Original Article

Joshi’s External Stabilization System versus Locked

Compression Plating in the Management of Tibial Plateau
Fractures: A Nonrandomized Prospective Study
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Najmul Huda, Sandeep Bishnoi, Mir Shahid, Kumar Keshav1, Danish Altaf2, Kapil Kumar
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Department of Orthopaedics, Teerthanker Mahaveer Medical College and Research Centre, Teerthanker Mahaveer University, Moradabad, 1Apex Trauma Centre,
SGPGIMS, Lucknow, Uttar Pradesh, India, 2Speciality Registrar, Tameside NHS Foundation Trust, Manchester, UK

Abstract
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

Introduction Materials and Methods

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,[1] includes restoration of
the articular surface, preservation of tissue envelope, achieving
bony stability, and restoring knee mobility, with normally
aligned extremity.[2]
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).[3‑8]
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.
Address for correspondence: Dr. Sandeep Bishnoi,
Department of Orthopaedics, Teerthanker Mahaveer Medical College and
Research Centre, Teerthanker Mahaveer University, Moradabad,
Uttar Pradesh, India. E‑mail: sandeepbishnoi.bishnoi@gmail.com

The present study was undertaken to compare the functional Submitted: 14‑Jun‑2021 Revised: 06-Jul-2021
outcome of all Schatzker types of tibial plateau fractures treated Accepted: 14‑Jul‑2021 Published: 02-Aug-2021
by ORIF/CRIF with plate and external fixation using JESS.
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How to cite this article: Huda N, Bishnoi S, Shahid M, Keshav K, Altaf D,

DOI: Kumar K. Joshi’s external stabilization system versus locked compression
10.4103/jbjd.jbjd_3_21 plating in the management of tibial plateau fractures: A nonrandomized
prospective study. J Bone Joint Dis 2021;36:14-20.

14 © 2021 Journal of Bone and Joint Diseases | Published by Wolters Kluwer - Medknow
 Huda, et al.: JESS versus plating in tibial plateau fractures

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.
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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

An informed written consent was taken from all the patients temporarily hold the reduction. Two or three transfixing “K”
willing to participate in the study on an informed consent form wires with/without 2 Schanz pins of 3.5 mm diameter were
as per the guidelines of institutional ethical committee (IEC). passed transversely through the subchondral bone to form
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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.
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.

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.
Surgical techniques
All the compound fractures were debrided. Articular
depression, if the present was first elevated/reduced and iliac
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.

Enrollment Assessed for eligibility (n = 67)

Excluded (n = 17)
• Not meeting inclusion criteria (n = 9)
• Declined to participate (n = 5)
• Other reasons (n = 3)

(n = 50)

Allocation
Allocated to open reduction/closed Allocated to Joshi’s external stabilizing
reduction internal fixation with plating system (n = 25)
(n = 25) • Received allocated intervention
• Received allocated intervention(n = 25) (n = 25)

Follow-Up
Lost to follow-up (n = 0) Lost to follow-up (n = 0)
Discontinued intervention (n = 0) Discontinued intervention (n = 0)

Analysis
Analyzed (n = 25) Analyzed (n = 25)

Figure 1: Study flow chart

Journal of Bone and Joint Diseases ¦ Volume 36 | Issue 2 | May-August 2021 15

 Huda, et al.: JESS versus plating in tibial plateau fractures
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Figure 2: Image showing the JESS fixator configuration, applied in tibial plateau fracture and postoperative anteroposterior and lateral view radiograph
of the extremity(JPEG)
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
16
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.
Statistical analysis
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
Journal of Bone and Joint Diseases ¦ Volume 36 | Issue 2 | May-August 2021
 Huda, et al.: JESS versus plating in tibial plateau fractures

difference in the distribution of tibial plateau fractures was 12 weeks (range: 11–13 weeks) in J group and 12.5 weeks
noted between the two groups. Type I fracture was present (range: 11–14 weeks) in P group, which was not significant.
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 Discussion
13 (26.0%) patients [Table 1 and Figure 3].
To date, very few studies have been conducted to compare
There was no significant difference in mean duration of hospital the results of tibial plateau fractures treated by ORIF/CRIF
stay between P (9.04 ± 2.99 days) and J (8.32 ± 2.59 days)
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with plating and Joshi’s external stabilizing system (JESS).

groups. Comparison of the functional outcome of tibial plateau
The comparison of mean MRFS at 3, 6, and 9 months
ORIF JESS Total
between the two groups was done using the unpaired t‑test. 16
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15
The score at 3, 6, and 9 months was significantly better in J 14 13
group [Table 2]. 12

