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MINISTRY OF EDUCATION AND TRAINING MINISTRY OF DEFENCE 108 INSTITUTE OF CLINICAL MEDICAL AND PHARMACEUTICAL SCIENCES LE DINH HAI STUDY IMAGES OF SACROILIAC JOINT FRACTURE DISLOCATIONS ON 3D COMPUTERIZ[.]

MINISTRY OF EDUCATION AND TRAINING MINISTRY OF DEFENCE

108 INSTITUTE OF CLINICAL MEDICAL AND PHARMACEUTICAL SCIENCES

-

LE DINH HAI

STUDY IMAGES OF SACROILIAC JOINT FRACTURE DISLOCATIONS ON 3D COMPUTERIZED TOMOGRAPHY AND EVALUATE THE RESULTS OF TREATMENT

USING THE INTERNAL FIXATION

Speciality: Orthopedic trauma and plastic

Code: 62720129 ABSTRACT OF MEDICAL PHD THESIS

Ha Noi - 2022

THE THESIS WAS DONE IN: 108 INSTITUTE OF CLINICAL MEDICAL AND PHARMACEUTICAL SCIENCES

Day Month Year 2022

The thesis can be found at:

1 National Library of Vietnam

2 Library of 108 Institute of Clinical Medical and Pharmaceutical Science

ABSTRACT

The sacroiliac joint is the largest axial joint in the body, which is between the sacrum and the pelvis, and connects the pelvis to the lower part of the spine - the sacrum The sacroiliac joint fracture dislocation injuries cause pelvic instability and severely affects the patient's muscle function Although routine X-ray helps to diagnose musculoskeletal injuries, particularly in emergency cases, this method neither fully evaluate fracture lines and fragments nor completely diagnoses the coordinated lesions in the pelvis Montana M.A.’s study showed that 35% of sacroiliac fracture dislocation cases were not detected on routine radiographs

Computerized tomography with three-dimensional (3D) reformat can reconstruct the pelvis in three dimensions to survey completely the injury of the pelvis and the sacroiliac joint as well as the associated injuries As a result, the appropriate treatments can be oriented According to Falker J.K.M et al., up to 30% of pelvic fracture cases require an alternative treatment after computing 3D tomography Currently, computed tomography is considered the golden standard in the diagnosis and treatment of sacroiliac joint fracture dislocations Internal fixation surgery was first used by Borrelli J.J (1996) to treat sacroiliac joint fracture dislocations The results showed that this method has low complication rate and enables patients to return to function earlier compared to the conservative treatment methods With the application of computerized tomography with 3D reformat in internal fixation using plates and percutaneous screws, Jatoi A (2019) reported the excellent and good functional outcome rate in the surgical treatment of sacroiliac joint fracture dislocation at 80%

Although the combination of X-ray and 3D computed

tomography is considered the standard method in planning the surgical treatment, there are no studies in Vietnam describing the role and the significance of pelvic 3D computed tomography in the diagnosis, classification and treatment of the sacroiliac joint fracture dislocations

In addition, according to the documents that we found, the studies evaluating the results of surgery to manage sacroiliac joint fracture dislocations using the internal fixation are also rarely mentioned by domestic authors or including limited number of patients with the pelvic fracture cases

Under the circumstances, we conducted the research: “Study images of sacroiliac joint fracture dislocations on 3D computerized tomography and evaluate the results of treatment using the internal fixation” with two objectives as follows:

1 Describing the imaginal characteristics of sacroiliac joint fracture dislocations on 3D computed tomography

2 Evaluating the results of treatment of closed sacroiliac joint fracture dislocations using the internal fixation

Chapter 1 BACKGROUND

1.1 Anatomy and biomechanics of the sacroiliac joint

1.1.1 Sacroiliac joint anatomy

1.1.2.4 Relationship between age and gender

1.2 Sacroiliac joint fracture dislocations

1.2.1 Clinical findings

Sacroiliac joint (SIJ) fracture dislocations appear in a traumatic circumstance, so it is necessary to conduct a fully physical examination of the organs in the priority order of the multi-trauma patient emergency Caution should be exercised to assess the pelvic stability (distraction test) due to the risk of worsening shock and blood loss The authors recommend that it should be performed when the vital signs are stable However, clinical examination in multi-traumatic patients is often difficult to determine the pelvic fracture, particularly in the patient who has impaired consciousness Therefore,

