Direct Anterior Fixation of Dens Fractures with a Cannulated Screw System

Etter, Christian; Coscia, Michael F.; Jaberg, H; Aebi, Max

doi:10.1097/00007632-199103001-00006

Cited by 93 publications

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“…Authors who recommend the anterior approach argue that this method is easy to perform and saves neck motion. Good results have been shown in young patients [1,10], and some authors claim equivalent results compared to posterior C1-C2 fusion [6,11]. Results of the anterior approach in elderly patients have only been covered in one report that we have come across [5].…”

Section: Discussionmentioning

confidence: 99%

Odontoid fractures: high complication rate associated with anterior screw fixation in the elderly

Andersson¹,

Rodrigues²,

Olerud

2000

European Spine Journal

202

122

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IntroductionFractures of the odontoid process of the axis have been the subject of many investigations, but most articles do not consider the biological impact of age. Few publications cover the subject in the elderly population, although odontoid fractures are the most common fractures of the cervical spine in this age group. There is still a lack of agreement on the best method of treatment among patients over 65 years of age. Conservative treatment carries a high risk of developing non-union [15,19] as does halovest treatment [8]. Posterior C1-C2 fusion according to Gallie has long been the method of choice. The Gallie technique, however, is not biomechanically optimal and has a failure rate of 1/5 [9]. By adding transarticular screws the mechanical situation was improved [14,16]. Recently, the anterior screw technique according to has gained increased popularity. In most reports, younger and older patients have been grouped together. Few publications have examined the results explicitly in the elderly population. Berlemann and Schwarzenbach [5] advocated the anterior screw technique in the elderly.The present study is a review of a consecutive series of odontoid fractures in patients over 65 years of age treated at our department between 1988 and 1994. The results of anterior screw fixation, posterior C1-C2 fusion, and conservative treatment are compared. Materials and methodsThe series consists of 29 consecutive patients (18 women) with a mean age of 78 (66-99) years with odontoid fractures treated at our department between 1988 and 1994. Patient demographics and results are presented in the Table 1. Twenty-four of the fractures were Abstract This study is a retrospective analysis of patients older than 65 years with odontoid fractures. The series consisted of 29 consecutive patients with odontoid fractures (18 women, mean age 78, range 66-99 years). Twenty-six patients were neurologically intact, Frankel E, whereas three had neurological symptoms: two Frankel D and one Frankel C. Eleven patients were treated with anterior screw fixation according to Böhler, seven with a posterior C1-C2 fusion. Ten patients with either minimally displaced fractures or with complicating medical conditions were treated conservatively. At follow-up, 7/7 patients with posterior fusion had healed without any problems, whereas 8/11 patients treated with anterior screw fixation, and 7/10 conservatively treated patients were either failures or had healed, but after a complicated course of events. We conclude that anterior screw fixation according to Böhler is associated with an unacceptably high rate of problems in the elderly. Probable causes may be osteoporosis with comminution at the fracture site, or stiffness of the cervical spine preventing ideal positioning of the screws. As non-operative treatment also often fails, the method of choice seems to be posterior C1-C2 fusion.

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Section: Discussionmentioning

confidence: 99%

Odontoid fractures: high complication rate associated with anterior screw fixation in the elderly

Andersson¹,

Rodrigues²,

Olerud

2000

European Spine Journal

202

122

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“…Julien et al [14] reviewed a mean overall union rate of 85.5% with posterior instrumented fusion of C1-2, while the fusion rates after AOSF were reported with 95, 90% for Type II and 100% for Type III. The results were echoed in several other studies with fusion rates ranging 84-96% [14][15][16][17][18][19][20][21][22][23][24][25].…”

Section: Discussionmentioning

confidence: 71%

“…First described by Bohler [13], several studies also reported on technical details, surgical outcomes and complications [2,6,[14][15][16][17][18][19][20][21][22][23][24][25]. AOSF allows osteosynthesis of reduced OF through a non-traumatic standardized surgical approach if compared to the posterior approach [26] and can preserve atlantoaxial motion.…”

