The Outcome of Using a Jamshidi Biopsy Trocar Needle in a Novel Technique for Bone Grafting in Percutaneous Internal Fixation of Scaphoid Non-Union

Abstract

INTRODUCTION: We report the outcome of using a novel technique of minimally invasive internal fixation and distal radius bone grafting using the Jamishidi Trephine needle and biopsy/graft capture device.

METHODS: The technique utilises a 8 mm incision at the distal pole of the scaphoid. The non-union is excavated using the standard Acutrak drill. An 8 gauge Jamshidi trephine needle is used to harvest bone graft from the distal radius which is impacted into the scaphoid and fixed with an Acutrak screw. Fifteen patients were available for retrospective review, 14 male, age mean 29.5 (15-56). Average time from injury to surgery was 167 days (45-72). Fractures classified according to Herbert giving 7 D1 and 8 D2 fractures, 14 waist and 1 proximal pole fractures, all of which had no humpback deformity.

RESULTS: Sixty-six percentages of the fractures went onto unite, 4/7 D1 and 6/8 D2 united (p > 0.05). Seventy-five percentages of fracture that had surgery in less than 3 months from time of injury went onto unite, whereas only 63% united in patients who had surgery later than 3 months (p > 0.05). DASH outcome for all patients improved from 86 down to 32 (p < 0.05). With those that united going down from 90 to 6. Those that did not unite went from 81 to 61.
CONCLUSION: The Jamshidi bone grafting technique shows comparable results (union rate 66%) to other techniques published in the literature (27-100%) providing the surgeon with an alternative and less demanding procedure than open scaphoid non-union surgery.

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Open Access Macedonian Journal of Medical Sciences. 2018 Mar 15; 6(3):506-510.
https://doi.org/10.3889/oamjms.2018.139
eISSN: 1857-9655
Clinical Science
The Outcome of Using a Jamshidi Biopsy Trocar Needle in a
Novel Technique for Bone Grafting in Percutaneous Internal
Fixation of Scaphoid Non-Union
Syed Bokhari*, Saifullah Hadi, Fahad Hossain, Bernd Ketzer
Pinderfields Hospital, Aberford Road, Wakefield, West Yorkshire, United Kingdom
Citation: Bokhari S, Hadi S, Hossain F, Ketzer B. The
Outcome of Using a Jamshidi Biopsy Trocar Needle in a
Novel Technique f or Bone Grafting in Percutaneous
Internal Fixation of Scaphoid Non-Union. Open Access
Maced J Med Sci. 2018 Mar 15; 6(3):506-510.
https://doi.org/10.3889/oamjms.2018.139
Keywords: Scaphoid bone; Bone transplantation; Radius;
Fracture fixation internal
*Correspondence: Syed Bokhari. Pinderfields Hospital,
Aberford Road, Wakefield, West Yorkshire, United
Kingdom. E-mail: bokhariawais@hotmail.com
Received: 28-Oct-2017; Revised: 20-Feb-2018;
Accepted: 28-Feb-2018; Online first: 12-Mar-2018
Copyright: © 2018 Syed Bokhari, Saifullah Hadi, Fahad
Hossain, Bernd Ketzer. This is an open-access article
distributed under the terms of the Creative Commons
Attribution-NonCommercial 4.0 International License (CC
BY-NC 4.0)
Funding: This research did not receive any financial
support
Competing Interests: The authors have declared that no
competing interests exist
Abstract
INTRODUCTION: We report the outcome of using a novel technique of minimally invasive internal fixation and
distal radius bone grafting using the Jamishidi Trephine needle and biopsy/graft capture device.
METHODS: The technique utilises a 8 mm incision at the distal pole of the scaphoid. The non-union is excavated
using the standard Acutrak drill. An 8 gauge Jamshidi trephine needle is used to harvest bone graft from the distal
radius which is impacted into the scaphoid and fixed with an Acutrak screw. Fifteen patients were available for
retrospective review, 14 male, age mean 29.5 (15-56). Average time from injury to surgery was 167 days (45-72).
Fractures classified according to Herbert giving 7 D1 and 8 D2 fractures, 14 waist and 1 proximal pole fractures,
all of which had no humpback deformity.
RESULTS: Sixty-six percentages of the fractures went onto unite, 4/7 D1 and 6/8 D2 united (p > 0.05). Seventy-
five percentages of fracture that had surgery in less than 3 months from time of injury went onto unite, whereas
only 63% united in patients who had surgery later than 3 months (p > 0.05). DASH outcome for all patients
improved from 86 down to 32 (p < 0.05). With those that united going down from 90 to 6. Those that did not unite
went from 81 to 61.
CONCLUSION: The Jamshidi bone grafting technique shows comparable results (union rate 66%) to other
techniques published in the literature (27-100%) providing the surgeon with an alternative and less demanding
procedure than open scaphoid non-union surgery.
Introduction
The management of scaphoid non - union,
continues to be a wide scale problem due to the
varying union rates achieved with vascularised and
non - vascularised bone grafting. Due to the non-
reproducible results outside of specialist centres,
vascularised bone graft still has not fully been
embraced.
We analysed our results of a novel technique
of non - vascularised bone grafting using a Jamshidi
biopsy trocar needle in non - unions that had not fallen
into a humpback malunion.
Methods
Between 2009 and 2014, 50 patients with
scaphoid fractures who underwent an operative
procedure at a busy District General Hospital were
identified by computer data capture software
(Bluespier, Droitwich, UK). Forty-five patients with an
acute fracture, humpback malunion deformity,
avascular necrosis, proximal pole fracture or incorrect
coding were excluded. This left 15 cases that
underwent percutaneous bone grafting and Acutrak
screw fixation for our study. There were no formalised
inclusion criteria, but we found that after a minimum
period of immobilisation of 6 weeks and no definite
signs of bony union an informed discussion were
undertaken with the patient regarding the risks and

