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Süvegh D, Juhász Á, Viola R, Al-Smadi MW, Viola Á. Treatment of Ankylosing Spondylitis Patients with Cervical Spinal Injury with Anterior Single-Stage Fixation with Bone Cement Augmentation. J Clin Med 2024; 13:3131. [PMID: 38892842 PMCID: PMC11172596 DOI: 10.3390/jcm13113131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2024] [Revised: 05/14/2024] [Accepted: 05/23/2024] [Indexed: 06/21/2024] Open
Abstract
Background/Objectives: Cervical spine fractures in ankylosing spondylitis (AS) are characterized as highly unstable fractures posing an elevated risk of neurological deficit and a significantly elevated mortality rate. This study assesses the efficacy and safety of single-stage plate stabilization with ventral cement augmentation in treating subaxial cervical spine fractures in patients with AS. Methods: Over 86 months, 38 patients diagnosed with AS received ventral plate stabilization with cement augmentation after suffering unstable subaxial cervical fractures. No additional dorsal stabilization was used in any of these surgeries. Results: There were no complications as a result of cement leakage. During the follow-up period, screw loosening and implant displacement were documented in two out of 38 cases. At the time of data analysis, 17 patients who had undergone treatment had died, representing 44.7% of the total cases. Seven patients died within 1 month, two patients died within 6 months, four patients died within 1 year, and four patients died after 1 year. Conclusions: Our study shows that a single-stage anterior screw and plate fixation of the cervical spine with cement augmentation could be a feasible and effective method to treat cervical spine fractures in patients with AS.
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Affiliation(s)
- Dávid Süvegh
- Department of Traumatology, Semmelweis University, Fiumei út 17., 1081 Budapest, Hungary; (D.S.); (Á.J.)
| | - Ádám Juhász
- Department of Traumatology, Semmelweis University, Fiumei út 17., 1081 Budapest, Hungary; (D.S.); (Á.J.)
| | - Réka Viola
- Department of Psychiatry, Peterfy Sandor Hospital, 1076 Budapest, Hungary;
| | - Mohammad Walid Al-Smadi
- Department of Neurosurgery and Neurotraumatology, Dr. Manninger Jenő National Traumatology Institution, 1081 Budapest, Hungary;
| | - Árpád Viola
- Department of Traumatology, Semmelweis University, Fiumei út 17., 1081 Budapest, Hungary; (D.S.); (Á.J.)
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Müller JU, Nowak S, Matthes M, Pillich DT, Schroeder HWS, Müller J. Biomechanical comparison of two different compression screws for the treatment of odontoid fractures in human dens axis specimen. Clin Biomech (Bristol, Avon) 2024; 111:106162. [PMID: 38159327 DOI: 10.1016/j.clinbiomech.2023.106162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2023] [Revised: 12/13/2023] [Accepted: 12/21/2023] [Indexed: 01/03/2024]
Abstract
BACKGROUND Lag screw osteosynthesis for odontoid fractures has a high rate of pseudoarthrosis, especially in elderly patients. Besides biomechanical properties of the different screw types, insufficient fragment compression or unnoticed screw stripping may be the main causing factors for this adverse event. The aim of the study was to compare two screws in clinical use with different design principles in terms of compression force and stability against screw stripping. METHODS Twelve human cadaveric C2 vertebral bodies were considered. Bone density was determined. The specimens were matched according to bone density and randomly assigned to two experimental groups. An odontoid fracture was induced, which were fixed either with a 3.5 mm standard compression screw or with a 5 mm sleeve nut screw. Both screws are certified for the treatment of odontoid fractures. The bone samples were fixed in a measuring device. The screwdriver was driven mechanically. The tests were analyzed for peak interfragmentary compression and screw-in torque with a frequency of 20 Hz. FINDINGS The maximum fragment compression was significantly higher with screw with sleeve nut at 346.13(SD ±72.35) N compared with classic compression screw at 162.68(SD ±114.13) N (p = 0.025). Screw stripping occurred significantly earlier in classic compression screw at 255.5(SD ±192.0)° rotation after reaching maximum compression than in screw with sleeve nut at 1005.2(SD ±341.1)° (p = 0.0039). INTERPRETATION Screw with sleeve nut achieves greater fragment compression and is more robust to screw stripping compared to classic compression screw. Whether the better biomechanical properties lead to a reduction of pseudoarthrosis has to be proven in clinical studies.
