We have reviewed 81 patients with fractures of the odontoid process treated between May 1983 and July 1997, by anterior screw fixation. There were 29 patients with Anderson and D'Alonzo type-II fractures and 52 with type III. Roy-Camille's classification identified the direction and instability of the fracture. Operative fixation was carried out on 48 men and 33 women with a mean age of 57 years. Associated injuries of the cervical spine were present in 15 patients, neurological signs in 13, and 18 had an Injury Severity Score of more than 15. Nine patients died and 11 were lost to follow-up. Of 61 patients, 56 (92%) achieved bony union at an average of 14.1 weeks. Two patients required a secondary posterior fusion after failure of the index operation. A full range of movement was restored in 43 patients; only six had a limitation of movement greater than 25%. We conclude that anterior screw fixation is effective and practicable in the treatment of fractures of the dens.
Fracture of the odontoid process of the axis is a common injury. Its treatment remains controversial. Nonunion, stiffness of the neck, cervical myelopathy and poorly tolerated external fixation are some of the problems associated with treatment.Current Surgical treatment of the fractured dens has usually been carried out by way of a posterior fusion of C1 and C2, with excellent rates of bony union between them. It is, however, associated with considerable mortality and morbidity and results in a decrease in the range of movement of the neck. 20-25The classification of Anderson and D'Alonzo 7 provides a guide to prognosis for healing. Type-I and type-III fractures give a good rate of union, while type II has a poor prognosis. Roy-Camille et al 26 analysed prognostic factors concerning the initial displacement, obliquity of the fracture, and rotational deformity (the 'Bobby-helmet' fracture). Horizontal or posterior oblique fracture lines, posterior displacement, and rotation deformity are all bad signs. Other factors associated with nonunion are age, 13,23 posterior displacement, 13,27 the degree of displacement, 3,11,13,23,28 fractures through the waist 3,7,11,13,26,29 and inadequate immobilisation. 3Reports by Nakanishi et al 30 and by Böhler 31 describe a direct anterior approach using a screw to fix the fractured dens. Between 1987 and 1991 further studies described the use of this technique. [32][33][34][35][36][37] The rates of union are comparable with those for C1 to C2 fusion, with few complications and good functional results. 32,34,35,38,39 We have reviewed a series of 81 patients to establish the place of anterior screw fixation in the treatment of fractures of the odontoid process. Patients and MethodsWe included all patients with fractures of the dens, treated by anterior screw fixation between May 1983 and July 1997. There were 48 men and 33 women. Their mean age at presentation was 57 years (15 to 92). We found a marked difference in age distribution according to gender; 67% (32) of the men were younger than 60 years, while 88% (29) of the women were over this age. The causes of the injury were motor-vehicle accidents (20 patients), motorcycle accidents (6), pedestrians being hit by cars (6), falls
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