Surgical treatment of sacroiliac joint infection

Abstract

Sacroiliac joint infection is rare and frequently missed; purpose of this study is to describe the clinical presentations, comorbidities, laboratory and imaging findings, surgical options and outcomes of this rare condition.

We reviewed all cases of Surgical treatment of sacroiliac joint infection operated at our institution between January 1994 and December 2011. Twenty-two patients were included: 14 females and 8 males, with mean age of 50 years. The mean follow-up period was 34 months. Twenty-four operations were performed. Coinciding infection was found in 11 cases (50 %). Twelve patients (54.5 %) presented acutely, while ten patients (45.5 %) had chronic infection.

Tuberculous infection was diagnosed in 5 cases and nonspecific infection in 13 cases. In four cases, no organism was isolated. Eleven cases were subjected to debridement only, while debridement and arthrodesis was needed in 11 cases. Eight patients had excellent clinical results, five good, three fair and four poor; one patient was lost to follow-up, and one patient died after 2 weeks. The operative technique depended on the course of the infection, bone destruction and general condition of the patient. There was a significant change in C-reactive protein and erythrocyte sedimentation rate preoperatively and 6 weeks postoperatively, while the difference in white blood cell count was nonsignificant.

In acute cases, the primary aim should be to save joint integrity by early debridement, depending on joint destruction and general patient condition. When it is chronic, it is not secure only to debride the joint, which should be fused.

J Orthopaed Traumatol (2013) 14:121129 DOI 10.1007/s10195-013-0233-3

ORIGINAL ARTICLE

Surgical treatment of sacroiliac joint infection

Hamdan Ahmed Ahmed Ezzat Siam

Gouda-Mohamed Gouda-Mohamed

Heinrich Boehm

Received: 11 August 2012 / Accepted: 4 March 2013 / Published online: 5 April 2013 The Author(s) 2013. This article is published with open access at Springerlink.com

AbstractBackground Sacroiliac joint infection is rare and frequently missed; purpose of this study is to describe the clinical presentations, comorbidities, laboratory and imaging ndings, surgical options and outcomes of this rare condition.

Materials and methods We reviewed all cases of surgical treatment of sacroiliac joint infection operated at our institution between January 1994 and December 2011. Twenty-two patients were included: 14 females and 8 males, with mean age of 50 years. The mean follow-up period was 34 months. Twenty-four operations were performed. Coinciding infection was found in 11 cases (50 %). Twelve patients (54.5 %) presented acutely, while ten patients (45.5 %) had chronic infection.

Results Tuberculous infection was diagnosed in 5 cases and nonspecic infection in 13 cases. In four cases, no organism was isolated. Eleven cases were subjected to debridement only, while debridement and arthrodesis was needed in 11 cases. Eight patients had excellent clinical results, ve good, three fair and four poor; one patient was lost to follow-up, and one patient died after 2 weeks. The operative technique depended on the course of the infection, bone destruction and general condition of the patient.

There was a signicant change in C-reactive protein and erythrocyte sedimentation rate preoperatively and 6 weeks postoperatively, while the difference in white blood cell count was nonsignicant.

Conclusions In acute cases, the primary aim should be to save joint integrity by early debridement, depending on joint destruction and general patient condition. When it is chronic, it is not secure only to debride the joint, which should be fused.

Keywords Sacroiliac joint infection

Pyogenic sacroiliitis Tuberculous sacroiliitis

Sacroiliac fusion

Introduction

Isolated sacroiliac joint (SIJ) infection is rare. Between 1878 and 1990, only 166 cases were documented in the English-language literature [1], although pyogenic sacroiliitis is estimated to account for 12 % of cases of septic arthritis or bone infection [2]. Skeletal tuberculosis accounts for 35 % of all tuberculosis, of which approximately 10 % occurs at the SIJ [3]. Predisposing factors include intravenous drug abuse, immune suppression, pregnancy, trauma and infection elsewhere in the body [4]. However, in over 40 % of patients, the primary site of infection may never be identied [1, 5]. Clinical ndings may be obscured, but usually include buttock pain and limping. In severe cases, the patient may be unable to nd a comfortable position in bed and demonstrates a positive exion, abduction and external rotation (FABER) test of the hip joint that dramatically aggravates the pain. Fever is not a constant nding [6]. Accurate diagnosis is frequently delayed due to lack of awareness of the condition

Parts of this study have been presented as an abstract in the 7th German Spine Conference in Stuttgart, Germany, December 68, 2012. Eur Spine J (2012); 21(11):2324405. doi:http://dx.doi.org/10.1007/s00586-012-2522-6

Web End =10.1007/s00586-012-2522-6 . Epub 2012 Sep 27.

