Role of Joshi's external stabilization system with

Chinese Journal of Traumatology xxx (2015) 1e6

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Original article

Role of Joshi's external stabilization system with percutaneous screw fixation in high-energy tibial condylar fractures associated with severe soft tissue injuries Ashish Kumar Gupta a, Rahul Sapra b, *, Rakesh Kumar b, Som Prakash Gupta b, Devwart Kaushik b, Sahil Gaba b, Mahesh Chand Bansal b, Ratan Lal Dayma b a b

Department of Orthopedics, Bhagwan Mahavir Hospital, New Delhi 110088, India Department of Orthopedics, SMS Medical College & Hospitals Jaipur, Jaipur, Rajasthan 302004, India

a r t i c l e i n f o

a b s t r a c t

Article history: Received 11 April 2014 Received in revised form 20 June 2014 Accepted 2 July 2014 Available online xxx

Purpose: The treatment of high-energy tibial condylar fractures which are associated with severe soft tissue injuries remains contentious and challenging. In this study, we assessed the results of Joshi's external stabilization system (JESS) by using the principle of ligamentotaxis and percutaneous screw fixation for managing high-energy tibial condylar fractures associated with severe soft tissue injuries. Methods: Between June 2008 and June 2010, 25 consecutive patients who were 17e71 years (mean, 39.7), underwent the JESS fixation for high-energy tibial condylar fractures associated with severe soft tissue injuries. Out of 25 patients, 2 were lost during follow-up and in 1 case early removal of frame was done, leaving 22 cases for final follow-up. Among them, 11 had poor skin condition with abrasions and blisters and 2 were open injuries (Gustilo-Anderson grade I & II). The injury mechanisms were motor vehicle accidents (n ¼ 19), fall from a height (n ¼ 2) and assault (n ¼ 1). The fractures were classified according to Schatzker classification system. Results: There were 7 type-V, 14 type-VI and 1 type-lV Schatzker's tibial plateau fractures. The average interval between the injury and surgery was 6.8 days (range 2e13). The average hospital stay was 13 days (range, 7e22). The average interval between the surgery and full weight bearing was 13.6 weeks (range 11e20). The average range of knee flexion was 121 (range 105ºe135 ). The normal extension of the knee was observed in 20 patients, and an extensor lag of 5ºe8º was noted in 2 patients. The complications included superficial pin tract infections (n ¼ 4) with no knee stiffness. Conclusion: JESS with lag screw fixation combines the benefit of traction, external fixation, and limited internal fixation, at the same time as allowing the ease of access to the soft tissue for wound checks, pin care, dressing changes, measurement of compartment pressure, and the monitoring of the neurovascular status. In a nutshell, JESS along with screw fixation offers a promising alternative treatment for highenergy tibial condylar fractures associated with severe soft tissue injuries. © 2015 The Authors. Production and hosting by Elsevier B.V. on behalf of Daping Hospital and the Research Institute of Surgery of the Third Military Medical University. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Keywords: Tibial plateau fractures External stabilization system Ligamentotaxis

1. Introduction The severity of a tibial plateau fracture and complexity of its treatment depends upon energy imparted to the limb.1 Highenergy tibial plateau fractures are characterized by significant fracture comminution and associated soft tissue damage with

* Corresponding author. E-mail address: [email protected] (R. Sapra). Peer review under responsibility of Daping Hospital and the Research Institute of Surgery of the Third Military Medical University.

implications for healing.2,3 Open reduction and internal fixation of these types of fractures have significant complication rates.4 Not only is the severity and number of complications high, but the number of repeat surgical interventions and their severity is greater. It requires extensive surgical exposure that leads to problems with wound healing and infection in the compromised soft tissue environment. Also, surgical incision may hamper future total knee arthroplasty, if the need arises.5 To overcome the drawbacks of nonoperative and other operative modalities, the minimally invasive technique of closed reduction by ligamentotaxis and fixation with percutaneous screws and K-wires has been developed and practiced. These techniques combine

http://dx.doi.org/10.1016/j.cjtee.2015.11.008 1008-1275/© 2015 The Authors. Production and hosting by Elsevier B.V. on behalf of Daping Hospital and the Research Institute of Surgery of the Third Military Medical University. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Please cite this article in press as: Gupta AK, et al., Role of Joshi's external stabilization system with percutaneous screw fixation in high-energy tibial condylar fractures associated with severe soft tissue injuries, Chinese Journal of Traumatology (2015), http://dx.doi.org/10.1016/ j.cjtee.2015.11.008