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benefits of performing surgery. Most patients who
consented to surgery were young, self - employed
males. Four shot - scaphoid radiographs were taken
preoperatively and then classified according to the
Filan and Herbert classification into either D1 - fibrous
union or D2 - pseudoarthrosis.
Figure 1: Eight mm incision at distal pole of scaphoid
Initial treatment involved a below elbow
plaster or splint immobilisation of at least 6 weeks.
Patients who failed to show progression towards
union after an initial period of non - operative
treatment were then considered for a further
conservative measure or operative treatment. In
conjunction with patient consultation, a decision was
then made to proceed with operative intervention with
our described technique. Patients were followed up
using clinical and radiological examination either with
radiographs or 3 - dimensional reconstruction such as
CT or MRI. After surgery, the patient was immobilised
in plaster for 6 weeks. At 6 weeks they were followed
up with scaphoid series radiographs and clinical
examinations while being allowed to mobilise.
Figure 2: Eight mm incision over listers tubercle
Union was confirmed with clinical and
radiological examinations, and patients were asked to
complete the Disabilities of Arm, Shoulder and Hand
(DASH) questionnaire. Outcomes used for analysis
were union rate, time from injury to surgery, the effect
of Herbert classification and its effect on union and
DASH scores. We defined early surgery from the time
of injury as surgery performed within 120 days of the
injury, and hence late surgery after 120 days.
Outcomes were assessed as time to
radiological union, or salvage procedure of excision
distal pole and using preoperative and postoperative
DASH score.
Figure 3: Jamshidi needle and tracer set
We used XLSTAT (Addinsoft, USA) for all
statistical tests. Non-parametric tests were used for
our results. The chi-squared test was used for
categorical variables, and the Wilcoxon Rank test was
used for continuous variables.
Figure 4: Harvesting of distal radius bone graft under fluoroscopic
guidance
The procedure is carried out on a radiolucent
arm table with upper arm tourniquet control. Two
small incisions are utilised. Fluoroscopy is used to
identify the distal pole of the scaphoid and an 8 mm
volar incision is made in the line of the scaphoid at the
distal pole (Figure 1).
Dissection is continued down to the distal pole
and wire is drilled down the scaphoid so that it is
located in central position on the AP, Lateral and
oblique views. The screw length is measured, and
then the scaphoid is drilled using the ‘Standard’