multi-it is necessary to perform diagnostic imaging

detected on routine radiographs

1.2.2.2 Computed tomography scan

The computed tomography scan (CT-scan), which was invented and completed by Hounsfield G in the UK in 1972, is an imaging method based on the principle of X-rays Therefore, CT-scan is extremely advantageous in detecting bone lesions Compared with X-ray, CT-scan has some outstanding advantages: (1) no phenomenon of superimposed images, (2) the injuries can be observed in many sections due to the image editing software, (3) with 3D reformat of

CT, the pelvis could be observed from many angles and rotated in all directions, (4) diagnosis of other organs injuries (bladder, rectum, appendages, etc.)

According to Pesantez R and Ziran P.H (2007), the pelvis has a complex anatomical structure, so it needs to be viewed in 3D images The 3D images of CT scan allowing to rebuild the ‟body mass” so the entire pelvis can be visualized in any plane and ‟dissected” into parts Sacral and sacroiliac fracture can be detected and “diagrammed” Day A.C (2007) classified SIJ injuries in posterior iliac crescent fracture dislocation by CT-scan and 3D reformat of CT-scan Nowadays, pelvic CT-scan is the gold standard in the diagnosis of pelvic injury (especially for posterior pelvic structures) and assessment of pelvic stability Based on CT-scan images, the surgeon can assess mechanism

of injury, stability of the pelvis, displaced degree of the fragment, damage of other organs, blood vessels, or nerves As a result, they can orient the appropriate treatment

1.2.3 Classification

There are 2 types of SIJ fracture dislocation: SIJ dislocations with

posterior iliac wing fracture, SIJ dislocations with sacral fracture

1.2.3.1 SIJ dislocation with fracture of posterior iliac wing:

Currently, two common classification systems of the pelvis fracture based on the traumatic forces are the Young-Burgess and the Tile M., both of two systems are used for the instable pelvis fracture,

so it is difficult to choose the surgical approaches, reductions and fixations Day A.C (2007) proposed a classification system for SIJ

dislocations with fracture of posterior iliac wing

Table 1.1 Classification and treatment of SIJ dislocation with

posterior iliac wing fracture

Type Injury characteristics Recommended treatment

Day 1 Injury < 1/3 of SIJ Use the Ilioinguinal approach,

anterior fixation SIJ Day 2 Injury < 1/3 - 2/3 of SIJ Use the posterior approach, lag

screw and anti-slipping plate Day 3 Injury > 2/3 of SIJ Method 1: MIO - iliosacral

screw navigation; Method 2: ORIF - anterior fixation SIJ

1.2.3.2 SIJ dislocation with sacral fracture

SIJ dislocations with sacral fracture have different treatment methods and prognoses Denis F (1988) classified sacral fractures into

3 regions: zone I: injuries located laterally to the sacral foramina (vertical fracture of sacral ala); zone II: injuries that involve the sacral foramina (vertical fracture of sacral foramina), zone III: injuries located medially to the sacral foramina (fracture of the central region)

1.3 Fracture dislocation of SIJ treatments

1.3.1 Conservative treatment

1.3.2 External fixation

1.3.3 Open reduction and internal fixation

1.3.3.1 Indications for surgery

Via our medical literature review, we did not find particular indications for internal fixation of SIJ fracture dislocations SIJ fracture dislocations cause instability of the posterior pelvic ring, so the objectives of treatment are reduction and stabilization of the posterior pelvic ring and the patient has a better chance of functional

recovery, particularly coordinated neurological damage cases

Lindahl J and Hirvensalo E have found that all posterior pelvic ring displacement and instability with sacral fractures, SIJ dislocations, and SIJ fracture dislocations should be indicated for closed reduction or open reduction and internal fixation Gansslen A (2005) and Pallister I (2007) suggested the reduction and internal fixation for pure SIJ dislocation, SIJ dislocations with posterior iliac wing fracture, sacral fracture causing internal or external rotation SIJ, complete instability or associated neurologic injuries However, the surgical methods may change because of local infection or other factors Day A.C (2007) indicated surgery for SIJ dislocations with posterior iliac wing fracture

