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Goh BC, Issa TZ, Lee Y, Vaccaro AR, Sebastian AS. Evidence and Controversies in Geriatric Odontoid Fracture Management. J Am Acad Orthop Surg 2024; 32:e84-e94. [PMID: 37793151 DOI: 10.5435/jaaos-d-23-00389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2023] [Accepted: 08/26/2023] [Indexed: 10/06/2023] Open
Abstract
Geriatric odontoid fractures are some of the most common spine injuries in our aging population, and their prevalence is only continuing to increase. Despite several investigational studies, treatment remains controversial and there is limited conclusive evidence regarding the management of odontoid fractures. These injuries typically occur in medically complex and frail geriatric patients with poor bone quality, making their treatment particularly challenging. In this article, we review the evidence for conservative management as well as surgical intervention and discuss various treatment strategies. Given the high morbidity and mortality associated with odontoid fractures in the elderly, thoughtful consideration and an emphasis on patient-centered goals of treatment are critical to maximize function in this vulnerable population.
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Somogyi R, Smith S, Kark J, Ryu WHA, Yoo J. Age-Based Incidence of Dens Fracture Has Unimodal Distribution Rather Than Commonly Claimed Bimodal Distribution. JB JS Open Access 2024; 9:e23.00059. [PMID: 38214006 PMCID: PMC10773694 DOI: 10.2106/jbjs.oa.23.00059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2024] Open
Abstract
Background Type-II dens fractures have long been described in the literature as occurring in a bimodal distribution, peaking in young adulthood as well as in older adulthood; however, the origin of this claim is unclear. The primary goal of this study was to examine the incidence of type-II dens fractures and assess for bimodality. Methods This is a retrospective cross-sectional review of the National Trauma Data Bank (NTDB) records on traumatic type-II dens fractures between October 2015 and December 2016. Rates were obtained from the NTDB, and the incidence per 100,000 was ascertained by utilizing U.S. Census data from 2016. Subgroupings by gender and Black or White race were also examined. Results Dens fractures occur unimodally, peaking around 89 years of age overall, skewed left by high rates in older White adults. The Black subgroup demonstrated trimodality, with the fracture incidence peaking at 25, 62, and 82 years of age. Rates among Black and White patients were similar until age 65, after which dens fractures occurred disproportionately in White patients. Fractures prior to age 75 occurred predominantly in men. Conclusions The evidence derived in this study challenges the common belief that type-II dens fractures occur bimodally across the entire population. However, there remains utility in considering younger and older patients as distinct groups for the purposes of management.
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Affiliation(s)
- Rita Somogyi
- Department of Orthopaedics and Rehabilitation, Oregon Health & Science University, Portland, Oregon
| | - Spencer Smith
- Department of Orthopaedics and Rehabilitation, Oregon Health & Science University, Portland, Oregon
| | - Jonathan Kark
- Department of Orthopaedics and Rehabilitation, Oregon Health & Science University, Portland, Oregon
| | - Won Hyung A. Ryu
- Department of Neurological Surgery, Oregon Health & Science University, Portland, Oregon
| | - Jung Yoo
- Department of Orthopaedics and Rehabilitation, Oregon Health & Science University, Portland, Oregon
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Florman JE, Gerstl JVE, Kilgallon JL, Riesenburger RI. Fibrous Nonunion of Odontoid Fractures: Is It Safe To Accept Nonoperative Management? A Systematic Review. World Neurosurg 2022; 164:298-304. [PMID: 35659587 DOI: 10.1016/j.wneu.2022.05.116] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Revised: 05/24/2022] [Accepted: 05/25/2022] [Indexed: 10/18/2022]
Abstract
OBJECTIVE Nonoperative management of odontoid fractures can result in solid fusion, unstable nonunion, and fibrous nonunion. Odontoid fractures with fibrous nonunion will not demonstrate dynamic instability on imaging studies. However, the safety of accepting this outcome has been debated. We have provided, to the best of our knowledge, the first systematic review of the existing literature to explore the safety of allowing fibrous nonunion as an acceptable outcome for odontoid fractures. METHODS The PubMed and Embase databases were searched in January 2022. The outcomes were extracted and categorized according to the mortality, neurologic sequelae, pain, neck disability index, and satisfaction. RESULTS Of a total of 700 abstracts screened, the full text of 79 reports was assessed, with 13 studies included. Of the included patients, 141 had had a fibrous nonunion, all described in observational studies. The follow-up ranged from 0.6 to 5.8 years. None of the 141 patients had experienced a neurologic event. One patient had died of trauma-related issues; however, causality was not reported. Most of the studies had reported good to excellent pain scores. Most of the neck disabilities reported had ranged from mild to moderate in severity. However, 1 study of 5 patients had reported severe disability. All the patients reported good or excellent satisfaction. CONCLUSIONS The evidence we found supports that it is safe to forgo surgery for carefully selected patients with nonunited odontoid fractures when near-anatomic alignment is present, dynamic instability is lacking on imaging studies, the neurologic examination findings are normal, and the risk of neck injury is low. Further study is needed to define the full natural history of fibrous nonunion of odontoid fractures.