Section: Introductionmentioning

confidence: 99%

“…Contraindications such as remote or compound fractures have to be respected for successful surgery [6,27]. Using AOSF, overall fusion rates were reported with up to 84-96% [14][15][16][17][18][19][20][21][22][23][24][25] and 23-93% in the elderly population [6-11, 28, 29]. The impact of patients' age at index surgery on outcome was discussed controversially.…”

Section: Introductionmentioning

confidence: 99%

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Efficacy of anterior odontoid screw fixation in the elderly patient: a CT-based biometrical analysis of odontoid fractures

et al. 2011

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In the elderly population, reported union rates with anterior odontoid screw fixation (AOSF) for odontoid fracture (OF) treatment vary between 23 and 93% when using plain radiographs. However, recent research revealed poor interobserver reliability for fusion assessment using plain radiographs compared to CT scans. Therefore, union rates in patients aged C60 years treated with AOSF have to be revisited using CT scans and factors for non-union to be analysed. Prospectively gathered consecutively treated patients using AOSF for odontoid fracture with age C60 years were reviewed. Medical charts were assessed for demographics, clinical outcomes and complications. Patients' preoperative radiographs and CT scans were analysed to characterize fracture morphology and type, fracture displacement, presence of atlanto-dental osteoarthritis as well as a detailed morphometric assessment of fracture surfaces (in mm 2 ). CT scans performed after a minimum of 3 months postoperatively were analysed for fracture union. Those patients not showing CT-based evidence of completely fused odontoid fracture were invited for radiographic follow-up at a minimum of 6 months follow-up. Follow-up CT-scan were studied for odontoid union as well as the number of screws used and the square surface of screws used for AOSF and the related corticocancellous osseous healing surface of the odontoid fragment (in %) were calculated. Patients were stratified whether they achieved osseous union or fibrous non-union. Patients with a non-union were subjected to flexionextension lateral radiographs and the non-union defined as stable if no motion was detected. The sample included 13 male (72%) and 5 female (18%) patients. The interval from injury to AOSF was 4.1 ± 5.3 days (0-16 days). Age at injury was 78.1 ± 7.6 years (60-87 years) and follow-up was 75.7 ± 50.8 months (4.2-150.2 months). 10 patients had dislocated fractures, 14 had Type II and 4 ''shallow'' Type III fractures according to the Anderson classification, 2 had stable C1-ring fractures, 8 had displayed atlantodental osteoarthritis. Fracture square surface was 127.1 ± 50.9 mm 2 (56.3-215.9 mm 2 ) and osseous healing surface was 84.0 ± 6.8% (67.6-91.1%). CT-based analysis revealed osseous union in 9 (50%) and non-union in 9 patients (50%). Union rates correlated with increased fracture surface (P = 0.02). Statistical analysis revealed a trend that the usage of two screws with AOSF correlates with increased fusion rates (P = 0.06). Stability at C1-2 was achieved in 89% of patients. CT scans are accepted as the standard of reference to assess osseous union. The current study offers an objective insight into the union rates of odontoid fractures treated with AOSF using CT scans in consecutive series of 18 patients C60 years. Literature serves evidence that elderly patients with unstable OF benefit from early surgical stabilization. However, although using AOSF for unstable OF yields segmental stability at C1-2 in a high number of patients as echoed in

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“…The duration of surgery ranged between 45 minutes and 2 hours. The surgical technique followed the recommendations by Etter et al (1991) using 2 cannulated screws and double-image intensification at perpendicular planes in 18 patients. In 1 patient, the technique was similar, but the screws used were not cannulated.…”

Section: Methodsmentioning

confidence: 99%

Dens fractures in the elderly: Results of anterior screw fixation in 19 elderly patients

Berlemann

Schwarzenbach

1997

Acta Orthopaedica Scandinavica

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Direct Anterior Fixation of Dens Fractures with a Cannulated Screw System

Cited by 93 publications

References 0 publications

Odontoid fractures: high complication rate associated with anterior screw fixation in the elderly

Odontoid fractures: high complication rate associated with anterior screw fixation in the elderly

Efficacy of anterior odontoid screw fixation in the elderly patient: a CT-based biometrical analysis of odontoid fractures

Dens fractures in the elderly: Results of anterior screw fixation in 19 elderly patients

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