Surgical Treatment Options for Sacroiliac Joint Pain Robert

Surgical Treatment Options for Sacroiliac Joint Pain Robert Limoni MD Orthopedic Surgery and Sports Medicine Baycare Clinic 1

MYTH #1 The Si Joint Doesn’t Cause Pain 2

Prevalence of SI Joint Pain Is the SI Joint truly a problem? 15 -30% 32 -43% Component of chronic LBP Symptomatic Post-Lumbar Fusion 30, 0% 27, 0% 22, 6% 18, 5% De. Palma – Pain Med 2011 14, 5% Bernard 1987 Schwarzer 1995 Maigne 1996 Irwin 2007 Sembrano 2009 32% 35% 43% 40% Katz 2003 Maigne 2005 De. Palma 2011 Liliang 2011 3

Myth #2 The SI joint Doesn’t Move 4

SI Joint Motion Multi-planar motion – Simultaneously rotate and translate through 3 axes of motion Motions (<4° in any plane) – Nutation / Counternutation • Primary motion Males: 1 - 2° Females: 2 - 4° Sacral Translation – (A-P motion) up to 1. 6 mm Sturesson 1989 5

mechanics standing sitting 6

Myth #3 If the xray is normal, the joint is not abnormal 7

Mechanism of osteoarthritis hip knee This Photo by Unknown Author is licensed under CC BY-NC This Photo by Unknown Author is licensed under CC BY-SA 8

Mechanisms of degeneration Degeneration in the foot The Butt Bunion This Photo by Unknown Author is licensed under CC BY-NC-SA 9

Myth #4 Patients with SI problems are crazy! 10

i. Fuse Implant System® Publications 54 8 II/IIb …………………. . . 6 III ……………. …. 5 IV …. ………. 17 Reviews …………. 3 Economics ………. 5 Other …. . . 7 Biomechanics … 3 I …. . . …………………. October RCT (INSITE, i. MIA) 2017 Prospective, Multicenter Comparison Retrospective Case Series Systematic Review, Metaanalysis Cost-effectiveness, Productivity, etc. Complications, Survivorship, etc. Stability, Implant Placement, etc. 11

Complete References in Bibliography 12

Complete References in Bibliography 13

Complete References in Bibliography 14

Myth # 5 Fusion of a joint requires denuding all cartilage and penetration of the subchondral plate 15

i. Fuse Implant System® • Unique Patented Design – Triangular shape (minimizes rotation) – Interference press fit (immediate stabilization) – Porous titanium surface (promotes bony ongrowth/ingrowth for long-term fusion)* • Strength of Experience 29, 000+ procedures worldwide (November 2017) • Clinical Evidence – i. Fuse Implant™, available since 2009, is the ONLY device for treatment of SI joint dysfunction supported by multiple prospective clinical studies including 2 RCTs – More than 50 peer-reviewed publications * Mac. Barb G, et al. Int J Spine Surg. 2017: 11; 116 -28. 16

i. Fuse-3 D™ • Same proven triangular shape • 1 st 3 D-printed implant for the SI joint • Demonstrates Substantial Bone Ongrowth, Ingrowth, and Through Growth 1 – Porous surface mimics cancellous bone – Self-harvesting technology – Ability to apply graft material 1. Mac. Barb G, et al. Int J Spine Surg. 2017: 11; 116 -28. 17

MIS SI Joint Fusion Technologies Examples of existing and/or developing technologies. i. Fuse Implant is the ONLY SI joint fusion technology supported by multiple prospective clinical publications, including 2 Randomized Controlled Trials. (May 2017) SI-BONE: i. Fuse Implant System® Globus: SI-LOK Joint Fixation System Medtronic: Rialto Sacroiliac Joint Fusion System VG Innovations: Si. Join Posterior Sacroiliac Joint Fusion System X-spine Systems: Silex Sacroiliac Joint Fusion System Zyga Technology: SImmetry Sacroiliac Joint Fusion System 18

Myth #6 Si Fusions are for Neurosurgeons 19

i. Fuse Procedure Overview Incision Drill Pin Soft Tissue Protector Broach Insert Implant Measure Repeat (optional with sharp-tip broach) 20

History and Exam of the SI Joint 21

Exacerbating Activities Pain with Transitional Motions - Supine to painful side Sit to stand Rolling over in bed Getting in /out of bed Pain while Stationary Unilateral Weight Bearing - Sitting on affected side - Prolonged standing/sitting - Putting on Socks/Shoes - Ascending/Descending Stairs - Getting in and out of Car - Prolonged Walking (85% of gait cycle is single leg stance) Janda 1983 Sexual Intercourse 22 22

Active provocative tests This Photo by Unknown Author is licensed under CC BY-SA 23

SI Joint: Physical Exam Active Straight Leg Raise To assess functional pelvic stability • Sensitivity: 87% • Specificity: 94% Mens 2001 24

SI Joint Provocative Tests passive Distraction Compression Thigh Thrust Gaenslen’s FABER 3 of 5 positive tests provides discriminative power for diagnosing SI joint pain Szadek – J Pain 2009 Laslett – J Manip Ther 2008 25

SI Joint: Provocative Tests The following five provocative tests, when performed in combination are proven to have a high degree of sensitivity and specificity: 1. 2. 3. 4. 5. Distraction* (Highest PPV**) Thigh Thrust* FABER Compression* Gaenslen’s Maneuver Laslett Szadek 3 or more positive tests Sensitivity 91% 85% Specificity 78% 76% * Most sensitive tests ** PPV = positive predictive value Laslett 2005, 2008 Szadek 2009 26 26

SI Joint: Physical Exam Fortin Finger Test Point to pain while standing • Able to localize pain with one finger • Within 1 cm of PSIS (inferomedial) • Consistent over at least 2 trials Ask patient to point to location of primary pain • Below L 5: Consider SI joint • Above L 5: Consider lumbar spine etiologies Fortin & Falco 1997 27

Thank you! 28