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Introduction
  •  Epidemiology
    • incidence
      • rare and only accounts for 1-2% of cases of septic arthritis
    • demographics
      • more common in children over the age of 10 than adults
    • risk factors in adults
      • intravenous drug abuse
      • immune suppression
      • pregnancy
      • trauma
      • infective endocarditis
      • sepsis
      • TB
  • Pathophysiology
    • microbiology
      • staphylococcus aureus
        • is the causative organism in most of these infections
      • mycobacterium tuberculosis
        • skeletal tuberculosis accounts for 3–5 % of all tuberculosis, of which approximately 10 % occurs at the SIJ
      • Salmonella
        • seen in the setting of Sickle Cell Disease
Presentation
  • Symptoms
    • progressive low back and buttock pain
    • unable to bear weight on affected side secondary to pain
    • fever
  • Physical exam
    • pain worsened by
      • compression of the iliac wings
      • palpation of the right sacroiliac (SI) joint
    • motion
      • normal  hip range of motion
    • provocative tests
      • Faber test   
        • positive flexion, abduction and external rotation (FABER) test of the hip joint that dramatically aggravates the pain
Imaging
  • Radiographs
    • indication
      • painful SI joints
    • views
      • AP and lateral pelvis
    • optional views
      • inlet/outlet views
    • findings
      • joint destruction
      • partial or complete fusion
      • periarticular osteopenia
      • widening and cavitation
  • MRI
    • is the most sensitive diagnostic study for SIJ infection
    • findings in the acute phase 
      • intra-articular fluid or gas
      • subchondral bone marrow edema
      • articular and periarticular post-gadolinium enhancement and soft tissue edema
    • findings in chronic phase
      • periarticular bone marrow reconversion
      • replacement of articular cartilage by pannus
      • bone erosion
      • subchondral sclerosis
      • joint space widening or narrowing and ankylosis 
    • outcomes
      • more sensitive than CT scan
Studies
  • Serum labs
    • elevated WBC
    • elevated ESR (>50) 
    • elevated CRP (>70)
  • Blood cultures
    • may be positive and should be obtained prior to starting antibiotics
Treatment
  • Nonoperative 
    • antibiotics targeted towards the specific organsim
      • indications
        • first line of treatment
      • technique
        • target staph aureus in children if no organism is identified from blood cultures
  • Operative
    • surgical debridement only - rarely needed in children
      • indications
        • acute cases with abscess present
        • failed antibiotic treatment
        • the presence of sequestered bone
    •  debridement and SI joint arthrodesis  
      • indications
        • chronic cases
        • sequestered bone with joint narrowing/destruction
        • recurrent infection
      • outcomes
        • longer operative times
        • more complications
Complications
  • chronic pain
  • recurrent infection
  • delayed wound healing
  • hardware complications 
  • sepsis
 

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