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A.K. Gupta et al. / Chinese Journal of Traumatology xxx (2015) 1e6

attributes of operative and nonoperative philosophies, are more biological and give excellent functional results.3,6e8 We reviewed our results with the use of Joshi's external stabilization system (JESS) with percutaneous screw fixation for the treatment of 25 high-energy tibial plateau fractures (Schatzker type IV, V & VI type) to evaluate the outcome and the merits and demerits of this modality of management in tibial condylar fractures. JESS frame provides adequate fixation of fracture in short operative time with no further damage to soft tissue and requires only basic instruments for surgery. Early mobilization of knee is possible with this device. Postoperative control of deformity and fracture is also possible. It also provides good clinical results and patient satisfaction.9 2. Materials and methods Totally, 25 patients with high-energy tibial plateau fractures, treated with JESS Helmet frame and percutaneous screw fixation from June 2008 to June 2010, were reviewed. Patients having highenergy tibial condylar fracture (Schatzker type IV, V &VI type) irrespective of age and sex were included. Open fractures (except Gustilo type I & type II), soft tissue infection at fracture site and patients not willing to take part in the study were excluded. Schatzker classification10 was used to classify these fractures. Data were collected at the time of admission to elicit age, sex, type of fracture, mode of injury, date of injury and any other associated injuries. After careful physical examination of the knee and leg, a lower tibial pin was passed and traction was applied on Bohler Braun splint with continuous attention to peripheral circulation of involved limb till definitive fixation. Initial radiographs included anterioposterior and lateral views of involved knee. Computed tomography with 3-D reconstruction was done to evaluate the degree of displacement. 2.1. Surgical technique Reduction of the fracture was done by traction ligamentotaxis on a fracture table in supine position under fluoroscopic control. Limited open reduction was done in 10 cases along with bone grafting for restoration of the depressed articular surface and pointed reduction forceps was used to compress the fracture fragments. A 2 mm guide wire was passed 5 mme10 mm distal and parallel to the joint line across the two displaced major fragment. Tibial condyle was fixed with 6.5 mm cannulated cancellous screw passed over guide wire. Three 2.0 mm K-wires were passed from postero-lateral, postero-medial and transverse direction to the proximal tibia at the level of the guide wire. A 14 inch long and 4 mm thick connecting rod was bent to make 5/8th of a circle and all wires were connected to this rod with 4 4 link joint, this helmet frame was reinforced with another connecting rod. Three Kwires each of 3 mm were passed perpendicular to long axis of tibia in diaphyseal region to construct diaphyseal hold. These K-wires connected with ‘Z’ connecting rods. This diaphyseal hold was connected to the metaphyseal helmet hold with two anterior and two posterior connecting rods to complete the procedure. 2.2. Postoperative period and follow-up Isometric quadriceps exercise and knee mobilization were started from postoperative day one to achieve full extension and 90 of flexion of knee joint as soon as possible. Partial weight bearing was allowed at 6e8 weeks and was gradually increased as tolerated. JESS helmet frame was removed after 14e16 weeks on evidence of clinical and radiological union and long knee brace was

