Fusion rates for odontoid fractures after treatment by anterior odontoid screw versus posterior C1–C2 arthrodesis: a meta-analysis



For odontoid fractures, surgical treatment approaches including anterior odontoid screw fixation approach and the posterior C1–C2 arthrodesis approach are generally adopted in practice. However, the choice of different surgical procedures remains controversial. In addition to surgical technique, the fusion rate is an important factor contributing to the clinical efficacy. Therefore, this study was aimed to investigate the discrepancy in fusion rate between these two surgical approaches through synthesizing the currently available evidence on the topic.


A computerized search of Ovid, Medline, Embase, and the Cochrane library up to December 2017 for literature on the complication rate during odontoid fracture treatment was conducted. Risk ratio (RR) with its 95% confidence interval (CI) was pooled to assess fusion rates after surgical treatments, including anterior odontoid screw fixation approach or posterior C1–2 arthrodesis procedure, for patients with odontoid fractures.


Thirteen studies were enrolled in the meta-analysis. Results show that no significant difference was found in the overall fusion rate (RR = 0.96, 95% CI 0.90–1.01). There was no significant heterogeneity among the studies (p value = 0.60). As to age- and economic-level subgroups, there was no statistical evidence to suggest an association of the patient age and economy development level with the choice of surgical approach. However, it is shown that better fusion rates of patients (≥ 60 years) in developed countries received a better fusion rates after posterior fixation compared with anterior group using the fixed-effect model (RR = 0.88, 95% CI 0.79–0.98).


Elderly patients (≥ 60 years) underwent posterior C1–2 arthrodesis fixation shows higher fusion rates in developed countries comparing with patients who underwent anterior odontoid screw fixation. Overall, there is no significant discrepancy between these two surgical approaches. However, the conclusion should be verified by further study enrolling larger sample size.

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  1. 1.

    Chutkan NB, King AG, Harris MB (1997) Odontoid fractures: evaluation and management. J Am Acad Orthop Surg 5(4):199

    CAS  Article  PubMed  Google Scholar 

  2. 2.

    Maak TG, Grauer JN (2006) The contemporary treatment of odontoid injuries. Spine 31(11 Suppl):S53

    Article  PubMed  Google Scholar 

  3. 3.

    Bohlman HH (1979) Acute fractures and dislocations of the cervical spine. An analysis of three hundred hospitalized patients and review of the literature. J Bone Jt Surg Am Vol 61(8):1119–1142

    CAS  Article  Google Scholar 

  4. 4.

    Clark CR (1985) Fractures of the dens. A multicenter study. J Bone Jt Surg Am Vol 67(9):1340–1348

    CAS  Article  Google Scholar 

  5. 5.

    Song KJ, Lee KB, Kim KN (2007) Treatment of odontoid fractures with single anterior screw fixation. J Clin Neurosci 14(9):824–830

    Article  PubMed  Google Scholar 

  6. 6.

    Graziano G, Jaggers C, Lee M, Lynch W (1993) A comparative study of fixation techniques for type II fractures of the odontoid process. Spine 18(16):2383–2387

    CAS  Article  PubMed  Google Scholar 

  7. 7.

    Lee SH, Sung JK (2006) Anterior odontoid fixation using a 4.5-mm Herbert screw: the first report of 20 consecutive cases with odontoid fracture. Surg Neurol 66(4):361

    Article  PubMed  Google Scholar 

  8. 8.

    Hou Y, Yuan W, Wang X (2011) Clinical evaluation of anterior screw fixation for elderly patients with type II odontoid fractures. J Spinal Disord Tech 24(8):E75

    PubMed  Google Scholar 

  9. 9.

    Smith HE, Vaccaro AR, Maltenfort M, Albert TJ, Hilibrand AS, Anderson DG, Harrop J, Fehlings MG, Kopjar B, Brodke DS (2008) Trends in surgical management for type II odontoid fracture: 20 years of experience at a regional spinal cord injury center. Orthopedics 31(7):650–650

    PubMed  Google Scholar 

  10. 10.

    Ni B, Guo Q, Lu X, Xie N, Wang L, Guo X, Chen F (2015) Posterior reduction and temporary fixation for odontoid fracture-a salvage maneuver to anterior screw fixation. Spine 40(3):168–174

    Article  Google Scholar 

  11. 11.

    Grob D, Jeanneret B, Aebi M, Markwalder TM (1991) Atlanto-axial fusion with transarticular screw fixation. J Bone Jt Surg Br Vol 73(6):972–976

    CAS  Article  Google Scholar 

  12. 12.

    Elsaghir H, Böhm H (2000) Anderson type II fracture of the odontoid process: results of anterior screw fixation. J Spinal Disord 13(6):527–530

    CAS  Article  PubMed  Google Scholar 

  13. 13.

