|Year : 2021 | Volume
| Issue : 2 | Page : 14-20
Joshi's external stabilization system versus locked compression plating in the management of tibial plateau fractures: A nonrandomized prospective study
Najmul Huda1, Sandeep Bishnoi1, Mir Shahid1, Kumar Keshav2, Danish Altaf3, Kapil Kumar1
1 Department of Orthopaedics, Teerthanker Mahaveer Medical College and Research Centre, Teerthanker Mahaveer University, Moradabad, Uttar Pradesh, India
2 Apex Trauma Centre, SGPGIMS, Lucknow, Uttar Pradesh, India
3 Speciality Registrar, Tameside NHS Foundation Trust, Manchester, UK
|Date of Submission||14-Jun-2021|
|Date of Decision||06-Jul-2021|
|Date of Acceptance||14-Jul-2021|
|Date of Web Publication||02-Aug-2021|
Department of Orthopaedics, Teerthanker Mahaveer Medical College and Research Centre, Teerthanker Mahaveer University, Moradabad, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
Context: Among the myriad treatment options available for tibial plateau fractures, Joshi's external stabilization system (JESS) is one of the established treatment modalities as an external fixation device. Closed reduction has the advantage of biological fixation and preservation of the already jeopardized local blood supply to the bone. Aim: This study was conducted to compare the functional results between locked compression plate and JESS as a fixation method for tibial plateau fractures. Setting and Design: This is a prospective, single-center, and nonrandomized study. Materials and Methods: Fifty patients with tibial plateau fractures were included in the study, who presented to our hospital between January 2016 and December 2018 and were treated alternatively by either plating (Group P) or JESS (Group J). Modified Rasmussen functional score (MRFS) was used for assessing the functional outcomes. Statistical Analysis Used: Microsoft Excel and Statistical software SPSS version 21.0. Results: The mean age in Group J and P was 39.52 ± 9.27 years and 39.00 ± 10.82 years, respectively. The mean follow-up period was 12 months (range: 9–24 months). Schatzker Type II was the most common fracture pattern (n = 15). The average union time was 12.3 weeks in Group J and 14 weeks in Group P (P = 0.036). The mean MRFS at 3, 6, and 9 months of follow-up was significantly better in the J group (P value at 3 months was 0.0204, at 6 months was 0.0226, and at 9 months was 0.0048). Conclusion: The study shows that the functional outcome of JESS for the management of tibial plateau fractures is better than plating.
Keywords: External fixation, fracture, tibial plateau fracture
|How to cite this article:|
Huda N, Bishnoi S, Shahid M, Keshav K, Altaf D, Kumar K. Joshi's external stabilization system versus locked compression plating in the management of tibial plateau fractures: A nonrandomized prospective study. J Bone Joint Dis 2021;36:14-20
|How to cite this URL:|
Huda N, Bishnoi S, Shahid M, Keshav K, Altaf D, Kumar K. Joshi's external stabilization system versus locked compression plating in the management of tibial plateau fractures: A nonrandomized prospective study. J Bone Joint Dis [serial online] 2021 [cited 2021 Oct 28];36:14-20. Available from: http://www.jbjd.org/text.asp?2021/36/2/14/322950
| Introduction|| |
Knee joint is the most crucial weight-bearing joint of the body. The goal of tibial plateau fractures treatment, which constitutes 1%–2% of all the fractures, includes restoration of the articular surface, preservation of tissue envelope, achieving bony stability, and restoring knee mobility, with normally aligned extremity.
The available treatment options for tibial plateau fractures include conservative treatment, open reduction and internal fixation/closed reduction and internal fixation (ORIF/CRIF), and various forms of external fixation including Joshi's external stabilization system (JESS).,,,,,
The present study was undertaken to compare the functional outcome of all Schatzker types of tibial plateau fractures treated by ORIF/CRIF with plate and external fixation using JESS.
| Materials and Methods|| |
The present study was a hospital-based prospective nonrandomized single-centered study in which percutaneous application of JESS fixator with or without limited internal fixation using cancellous screws was compared with standard ORIF/CRIF using locked compression plate for tibial plateau fractures by recruiting the patients who presented to the department of Orthopaedics of our hospital, between January 2016 and December 2018.
Skeletally mature patients having tibial plateau fractures of <3-week duration and Gustilo-Anderson compound Grades I and II were included in the study. Those having any other fracture in the same limb, pathological fracture or suspected vascular injury, impending compartment syndrome, preexisting osteoarthritis of the knee (Kellgren-Lawrence Grade III-IV) were excluded from the study.
An informed written consent was taken from all the patients willing to participate in the study on an informed consent form as per the guidelines of institutional ethical committee (IEC). The study design, procedure, and informed consent were approved by the IEC.
