Computed tomographic findings in patients with persistent sacroiliac pain after posterior iliac graft harvesting

STUDY DESIGN: A retrospective study of 24 sacroiliac joint computed tomographic (CT) scans of patients with persistent donor site pain. OBJECTIVE: To illustrate the computed tomographic findings of sacroiliac joints in patients who underwent posterior iliac bone graft harvesting with subsequent persistent donor site pain. SUMMARY OF BACKGROUND DATA: In a previous study the posterior iliac bone harvesting site was divided into three zones. Zone 1 carried no risk of violation of the synovial part of the sacroiliac joint. In Zones 2 and 3 there was a potential risk of violation to the synovial part of the sacroiliac joint. There is no study in the literature on the effect of violating the different parts of the sacroiliac joint during posterior iliac bone graft harvesting. METHODS: Computed tomographic scans of the sacroiliac joints of 22 patients with persistent pain in 24 sacroiliac joints after posterior iliac bone graft harvesting were retrospectively reviewed. RESULTS: Of the 16 sacroiliac joints with evidence of disruption of the inner table at the ligamentous part, 10 showed mild degenerative changes, and 6 showed moderate changes. Three joints with evidence of disruption of the inner table at the synovial part showed severe degenerative changes. Five joints with no evidence of inner table disruption did not show degenerative changes. CONCLUSION: There is a high prevalence of inner table disruption in patients with persistent sacroiliac joint pain after posterior iliac bone graft harvesting. The computed tomographic scan showed that involvement of the synovial part caused more severe degenerative changes than involvement of the ligamentous part.     

Dislocation of the sacroiliac joint associated with rheumatoid arthritis. A case report

Rheumatoid arthritis (RA) affects the articular surfaces and the ligamentous supporting structures of synovial-lined joints. In approximately one-fourth of the patients with RA, the sacroiliac joints demonstrate radiographic changes of subchondral bony erosions and articular destruction, as well as ankylosis. Subluxation or dislocation of the sacroiliac joint usually is associated with significant trauma to the pelvis. Nontraumatic disruption of the sacroiliac joint is a rare occurrence, but it should be considered in evaluating a patient with longstanding RA, sacroiliac joint tenderness, and radiating lower extremity symptoms.     

The morphology of ligamentous sacroiliac lesions – challenge to the antero-posterior compression mechanism

Aim: This paper evaluates computer tomographic morphology of partial ligamentous lesions of the sacroiliac joint. We hypothesised that in antero-posterior compression (APC) injuries the anterior superior portion of the sacroiliac joint (SIJ) should open up the most as suggested by the vector forces outlined in the Young and Burgess classification.Methods: All patients who underwent operative fixation of a ligamentous APC pelvic injury between July 2009 and December 2015 in a single Level-1 trauma centre were included. Patients were case matched (1:1) to controls without pelvic injury. SIJ width was measured by two independent reviewers at the anterior superior and anterior inferior part of the SIJ. Wilcoxon ranged test was applied for analysis.Results: 70 patients (35 cases, 35 controls) were evaluated. Median inferior and superior SI joint widths were 5.27 (IQR 3.68-7.80) and 4.05 (IQR 3.13-5.31) mm in cases versus 2.24 (IQR 1.83-2.50) and 2.44 (IQR 2.14-2.65) mm in controls, respectively. The difference between the inferior and superior SI width in cases was larger than in controls (p-value < 0.01, median of -0.22 mm in the control group versus 1.51 mm in the cases).Conclusion: Our data suggests that the inferior part of the SIJ opens up after injury more, relative to its superior portion. The vector of the force involved in rotationally unstable pelvic injuries is unlikely to be antero-posterior if the force causes the SI joint to widen up inferiorly first. This should be considered in SIJ fixation and challenges the APC mechanism in pure ligamentous rotationally unstable pelvic ring injuries.     

