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Robinson, A.-L. (2018). Axis Fractures in Elderly: Epidemiology and Treatment related outcome. (Doctoral dissertation). Uppsala: Acta Universitatis Upsaliensis
Open this publication in new window or tab >>Axis Fractures in Elderly: Epidemiology and Treatment related outcome
2018 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Background: Axis fractures are a common injury in the elderly population. Treatment is often complicated due to osteoporosis and patient comorbidity. Knowledge of the incidence of these fractures, as well as their treatment, outcome and mortality rate, will improve knowledge and decision-making processes for this fragile group of patients.

Objectives: This thesis aims (1) to review the literature on the non-surgical and surgical treatment of odontoid fractures type 2 in the elderly population, (2) to provide an updated overview of axis fracture subtypes, their incidence and their treatment in a cohort in two university cities, (3) to map the incidence of fractures and the treatment of these patients in Sweden, (4) to investigate the effect on mortality of both the surgical and non-surgical treatment of axis fractures and (5) to present the protocol for a randomized controlled trial (RCT) on the treatment of odontoid fractures type 2 in the elderly population.

Methods: A systematic review was performed using the MeSH keywords “odontoid AND fracture AND elderly”. The data for the cohort study were extracted from the regional hospital information system. The radiographs were reviewed retrospectively. Data were extracted from the Swedish National Patient Registry (NPR) and the mortality registry for the national registry studies. Finally, the RCT protocol was carried out according to the SPIRIT and CONSORT statements for clinical trial reporting.

Results and conclusions: So far, there has been a scarcity of existing evidence on treatment of odontoid fractures type 2 in the elderly population. In this thesis, we found in two university cities an increased incidence, and a trend towards more surgical treatment of type 2 and 3 odontoid fractures 2002-2014. Between 1997 and 2014 in Sweden, there was an increasing incidence of C2 fractures, but the treatment trend went towards more non-surgical treatment. Surgically treated patients had a greater survival rate than non-surgically treated patients. Among those over 88 years of age, surgical treatment lost its effect on survival. In the RCT we will study the function of patients with odontoid fractures type 2 and by comparing non-surgical treatment with posterior C1-C2 fusion, the cost-effectiveness of the treatment options.

Place, publisher, year, edition, pages
Uppsala: Acta Universitatis Upsaliensis, 2018. p. 84
Series
Digital Comprehensive Summaries of Uppsala Dissertations from the Faculty of Medicine, ISSN 1651-6206 ; 1399
Keywords
odontoid fracture, treatment, elderly, cervical spine, axis fracture
National Category
Orthopaedics
Research subject
Orthopaedics
Identifiers
urn:nbn:se:uu:diva-333901 (URN)978-91-513-0163-1 (ISBN)
Public defence
2018-01-12, Gunnesalen, Ing 10, Psykiatrins hus, Sjukhusvägen, Uppsala, 09:00 (Swedish)
Opponent
Supervisors
Available from: 2017-12-21 Created: 2017-11-22 Last updated: 2018-03-08
Robinson, A.-L., Olerud, C. & Robinson, Y. (2018). Surgical treatment improves survival of elderly with axis fracture: a national population-based multi-registry cohort study. The spine journal, 18, 1853-1860
Open this publication in new window or tab >>Surgical treatment improves survival of elderly with axis fracture: a national population-based multi-registry cohort study
2018 (English)In: The spine journal, ISSN 1529-9430, E-ISSN 1878-1632, Vol. 18, p. 1853-1860Article in journal (Refereed) Published
Abstract [en]

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.

