The

Symptomatic

SI Joint

Clinical

Examination,

Diagnosis and

Treatment

1

Biagio Mazza, PT

DPT, MPT, OCS, SCS, COMT, CSCS, NSCA-CPT

• MPT - 2001, Rockhurst University, KC, MO

• DPT - 2010, EIM Institute of Health

• APTA Board Certified – Orthopedics and Sports

• Certified Orthopedic Manual Therapist (Spine) – IAOM

• Private Practice Owner: Elite Physical Therapy, KC,MO

• Residence: Prairie Village, KS

• 2 Boys – Anthony 10, Christian 6

• Paid consultant of SI-BONE, Inc. 2

Genne’ DeHenau McDonald PT

• Physical Therapy Degree 1989• Oakland University, Rochester, Michigan

• 26 years clinical experience

• Former Adjunct Faculty and Clinical Lecturer• University of Florida DPT Curriculum

• Former Faculty Herman and Wallace Pelvic Health Institute

• Publications• Musculoskeletal LBP During Pregnancy• Piriformis Syndrome

• Program/Project Manager Medical Affairs SI-BONE

1. Understand the prevalence of SI joint pain.

2. Review anatomy and biomechanics of the SI joint.

3. Review the integrated model of SI joint function.

4. Understand the relationship between the lumbar spine, SI joint and hip.

5. Review subjective history for patient with SI joint pain.

6. Correctly perform SI joint provocation testing

7. Review SI joint rehabilitation.

Course Objectives

4

Prevalence of SI Joint Pain

15-30%Component of LBP

22.6%

30.0%

18.5%

27.0%

14.5%

0%

5%

10%

15%

20%

25%

30%

35%

Bernard1987

Schwarzer1995

Maigne1996

Irwin2007

Sembrano2009

32-43%Symptomatic Post-Lumbar Fusion

32% Katz 2003

35% Maigne 2005

43% DePalma 2011

40% Liliang 2011

DePalma – Pain Med 2011

Is the SI Joint truly a problem?

5

SIJ & Adjacent Segment Degeneration

75% of post lumbar fusion patients showed SI joint degenerative changes on CT scan five (5) years after lumbar fusion. Ha et al 2008

Lumbar fusion leads to increases in angular motion and increases in joint stress at the sacroiliac joint. Ivanov et al 2008

6

Sacroiliac Joint

Articular Surface

Anatomy

7

Anterior Ligaments Posterior Ligaments

Anatomy

8

Biomechanics

Nutation

Sacral base movement

anteroinferior

Counternutation

Sacral base movement

posterosuperior

Translation

Linear motion; motion in

any one direction

Nutation

Counternutation

Forst 2006

9

SI Joint Motion

Multi-planar motion

– Simultaneously rotate and

translate through 3 axes of motion

Motions (<4° in any plane)

– Nutation/Counternutation

• Primary motion

Males: 1 - 2°

Females: 2 - 4°

Sacral Translation

– (A-P motion) up to 1.6mm

Sturesson 1989

10

Integrated Model of SI Joint Function

• Describes effective transfer of force and load across the SI joint from the lower extremities to the spine.

Snijders & Vleeming 1993

• Requires a stable core (lumbar spine, pelvis and soft tissues)

• 3 Components of Functional Stability

Passive (form closure)

Active (force closure)

Neuromuscular Control (motor control)

Panjabi 1992

11

Form Closure/Structural Integrity: The shape of the sacrum and the integrity of the supporting ligaments

contribute to SI joint stability

Lee 1998, Vleeming 1990a, Vleeming 1990b

The Integrated Model of SIJ Function

Force Closure/Joint Compression: The external dynamic forces created by

contraction of the stabilizing muscles and their fascial and

ligamentous attachments

Lee 1998, Vleeming 1990a, Vleeming 1990b

Motor Control: Nervous system coordination / co-activation of

deep stabilizing muscles (onset, duration, timing)

Snijders 1993, Hodges 1996, Richardson 2002

Components

Core muscles should contract before load reaches the low

back and pelvis to prepare the system for impending load.

