title: Efficacy of nonfusion treatment for subacute and chronic atlanto-axial rotatory fixation in children.
abstract: BACKGROUND
  Historical guidelines suggest limited efficacy for nonfusion treatment of chronic atlanto-axial rotatory subluxation/fixation (AARF). Surgical fusion has potential side effects; therefore, it is important to understand the role for nonfusion treatment of chronic AARF. This case series examines the success rate of nonfusion treatment.
  
  
  METHODS
  A key word search was used to identify all patients with AARF with delayed presentation of ≥ 4 weeks. Fifteen patients met study inclusion criteria and had adequate clinical information for review. Data collected included age, sex, delay in presentation, mechanism of injury, severity of subluxation (Fielding classification), treatment, follow-up, and clinical information at latest follow-up.
  
  
  RESULTS
  There were 11 girls and 3 boys with an average age of 7.2 years (range, 1.5 to 12 years). Initial treatment of 3 patients included fusion. Eleven patients were initially treated without fusion. Eight of these 11 patients were successfully reduced with either halter traction, halo gravity traction, and noninvasive halo or halo vest, and reduction was maintained without fusion (73%) at 10.3 years follow-up. Three patients (27%) experienced recurrence of AARF at an average time of 2 weeks (range, 0 to 4 wk) and were treated with fusion. Average delay in presentation for all patients was 18 weeks (range, 4 to 92 wk), whereas it was 6 weeks and 9.3 weeks in those successfully treated without fusion and in those who failed nonfusion treatment, respectively. Age, delay in presentation, and underlying diagnosis were similar for fusion and nonfusion groups.
  
  
  CONCLUSIONS
  Although AARF may recur after a trial of reduction and nonfusion treatment, pediatric patients with delayed presentation (>1 month) of AARF may be treated with an initial trial of nonfusion treatment. Parents should be counseled about the risk of recurrence and possible need for ultimate fusion.
  
  
  METHODS
  Level III, therapeutic retrospective comparative study.
authors.affiliation: Boston Children's Hospital, Boston, MA.
authors.forename: Michael P
authors.initials: MP
authors.lastname: Glotzbecker
authors.forename: Aubrey M
authors.initials: AM
authors.lastname: Wasser
authors.forename: Michael T
authors.initials: MT
authors.lastname: Hresko
authors.forename: Lawrence I
authors.initials: LI
authors.lastname: Karlin
authors.forename: John B
authors.initials: JB
authors.lastname: Emans
authors.forename: Daniel J
authors.initials: DJ
authors.lastname: Hedequist
mesh_terms: D001268:Atlanto-Axial Joint / Q000000981:diagnostic imaging / Q000293:injuries*; D002648:Child; D002675:Child, Preschool; D057210:Delayed Diagnosis; D005260:Female; D006801:Humans; D007223:Infant; D004204:Joint Dislocations / Q000175:diagnosis / Q000000981:diagnostic imaging / Q000601:surgery / Q000628:therapy*; D008297:Male; D011859:Radiography; D012189:Retrospective Studies; D013123:Spinal Fusion