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Affiliation(s)
- Jan-Uwe Müller
- Department of Neurosurgery, University Medicine, Greifswald, Germany.
| | - Stephan Nowak
- Department of Neurosurgery, University Medicine, Greifswald, Germany
| | - Marc Matthes
- Department of Neurosurgery, University Medicine, Greifswald, Germany
| | | | | | - Jonas Müller
- Department of Neurosurgery, University Medicine, Greifswald, Germany
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Oitment C, Thornley P, Koziarz F, Jentzsch T, Bhanot K. A Review of Strategies to Improve Biomechanical Fixation in the Cervical Spine. Global Spine J 2022; 12:1596-1610. [PMID: 35020520 PMCID: PMC9393983 DOI: 10.1177/21925682211063855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
STUDY DESIGN Systematic review. OBJECTIVES Review the surgical techniques and construct options aimed at improving the biomechanical strength of cervical constructs. METHODS A systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A search of the MEDLINE, Embase, and Cochrane Library databases was performed to identify all studies examining biomechanical strategies utilized in the osteoporotic cervical spine. Screening was performed in duplicate for all stages of the review process. RESULTS An initial search returned 3887 articles. After deletion of duplications and review of abstracts and full text, 39 articles met inclusion criteria. Overall, the surgical techniques reviewed aimed at obtaining rigid fixation in the setting of poor bone quality, or dispersing the forces at the bone-implant interface. We identified 6 key techniques to improve biomechanical fixation. These include bicortical fixation, appropriate screw selection (size and trajectory), PMMA augmentation, load sharing techniques, consideration of ancillary fixation around the occipitocervical junction, and supplementing the construct with post-operative collar or halo. CONCLUSION The summation of the literature highlights a framework of modalities available to surgeons to improve biomechanical fixation in the cervical spine. While these may improve construct strength in the setting of osteoporosis, there is a paucity of evidence available to make recommendations in this patient population.
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Affiliation(s)
- Colby Oitment
- Division of Orthopedic Surgery, Hamilton General Hospital, McMaster University, Hamilton, ON, Canada,Dr Colby Oitment, MD, McMaster University, Department of Orthopedic Surgery, Hamilton General HospitalAffiliation, McMaster University, 1200 Main St West, Hamilton, ON L8S 4L8, Canada.
| | - Patrick Thornley
- Division of Orthopedic Surgery, Hamilton General Hospital, McMaster University, Hamilton, ON, Canada
| | - Frank Koziarz
- Department of Graduate Studies, Health Research Methodology (HRM), and Epidemiology, McMaster University, Hamilton, ON, Canada
| | - Thorsten Jentzsch
- Division of Orthopaedic Surgery, St Michael’s Hospital, Toronto, ON, Canada,Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Kunal Bhanot
- Division of Orthopaedic Surgery, St Michael’s Hospital, Toronto, ON, Canada,Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
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A biomechanical comparison of a cement-augmented odontoid screw with a posterior-instrumented fusion in geriatric patients with an odontoid fracture type IIb. 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 2021; 30:1566-1573. [PMID: 33929612 DOI: 10.1007/s00586-021-06848-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Revised: 02/22/2021] [Accepted: 04/15/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE Possible surgical therapies for odontoid fracture type IIb include odontoid screw osteosynthesis (OG) with preservation of mobility or dorsal C1/2 fusion with restriction of cervical rotation. In order to reduce material loosening in odontoid screw osteosynthesis in patients with low bone density, augmentation at the base of the axis using bone cement has been established as a suitable alternative. In this study, we compared cement-augmented OG and C1/2 fusion according to Harms (HG). METHODS Body donor preparations of the 1st and 2nd cervical vertebrae were randomized in 2 groups (OG vs. HG). The range of motion (ROM) was determined in 3 principle motion plains. Subsequently, a cyclic loading test was performed. The decrease in height of the specimen and the double amplitude height were determined as absolute values as an indication of screw loosening. Afterward, the ROM was determined again and loosening of the screws was measured in a computed tomography. RESULTS A total of 16 were included. Two groups of 8 specimens (OG vs. HG) from patients with a median age of 80 (interquartile range (IQ) 73.5-85) years and a reduced bone density of 87.2 (IQ 71.2-104.5) mg/cc dipotassium hydrogen phosphate were examined for their biomechanical properties. Before and after exposure, the OG preparations were significantly more mobile. At the time of loading, the OG had similar loading properties to HG decrease in height of the specimen and the double amplitude height. Computed tomography revealed similar outcomes with regard to the screw loosening rate (62.5 vs. 87.5%, p = 0.586). CONCLUSION In patients with an odontoid fracture type IIb and reduced bone density, cement-augmented odontoid screw yielded similar properties in the loading tests compared to the HG. It may, therefore, be considered as a primary alternative to preserve cervical mobility in these patients.
