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International Journal of Spine Surgery Feb 2020The sacroiliac joints (SIJs), the largest axial joints in the body, sit in between the sacrum and pelvic bones on either side. They connect the spine to the pelvis and...
BACKGROUND
The sacroiliac joints (SIJs), the largest axial joints in the body, sit in between the sacrum and pelvic bones on either side. They connect the spine to the pelvis and thus facilitate load transfer from the lumbar spine to the lower extremities. The majority of low back pain (LBP) is perceived to originate from the lumbar spine; however, another likely source of LBP that is mostly overlooked is the SIJ. This study (Parts I and II) aims to evaluate the clinical and biomechanical literature to understand the anatomy, biomechanics, sexual dimorphism, and causes and mechanics of pain of the SIJ leading to conservative and surgical treatment options using instrumentation. Part II concludes with the mechanics of the devices used in minimal surgical procedures for the SIJ.
METHODS
A thorough review of the literature was performed to analyze studies related to normal SIJ mechanics, as well as the effects of sex and pain on SIJ mechanics.
RESULTS
A total of 65 studies were selected related to anatomy, biomechanical function of the SIJ, and structures that surround the joints. These studies discussed the effects of various parameters, gender, and existence of common physiological disorders on the biomechanics of the SIJ.
CONCLUSIONS
The SIJ lies between the sacrum and the ilium and connects the spine to the pelvic bones. The SIJ transfers large bending moments and compression loads to lower extremities. However, the joint does not have as much stability of its own against the shear loads but resists shear due the tight wedging of the sacrum between hip bones on either side and the band of ligaments spanning the sacrum and the hip bones. Due to these, sacrum does not exhibit much motion with respect to the ilium. The SIJ range of motion in flexion-extension is about 3°, followed by axial rotation (about 1.5°), and lateral bending (about 0.8°). The sacrum of the female pelvis is wider, more uneven, less curved, and more backward tilted, compared to the male sacrum. Moreover, women exhibit higher mobility, stresses/loads, and pelvis ligament strains compared to male SIJs. Sacroiliac pain can be due to, but not limited to, hypo- or hypermobility, extraneous compression or shearing forces, micro- or macro-fractures, soft tissue injury, inflammation, pregnancy, adjacent segment disease, leg length discrepancy, and prior lumbar fusion. These effects are well discussed in this review. This review leads to Part II, in which the literature on mechanics of the treatment options is reviewed and synthesized.
PubMed: 32123652
DOI: 10.14444/6077 -
JBJS Essential Surgical Techniques 2022Various techniques for periacetabular osteotomy have been reported to prevent the progression of osteoarthritis in dysplastic hips. Bernese periacetabular osteotomy,...
UNLABELLED
Various techniques for periacetabular osteotomy have been reported to prevent the progression of osteoarthritis in dysplastic hips. Bernese periacetabular osteotomy, which involves the use of an anterior approach, is widely performed throughout the world because it offers preservation of the blood supply to the bone fragment and lateral pelvic muscles. However, Bernese periacetabular osteotomy has potential complications, such as nonunion at the osteotomy site, postoperative fracture, nonunion of the pubis and ischium, and damage to the main trunk of the obturator artery. Spherical periacetabular osteotomy (SPO) has been developed to resolve some of disadvantages of Bernese periacetabular osteotomy. Although SPO involves some technical difficulty, the procedure is safe when performed with use of appropriate preoperative 3-dimensional planning and surgical technique.
DESCRIPTION
Preoperative 3-dimensional planning is utilized to decide the radius of the curved osteotome, locations of the reference points for the osteotomy line, and depth of the bone groove at the teardrop area. The pelvic positioning is arranged fluoroscopically to match the neutral position based on preoperative planning. A 7-cm incision is made along the medial margin of the iliac crest. An anterior iliac crest osteotomy of 4.5 cm (length) × 1 cm (medial wedge-shaped) is performed. The operative field is maintained with aluminum retractors. The osteotomy line is completed by connecting the preoperatively planned reference points on the inner cortex of the ilium. The bone groove is made along the osteotomy line with use of a high-speed burr. A blunt osteotome is inserted into the bone groove at the teardrop area until it reaches the preoperatively planned depth. The blunt osteotome makes a pathway for the curved osteotome without breaking the quadrilateral surface (QLS) or perforating the hip joint. The special curved osteotome is inserted manually until it reaches the bottom of the groove, and the posterior cortex is cut. After the top of the teardrop is divided fluoroscopically, the anterior ischial cortex is osteotomized with a sharpened spiked Cobb elevator at the infracotyloid groove. An angled curved osteotome is used for the osteotomy of the superior area of the teardrop area. The bone fragment is rotated with a spreader and an angled retractor, and fixed with 2 absorbable screws. Beta-tricalcium phosphate blocks are inserted into the bone gap. The osteotomized wedge-shaped iliac bone is repositioned and fixed.
