Management of Acute Odontoid Fractures with Single-screw Anterior Fixation

Subach, Brian R.; Morone, Michael A.; Haid, Regis W.; McLaughlin, Mark R.; Rodts, Gerald R.; Comey, Christopher H.

doi:10.1097/00006123-199910000-00015

Cited by 157 publications

(115 citation statements)

References 31 publications

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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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Section: Discussionmentioning

confidence: 71%

Section: Introductionmentioning

confidence: 99%

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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“…But 35% judged their outcome as moderate or poor and 20% assumed that they would need additional treatment for their neck condition in the future. In contrast, in literature the results of various treatment modalities for C2-fractures, particularly for odontoid fractures, were frequently recognized as 'good' if not 'excellent' [25,62,72]. In the past, detailed data have been sparse commonly not exceeding cross-sectional assessments and despite the prevailing opinion that overall outcome was favourable, long-term analysis identified persisting symptoms of pain and stiffness in a meaningful number of patients [1,11,57,76].…”

Section: Clinical Outcomementioning

confidence: 99%

“…The lack of a comprehensive treatment-oriented classification of C2-fractures, that guides when to operate and when to select conservative treatment, reflects the fact that there exists no ideal solution for the clinical problem, yet [56]. In contrast, there is a large body of literature concerning techniques, indications and union rates in C2-fractures [72], but data regarding the most important outcome measure, the functional and clinical outcome, are scant [24,68]. Currently, in addition to nonsurgical treatment including semirigid collars or the Halo-thoracic-vest (HTV), contemporary surgical techniques for the treatment of C2-fractures include anterior odontoid screw fixation (AOSF) [2,62], posterior and anterior transarticular screw fixation C1-2 [51], C1-lateral mass and C2-Isthmus/lamina fixation [32] and plated anterior discectomy and fusion for the unstable Hangman's fracture (Hmfx) [46,83].…”

Section: Introductionmentioning

confidence: 99%

C2-fractures: part II. A morphometrical analysis of computerized atlantoaxial motion, anatomical alignment and related clinical outcomes

et al. 2009

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Knowledge on the outcome of C2-fractures is founded on heterogenous samples with cross-sectional outcome assessment focusing on union rates, complications and technical concerns related to surgical treatment. Reproducible clinical and functional outcome assessments are scant. Validated generic and disease specific outcome measures were rarely applied. Therefore, the aim of the current study is to investigate the radiographic, functional and clinical outcome of a patient sample with C2-fractures. Out of a consecutive series of 121 patients with C2 fractures, 44 met strict inclusion criteria and 35 patients with C2-fractures treated either nonsurgically or surgically with motion-preserving techniques were surveyed. Outcome analysis included validated measures (SF-36, NPDI, CSOQ), and a functional CT-scanning protocol for the evaluation of C1-2 rotation and alignment. Mean followup was 64 months and mean age of patients was 52 years. Classification of C2-fractures at injury was performed using a detailed morphological description: 24 patients had odontoid fractures type II or III, 18 patients had fracture patterns involving the vertebral body and 11 included a dislocated or a burst lateral mass fracture. Thirty-one percent of patients were treated with a halo, 34% with a Philadelphia collar and 34% had anterior odontoid screw fixation. At follow-up mean atlantoaxial rotation in left and right head position was 20.2°and 20.6°, respectively. According to the classification system of posttreatment C2-alignment established by our group in part I of the C2-fracture study project, mean malunion score was 2.8 points. In 49% of patients the fractures healed in anatomical shape or with mild malalignment. In 51% fractures healed with moderate or severe malalignment. Self-rated outcome was excellent or good in 65% of patients and moderate or poor in 35%. The raw data of varying nuances allow for comparison in future benchmark studies and metaanalysis. Detailed investigation of C2-fracture morphology, posttreatment C2-alignment and atlantoaxial rotation allowed a unique outcome analysis that focused on the identification of risk factors for poor outcome and the interdependencies of outcome variables that should be addressed in studies on C2-fractures. We recognized that reduced rotation of C1-2 per se was not a concern for the patients. However, patients with worse clinical outcomes had reduced total neck rotation and rotation C1-2. In turn, C2-fractures, especially fractures affecting the lateral mass that healed with atlantoaxial deformity and malunion, had higher incidence of atlantoaxial degeneration and osteoarthritis. Patients with increased severity of C2-malunion and Electronic supplementary material The online version of this article

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Computational anatomy of the dens axis evaluated by quantitative computed tomography: Implications for anterior screw fixation

Gehweiler

Wähnert

Meier

et al. 2017

Journal Orthopaedic Research

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The surgical fracture fixation of the odontoid process (dens) of the second cervical vertebra (C2/axis) is a challenging procedure, particularly in elderly patients affected by bone loss, and includes screw positioning close to vital structures. The aim of this study was to provide an extended anatomical knowledge of C2, the bone mass distribution and bone loss, and to understand the implications for anterior screw fixation. One hundred and twenty standard clinical quantitative computed tomography (QCT) scans of the intact cervical spine from 60 female and 60 male European patients, aged 18-90 years, were used to compute a three-dimensional statistical model and an averaged bone mass model of C2. Shape and size variability was assessed via principal component analysis (PCA), bone mass distribution by thresholding and via virtual core drilling, and the screw placement via virtual positioning of screw templates. Principal component analysis (PCA) revealed a highly variable anatomy of the dens with size as the predominant variation according to the first principal component (PC) whereas shape changes were primarily described by the remaining PCs. The bone mass distribution demonstrated a characteristic 3D pattern, and remained unchanged in the presence of bone loss. Virtual screw positioning of two 3.5 mm dens screws with a 1 mm safety zone was possible in 81.7% in a standard, parallel position and in additional 15.8% in a twisted position. The approach permitted a more detailed anatomical assessment of the dens axis. Combined with a preoperative QCT it may further improve the diagnostic procedure of odontoid fractures. © 2017 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 35:2154-2163, 2017.

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Management of Acute Odontoid Fractures with Single-screw Anterior Fixation

Abstract: Single-screw anterior odontoid fixation was associated with a relatively low complication rate and a high fusion rate in this study. We think that this should be the preferred treatment method for acute Type II odontoid fractures.

Cited by 157 publications

References 31 publications

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

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

C2-fractures: part II. A morphometrical analysis of computerized atlantoaxial motion, anatomical alignment and related clinical outcomes

Computational anatomy of the dens axis evaluated by quantitative computed tomography: Implications for anterior screw fixation

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