Surgical Strategy and Decision-Making in Recurrent Atlanto-Axial Dislocations: The Role of Traction.

Objective: To analyse patients with recurrent atlanto-axial dislocation and give a criterion of an ideal patient who can benefit from redo surgery.

Methods: This retrospective study was conducted in a tertiary care center, which included 20 patients who failed atlanto-axial surgery from January 2013 to June December 2021. They were evaluated using X-ray, computed tomography, and magnetic resonance imaging examinations, and their clinical data were accessed from the hospital's medical records department and the picture archiving and communication system. They were given a trial of traction to look for clinical and/or radiological improvement. Those showing clinical and/or radiological improvement underwent redo fixation. The operative steps involved removing joint capsules, denuding articular cartilage and joint preparation followed by reduction of basilar invagination by the combination of spacer and/or bone graft and putting screws in C1/Occiput and C2. A strut graft was placed between Occiput/C1 and C2.

Results: The mean change in modified Japanese Orthopaedic Association Scores and Nurick grade following the first surgery was statistically significant (1.00 ± 0.73, P value 0.002 and -0.15 ± 0.27, P value 0.046, respectively). On similar paths, the mean change in modified Japanese Orthopaedic Association Scores and Nurick grade following the second surgery was also statistically significant (4.25 ± 0.32, P value < 0.001 and -1.2 ± 0.11, P value < 0.001, respectively). Improper usage of constructs (31.57%), inadequate/no joint preparation (42.10%/57.90%), and poor choice of graft (100%) were the leading causes of failure of index surgery.

Conclusions: The best candidates who can benefit after redo surgery are the ones who exhibit either clinical and/or radiological improvement on the trial of traction, as the pathological C1-C2 joints are either not fused or have undergone pseudoarthrosis. Those patients who do not exhibit significant clinical or radiological improvement post-trial of traction should not be offered subsequent surgical intervention.