CLINICAL TECHNIQUE |
https://doi.org/10.5005/jojs-10079-1140 |
Role of Joshi’s External Stabilization System Fixator in Proximal Humerus Fractures
Department of Orthopaedics, Parvathy Nursing Home, Kalakkad, Tamil Nadu, India
Corresponding Author: Baskar Chockalingam, Department of Orthopaedics, Parvathy Nursing Home, Kalakkad, Tamil Nadu, India, Phone: +919789384631, e-mail: orthobaskey@gmail.com
Received: 11 August 2023; Accepted: 01 December 2023; Published on: 12 January 2024
ABSTRACT
Background: Proximal humerus fracture (PHF) contributes 4–5% of fractures that are bimodal in distribution. The most common etiology includes accidental falls in elderly population and road traffic accident (RTA) in younger population. There is a wide range of treatments starting from conservative to advanced techniques like replacement. The outcome depends on various factors like mode of treatment, age of the patient, anatomy of fracture, and associated pathological conditions. In this study, we justify how Joshi’s external stabilization system (JESS) method scores over other methods of fixation.
Material and methods: This study includes 42 patients aged between 19 and 88, out of which 24 were females and 18 males. All surgeries were done between 2019 and 2022 under regional block. Fractures are classified according to Neer’s classification. All patients were followed up regularly and assessment was done based on both functional and radiological improvement.
Results: The total number of cases was 42. The number of patients aged above 45 years was 29 and <45 years were 13.
Out of the 42 cases, 24 cases were due to RTA. Based on Neer’s classification, Neer type I, II, IV, and head split cases were 13, 16, 11, and 2, respectively. The outcome was assessed based on constant score. Two cases progressed to nonunion and four cases underwent premature removal due to various reasons. Finally, 66% of the cases showed excellent outcomes.
Discussion: Proximal humerus fractures (PHF) have always been a challenge for orthopedic surgeons and remain controversial. As we mentioned earlier here, one of the main factors deciding the outcome is mode of fixation. JESS has the advantage of rigid fixation, early mobilization, and no loosening. JESS stands superior to plating and K-wires in this aspect. Hence, JESS fixation in PHF is a wonderful and viable option for fixation method irrespective of the age and fracture pattern.
How to cite this article: Chockalingam B. Role of Joshi’s External Stabilization System Fixator in Proximal Humerus Fractures. J Orth Joint Surg 2024;6(1):65–68.
Source of support: Nil
Conflict of interest: None
Keywords: Joshi’s external stabilization system, Murley score, Proximal humerus fracture
INTRODUCTION
Proximal humerus fracture (PHF)accounts for 5–9%1 of all fractures and is the third most common fracture after hip2 and distal radius. It is bimodal3 in distribution. It frequently occurs in elderly population due to osteoporosis4 and in young individuals4,5 due to high-velocity injuries like road traffic accident (RTA). About 80% of PHF are undisplaced or minimally displaced and are well managed conservatively.6 The remaining cases are to be managed surgically for better functional and radiological outcome. The controversy starts here: Which is the best method of fixation, since a great variety of options7 like locking plates,8 nails, K-wires, and external fixators [Joshi’s external stabilization system (JESS) and Ilizarov], prosthetic replacement9 are available. All of them suffer from a substantial persistent rate of mechanical failure and other complications like a stiff shoulder, etc.
OBJECTIVES
Though the treatment options are a wide spectrum,10 the outcome depends mainly on many factors like age, anatomy of the fracture, comminution, associated pathological conditions, and mode of treatment. In this study, we have evaluated and assessed the functional outcome of the fractures treated with JESS11 and its superiority over the other modes of fixation irrespective of the age and nature of the fracture.
MATERIALS AND METHODS
This study was conducted between 2019 and 2022 at (Parvathy Nursing Home) in Kalakkad, Tirunelveli district by a single surgeon. All the cases were operated under regional block. There were 42 patients (24 females and 18 males) aged between 19 and 88, and the procedures were done between 2019 and 2022. Based on Neer’s classification, the number of patients under Neer type II, III, IV, and head split were 13, 16, 11, and 2, respectively. Twenty-nine patients were >45 years old. Upon admission, a careful history was obtained, and the severity of trauma was assessed. Other injuries and fractures were ruled out. X-ray AP and axillary views were taken, and computed tomography (CT) was performed whenever necessary (Fig. 1). All surgeries were done under regional block. All patients were followed up regularly, and assessed functionally and radiologically.