Muller F and Bachmann G.H (1978) recommended integrating anterior external fixation or internal fixation to stabilize the anterior iliac ring for the cases accompanying anterior iliac ring injuries not corrected the displacements despite the previous surgery

1.3.3.2 Global Research

Borrelli J.J (1996) performed internal fixation for 22 SIJ dislocations with posterior iliac wing fracture patients The author used compression screws and neutral plates for internal fixation via the posterior lateral approach The study results showed that all patients had bone healing clinically and on imaging after 3

postoperative months

Jatoi A.’s study (2019) on 15 SIJ dislocation with posterior wing fracture patients (aged 20 - 60 years) showed that the Day I, Day II, and Day III rates were 33%, 47%, and 20% respectively The author used the anterior approaches for Day I and Day II, posterior external approaches for Day III All patients were used with plates and percutaneous screws: the anterior SIJ fixation plates used for Day I, posterior SIJ fixation plates and iliosacral screws used for Day II and Day III The functional outcome according to the Majeed S.A.’s score showed the excellent result accounted for 60%, good result 20% and the poor result 20% There was a case of injury to the anterior branch

of the L5 lumbar spinal nerve and a case of wound infection which used the posterior approach All patients had bone healing

Currently, pelvic internal fixations are used in the treatment of unstable pelvic fractures However, the final outcomes still depend on the injury patterns as well as the associated complications

to Majeed S.A score We have not noted any specialized researches

in the country on surgical treatment the SIJ fracture dislocations

Chapter 2 OBJECTS AND METHODS

2.1 CT-scan with 3D rendering of SIJ fracture dislocations 2.1.1 Objects: All patients were diagnosed with SIJ dislocations,

closed SIJ fracture dislocations with displacement on X-ray and indicated surgical intervention using the internal fixation at the Trauma and Orthopaedics department - Cho Ray hospital (from January 2015 to September 2019) Patients were included in or excluded from the study group based on the following criteria:

- Inclusion criteria: SIJ fracture and dislocation patients have all kinds

of imaging: pelvic X-ray, pelvic CT-scan, 3D pelvic CT-scan

- Exclusion criteria: There are associated injuries on CT-scan films as

iliac wing fracture without SIJ damaging; L5-S1 vertebrae fracture dislocations and acetabular fracture

2.1.2 Methods: Study design: prospective, descriptive, non-controls study Performing procedure:

- Analysing the cross sectional CT-scan of SIJ: Location of iliac wing

fracture contiguous to SIJ, the location of the sacral fracture relative

to the intervertebral foramen, anteroposterior and mediolateral displacement of the fragments relative to the rest

- Analysing 3D image rendering of the pelvic CT-scan in sequence:

plain AP view, right posterior oblique view, left posterior oblique view, right anterior oblique view, left anterior oblique, plain posteroanterior view

- Classification: (1) SIJ dislocations with posterior iliac wing fracture,

(2) SIJ dislocations with sacral fracture, (3) SIJ dislocations with posterior iliac wing fracture and sacral fracture

- Measure the degree of axial displacement on the pelvic X-ray:

measure the maximum deformation (in millimetres) due to upward movement (towards the head)

2.1.3 Evaluation criteria

- Trauma characteristics: injury location, the displacement direction

- Morphological injury: pure SIJ dislocation, SIJ dislocation with posterior iliac wing fracture, SIJ dislocation with sacral fracture, SIJ dislocation with iliac wing and sacral fracture

group based on the following criteria:

2.2.1.1 Inclusion criteria: Patients with pure closed SIJ dislocation

or closed SIJ dislocation with posterior iliac fracture, closed SIJ

dislocation with sacral fracture Follow-up period is at least 6 months

2.2.1.2 Exclusion criteria

Patients have contraindications to internal fixation such as injured SIJ with extensive soft-tissue destruction or other life-threatening organ damage The patients have SIJ fracture and dislocation without being treated by internal fixation Patients have acetabular surgery Patients have spinal cord injuries or spinal fractures

2.2.1.3 Sample size

The sample size is calculated by the formula [3]: n = !(#$∝ && ⁄ ) * + * (,-+)