12

Form Closure

Osseous Structures – Macro, Micro

Supporting Ligaments

13

The Integrated Model of SI Joint Function:

Force Closure – Local Muscles

Local Core Muscles

• Transversus Abdominus

• Multifidus

• Pelvic Floor Muscles

• Diaphragm

– More research being done on other contributing muscles

Local System: contracts prior to upper/lower limb movement regardless of direction Hodges 1997, 2003; Hodges & Richardson 1997; Hodges 1999; Moseley 2002,2003

14

The Integrated Model of SI Joint Function:

Force Closure – Global Muscles

Vleeming’s slings:

Large Muscle Groups and their Fascial Connections

– Posterior Oblique System

– Anterior Oblique System

– Deep Longitudinal System

– Lateral System

Global System: Contracts later and is direction dependent

Radebold 2000, 2001; Hodges 2003

Radebold 2000, 2001; Hodges 2003

15

Thoracolumbar Fascia & Paraspinal Muscles

Caudal part of the TLF, in combination with efficient paraspinal muscles, plays major role in force closure of SI joint

Macintosh & Bogduk – Spine 1993, Vleeming – Spine 1995

16

Motor Control

• Optimal force closure of the SI joint

• Studies showing alteration of muscle activation patterns in low back, groin, and SI joint pain populations– TrA Delayed in LBP Hodges & Richardson 1996

– TrA Delayed in Groin Injuries Cowen 2004

– Altered Motor Control with SI joint Pain O’Sullivan 2002

• Timing, sequence and amplitude of muscle firing– Afferent input from receptors in joints, ligaments, fascia and muscles

– Efferent response of central and peripheral nervous systems Hodges 2003

17

Evaluation of the

Patient with

Sacroiliac Joint Pain

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Can we diagnose SI joint pain?

• Common pain patterns from multiple conditions

– Spine (stenosis, facet, spondy, disc herniation, DDD, etc.)

– SI Joint

– Hip (OA, FAI, early AVN, etc.)

– Pelvis (Glut tear, piriformis, pelvic floor)

• Imaging not routinely helpful

• History and Physical Examination

− Provocative maneuvers Laslett 2005, Szadek 2009

− SI joint ROM & Position testing not reliable Freburger 1999, Robinson 2007

• Diagnostic Injection

19

Lower lumbar region (72%)

Devin – JAAOS 2012 Vanelderen – Evid Based Med 2010

Lateral hip – common

Thigh and Groin (55%)

Buttock pain (71%)

Lower extremity common (28%)

Groin not uncommon (14%)

Lateral hip & thigh common

Buttock, PSIS (94%)

Devin – JAAOS 2012

Spinal Stenosis

Lower extremity common

Lateral hip – common

Lumbar region common

Buttock common

Knee or below (47%)

Groin uncommon (except L1, L2)

Lumbar Spine – SI Joint – Hip

Pain Referral Patterns

Lumbar pain uncommon

SI JointIsolated

Hip Pathology

20

Potential Causes of SIJ Pain: Traumatic

• MVA: Foot on Brake

• Slip and Fall

• Lifting and Twisting

• Traction Injuries

21

21

Potential Causes of SI Joint Pain: Gradual Onset

• Laxity of the SI joint / Pregnancy

• Repetitive Forces on SI joint and

Supporting Structures

• Biomechanical Abnormalities

– Leg length inequality

– Pelvic obliquity/scoliosis

– Iliac crest bone graft

• Adjacent Segment Degeneration

– After lumbar spinal fusion

• Post Infection Degeneration

22

22

Hip and Adjacent Segment (SI Joint)

Hip and SI Joint

76% (25/33) of patients with symptomatic SI joint pathology had at least one abnormal finding on hip radiograph

A significant number met the strict diagnostic criteria for FAI.

