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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 Reviewer: This thesis will be presented at Institute Council at: 108 Institute of Clinical Medical and Pharmaceutical Sciences Day Month Year 2022 The thesis can be found at: National Library of Vietnam 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: Describing the imaginal characteristics of sacroiliac joint fracture dislocations on 3D computed tomography Evaluating the results of treatment of closed sacroiliac joint fracture dislocations using the internal fixation Chapter BACKGROUND 1.1 Anatomy and biomechanics of the sacroiliac joint 1.1.1 Sacroiliac joint anatomy 1.1.1.1 Articular surface 1.1.1.2 Neurovasculature 1.1.2 Biomechanics of the sacroiliac joint 1.1.2.1 Stability 1.1.2.2 Kinematics 1.1.2.3 Function 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 multitraumatic 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 multitraumatic patients is often difficult to determine the pelvic fracture, particularly in the patient who has impaired consciousness Therefore, it is necessary to perform diagnostic imaging 1.2.2 Diagnostic imagings 1.2.2.1 X-ray The authors used three radiographs to assess pelvic injuries: (1) plain anteroposterior view, (2) inlet view and (3) outlet view Thaunat M (2008) measured the pelvic deformity due to ascending displacement, which is the largest deformation of the pelvis compared to the deformation caused by internal displacement or anteroposterior displacement Routine radiographs facilitate the initial diagnosis of fracture dislocation SIJ, particularly in emergency situations with fundamental diagnosis of bone and joint injuries The overlap of organs in the pelvis obscures the injuries and limits the field of view Consequently, this makes it difficult to diagnose complex damages and impossible to identify the coordinated injuries of the organs inside the pelvis SIJ fracture dislocation injuries are often complicated with many fragments and delicate fractures that are difficult to detect Montana’s study showed that 35% of SIJ fracture dislocation cases were not 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 Xray, 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 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 Injury < 1/3 of SIJ Use the Ilioinguinal approach, anterior fixation SIJ Day Injury < 1/3 - 2/3 of SIJ Use the posterior approach, lag screw and anti-slipping plate Day 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 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 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 1.3.3.3 Research in Vietnam In Vietnam, this technique has only been performed at a few hospitals where there is a deep specialization in orthopaedic trauma Le Van Tuan (2015) reported 92 cases of pelvic fractures treated with internal fixation The excellent and the good functional outcome reached 88.5%, the moderate outcome 6.6% and the poor outcome 4.9% Pham The Sinh (2016) studied 36 cases of SIJ fracture dislocation and did not differentiate other factors such as closed fracture, open fracture or associated pelvic and acetabular fractures The author classified injuries according to Tile's classification, evaluated the post-operative X-ray results according to acetabular fracture fixation scale of Matta J.'s (1996) and hip function according to Majeed S.A score We have not noted any specialized researches in the country on surgical treatment the SIJ fracture dislocations Chapter 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 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 - cm long and along the transverse line of the superior pubic ramus 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 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 12 2.2.2.3 Monitor and evaluate treatment outcome - Evaluation of post-operative short-term outcomes (≤ months): Primary wound healing rate SIJ fracture dislocation reduction results: the remaining displacement gap post-operative (in millimetres) Comparison of pre-operative and post-operative displacement Degree of anatomical recovery according to Lindahl's scale - Evaluation of post-operative long-term outcomes (≥ months): Results of bone healing Functional outcomes: Evaluate according to Majeed’s score Level of functional rehabilitation Associated factors to the functional outcomes: injuries patterns, number of injured sides, the time point of surgical intervention and anatomical reduction 2.3 Data collection and processing 2.3.1 Method of data collection 2.3.2 Data processing 2.4 Medical ethics Chapter RESEARCH RESULTS During the process of study, we collected 48 patients, who were treated by internal fixation, with 56 fracture dislocation SIJ injuries 3.1 Characteristics of the research sample 3.1.1 Characteristics of the study patient group: - Gender: Female: 21 patients (43.8%) Male: 27 patients (56.2%) The difference was not statistically significant (p = 0.75) - Age: Average age: 27.4 ± 10.6 years old (14 – 64 years old) - Causes of trauma: There is a difference between the causes of trauma in men and women (p = 0.035 - Fisher Exact test) The rate of injury from traffic accidents in women (90.4%) is higher than in men (63%) In contrast, the rate of work-related injury in men (33.3%) is higher 13 than that of women (4.8%) - Injury location: Left Side: 21 patients, Right side: 19 patients, bilateral injury: patients 3.1.2 Associated injuries 3.2 CT-scan with 3D rendering images 3.2.1 Morphology of injury: Pure SIJ dislocation (3/56 SIJ, 5,4%), SIJ dislocation with posterior iliac wing fracture (23/56 SIJ, 41,1%), SIJ dislocation with sacral fracture (17/56 SIJ, 30,4%), SIJ dislocation with posterior iliac wing and sacral fracture (13/56 SIJ, 23,2%) 3.2.2 Classification of injury 3.2.2.1 SIJ dislocations with posterior iliac wing fracture: There were types of Day injuries, Day III accounted for the highest rate 41,7% (15/36 SIJ), Day II (30,6%, 11/36 SIJ) and