H. Ahmed A. E. Siam (&) G.-M. Gouda-Mohamed

H. BoehmDepartment of Spinal Surgery and Paraplegiology, Zentralklinik Bad Berka, Robert Koch Allee 9, 99438 Bad Berka, Germanye-mail: [email protected]

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Table 1 Demography, associated infections and comorbidities

Case Age (years)

Sex Main presentation

Other infections Comorbidities Previous operations Affected side

Course

None None Left Chronic

2 42.4 F Fistula Spondylodiscitis L5S1 None Multiple curettage operations before 6 months

Left Chronic

1 42.5 M Fistula Pulmonary tuberculosis, epididymitis

3 63.1 M Acute paraplegia

Spondylodiscitis T78, acute necrotising cholecystitis

Incomplete paraplegia subT7, diabetes mellitus

T78 fusion before2 months

Left Acute

4 56 M Fistula Psoas abscessa None Multiple operations in SIJ

Right Chronic

5 24.8 F Local pain Broncho-pneumonia, psoas abscess, staphylococcal septicaemia

Anorexia nervosa (body weight 36 kg)

None Left Chronic

6 68.8 F Local pain Spondylodiscitis L23, epidural abscess

Cardio-respiratory insufciency, diabetes mellitus, morbid obesity

None Right Acute

7 64.1 M Local pain Psoas abscessa None None Left Chronic

8 44.1 M Local pain None None None Right Acute

9 30.3 F Local pain Staphylococcal septicaemia None None Right Chronic

10 63.3 F Sciatic pain None Rectal carcinoma (radio-and chemotherapy)

Cortisone local injection

Right Acute

11 61.4 F Back pain None None Seven operations in SIJ before 30 years

Right Chronic

12 25.2 M Difcult weight bearing

None None None Left Acute

None None Left Acute

13 65.6 F Difcult weight bearing

Psoas abscess, epidural abscess

14 45.9 F Difcult weight bearing

None None None Right Acute

15 43.1 F Acute paraplegia

Chronic leg ulcerations, incomplete paraplegia sub T9 with spondylodiscitis T910

None None Left Acute

16 42 F Local pain None Morbid obesity Local injection Right Acute 17 79.6 F Acuteparaplegia

Spondylodiscitis L23 Morbid obesity Bone graft before

2 years, same side

Right Acute

None Left Acute

19 44.3 F Local pain None None None Left Chronic

20 52.8 M Local pain Spondylodiscitis L5S1, psoas abscess, sacral decubitus ulcer

Complete paraplegia sub T7, diabetes mellitus, morbid obesity

18 68.5 F Back pain Candida sepsis, staphylococcal sepsis, sacral decubitus, acute bronchitis

Cardio-respiratory insufciency, multiple organ failure, corticosteroid therapy

Myocutaneous ap before 7 years because of sacral decubitus ulcer

Bilateral Chronic

21 16.6 M Local pain None None None Left Acute

22 54.7 M Sciatic pain None None None Right Chronic

a Psoas abscess alone was not considered as an associated infection because it is a part of the SIJ infection process itself

by clinicians, non-specic clinical presentation and poorly localising signs of infection; mimicking features of septic arthritis of the hip, osteitis of the ilium and lumbar disc

herniation [79]. Magnetic resonance imaging (MRI) has been proved to be the best tool for early diagnosis of SIJ infection. MRI ndings in the acute phase are intra-

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Table 2 Preoperative imaging and laboratory ndings preoperatively and 6 weeks postoperatively in patients with non-specic infection

Case Preoperative imaging Preoperative lab 6 weeks postoperative

Radiographs MRI CT WBC (/mm3)

ESR (mm/h)

CRP (mg/dL)

WBC (/mm3)

ESR (mm/h)

CRP (mg/dL)