A cadaveric biomechanical evaluation of anterior posterior compression II injuries

PurposePelvic fractures are associated with high morbidity and often require surgical intervention. An Anterior Posterior Compression (APC) II injury consists of disruption at the pubic symphysis and anterior sacroiliac joint. Studies investigating specific ligamentous contributions would aid in development of novel fixation techniques. The objective of this study is to determine the level of pelvic destabilization from progressive soft tissue disruptions associated with APC II injuries.MethodsSix fresh-frozen cadaveric pelvises were dissected of soft tissues, preserving joint capsules and ligaments. Each pelvis was secured in a double-leg stance and joint motion was tracked with the specimens cyclically loaded to 60% body weight. Each specimen was measured in the intact state and again following stepwise destabilization to an APC II injury model (PS: sectioned pubic symphysis, IPS JOINT: PS + ipsilateral anterior sacroiliac, sacrotuberous, sacrospinous ligaments sectioned, IPS LIGS: IPS JOINT + ipsilateral interosseous ligaments sectioned, IPS JOINT+CONT ASI: IPS LIGS + contralateral anterior sacroiliac ligament disruption).ResultsCompared to the intact state, there was a statistically significant increase in movement in the IPS JOINT (ipsilateral 177%, p<0.001; contralateral 46%, p<0.005) and IPS JOINT+CONT ASI (ipsilateral 184%, p<0.002; and contralateral 62%, p<0.002) states bilaterally. No significant change was demonstrated in the PS or IPS LIGS state.ConclusionDisruption of ipsilateral ligamentous structures destabilized both sacroiliac joints. The interosseous and posterior sacroiliac ligaments provide the majority of stability of the sacroiliac joint and will likely benefit most from surgical stabilization.Level of Evidencemechanism-based reasoning.     

Failure load and displacement of the human sacroiliac joint under in vitro loading

Summary The stability of the sacroiliac joint was studied using an in vitro loading system. Forty-nine sacroiliac joints taken from fresh cadavers were examined. The ligamentous structures of the joint disrupted at 3368 ± 923 N under transverse loading. Higher disruption forces were observed under ventrocranial (4933 ± 1038 N) and dorsocranial (5150 ±947 N) loading. At joint failure the displacement in loading direction ranged from 5.5 ± 2.3 mm in the transverse to 6.6 ± 2.3 mm in the dorsocranial direction. In some experiments the interlocking effect between the articular surfaces of the sacrum and ilium were examined. The best interlocking capacity was observed under dorsocranial loading. This capacity is much higher than the friction in other human joints. The study shows that correct anatomical reconstruction without displacement increases the stability of the disrupted sacroiliac joint.

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Zusammenfassung. Die Stabilität des Sakroiliakalgelenkes wurde mit einem in vitro Belastungssystem untersucht. Neunundvierzig Sakroiliakalgelenke von frisch entnommenen Leichenbecken wurden getestet. Die Bandstrukturen des Gelenkes zerrissen unter transversaler Belastung bei 3368 ± 923 N. Höhere Kräfte wurden bei Zerreißungen unter ventrocranialer (4933 ± 1038 N) and dorsocranialer (5150 ± 947 N) Belastung beobachtet. Bei Zerreißung betrug die Dislokation des Gelenkes in Belastungsrichtung zwischen 5,5 ± 2,3 mm unter transversaler and 6,6 ± 2,3 mm unter dorsocranialer Belastung. Unter dorsocranialer Belastung trägt die Verzahnung der Gelenkflächen von Kreuz- und Darmbein mehr zur Gelenkstabilität bei als unter ventrocranialer. Die Reibung in anderen menschlichen Gelenken ist wesentlich geringer. Die Studie zeigt, daß die anatomisch richtige Wiederherstellung ohne Dislokation die Stabilität des geschädigten Sakroiliakalgelenkes verbessert.

