Advertisement

European Spine Journal

, Volume 25, Issue 7, pp 2210–2217 | Cite as

Anterior transarticular atlantoaxial screw fixation in combination with dens screw fixation for type II odontoid fractures with associated atlanto-odontoid osteoarthritis

  • Christoph Josten
  • Jan-Sven Jarvers
  • Stefan Glasmacher
  • Christoph-Eckhard Heyde
  • Ulrich J. Spiegl
Original Article

Abstract

Purpose

The purpose of this study was to evaluate the 1-year outcome after anterior transarticular atlantoaxial fixation and odontoid fusion (TAFOF) for type II odontoid fractures and atlanto-odontoid osteoarthritis (AO) in elderly patients.

Methods

All geriatric patients, age 70 or older, with acute traumatic type II odontoid fractures and moderate or severe AO treated by TAFOF were included. The study was performed at a single institution between June 2008 and August 2013. Patients were evaluated clinically and radiologically after 1 year. Main parameter of interest were in-hospital and 1-year mortality rates, complication rates (re-operations, prolonged hospital stay, blood transfusion; non-union), and the patients’ pain (0: no pain; 10: maximal pain) and satisfaction level (0: lowest satisfaction; 10: highest satisfaction) after 1 year.

Results

A total of 83 patients were included with an average age of 84.7 years (range 70–101 years). 39 patients were subdivided as “old” with an age 70–84 years and 44 patients were defined as “very old” with an age of 85 or higher. The average operation time was 64.7 min. Three patients died during the inpatient stay (3.6 %). Twenty patients (24.1 %) were lost contact follow-up. The 1-year mortality was 25.4 % with a significantly higher mortality rate in very old patient group (p = 0.01). At the 1-year follow-up, the mean pain level was 3.3 and the mean patient satisfaction level was 6.5. Osseous consolidation of the dens was visible in 90.2 % of patients. Revision surgery was performed in three patients (3.6 %). Generally, a significantly higher complication rate was seen after single-screw fixation of the dens compared to a double-screw fixation in combination with TAF (p = 0.042).

Conclusions

Anterior TAFOF leads to promising 1-year results with low in-hospital mortality and a high fusion rate in geriatric patients with type II odontoid fractures and relevant AO. Double-screw dens fixation seems to reduce the complication rate.

Keywords

Type II odontoid fracture Atlanto-odontoid osteoarthritis Ventral approach Transarticular atlantoaxial fixation Geriatric patient population 

Notes

Compliance with ethical standards

Conflict of interest

One of the authors (JC) received royalty from the following companies: Zimmer, inc., Warshaw, IN, USA; DepuySynthes, inc., West Chester, PA, USA; Medtronic, Minneapolis, MN, USA; Ziehm, inc., Nürnberg, Germany. In addition, the author CEH is an independent consultant for Medacta, inc., Castel San Pietro, Switzerland.