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Affiliation(s)
- Jeffrey E Florman
- Neuroscience Institute, Maine Medical Center, Portland, Maine, USA; Department of Neurosurgery, Tufts University Medical Center, Boston, Massachusetts, USA.
| | - Jakob V E Gerstl
- Neuroscience Institute, Maine Medical Center, Portland, Maine, USA; Computational Neuroscience Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - John L Kilgallon
- Computational Neuroscience Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Ron I Riesenburger
- Department of Neurosurgery, Tufts University Medical Center, Boston, Massachusetts, USA
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Coleman N, Chan HYH, Gibbons V, Baker JF. Comparison of Hard and Soft Cervical Collars for the Management of Odontoid Peg Fractures in the Elderly. Geriatr Orthop Surg Rehabil 2022; 13:21514593211070263. [PMID: 35320993 PMCID: PMC8935567 DOI: 10.1177/21514593211070263] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2020] [Revised: 11/16/2021] [Accepted: 12/10/2021] [Indexed: 11/16/2022] Open
Abstract
Introduction Odontoid peg fractures (OF) are the most common cervical spine fracture in the elderly. This retrospective analysis aimed to compare the outcomes of older patients with OF who had been managed non-operatively with either a hard or soft cervical collar. Materials and Methods We analysed the retrospective data of the clinical and radiographic records of patients 60 years or older who presented over a 10-year period with OF and were treated non-operatively with a cervical collar. Mortality was the primary outcome measure with mechanism of injury, complications, and fracture healing secondary measures. Results 45 patients (hard collar n = 22; soft collar n = 23) were included with comparable demographics for frailty and co-morbidities in each group; age was significantly higher in the soft collar group (80.6 vs 86.4 years; P = .0065). Associated injuries and complications were not significantly different overall, or when Type II fractures were separately analysed (P = .435 associated injuries, P = .121 complications). All-cause mortality was greater in the soft collar group (30-day mortality hard: 0%, soft: 9%; 1-year mortality hard: 18%, soft: 48% P = .035). However, once corrected for age, this proved not to reach significance (P = .333) in any fracture type. Non-union was common (77%) but was not significantly different (hard = 70%; soft = 87%; P = .419). Discussion Consistent with other reports, non-union rates remained substantial regardless of which collar was used. After controlling for age, there was no difference in all-cause mortality between elderly patients treated with a hard or soft cervical collar for odontoid peg fractures. Conclusions Soft collars appear suitable for the treatment of odontoid peg fractures in the elderly without compromising outcome. Larger cohort analyses will help confirm this finding.
