A comparative study of clinical and functional outcome between K-Wire and jess for fixation of extra articular metacarpal fractures

INTRODUCTION

Hand is a specialised structure that interacts with the environment and is sensitive to functional impairment. It has evolved into a versatile organ capable of complex functions ranging from lifting heavy objects to grasping, pinching, and hooking actions.

Hand injury is common and accounts for around 15% of cases reporting to emergency department.¹ Among these metacarpal fractures, they comprise 18–44% of the cases.²

Most of these injuries are considered trivial and neglected and are treated with splints and plasters, which later result in functional limitation. The conservative treatment has poor outcomes in open unstable, comminuted, juxtaarticular fractures causing increased incidence of malunion, nonunion, and stiffness. Thus there is a need for surgical intervention.³

The main objective of surgical fixation is to provide rigid enough fixation to start early mobilisation so as to prevent stiffness, which results in a good functional outcome. K-wire has been a standard primary treatment for hand fractures worldwide since its introduction. Joshi’s external stabilisation system (JESS) was introduced by Dr. BB Joshi in as a modified mini external fixation. It provides adequate bony stabilisation and rotational stability allowing for better soft tissue healing and care.

The purpose of this study is to compare the functional outcomes of extrarticular metacarpal fractures fixed with K-wire and JESS.

MATERIAL AND METHODS

A hospital-based randomised control study was undertaken among the patients admitted for extrarticular metacarpal fractures. A total of 34 patients over a period of two years from October 2020 to October 2022 constituted the study sample. Clearance was obtained from the institutional ethical committee. A bilingual, informed, written consent was obtained before the patients were included in the study.

RESULTS

In our study, 60 patients were randomly divided into two groups and treated with either K-wire (30 patients) or JESS (30 patients) and followed up for a period of six months.

The mean age of the patients was 31.92 years in the K-wire group and 34.18 years in the JESS fixation group, and the majority of them were males in both groups with right-hand dominant injuries. There were different modes of injuries; the demographic details have been mentioned [Table 1].

Within group analysis of VAS, qDASH, and ROM showed significant improvement over time at two weeks, six weeks, 12 weeks, and six months (P < 0.05).

Similarly, intergroup analysis of VAS, qDASH, and ROM also showed significant difference favouring JESS fixation, with P < 0.05 [Table 2].

Comparison was also done between open and closed subtypes for both the modalities of fixation based on VAS, qDASH, and ROM. Closed injuries showed better results compared to open metacarpal fractures.

In terms of radiological outcomes, 57 out of 60 cases showed bony union on subsequent follow-up radiographs.

About 83.33% (25 out of 30) of patients fixed with JESS had excellent results, 13.33% (4 out of 30) had good results, and 3.33% (1 out of 30) had fair results. 70% (21 out of 30) of patients fixed with K-wire had excellent results, 23.33% (7 out of 30) had good results, and 6.66% (2 out of 30) had fair results. Overall, the results favoured JESS fixation over K-wire in terms of VAS score, qDASH score, and total active ROM by ASSH score.

In 7 cases, complications such as pin tract infection, stiffness, persistent pain, and malunion were noted, but there was no significant difference in the two modalities of fixation in terms of complications.

Pin tract infection and loosening were common complications following JESS fixation. However, pin tract infection was superficial and resolved after removal of pins and starting antibiotics. Complications are mentioned in Table 3.

Clinical pictures and radiographs at the time of fixation and after bony union at six-week follow-up are shown in Figures 1 and 2.

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Figure 1:

Type 3b open fracture of 2nd, 3rd, 4th, and 5th metacarpal treated with K-wire. (a) Preoperative wound picture. (b) Immediate postoperative radiograph. (c) and (d) After K-wire removal at 6 weeks. (e) and (f) Postop clinical pictures showing excellent ROM. ROM: Range of movements.

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Figure 2:

Closed fracture midshaft of 1st metacarpal fixed with JESS. (a) Preoperative radiograph. (b) and (c) Immediate postoperative radiograph. (d) After JESS removal at 6 weeks. (e) and (f) Postop clinical pictures showing excellent ROM. JESS: Joshi’s external stabilisation system, ROM: Range of movements.

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DISCUSSION

The hand is a specialised structure sensitive to functional impairment. These fractures result in significant disability leading to a long-term negative functional outcome and loss of ability to work and live at preinjury level.

There is a 77% loss of function in case of unstable fractures treated with closed conservative methods as reported by James et al.⁷ Hence, operative fixation is necessary to ensure meticulous reduction and rigid enough fixation to promote healing and to start early rehabilitation.⁸

The ultimate objective is to restore the structure and function of hand as close to normal as possible.

In our study, we have used two methods of fixation: k-wire and JESS fixation, with an objective to determine which of the two has a better functional outcome.

K-wire is a simple, lightweight, and affordable implant and can be introduced percutaneously without exposing fracture site. It is stable enough to allow early mobilisation without subjecting the hand to surgical trauma of open reduction.⁹

JESS is a versatile, simple, adaptable, and light-weight implant. It has an advantage of possible conversion to dynamic mobilisation units and integration with splints to add to its versatility.¹⁰ JESS provides rigid fixation and has advantage in open fractures where other forms of immobilisation like plasters are not appropriate. It is possible to compress, distract, and neutralise the fracture fragments, thus allowing simultaneous treatment of both bony and soft tissue injuries.¹¹ JESS uses thin, smooth wires to create a stable skeletal environment that aids quick soft tissue healing by establishing microvascular circulation while permitting simulataneous active and passive movements of uninjured adjacent joints.¹⁰

Metacarpal fractures are commonly seen in young and middle-aged individuals. In our study, the most common mode of injury in both groups was road traffic accidents (RTA), followed by machinery injury. These results are comparable to previous studies by Drenth et al.¹²

The average age of the study population was 31.92 years in case of K-wire group and 34.18 years in case of JESS fixation group. Both groups showed male preponderance with right-hand dominant injuries. A study by Parson et al also relates to similar trends.¹³

Various previous studies conducted on the use of JESS fixation show similar results to the present study [Table 4].

Hastings¹⁴ identified numerous complications of external fixation, including pin track infection, osteomyelitis, fracture through pin holes after removal, neurovascular injury during insertion, over-distraction with subsequent non-union, loss of reduction, restriction of tendon gliding and motion, and encroaching with adjacent digits by the fixator. Post-operative stiffness following K-wiring was dealt with aggressive physiotherapy and acceptable range of movements was achieved in the long run.

CONCLUSION

Based on the above results, JESS fixation proved to be statistically and functionally better treatment option, especially in cases of open and juxtaarticular fractures where it can preserve the joint function and provide early rehabilitation.

Based on our study, both the treatment modalities provide satisfactory results in terms of clinical and functional outcomes for extraarticular metacarpal fractures. However, considering the overall results, JESS fixator has a statistically significant edge over K-wire fixation, especially in comminuted, open, and juxtaarticular metacarpal fractures.

It also had a relatively lower incidence of postoperative complications than the K-wire fixation group. Due importance should be given on regular pin tract dressings and effective and early postoperative mobilisation to prevent complications.

But this study has some limitations. The sample size was not calculated in this study. The scanty literature necessitates similar studies to bring out more facts about the use of JESS fixation in metacarpal injuries.