    Ochoa G (2005) Surgical management of odontoid fractures. Inj Int J Care Inj 36(2):S54–S64

    Article  Google Scholar 

  14. 14.

    Polin RS, Szabo T, Bogaev CA, Replogle RE, Jane JA (1996) Nonoperative management of Types II and III odontoid fractures: the Philadelphia collar versus the halo vest. Neurosurgery 38(3):456–457

    Google Scholar 

  15. 15.

    Shen Y, Miao J, Li C, Fang L, Cao S, Zhang M, Yan J, Kuang Y (2015) A meta-analysis of the fusion rate from surgical treatment for odontoid factures: anterior odontoid screw versus posterior C1-C2 arthrodesis. Eur Spine J 24(8):1649–1657

    Article  PubMed  Google Scholar 

  16. 16.

    Sawarkar DP, Singh PK, Siddique SA, Agrawal D, Satyarthee GD, Gupta DK, Sinha S, Kale SS, Sharma BS (2015) Surgical management of odontoid fractures at level one trauma center: a single-center series of 142 cases. Neurol India 63(1):40–48

    Article  PubMed  Google Scholar 

  17. 17.

    Wells GA, Shea BJ, O’Connell D, Peterson J, Welch V, Losos M, Tugwell P (2014) The Newcastle–Ottawa Scale (NOS) for assessing the quality of non-randomized studies in meta-analysis. Appl Eng Agric 18(6):págs. 727–734

    Google Scholar 

  18. 18.

    Higgins JP, Thompson SG (2002) Quantifying heterogeneity in a meta-analysis. Stat Med 21(11):1539

    Article  PubMed  PubMed Central  Google Scholar 

  19. 19.

    Higgins JP, Thompson SG, Deeks JJ, Altman DG (2003) Measuring inconsistency in meta-analyses. BMJ 327(7414):557–560

    Article  PubMed  PubMed Central  Google Scholar 

  20. 20.

    Sterne JAC, Egger M (2001) Funnel plots for detecting bias in meta-analysis: guidelines on choice of axis. J Clin Epidemiol 54(10):1046–1055

    CAS  Article  PubMed  Google Scholar 

  21. 21.

    Andersson S, Rodrigues M, Olerud C (2000) Odontoid fractures: high complication rate associated with anterior screw fixation in the elderly. European spine journal: official publication of the European Spine Society, the European Spinal Deformity Society, and the European Section of the Cervical. Spine Res Soc 9(1):56

    CAS  Google Scholar 

  22. 22.

    Chiba K, Fujimura Y, Toyama Y, Fujii E, Nakanishi T, Hirabayashi K (1996) Treatment protocol for fractures of the odontoid process. J Spinal Disord 9(4):267

    CAS  Article  PubMed  Google Scholar 

  23. 23.

    Fujii E, Kobayashi K, Hirabayashi K (1988) Treatment in fractures of the odontoid process. Spine 13(6):604–609

    CAS  Article  PubMed  Google Scholar 

  24. 24.

    Kim SK, Shin JJ, Kim TH, Shin HS, Hwang YS, Park SK (2011) Clinical outcomes of halo-vest immobilization and surgical fusion of odontoid fractures. J Korean Neurosurg Soc 50(1):17–22

    Article  PubMed  PubMed Central  Google Scholar 

  25. 25.

    Konieczny MR, Gstrein A, Müller EJ (2012) Treatment algorithm for dens fractures: non-halo immobilization, anterior screw fixation, or posterior transarticular C1–C2 fixation. J Bone Jt Surg Am Vol 94(19):e144(141

    Article  Google Scholar 

  26. 26.

    Mashhadinezhad H, Samini F, Mashhadinezhad A, Birjandinejad A (2012) Clinical results of surgical management in type II odontoid fracture: a preliminary report. Turk Neurosurg 22(5):583–587

    PubMed  Google Scholar 

  27. 27.

    Platzer P, Thalhammer G, Oberleitner G, Schuster R, Vécsei V, Gaebler C (2007) Surgical treatment of dens fractures in elderly patients. J Bone Jt Surg Am Vol 89(8):1716–1722

    Article  Google Scholar 

  28. 28.

    Ziai W, Hurlbert R (2000) A six year review of odontoid fractures: the emerging role of surgical intervention. Can J Neurol Sci 27(4):297–301

    CAS  Article  PubMed  Google Scholar 

  29. 29.

    Joaquim AF, Patel AA (2015) Surgical treatment of type II odontoid fractures: anterior odontoid screw fixation or posterior cervical instrumented fusion? Neurosurg Focus 38(4):E11

    Article  PubMed  Google Scholar 

  30. 30.

    Fagin AM, Cipolle MD, Barraco RD, Eid S, Li PM, Pasquale MD (2010) Odontoid fractures in the elderly: should we operate? J Trauma 68(3):583

    Article  PubMed  Google Scholar 

  31. 31.

