Published on: 30 December 2023


Background: External fixators provide a flexible approach for addressing intricate foot deformities such as clubfoot, particularly in situations involving inflexible or recurrent deformities, neglected cases, or deformities associated with neuromuscular conditions.

Case description: A 10-year-old patient of arthrogryposis multiplex congenita (AMC) with congenital talipes equinovarus (CTEV) undergoing treatment with Joshi’s external stabilization system (JESS) presented with inadvertent metatarsal lengthening with hallux valgus. The complication was treated by a metatarsal shortening osteotomy.

Conclusion: JESS is frequently used to treat relapsed, recurrent, and rigid clubfeet including cavovarus foot deformities seen in AMC. This method of differential distraction has shown promising results with fewer complications than soft tissue releases. The reported complications include pin tract infection, loosening of pins, wire cut through, flexion of toes, and recurrence; however, the present complication of inadvertent metatarsal lengthening has not yet been described.

How to cite this article: Johari AN, Anjum R. Inadvertent Metatarsal Lengthening and Hallux Valgus Associated with JESS in a Case of AMC: A Rare and Unreported Complication. J Foot Ankle Surg (Asia-Pacific) 2024;11(1):42–45.

Source of support: Nil

Conflict of interest: None

Patient consent statement: The author(s) have obtained written informed consent from the patient’s parents/legal guardians for publication of the case report details and related images.

Keywords: Arthrogryposis multiplex congenita, Case report, Complication, Congenital talipes equinovarus, External fixation, Joshi’s external stabilization system, Metatarsal lengthening


Foot deformities are very commonly encountered in arthrogryposis multiplex congenita (AMC) and are usually the most common indication for surgery in such cases.1 External fixators offer a versatile method of correction of complex deformities of the foot, like clubfoot, more so in cases with rigid, relapsed, neglected, or those associated with neuromuscular conditions.2 Joshi’s external stabilization system (JESS), first described in 1990 by Dr BB Joshi, is based on the principle of tissue histogenesis through controlled distraction, which gradually corrects the deformities.3 The standard protocol in the management of equinovarus foot deformity is to start with serial plaster casts and tendo-Achilles tenotomy, with surgery reserved for relapsed, rigid (syndromic), or some neglected cases that are not amenable to stretching by casts.4,5


We present a case of AMC with bilateral congenital talipes equinovarus (CTEV) deformity in a 10-year-old male. Before coming to the present scenario, a brief past history of patient is given below. The patient was initially managed by serial Ponseti casting started within the first week of life. The casts were changed every week, and a total of eight casts were applied; however, the deformities persisted, albeit in a lesser magnitude, followed by recurrence of cavovarus bilaterally. The patient was operated on, and posteromedial release was done bilaterally at the age of 6 months. He was put on plastic-molded ankle–foot orthosis (AFO) with feet in maximum external rotation following surgery. The patient maintained status till 2 years of age, and was lost to follow-up thereafter, and was seen again at 5 years of age. We examined the patient at 5 years of age, and at this time, he had bilateral equinovarus deformities of foot, bilateral knee flexion deformity (FD) of 20°, and hip FD of 15 and 25° on right and left side, respectively. Casting was performed weekly for both feet, achieving an external rotation of 20–30° on either side and neutral dorsiflexion after six casts on right and five casts on the left foot; there was no further correction possible with progressive casting. He was given an AFO with the foot in maximum external rotation, and Pedi wraps for keeping knee straight, to which he was not fully compliant. The deformities relapsed after 4 years with bilateral equinus of 10–15°, varus and adduction of foot, and knee FD of 20–30°. The child was using a knee–ankle–foot orthosis (KAFO) with crutches/walker for mobilization preoperatively. He was operated on with JESS using the standard surgical technique on right foot and a posteromedial release on the left foot (Figs 1 and 2). The surgical technique of JESS involves the insertion of K-wires in the tibia, calcaneum, and metatarsals and connecting rods and distractors between these points. Two parallel wires are passed in the proximal tibial diaphysis from lateral to medial using Z rod as a guide; the wires should be parallel to the knee joint. Next, the calcaneum wires are put from medial to lateral side, protecting the neurovascular structures. The wires should be perpendicular to the axis of calcaneum, and the distance between two wires should be equivalent to the distance between two holes in the distractor link. One wire/pin is put along the long axis of calcaneum, starting just below the insertion of tendo-Achilles. The hindfoot wires were connected using L rods and transverse connecting rods. The metatarsals were fixed by pu