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Affiliation(s)
- Nichola Coleman
- Department of Orthopaedic Surgery, Waikato Hospital, Hamilton, New Zealand
| | - Hoi-Ying H Chan
- Department of Orthopaedic Surgery, Waikato Hospital, Hamilton, New Zealand
| | - Veronique Gibbons
- Clinical Effectiveness, Quality and Patient Safety, Waikato Hospital, Hamilton, New Zealand
| | - Joseph F Baker
- Department of Orthopaedic Surgery, Waikato Hospital, Hamilton, New Zealand.,Department of Surgery, University of Auckland, Auckland, New Zealand.,Waikato Institute of Surgical Education and Research, Hamilton, New Zealand
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Odontoid Fractures: A Standard Review of Current Concepts and Treatment Recommendations. J Am Acad Orthop Surg 2022; 30:e561-e572. [PMID: 35266921 DOI: 10.5435/jaaos-d-21-00165] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Accepted: 11/08/2021] [Indexed: 02/01/2023] Open
Abstract
Odontoid fractures represent the most common fractures involving C2 and the most common cervical spine fractures in patients older than 65 years. Despite their increasing frequency, optimal management of these injuries remain a subject to debate. Although types I and III injuries have relatively good healing potential with nonsurgical treatment, type II fractures carry a higher risk for nonunion. In particular, elderly patients are at risk for nonunion or fibrous malunion after nonsurgical treatment; however, increased medical comorbidities and poor bone quality also increase the risks of surgery in this cohort. The high morbidity and mortality associated with these injuries has made it an area of particular interest among spine surgeons. The purpose of this review was to summarize the pathophysiology, evaluation, and diagnosis of these injuries and to review controversies in management and considerations for treatment based on the most recent available literature.
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Gembruch O, Lemonas E, Ahmadipour Y, Sure U, El Hindy N, Dodel R, Müller O. Treatment of Odontoid Type II Fractures in Octogenarians: Balancing Two Different Treatment Strategies. Neurospine 2019; 16:360-367. [PMID: 31154696 PMCID: PMC6603819 DOI: 10.14245/ns.1836250.125] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Accepted: 12/31/2018] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE Demographic changes have led to a higher incidence of C-2 fractures, especially in elderly patients. For patients with type II fractures, treatment remains controversial, as discussed by Anderson and D'Alonzo, due to the rising morbidity and mortality rates for any treatment. The aim of this study was to compare conservative and surgical management in patients with type II C-2 fractures regarding outcomes, complications, and the mortality rate. METHODS A retrospective analysis was performed of the medical records, X-rays, and/or computed tomography scans of patients ≥80 years of age with type II fractures who were admitted to our Department of Neurosurgery between January 1990 and December 2017. The success of treatment was evaluated 3 months after surgery. RESULTS In total, 125 patients were included, of whom 98 were treated surgically and 27 were treated conservatively. Surgical treatment was successful in 90.8% of cases, while conservative treatment was successful in 70.0%. The in-hospital mortality was 14.29% and the 3-month mortality was 27.8% in the surgical group, compared to 3.7% and 20% in the conservatively treated group. The in-hospital complication rate was 22.4% in the surgically treated patients and 7.4% in the conservatively treated patients. CONCLUSION Surgical treatment of type II fractures seemed to be associated with higher success and complication rates than conservative treatment. Nevertheless, 3-month mortality was comparable in both groups. Therefore, we conclude that surgical treatment for type II fractures in elderly patients is superior to conservative management, although conservative treatment remains a valuable option in elderly patients with severe comorbidities.