All the fractures were classified using the Schatzker system.
Fifty patients with tibial plateau fractures were included as per the inclusion criteria. All even-numbered patients were treated by JESS and formed Group J, all odd-numbered patients underwent plating and constituted Group P [Figure 1]. All the surgeries were performed by the same surgical team.
Sample size calculation
The sample size was calculated using the nMaster software developed by Department of Biostatistics, CMC, Vellore, India. We needed to recruit a total of 25 patients in each group to detect significant difference between the groups at 5% alpha error and 80% power.
All the compound fractures were debrided. Articular depression, if the present was first elevated/reduced and iliac crest bone grafting was done. Spinal or general anesthesia was administered in all cases.
In Group J, under the guidance of image intensifier, all tibial plateau fractures were managed by JESS fixator. On the OT table, patients were laid supine. Ligamentotaxis was used to achieve reduction with or without fracture table. In all the cases, reduction clamps and small k wires were used to temporarily hold the reduction. Two or three transfixing “K” wires with/without 2 Schanz pins of 3.5 mm diameter were passed transversely through the subchondral bone to form the proximal metaphyseal hold and connected using rods in the form of arches. Three K wires were passed through distal fragments 1–2 cm apart to form the diaphyseal hold. Metaphyseal and diaphyseal holds were then connected to each other by two anterior and two posterior rods with beta clamps to form the JESS assembly while maintaining the reduction and alignment [Figure 2]. In few of the cases, limited internal fixation by using one or two 6.5 mm cancellous screws was done to provide interfragmentary compression across the condyles.
|Figure 2: Image showing the JESS fixator configuration, applied in tibial plateau fracture and postoperative anteroposterior and lateral view radiograph of the extremity(JPEG)|
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In Group P, anterolateral approach was used for locking lateral proximal tibial plate in all the cases except Schatzker Type IV. For open reduction, an incision was given 2–3 cm proximal to the joint line staying just lateral to the periphery of patellar tendon and was curved anteriorly over the Gerdy's tubercle and extended along the shaft of tibia. The tibialis muscle along with the underlying periosteum was elevated from the proximal part of tibia. Reduction by longitudinal traction was achieved, and locking plate was applied using standard technique over the anterolateral aspect.
Posteromedial approach was used to access the proximal tibia for medial and posteromedial plating in Schatzker Type IV, V, and VI. Patient was placed supine with leg externally rotated, and a 5–6 cm longitudinal incision over the posteromedial border of the proximal tibia was given. After deepening, the incision saphenous vein was dissected and pes anserinus was reflected. Now, either a medial locking plate was used or posteromedial fixation was achieved by creating an epiperiosteal plane between the pes and medial head of gastrocnemius which is needed to buttress the posteromedial fragment.
Standard minimally invasive percutaneous plate osteosynthesis (MIPPO) technique was used in selected cases of Schatzker Types I, II, and III, where reduction was achieved by ligamentotaxis. After achieving reduction plate of adequate length was slid below the submuscular tunnel and secured with appropriate size screws on either side of fracture site.
In Group P, out of 25 patients, 13 patients underwent MIPPO technique and rest of the 12 patients were done by the anterolateral/posteromedial or combined approach. Fragment-specific fixation was done additionally, wherever required.
In the immediate postoperative period, a single intravenous shot of a broad-spectrum antibiotic (cefuroxime) was given. The patients were encouraged to start gentle knee flexion by the 2nd postoperative day, and active range of movement exercises (ROM) for the knee as well as the quadriceps strengthening exercises were started as soon as tolerated by pain. Patients were mobilized nonweight bearing with assistive devices for 4–6 weeks, after which partial weight bearing was started. Full weight bearing was advised after achieving union. Regular follow-ups were done at 6 weeks, then at 3, 6, 9, and 12 months of the surgery. After achieving radiological union, JESS was removed and patients were put on stringent protocol of knee ROM and quadriceps exercises. Modified Rasmussen functional score (MRFS) was used for assessing the functional outcomes. The score was calculated at follow-up of 3, 6, and 9 months. A score of 28–30 meant excellent results, a score of 24–27 meant good results, a score of 20–23 qualifies for fair results, and a score of <20 meant poor results.
Radiograph of the knee joint with leg, both anteroposterior and lateral views, were done at each visit. These radiographs were assessed for quality of reduction, position of implant, and presence of any complications.