42% Hip OA

45% Subchondral cyst

21% Retroversion

12% Lateral CE* angle >40%

47% Coxa profunda

33% Cam impingement

Morgan 2013

* Center Edge

23

Positive Subjective

History

Positive SI Joint Provocative

Testing

Lumbar Spine

and

Hip Exam

Positive Response to Intra-articular

Injection

24

Elements of the Diagnosis

HISTORY

• When did the pain start?

• Prior trauma– A fall on the buttock

– Car accident (T-bone, rear-end, head-on)

– Lift/Twist

– Other

• Prior lumbar fusion– Prior iliac bone graft harvest

• Pregnancy

COMPLAINTS

• Lower back pain

• Sensation of numbness, tingling or weakness

• Pelvis / buttock pain

• Hip / groin pain

• Feeling of leg instability, buckling, or giving way

• Disturbed sleep patterns

• Disturbed sitting patterns (unable to sit for long periods, on one side)

• Pain going from sitting to standing

25

25

History and Complaints

Pain Diagram

• Pain in buttock and posterior thigh

– Usually not midline

– Usually below L5

– At or lateral to PSIS

– Occasionally groin

• Secondary pain in lateral thigh,

groin, and/or lateral calf

Fortin 1999

26

History: SI Joint Pain Presentation

26

Exacerbating Activities

Unilateral Weight Bearing- Putting on Socks/Shoes

- Ascending/Descending Stairs

- Getting in and out of Car

- Prolonged Walking

(85% of gait cycle is single leg stance)Janda 1983

Sexual Intercourse

Pain with Transitional Motions- Supine to painful side - Sit to stand- Rolling over in bed- Getting in /out of bed

Pain while Stationary- Sitting on affected side- Prolonged standing/sitting

27

27

Relieving Activities

• Bearing weight on unaffected side

• Lying on unaffected side

• Manual or belt stabilization

28

28

Lumbar Spine – Hip – SI Joint

Physical Examination

29

Assess Lumbar Spine: Facet Joint Pain

• Incidence 10-15% in patients with chronic LBP Saravanakumar 2008

• Low back pain from the facet joints: radiates down into the buttocks and posterior thigh.

• Clinical Findings – Point tenderness overlying the inflamed facet joints – Loss in spinal muscle flexibility (guarding)– More discomfort leaning backward than forward.

• No history findings or examination maneuver has been found to be unique or specific to this entity Kayser 2008, Cohen 2007, Jackson 1998

30

The McKenzie Procedure• More accurate than MRI in:

– Differentiating discogenic from non-discogenic LBP

– Differentiating contained from non-contained discs

(Donelson 1997, 1990)

• Measures patient's symptomatic response to

repeated end-range movements

• Discogenic pain is associated with centralization

with repeated end range movements

(Young 2003, Hancock 2007)

• Most common direction of testing that centralizes

pain is extension

Assess Lumbar Spine: Disc-Related Pain

31

These can all be performed quickly in supine before

performing provocative testing

for the SI joint.

Assess Lumbar Spine: Physical Exam

Standard tests to rule out lumbar radiculopathy

• DTRs• Neuro Exam

Passive Straight Leg Raise To rule out lumbar radicular pain + at 35-70°

• Sensitivity 91%• Specificity 26%

Deville 2000

Slump TestTo rule out lumbar disc herniation's

• Sensitivity 84%• Specificity 83%

Majlesi 2008

32

Assess Hip: Physical Examination

FABER: For Intra-articular hip pathology (if pain anterior)

• Hip flexion, abduction and ER with overpressure

• 88% sensitive (Martin 2005)

Scour: For Hip OA and other pathologies

• Sensitivity 62% - 91%

• Specificity 43% - 75%(Konin 2006, Magee 2008)

FADIR: For FAI and labral tears:

• Hip flexion, adduction, IR

• Sensitivity = 75%,

• Specificity = 43% (Austin 2008)

FAIR: For Piriformis Syndrome (assure pain is posterior)