Keywords
Axis fractures, odontoid fractures, surgical treatment, mortality, elderly, spinal fractures
National Category
Orthopaedics
Research subject
Orthopaedics
Identifiers
urn:nbn:se:uu:diva-333896 (URN)10.1016/j.spinee.2018.03.021 (DOI)000449830800015 ()29649609 (PubMedID)
Available from: 2017-11-18 Created: 2017-11-18 Last updated: 2018-12-21Bibliographically approved
Robinson, A.-L., Schmeiser, G., Robinson, Y. & Olerud, C. (2018). Surgical vs. non-surgical management of displaced type-2 odontoid fractures in patients aged 75 years and older: study protocol for a randomised controlled trial. Trials, 19, Article ID 452.
Open this publication in new window or tab >>Surgical vs. non-surgical management of displaced type-2 odontoid fractures in patients aged 75 years and older: study protocol for a randomised controlled trial
2018 (English)In: Trials, ISSN 1745-6215, E-ISSN 1745-6215, Vol. 19, article id 452Article in journal (Refereed) Published
Abstract [en]

Background: Displaced odontoid fractures in the elderly are treated non-surgically with a cervical collar or surgically with C1-C2 fusion. Due to the paucity of evidence, the treatment decision is often left to the discretion of the expert surgeon.

Methods: The Uppsala Study on Odontoid Fracture Treatment (USOFT) is a multicentre, open-label, randomised controlled superiority trial evaluating the clinical superiority of the surgical treatment of type-2 odontoid fractures, with a 1-year Neck Disability Index (NDI) as the primary endpoint. Fifty consecutive patients aged >= 75 years, with displaced type-2 odontoid fracture, are randomised to non-surgical or surgical treatment. Excluded are patients with an American Society of Anaesthesiologists (ASA) score >= 4, dementia nursing care or anatomical cervical anomalies. The minimal clinically important difference of the NDI is 3.5 points. A minimum of 16 patients are needed in each group to test the superiority with 80% power. By considering a 1-year mortality forecast of 29%, up to 25 participants are recruited in each group. The non-surgical group is fitted with a rigid cervical collar for 12 weeks. The surgical group is treated with a posterior C1-C2 fusion. All participants are monitored with regard to the NDI, EuroQol score (EQ-5D), socio-demographics and computed tomography (CT) at the time of injury, at 6 weeks, 3 months and 12 months. At 12 months, a dynamic radiographical investigation of upper cervical stability is performed. The secondary endpoints are: EQ-5D score, activities of daily living (ADL), bony union, upper cervical stability and mortality.

Discussion: USOFT is the first randomised controlled trial comparing non-surgical and surgical management of type-2 odontoid fractures in the elderly. Using the NDI and EQ-5D as endpoints, future value-based decisions may consider quality-adjusted life years gained. Major limitations are (1) the allocation bias of the open-label study design, (2) that only higher training levels of all core specialties of spine surgery are included in the surgical treatment arm and (3) that only one type of surgical stabilisation is investigated (posterior C1-C2 fusion), while other methods are not included in this study.

Place, publisher, year, edition, pages
BMC, 2018
Keywords
Odontoid fractures, Elderly, Osteoporosis, Spinal fractures, Surgical treatment
National Category
Orthopaedics
Identifiers
urn:nbn:se:uu:diva-363928 (URN)10.1186/s13063-018-2690-8 (DOI)000442498800004 ()30134944 (PubMedID)
Available from: 2018-10-24 Created: 2018-10-24 Last updated: 2018-10-24Bibliographically approved
Robinson, A.-L., Moller, A., Robinson, Y. & Olerud, C. (2017). C2 Fracture Subtypes, Incidence, and Treatment Allocation Change with Age: A Retrospective Cohort Study of 233 Consecutive Cases. BioMed Research International, Article ID 8321680.
Open this publication in new window or tab >>C2 Fracture Subtypes, Incidence, and Treatment Allocation Change with Age: A Retrospective Cohort Study of 233 Consecutive Cases
2017 (English)In: BioMed Research International, ISSN 2314-6133, E-ISSN 2314-6141, article id 8321680Article in journal (Refereed) Published
Abstract [en]