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Affiliation(s)
- Oliver Gembruch
- Department of Neurosurgery, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Elias Lemonas
- Department of Neurosurgery, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Yahya Ahmadipour
- Department of Neurosurgery, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Ulrich Sure
- Department of Neurosurgery, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Nicolai El Hindy
- Department of Neurosurgery, University Hospital Essen, University of Duisburg-Essen, Essen, Germany.,Department of Spine Surgery, Katholisches Klinikum Lünen/Werne GmbH, St. Christophorus-Krankenhaus, Werne, Germany
| | - Richard Dodel
- Department of Geriatric Medicine, University Hospital Essen, University of Duisburg-Essen, Essen, Germany.,Geriatric Center Haus Berge, Contilia Group, Essen, Germany
| | - Oliver Müller
- Department of Neurosurgery, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
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Robinson AL, Olerud C, Robinson Y. Surgical treatment improves survival of elderly with axis fracture-a national population-based multiregistry cohort study. Spine J 2018; 18:1853-1860. [PMID: 29649609 DOI: 10.1016/j.spinee.2018.03.021] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2017] [Revised: 02/27/2018] [Accepted: 03/26/2018] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Fractures of the axis (C2) are the most common cervical spinal injuries in the elderly population. Several authors have reported improved survival among elderly patients with C2 fractures when treated surgically. PURPOSE We aimed to analyze whether surgery improves survival of elderly with C2 fractures. STUDY DESIGN/SETTING An observational population-based longitudinal multi-registry study was carried out. PATIENT SAMPLE Swedish Patient Registry 1997 to 2014 and Swedish Cause of Death Registry 1997 to 2014 served as source of patient sample. OUTCOME MEASURES Survival after C2 fracture according to non-surgical and surgical treatment was the outcome measure. METHODS We included all patients treated for the primary diagnosis of C2 fracture (10th revision of the International Statistical Classification of Diseases and Related Health Problems or ICD-10: S12.1) at an age ≥70 years and receiving treatment at a health-care facility. Non-surgical treatment comprises cervical collar or halo-vest treatment. Surgical treatment was identified in the Swedish patient registry extract using the Swedish classification of procedural codes. Survival was determined using the Kaplan-Meier method. Comorbidity was determined using the Charlson Comorbidity Index. RESULTS Of the included 3,375 elderly patients with C2 fractures (43% men, aged 83±7 years), 22% were treated surgically. Surgical treatment was assigned based on age, gender, and year of treatment. The 1-year survival of 2,618 non-surgically treated patients was 72% (n=1,856), and 81% (n=614) for the 757 surgically treated (p<.001, relative risk reduction=11%). Adjusted for age, gender, comorbidity, and year of injury, surgically treated patients had greater survival than non-surgically treated patients (hazard ratio=0.88, 95% confidence interval: 0.79-0.97). Among those above 88 years of age (95% confidence interval: 85-92), surgical treatment lost its effect on survival. CONCLUSIONS Despite the frailty of elderly patients, the morbidity of cervical external immobilization with a rigid collar seemingly weighs greater than surgical morbidity, even in octogenarians. For those above 88 years of age, non-surgical treatment should be primarily attempted.
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Affiliation(s)
- Anna-Lena Robinson
- Stockholm Spine Center, Löwenströmska Sjukhuset, 194 89 Upplands-Väsby, Sweden; Department of Surgical Sciences, Uppsala University Hospital, 751 85 Uppsala, Sweden.
| | - Claes Olerud
- Department of Surgical Sciences, Uppsala University Hospital, 751 85 Uppsala, Sweden
| | - Yohan Robinson
- Department of Surgical Sciences, Uppsala University Hospital, 751 85 Uppsala, Sweden; Department of Research and Development, Swedish Armed Forces Centre for Defence Medicine, Box 5155, 425 05 Västra Frölunda, Sweden
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8
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Anterior management of C2 fractures using miniplate fixation: outcome, function and quality of life in a case series of 15 patients. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2018; 27:1332-1341. [DOI: 10.1007/s00586-018-5556-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/15/2017] [Revised: 03/03/2018] [Accepted: 03/20/2018] [Indexed: 12/27/2022]
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Peck GE, Shipway DJH, Tsang K, Fertleman M. Cervical spine immobilisation in the elderly: a literature review. Br J Neurosurg 2018; 32:286-290. [PMID: 29488398 DOI: 10.1080/02688697.2018.1445828] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
Developed populations are ageing rapidly and by 2040, approximately 1 in 4 adults will be over 65 years of age. This is resulting in higher incidence of traumatic injury in older patients. Cognitive and physical comorbidities in this group can pose significant challenges. Due to mechanisms of injury and pre-existing degenerative spinal disease, cervical spine fractures are particularly prevalent in elderly patients. These are associated with significant morbidity and mortality. In this literature review we examine current evidence surrounding the use of cervical spine immobilisation in elderly patients in the pre-hospital and emergency department setting and also as a treatment option for cervical spine fractures. We explore evidence surrounding the complications that can arise from cervical spine immobilisation, including the development of pressure sores, raised intracranial pressure, dysphagia, breathing difficulties, delirium, compliance issues, mobility and functional outcome.