• Sensitivity 88%

• Specificity 83% (Fishman, 2002)

33

Range of Motion Testing of the Hip (Birrell 2001)

• The most predictive finding for osteoarthritis is decreased range of motion with restriction in internal rotation

• For those patients with one plane of restricted movement, the sensitivity for severe osteoarthritis is 100% and specificity is 42%

• Used to rule in/out osteoarthritis

Femoral Neck Anteversion (FNA) Assessment Compare bilaterally

• If IR is 30 degrees > then external rotation, predictor of FNA (Swanson 1963)

• Trochanteric Prominence Angle Test (TPAT) or Craig test

TPAT predicted the FNA measured intraoperatively, more accurately than either the CT or Magilligan method (Ruwe 1992)

Assess Hip: Physical Examination

34

Assess Hip: OA & FAI

• There is a strong association between early hip OA (osteoarthritis) and FAI (femoral acetabular impingement)

• Altman Criteria for Hip OA: – Hip IR > 15 degrees, Pain with Hip IR– Morning stiffness for < 60 min and Age > 50 years OR– Hip IR < 15 degrees, and Hip Flexion < 115 degrees

– (Sensitivity 86 % Specificity 75 %) Altman 1991

• Patients with hip OA often develop osteophytic changes and bony over-growth of the acetabular rim and femoral head

• This would create FAI in and of itself Chibulka 2009, Phillippon 2007

Clinical Presentation• Both may present with positive tests for FABER and FADIR• Both may present with a decrease in hip flexion and internal rotation (ROM)

35

Contact between the femoral head-neck junction and the acetabular rim

• Insidious onset 50% of cases Samora 2011

• Symptoms– Persistent insidious deep groin, lateral hip

or buttock pain – Pain increased with prolonged sitting or

standing and hip flexion-type movements– Decreased hip ROM

Two Types • CAM (More common in young males)

– Anterior-superior aspect

• Pincer (More common in females)– Anterior acetabular labrum and chondral

injury in posterior-inferior acetabular rimGanz 2003

Confirmation• Arthroscopy: Gold Standard• MRI

Assess Hip: FAI (Femoral-Acetabular Impingement)

36

Assess Hip: Labral Tear Clinical Findings

• Morphological changes in proximal femur or acetabulum lead to abnormal contact during hip flexion Samora 2011

• Clinical Symptoms: anterior groin pain (96-100%), clicking, locking (58%), catching, instability, giving way and/or stiffness Martin 2006, Lewis 2006

– Predisposing factor: Coxa Valga = 87% of cases

• Clinical Sign: FADIR TEST

Method of Injury – Hip external rotation + extension, direct trauma, abnormal loading patterns

MRI – May demonstrate labral tear, but often the bony articular pathology are missed

MRA – Gold standard is magnetic resonance arthrogram Samora 2011

37

Piriformis compresses or irritates the sciatic nerve• Incidence: 17.2% among low back pain patient

Chen 2013

Clinical symptoms• A dull ache in the buttock.• Pain down the back of the thigh, calf and foot

(sciatica)• Pain when walking up stairs or inclines.• Increased pain after prolonged sitting.

Clinical Sign• FAIR Test: Reproduction of symptoms when

piriformis muscle is put on stretch.(hip flexion, adduction and internal rotation)

Fishman 2002, Loren 2010

Assess Hip: Piriformis Syndrome

Magnetic Resonance Neurography: Type of MRI that highlights

inflammation and compression of the nerves.

