How to Optimize a Bone Graft in Arthroscopy of the Wrist: The “Gun Barrel Trick”

Arthroscopy has been shown to be useful in performing procedures requiring the use of autologous bone grafts, such as the treatment of scaphoid pseudarthrosis,[1] partial wrist fusion,[2] and many other indications. Classically performed by an open approach, these grafts had to adapt to a minimally invasive approach compatible with arthroscopy, with their intra-articular introduction becoming more delicate. The introduction of the graft using dissecting forceps directly intra-articularly is neither desirable nor possible and is, moreover, deleterious for the graft. In addition, arthroscopic procedures requiring the use of a cancellous bone graft are lengthy, especially intracarpal arthrodesis,[3] while the tourniquet time is limited. We present a tip to facilitate the placement and shorten the time of introduction of the bone graft while optimizing the time of surgery.

First, you need to have several intramuscular needle caps (20 gauge) and bevel their ends for better intra-articular penetration during the introduction of the intra-articular graft. The empty containers created in this way will then be filled with the previously fragmented cancellous bone graft to obtain several “loads” like a revolver barrel ([Fig. 1]). The origin of the graft (distal radius, iliac crest, etc.) does not constitute any obstacle to performing this technique. Similar to using a Jamshidi,[4] the graft can be crowded and compacted to achieve a compact and good quality graft while being careful not to jam the graft in the Jamshidi. However, unlike the Jamshidi, several “loads” can be prepared ahead of the introduction. The filling of the caps can in fact be performed using the operating aid, which saves operating time. The caps are then introduced via the arthroscopic approach of the wrist, using rotational movements to facilitate passage. Once introduced into a position deemed satisfactory under arthroscopic control, the metal introducer of the arthroscope is used as a pusher to introduce the graft into the joint. Once the “loads” have been emptied successively one by one, the graft will then be positioned under arthroscopic control using the feeler ([Fig. 2]).

Fig. 1 Left: removal of a previously divided cancellous bone graft. Right: caps filled with the cancellous bone graft constituting “loads” to be introduced intra-articularly.

Fig. 2 The end of the plugs is cut in a bevel shape for better insertion into the arthroscopic passages (A). Once introduced through the first radiocarpal tract, the bone graft is then pushed into the joint using the introducer (B). Arthroscopic control is performed to ensure the correct positioning of the bone graft during its introduction (C).

This trick remains easily reproducible and inexpensive and requires very little equipment (except that of arthroscopy), allowing rapid placement of the graft in a targeted manner, even in cramped places,[5] and saves time during the preparation of grafts. However, this method with needle caps is prohibited in some facilities. The reason is that there are concerns about complications that a tip of the cap will remain in the body. To avoid this, we recommend that the cap be sharpen cleanly to remove any debris that may come loose during arthroscopy and place the tip of the cap in the trash. Currently, we do not report any complications related to plastic debris and we have never seen debris during arthroscopy.

Publikationsverlauf

Eingereicht: 23. Januar 2022

Angenommen: 13. Mai 2022

Artikel online veröffentlicht:
28. Juni 2022

• References

• 1 Liu B, Wu F, Ng CY. Wrist arthroscopy for the treatment of scaphoid delayed or nonunions and judging the need for bone grafting. J Hand Surg Eur Vol 2019; 44 (06) 594-599
• 2 Baur E-M. Arthroscopic-assisted partial wrist arthrodesis. Hand Clin 2017; 33 (04) 735-753
• 3 del Piñal F, Tandioy-Delgado F. (Dry) arthroscopic partial wrist arthrodesis: tips and tricks. Handchir Mikrochir Plast Chir 2014; 46 (05) 300-306
• 4 Bokhari S, Hadi S, Hossain F, Ketzer B. The outcome of using a Jamshidi biopsy trocar needle in a novel technique for bone grafting in percutaneous internal fixation of scaphoid non-union. Open Access Maced J Med Sci 2018; 6 (03) 506-510
• 5 de Villeneuve Bargemon J-B, Jaloux C, Levet P, Levadoux M. Arthroscopic treatment of capitate nonunion: a new technique. J Wrist Surg 2022; 11 (04) 353-357