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The JRGOS Case Corner is submitted by Ishaq Ibrahim, MD, JRGOS Board Member, and Orthopaedic Traumatologist at Beth Israel Deaconess Medical Center. Dr. Ibrahim is the 2024 Crawford Mentorship Award Recipient. Dr. Ibrahim was nominated for the JRGOS Mentorship award by his resident mentee Joe Ehiorobo, MD. Dr Ibrahim completed his orthopaedic residency at the Harvard Combined Orthopaedics Program and his traumatology fellowship at R Adams Cowley Shock Trauma Center.

Ishaq Ibrahim, MD

Case Presentation

History:

A 35-year-old male presents to the clinic with persistent lower back and anterior pelvic pain, ongoing since a motor vehicle collision that occurred abroad 1 year ago. At the time of the accident, he was diagnosed with a pelvic ring injury, which was managed non-operatively.

Physical Exam:

He reports tenderness over the pubic symphysis and bilateral sacroiliac joints, with pain elicited by provocative maneuvers. He is ambulatory, but with an unsteady, broad-based gait. Neurological and vascular examinations of the bilateral lower extremities are normal.

Diagnostic Imaging

X-ray Views:

Preoperative CT:

CT imaging confirms widening of the right SI joint and shows arthrosis of the left SI joint. MRI of the spine is negative for evidence of myelopathy.

Diagnosis

Neglected anterior-posterior compression pelvic ring injury

Treatment Plan

SI Joint injections

After an unsuccessful course of formal physical therapy, the patient was referred for sacroiliac (SI) joint injections as both a diagnostic and therapeutic intervention yielding excellent symptomatic relief on both sides. Given the positive response, surgical stabilization of the pelvic ring with bilateral SI joint fusion was indicated.

Intraoperative Video and Operative Plan

Fusion of pubic symphysis and bilateral SI joints

The pubic symphysis is exposed through a Pfannenstiel incision. The symphyseal cartilage is excised and prepped. A supracetabular external fixator is applied for reduction of the pelvic ring, and additional compression is achieved using an open compressor clamp. The pubic symphysis is plated and the SI joints are then fused utilizing a combination of iFuse 3D and TORQ implants.

Postoperative Course

Postoperative X-rays:

Pelvic series 5 months post-op showing stable pelvic ring without loosening or failure.

The patient is mobilized post-operatively with a walker and protected weight bearing on the right side for 8 weeks. At 3 months he is ambulating independently without pain and at 5 months returned to playing recreational soccer.

Implants

• Synthese symphyseal plate

• Synthese large external fixator with open compressor clamps, SI Bone iFuse 3D implants

• SI Bone iFuse Torque screws

Hot Tips, Pearls, & Pitfalls:

• Preoperative sacroiliac (SI) joint injections can serve both diagnostic and therapeutic purposes in assessing potential response to fusion surgery.

• During revision pelvic surgery, be mindful of bladder adhesions and scarring. Careful subperiosteal dissection is essential to prevent inadvertent bladder injury.

Submitted by Ishaq Ibrahim, MD