Filler 2005

38

Incidence• Common finding on MR imaging in patients

with buttock, lateral hip, or groin pain.Kingzett-Taylor 1999

Clinical Symptoms• Dull lateral hip pain, buttock or groin pain

Clinical Signs

• Focal tenderness at the gluteal insertion

• Weak hip abduction

• Pain with passive and then resisted hip internal rotation with the hip flexed to 90°

Sen 88%, Spec 97.3%

• Pain on one-legged stance for 30 sec or moreSen 100 % Spec 97.3%

Lequesne 2008

Assess Hip:

Gluteus Medius & Minimus Tears

39

Point to pain while standing • Able to localize pain with one finger

• Within 1 cm of PSIS (inferomedial)

• Consistent over at least 2 trials

Ask patient to point to location of primary pain

• Below L5: Consider SI joint

• Above L5: Consider lumbar spine etiologies

SI Joint: Physical Exam

Fortin Finger Test

Fortin & Falco 1997

40

SI Joint: Physical Exam

Active Straight Leg Raise

To assess functional pelvic stability

• Sensitivity: 87%

• Specificity: 94%Mens 2001

41

SI Joint: Provocative Tests

The following five provocative tests, when performed in combination are proven to have a high degree of sensitivity and specificity:

1. Distraction* (Highest PPV**)

2. Thigh Thrust*

3. Compression*

4. FABER

5. Gaenslen’s Maneuver

42

Laslett Szadek

3 or more positive tests

Sensitivity 91% 85%

Specificity 78% 76%

Laslett 2005, 2008

Szadek 2009

* Most sensitive of tests

** PPV = positive predictive value

42

• Specificity increases when symptoms don’t centralize or peripheralize

with thorough, multidirectional repeated movement assessment

(McKenzie Assessment)

• In some cases a patient may not tolerate having five (5) tests

performed. Therefore, it’s recommended that the three (3) most

sensitive, specific and reliable tests be performed first.

Laslett 2005, Laslett 2008, Szadek 2009

How to Interpret Your Results

1 Positive Test = Suspicion

2 Positive Tests = Fair Confidence

3+ Positive Tests = High Confidence

SI Joint: Specificity of Provocative Tests

43

SI Joint: Provocative Tests

Distraction Thigh Thrust

FABER Compression

Gaenslen’s Maneuver

44

Assure the tester position is above the patient by lowering table or

standing on a sturdy stool in order to provide adequate force.

Start with light pressure and gradually increase, keeping hands

cupped to minimize local contact pressure (30 second max).

Keep arms straight and lean forward with your upper body to create

gentle steady force.

Stabilize patient on the table to prevent muscle guarding.

Stabilize contralateral ASIS during Thigh Thrust and FABER tests.

If pain is provoked with test, ask patient to identify pain location to

confirm it is their typical pain.

45

SI Joint: Provocative Test Tips

• Quadratus Lumborum

• Gluteus Maximus

• Piriformis

• Levator Ani

Travell and Simons 1992

46

SIJ Region Pain – Myofascial Causes

Negative

Lumbar and

hip exam

Positive

History

Positive Fortin

Finger Test

and Physical

Exam

Positive Pain

Provocative

Tests

47

Justification for SI Joint Injection

47

What’s the Reference Standard for Diagnosis?

Diagnostic Injection• Confirm with contrast and

imaging

• Low volume, local anesthetic

• 50-75% pain reduction

Therapeutic Injection• Local anesthetic + corticosteroid

• May provide intermediate or long

term relief

• Results of therapeutic injections

can be unpredictable

Injection Under Fluoroscopy

48

48

• Patient pain diary

• Significant positive clinical response

– 50-75% VAS reduction indicates positive diagnosis of SI joint as pain generator

– Obtain copy of arthrogram to ensure accuracy

• Equivocal or no relief

– < 50% VAS reduction indicates a non-significant clinical response

– May have SI joint pain, but consider other pain sources

49

Injection Assessment

49

Conservative Treatment

Options for

Sacroiliac Joint Pain

50

Conservative Treatment Options

Symptom Management

• Medications (non steroidal anti-inflammatories,

oral steroids, pain medications)

• External SI joint stabilization with belting

• Therapeutic SI joint injections (1-4 per year)

• Physical Therapy

Sembrano 2011

Cohen 2005

51

Treat the joint by returning it to its normal relationships so outcomes may be enhanced. Fife 2008

Conservative Treatment Options: Goal

• Optimal SI joint function occurs with the SI Joint in neutral (mid-range) position.