Day I (27,8% ,10/36 SIJ) 3.2.2.2 SIJ dislocations with sacral fractures: There were types of sacral fractures, in which Denis II sacral fractures accounted for the highest rate (18/30 SIJ, 60%) Denis I 36,7% (11/30 SIJ) and Denis III 3,3% (1/30 SIJ) 3.2.2.3 SIJ dislocation with posterior iliac wing and sacral fractures: there were 13 SIJ combined with Day’s classification and Denis’s classification and no Denis III injury was recorded 3.2.2.4 SIJ fracture dislocations on both sides: There were cases of bilateral SIJ injuries, in which there was only patient with pure unilateral SIJ dislocation and fracture dislocation on the opposite side There were patients with bilateral SIJ fracture dislocation 3.2.3 Displacement characteristics 3.2.3.1 Direction of displacement 14 Table 3.10: Direction of displacement of the injury (n=56 SIJ) Type of injury Day Day - Denis SIJ Total (%) Denis disloof cation SIJ Upward Superior, 8 24 42,8 4 12 21,4 10 17,9 0 1,8 0 1 1,8 0 5,35 5,35 1 3,6 23 13 17 56 100 displacement posterior, (n =48) lateral Superior, anterior, lateral Superior, anterior, medial Superior, lateral Superior, medial Non-upward lateral displacement posterior, (n = 8) lateral anterior, lateral Total Commentary: Generally, all SIJs were displaced Most of them displaced superiorly, posteriorly and laterally (42.8%) Ten cases had anteriorly, superiorly and medially displacement Additionally, the 12th, 16th and 42nd patient had the locking-type of SIJ injuries (significant medially displacements) which are the rare and complex 15 Table 3.11: Axially displaced direction of the Day injury type (n=36) Axial displacement Day I Day II Day III Total Upward displacement 11 14 30 Non-upward displacement Total 10 11 15 36 3.2.3.2 Degree of axial displacement of 56 injuries per 48 patients: Average displacement gap: 16.5 ± 1.7 mm Lowest displacement gap: mm (8 cases) Highest displacement gap: 56 mm 3.2.4 Associated injuries 3.3 Results of clinical study: When we hospitalized the patients at the Orthopaedic Department of Cho Ray Hospital, the patient was no longer in an emergency and the life-threatening injuries were under control Thus, the time point of surgical intervention was often late 3.3.1 Surgical time point and management of combined injuries - The time point of surgical intervention: The average time from injury to surgical procedure was 17 ± 11 days (5 – 68th days) - Anterior strengthening fixation: 8/48 patients used anterior iliac ring strengthening fixation (16.7%), the plates were the most used instruments (4/8 patients) - Management of associated injuries 3.3.2 Post-operative short-term outcomes 3.3.2.1 The primary wound healing rate: Primary wound healing: 44 patients (91.7%) Secondary wound healing: 04 patients (8.3%) 3.3.2.2 Results of SIJ fracture dislocation fixation - Remain postoperative displacement: Median value of remain displacement gap: 3.15 mm (0 mm - 36.9 mm) - Comparison of pre- and postoperative displacement: the average 16 displacement gap was improved: 11.7 ± 9.5 mm (range of improvement: - 47 mm) 3.3.2.3 Level of anatomic reduction: Assessment according to Lindahl's scale: excellent 66.1% (37 SIJ), good: 1.4% (12 SIJ), moderate 7.1% (4 SIJ), poor 5.4% (3 SIJ) 3.3.2.4 Outcomes of complications treatment § Management of post-operative complications: (1) Infectious complications: 04/48 patients Deep infection: 02 patients Superficial infection: 02 patients No patient had to remove the implants (2) Vascular complications: 01/48 patients, the superior gluteal branch of the internal iliac artery After Digital Subtraction Angiography (DSA) and occluding the artery, the hemodynamic status was stable § Management of associated injuries 3.3.3 Post-operative long-term outcomes: The average period of monitoring was 29.5 ± 13 months (6 – 60 months) 3.3.3.1 Bone healing results: All patients recorded bone healing on X-ray images 3.3.3.2 Result of functional rehabilitation: The degree of functional outcomes according to the Majeed’s score: Table 3.3 Functional outcome according to Majeed’s score Functional result Total Percentage (%) Excellent 42 87,5 Good 6,3 Moderate 2,1 Poor 4,2 Total 48 100 17 - The correlation of functional outcomes with morphology of injury: the difference is not statistically significant (p = 0.333) - The correlation of functional outcomes with the number of injured sides: the difference is not statistically significant (p = 0.687) - The correlation of functional outcomes with the time of surgical intervention: the difference is not statistically significant (p = 0.475) - The correlation of functional outcomes with the anatomic reduction: the difference is not statistically significant (p = 0.086) Chapter DISCUSSION 4.1 Characteristics of the study patient group 4.1.1 Etiology 4.1.2 Asociated injury 4.2 Characteristics of injuries on X-ray and CT-scan images 4.2.1 Injury morphology The SIJ fracture dislocation had the highest rate (53 SIJ - 94.6%) In which, SIJ dislocation with iliac wing fracture accounted for the highest rate (44.6%) In this type, the SIJ is partially or completely damaged but the posterior ligament is still attached to the posterior iliac fragment Consequently, it is necessary to fix the posterior iliac fragment and SIJ to stabilize the posterior part of the SIJ Many authors have noted that the post-operative results in cases of SIJ dislocation with posterior iliac fractures are better than those of pure SIJ dislocation because the entire anterior and posterior ligaments of the SIJ are ruptured in cases of pure SIJ dislocation In our study, there were cases of pure SIJ dislocation (5.4%) in which there were two cases of unilateral pure SIJ dislocation (the 37th patient (14 years old) and the 39th patient (16 years old) Most reports have noted that this is a rare injury and usually occurs in young 18 ... (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... 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... 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