The currently available data on the distribution of C2 fracture subtypes is sparse. This study was designed to identify the proportions of the second cervical vertebra (C2) fracture subtypes and to present age and gender specific incidences of subgroups. A dataset of all patients treated between 2002 and 2014 for C2 fractures was extracted from the regional hospital information system. C2 fractures were classified into odontoid fractures types 1, 2, and 3, Hangman's fractures types 1, 2, and 3, and atypical C2 fractures. 233 patients (female 51%, age 72 +/- 19 years) were treated for a C2 fracture. Odontoid fractures were found in 183 patients, of which 2 were type 1, 127 type 2, and 54 type 3, while 26 of C2 fractures were Hangman's fractures and 24 were atypical C2 fractures. In the geriatric subgroup 89% of all C2 fractures were odontoid, of which 71% were type 2 and 29% type 3. There was an increasing incidence of odontoid fractures types 2 and 3 from 2002 to 2014. 40% of C2 fractures were treated surgically. This study presents reliable subset proportions of C2 fractures in a prospectively collected regional cohort. Knowledge of these proportions facilitates future epidemiological studies of C2 fractures.

Place, publisher, year, edition, pages
HINDAWI LTD, 2017
National Category
Orthopaedics
Identifiers
urn:nbn:se:uu:diva-320489 (URN)10.1155/2017/8321680 (DOI)000394008200001 ()
Available from: 2017-04-20 Created: 2017-04-20 Last updated: 2018-01-13Bibliographically approved
Robinson, A.-L., Olerud, C. & Robinson, Y. (2017). Epidemiology of C2 Fractures in the 21st Century: A National Registry Cohort Study of 6,370 Patients from 1997 to 2014. Advances in Orthopedics, Article ID 6516893.
Open this publication in new window or tab >>Epidemiology of C2 Fractures in the 21st Century: A National Registry Cohort Study of 6,370 Patients from 1997 to 2014
2017 (English)In: Advances in Orthopedics, ISSN 2090-3464, E-ISSN 2090-3472, article id 6516893Article in journal (Refereed) Published
Abstract [en]

Objective. C2 fractures are a common injury in the elderly population. Treatment is often complicated due to osteoporosis and patient comorbidity. This study aims to investigate the incidence and treatment trend of C2 fractures in Sweden. Methods. Patients with the principal and secondary diagnosis of fracture of the second vertebrae (ICD-10: S12.1) between 1997 and 2014 were identified in the Swedish National Patient Registry (NPR). Results. Between 1997 and 2014, 6,370 patients with a C2 fracture (51% male; age: ) were identified in the NPR. The incidence of C2 fractures increased from 3 to 6 per 100,000 (; ), mainly due to an increase of incidence in the geriatric subgroup (≥70 years). The percentage of surgically treated patients decreased from 1997 to 2014 (; ). Younger age, male gender, spinal cord injury, and earlier year of admission were associated with surgical treatment assignment.Discussion. This study documents a rising incidence of C2 fractures in the elderly during the last two decades in Sweden. Greater awareness of fractures, improved diagnostics, coding, and a higher activity level of the patients are plausible causes. The declining trend of surgical treatment warrants further study.

Place, publisher, year, edition, pages
Hindawi Publishing Corporation, 2017
National Category
Orthopaedics
Research subject
Epidemiology; Orthopaedics
Identifiers
urn:nbn:se:uu:diva-332535 (URN)10.1155/2017/6516893 (DOI)000413430600001 ()
Available from: 2017-10-30 Created: 2017-10-30 Last updated: 2018-02-05Bibliographically approved
Robinson, Y., Robinson, A.-L. & Olerud, C. (2015). Complications and Survival after long Posterior Instrumentation of Cervical and Cervicothoracic Fractures related to Ankylosing Spondylitis or Diffuse Idiopathic Skeletal Hyperostosis. Spine, 40(4), E227-E233
Open this publication in new window or tab >>Complications and Survival after long Posterior Instrumentation of Cervical and Cervicothoracic Fractures related to Ankylosing Spondylitis or Diffuse Idiopathic Skeletal Hyperostosis
2015 (English)In: Spine, ISSN 0362-2436, E-ISSN 1528-1159, Vol. 40, no 4, p. E227-E233Article in journal (Refereed) Published
Abstract [en]

STUDY DESIGN: 

Prospective cohort study.

OBJECTIVE: 

This study investigates the results of long posterior instrumentation with regard to complications and survival.

SUMMARY OF BACKGROUND DATA: 

Fractures of the cervical spine and the cervicothoracic junction related to ankylosing spinal disease (ASD) endanger both sagittal profile and spinal cord. Both anterior and posterior stabilization methods are well established, and clear treatment guidelines are missing.