&

∝∶ type 1 error, choose ∝=5%

d: acceptable error, taken at 5%, d = 0.05

P: the excellent and good functional outcomes rate according to Majeed S.A.'s score According to the author Khaled S (2016), the excellent and good functional outcomes rates are at 95% [71] So, we chose p = 0.95

n = ,,12 * 3,14 * 3,34

3,34 & = 37,24 Thus, the minimum sample size in the study was 38 cases

2.2.2 Methods

Study design: the prospective study, surgical intervention, longitudinal

study, non-cases-control study

2.2.2.1 Operative technique

§ Examining and preparing patients

§ Preparing surgical instruments

§ The method of anaesthesia

§ Reduction and internal fixation methods

SIJ dislocation, SIJ dislocation with iliac wing fracture type Day I:

The patient lies supine on the operating table with an elevated hip

on the surgical side The skin incision is about 10-12 cm, laterally

parallel to the iliac crest and 1-2 cm from the iliac crest (the upper part

of the ilioinguinal incision) Exposing the medial side of the iliac wing and the fracture of the iliac wing then pulling the psoas major toward the SIJ by using two Hohmann retractors In sequence, exposing the anterior part of the SIJ and retracting the entire anterior branch of the L4 - L5 lumbar spinal nerve medially to expose the anterior sacral wing Performing reduction: firstly, use a clamp to reduce SIJ or use two 4.5 mm screws (a screw is placed on the iliac wing (close to SIJ) and another screw is placed on sacral wing (close to SIJ)) Next, use a clamp (Farabeuf clamp) to reduce SIJ via leaning on the 2 screws above Then, fix SIJ with 2 anterior plates for iliac wing fragment and SIJ or 2 percutaneous compression screws for SIJ and a screw for iliac wing fragment Finally, place a negative pressure drainage and close the incision layer by layer

SIJ dislocation with sacral fracture, SIJ dislocation with sacrum and iliac wing fractures type Day II, III: The patient lies prone on the

operating table Make a skin incision from the superior posterior iliac spine to inferior posterior iliac spine about 6–8 cm Dissection of the skin and the subcutaneous tissue, laterally pull a part of the gluteal

muscle to show the SIJ and the posterior part of sacrum

Day II and Day III: Reducing the crescent fragment of iliac wing

and fix it with compression screws or plate Reducing and fix the SIJ with SIJ compression screws

Denis I, II, III: Reducing the sacrum with pelvic reduction

forceps For the upward displacement, use two Schanz 6.0 mm nails

to place in each side of the posterior superior iliac spine Then, place two branches of Jungbluth forceps on two Schanz nails and reduce the displacement axially Next, incise the opposite side about 4-6 cm and

place a 3.5mm pelvic plate with 12-14 holes under the muscle skin and between the spines S1, S2 to compress the normal and the damaged SIJ Reinforce the fracture with percutaneous SIJ screws in cases of unstable longitudinal tearing If SIJ fracture displaces upward, strengthen the fracture with a screw rod from L5 to the posterior superior iliac spine Finally, place a negative pressure drainage, close the incision layer by layer

SIJ dislocation with sacral and iliac fractures type Day I:

Combine the anterior and posterior approaches to make reduction and fix the pelvic fractures, the SIJ and the sacrum

Due to the late surgical intervention or the difficulty in reduction of the SIJ and the insufficiently stable fixation of the posterior iliac ring,

we reinforce the fixation of the anterior iliac ring The incision is about

6 - 8 cm long and along the transverse line of the superior pubic ramus

2 cm Separating the rectus abdominis muscle in midline to expose the pubic joint and the superior-anterior pubic ramus Reduction of pubic joint and pubic fracture Then, fix the pubic joint with a pelvic plate and 3.5 mm screws Finally, place a drainage and close the incision layer by layer

In cases of patient with cystectomy or pubic wound, we cannot perform internal fixation Therefore, we use an external fixation with

4 Schanz nails In detail, two screws are put in the anterior inferior iliac spines while other two screws are put in the iliac crests However, patients who need anterior fixations for more than three months, we placed the rod and two screws in the anterior inferior iliac spine

§ Treatment of associated injuries: according to each speciality

2.2.2.2 Post-operative treatment: Monitoring, rehabilitation, detection and management of post-operative complications