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Affiliation(s)
- George Edward Peck
- a Division of Surgery , Imperial College Healthcare NHS Trust, St Mary's Hospital , London , UK
| | | | - Kevin Tsang
- c Division of Neurosurgery , Imperial College Healthcare NHS Trust, St Mary's Hospital , London , UK
| | - Michael Fertleman
- a Division of Surgery , Imperial College Healthcare NHS Trust, St Mary's Hospital , London , UK
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Iyer S, Hurlbert RJ, Albert TJ. Management of Odontoid Fractures in the Elderly: A Review of the Literature and an Evidence-Based Treatment Algorithm. Neurosurgery 2017; 82:419-430. [DOI: 10.1093/neuros/nyx546] [Citation(s) in RCA: 57] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2017] [Accepted: 10/01/2017] [Indexed: 11/12/2022] Open
Abstract
Abstract
Odontoid fractures are the most common fracture of the axis and the most common cervical spine fracture in patients over 65. Despite their frequency, there is considerable ambiguity regarding optimal management strategies for these fractures in the elderly. Poor bone health and medical comorbidities contribute to increased surgical risk in this population; however, nonoperative management is associated with a risk of nonunion or fibrous union. We provide a review of the existing literature and discuss the classification and evaluation of odontoid fractures. The merits of operative vs nonoperative management, fibrous union, and the choice of operative approach in elderly patients are discussed. A treatment algorithm is presented based on the available literature. We believe that type I and type III odontoid fractures can be managed in a collar in most cases. Type II fractures with any additonal risk factors for nonunion (displacement, comminution, etc) should be considered for surgical management. However, the risks of surgery in an elderly population must be carefully considered on a case-by-case basis. In a frail elderly patient, a fibrous nonunion with close follow-up is an acceptable outcome. If operative management is chosen, a posterior approach is should be chosen when fracture- or patient-related factors make an anterior approach challenging. The high levels of morbidity and mortality associated with odontoid fractures should encourage all providers to pursue medical co-management and optimization of bone health following diagnosis.
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Affiliation(s)
- Sravisht Iyer
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York
| | - R John Hurlbert
- Spine Program, Department of Surgery, University of Arizona—College of Medicine, Tuscon, Arizona
| | - Todd J Albert
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York
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11
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Abstract
Odontoid fractures are the most common cervical fracture type among the elderly population. Several treatment options exist for these patients, ranging from immobilization with a semirigid orthosis to surgical arthrodesis. This report reviews the key points in the management of odontoid fractures in the aged patient, including diagnosis, the various forms of conservative therapies, and the options for surgical intervention.
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Affiliation(s)
- Jian Guan
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, 175 North Medical Drive East, Salt Lake City, UT 84132, USA
| | - Erica F Bisson
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, 175 North Medical Drive East, Salt Lake City, UT 84132, USA.
