Management of Instability following Pyogenic Sacroiliitis
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Septic arthritis of the sacroiliac joint (SI-joint) is a rare and often delayed diagnosis. Management usually consists of intravenous antibiotics and debridement of infected tissue. However, very few reports consider the management of the secondary instability of the sacroiliac joint

A 16-year-old girl with fever and low back pain radiating to the left buttock. A viral coxitis was diagnosed, and the patient was sent home with NSAIDs and bed rest. Because of progressing pain and inability to walk, the patient presented in the emergency room 5 days later. Upon examination, she was febrile, and palpation of the SI-joint and coccyx was painful. Neurological examination was normal. Laboratory findings showed increased C-reactive protein (318 mg/l) and leucocytosis (14.2 G/l).

MRI of the pelvis and SI-joints showed a bulge in the intra-articular capsule of the left SI-joint and bone remodelling. Blood cultures were sampled, and ultrasound-guided aspiration was performed. Direct examination revealed gram-positive cocci. Intravenous antibiotics (daptomycin 350 mg/day) were started following the aspiration. Cultures became positive for S. aureus, and antibiotic treatment was switched to gentamicin.

Antibiotherapy was subsequently switched to flucloxacillin. Five days after initial treatment, because of increasing fever and inflammation markers, a new MRI was performed, showing abscesses anterior to the left SI-joint. Surgical debridement was performed, using the Olerud approach to the SI-joint. After aggressive debridement and evacuation of pus, there was obvious instability of the SI-joint in the lateral-medial and craniocaudal directions. Therefore, even in the absence of significant joint destruction in the preoperative MRI, an arthrodesis was performed using two titanium reconstruction plates angulated with each other. In addition, Vancomycin-loaded calcium sulphate pellets were added inside and around the articulation to provide a high local concentration of Vancomycin as described before
Four days later, because of recurring pain, a new MRI was performed, showing a surgical site hematoma, which was evacuated.

Subsequent clinical course was favorable; the patient was discharged at day 26 with some residual pain, normalized inflammation markers of infection, and 15 kg partial weight-bearing on the operated leg. After 6 weeks, she did not have any episode of fever and only little pain on palpation of her left SI-joint. Intravenous antibiotics were given for 9 weeks in our outpatient department, and 30 kg partial weight-bearing on the operated leg was allowed for 6 more weeks. Biological inflammatory markers were normal, and an anteroposterior pelvic radiograph was satisfactory after 3 months. After 4 months, the patient was pain-free and could perform her usual activities without any restriction. Before allowing heavier sports activities, a CT scan was performed at 4 months revealing the first signs of joint fusion without osteolysis or secondary displacement. One year after surgery , the SI-joint was no more visible on the pelvic radiograph as a sign of complete SI-joint fusion.

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