The Joshi external stabilization system (JESS) is a Kirschner wire and link-based external stabilization system which was initially developed by Prof B.B Joshi for the management of industrial hand injuries ^[1]. The ease of application and quick learning curve have made it a very attractive option for orthopedic surgeons who are often faced with a dilemma regarding management of complex clinical situations. Using nail and plates are often the solution for most trauma cases. This editorial aims to illustrate the relevance of JESS for an Orthopaedic Surgeon.
The JESS fixator is based on ligamentotaxis, distraction histogenesis, and segmental fixaton, which is relatively minimally invasive. Simple components, modularity and light weight make it an ideal tool for any orthopedic surgeon to add to their skill set. The versatility of indications ranges from trauma, deformity corrections, as well as reconstructive surgeries. With a relatively high safety profile and easy application, it becomes a powerful tool, especially in resource-limited settings. These principles follow the vision of Prof Joshi, who conceptualized a system which can be easily applied by any surgeon with minimum instrumentation at places with limited resources.
Irrespective of the indication, the construct aims to maximize the construct stability and decrease stress at the pin-bone interface by pre-tensioning the pins. It allows for a shorter hospital stay, early initiation of physiotherapy and return to work. There are relatively less infections due to less disruption of the skin compared to a plate or nail. External fixation also allows for improved tissue healing, better wound management, and easy removal.
The use of the JESS fixator in hand and foot injuries as well as correction in cases of congenital talipes equinovarus has widespread acceptance with many authors [2-5]. Most surgeons, however, have limited awareness regarding its other indications. The system can be used to fix difficult proximal humerus fractures (Fig. 1) and proximal tibia fractures (Fig. 2) in specific indications with promising results [6-11]. However, the evidence regarding JESS in these fractures is limited and of relatively poor quality.
Despite such advantages, concerns regarding cosmesis are a common reason for patients not opting for the fixator. Its inability to reduce fractures, possible impalement to tendon, nerves, and vessels if safe zones are not followed remain a major concern with many. These can be reduced by simply planning the case in advance. The biggest drawback is the inability of this system to reduce fractures. The JESS fixator is not a tool which can be used for reduction of a displaced fracture like in the cases of plates or screws. However, the system is biomechanically strong enough to able to hold a well reduced fracture. The implications of this are that the surgeon may possibly need to perform an open reduction or use additional implants like screws for reducing the fracture before applying the fixator
As surgeons, we often need to optimize the management of patients not only in terms of early and appropriate surgery but also economically. The JESS fixator is an excellent and versatile tool for both the young and the experienced surgeons. Technology and artificial intelligence breakthroughs are driving innovation and techniques in orthopedics but it is imperative to maintain context. Not everyone has or will have access to the latest technology and as we all have experienced at some point, another technology may fail us at the most crucial steps. Keeping it simple is often the key. To conclude, the JESS system is a simple, easy system which is not only just limited to applications in hand and foot surgery but also in other trauma and reconstructive surgeries. The need of the hour is generation of awareness regarding its versatility as well as generating more quality evidence for its use.