The Sacroiliac Joint in 2019 No abstract available

Anatomy and Biomechanics of the Sacroiliac Joint Sacroiliac (SI) joint pain is a difficult problem that is becoming increasingly recognized for its contribution to low back pain. In certain circumstances it may present independently. However, in many scenarios the SI joint represents one of many factors contributing to axial back pain and its various referral patterns. Low back pain remains a significant burden on the health care system, accounting for ∼12 million physician office visits per year in the United States. It remains among the leading causes of disability, with expenditures in excess of $80 billion dollars every year. Surgical management of low back pain results in variable success rates ranging from 35% to 89%, suggesting that the etiology of back pain is complex, often multifactorial, and frequently not clearly known. Studies have shown that SI joint pathology may present in association with, or contribute directly to, back pain as often as 20% to 45% of the time. Despite this, the SI joint is often overlooked as a contributing source of back pain. It is necessary to maintain an index of suspicion, as well as understand the relevant anatomy, biomechanics, and clinical presentation involved in SI joint mediated pain, to be able to arrive at an appropriate diagnosis. This section presents a review of SI joint anatomy and biomechanics to establish a foundation necessary for understanding the clinical manifestations of SI joint dysfunction and treatment options.

Clinical Diagnosis of Sacroiliac Joint Pain There is a need to establish a standardized clinical examination, based on best available evidence, that identifies those patients with persistent back and buttock pain whose symptoms arise from the sacroiliac joint. This clinical examination is the first step in the selection of patients for controlled and guided diagnostic intra-articular block (the reference standard). This in turn is the prerequisite for selection of patients for minimally invasive therapies such as intra-articular steroid injection or for surgical fusion. The use of pain location and results from pain provocation tests is described within the context of a clinical reasoning algorithm. A cluster of at least 2, preferably 3 provocation tests in the absence of any clear diagnosis of a pain source other than the sacroiliac joint, has a sensitivity of 91% and specificity of 89%. The clinical examination described is reliable, requires no special equipment, and is available from trained clinicians in most developed countries.

The Evidence for Sacroiliac Joint Surgery Sacroiliac joint (SIJ) dysfunction is a condition that has a significant impact on patient’s quality of life. In the past, accurate diagnosis of this condition has proven difficult and even when diagnosed, effective treatments with acceptable morbidity have been lacking. Recently, the use of composites of various physical examination tests in conjunction with joint injections has proven capable of diagnosing the condition with acceptable degrees of sensitivity and specificity. In addition, the advent of minimally invasive techniques for the fusion of the SIJ now offer patients an effective treatment option with morbidity far less than traditional open approaches. This paper is intended as a review of the evidence with regard to SIJ dysfunction and the various treatment options available for this condition. We first discuss the approach to diagnosing the condition and the evidence for the use of composites of physical examination tests and joint injections in reaching the diagnosis. This is followed by a detailed discussion of the various treatment options, broadly speaking these include conservative management, open surgical fusion, and minimally invasive fusion. We discuss the evidence examining the effectiveness of these treatment strategies including the various studies that directly compare the different modalities. On the basis of this evidence we recommend patients with SIJ dysfunction should first undergo a 6-month trial of conservative management before being considered for surgical intervention. If surgery is being considered, we recommend that due to the lower morbidity, minimally invasive techniques are the preferred approach.

Navigating the Murk: Ethical and Practical Considerations for the Surgical Treatment of the Sacroiliac Joint Syndrome The field of spine surgery has many controversies. The surgical treatment of the sacroiliac (SI) joint is, too, fraught with debate. The diagnosis of painful SI joints is currently limited to relief following “diagnostic” injections and pain generated from a suite of clinical maneuvers. Diagnoses of SI joint dysfunction are dependent entirely on patient-reported responses to provocative maneuvers and invasive procedures. There is a glaring lack of objective radiographic and objective physical examination findings for this syndrome. The evidence for treatment, and specifically for the surgical treatment of the SI joint is reviewed and critiqued. Although the surgical techniques are simple, consensus is elusive for both indication and optimal technique. Ethical principles for surgical innovation and practical considerations for the treatment of the SI joint syndrome are discussed at length. Discussed as well are key points to consider when providing informed consent to a patient before proceeding with surgical intervention for this procedure and diagnosis. Spine surgery is a field with considerable regional variation in practice. Even today, the precise indications for arthrodesis, extent, and approach, remain frequently debated; however, as much conversation takes place surrounding lumbar surgery, even more confusion, bias, opinion, and deliberation exists when surgical treatment of the SI joint is considered. This chapter discusses the unique challenges associated with the SI joint and provides practical considerations for the treatment thereof.

Health Care Economics of SI Joint Fusion Increased interest in the sacroiliac joint (SIJ) as a contributor to chronic low back pain has resulted in an expanding set of surgical and nonsurgical treatment options. Evidence for the effectiveness of nonsurgical treatment is limited, impeding assessment of the overall value of such treatments. For surgical treatment, only triangular titanium implants, used during minimally invasive SIJ fusion, have been the subject of rigorous clinical and economic evaluations. Randomized trials of triangular titanium implants have shown marked immediate and sustained improvements in pain, disability, and quality of life with incremental cost-effectiveness ratios that are at least as good as high-volume orthopedic procedures and lower than those for other spine surgeries. Other devices for SIJ fusion are available but the limited evidence base prevents any conclusions regarding those devices.

Unhas Suture, A Novel Tendon Repair Technique: An In Vitro Experimental Study Comparing Unhas Suture and Bunnell Suture in Tensile Strength and Gap Formation Purpose: Developing a simple and yet strong repair technique that allows smooth gliding of the tendon within the tendon sheath has remained a challenge to meet the biomechanical needs of early active rehabilitation. Our Objective was to compare Unhas and Bunnell suture technique in terms of strength and gap resistance in tendon repair. Materials and Methods: Thirty feet of healthy roosters Gallus domesticus were harvested and assigned randomly into 2 groups of 15 feet each. The tendons were repaired using Unhas suture and Bunnell suture utilizing monofilament nylon 4-0. Every specimens were tested by using repaired tendon gap formation apparatus and then measured when it produced an initial gap and 2-mm gap at the repair site. The measurements were then analyzed for statistical significance. Results: Significant difference in initial gap was detected between repaired tendon using Unhas suture and Bunnell suture. Two-millimeter gap forces were tested and Unhas suture group was also significantly higher compared with Bunnell suture group. Conclusions: Unhas suture was proven to be able to resist gap forces either in initial gap or 2-mm gap compared with Bunnell suture Clinical Relevance: Unhas suture may be a reliable alternative in tendon repair that provides tensile strength, gapping resistance and also provide easiness which can be performed with conventional suture material and less operating time.

A Simple Technique to Improve the Accuracy of Plaster Molding in Metacarpal Neck Fractures Metacarpal neck fractures are mostly reduced in A&E or in fracture clinic. Once the cast is applied a simple technique is described to locate the metacarpal head. On the uninjured hand, measurement is taken from the tip of corresponding finger to the metacarpal head. This measurement is transferred on to the cast for further reduction and moulding. This technique provides a reliable outcome.

The Use of a Lacrimal Probe in Closed Catheter Irrigation of Pyogenic Flexor Tenosynovitis Pyogenic flexor tenosynovitis is a destructive closed space infection of the flexor tendon sheath. Here, we describe an adjunct to its normal surgical treatment by ways of using a lacrimal probe.

The Modified Anterolateral Approach to the Humerus No abstract available