given for support if the patient had gross comminution. Patients were followed at regular interval till last followeup and evaluated with the Rasmussen's criteria11 & Iowa knee score.12 3. Results Out of 25 patients, 2 were lost during follow-up and in 1 case early removal of frame was done (case 23), leaving 22 cases for final follow-up. There were 20 males (90.9%) and 2 females (9.09%) patients with a mean age of 39.7 years (17e71 years). Road traffic accidents were the major cause of injury (19 cases, 86.36%), fall from height (2 cases, 9.09%) and assault (1 case, 4.54%) were other culprits. Four patients (18.18%) had other major ipsilateral lower extremity injuries. According to Schatzker classification, there were 14 type VI (63.64%), 7 type V (31.81%) and 1 type IV (4.54%). Out of 22 cases, 11 patients (50.00%) had poor skin condition in form of abrasions or blisters and 2 patients (9.09%) had Gustilo type I and II injury respectively which were immediately irrigated and debrided prior to definitive fixation (Figs. 1 and 2). Patients were operated at a mean interval of 6.8 days (range 2e13 days). The delay in surgery was due to poor skin conditions. Limited open reduction was allowed only after such injuries resolved. Out of 22 cases, 10 cases (45.45%) required additional bone grafting to fill up the gap which was made after elevating and maintaining the articular surface during surgery. Mean interval between surgery and partial weight bearing was 8.9 weeks (range 8e13 weeks). Causes of delayed partial weight bearing (n ¼ 2, 9.09%) was mainly other associated injuries which require prolonged nonweight bearing. Mean interval between surgery and full weight bearing was 13.6 weeks (range 11e20 weeks). Most of the patients were allowed complete weight bearing at 10e15 weeks. Two patients (9.09%) had delayed complete weight bearing because of excessive comminution at fracture site. The JESS helmet frame was retained till the signs of union were seen on X-rays. The mean interval between surgery and removal of JESS frame was 16 weeks (range 10e25 weeks). In one case early removal (at 10 weeks) of frame was done (case 23) because of preoperative peroneal nerve palsy for which patient underwent surgical intervention. The most common complication seen was superficial pin track infection (n ¼ 4) which was easily controlled by regular pin track dressing and a course of oral antibiotics. Deep infection, septic arthritis, non union or breakage of wires was not noted in any of the patients. Patients were followed up for a minimum of 1 year with a mean of 27 months (12e40 months). The mean score according to Rasmussen's criteria at the final follow-up was 42.7. All cases had excellent or good outcome at 1 year follow-up. The mean Iowa Knee score was 91.5. Total range of motion 120 or more was noted in most of the patients. Out of 22 cases 18 patients (81.81%) had total range of motion (ROM) 120 or more. 2 cases (9.09%) had more than 130 range of motion and 2 cases (9.09%) had range of motion up to 105 . Mean range of knee motion was 121 (range 105 e135 ). Normal extension of knee was observed in 20 patients (90.9%) and extensor lag of 5 e8 was noted in 2 patients (9.09%, Figs. 3 and 4). 4. Discussion High-energy tibial plateau fractures are recognized by complex fracture patterns with associated serious soft tissue injury internally and externally, which presents multifaceted problems of difficulty in achieving a stable, aligned congruous joint with painless restoration of motion and function. There is a universal agreement that accurate restoration of joint surface, stable fixation and early knee motion are equally important. To overcome the demerits of both the conventional operative and nonoperative philosophies



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Fig. 1. A: Preoperative skin condition of the patient. B: Preoperative X-ray of the knee in anteroposterior and lateral views. C&D showing CT scan images of Schatzker Type VI injury of proximal tibia.

and to combine the beneficial attributes of these, minimally invasive techniques have been developed and utilized. The mean age of the patients in our study was about 40 years at the time of surgery. There are 81% of our patients in age group of 17e50 years. This implies that the majority of the patients were economically productive. The high incidence of fractures in young patients highlights the high-energy mechanism of this injury. Related studies also highlight the gloomy fact that the knee injuries affect predominantly the productive age group and levy an enormous economic burden on the financial health of the nation.6e9 Our study comprising of 90.9% males and 9.1% females confirms the fact that males who are involved more in outdoor occupational activities bear the brunt of knee injuries. Plating for bicondylar tibial plateau fractures done via open reduction techniques requires extensive soft tissue handling, mobilization, stripping and devitalization to achieve satisfactory reduction. This devitalization of the soft tissues hinders wound healing and increases the chances of infection. Because of the larger diameter of the half pins and the poor purchase in the metaphyseal

bone, medial condylar comminution is not addressed in hybrid fixation by using a lateral side open reduction and internal fixation, combined with unilateral external fixation.8 Across the knee external fixation does not allow an early range of movement leading to joint stiffness, thus impairing articular fracture healing.3 Stannard et al13 used the less invasive stabilisation system with a precontoured plate that must fit a wide variety of tibial shapes and sizes. The soft-tissue envelope at the proximal tibia is thin, providing limited coverage for the proximal end of the plate. This causes a slightly higher risk of implant-associated pain than conventional plates. As demonstrated in several studies, the rate of posttraumatic arthritis is high. The Canadian Orthopedic Trauma Society showed that 30% of patients had radiological signs of arthritis at two years regardless of treatment.14 In general, arthroplasty in this setting is technically simpler with a lower complication rate if prior incisions, soft-tissue scarring, and implanted hardware are minimized. This would typically favor the JESS group. However, the presence of indolent infection from old pin tracks in the proximal end of the


