Comparative Effectiveness of Conservative Management Versus Surgical Fixation in Acute Type II Odontoid Fractures.

Abstract

Managing acute type II odontoid fractures in the elderly is challenging because of comorbidities and frailty. This study evaluates radiological and functional outcomes of conservative vs surgical treatment. A retrospective analysis at a single US institution on elderly patients with acute type II odontoid fractures (January 2015-December 2023) was performed. Bivariate and logistic regression analyses compared outcomes and identified predictors of union. The study included 273 patients, 20 of which expired during hospital admission, leaving 253 patients available for analysis with outcomes data. The median age was 82 years (IQR: 74-90), and 53% were female. Of 253 patients, 235 (93%) received conservative treatment and 18 (7%) underwent surgical fixation. At a median radiological follow-up of 3.75 months, surgical patients had higher fracture union rates (44% vs 10%, P < .01). Modified Rankin Scale ≤2 rates were similar (75% vs 73%, P = .85), but conservative treatment showed higher excellent pain control (75% vs 47%, P < .01). Logistic regression showed high union prediction accuracy (area under the curve = 0.93). Surgical fixation was the strongest predictor of union (adjusted odds ratio [aOR] = 6.6, 95% CI 1.8-24.5). Age ≥80 years (aOR = 0.1, 95% CI 0.05-0.2), smoking history (aOR = 0.2, 95% CI 0.1-0.6), osteoporosis (aOR = 0.1, 95% CI 0.02-0.6), and mild (aOR = 0.12, 95% CI 0.06-0.3), moderate (aOR = 0.08, 95% CI 0.03-0.2), and severe frailty (aOR = 0.04, 95% CI 0.01-0.1) were negatively associated with union. Angulation ≥11° also reduced union odds (aOR = 0.16, 95% CI 0.07-0.4). Surgical fixation positively predicts fracture union, whereas advanced age, smoking, osteoporosis, frailty, and angulation (≥11°) reduce union odds. Surgery may enhance union odds, but conservative management remains effective with better pain control, without compromising long-term functional outcomes.