3 Periarticular osteopaenia

Bone and iliacus and gluteal muscle oedema and abscess formation

13,700 70 87 8,400 12 21

5 Sclerosis and narrowing of joint space

Localised area of uid in the joint

Sclerosis and cavitation

13,400 92 250 9,600 33 46

6 Normal Abscess and oedema in gluteal muscle

10,600 89 117 7,100 19 57.2

7 Partially fused joint and localised area of cavitation

Localised cavity with uid signal

7,800 79 27.5 9,000 83 18.7

8 Normal Periarticular bone oedema, uid signal in the joint and soft tissue

4,300 66 65.2 6,300 32 11.4

9 Narrow joint Abscess formation and soft tissue and bone oedema

Joint narrowing and destruction

9,800 73 81.3 5,700 26 7.9

10 Sclerosis and cavitation

Posterior abscess formation 15,500 133 251.7 7,600 93 10.1

12 Normal Periarticular oedema and uid signal

19,700 64 255.4 8,700 55 13.3

13 Normal Fluid signal in joint and bone oedema

10,900 83 90.5 6,900 64 16.9

14 Widening of the joint space

Fluid signal in the joint and periarticular oedema

Joint widening and sclerosis of the edges

12,200 128 135.1 7,900 29 12.6

15 Widening and cavitation of the joint surfaces

Abscess formation and bone and soft tissue oedema

Widening and localised cavitation

8,800 78 110 8,300 32 5.6

16 Wide joint with sclerosis

Abscess formation and soft tissue oedema

3,600 103 104 6,800 61 12.7

17 Wide joint Tissue and joint uid signal Joint widening 11,800 74 153.2 7,600 71 55.6

18 Normal Fluid in the joint and adjacent tissue anteriorly

13,600 86 79 27,400 51 65.3

19 Periarticular osteopaenia

Bone oedema and uid signal in the joint

4,800 46 9.7 4,900 20 1.5

21 Normal Fluid signal, periarticular and in the joint

10,100 77 258.7 7,300 39 16.8

22 Widening and cavitation

Abscess and soft tissue oedema posterior and anterior

Sclerosis and cavitation of the joint

5,000 38 7.6 5,900 73 13.1

articular uid, subchondral bone marrow oedema, articular and periarticular post-gadolinium enhancement and soft tissue oedema, and in the chronic phase: periarticular bone marrow reconversion, replacement of articular cartilage by pannus, bone erosion, subchondral sclerosis, joint space widening or narrowing and ankylosis [10]. The purpose of this study is to describe the authors experience regarding the clinical presentations, comorbidities, laboratory and radiological ndings as well as operative options and postoperative outcome of sacroiliac joint infections.

Materials and methods

This is a retrospective clinical study in a single facility. Between January 1994 and December 2011, 22 patients were operated in our institution for treatment of sacroiliac joint infection. Cases of non-infectious sacroiliitis and conservatively treated infections were excluded from this study.

The criteria for diagnosis were: clinical; local pain and tenderness in the SIJ, limping, clinical manifestations and laboratory ndings suggesting infection [chemical:

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Table 3 Preoperative imaging and laboratory ndings preoperatively and 6 weeks postoperatively in patients with tuberculous infection

Case Preoperative imaging Preoperative lab 6 weeks postoperative

Radiographs MRI CT WBC (/mm3)

ESR (mm/h)

CRP (mg/dL)

WBC (/mm3)

ESR (mm/h)

CRP (mg/dL)

1 Joint destruction and sclerosis

Fluid signal 5,100 59 38 7,300 81 30

4,600 95 48 5,200 32 13

4 Partially fused Localised uid cavity 5,600 112 40 7,100 42 15

11 Fused joint Abscess above the joint Fused joint with cavity

13,600 34 35.6 13,400 38 7.8

2 Bone sclerosis and partially fused joint

Localised uid signal in the joint

Fused joint with localised cavitation

20 Partially fused joint Fluid signal in the sacrum and parts of the joint

Sclerosis and cavitation of the sacrum

8,300 60 125.6 5,000 48 48.5

elevated white blood cell (WBC) count, C-reactive protein (CRP) and/or erythrocyte sedimentation rate (ESR); and microbiological: positive blood and/or intraoperative culture], in association with early MRI and late radiographic changes in the SIJ (periarticular bone destruction and cavitation, joint space widening, sclerosing); all conrming the diagnosis. Cases of non-specic infection were considered acute when presenting within 1 month of onset of clinical symptoms and chronic when presented later. All tuberculous cases were chronic.

The mean follow-up (FU) period was 34 months (690 months). One patient was lost to FU, and one patient died 2 weeks after surgery due to multiple organ failure.

Clinical examination, laboratory investigations and plain radiographs were done routinely: preoperatively, 1 day and 2 weeks postoperatively and at the FU visits (6 weeks, 3 months, 1 year postoperatively and then every 2 years). Patients were followed up by their family physicians for clinical or laboratory changes. MRI was done preoperatively, after 3 months and 1 year (and when recurrence was suspected). Computed tomography (CT) was needed preoperatively only in nine cases for assessment of bone destruction and postoperatively for assessment of bony fusion, only when symptomatic.

