In the February 3, 2016 JBJS study by Joestl et al., the authors report persistent radiographic nonunions in nearly 100% of 28 geriatric patients five years after being treated nonoperatively for a dens fracture nonunion. Traditionally these older patients were placed in halo vests or hard cervical collars, based on the rationale that frail, elderly patients might not survive upper-cervical fusion. That strategy, however, often results in skin problems, pin-site infections, and chronic upper-cervical and posterior-cranium pain.
With an increasingly elderly population looming during the next two decades, we will be seeing dens injuries and nonunions in higher numbers. The increased numbers of patients presenting with this injury may allow for a carefully planned multicenter randomized controlled trial, but I think the current status of information regarding this fracture is robust enough to suggest the following treatment approach: Much like the way we currently manage elderly patients with hip fractures, we should be prepared to more seriously consider operative treatment for patients over the age of 65 with a dens fracture—especially when there is concern about persistent nonunion and instability or development of neurological impairments. Although that may formerly have been considered an aggressive approach (and may still be ill-advised in high-surgical-risk patients), this study–plus systematic reviews of other smaller cohort studies–provides ample justification to consider proceeding operatively.
Marc Swiontkowski, MD