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Capek L, Rehousek P, Henys P, Bleibleh S, Jenner E, Kulvajtova M, Skala-Rosenbaum J. Cement augmentation of odontoid peg fractures: the effect of cement volume and distribution on construct stiffness. 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 2020; 29:977-985. [PMID: 31902000 DOI: 10.1007/s00586-019-06286-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Revised: 12/13/2019] [Accepted: 12/31/2019] [Indexed: 11/26/2022]
Abstract
PURPOSE The cement augmentation of a conventional anterior screw fixation in type II odontoid process fractures for elderly patients significantly increased stiffness and load to failure under anterior-posterior load in comparison with non-augmented fixation. The amount and quality of bone cement are usually taken ad hoc in clinical practise. In this study, we wanted to clarify the role of bone cement amount and its quality to the stiffness of odontoid and vertebrae body junction. METHODS Finite-element method was used to achieve different scenarios of cement augmentation. For all models, an initial stiffness was calculated. Model (1) the intact vertebrae were virtually potted into a polymethylmethacrylate base via the posterior vertebral arches. A V-shaped punch was used for loading the odontoid in an anterior-posterior direction. (2) The odontoid fracture type IIa (Anderson-D'Alonzo classification) was achieved by virtual transverse osteotomy. Anterior screw fixation was virtually performed by putting self-drilling titanium alloy 3.5 mm diameter anterior cannulated lag screw with a 12 mm thread into the inspected vertebrae. A V-shaped punch was used for loading the odontoid in an anterior-posterior direction. The vertebrae body was assumed to be non-cemented and cemented with different volume. RESULTS The mean cement volume was lowest for body base filling with 0.47 ± 0.03 ml. The standard body filling corresponds to 0.95 ± 0.15 ml. The largest volume corresponds to 1.62 ± 0.12 ml in the presence of cement leakage. The initial stiffness of the intact C2 vertebrae was taken as the reference value. The mean initial stiffness for non-porous cement (E = 3000 MPa) increased linearly (R2 = 0.98). The lowest stiffness (123.3 ± 5.8 N/mm) was measured in the intact C2 vertebrae. However, the highest stiffness (165.2 ± 5.2 N/mm) was measured when cement leakage out of the odontoid peg occurred. The mean initial stiffness of the base-only cemented group was 147.2 ± 8.4 N/mm compared with 157.9 ± 6.6 N/mm for the base and body cemented group. This difference was statistically significant (p < 0.0061). The mean initial stiffness for porous cement (E = 500 MPa) remains constant. Therefore, there is no difference between cemented and non-cemented junction. This difference was not statistically significant (p < 0.18). CONCLUSION The present study showed that the low porous cement was able to significantly influence the stiffness of the augmented odontoid screw fixation in vitro, although further in vivo clinical studies should be undertaken. Our results suggest that only a small amount of non-porous cement is needed to restore stiffness at least to its pre-fracture level and this can be achieved with the injection of 0.7-1.2 ml of cement. These slides can be retrieved under Electronic Supplementary Material.
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Affiliation(s)
- Lukas Capek
- Technical University of Liberec, Studentska 1402/2, 461 17, Liberec, Czechia
| | - Petr Rehousek
- Royal Orthopaedic Hospital, Bristol Rd South, Birmingham, B32 1AP, UK
- Third Faculty of Medicine, Charles University, Prague, Ruska 2411/87, 100 00, Praha 10, Vinohrady, Czechia
| | - Petr Henys
- Technical University of Liberec, Studentska 1402/2, 461 17, Liberec, Czechia.
