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. 2022 Aug;48(4):2967-2976.
doi: 10.1007/s00068-022-01985-0. Epub 2022 May 21.

Reevaluation of a classification system: stable and unstable odontoid fractures in geriatric patients-a radiological outcome measurement

Amelie Deluca  1   2 , Florian Wichlas  3 , Christian Deininger  4   3 , Andreas Traweger  4 , Ernst J Mueller  5
Affiliations

Reevaluation of a classification system: stable and unstable odontoid fractures in geriatric patients-a radiological outcome measurement

Amelie Deluca et al. Eur J Trauma Emerg Surg. 2022 Aug.

Abstract

Objectives: We carried out a retrospective cohort study to differentiate geriatric odontoid fractures into stable and unstable and correlated it with fracture fusion rates. Results are based on the literature and on our own experience. The authors propose that the simple Anderson and D'Alonzo classification may not be sufficient for geriatric patients.

Methods: There were 89 patients ≥ 65 years who presented at our institution with type II and III odontoid fractures from 2003 until 2017 and were included in this study. Each patient was categorized with CT scans to evaluate the type of fracture, fracture gap (mm), fracture angulation (°), fracture displacement (mm) and direction (ventral, dorsal). Fractures were categorized as stable [SF] or unstable [UF] distinguished by the parameters of its angulation (< / > 11°) and displacement (< / > 5 mm) with a follow-up time of 6 months. SFs were treated with a semi-rigid immobilization for 6 weeks, UFs surgically-preferably with a C1-C2 posterior fusion.

Results: The classification into SFs and UFs was significant for its angulation (P = 0.0006) and displacement (P < 0.0001). SF group (n = 57): A primary stable union was observed in 35, a stable non-union in 10, and an unstable non-union in 8 patients of which 4 were treated with a C1/2 fixation. The overall consolidation rate was 79%. UF group (n = 32): A posterior C1-C2 fusion was carried out in 23 patients, a C0 onto C4 stabilization in 7 and an anterior odontoid screw fixation in 2. The union rate was 100%. Twenty-one type II SFs (91%) consolidated with a nonoperative management (P < 0.001). A primary non-union occurred more often in type II than in type III fractures (P = 0.0023). There was no significant difference in the 30-day overall case fatality (P = 0.3786).

Conclusion: To separate dens fractures into SFs and UFs is feasible. For SFs, semi-rigid immobilization provides a high consolidation rate. Stable non-unions are acceptable, and the authors suggest a posterior transarticular C1-C2 fixation as the preferred surgical treatment for UFs.

Level of evidence: Level III.

Keywords: Geriatric patients; Odontoid fractures; Operative and non operative management.

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Conflict of interest statement

The authors declare that there is no Conflict of intererst.

Figures

Fig. 1
Fig. 1
Study flow diagram: during the study period, inclusion criteria were met by 89 elderly patients with an odontoid fracture
Fig. 2
Fig. 2
Odontoid fracture classification according to ventral or dorsal dislocation (blue), angulation (green) or gap (red)
Fig. 3
Fig. 3
Treatment algorithm of odontoid fracturs in the elderly (top). Classification into SFs and UFs based on target cut off points (red line)—angulation and displacement (bottom)
Fig. 4
Fig. 4
Summarized data and treatment protocol of stable odontoid fractures in the elderly
Fig. 5
Fig. 5
Summarized data and treatment protocol of unstable and operatively treated odontoid fractures in the elderly
Fig. 6
Fig. 6
Comparison of type II odontoid fractures in the SF und UF group according to angulation and displacement. *P < 0.01
See this image and copyright information in PMC

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