Microsoft Excel and Statistical software SPSS 21, IBM Cloud Pak®, Chicago, Illinois, US was used for the statistical analysis of the data. SPSS is one of the brands under IBM Software Groups Business Analytics Portfolio. Mean and standard deviation presented the quantitative or numerical variables while the qualitative or categorical variables were shown as number and percentage. The Student's t-test was applied to find the significant difference between the groups for continuous variables. For categorical variables, Chi-square test was used. Comparison of the continuous variables over the time interval was calculated by repeated measures ANOVA test with post hoc Bonferroni test. A P < 0.05 was considered to be statistically significant.
| Results|| |
There were 23 (92.0%) males and 2 (8.0%) females in J group whereas there were 16 (64.0%) males and 9 (36.0%) females in P group. In P group, the mean age was 39.00 ± 10.82 years and in J group, age was 39.52 ± 9.27 years. The mean follow-up period was 12 months (range: 9–24 months) [Table 1].
In the J group, 2 patients each had compound Grade I and compound Grade II fractures whereas in the P group, compound Grade II fracture was seen in 3 patients.
The comparison of distribution of tibial plateau fracture (according to Schatzker classification) between P and J groups was done using the Chi-square test. No significant difference in the distribution of tibial plateau fractures was noted between the two groups. Type I fracture was present among 10 (20.0%), Type II among 15 (30.0%), Type IV among 2 (4.0%), Type V among 10 (20.0%), and Type VI among 13 (26.0%) patients [Table 1] and [Figure 3].
|Figure 3: Distribution of the study population according to type of tibial plateau fracture|
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There was no significant difference in mean duration of hospital stay between P (9.04 ± 2.99 days) and J (8.32 ± 2.59 days) groups.
The comparison of mean MRFS at 3, 6, and 9 months between the two groups was done using the unpaired t-test. The score at 3, 6, and 9 months was significantly better in J group [Table 2].
|Table 2: Comparison of mean Rasmussen functional score at 3, 6, and 9 months between P group and J group|
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Superficial skin infection was found among 2 (8.0%) patients in P group and 6 (24.0%) patients in J group which responded well to broad-spectrum antibiotics. Deep infection was found in 1 (4.0%) patient in the P group. This patient required debridement and the infection healed [Table 1].
Mean range of knee flexion was 126° in J group and 115° in P group. Mean time to union in J group was 12.3 weeks and P group was 14 weeks, and both were found to be significantly better in J group [Table 1]. The JESS was removed after a mean duration of 12.3 weeks (range: 8–17 weeks), mean interval of time from surgery to full weight bearing was 12 weeks (range: 11–13 weeks) in J group and 12.5 weeks (range: 11–14 weeks) in P group, which was not significant.
| Discussion|| |
To date, very few studies have been conducted to compare the results of tibial plateau fractures treated by ORIF/CRIF with plating and Joshi's external stabilizing system (JESS). Comparison of the functional outcome of tibial plateau fractures treated by ORIF/CRIF with plate and JESS was the main aim of this study.
Many authors have reported good functional and radiological outcomes of treating tibial plateau fractures using less invasive surgical intervention in the form of various configurations of circular external fixator or JESS application. Many of these authors have also reported reasonably good strength of fixation provided by these constructs.,,,,
Closed reduction based on the principles of ligamentotaxis has the advantage of biological fixation of the tibial plateau fractures, preserving the already jeopardized local blood supply to the bone and it also respects the traumatized local soft tissue besides being economical.,
Renowned Indian Orthopedic surgeon, Dr. B. B. Joshi and his team were the first ones to design a wire-based external fixator system called JESS. In this method with the help of link joints, the Kirschner wires are connected to arches and/or connecting rods. Reasonable restoration of metaphyseal reduction, using ligamentotaxis, by distraction of the proximal metaphyseal and proximal diaphyseal assembly is expected from these fixator systems.,,
Since any fracture around a weight-bearing joint such as the knee can result in significant morbidity and reduced quality of life, hence the treatment of proximal tibial fractures has become a challenge for the orthopedic surgeons.
Regardless of the treatment option selected anatomic reduction and stable fixation is desirable to prevent secondary osteoarthritis. Soft tissue complications often arise which can be significantly minimized by staging the treatment of the patient. The concept of preserving the blood supply and relatively atraumatic surgical technique led to the development of biological fixation. The external fixation avoids further soft tissue damage, but other potential risks such as infections of pin tract and poor patient compliance can occur. Using this technique, soft tissue damage is reduced and shows higher union rate.
In our study, tibial plateau fractures were the most common within the age range of 30–45 years (n = 30, 60.0%) [Table 1]. In the study conducted by Swamy et al., 40% of patients were in the economically productive age group of 31–40 years. Honkonen also stated the age incidence of 20–60 years (an average age of 39.8 years) which correlates with our study. In the present study, males were most affected [Table 1] which was similar to the findings reported by Albuquerque et al. (70.3% males), Manidakis et al. (58.4% males), and Mehin et al. (56% males).