Fig. 1: Pre-op
Surgical Technique
All were done under regional block in a beach chair position. It’s an à la carte approach depending on the type of fracture, bone stock, associated with dislocation or not. The first step is to bring the head into position, which is done by the joystick method using blunt thick K-wires and temporarily fixed with the glenoid in a very unstable situation (Figs 2A and B). The second step is to introduce 2- or 2.5-long K-wires, two or three in number, as a core K-wire from GT to the medullary cavity, which is the main structure to connect all peripheral K-wires (Fig. 3). The third step is to introduce K-wires into the head fragment depending on the number of fragments and bone quality in a circumferential fashion, which has been connected with a connecting rod or thick K-wire bent according to the pattern (Figs 4A and B). The fourth step is to bend the long core K-wires into 180° and connect the head K-wires after disimpacting the head into valgus. The final step is to pass calcar K-wires and shaft K-wires in a single or double row depending on the bone quality and connect one with another and tighten with core K-wires (Fig. 5). Stability was assessed under C-arm, dressing done, and an arm sling was applied.
Figs 2A and B: Joy sticking
Fig. 3: Core K-wire
Figs 4A and B: K-wires for head fragment
Fig. 5: Final construct
Post-op Protocol
Simple sling for 3 weeks, dressing as an outpatient department (OPD) for every 3 days. Flexion and extension and pendulum exercises started on the 2nd and 3rd post-op day. Abduction started cautiously from the 3rd week, and isometric exercises started from the 3rd to 6th week. Post-op X-rays were taken every week, 2nd week, every month till 3rd, 6th, and 24th months, respectively.
RESULTS
In our study, fractures were classified according to Neer’s classification, and radiological union was assessed by post-op X-ray AP and axillary views. The functional results were assessed by the Murley Constant score (excellent >85, good 71–85, fair 50–70, poor <50). Out of our 42 cases, 32 cases were domestic injuries, and the remaining were high-velocity in etiology. The interval between the injury and the surgery plays an important role, as the prime aim of the study is to show the superiority in results like good functional outcomes. Complications observed in our study include pin tract infection (2), early pin removal (1), pin loosening (1), malunion (2), nonunion (2), and no neurovascular injury.
Case 1 (Figs 6A to D)
Figs 6A to D: (A) Pre-op pic AP view; (B) Prep lateral view; (C) Post-op; (D) Pin tract dressing
Case 2 (Figs 7A and B)
Figs 7A and B: (A) Pre-op and Post-op X-ray; (B) Clinical picture
DISCUSSION
Though PHF is the third-most common fracture and is expected to increase significantly in near future, still management is very challenging for surgeons and debatable in the trauma world. Most of the undisplaced fractures and some displaced fractures have been managed well by conservative methods. Remaining displaced fractures need surgical management and controversy starts here as the mode of fixation is very wide from K-wires, external fixation, locking plates, intramedullary (IM) nail, suture anchor fixation, and prosthetic replacement. Every method has its pros and cons in terms of final outcome in the form of union and functionality. Most of them suffer from a substantial rate of mechanical failure as well as many complications. Outcome depends upon many factors like age, type of fracture, comminution, habits like smoking, bone stock, activity of the patient, and surgeon factors like experience.12 Two philosophies have been described in implant choice: (1) rigid and (2) semirigid. Rigid gives maximum stability in young patients with good bone quality. Semirigid allows some interfragmentary micromotion and decreases forces acting on the bone metal interface during strain and gives elastic kind of fixation. Though lot of options are available for PHFs every modality has its own drawbacks. Though conservative is the mainstay of treatment, it is also not exempted from complications like malunion, stiffness, and pain due to many reasons like impingement. K-wires are the most commonly used fixation method, especially in very elderly patients but easy K-wire pull out, pin tract infection, shoulder stiffness, and inability to mobilize early are the common disadvantages. After the introduction of reverse shoulder arthroplasty, the trend is moving toward arthroplasty and the threshold has come down drastically but its outcome is not as great as expected because of many reasons. The most commonly used mode of fixation is open reduction and internal fixation with proximal humerus internal locking system (PHILOS)13 plate. Due to extensive dissection and intraoperative bleeding14,15 lead to adhesions, stiffness, avascular necrosis (AVN), and implant failure due to thin shell of bones. So, the best implant should provide early range of motion (ROM), be minimally invasive16–19 and preserve the biology, be surgeon friendly, good stability which is JESS carrying all features of a good implant. Though JESS fixation gives consistent favorable outcome, it has complications like pin tract infection, compliance issues, malunion, and early pin removal which all can be managed very well. In our study, premature removal was done in patient who was having behavior problems and two nonunion because of very bad fracture with dislocation and lost follow-up, and surprisingly, there was no functional limitation in the above two cases. The follow-up was done with Murley Score which was good in most of the cases and became excellent after 2 months of dedicated physiotherapy.