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Partly presented at the 102nd Congress of the German Society of Surgery (Chirurgisches Forum 85, Springer, Berlin Heidelberg New York 1985)     

Failure load and displacement of the human sacroiliac joint under in vitro loading

The stability of the sacroiliac joint was studied using an in vitro loading system. Forty-nine sacroiliac joints taken from fresh cadavers were examined. The ligamentous structures of the joint disrupted at 3368 +/- 923 N under transverse loading. Higher disruption forces were observed under ventrocranial (4933 +/- 1038 N) and dorsocranial (5150 +/- 947 N) loading. At joint failure the displacement in loading direction ranged from 5.5 +/- 2.3 mm in the transverse to 6.6 +/- 2.3 mm in the dorsocranial direction. In some experiments the interlocking effect between the articular surfaces of the sacrum and ilium were examined. The best interlocking capacity was observed under dorsocranial loading. This capacity is much higher than the friction in other human joints. The study shows that correct anatomical reconstruction without displacement increases the stability of the disrupted sacroiliac joint.     

Fixation of posterior pelvic ring disruptions through a posterior approach

Objective  Stable internal screw fixation of posterior pelvic ring disruptions through a posterior approach. Indications  Complete, unstable sacroiliac dislocations with incompetence of anterior and posterior sacroiliac ligaments. Sacroiliac fracture dislocations. Displaced vertical sacral fractures. Contraindications  Damage to posterior soft tissues. Acceptable closed reduction of sacrum or sacroiliac joint. Ipsilateral acetabular fractures treated through an anterior approach. Inadequate intraoperative fluoroscopic visualization of posterior pelvis. Surgical Technique  Vertical paramedian incision overlying the sacroiliac joint. Release of origin of gluteus maximus. Inspection and reduction of sacroiliac joint. Stabilization with iliosacral screws under image intensification. Secure repair of gluteal fascia. Results  107 patients with unstable pelvic ring fractures were treated with open reduction and internal fixation of which 83 had an open reduction of posterior ring injuries. Accuracy of reduction: more than 95% of patients had residual displacement of less than 10 mm. Two patients had a deep wound infection postoperatively. Two-thirds of the patients were able to resume their previous occupation. Pain was either absent or occurred only with strenuous activities. 63% had a normal gait.     

骶髂关节退行性变的临床及X线表现（附64例分析）

本文对６４例骶髂关节退行性变进行了分析，主要ｘ线表现为关节间隙狭窄、关节面硬化、关节下缘有刺状、喙状增生、骨桥形成及关节面下假囊肿出现。中老年女性尤为好发，病因是由于长期姿势不正。妊娠期间韧带松弛，亦或全身退变的一部分。     

Radiological evaluation of the posterior pelvic ring in paediatric patients: Results of a retrospective study developing age- and gender-related non-osseous baseline characteristics in paediatric pelvic computed tomography – References for suspected sacroiliac joint injury

IntroductionThe prevalence of paediatric pelvic injury is low, yet they are often indicative of accompanying injuries, and an instable pelvis at presentation is related to long-term poor outcome. Judging diastasis of the sacroiliac joint in paediatric pelvic computed tomography is challenging, as information on their normal appearance is scarce. We therefore sought to generate age- and gender-related standard width measurements of the sacroiliac joint in children for comparison.Patients and methodsA total of 427 pelvic computed tomography scans in paediatric patients (<18 years old) were retrospectively evaluated. After applying exclusion criteria, 350 scans remained for measurements. Taking a standard approach we measured the sacroiliac joint width bilaterally in axial and coronal planes.ResultsWe illustrate age- and gender-related measurements of the sacroiliac joint width as a designated continuous 3rd, 15th, 50th, 85th and 97th centile graph, respectively. Means and standard deviations in the joint width are reported for four age groups. There are distinct changes in the sacroiliac joint's appearance during growth. In general, male children exhibit broader sacroiliac joints than females at the same age, although this difference is significant only in the 11 to 15-year-old age group.ConclusionThe sacroiliac joint width in children as measured in coronal and axial CT scans differs in association with age and gender. When the sacroiliac joint width is broader than the 97th centile published in our study, we strongly encourage considering a sacroiliac joint injury.     