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12
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Sime D, Gabbe B, Liew S. Outcomes of halo immobilization in the management of subaxial cervical facet fractures. ANZ J Surg 2016; 87:159-164. [DOI: 10.1111/ans.13656] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2016] [Revised: 05/07/2016] [Accepted: 05/12/2016] [Indexed: 11/30/2022]
Affiliation(s)
- David Sime
- Department of Orthopaedic Surgery; Alfred Health; Melbourne Victoria Australia
| | - Belinda Gabbe
- Department of Epidemiology and Preventive Medicine; Monash University; Melbourne Victoria Australia
| | - Susan Liew
- Department of Orthopaedic Surgery; Alfred Health; Melbourne Victoria Australia
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13
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Abstract
STUDY DESIGN Cost-effectiveness analysis. OBJECTIVE To examine the cost-effectiveness of operative versus non-operative treatment of type-II odontoid fractures in patients older than 64 years old. SUMMARY OF BACKGROUND DATA Significant controversy exists regarding the optimum treatment of geriatric patients with type-II odontoid fractures. Operative treatment leads to lower rates of non-union but carries surgical risks. Non-operative treatment does not carry surgical risks but has higher non-union rates. METHODS A decision-analytic model was created to compare operative and non-operative treatment of type-II odontoid fractures among three age cohorts (65-74, 75-84, >84) based on expected costs, quality-adjusted life years (QALYs) and incremental cost-effectiveness ratios (ICERs; cost per QALY gained). Age-specific mortality rates for both treatments, costs for treatment, and complication rates were taken from the literature, and data from 2010 US life tables were used for age-specific life expectancy. Costs of complications were estimated using data obtained at a level-I trauma center using micro-costing. Sensitivity analyses of all model parameters were conducted. RESULTS Among the 65- to 74-year-old cohort, operative treatment was more costly ($53,407 vs. $30,553) and more effective (12.00 vs. 10.11 QALY), with an ICER of $12,078/QALY. Among the 75- to 84-year-old cohort, operative treatment was more costly ($51,308 vs. $29,789) and more effective (6.85 vs. 6.31 QALY), with an ICER of $40,467/QALY. Among the over-84 cohort, operative treatment was dominated by non-operative treatment as it was both more costly ($45,978 vs. $28,872) and less effective (2.48 vs. 3.73 QALY). The model was robust to sensitivity analysis across reasonable ranges for utility of union, disutility of complications and delayed surgery, and probabilities of non-union and complications. CONCLUSION Operative treatment is cost-effective in patients age 65 to 84 when using $100,000/QALY as a benchmark but less effective and more costly than non-operative treatment in patients older than 84 years. LEVEL OF EVIDENCE 2.
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Joestl J, Lang NW, Tiefenboeck TM, Hajdu S, Platzer P. Management and Outcome of Dens Fracture Nonunions in Geriatric Patients. J Bone Joint Surg Am 2016; 98:193-8. [PMID: 26842409 DOI: 10.2106/jbjs.o.00101] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Dens fractures are known to have high rates of pseudarthrosis. The aim of this study was to define clinical and radiographic long-term outcomes, specifically in relation to osseous union, cervical spine movement, neurological sequelae, and quality of life, in a geriatric cohort (sixty-five years of age or older) treated operatively or nonoperatively for a dens fracture nonunion. METHODS Forty-four patients (twenty-eight women and sixteen men; average age, seventy-two years) met the inclusion criteria and were enrolled in this study. Sixteen patients (36%) underwent operative stabilization with posterior cervical arthrodesis, and twenty-eight (64%) were treated nonoperatively with a predefined protocol. All patients had a post-treatment follow-up period of at least five years. RESULTS Radiographic evaluation showed osseous union at the site of the C1-C2 arthrodesis in all sixteen patients who had undergone surgical treatment. Clinical follow-up revealed that fourteen had satisfactory results following postoperative rehabilitation. In contrast, radiographic evaluation of the twenty-eight nonoperatively treated patients showed persistence of the pseudarthrosis of the dens in twenty-six and osseous union of the dens in two. All twenty-eight patients (100%) had a satisfactory clinical outcome. CONCLUSIONS C1-C2 arthrodesis was a reliable treatment option for dens fracture nonunions that were unstable, those associated with neurological symptoms, and those causing persistent pain. Clinical and radiographic monitoring was an acceptable nonoperative treatment option but was associated with a very low rate of osseous union of the dens.
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Affiliation(s)
- Julian Joestl
- Department of Trauma Surgery, Medical University of Vienna, Austria
| | - Nikolaus W Lang
- Department of Trauma Surgery, Medical University of Vienna, Austria
| | | | - Stefan Hajdu
- Department of Trauma Surgery, Medical University of Vienna, Austria
| | - Patrick Platzer
- Department of Trauma Surgery, Medical University of Vienna, Austria
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