Surgery was indicated (from senior authors experience, H.B.) in cases of failure of conservative measures, abscess formation from the beginning, bone destruction, septicaemia or neurological decits.

All patients underwent operative treatment in the form of debridement with or without joint arthrodesis. The surgical approach was either posterior, anterior or combined anterior and posterior. The localisation of the infection (abscess and soft tissue inltration) as demonstrated by MRI dictated the operative approach.

Postoperative treatment included culture-based antimicrobial therapy or broad-spectrum antibiotic therapy when

no organism was isolated, for 6 weeks in non-specic infections and 612 months in tuberculous infections.

We concluded the nal functional outcome by questionnaires including Odoms criteria [11] that categorised patients satisfaction into four grades of excellent, good, fair and poor as follows:

Excellent: all preoperative symptoms relieved, abnormal ndings unchanged or improved;

Good: minimum residual of preoperative symptoms not requiring medication or limiting activity, and abnormal ndings unchanged or improved;

Fair: denite relief of some preoperative symptoms with others remaining unchanged or only slightly improved;

Poor: symptoms and signs unchanged from preoperative status or worse.

The infection was considered to be healed by the disappearance of clinical symptoms (pain, fever, stula etc.) and laboratory parameters of infection (WBC, CRP and ESR) as well as radiographic and MRI conrmation of subsidence of infection (disappearance of bone oedema, abscess resolution etc.).

The joint was considered to be fused by the following radiographic criteria (when fusion is doubtful, follow-up CT after 1 year is advisable):

1. Absence of radiolucency crossing the entire joint space2. Side-wall fusion and inter-run fusion3. Absence of loosening or metal compromise in plain radiographs

4. Clinically: absence of local symptoms of the joint (pain and tenderness)

Descriptive statistics were determined by calculation of the mean, standard deviation and range. Statistical analysis was needed to compare the preoperative laboratory

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Clinical

outcome

86Excellent

Antimicrobialtherapy(months)Follow-up

(months)

1DebridementandfusionPosteriorBonegraftandscrews90450M.tuberculosisRifampicin?isoniazid(6)25Good

2Debridementand

sequestrectomy

PosteriorNone50300M.tuberculosisRifampicin?isoniazid(12a )Lost

Bonegraft110500S.aureusClindamycin(3)18Good

4DebridementPosterior/posteriorb None45/35320/480M.tuberculosisRifampicin?isoniazid(6)6Poor

5DebridementandfusionPosteriorBonegraftandscrews70375S.aureusAmpicillinsulbactam(2)7Excellent

6DebridementPosteriorNone30175S.aureusFlucloxacillin(2)8Poor

7DebridementPosteriorand

anterior

None601,000NoorganismCiprooxacin(3)37Excellent

Bonegraftwithcageandscrews130600S.aureusClindamycin(3)90Excellent

Bonegraftwithcageandscrews215750S.aureusClindamycin(3)49Excellent

10DebridementPosteriorNone60190S.aureusCefuroxime(3)21Good

11DebridementPosteriorNone1570M.tuberculosisCiprooxacin(4),

ethambutol?rifampicin?isoniazid?

pyrazinamide(6)

None60100S.aureusFlucloxacillin(3)80Excellent

13DebridementAnteriorNone45300S.aureusCiprooxacillin(3)61Fair

14DebridementandfusionAnteriorBonegraftwithcage95400S.aureusClindamycin(3)53Fair

15DebridementandfusionAnterior/anteriorb Bonegraftthenbonegraftwith

cage

270/160300/700E.faecalisFlucloxacillin(3)42Poor

16DebridementandfusionAnteriorBonegraftwithcage100100S.aureusClindamycin(3)15Excellent

17DebridementandfusionAnteriorBonegraft30200NoorganismCiprooxacin(3)8Excellent

18DebridementAnteriorNone80250S.aureusClindamycin(2a )Died

19DebridementPosteriorNone1050NoorganismFlucloxacillin(2.5)36Fair

20DebridementandfusionPosteriorBonegraft95300M.tuberculosisNitrofurantoin?rifampicin?isoniazid(6)9Poor

21DebridementPosteriorand

anterior

None130500S.aureusFlucloxacillin(0.5)21Good

Bonegraftwithscrews185200NoorganismClindamycin(3)7Good

Causative

organism

Bloodloss

(ml)

a Bothvaluesindicatetheintendedperiodofantimicrobialtherapy,whichwasinterruptedbypatientdeathorlossofFU

b Patientswhounderwenttwooperations

Table4Operativeandpostoperativeresults

CaseOperationtypeApproachFusionmethodOperativetime

(min)

3DebridementandfusionPosteriorand

anterior

8DebridementandfusionPosteriorand

anterior

9DebridementandfusionPosteriorand

anterior

12DebridementPosteriorand

anterior

22DebridementandfusionPosteriorand

anterior

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Fig. 1 Diagram comparing the mean operative time of surgery

ndings versus the 6-week postoperative values using the Wilcoxon signed-rank test, and statistical signicance was dened as p \ 0.05.