Superficial skin infection was found among 2 (8.0%) patients 10

10
9
10

in P group and 6 (24.0%) patients in J group which responded 8

8
7
well to broad‑spectrum antibiotics. Deep infection was found 6 6
6
in 1 (4.0%) patient in the P group. This patient required 4
5

debridement and the infection healed [Table 1]. 4 3

2 2
2
Mean range of knee flexion was 126° in J group and 115° in 0
P group. Mean time to union in J group was 12.3 weeks and P 0
TYPE 1 TYPE 2 TYPE 4 TYPE 5 TYPE 6
group was 14 weeks, and both were found to be significantly
TIBIAL PLATEAU # SCHATZKER TYPE
better in J group [Table 1]. The JESS was removed after a
mean duration of 12.3 weeks (range: 8–17 weeks), mean Figure 3: Distribution of the study population according to type of tibial
interval of time from surgery to full weight bearing was plateau fracture

Table 1: Summary of results in terms of different parameters

Parameters Group J Group P P
Number of patients 25 25
Male 23 16 0.360
Female 2 9 0.360
Mean age (years) 39.52±9.27 39.00±10.82 0.856
Schatzker type
I 7 3 0.259
II 6 9
III 0 0
IV 0 2
V 4 6
VI 8 5
Duration of hospital stay (stay) 8.32±2.59 9.04±2.99 0.368
Mean range of knee flexion (°) 126 115 0.024
Mean time to union (weeks) 12.3 14 0.036
Mean functional score at 9‑month follow‑up 28.98 27.83 0.0048
Infection
Superficial 6 2 0.200
Skin
Deep 1 0

Table 2: Comparison of mean Rasmussen functional score at 3, 6, and 9 months between P group and J group
Rasmussen functional Mean±SD Mean t‑test P
score (months) difference
P group J group
3 17.17±3.86 19.64±3.41 −2.47 2.398 0.0204*
6 24.33±2.67 26.12±2.70 −1.79 2.357 0.0226*
9 27.83±1.24 28.98±1.50 −1.15 2.955 0.0048*
*Significant difference. Unpaired t‑test. SD: Standard deviation

Journal of Bone and Joint Diseases ¦ Volume 36 | Issue 2 | May-August 2021 17

 Huda, et al.: JESS versus plating in tibial plateau fractures
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
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authors have also reported reasonably good strength of fixation
provided by these constructs.[4‑8]
Closed reduction based on the principles of ligamentotaxis
has the advantage of biological fixation of the tibial plateau
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fractures, preserving the already jeopardized local blood supply
to the bone and it also respects the traumatized local soft tissue
besides being economical.[9,10]
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.[10‑12]
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.[11]
Regardless of the treatment option selected anatomic
reduction and stable fixation is desirable to prevent secondary
osteoarthritis.[13] 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.[14]
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.,[15] 40% of patients
were in the economically productive age group of 31–40 years.
Honkonen[16] 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.[1] (70.3% males), Manidakis et al.[17] (58.4% males), and
Mehin et al.[18] (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.[19]
Biswas et al.[20] found that Type I pure cleavage fractures were
predominantly seen among 26.67% of patients followed by
18
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,[21] Canadian Orthopaedic Trauma Society,[22]
and Chan and Keating[23] [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.[24‑26] 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[21] 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[22] 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[23] 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.[7,27] 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,[22] 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[21] 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
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 Huda, et al.: JESS versus plating in tibial plateau fractures

Table 3: Comparative results in the studies

Author Operative technique Fracture Mean Functional Mean Meantime Complications, n (%)
pattern follow‑up assessment range to‑ union
(Schatzker (range), of knee (range),
system) months flexion (°) weeks
Present Plating (n=25) ALL type 12 MRFS (good/excellent) J group: 126 P group: 14 Infection P group J group
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study JESS (n=25) P group: 27.83 P group: J group: 12.3 Superficial 2 (8) 6 (24)
J group: 28.98 115 Deep 1 (4) 0
Yu and External fixator group Type 4/5 EF: 35.42 MRFS, KSCRS, EF: 109.4 EF: 17.73 Infection EF group PF group
Fenglin[21] (n=567) PF: 27.21 Honkonen‑Jarvinen PF: 118.5 PF: 15.64 Pin tract 78 (13.7)
functional criteria, HSS
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Plate fixator group Superficial 5 (1.53)

(n=325) knee score <90% good/
excellent
Canadian Standard open Type 5/6 24 HSS knee score (good/ ORIF ORIF Fixator
Orthopaedic reduction and Internal excellent) group: 113 group group
Trauma Fixation (n=40) ORIF group: 68 Fixator Infection 8 2
Society[22] Circular fixator (n=42) Fixator group: 75 group: 123 Total 37 16
Chan and Internal fixation All type 24 MRFS (good/excellent) Infection InternalExternal
Keating[23] (n=24) Internal fixation: 31.73 fixationfixation
External fixation External fixation: 28.81 Superficial 3 6 (pin tract
(n=35) infection)
Deep 3
J group: JESS group, P group: Plating group, EF: External fixator, PF: Plate fixator, ORIF: Open reduction and internal fixation, KSCRS: Knee society
clinical rating score, HSS: Hospital for special surgery, MRFS: Modified Rasmussen functional score, JESS: Joshi’s external stabilization system

systems, allow for early surgery and hence, early stabilization
of the fracture with minimal devitalization.[28] In a study done
by Biswas et al.,[20] 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.[7] 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.[7,29]
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.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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