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Acutrak drill bit. The authors prefer to carry out all
drilling on hand power which allows for much more
controlled scaphoid excavation. A dorsal incision of
5mm based just proximal to Lister’s tubercle is made,
and a bare area of bone is identified (Figure 2).
Figure 5: Distal radius bone graft harvest
An 8 Gauge Jamshidi trocar and biopsy
needle (Figure 3) is then inserted into the distal radial
metaphysis (Figure 4) in a corkscrew motion to
capture a column of cancellous tube-shaped autograft
(Figure 5).
The capture device fits exactly into the drill
hole made by the standard Acutrak drill bit (Figure 6).
Figure 6: Insertion of tracer into scaphoid Insertion of tracer into
scaphoid
The hook-shaped biopsy extractor is then
used to expel and impact the cancellous autograft into
the scaphoid non - union (Figure 7).
Multiple grafts can be extracted and impacted
into scaphoid until it becomes difficult to insert
anymore. The guide wire is then re-drilled under
fluoroscopy control into the centre -centre position.
The screw length does not have to be re-measured as
there is no change in the shape of the scaphoid with
the introduction of the graft.
Figure 7: Graft packed into scaphoid using pusher
The drill bit is then passed over the guide wire
but in reverse to impact the graft swarf into the
scaphoid bone and also make room for the screw.
The screw is then inserted, and radiographs were
taken to ensure correct positioning (Figure 8).
Figure 8: Acutrak screw to compress scaphoid
Results
In the 14 men and 1 woman, the average time
from injury to the time of surgery was 167 days
(Range 45 - 472). Mean age of 29.5 years (range 15 -
56). All patients were studying, in employment or
actively seeking employment. Two wrist surgeons
reviewed the pre-operative radiographs, and any
discordance agreed upon after discussion. This
classification review resulted in seven D1 (fibrous
union) and eight D2 (pseudoarthroses) fractures.
Fourteen fractures were of the scaphoid waist and
only one proximal pole.
The average time to union was 70.9 days
(range 41 - 293). One patient was an outlier at 293
days, and if this patient is excluded, then the average
reduces to 46.2 days (range 41 - 58 days).