| | - Sabri Bleibleh
- Royal Orthopaedic Hospital, Bristol Rd South, Birmingham, B32 1AP, UK
| | - Edward Jenner
- Royal Orthopaedic Hospital, Bristol Rd South, Birmingham, B32 1AP, UK
| | - Marketa Kulvajtova
- Third Faculty of Medicine, Charles University, Prague, Ruska 2411/87, 100 00, Praha 10, Vinohrady, Czechia
| | - Jiri Skala-Rosenbaum
- Third Faculty of Medicine, Charles University, Prague, Ruska 2411/87, 100 00, Praha 10, Vinohrady, Czechia
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Osterhoff G, Schnake K, Scheyerer MJ, Ullrich BW, Hartmann F, Franck A, Koepp H, Reinhold M, Schmeiser G, Sprengel K, Zimmermann V, Siekmann H, Badke A, Gebhard H, Täubel KC, Grüninger S, Verheyden AP, Schleicher P, Spiegl UJA. Recommendations for Diagnosis and Treatment of Odontoid Fractures in Geriatric Patients. ZEITSCHRIFT FUR ORTHOPADIE UND UNFALLCHIRURGIE 2019; 158:647-656. [PMID: 31634954 DOI: 10.1055/a-0989-2791] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Odontoid fractures in geriatric patients represent an entity of increasing incidence with a high rate of morbidity and mortality. The optimal diagnostic and therapeutic management is being controversially discussed in the literature. METHODS In a consensus process and based on the current literature, the members of the working groups "Osteoporotic Fractures" and "Upper Cervical Spine" of the German Society for Orthopaedics and Trauma Surgery (DGOU) defined recommendations for the diagnostics and treatment of odontoid fractures in geriatric patients. RESULTS For the diagnosis of odontoid fractures in symptomatic patients, computed tomography represents the gold standard, along with conventional radiographs. Magnetic resonance and dynamic imaging can be used as ancillary imaging modalities. With regard to fracture classification, the systems described by Anderson/D'Alonzo and by Eysel/Roosen have proved to be of value. A treatment algorithm was developed based on these classifications. Anderson/D'Alonzo type 1, type 3, and non-displaced type 2 fractures usually can be treated non-operatively. However, a close clinical and radiological follow-up is essential. In Anderson/D'Alonzo type 2 fractures, operative treatment is associated with better fracture healing. Displaced type 2 and type 3 fractures should be stabilized operatively. Type 2 fractures with suitable fracture patterns (Eysel/Roosen 2A/B) can be stabilized anteriorly. Posterior C I/II-stabilization procedures are well established and suitable for all fracture patterns.
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Affiliation(s)
- Georg Osterhoff
- Klinik für Orthopädie, Unfallchirurgie und Plastische Chirurgie, Universitätsklinikum Leipzig
| | - Klaus Schnake
- Zentrum für Wirbelsäulen- und Skoliosetherapie, Schön Klinik Nürnberg/Fürth, Fürth
| | - Max J Scheyerer
- Klinik und Poliklinik für Orthopädie und Unfallchirurgie, Universitätsklinikum Köln
| | - Bernhard W Ullrich
- Klinik für Unfall- und Wiederherstellungschirurgie, BG Klinikum Bergmannstrost GgmbH Halle/Saale
| | - Frank Hartmann
- Zentrum für Unfallchirurgie und Orthopädie, Ev. Stift St. Martin, Gemeinschaftsklinikum Mittelrhein, Koblenz
| | - Alexander Franck
- Klinik für Orthopädie und Unfallchirurgie, Regiomed Klinikum Coburg
| | - Holger Koepp
- Wirbelsäulenzentrum, St. Josefs-Hospital, Wiesbaden
| | - Maximilian Reinhold
- Klinik für Unfallchirurgie, Orthopädie und Handchirurgie, Klinikum Südstadt Rostock
| | | | - Kai Sprengel
- Klinik für Traumatologie, UniversitätsSpital Zürich, Schweiz
| | - Volker Zimmermann
- Abt. Unfallchirurgie und Orthopädische Chirurgie, Klinikum Traunstein
| | - Holger Siekmann
- Department für Orthopädie, Unfall- und Wiederherstellungschirurgie, Martin-Luther-Universität Halle-Wittenberg, Halle
| | - Andreas Badke
- Klinik für Unfall- und Wiederherstellungschirurgie, BG Unfallklinik Tübingen
| | | | - Kai C Täubel
- Orthopädisch-Unfallchirurgisches Zentrum, ALB FILS KLINIKEN, Standort Klinik am Eichert, Göppingen
| | - Sebastian Grüninger
- Universitätsklinik für Orthopädie und Unfallchirurgie, Paracelsus Medizinische Privatuniversität, Klinikum Nürnberg
| | - Akhil P Verheyden
- Klinik für Unfall-, Orthopädische und Wirbelsäulenchirurgie, Ortenau Klinikum Lahr-Ettenheim
| | | | - Ulrich J A Spiegl
- Klinik für Orthopädie, Unfallchirurgie und Plastische Chirurgie, Universitätsklinikum Leipzig