This study has been approved by the institutional ethics committee in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki. All persons included in the study gave their informed consent to have their data and diagnostic ndings involved in medical research prior to their inclusion in the study.

Results

Twelve patients (54.5 %) presented acutely, while ten patients (45.5 %) had chronic infection (Table 1). Marked weight loss was reported by two patients (9.1 %). At time of admission, coinciding infection was found in 11 cases (50 %), of which 6 cases were spondylodiscitis and 1 case was epidural abscess. Eight patients had received antimicrobial therapy.

Radiographs were done preoperatively in all patients. In the acute stage of non-specic infections it appeared to be normal, while in chronic cases it showed blurring of the outlines of the sacroiliac joint, widening of the joint space, periarticular osteopaenia, sclerosis and erosion of the joint margins. MRI was done preoperatively for all patients. It demonstrated abscess formation in the piriformis, iliacus, gluteus or iliopsoas muscle as well as inammatory signal changes in the surrounding soft tissues. Anterior capsule may be stretched or damaged. Other ndings included: bone oedema, soft tissue inltration and myositis. CT was done preoperatively in nine cases with chronic infection and showed joint space widening, sclerosis of the margins of the joint, cavitations and sequestrum formation (Tables 2, 3).

Laboratory ndings

In tuberculous infection, mean values were as follows: C-reactive protein (CRP) of 57.44 38.39 mg/dL, erythrocyte sedimentation rate (ESR) of 72 31.17 mm/h and white blood cell (WBC) count of 7,440 3,729/mm3.

Postoperatively, the mean CRP was 22.86 16.54 mg/dL, ESR was 48.2 19.24 mm/h and WBC was 7,600 3,410/mm3 (Table 3). In non-specic infection, the mean CRP was 122.52 84.74 mg/dL, ESR was 81.12 24.32 mm/h and WBC was 10,329.4 4,343/mm3, while postoperatively CRP was 22.69 19.92 mg/dL, ESR was46.65 24.29 mm/h and WBC was 8,552.9 5,012/mm3 (Table 2). The change was statistically signicant for CRP and ESR (p \ 0.001 and =0.001, respectively), while in

WBC the difference was nonsignicant (p = 0.082).

Operative treatment

Eleven cases (50 %) were subjected to debridement only, while debridement and arthrodesis was needed in the other 11 cases. Two patients required revision because of recurrent infection (after complete healing); one was posteriorly debrided for the second time, and one had attempted fusion through anterior approach and was reoperated with a stand-alone cage; i.e. this study included 24 surgeries in the 22 reviewed patients (Table 4). The mean operative time for debridement without fusion was 35 min for posterior approach, 62.5 min for anterior approach and83.33 min for combined anterior and posterior approaches, while in debridement and fusion it was 85, 131 and 160 min, respectively (Fig. 1).

The causative organism was Mycobacterium tuberculosis in 5 cases (22.7 %), Staphylococcus aureus in 12 cases(54.5 %) and Enterococcus faecalis in 1 case. In four cases, no organism was isolated (Table 4).

The postoperative immobilisation period depended on the general condition of the patient and the operative technique. Postoperative treatment included culture-based antimicrobial therapy or broad-spectrum antibiotic therapy when no organism was isolated (Table 4).

Outcome

Functionally, eight patients had excellent results (40 %), ve good (25 %), three fair (15 %) and four poor (20 %) (Table 4).

Sound fusion was achieved in ten cases (50 %) within the rst year after surgery; in the other ten cases, no signs of fusion were found in nal radiographs.

