1. Treatment of neglected atlanto-axial rotatory displacement
FRANSEN N, MOENS P, SCHELFAUT S Department of Orthopaedic Surgery, University Hospital Leuven, Belgium
Disclosure: No conflict of interest

2. Background Atlanto-axial rotatory instability causes: Torticollis
Neck pain
Often misdiagnosed or delayed referral
> irreducible displacement
Standard treatment: 2 stage surgery
Anterior, peroral reduction (odontoidectomy)
Posterior fixation

3. Purpose
Present an alternative treatment option for late-presenting , irreducible displacements
Reduction with halo gravity traction during longer period
Posterior fixation in 1 stage surgery
Use of a structural autograft

4. Methods
Retrospective analysis of single institution database from December 2014 till May 2016
Reviewed inpatient medical chart and imaging studies (pre-, post-reduction & postoperative CT)
3 reported cases
Mean duration of symptoms: 4 months (3-9 months)
Demographics
Fielding grade
Comorbidities
Therapy
Case 1
Female, 10y II
Down & West syndr.
C0-C2 fusion
Case 2
Female, 9y
III /
C1-C2 fusion
Case 3
Female, 5y I
Grisel, Retardation

5. Reduction: Halo gravity Traction
HALO 6-8 pins, with torque 4-8 lbs
Starting weight 4-6 lbs + 1-2lbs every second day
Maximum weight: ½ of total body weight (TBW)
Lying, sitting, standing/walking, physiotherapy
Daily pin tract care
Regular neurological assesment (also cranial nerves)
Weekly: X-ray cervical spine
Results
Reduction in all cases
Mean duration: 23,6 days (20-26 days)
Mean weight: 43,7% of TBW (40-48%)
No permanent neurovascular impairement

6. PRE
POST
Structural deformity

7. Fixation: Posterior HARMS Fusion (2x C1-C2 fusion & 1x C0-C2 fusion)
Delayed referral
Structural deformities
Permanent instability
One solution:
SURGICAL FIXATION

8. Use of structural allograft Tabula externa of pelvis
To promote bony consolidation
4 months postoperative

9. Postoperative care Immobilisation 6-8 weeks Halo Jacket
6 weeks soft collar
Follow-up
6 weeks, 3 months, 6 months, 1 year
X-ray at each visit, CT at 3 months-visit
Follow-up until skeletal maturity (1x/year)

10. Results Follow up: 6-23 months No pain
Reduced head rotation, but good function (physiotherapy)
Complete bony fusion at 3-4 months

11. Conclusion
Delayed diagnosis or referral leads to irreducible atlanto-axial rotatory displacement with structural deformities.
Structural deformities inhibit a succesfull conservative treatment.
Closed reduction with halo gravity traction is a promising and safe alternative for open transoral reduction.
The posterior instrumented fixation and use of the structural autograft result in an effective one stage surgical treatment.

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