DonTigney 1990, 1994, 1999, 2005; Fujiwara 1999;

Pool-Goudzwaard 2001, 2003; Snijders 1993, 2004; Vleeming 1996

• Treatment goal should be restoration of normal movement and SI joint position.

52

Conservative Treatment Options:

Physical Therapy

• Modification of Activities of Daily Living (ADLs)– specific focus on activities that may create or exacerbate symptoms.

• Patient education regarding maintaining optimal alignment

with positioning, posture and body mechanics

• Stabilization Exercise/ Neuromuscular Re-education – Specific focus on timing and engagement of local and global core muscles

Snijders 1993a, 1993b, Hodges 1996, Richardson 2002

53

Conservative Treatment Options:

Physical Therapy

• Achieve normal muscle strength balance where

existing deficits (include gluteus medius assessment)Lee 1998, Vleeming 1990, Vleeming 1989

• Achieve normal muscle length balance where existing

imbalances exist – Consideration of muscles that attach to the ilium and sacrum directly and

indirectly, especially limiters of hip internal rotation.Cibulka 1998, Lee 1998, Vleeming 1990, Vleeming 1989

• Adjacent segment joint and soft tissue restriction

mobilization and manipulation as needed *

– Consider the hip structures, lumbar and thoracic regions, knee and ankle

joints.

54

• Manual techniques to address myofascial pain

• Balance assessment and training

• Gait training

• Regain or maintain cardiovascular health

• Modalities for pain and muscle spasm

Conservative Treatment Options:

Physical Therapy

55

Surgical Treatment Options

for

Sacroiliac Joint Pain

56

Smith-Petersen 1926 Campbell 1927 Gaenslen 1927

Bloom 1937 iFuse 2008

Treatment Options: Surgical

57

57

MIS SI Joint Fusion Technologies

Examples of existing

and/or developing

technologies.

The iFuse Implant

System is the only

technology supported

by published clinical

evidence.

(May 2015)

SI-BONE:

iFuse Implant System®

Globus:

SI-LOK Joint Fixation System

Medtronic:

Rialto Sacroiliac Joint Fusion System

VG Innovations:

SiJoin Posterior Sacroiliac Joint Fusion System

X-spine Systems:

Silex Sacroiliac Joint Fusion System

Zyga Technology:

SImmetry Sacroiliac Joint Fusion System

58

iFuse Implant System®

• Unique DesignTriangular shape – minimizes rotation

Interference press fit

Porous TPS coating – large surface area

Specifications• 3X stronger than screw

(iFuse vs. 8.0mm cannulated screw, Mauldin 2009, SI-BONE)

• 31X rotational resistance greater than screw(Torsional Rigidity, iFuse vs. 7.3mm screw, 300191-A, SI-BONE)

• Strength of Experience and Focus17,000+ procedures worldwide (September 2015)

Outstanding training programs

Knowledge in the OR

Reimbursement support

• Clinical Evidence

59

Incision Pin Soft Tissue Protector Measure

Drill Broach Insert Implant Repeat

iFuse Procedure Overview

60

I

IIb

III

IV

Clinical – Other

Biomechanics

...... 2Complaints analysis

Intraoperative neuromonitoring

…....................... 2 RCT (INSITE, 102 iFuse vs. 46 NSM)

... 2Stability achieved & maintained post-cycles

Implant placement technique comparison

…................. 3Prospective, multicenter (SIFI)

Systematic Review

….… 10 Retrospective case series

…............. 3 Open vs. iFuse

Complete References in Bibliography61

iFuse Implant System® Publications

Proprietary and Confidential.

VAS SI Joint Pain

62Complete References in Bibliography

Proprietary and Confidential.

Rapid and Sustained Pain Relief –VAS SIJ Pain

Complete References in Bibliography63Proprietary and Confidential.