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Open Access Maced J Med Sci. 2018 Mar 15; 6(3):506-510. 509
Ten out of 15 patients went onto unite of
which 4 of these were D1 fibrous unions, and 6 were
D2 pseudoarthroses. Hence 4 out of 7 D1 fractures
united and 6 out of 8 D2 fractures united. Despite D2
having a higher union rate, there is no significant
difference between the 2 Herbert groups (p > 0.05).
Of the 5 that did not unite the average time
from injury to surgery was 138 days (range 55 - 208).
This is compared to 180 days for the ten that united
(range 45 - 472). The patient with the proximal pole
fracture did not unite but was pain-free, with good
function.
Comparing the two groups of those having to
wait less than 120 days compared to more than 120
days gave a 75% vs 63% union rate, this resulted in
no statistical difference between the 2 groups when
examining time from injury to surgery and its effect on
bony union (p > 0.05).
DASH outcomes improved from a mean
preoperative score of 86 (68-94) to 32 (0-100) for all
patients which were statistically significant (p < 0.05).
Those patients that united improved from 90 down to
6 whereas those that did not unite went from 81 to 61.
The magnitude of improvement following surgery
between those that did and those that did not unite
was statistically significant (p = 0.02).
There is no difference in DASH scores in
those who had surgery before 120 days verses those
after 120 days (P= 0.686).
Table 1: Outcomes of Surgery
Patient
Age
Herbert
classfn
Proximal
pole or
Waist
Outcome
Time to
union
Time from
injury to
surgery
Pre-op
DASH
Post op
DASH
JB
15
D2
Waist
United
44
274
84
0
SW
22
D1
Waist
United
48
472
87
18
DS
19
D1
Waist
United
293
182
93
15
CD
49
D2
Waist
United
51
76
91
0
CJ
30
D2
Waist
United
41
236
88
0
LM
21
D2
Waist
United
41
93
86
18
MW
20
D2
Waist
United
58
157
93
0
PW
40
D1
Waist
United
42
45
94
0
DT
32
D2
Waist
United
49
86
89
6
DS
34
D1
Waist
United
42
187
88
0
AF
26
D2
Waist
Non-united
N/a
175
88
84
PR
23
D1
Waist
Non-united
N/a
128
68
27
GD
24
D2
Waist
Non-united
N/a
208
91
76
SS
25
D1
Waist
Non-united
N/a
55
94
94
PA
34
D1
Proximal
Pole
Non-united
N/a
124
68
21
Discussion
The management of scaphoid non-union
continues to be a problem for surgeons who deal with
scaphoid fractures. The goals of treatment for
scaphoid non-union include union, correction of
deformity, and relief of symptoms and limitation of
arthrosis [7]. Factors that adversely affect the
outcome of scaphoid non - union included the duration
of non - union, no punctate bleeding of the proximal
pole at the time of surgery and failed previous surgery
[11]. Our study involved percutaneous surgery hence
we could not identify whether there was punctate
bleeding from the proximal pole and none of the
patients had undergone previous surgery.
Minimally invasive surgery is indicated in early
scaphoid without cystic bone resorption, without
appreciable collapse of the scaphoid architecture and
avascular necrosis of the proximal pole [2].
Non-vascularised bone graft has varying
success in the literature with union rates of 66% iliac
crest vs 67% distal radius with donor site pain in the
iliac crest group [11]. In a different study of 5246
cases of non-union, the group which was fixed with
non-vascularised bone graft showed a union rate of
84%(6). Other groups have found 100% union rates
with iliac crest bone graft [1]. Our study shows a rate
of 66% which is comparative with the results from
Tambe’s group [11] but inferior to the other groups.
Comparing bone grafting techniques versus
non-bone grafting techniques the authors are aware
that there is literature supporting percutaneous
fixation without grafting. Union rates are similar to
ours published. However, we feel that in our
experience the minimal extra surgical time provides a
bone graft which speeds up a time to union. Union
rates have been reported in non-bone grafting papers
as averaging thirteen [5], fourteen [8] and nineteen [9]
weeks. In our study the average was ten weeks and
when the one outlier is excluded this reduced to six
weeks. Hence we feel the advantage of our technique
is the speed at which the bone unites compared to
non-bone grafting techniques. This is especially
important in the population that is being treated, those
of young, fit, active males in current employment
looking to get back to work as soon as possible.
Vascularised bone grafting techniques seem
to achieve superior rates of the union in specialist
centres however when these are attempted elsewhere
lower rates of the union are attained. Union rates vary
from 27% to 100% [9] [10] [12]. Pedicles are usually
harvested from the distal radius. However, more
advanced techniques such as medial femoral condyle
vascularised graft are producing [4] high rates of the
union. Taking these superior results from specialist
centres into account the jury is still out on whether
there is truly an advantage for vascularised against
non-vascularised bone graft. In a rare randomised
control trial comparing vascularised to non-
vascularised grafts, there was no difference between
the two groups in union rates, time to union and
functional results [1].
We feel that this is a technique which is not
technically demanding, reproducible in any centre and
has minimal if any donor site morbidity. We are aware
that the general outline of the technique has
previously been described, but we feel the novelty lies
in 1) the use of a Jamshidi needle, 2) the perfect fit of
the Jamshidi harvesting tool into the drill hole created

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by the Acutrak drill and 3) the ability to use the graft
extractor to impact the graft into the non - union site.
We acknowledge limitations in our study
being the absence of dynamometry and grip strength
testing and also that it is an underpowered study as
exhibited by lack of any statistical differences.
Interestingly with our technique, there was no
significant difference between union rate of surgery
before versus those after 120 days, but this is limited
by the small numbers of patients in the study.
Our practice has changed after analysing our
results, and we are ensuring that patients who are
showing any progression towards a delayed union
receive early operative intervention and we are only
using this technique on waist fractures. If patients
present with a marked delay we are now considering
iliac crest bone grafting due to the shown increase in
union rates in Braga-Silva’s group [1].
Our union rate is 66% overall which is
comparable to rates across the literature and also
results in satisfactory subjective patient outcomes as
measured by DASH scores.
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