Orthopedics - Oleksa A.P. 2006

Bone and Joint Tuberculosis
Tuberculous Sacroiliitis

Tuberculous sacroiliitis is classified as a severe form of joint disease because the sacroiliac joint has a complex Anatomical Structure that complicates Diagnosis, and surgical intervention demands extreme precision due to the close proximity of major neurovascular structures.

The sacroiliac joint is flat, irregular yet congruent, ear-shaped (articulatio auricularis), and has limited mobility; it is formed by the Articulation of the ilium and the sacrum. The Joint Capsule is exceptionally strong, taut, and attached to the bone margins adjacent to the articular Cartilage. Very robust ligaments stabilize the joint on both sides. The posterior and dorsal sacroiliac ligaments, which are intimately connected, secure the joint posteriorly, whereas the ventral sacroiliac ligament—up to 3 cm wide and tightly fused with the capsule of the upper joint and periosteum—spans the joint anteriorly. The iliac Muscle as well as the psoas Major and minor Muscles (m. ileopsoas) lie adjacent to it.

At the level of the sacrum, the fifth lumbar nerve passes between the lateral surface of the first sacral vertebral body and the sacroiliac articulation medially and laterally, crossing it between the upper and middle thirds.

Upon exiting the sacral foramen, the first sacral nerve courses laterally and inferiorly, crossing the sacroiliac articulation below the linea terminalis. These nerves lie on the periosteum, and at the level of the bone junction, on the capsule, to which they are anchored by fibrous structures. The remaining sacral nerves do not cross this osseous junction.

In the region of the sacroiliac joint, sharing the same fascial plane as the nerves, are the iliolumbar artery and vein, which bifurcate at this level into the external and internal iliac Arteries; the latter branches extensively within the pelvic adipose tissue to supply the pelvic Organs, while its terminal branch (the superior gluteal artery) exits the pelvis alongside the sciatic nerve (n. ischiadicus) through the greater sciatic notch (incisura ischiadica major).

We have briefly reviewed the Anatomy of the sacroiliac articulation and the adjacent neurovascular plexus to emphasize the necessity for meticulous surgical technique should an operation be required.

Surgery for tuberculous sacroiliitis may be performed across all Phases of the tuberculous disease process.

In cases of tuberculous osteitis (during the prearthritic phase) located in one of the bones adjacent to the joint, the lesion is surgically excised via an appropriate bone approach. In the presence of Arthritis (the arthritic phase), the Procedure of choice is conservative resection according to Pokatylov.

Surgical technique. With the patient positioned in lateral recumbency on the unaffected side, under general anesthesia with comprehensive Anesthetic Management, the joint area is exposed using the Smith-Petersen approach. An osteotome is then placed on the bone at the midpoint of the greater sciatic notch (incisura ischiadica major) and advanced from inferior to superior, osteotomizing the ilium parallel to the joint plane all the way to the posterior superior iliac spine (spina iliaca posterior superior). The osteotomy of the sacrum is performed parallel to the first, offset by 1 cm from the joint.

In the upper region, the previous cuts are connected transversely using an osteotome, and the U-shaped segment of excised bone is removed together with the lower half of the joint.

If caseous osteonecrosis is present in the adjacent bone areas, they are curetted using a sharp Volkmann spoon. Joint arthrodesis is not performed. The wound is irrigated with an antibiotic solution, closed, and drained for 24–48 hours if necessary.

In arthritic sacroiliitis accompanied by abscess extension into the sacral foramina or the sacral canal, the procedure is supplemented by unroofing these foramina up to the sacral canal, followed by the removal of caseous masses, pus, and sequestra.

If the tuberculous focus is located in the anterior region of the sacroiliac joint in the presence of an intrapelvic abscess, Nychay's procedure is performed via an intrapelvic subperiosteal approach.

Surgical technique. With the patient in lateral recumbency on the unaffected side under general anesthesia, an arcuate incision is made along the iliac crest from the upper margin of the transverse process of the fifth lumbar vertebra to the anterior superior iliac spine (spina iliaca anterior superior). The Tissues, including the Abdominal muscles originating from the iliac crest, are divided layer by layer. The wound edges are then retracted, the periosteum is detached along the crest and elevated from the bone using a raspatory down to the greater sciatic notch (incisura ischiadica major), while gently retracting the iliac muscle (m. iliacus).

If an intrapelvic abscess is encountered, it is lavaged under pressure. A Volkmann spoon is used to remove the focus of bone destruction along with sequestra, caseous material, and granulation tissue. It is essential to excise all pathological tissue within healthy bone margins. The wound is flooded with an antibiotic solution and closed primarily in layers. When indicated, an aspiration drain is left in the wound for 2 to 3 days.

Postoperatively, patients are nursed in a plaster bed for 4–5 months, continuing with antibacterial therapy, hematopoiesis and immune system stimulants, protein infusions (and fresh Blood transfusions when necessary), alongside a balanced, vitamin-rich diet.

Thus, for the synovial form of sacroiliitis and osteitis involving one of the bones adjacent to the joint, Pokatylov’s conservative resection is performed, whereas destruction in the anterior joint compartments warrants Nychay’s intrapelvic subperiosteal operation. For extensive joint involvement complicated by cold abscesses, an extended U-shaped or combined resection with abscess evacuation is carried out.

Comprehensive Treatment of sacroiliitis, tailored to the localization of the lesion and the extent of destructive changes, can lead to complete patient recovery within 10–12 months.