METHODS: 

Forty-one consecutive patients with fractures of the cervicothoracic junction related to ASD were treated by posterior instrumentation. All patients were followed prospectively for 2 years using a standardized protocol.

RESULTS: 

Five patients experienced postoperative infections, 3 patients experienced postoperative pneumonia, 2 patients required postoperative tracheostomy, and 1 patient had postoperative cerebrospinal fluid leakage due to accidental durotomy. No patient required reoperation due to implant failure or nonunion. Mean survival was 52 months (95% confidence interval: 42-62 mo). Survival was affected by patient age, sex, smoking, and spinal cord injury.

CONCLUSION: 

Patients with ASD experiencing a fracture of the cervicothoracic region are at high risk of developing complications. The posterior instrumentation of cervical spinal fractures related to ASD is recommended due to biomechanical superiority. Level of Evidence: 4.

National Category
Orthopaedics
Research subject
Orthopaedics
Identifiers
urn:nbn:se:uu:diva-238966 (URN)10.1097/BRS.0000000000000726 (DOI)000349767500008 ()25494322 (PubMedID)
Available from: 2014-12-17 Created: 2014-12-17 Last updated: 2018-01-11Bibliographically approved
Robinson, Y. & Robinson, A.-L. (2015). Hög komplikationsfrekvens vid operativ och konservativ behandling av kotfrakturer vid ankyloserande spondylit. BestPractice Reumatologi (23), 20-22
Open this publication in new window or tab >>Hög komplikationsfrekvens vid operativ och konservativ behandling av kotfrakturer vid ankyloserande spondylit
2015 (Swedish)In: BestPractice Reumatologi, ISSN 1903-6590, no 23, p. 20-22Article in journal (Other academic) Published
National Category
Orthopaedics
Research subject
Epidemiology
Identifiers
urn:nbn:se:uu:diva-253689 (URN)
Available from: 2015-06-01 Created: 2015-06-01 Last updated: 2018-01-11Bibliographically approved
Robinson, Y., Robinson, A.-L. & Olerud, C. (2014). Systematic Review on Surgical and Nonsurgical Treatment of Type II Odontoid Fractures in the Elderly. BioMed Research International, 2014, 231948
Open this publication in new window or tab >>Systematic Review on Surgical and Nonsurgical Treatment of Type II Odontoid Fractures in the Elderly
2014 (English)In: BioMed Research International, ISSN 2314-6133, Vol. 2014, p. 231948-Article, review/survey (Refereed) Published
Abstract [en]

Odontoid fractures type II according to Anderson and d’Alonzo are not uncommon in the elderly patients. Still, due to the paucity of evidence the published treatment guidelines are far from equivocal. This systematic review focuses on the published results of type II odontoid fracture treatment in the elderly with regard to survival, nonunion, and complications. After a systematic literature research 38 publications were included. A cumulative analysis of 1284 published cases found greater survival if elderly patients with odontoid fractures type II received surgical treatment (RR = 0.64). With regard to nonunion in 669 published cases primary posterior fusion had the best fusion results. The systematic literature review came to the following conclusions. (1) Surgical stabilisation of odontoid fractures type II improves survival in patients between 65 and 85 years of age compared to nonsurgical treatment. (2) Posterior atlantoaxial fusion for odontoid fractures type II in the elderly has the greatest bony union rate. (3) Odontoid nonunion is not associated with worse clinical or functional results in the elderly. (4) The complication rate of nonsurgical treatment is similar to the complication rate of surgical treatment of odontoid fractures type II in the elderly.

Place, publisher, year, edition, pages
Hindawi Publishing Corporation, 2014
National Category
Orthopaedics
Identifiers
urn:nbn:se:uu:diva-218396 (URN)10.1155/2014/231948 (DOI)000331736300001 ()
Available from: 2014-02-11 Created: 2014-02-11 Last updated: 2018-01-11Bibliographically approved
Organisations
Identifiers
ORCID iD: ORCID iD iconorcid.org/0000-0002-0705-033X

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