What is the recommended treatment for increased sclerosis and cystic change in the proximal scaphoid?

Treatment of Proximal Scaphoid Sclerosis and Cystic Change

The recommended treatment for increased sclerosis and cystic change in the proximal scaphoid is radical curettage of sclerotic bone combined with bone grafting and internal fixation, with contrast-enhanced MRI required preoperatively to assess proximal pole viability. 1, 2

Preoperative Imaging Assessment

CT without contrast is the optimal imaging modality to evaluate the extent of sclerosis and cyst formation, assess trabecular bridging, and define nonunion characteristics. 1

MRI with IV contrast must be obtained to assess proximal pole viability before surgery, as it increases sensitivity, specificity, and accuracy compared to noncontrast MRI for detecting osteonecrosis. 1 This is critical because avascular proximal poles may require modified surgical approaches. 1

Surgical Treatment Algorithm

Core Surgical Principles

Radical curettage of sclerotic bone ends is the priority in surgical intervention for scaphoid nonunion with sclerosis. 3, 2 The sclerotic bone must be freshened and removed to expose viable bleeding bone. 3

Bone grafting combined with internal fixation achieves union in approximately 90% of cases. 3, 2 The specific approach depends on the extent of sclerosis and cyst formation:

Standard Approach: Curettage + Bone Graft + Fixation

• Trapezoidal iliac crest bone grafting with Herbert screw fixation after radical curettage achieves healing in 9 of 10 cases, restores scaphoid anatomy, and promotes excellent wrist function. 2
• This technique reconstitutes scaphoid length to within 0.2 mm of the normal side and normalizes the scapholunate angle. 2
• Mean postoperative grip strength reaches 45 kg with near-normal range of motion. 2

Enhanced Approach: Addition of Osteogenic Protein-1 (BMP-7)

For proximal pole sclerosis specifically, adding OP-1 (BMP-7) to bone grafting dramatically accelerates healing. 4 This approach offers several advantages:

• Reduces radiographic healing time from 9 weeks to 4 weeks compared to autologous graft alone. 4
• Replaces sclerotic bone with well-vascularized bone as demonstrated by helical CT and scintigraphy. 4
• Allows use of allogenic bone graft with outcomes equivalent to autologous graft, avoiding donor site morbidity. 4

Human bone morphogenetic protein has also shown success in treating proximal pole nonunions without conventional bone grafting, achieving healing by 12 weeks with no avascular necrosis at 6-year follow-up. 5

Postoperative Immobilization

Forearm cast immobilization for 6 weeks is sufficient when using modern fixation techniques, which differs from older methods requiring axilla-to-palm casting for up to 12 weeks. 3

Common Pitfalls to Avoid

• Inadequate removal of sclerotic bone leads to persistent nonunion—radical curettage is essential, not conservative debridement. 3, 2
• Failure to verify proximal pole viability preoperatively with contrast-enhanced MRI may result in inappropriate surgical planning. 1
• Using CT alone without MRI misses critical information about bone viability and vascularity. 1

Expected Outcomes

With appropriate surgical treatment, patients achieve:

• Full wrist range of motion without pain in the majority of cases. 6
• Return to work including manual labor in 8 of 10 patients. 2
• Subjective ratings of good or excellent in 9 of 10 patients. 2