References

  1. 1.
    Anderson LD, D’Alonzo RT (1974) Fractures of the odontoid process of the axis. J Bone Joint Surg 56(8):1663–1674PubMedGoogle Scholar
  2. 2.
    Borm W, Kast E, Richter HP, Mohr K (2003) Anterior screw fixation in type II odontoid fractures: is there a difference in outcome between age groups? Neurosurgery 52(5):1089–1092 (discussion 1092–1084)CrossRefPubMedGoogle Scholar
  3. 3.
    Platzer P, Thalhammer G, Ostermann R, Wieland T, Vecsei V, Gaebler C (2007) Anterior screw fixation of odontoid fractures comparing younger and elderly patients. Spine (Phila Pa 1976) 32(16):1714–1720. doi: 10.1097/BRS.0b013e3180dc9758 CrossRefGoogle Scholar
  4. 4.
    Schoenfeld AJ, Bono CM, Reichmann WM, Warholic N, Wood KB, Losina E, Katz JN, Harris MB (2011) Type II odontoid fractures of the cervical spine: do treatment type and medical comorbidities affect mortality in elderly patients? Spine (Phila Pa 1976) 36(11):879–885. doi: 10.1097/BRS.0b013e3181e8e77c CrossRefGoogle Scholar
  5. 5.
    Pal D, Sell P, Grevitt M (2011) Type II odontoid fractures in the elderly: an evidence-based narrative review of management. Eur Spine J 20(2):195–204. doi: 10.1007/s00586-010-1507-6 CrossRefPubMedGoogle Scholar
  6. 6.
    Chapman J, Smith JS, Kopjar B, Vaccaro AR, Arnold P, Shaffrey CI, Fehlings MG (2013) The AOSpine North America geriatric odontoid fracture mortality study: a retrospective review of mortality outcomes for operative versus nonoperative treatment of 322 patients with long-term follow-up. Spine (Phila Pa 1976) 38(13):1098–1104. doi: 10.1097/BRS.0b013e318286f0cf CrossRefGoogle Scholar
  7. 7.
    Fehlings MG, Arun R, Vaccaro AR, Arnold PM, Chapman JR, Kopjar B (2013) Predictors of treatment outcomes in geriatric patients with odontoid fractures: AOSpine North America multi-centre prospective GOF study. Spine (Phila Pa 1976) 38(11):881–886. doi: 10.1097/BRS.0b013e31828314ee CrossRefGoogle Scholar
  8. 8.
    Robinson Y, Robinson AL, Olerud C (2014) Systematic review on surgical and nonsurgical treatment of type II odontoid fractures in the elderly. BioMed Res Int 2014:231948. doi: 10.1155/2014/231948 CrossRefPubMedPubMedCentralGoogle Scholar
  9. 9.
    Vaccaro AR, Kepler CK, Kopjar B, Chapman J, Shaffrey C, Arnold P, Gokaslan Z, Brodke D, France J, Dekutoski M, Sasso R, Yoon ST, Bono C, Harrop J, Fehlings MG (2013) Functional and quality-of-life outcomes in geriatric patients with type-II dens fracture. J Bone Joint Surg 95(8):729–735. doi: 10.2106/JBJS.K.01636 CrossRefPubMedGoogle Scholar
  10. 10.
    Tashjian RZ, Majercik S, Biffl WL, Palumbo MA, Cioffi WG (2006) Halo-vest immobilization increases early morbidity and mortality in elderly odontoid fractures. J Trauma 60(1):199–203. doi: 10.1097/01.ta.0000197426.72261.17 CrossRefPubMedGoogle Scholar
  11. 11.
    Gallie W (1939) Fractures and dislocations of the cervical spine. Am J Surg 3:495–499CrossRefGoogle Scholar
  12. 12.
    Magerl F, Seemann PS (1986) Stable posterior fusion of the atlas and axis by transarticular screw fixation. In: Kehr P, Weidner A (eds) Cervical spine. Springer, New YorkGoogle Scholar
  13. 13.
    Goel A, Laheri V (1994) Plate and screw fixation for atlanto-axial subluxation. Acta Neurochir (Wien) 129(1–2):47–53CrossRefGoogle Scholar
  14. 14.
    Harms J, Melcher RP (2001) Posterior C1–C2 fusion with polyaxial screw and rod fixation. Spine (Phila Pa 1976) 26(22):2467–2471CrossRefGoogle Scholar
  15. 15.
    Goel A, Gupta S (1999) Vertebral artery injury with transarticular screws. J Neurosurg 90(2):376–377PubMedGoogle Scholar
  16. 16.
    Polli FM, Miscusi M, Forcato S, Raco A (2014) Atlantoaxial anterior transarticular screw fixation: a case series and reappraisal of the technique. Spine J: Off J North Am Spine Soc. doi: 10.1016/j.spinee.2014.09.019 Google Scholar
  17. 17.
    Lakshmanan P, Jones A, Howes J, Lyons K (2005) CT evaluation of the pattern of odontoid fractures in the elderly—relationship to upper cervical spine osteoarthritis. Eur Spine J 14(1):78–83. doi: 10.1007/s00586-004-0743-z CrossRefPubMedGoogle Scholar
  18. 18.
    Etter C, Coscia M, Jaberg H, Aebi M (1991) Direct anterior fixation of dens fractures with a cannulated screw system. Spine (Phila Pa 1976) 16(3 Suppl):S25–S32CrossRefGoogle Scholar
  19. 19.
    Lu J, Ebraheim NA, Yang H, Heck BE, Yeasting RA (1998) Anatomic considerations of anterior transarticular screw fixation for atlantoaxial instability. Spine (Phila Pa 1976) 23(11):1229–1235 (discussion 1236)CrossRefGoogle Scholar