Viscosupplementation: A new concept in the treatment of sacroiliac joint syndrome: A preliminary report of four cases

Background and Objectives. We describe a new therapeutic modality for sacroiliac joint syndrome that represents an alternative to other treatment modalities. We report on four cases of sacroiliac joint syndrome with severe pain. Methods: Three patients had undergone operative treatment of the lumbar spine and one patient suffered from severe osteoarthritis of the spine. All patients were diagnosed with sacroiliac joint syndrome by means of patient history, physical examination, and intra-articular local anesthetic injection preceded by sacroiliac arthrogram. All patients received three injections of Hylan GF 20 in the sacroiliac joints 2 weeks apart. Results: Twelve to 16 weeks after the injections, the pain was reported to be 40–67% better when measured on the visual analog scale. The duration of the beneficial effect of Hylan on arthralgia and joint function was undetermined. Conclusions. Viscosupplementation of the sacroiliac joint induced a significant degree of analgesia in all four patients. This treatment modality could represent an option in the management of sacroiliac joint pain and dysfunction.     

Anatomie et imagerie de l’articulation tarsométatarsienne (articulation de Lisfranc)

The tarsometatarsal joint (Lisfranc joint) is a synovial articulation of plane variety that is made up of three compartments. It is located between the bases of the five metatarsals and the anterior tarsal bones (medial, intermediate, lateral cuneiforms and cuboid bones). A great stability is provided by the particular shape of the joint compared to a mortise created by the cuneiform bones and the base of the second metacarpal, sometimes referred to as the “keystone concept?? as well as strong dorsal, plantar and interosseous ligaments, including mainly the first medial cuneometatarsal interosseous ligament (Lisfranc ligament). Traumatic lesions are the commonest disorders of this joint. Violent accidents including a mechanism of forced plantar flexion combined with rotation are the main causes of injury. Imaging of the tarsometatarsal joint includes conventional radiographs, computed tomography (CT) and magnetic resonance imaging (MR). Conventional radiographic projections remain the first-line imaging modality. However, owing to their often subtle radiographic presentation, Lisfranc lesions are frequently overlooked. Due to its excellent spatial resolution and three-dimensional imaging capabilities, CT is the procedure of choice for the evaluation of the injured foot. MR may be more accurate at detecting ligamentous and synovial disorders particularly owing to its high density resolution.     

Articular synovial chondromatosis of the finger

Abstract

A 40-year-old woman presented with a six-month history of synovial chondromatosis of the metacarpophalangeal joint of the right ring finger, which was resected through both dorsal and volar incisions. To our knowledge there have been only 17 reported cases of articular synovial chondromatosis of the digital joint so far. We present a case affecting the metacarpophalangeal joint with a review of scattered information found in other 17 reports.     

Sacroiliac joint pain after lumbar fusion. A study with anesthetic blocks

Low back pain persisting or appearing after a technically successful lumbar fusion challenges clinicians. In this context, the sacroiliac joint could be a possible source of pain, but the frequency of its responsibility is not really known. We used sacroiliac anesthetic blocks, the gold standard for diagnosis, to determine this frequency. Our second goal was to search predictive factors for a positive block. Our prospective series consisted of 40 patients with persistent low back pain after a technically successful fusion who received a sacroiliac anesthetic block under fluoroscopic control. The diagnostic criterion was a relief of more than 75% of the pain on a visual analog scale. We found a 35% rate of positive blocks. The only criterion that characterized these patients was a postoperative pain different from the preoperative pain in its distribution ( p =0.017). A free interval of more than 3 months between surgery and appearance of the pain had an indicative value ( p =0.17). An increased uptake in the sacroiliac on bone scintigraphy or a past history of posterior iliac bone-graft harvesting had no significant value ( p =0.74 and p =1.0, respectively). The sacroiliac joint is a possible source of pain after lumbar fusion. The anesthetic block under fluoroscopic control remains the gold standard.     

The sacroiliac joint after hip arthrodesis (author's transl)

After an introductory chapter about the anatomy and the function of the sacroiliac joint we examined the influence of an arthrodesis of the hip joint on the sacroiliac joint. We observed that an arthrosis of this joint is being formed because of the change in statics and dynamics, which appears radiologically, but rarely clinically. Subjective symptoms, if existant, have their cause mostly in alterations of the lumbar spine. Finally we observed that alterations of the sacroiliac joint after an arthrodesis of the hip joint are mostly insignificant for the patient and do not influence the success of this operation.     