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Fig. 2. A: Preoperative skin condition of another patient. B: Preoperative X-ray of the knee joint in anteroposterior & Lateral views. C&D showing CT scan images of the same patient.

tibia is also a concern for future arthroplasty. Extended lateral incisions, lateral arthrotomies, and the lateral hockey stick incision often used in the treatment of tibial plateau fractures may lead to wound complications.15 Saleh et al5 treated 15 patients after open reduction and internal fixation of fractures of tibial plateau by total knee arthroplasty. Adequate functional outcome with the Hospital for Special Surgery outcome score increased from 51 to 80 points, but there was a high rate of complications with infection in 20% and rupture of the patellar tendon in 13%. In our study this thing was kept in mind during minimal open reduction and small size incisions were appropriately placed, keeping in mind a candidate for future total knee replacement. In our study, none of the patients had symptoms relevant to joint instability or meniscal abnormality requiring ligament repair or reconstruction and meniscal repair. Although treatment of ligament injuries associated with tibial plateau fractures remains controversial, it is generally agreed that late instability following tibial plateau fractures is a major cause of unacceptable results. Whether this late instability is caused by ligamentous laxity or bony deformity remains debatable. There is no general agreement that the repair of associated ligament injuries at the time of

fracture fixation is necessary or will improve late instability following these fractures. According to Delamarter et al,16 operative repair of medial and lateral collateral ligaments with appropriate treatment of the bony plateau fracture may reduce late instability and may improve overall morbidity in these concomitant injuries. However, operative repair of the cruciate ligaments did not improve follow-up instability and overall results, as was the case in medial collateral ligament or lateral collateral ligament repairs. Furthermore, periarticular fibrosis after soft tissue injuries around the knee may be responsible for the absence of symptoms relevant to instability.17 Belanger and Fadale18 in 1997 stated that complications of arthroscopic assisted reduction and fixation are infrequent but potentially severe and there is a possibility of compartment syndrome unless a low pressure flow is used. In addition, there is a question about sterility with arthroscopic assisted technique. Furthermore arthroscopic assisted reduction is a more demanding operative technique and is costly. It is not advisable in polytrauma patient or in cases with multiple fractures. It is a good, but not always a necessary option, if performed by a well trained orthopedic surgeon.



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Fig. 3. A: Postoperative X-ray of the same patient as in Fig. 1 showing JESS fixator with cancellous screws in situ. B: X-ray images of the same patient after JESS removal. C&D showing final ROM of the knee joint.

Closed reduction or limited open reduction by using JESS and percutaneous cancellous screws prevents iatrogenic soft tissue damage and minimizes further devitalization of the bone and stripping of the periosteal blood supply. The juxta-articular lag screw offers superior metaphyseal purchase, supports the subchondral bone thus preventing collapse, fixes the small cancellous fracture fragments, and allows for early rehabilitation (physiotherapy and weight bearing). This reduces hospital stay and the cost. The principle of ligamentotaxis is used to achieve metaphyseal reduction. JESS with lag screw fixation combines the benefit of traction, external fixation, and limited internal fixation, at the same time as allowing the ease of access to the soft tissue for wound checks, pin care, dressing changes, the measurement of compartment pressure, and in monitoring of the neurovascular status. Thus, this technique may be used in periarticular fractures with a metaphyseal/subchondral comminuation where routine plate osteosynthesis may be difficult. It may also be used in plateau fractures that present with a metaphyseal-diaphyseal comminuation, as well as in fractures with soft tissue compromise (open

wounds, compartment syndrome, abrasion, contusion, crushing, or marked swelling). Ligamentotaxis can be best utilized for achieving anatomical reduction when surgery is performed early. Severe soft tissue injuries which are associated with tibial plateau fractures preclude early surgical intervention. JESS with lag screw fixation is a feasible option for early surgical intervention, whenever severe soft tissue injuries are present. Postoperative control of deformity and fracture is also possible with this treatment modality.9,19 This is particularly useful in complex fracture patterns when intraoperative restoration of mechanical axis of the tibia is difficult. We enjoyed a short learning curve on the use of JESS frames. The results improved with experience, careful preoperative planning, and a thorough knowledge of the neurovascular anatomy. Good intraoperative imaging is needed to decrease the incidence of malreduction while learning. Pin tract infection is a potential problem despite the use of the K-wires. To avoid the disastrous complication of septic arthritis, Reid et al20 suggested placing the wires at least 15 mm away from joint surface, monitoring the status of pin sites


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Fig. 4. A: Postoperative X-ray of the same patient as in Fig. 2 showing JESS fixator with screws in situ. B showing X-ray image after JESS fixator removal. C&D showing final ROM of the knee joint.