Complete References in Bibliography64Proprietary and Confidential.

Post-Operative Considerations

Individual Treatment Plans

Considerations:

• Age

• Weight

• Bone quality

• Associated health factors

Post Surgical Decisions

• Plan for protected weight bearing

• Activity limitations

• Post op rehab plans

• Plan for return to activity

6565

Post-Operative Guidelines

To assist HCPs with Patient Education

66

Weight-bearing Status

Post-Operative Swelling Prevention

Precautions and Activity Guidelines

Post-Operative Guidelines and Precautions

67

Description of Core Strengthening

Exercises for DVT Prevention combined with basic core

strengthening

Circulation and Stabilization Exercises

68

Bed Mobility, Transfers and Stairs

Patient is instructed in maintenance of neutral lumbopelvic mechanics with

movement and utilization of TrA muscle to assist with stabilization

69

Post-Operative Physical Therapy Considerations

Review of common musculoskeletal problems affecting the SI joint or affected by chronic SI disorders

Suggested areas to address post-operatively based on best practice and

current evidence

70

Post-Operative Considerations

Patient Education: Positioning, Posture and Body Mechanics

Gait Training

Balance Assessment and Training

Timing and Engagement of Core Local/Global Stabilizers

Achieve Normal Muscle Strength and Length Balance

71

Post-Operative Considerations

Eliminate Restrictions in Adjacent Structures

• Hip Capsule

• Lumbar and Thoracic Spine / Knee and Ankle Joints

Retraining of Functional Movement Patterns/Motor Control

• With Activities of Daily Living

• With Recreational Activities in Patient Population

Regain / Maintain Cardiovascular Health

72

Conclusion

• SI joint can be painful: pathology is prevalent

and underdiagnosed

• SI joint stability depends on a complex

integrated system – Form and Force Closure,

Motor Control

• Must understand the lumbar spine-SI joint-hip

complex and how they interact

73

Conclusion

• Diagnosis of SI joint pain

– History

– Physical Examination of spine, hip and SI joint

– Correct Performance of SI joint provocative tests

• Treatment options for SI joint pathology

– Non-surgical management

– Surgical option – MIS SI joint fusion

– Pre and post-operative considerations

74

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SI-BONE, SI University and iFuse Implant System are registered trademarks of SI-BONE, Inc.

© 2015 SI-BONE, Inc. All rights reserved.

U.S. Patent Nos. 8,202,305; 8,840,623; 8,986,348; and 9,039,743; pending U.S. and foreign patent applications

9228.061815

The iFuse Implant System® is intended for sacroiliac fusion for conditions including

sacroiliac joint dysfunction that is a direct result of sacroiliac joint disruption and

degenerative sacroiliitis. This includes conditions whose symptoms began during

pregnancy or in the peripartum period and have persisted postpartum for more

than 6 months.

There are potential risks associated with the iFuse Implant System. It may not be

appropriate for all patients and all patients may not benefit. For information about

the risks, visit: www.si-bone.com/risks

One or more of the individuals named herein may be past or present SI-BONE

employees, consultants, investors, clinical trial investigators, or grant recipients.

Research described herein may have been supported in whole or in part by SI-

BONE.

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iFuse Implant System – Bibliography

LEVEL I – Randomized Clinical Trial

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LEVEL IIb – Prospective, Multicenter

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LEVEL III – Clinical Comparison (Open vs. MIS)

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LEVEL IV – Clinical

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Sachs D, Capobianco R. Minimally invasive sacroiliac joint fusion: one-year outcomes in 40 patients. Adv Orthop. 2013;2013:536128.

Rudolf L. MIS Fusion of the SI Joint: Does Prior Lumbar Spinal Fusion Affect Patient Outcomes? Open Orthop J. 2013;7:163–8.

Sachs D, Capobianco R. One year successful outcomes for novel sacroiliac joint arthrodesis system. Ann Surg Innov Res. 2012;6:13.

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Clinical – Other

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Biomechanics

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