  20. 20.
    Reindl R, Sen M, Aebi M (2003) Anterior instrumentation for traumatic C1–C2 instability. Spine (Phila Pa 1976) 28(17):329–333. doi: 10.1097/01.BRS.0000083328.27907.3B CrossRefGoogle Scholar
  21. 21.
    Kocher MS, Horan MP, Briggs KK, Richardson TR, O’Holleran J, Hawkins RJ (2005) Reliability, validity, and responsiveness of the American shoulder and elbow surgeons subjective shoulder scale in patients with shoulder instability, rotator cuff disease, and glenohumeral arthritis. J Bone Joint Surg 87(9):2006–2011. doi: 10.2106/JBJS.C.01624 CrossRefPubMedGoogle Scholar
  22. 22.
    Xu Z, Liu T, He B, Guo H, Zheng Y, Hao B (2015) Transoral anterior release, odontoid partial resection, and reduction with posterior fusion for the treatment of irreducible atlantoaxial dislocation caused by odontoid fracture malunion. Eur Spine J 24(4):694–701. doi: 10.1007/s00586-014-3747-3 CrossRefPubMedGoogle Scholar
  23. 23.
    Osti M, Philipp H, Meusburger B, Benedetto KP (2011) Analysis of failure following anterior screw fixation of Type II odontoid fractures in geriatric patients. Eur Spine J 20(11):1915–1920. doi: 10.1007/s00586-011-1890-7 CrossRefPubMedPubMedCentralGoogle Scholar
  24. 24.
    Zapletal J, Hekster RE, Straver JS, Wilmink JT (1995) Atlanto-odontoid osteoarthritis. Appearance and prevalence at computed tomography. Spine 20(1):49–53CrossRefPubMedGoogle Scholar
  25. 25.
    Frangen TM, Zilkens C, Muhr G, Schinkel C (2007) Odontoid fractures in the elderly: dorsal C1/C2 fusion is superior to halo-vest immobilization. J Trauma 63(1):83–89. doi: 10.1097/TA.0b013e318060d2b9 CrossRefPubMedGoogle Scholar
  26. 26.
    Tian NF, Hu XQ, Wu LJ, Wu XL, Wu YS, Zhang XL, Wang XY, Chi YL, Mao FM (2014) Pooled analysis of non-union, re-operation, infection, and approach related complications after anterior odontoid screw fixation. PLoS ONE 9(7):e103065. doi: 10.1371/journal.pone.0103065 CrossRefPubMedPubMedCentralGoogle Scholar
  27. 27.
    Bisson EF, Mumert ML, Mazur MD, Dailey AT, Schmidt MH (2015) The fate of type II odontoid fractures after posterior atlantoaxial fusion: where does healing occur? J Neurol Surg A Cent Eur Neursurg 76(4):274–278. doi: 10.1055/s-0034-1376192 CrossRefGoogle Scholar
  28. 28.
    Han B, Li F, Chen G, Li H, Chen Q (2015) Motion preservation in type II odontoid fractures using temporary pedicle screw fixation: a preliminary study. Eur Spine J 24(4):686–693. doi: 10.1007/s00586-014-3693-0 CrossRefPubMedGoogle Scholar
  29. 29.
    Wang L, Liu C, Zhao Q, Tian J (2014) Posterior pedicle screw fixation for complex atlantoaxial fractures with atlanto-dental interval of ≥5 mm or C2–C3 angulation of ≥11. J Orthop Surg Res 9:104. doi: 10.1186/s13018-014-0104-5 CrossRefPubMedPubMedCentralGoogle Scholar
  30. 30.
    Venkatesan M, Northover JR, Wild JB, Johnson N, Lee K, Uzoigwe CE, Braybrooke JR (2014) Survival analysis of elderly patients with a fracture of the odontoid peg. Bone Joint J 96-B(1):88–93. doi: 10.1302/0301-620X.96B1.32024 CrossRefPubMedGoogle Scholar
  31. 31.
    White AP, Hashimoto R, Norvell DC, Vaccaro AR (2010) Morbidity and mortality related to odontoid fracture surgery in the elderly population. Spine (Phila Pa 1976) 35(9 Suppl):S146–S157. doi: 10.1097/BRS.0b013e3181d830a4 CrossRefGoogle Scholar
  32. 32.
    Jenkins JD, Coric D, Branch CL Jr (1998) A clinical comparison of one- and two-screw odontoid fixation. J Neurosurg 89(3):366–370. doi: 10.3171/jns.1998.89.3.0366 CrossRefPubMedGoogle Scholar
  33. 33.
    Feng G, Wendlandt R, Spuck S, Schulz AP (2012) One-screw fixation provides similar stability to that of two-screw fixation for type II dens fractures. Clin Orthop Relat Res 470(7):2021–2028. doi: 10.1007/s11999-012-2389-1 CrossRefPubMedPubMedCentralGoogle Scholar
  34. 34.
    Dailey AT, Hart D, Finn MA, Schmidt MH, Apfelbaum RI (2010) Anterior fixation of odontoid fractures in an elderly population. J Neurosurg Spine 12(1):1–8. doi: 10.3171/2009.7.SPINE08589 CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2016

Authors and Affiliations

  • Christoph Josten
    • 1
  • Jan-Sven Jarvers
    • 1
  • Stefan Glasmacher
    • 1
  • Christoph-Eckhard Heyde
    • 1
  • Ulrich J. Spiegl
    • 1
  1. 1.Department of Orthopaedics, Trauma and Plastic Surgery, Spine CenterUniversity of LeipzigLeipzigGermany

Personalised recommendations