(especially at juxta-articular locations), and removing any pin revealing features of infection. References 1. Berkson EM, Virkus WW. High-energy tibial plateau fractures. J Am Acad Orthop Surg. 2006;14:20e31. 2. Narayan B, Harris C, Nayagam S. Treatment of high-energy tibial plateau fractures. Strat Traum Limb Recon. 2006;1:18e28. 3. Kataria H, Sharma N, Kanojia RK. Small wire external fixation for high-energy tibial plateau fractures. J Orthop Surg. 2007;15:137e143. 4. Schatzker J, McBroom R, Bruce D. The tibial plateau fracture. The Toronto experience 1968e1975. Clin Orthop Relat Res. 1979:94e104. 5. Saleh KJ, Sherman P, Katkin P, et al. Total knee arthroplasty after open reduction and internal fixation of fractures of the tibial plateau: a minimum five-year follow-up study. J Bone Jt Surg Am. 2001;83-A:1144e1148. 6. Blokker CP, Rorabeck CH, Bourne RB. Tibial plateau fractures. An analysis of the results of treatment in 60 patients. Clin Orthop Relat Res. 1984:193e199. 7. Dendrinos GK, Kontos S, Katsenis D, et al. Treatment of high-energy tibial plateau fractures by the Ilizarov circular fixator. J Bone Jt Surg Br. 1996;78: 710e717. 8. Gaudinez RF, Mallik AR, Szporn M. Hybrid external fixation of comminuted tibial plateau fractures. Clin Orthop Relat Res. 1996;328:203e210. 9. Joshi BB. Management of Proximal Tibial Fracture. In Trauma. 1st ed. JESS Research and Development Society; 2007:225e230. 10. Schatzker J. Compression in the surgical treatment of fractures of the tibia. Clin Orthop Relat Res. 1974:220e239.

11. Rasmussen PS. Tibial condylar fractures. Impairment of knee joint stability as an indication for surgical treatment. J Bone Jt Surg Am. 1973;55:1331e1350. 12. Knee Rating scale: Clinical orthopaedics & related research no. 367. The Hospital for Special Surgery Knee Rating Score. October 1999:7. 13. Stannard JP, Wilson TC, Volgas DA, et al. The less invasive stabilization system in the treatment of complex fractures of the tibial plateau: short-term results. J Orthop Trauma. 2004;18:552e558. 14. Musahl V, Tarkin I, Kobbe P, et al. New trends and techniques in open reduction and internal fixation of fractures of the tibial plateau. J Bone Jt Surg Br. 2009;91: 426e433. 15. Vince KG, Abdeen A. Wound problems in total knee arthroplasty. Clin Orthop Relat Res. 2006;452:88e90. 16. Delamarter RB, Hohl M, Hopp Jr E. Ligament injuries associated with tibial plateau fractures. Clin Orthop Relat Res. 1990:226e233. 17. Sangwan S, Siwach R, Singh R, et al. Minimal invasive osteosynthesis: a biological approach in treatment of tibial plateau fractures. Indian J Orthop. 2002;36:246e250. 18. Belanger M, Fadale P. Compartment syndrome of the leg after arthroscopic examination of a tibial plateau fracture. Case report and review of the literature. Arthroscopy. 1997;13:646e651. 19. Zahid M, MKA S, Siddiqui YS, et al. The role of the JESS (Joshi's external stabilization system) fixator in the management of tibial plateau fractures which are associated with severe soft tissue injuries. J Clin Diagn Res. 2010;4: 3356e3361. 20. Reid JS, Van Slyke MA, Moulton MJ, et al. Safe placement of proximal tibial transfixation wires with respect to intracapsular penetration. J Orthop Trauma. 2001;15:10e17.