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Fig. 2 a Case 9: MRI performed after admission showed high signal intensity in the right SIJ and adjacent muscles with abscess formation and bone oedema. b CT revealed widening of the joint space, cavitations and sequestrum formation. c Postoperative radiograph revealed good position of the cage and screws. The patient was allowed to bear weight with assistance after 6 weeks and to fully bear

weight after 4 months, after conrmation of bony fusion of the joint. After 1 year, the patient had no complaints and was satised. d FU radiographs showed complete bony fusion of the joint. At the last FU visit (49 months postoperatively), she had excellent functional outcome, no pain and no limitations of daily activity. She returned to work and practised sport regularly

Complications included recurrence of infection in two cases, delayed wound healing in three cases and chronic pain in three cases.

Discussion

SIJ infection is a rare condition [1] which is usually associated with multiple predisposing factors and infection elsewhere in the body [4]. Clinically, it may be obscured by hip pain and poorly localising signs of infection with or without fever [69].

Despite the limitations of this retrospective study, including a relatively heterogeneous group of patients with

a wide variation of preoperative conditions and surgical methods and the lack of similar studies to compare with, it represents the largest series of surgical treatment of this rare condition. It identies the clinical, laboratory and radiological ndings as well as surgical options and outcomes of this joint infection.

Bacterial infection of the SIJ is thought to occur most commonly by haematogenous spread [5, 12]. Vyskocil et al. [1] reviewed 166 reported cases of septic sacroiliitis and demonstrated that no associated factors were noted in 41 % of patients. In this series, there was an associated infection in 11 patients (50 %). Comorbidities were present in eight patients (36.36 %). The diagnosis of SIJ infection should be suspected in the presence of certain clinical,

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Fig. 3 a Case 12: MRI performed 1 week after onset of the patients symptoms showed high signal intensity in the left SIJ and iliacus muscle with abscess formation. The patient was operated by combined anterior and posterior debridement. Full mobilisation was

allowed after 2 weeks. The patient was satised. b FU MRI after 2 months revealed no more abnormal inammatory signals. At the last FU visit after 80 months, the patient had excellent functional outcome

laboratory and radiological ndings. The clinical symptoms are local sacroiliac pain, low back pain with or without sciatic pain, associated with inability to bear weight in most cases. On the other hand, fever was not a constant presenting symptom [6]. In our study, only four patients (18.2 %) had fever. Other presenting symptoms included stula and abscess formation. On local examination, there was always tenderness on direct pressure over the joint with positive Gaenslens and FABER tests in all patients, which is consistent with the ndings of Delbarre et al. [6] and Ramlakan and Govender [13].

Murphy et al. [14] showed that MRI in comparison with CT is both more sensitive for early diagnosis and superior in evaluation of cartilage integrity and early detection of osseous erosions in patients with inammatory and infectious sacroiliitis. In our series, MRI was done in all patients preoperatively, while CT was done in only nine cases(40.1 %), in chronic cases for assessment of the extent of bony destruction and operative planning. Isotope bone scanning is a helpful tool for diagnosis; however, it has three main disadvantages: the inability to differentiate infectious from non-infectious sacroiliitis [2, 8, 12, 15], the inability to differentiate sacroiliitis from psoas or gluteal abscess and the inability to identify spread of the infection from the joint into the surrounding tissues [16].

Our clinical results were excellent or good in 13 patients (65 %), these results being comparable to those of Schubert et al. [17], who performed debridement and primary arthrodesis in nine patients with pyogenic SIJ infections (Figs. 2, 3, 4).

There is debate over whether to perform arthrodesis of the joint or to limit surgery to drainage of the abscess and debridement of the joint. The operative management of SIJ

infections, from our experience, consists of debridement in cases of acute soft tissue infection or cases of mild bone destruction. Joint arthrodesis is recommended in generally ill patients even with mild joint destruction for early

Fig. 4 a Case 11: Preoperative MRI showed localised area of high signal inammatory intensity in the right SIJ. The SIJ was debrided posteriorly. The patient was allowed to fully bear weight after 2 weeks. b CT conrmed solid joint fusion after 1 year. The last clinical FU after 86 months showed excellent outcome, no pain and normal daily activities

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Fig. 5 Flowchart of the recommended treatment pathway

assisted mobilisation as well as in patients with chronic joint affection (Fig. 5).

In acute cases, the primary aim should be to save joint integrity by early debridement, depending on joint destruction and general patient condition. When it is chronic, it is not secure only to debride the joint, which should be fused.

Acknowledgments Special thanks go to Mrs. Marufke and Mrs. Haedicke, who helped our team to collect and scan old documents and materials from medical records.

Conict of interest None.

Open Access This article is distributed under the terms of the Creative Commons Attribution License which permits any use, distribution, and reproduction in any medium, provided the original author(s) and the source are credited.

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