ALTERNATIVES
Alternatives include the Bernese periacetabular osteotomy, rotational acetabular osteotomy, and triple innominate osteotomy.
RATIONALE
Bernese periacetabular osteotomy utilizes an anterior approach, cuts into the QLS, and preserves the posterior column. In contrast, SPO preserves the QLS and does not cut the pubis. These features of SPO have some advantages. The large osteotomized surface is advantageous for osseous fusion, and preserving the QLS and pubis protects the trunk of the obturator artery. Furthermore, the preservation of the connection between the ilium, ischium, and pubis in SPO maintains a more stable pelvic ring than in Bernese periacetabular osteotomy. The osteotomy line is arranged to prevent leg shortening caused by thin medial bone stock of the bone fragment. Although splitting the teardrop area in SPO is somewhat technically difficult, particularly in cases with a thin teardrop, it can be safely done with use of preoperative 3-dimensional planning and appropriate surgical technique.In addition, the use of our medial wedge-shaped osteotomy at the iliac crest has 2 advantages: protection of the lateral femoral cutaneous nerve and preservation of the attachment of the tensor fascia latae muscle.
EXPECTED OUTCOMES
The advantages of SPO are a stable pelvic ring postoperatively, reduced risk of nonunion at the osteotomy site, no risk to the trunk of the obturator artery, preservation of the blood supply to the bone fragment, a small incision, and early muscle recovery.
IMPORTANT TIPS
Preoperative 3-dimensional planning of the osteotomy design is essential.The special curved osteotomes are designed so that osteotomy of the posterior cortex is completed when the handles are perpendicular to the pelvis.The special curved osteotomes are made with a radius of either 50 or 60 mm, which are the most suitable sizes for the Japanese population. Larger-diameter osteotomes may be required for different races.As the rotated bone fragment is relatively small, it is difficult to obtain rigid fixation of the osteotomy site. Hence, the fragment can move slightly in the early phase after surgery. Careful rehabilitation is needed.
ACRONYMS AND ABBREVIATIONS
AIIS = anterior inferior iliac spineASIS = anterior superior iliac spineLFCN = lateral femoral cutaneous nerveG.T. = greater trochanterK-wire = Kirschner wireBeta (β)-TCP = beta-tricalcium phosphate.
PubMed: 36816525
DOI: 10.2106/JBJS.ST.21.00048 -
The Bone & Joint Journal Nov 2013Pelvic discontinuity represents a rare but challenging problem for orthopaedic surgeons. It is most commonly encountered during revision total hip replacement, but can... (Review)
Review
Pelvic discontinuity represents a rare but challenging problem for orthopaedic surgeons. It is most commonly encountered during revision total hip replacement, but can also result from an iatrogentic acetabular fracture during hip replacement. The general principles in management of pelvic discontinuity include restoration of the continuity between the ilium and the ischium, typically with some form of plating. Bone grafting is frequently required to restore pelvic bone stock. The acetabular component is then impacted, typically using an uncemented, trabecular metal component. Fixation with multiple supplemental screws is performed. For larger defects, a so-called 'cup-cage' reconstruction, or a custom triflange implant may be required. Pre-operative CT scanning can greatly assist in planning and evaluating the remaining bone stock available for bony ingrowth. Generally, good results have been reported for constructs that restore stability to the pelvis and allow some form of biologic ingrowth.