骶髂关节结核的误诊及早期诊断

目的探讨骶髂关节结核误诊原因及提高其早期诊断措施。方法回顾性分析17例骶髂关节结核临床表现、体征及影像学特征，了解误诊情况。结果本组病例早期误诊率较高，17例中16例曾误诊为其他疾病。结论骶髂关节结核进展缓慢，早期症状及影像学表现不典型，且与骶髂关节其他疾病相类似是误诊的主要原因。掌握其发病特征，结合骶髂关节被动运动性疼痛试验检查，早期骶髂关节正位片及CT检查是提高其早期诊断的主要措施。     

Experimental study of the sacroiliac joint micromotion in pelvic disruption

OBJECTIVE: To measure the sacroiliac (SI) joint micromotion when different ligamentous lesions are created to simulate various degrees of pelvic anteroposterior compression injury. DESIGN: Cadaveric study. MATERIALS AND METHOD: Six SI joints were studied using a special device that made it possible to vary up to 310 N the loads applied on the ischial tuberosity and to measure simultaneously the SI micromotion. RESULTS: SI micromotion increases when the sacrospinous and sacrotuberous ligaments, and even more when the interosseous ligaments, have been sectioned off. In these cases, the stability of the SI joint is not restored by an isolated pubic fixation. CONCLUSION: This microinstability of the SI joint could contribute to the pain and arthritic changes sometimes observed in patients after anteroposterior compression injury. These experimental results could justify a larger spectrum of indications of SI joint fixation, but this should be confirmed by clinical study.     

Spondyloarthropathy in progressive ankylosis (ank/ank) mice: morphological features

Progressive ankylosis mice rapidly develop an ankylosing spondyloarthropathy that rapidly affects all of the articulations of the vertebral column. The disorder symmetrically affects the nonsynovial synchondroses and symphyses of the intervertebral spaces, the diarthrodial synovial apophyseal and costovertebral joints, and the sacroiliac joint. These joints present a clear progression from syndesmophyte formation through joint bridging to total fusion. The similarities and differences of the disorder identified in this mouse and human spondyloarthropathies are discussed.     

Computed tomography findings in patients with sacroiliac pain

This retrospective study evaluated the diagnostic value of computed tomography in patients with sacroiliac pain. Computed tomography scans of the sacroiliac joints of 62 patients with sacroiliac joint pain were reviewed. The criteria to include the patient in the current study were pain relief after a local injection in the sacroiliac joint under computed tomography guidance, a physical examination consistent with a sacroiliac origin of the pain, and negative magnetic resonance imaging of the lumbar spine. A control group consisted of 50 patients of matched age who had computed tomography scans of the pelvis for a reason other than pelvic or back pain. Computed tomography scans showed one or more findings in 57.5% and 31% of the sacroiliac joints in the symptomatic and the control groups, respectively. The computed tomography scans were negative in 37 (42.5%) symptomatic sacroiliac joints with a positive sacroiliac joint injection test. The sensitivity of computed tomography was 57.5 % and its specificity was 69%. The finding of the current study suggests limited diagnostic value of computed tomography in sacroiliac joint disease because of its low sensitivity and specificity. With clinical suspicion of a sacroiliac origin of pain, intraarticular injection is currently the only means to confirm that diagnosis.     

Sacroiliac joint pain due to bacterial infection: a report of two cases

Isolated infection of the sacroiliac joint is a rare cause of low back pain. Delayed diagnosis can result in significant morbidity. The diagnosis may be missed initially if physicians do not consider the possibility of infection. The clinical index of suspicion should increase in the presence of certain historical and examination findings. These include intravenous drug use, immunosuppression, recent infection elsewhere, fever and warmth or swelling over the sacroiliac joint. Two cases of sacroiliac joint pain due to Staphylococcus aureus infection are presented, with an overview of the etiology, diagnosis and management of the disorder.