Chinese Journal of Traumatology 18 (2015) 326e331

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Chinese Journal of Traumatology

journal homepage: http://www.elsevier.com/locate/CJTEE

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
Department of Orthopedics, Bhagwan Mahavir Hospital, New Delhi 110088, India
b
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: Purpose: The treatment of high-energy tibial condylar fractures which are associated with severe soft
Received 11 April 2014 tissue injuries remains contentious and challenging. In this study, we assessed the results of Joshi's
Received in revised form external stabilization system (JESS) by using the principle of ligamentotaxis and percutaneous screw
20 June 2014
fixation for managing high-energy tibial condylar fractures associated with severe soft tissue injuries.
Accepted 2 July 2014
Methods: Between June 2008 and June 2010, 25 consecutive patients who were 17e71 years (mean,
Available online 1 December 2015
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
Keywords:
Tibial plateau fractures
done, leaving 22 cases for final follow-up. Among them, 11 had poor skin condition with abrasions and
External stabilization system blisters and 2 were open injuries (Gustilo-Anderson grade I & II). The injury mechanisms were motor
Ligamentotaxis 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 high-
energy 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/).

1. Introduction implications for healing.2,3 Open reduction and internal fixation of

The severity of a tibial plateau fracture and complexity of its
treatment depends upon energy imparted to the limb.1 High-
energy tibial plateau fractures are characterized by significant
fracture comminution and associated soft tissue damage with
* Corresponding author.
E-mail address: saprarahul@gmail.com (R. Sapra).
Peer review under responsibility of Daping Hospital and the Research Institute
of Surgery of the Third Military Medical University.
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 prob-
lems 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/).
 A.K. Gupta et al. / Chinese Journal of Traumatology 18 (2015) 326e331
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 stabi-
lization 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 de-
merits 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 high-
energy 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 K-
wires 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
327
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%) pa-
tients 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 inter-
vention. 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 Ras-
mussen'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 inter-
nally and externally, which presents multifaceted problems of dif-
ficulty 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
328 A.K. Gupta et al. / Chinese Journal of Traumatology 18 (2015) 326e331
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 inva-
sive 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 enor-
mous 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 activ-
ities 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 con-
ventional 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
 A.K. Gupta et al. / Chinese Journal of Traumatology 18 (2015) 326e331
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 in-
cisions, 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 in-
cisions 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 lig-
ament 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
329
fracture fixation is necessary or will improve late instability
following these fractures. According to Delamarter et al,16 opera-
tive repair of medial and lateral collateral ligaments with appro-
priate treatment of the bony plateau fracture may reduce late
instability and may improve overall morbidity in these concomi-
tant 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 syn-
drome 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 al-
ways a necessary option, if performed by a well trained orthopedic
surgeon.
330 A.K. Gupta et al. / Chinese Journal of Traumatology 18 (2015) 326e331
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 sub-
chondral bone thus preventing collapse, fixes the small cancellous
fracture fragments, and allows for early rehabilitation (physio-
therapy and weight bearing). This reduces hospital stay and the
cost. The principle of ligamentotaxis is used to achieve meta-
physeal 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 comminu-
ation, 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, when-
ever severe soft tissue injuries are present. Postoperative control of
deformity and fracture is also possible with this treatment mo-
dality.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 mal-
reduction 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
 A.K. Gupta et al. / Chinese Journal of Traumatology 18 (2015) 326e331
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.
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