Comparative outcomes of anterior versus posterior fixation in odontoid fractures: A longitudinal population-based analysis

Introduction

The optimal surgical strategy for managing odontoid fractures in geriatric populations remains controversial, especially regarding the trade-offs between nonunion risk, perioperative complications, and long-term morbidity. This study aimed to compare postoperative outcomes between anterior odontoid fixation and posterior C1–C2 fusion approaches in older adults.

Methods

Using the TriNetX Diamond Network, we retrospectively identified patients aged ≥65 years who underwent anterior vs posterior cervical fixation for odontoid fractures from 2007 to 2023. Propensity score matching (PSM) was used to control for baseline characteristics across 23 variables, yielding two cohorts of 715 patients each. Outcomes were assessed at 90 days and 1-year, including opioid utilization, mortality, myocardial infarction (MI), deep vein thrombosis/pulmonary embolism (DVT/PE), surgical site infection (SSI), and hardware complications.

Results

Anterior fixation was associated with significantly lower rates of opioid utilization at both 90 days (RR 0.85, 95 % CI 0.796–0.901; p < 0.05) and 1-year (RR 0.867, 95 % CI 0.818–0.919; p < 0.05). No significant differences were observed in rates of MI, DVT/PE, SSI, hardware complications, or mortality between groups.

Conclusion

Among geriatric patients with odontoid fractures, anterior fixation was associated with lower opioid consumption at 90 days and 1-year postoperatively. Other complication rates were comparable, suggesting that surgical approach can be tailored to patient anatomy and surgeon preference without compromising safety.