Topics: Acetabulum; Arthroplasty, Replacement, Hip; Bone Plates; Bone Screws; Bone Transplantation; Hip Fractures; Hip Prosthesis; Humans; Iatrogenic Disease; Pelvic Bones; Periprosthetic Fractures; Postoperative Complications; Prosthesis Design; Prosthesis Failure; Reoperation; Tomography, X-Ray Computed
PubMed: 24187366
DOI: 10.1302/0301-620X.95B11.32764 -
Proceedings of the Royal Society of... Jul 1969
Topics: Female; Femoral Neck Fractures; Fractures, Bone; Humans; Ilium; Middle Aged; Osteomalacia; Phosphates; Radiography; Vitamin D
PubMed: 5803531
DOI: No ID Found -
RoFo : Fortschritte Auf Dem Gebiete Der... May 2020Avulsion injuries of the pelvis and hip region are typical injuries in adolescent athletes but can be found in adults as well. Typical sites for avulsion injuries... (Review)
Review
BACKGROUND
Avulsion injuries of the pelvis and hip region are typical injuries in adolescent athletes but can be found in adults as well. Typical sites for avulsion injuries include the origin/insertion of tendons and ligaments. Among adolescents, the not yet ossified apophysis is also frequently involved. The pelvis and hip are especially prone to such injuries due to their complex musculotendinous anatomy. Clinical history and physical examination in combination with the recognition of typical imaging findings are essential for correct diagnosis of these mostly acute, but sometimes also chronic injuries.
METHODS
This review article describes typical avulsion injuries of the pelvis and hip and illustrates common radiological findings. Taking current literature into account, there is a special focus on the trauma mechanism, clinical examination, typical imaging findings and clinical management.
RESULTS AND CONCLUSION
Detailed knowledge of musculotendinous anatomy and typical injury mechanisms allows a correct diagnosis of avulsion injuries often only based on clinical examination and radiographic findings. Further imaging with ultrasound and MRI may be necessary to evaluate tendon retraction in non-osseous avulsion injuries and extent of soft-tissue damage. Knowledge of potential complications of acute/chronic injuries can help to avoid unnecessary examinations or invasive interventions. Conservative management of avulsion injuries usually leads to functionally good results. However, in the case of competitive athletes, relatively wide bone fragment dislocation or marked tendon retraction, operative re-fixation may be considered in order to expedite the rehabilitation process.
KEY POINTS
· Avulsion injuries are common injuries at the pelvic region especially in adolescent athletes, due to not yet ossified apophysis.. · Excellent anatomical knowledge is essential for proper diagnostic evaluation and predicting the mechanism of injury.. · Imaging plays a crucial role in diagnosing avulsion injuries starting from X-Ray and using MRI and CT for anatomical details by utilizing multiplanar capabilities..
CITATION FORMAT
· Albtoush OM, Bani-Issa J, Zitzelsberger T et al. Avulsion Injuries of the Pelvis and Hip. Fortschr Röntgenstr 2020; 192: 431 - 440.
Topics: Abdominal Muscles; Adolescent; Adult; Athletic Injuries; Enthesopathy; Female; Fractures, Avulsion; Hip Fractures; Humans; Ilium; Imaging, Three-Dimensional; Ligaments; Magnetic Resonance Imaging; Male; Muscle, Skeletal; Pelvic Bones; Physical Examination; Tendon Injuries
PubMed: 32106326
DOI: 10.1055/a-1082-1598 -
BMJ Case Reports Jan 2018Scaphoid non-union affects wrist joint function and is often associated with a predictable pattern of degenerative change. A 30-year-old man presented with a symptomatic... (Review)
Review
Scaphoid non-union affects wrist joint function and is often associated with a predictable pattern of degenerative change. A 30-year-old man presented with a symptomatic 15-year-old right scaphoid fracture with secondary scaphoid non-union advanced collapse of his right wrist. There was no evidence of avascular necrosis. The initial injury was from a fall onto his outstretched hand. We performed a right scaphoid open reduction, internal fixation and iliac crest bone graft. One year after the operation, the patient had good wrist function and grip strength. A CT scan showed union of the fracture. Studies have shown that if the time between initial fracture and treatment of non-union exceeds 5 years, the chances of healing of the non-union are markedly reduced. In our case, despite the long duration between timing of injury and surgery, there was union and good return of function.
Topics: Accidental Falls; Adult; Bone Transplantation; Fracture Fixation; Fracture Fixation, Internal; Fracture Healing; Fractures, Ununited; Humans; Ilium; Male; Open Fracture Reduction; Scaphoid Bone; Time Factors
PubMed: 29301797
DOI: 10.1136/bcr-2017-221615