Posterior Recess with Nadia implant SI Joint Fusion
Guy R. Fogel, MD, FAAOS Contents Minimally Invasive Procedures SI Joint Fusion posterior recess
Posterior Recess Sacro-iliac Joint fusion with Nadia from Ilon
The involvement of the SIJ in low back complaints has been suspected for many years. It was not until recently, that the means of diagnosis and more effective treatment have made it clear that the SIJ is a significant pain generator which often mimics the pain of the hip or spine.
The diagnosis of sacroiliac disease is established by a process of inclusion (sacroiliac-type findings such as regional posterior hemipelvic pain and imaging changes), and exclusion (ruling out similar complaints of pain of the hip or spine).
The pain of the sacroiliac joint is most well understood as following an osteoarthritis model. The great majority of painful sacroiliac joints demonstrate visible manifestations of degenerative change including cartilage loss, sclerosis, and osteophyte formation. Subluxation, osteophyte formation, and capsular distention may compress the nerves or cause irritation of the overlying lumbar plexus. These symptoms often resemble radicular symptoms from lumbar spine or hip related causes.
The neurovascular anatomy surrounding the sacroiliac joint is amenable to the proper surgical approach. For this reason, the guide pin of the NADIA technique approaches the sacroiliac articulation within the safety of the recess and exits into the safety of the interior of the anterior pelvic bone. The NADIA NeuroSafe ® posterior approach never crosses critical neurovascular anatomy. Safety is planned into every step.
You may need to obtain crutches or a walker for use after surgery. You will be partial weightbearing on that side for 4-6 weeks. Your doctor will help you decide which type is best for you and tell you where to get them. You will be told when to stop eating and drinking before surgery. It is critical to inform your doctor if you are taking any blood thinning medication. At the hospital, your temperature, pulse, breathing and blood pressure will be checked. An IV (intravenous) line may be started to provide fluids and medications needed during surgery.
The NADIA implant system utilizes a posterior medial approach to bridge the sacroiliac joint. This unique approach works within the lines of tissue tension to avoid and protect nerves, blood vessels, fascial tissue and muscle structure. The surgical approach is reproducible and preserving the anatomy is a priority. The midline incision allows access to the biomechanical weightbearing axis.
SI joint fusion is performed in an operating room with either general or spinal anesthesia. Typically, you will be positioned lying face down. Your surgeon will use a specially designed system to guide the instruments that prepare the bone and insert the implants.
(Image 1) The NADIA implant is Ti and HA coated with distraction threads and is thimble sized.
The entire procedure is performed through a midline posterior incision (approx. 3 cm long), working laterally into the posterior recess of the SI joint. During the procedure, fluoroscopy provides your surgeon with live imaging to enable proper placement of the implants. Typically, one implant is used and sized in length and width to your anatomy.
(Image 2) Here is an artist representation of the Nadia implant in the posterior recess of the SI joint
(image 3) Here is a CT showing successful ingrowth of bone across the NADIA implant and the recess.
The procedure takes approximately one hour. You may feel comfortable enough to return home the same day of surgery or perhaps the morning after. Your surgeon will make this decision based on your post-surgical status.
After discharge, your surgeon will arrange follow-up visits to assess your incision, and how you are progressing. You may experience some post-operative buttock swelling, which can be helped by icing the region after surgery, as directed by your surgeon. Your progress will be assessed by your doctor and he/she will decide when you can return to full weight bearing. Your surgeon will make decisions about your post-surgical case based on your medical health.
Prophylactic Antibiotics and Anticoagulation
Perioperative antibiotics are given while in the operating room, and antithrombotic prophylaxis are generally related to exercise.
Protected Weight Bearing
Patients are kept touch-down (toe touch) weight bearing on crutches or walker for six weeks.
After six weeks, patients are cautiously encouraged to resume activities, respectful of balance, comfort and safety.
Nonsteroidal anti-inflammatory drugs may be used. A sacroiliac joint fusion is an operation where success depends on good health.
Patients should be encouraged to stop smoking. Smoking may cause healing delay or nonunion.
Smoking also complicates the patient’s use of narcotics.
Chronic pain syndromes are common within the SIJ population. Narcotics, antidepressants, and deconditioning all play a part in the patient with a severe problem or delayed diagnosis.
Individually or collectively, these problems complicate or slow the patient’s recovery. The patient may require additional support beyond a typical period of bone healing.
We encourage family involvement. Within the office we try to create a supportive environment for our patients.