    Guo Q, Zhang M, Wang L, Lu X, Guo X, Ni B (2015) Comparison of atlantoaxial rotation and functional outcomes of two non-fusion techniques in the treatment of Anderson-D’Alonzo type II odontoid fractures. Spine 41:1

    Google Scholar 

  32. 32.

    Omeis I, Duggal N, Rubano J, Cerabona F, Abrahams J, Fink M, Das K (2009) Surgical treatment of C2 fractures in the elderly: a multicenter retrospective analysis. Spine J 22(2):91–95

    Google Scholar 

  33. 33.

    Smith HE, Kerr SM, Maltenfort M, Chaudhry S, Norton R, Albert TJ, Harrop J, Hilibrand AS, Anderson DG, Kopjar B (2008) Early complications of surgical versus conservative treatment of isolated type II odontoid fractures in octogenarians: a retrospective cohort study. J Spinal Disord Tech 21(8):535–539

    Article  PubMed  Google Scholar 

  34. 34.

    Platzer P, Thalhammer G, Sarahrudi K, Kovar F, Vekszler G, Vécsei V, Gaebler C (2007) Nonoperative management of odontoid fractures using a halothoracic vest. Neurosurgery 61(3):522–529

    Article  PubMed  Google Scholar 

  35. 35.

    Th KC, Mirza SK, Jarell AD, Chapman JR, Shaffrey CI, Newell DW (2000) Type II odontoid fractures in the elderly: early failure of nonsurgical treatment. Neurosurg Focus 8(6):e7

    Google Scholar 

  36. 36.

    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 36(11):879

    Article  PubMed  PubMed Central  Google Scholar 

  37. 37.

    Platzer P, Thalhammer G, Ostermann R, Wieland T, Vécsei V, Gaebler C (2007) Anterior screw fixation of odontoid fractures comparing younger and elderly patients. Spine 32(16):1714–1720

    Article  PubMed  Google Scholar 

  38. 38.

    Aldrian S, Erhart J, Schuster R, Wernhart S, Domaszewski F, Ostermann R, Widhalm H, Platzer P (2012) Surgical vs nonoperative treatment of Hadley type IIA odontoid fractures. Neurosurgery 70(3):676

    Article  PubMed  Google Scholar 

  39. 39.

    Chaudhary A, Drew B, Orr RD, Farrokhyar F (2010) Management of type II odontoid fractures in the geriatric population: outcome of treatment in a rigid cervical orthosis. J Spinal Disord Tech 23(5):317

    Article  PubMed  Google Scholar 

  40. 40.

    Pepin JW, Bourne RB, Hawkins RJ (1985) Odontoid fractures, with special reference to the elderly patient. Clin Orthop Relat Res 193(193):178

    Google Scholar 

  41. 41.

    Bednar DA, Parikh J, Hummel J (1995) Management of type II odontoid process fractures in geriatric patients; a prospective study of sequential cohorts with attention to survivorship. J Spinal Disord 8(2):166–169

    CAS  Article  PubMed  Google Scholar 

  42. 42.

    Seybold EA, Bayley JC (1998) Functional outcome of surgically and conservatively managed dens fractures. Spine 23(17):1837–1845

    CAS  Article  PubMed  Google Scholar 

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We thank the research team in the Orthopedics Department of Tian Jin 4th Center Hospital for their assistance with the study.


The authors declare that there is no funding support for this study.

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LB and CJ contribute equally to the paper. They together designed the research. LB analysed the data and prepared the typescript. CJ revised the manuscript. The other authors provided the subject data. Both two authors read and approved the final manuscript.

Corresponding author

Correspondence to Chen Juwen.

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We declare that we have no financial and personal relationships with other people or organizations that can inappropriately influence our work; there is no professional or other personal interest of any nature or kind in any product, service and/or company that could be construed as influencing the position presented in, or the review of, the manuscript entitled, “Fusion rates for odontoid fractures after treatment by anterior odontoid screw versus posterior C1–C2 arthrodesis:A meta-analysis”.

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The study was approved by the Medical Ethics Committee of Tian Jin 4th Center Hospital, Tianjin, China.

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All authors Li Baogui and Chen Juwen of this paper “Fusion rates for odontoid fractures after treatment by anterior odontoid screw versus posterior C1–C2 arthrodesis:A meta-analysis” consent to publish on BMC Musculoskeletal Disorders once it is accepted.

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Baogui, L., Juwen, C. Fusion rates for odontoid fractures after treatment by anterior odontoid screw versus posterior C1–C2 arthrodesis: a meta-analysis. Arch Orthop Trauma Surg 139, 1329–1337 (2019). https://doi.org/10.1007/s00402-019-03164-0

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  • Odontoid fractures
  • Anterior odontoid screw
  • Posterior C1–2 arthrodesis
  • Complication rate
  • Meta-analysis