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Goz V, Spiker WR, Lawrence B, Brodke D, Spina N. Odontoid Fractures: A Critical Analysis Review. JBJS Rev 2019; 7:e1. [PMID: 31389849 DOI: 10.2106/jbjs.rvw.18.00122] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Vadim Goz
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, Utah
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Schwarz F, Lawson McLean A, Waschke A, Kalff R. Cement-augmented anterior odontoid screw fixation in elderly patients with odontoid fracture. Clin Neurol Neurosurg 2018; 175:144-148. [DOI: 10.1016/j.clineuro.2018.11.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2018] [Revised: 11/01/2018] [Accepted: 11/04/2018] [Indexed: 11/15/2022]
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Rehousek P, Jenner E, Holton J, Czyz M, Capek L, Henys P, Kulvajtova M, Krbec M, Skala-Rosenbaum J. Biomechanical comparison of cemented versus non-cemented anterior screw fixation in type II odontoid fractures in the elderly: a cadaveric study. Spine J 2018; 18:1888-1895. [PMID: 29783086 DOI: 10.1016/j.spinee.2018.05.019] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2018] [Revised: 04/21/2018] [Accepted: 05/16/2018] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Odontoid process fractures are the most common injuries of the cervical spine in the elderly. Anterior screw stabilization of type II odontoid process fractures improves survival and function in these patients but may be complicated by failure of fixation. PURPOSE The present study aimed to determine whether cement augmentation of a standard anterior screw provides biomechanically superior fixation of type II odontoid fractures in comparison with a non-cemented standard screw. STUDY DESIGN Twenty human cadaveric C2 vertebrae from elderly donors (mean age 83 years) were obtained. METHODS Anderson and D'Alonzo type IIa odontoid fracture was created by transverse osteotomy, and fluoroscopy-guided anterior screw fixation was performed. The specimens were divided into two matched groups. The cemented group (n=10) had radiopaque high viscosity polymethylmethacrylate cement injected via Jamshidi needle into the base of the odontoid process. The other group was not augmented. A V-shaped punch was used for loading the odontoid in an anteroposterior direction until failure. The failure state was defined as screw cutout or 5% force decrease. Mean failure load and bending stiffness were calculated. RESULTS The mean failure load for the cemented group was 352±12 N compared with 168±23 N for the non-cemented group (p<.001). The mean initial stiffness of the non-cemented group was 153±19 N/mm compared with 195±29 N/mm for the cemented group (p<.001) CONCLUSIONS: Cement augmentation of an anterior standard screw fixation of type II odontoid process fractures in elderly patients significantly increased load to failure under anteroposterior load in comparison with non-augmented fixation. This may be a valuable technique to reduce failure of fixation.
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Affiliation(s)
- Petr Rehousek
- Royal Orthopaedic Hospital, Bristol Rd South, Birmingham B32 1AP, UK; Third Faculty of Medicine, Charles University, Ruska 2411/87, 100 00 Praha 10-Vinohrady, Prague, Czechia.
| | - Edward Jenner
- Royal Orthopaedic Hospital, Bristol Rd South, Birmingham B32 1AP, UK
| | - James Holton
- Royal Orthopaedic Hospital, Bristol Rd South, Birmingham B32 1AP, UK
| | - Marcin Czyz
- Royal Orthopaedic Hospital, Bristol Rd South, Birmingham B32 1AP, UK
| | - Lukas Capek
- Technical University of Liberec, Studentska 1402/2, 461 17 Liberec, Czechia
| | - Petr Henys
- Technical University of Liberec, Studentska 1402/2, 461 17 Liberec, Czechia
| | - Marketa Kulvajtova
- Third Faculty of Medicine, Charles University, Ruska 2411/87, 100 00 Praha 10-Vinohrady, Prague, Czechia
| | - Martin Krbec
- Third Faculty of Medicine, Charles University, Ruska 2411/87, 100 00 Praha 10-Vinohrady, Prague, Czechia
| | - Jiri Skala-Rosenbaum
- Third Faculty of Medicine, Charles University, Ruska 2411/87, 100 00 Praha 10-Vinohrady, Prague, Czechia
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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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