We followed the Schatzker's classification system. Type II was most common fracture pattern observed [Table 1]. Sixty-four percent of patients sustained a fracture of the lateral condyle (Schatzker 1/2/3) as reported by Rademakers et al. Biswas et al. found that Type I pure cleavage fractures were predominantly seen among 26.67% of patients followed by Types II and V (20%), Type VI (13.33%), Type IV (10%), and Type III (6.67%). Schatzker studied the proximal tibial fractures and found that Types II and III fractures were commonly reported.
In our study, we evaluated the patients using Modified Rasmussen functional scoring which is a subjective score. The mean MRFS at 3, 6, and 9 months was significantly (P = 0.0204, 0.0226, and 0.0048, respectively) better in the J group, which was clinically relevant [Table 2]. One of the possible explanations for this difference can be the fact that plating leads to more damage to soft tissue around the joint which affects the functional outcome. On the other hand, JESS fixation is performed in a minimally invasive manner and thus compromises soft tissues to a lesser extent and has better outcome. Our study showed that in Group P, 88.0% and 12.0% of patients had excellent and good functional score, respectively, whereas 96.0% of the patients in the J group had excellent while 4.0% had good score at 9-month follow-up which is similar to the study group of Yu and Fenglin, Canadian Orthopaedic Trauma Society, and Chan and Keating [Table 3].
Infection is the most overwhelming obstacle associated with the management of tibial plateau fractures. Careful surgical timing, soft tissue handling, indirect reduction techniques, and minimally invasive surgery can decrease the chances of further devascularization and infection. Infection rates range between 0 and 87.5% in the literature.,, In our study, superficial skin infection was found among 8.0% of patients in the P group and pin tract infection was seen in 24.0% of patients in the J group whereas deep infection was found among 4.0% of patients in the P group [Table 1]. Yu and Fenglin reported the rate of pin tract infection in 13.75% of external fixator group, while superficial infection in 5 (1.53%) cases of plating group. Canadian Orthopaedic Trauma Society conducted a study and found infection in 2 cases of fixator group and 8 cases of ORIF group out of the 82 cases. Conversely, Chan and Keating found infection either superficial or deep, more pronounced with external fixation (n = 9) than internal fixation (n = 3) [Table 3]. Pin tract infection has often been cited as one of the great drawbacks of JESS fixation., However, in our study observing that none of those cases led to deep infection and all of those healed once JESS was removed makes us believe that pin tract infection is not a heavy price to be paid.
In the study conducted by Canadian Orthopaedic Trauma Association, the mean range of knee flexion was 113° in ORIF group and 123° in fixator group which is similar to our study. Conversely, Yu and Fenglin found mean range of flexion better in plate group (118.5°) than external fixator group (109.4°). The mean time to union in J group was 12.3 weeks and P group was 14 weeks which is converse to the study by Liang Yu where mean time to union in the plate fixator group was 15.64 weeks and in external fixator group was 17.73 weeks [Table 3].
In contrast to traditional techniques of internal fixation, even when there is severe soft tissue loss, the external stabilization systems, allow for early surgery and hence, early stabilization of the fracture with minimal devitalization. In a study done by Biswas et al., the average hospital stay was 12.5 days using the mini external fixation which helps the patient to return to his daily life. In our study, the mean duration of hospital stay for ORIF/CRIF group was 9.04 ± 2.99 days and JESS group was 8.32 ± 2.59 days.
A study consisting of 21 consecutive patients for high-energy tibial plateau fractures which were associated with severe soft tissue injuries was conducted by Zahid et al. All the participants underwent JESS fixation. The mean interval between the surgery and full weight bearing was 16 (range; 13–19) weeks similar to our study. They concluded that JESS with lag screw fixation combines the benefit of traction, external fixation, and limited internal fixation.
JESS may have a disadvantage in not providing interfragmentary compression across the fractured condylar fragments when used with simple K-wires. Thus, in 5 cases of this study, minimal/limited internal fixation with one or two percutaneously inserted cancellous screws was done. Many studies have concluded good results for the use of additional lag screw fixation of tibial plateau fractures which were treated with external fixators.,
In the present study, 96.0% of the patients had excellent and 4% had good results as per the Rasmussen functional score at 9-month follow-up in JESS group. Early physiotherapy aids early active joint movements which avoids fracture disease. Early fracture union and better functional outcome help in early return to work, which in turn diminish the economic burden on family.
| Conclusion|| |
The authors conclude that the functional outcomes of JESS are better than plating in the management of tibial plateau fractures at follow-up of 3, 6, and 9 months after surgery. JESS can be used as a safe and effective surgical procedure for definitive management of all types of tibial plateau fractures. The strength of the study was that the sample size was adequate with a mean follow-up of 12 months. By including all the types of Schatzker fractures, we created a diverse group which is the limitation of the study.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3]