CONCLUSION
Joshi’s external stabilization system (JESS) happens to be a wonderful option to manage PHF. Irrespective of fracture type and age.
It gives a good anatomical reduction, preserving biology stable fixation, early ROM, cost-effective, early union, can be tried in special situations, and less time-consuming. Early mobilization, proper follow-up, pre-op counseling, and scheduled physiotherapy are the pivotal important factors in bringing better outcomes.
REFERENCES
1. Court-Brown CM, Caesar B. Epidemiology of adult fractures: a review. Injury 2006;37(8):691–697. DOI: 10.1016/j.injury.2006.04.130
2. Baron JA, Barrett JA, Karagas MR. The epidemiology of peripheral fractures. Bone 1996;18(3 Suppl):209S–213S. DOI: 10.1016/8756-3282(95)00504-8
3. Kannus P, Niemi S, Sievanen H, et al. Stabilized incidence in proximal humeral fractures of elderly women: nationwide statistics from Finland in 1970-2015. J Gerontol A Biol Sci Med Sci 2017;72(10):1390–1393. DOI: 10.1093/gerona/glx073
4. Lind T, Krøner K, Jensen J. The epidemiology of fractures of the proximal humerus. Arch Orthop Trauma Surg 1989;108(5):285–287. DOI: 10.1007/BF00932316
5. Lauritzen JB, Schwarz P, Lund B, et al. Changing incidence and residual lifetime risk of common osteoporosis-related fractures. Osteoporos Int 1993;3(3):127–132. DOI: 10.1007/BF01623273
6. Roux A, Decroocq L, El Batti S, et al. Epidemiology of proximal humerus fractures managed in a trauma center. Orthop Traumatol Surg Res 2012;98(6):715–719. DOI: 10.1016/j.otsr.2012.05.013
7. Scott Powell E, Robert W. Textbook of Operative Techniques in Upper Extremity Sports Injuries. 1995. pp. 313–340.
8. Horak J, Nilsson BE. Epidemiology of fracture of the upper end of the humerus. Clin Orthop Relat Res 1975;112:250–253.
9. Lous Bigiliani U. Fractures of Proximal Humerus. Philadelphia: WB Saunders; 1990. pp. 278–334.
10. Kumar R, Gupta A, Sharma VP, et al. Strength of the Joshi External Stabilising System. J Orthop Surg (Hong Kong) 2011;19(1):72–75. DOI: 10.1177/230949901101900117
11. Vallier HA. Treatment of proximal humerus fractures. J Orthop Trauma 2007;21(7):469–476. DOI: 10.1097/BOT.0b013e318133479c
12. Bell JE, Leung BC, Spratt KF, et al. Trends and variation in incidence, surgical treatment, and repeat surgery of proximal humeral fractures in the elderly. J Bone Joint Surg Am 2011;93(2):121–131. DOI: 10.2106/JBJS.I.01505
13. Ebraheim NA, Patil V, Husain A. Mini-external fixation of two- and three-part proximal humerus fractures. Acta Orthop Belg 2007;73(4):437–442.
14. Monga P, Verma R, Sharma VK. Closed reduction and external fixation for displaced proximal humeral fractures. J Orthop Surg (Hong Kong) 2009;17(2):142–145. DOI: 10.1177/230949900901700203
15. Kristiansen B, Kofoed H. External fixation of displaced fractures of the proximal humerus. Technique and preliminary results. J Bone Joint Surg Br 1987;69(4):643–646. DOI: 10.1302/0301-620X.69B4.3611174
16. Handoll HH, Gibson JN, Madhok R. Interventions for treating proximal humeral fractures in adults. Cochrane Database Syst Rev 2003;4:CD000434. DOI: 10.1002/14651858.CD000434
17. Bogner R, Hubner C, Matis N, et al. Minimally-invasive treatment of three- and four-part fractures of the proximal humerus in elderly patients. J Bone Joint Surg Br 2008;90(12):1602–1607. DOI:10.1302/0301-620X.90B12.20269
18. Seeley DG, Browner WS, Nevitt MC, et al. Which fractures are associated with low appendicular bone mass in elderly women? The study of osteoporotic fractures research group. Ann Intern Med 1991;115(11):837–842. DOI: 10.7326/0003-4819-115-11-837
19. Rose SH, Melton LJ 3rd, Morrey BF, et al. Epidemiologic features of humeral fractures. Clin Orthop Relat Res 1982;168:24–30.
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