The Clinical Evidence Behind Biologic Therapies Promoted at Annual Orthopaedic Meetings: A Systematic Review.

PURPOSE: The purpose of this study is to systematically evaluate the available clinical data for biologic therapies promoted for articular cartilage defects and osteoarthritis of the knee at the 2016 American Orthopaedic Society for Sports Medicine Meeting (AOSSM) and the 2017 Arthroscopy Association of North America meeting (AANA). METHODS: Our sample included all exhibitors at the 2016 AOSSM meeting and 2017 AANA meeting. All biologic products marketed at each conference were identified by reviewing exhibition booths and company websites. A systematic review of the clinical data on each product was then completed using PubMed, EMBASE, and the product's own webpage. All clinical peer-reviewed studies with level I-IV evidence were included in the study. Basic science or preclinical studies were excluded. RESULTS: There were 16 products promoted for biologic therapy for articular cartilage defects or osteoarthritis of the knee at the AOSSM meeting and 11 products promoted at the AANA meeting. A total of 280 articles detailed clinical findings for the articular cartilage products displayed at AOSSM and AANA. Of the 280, there were 36 level I evidence studies, 37 level II evidence studies, 18 level III evidence studies, and 189 level IV evidence studies. Of these articles, 91% were for 4 products. Of all biologic products promoted at the 2 meetings, 65% did not have any peer-reviewed clinical data supporting their use. CONCLUSION: Overall, many biologic therapies promoted at leading arthroscopy and sports medicine conferences did not have clinical evidence evaluating their use in the peer-reviewed literature. Although scientific advancement requires new technology, orthopaedic surgeons should be cautious about using biologic therapies in their practice with no proven efficacy. There are likely promising new interventions that, with additional scientific research, will be proven efficacious for our patients. CLINICAL RELEVANCE: This article gives orthopaedic surgeons a detailed example of some of the biologic treatments being offered on the market for the treatment of knee articular cartilage disease. When patients request these treatments, physicians must be able to explain the data supporting their use.

Extensor Tendon Injury Associated With Dorsal Entry Flexible Nailing of Radial Shaft Fractures in Children: A Report of 5 New Cases and Review of the Literature.

BACKGROUND: Extensor pollicis longus (EPL) tendon injury following the dorsal approach to elastic stable intramedullary nailing (ESIN) of the radius has been reported in a growing number of cases in the literature. This study includes 5 new cases from our institution as well as a comprehensive review of previously reported cases from the literature. METHODS: We conducted a retrospective chart review of all patients undergoing ESIN between January 1, 2004 and December 31, 2013 at our institution. Those patients with an EPL injury or rupture were identified and clinical data collected included operative technique, diagnosis, treatment, and outcomes data. In addition, we performed a systematic review of the literature using Pubmed MEDLINE database, the Chochrane database, Scopus, Web of Science, and Embase. A total of 28 cases of EPL injury following ESIN of the radius were identified in the literature and the relevant data were extracted from those studies. RESULTS: All 33 pediatric cases of EPL tendon injury occurred after entry to the radial canal was obtained by the dorsal approach to ESIN. EPL injury was diagnosed an average of 10 weeks following the index procedure. Extensor indicis pollicis to EPL transfer was performed in 13 patients, tendon release/lysis of adhesions in 5, EPL repair in 2, EPL graft reconstruction from palmaris longus tendon in 1, 3 patients refused further intervention, and treatment was unreported in 7 cases. By 12-month follow-up, all operatively treated patients had a good functional outcome with near anatomic extension at the thumb interphalangeal joint, no pain, and no further complication. CONCLUSIONS: EPL tendon injury was found to be a complication unique to the dorsal entry approach for ESIN of the radius. The lateral approach appears to offer a safer alternative with regard to the EPL tendon. We suggest that physicians consider the risk of EPL tendon injury when planning for ESIN of the radius, and make an effort to avoid direct injury when using a dorsal approach. LEVEL OF EVIDENCE: Level III-therapeutic.

Surgical Decision Making for Thoracolumbar Spine Injuries in Polytrauma Patients.

The management of thoracolumbar spine injuries in patients with multiple traumatic injuries is a challenge complicated by multiple competing medical and surgical demands. Safe and effective treatment of polytrauma patients with a thoracolumbar spine injury requires a multidisciplinary approach that involves surgical and critical care teams. The Thoracolumbar Injury Classification and Severity Score, which was developed to facilitate consistent surgical decision making in patients with a thoracolumbar spine injury, provides objective criteria for the classification and management of thoracolumbar spine injuries. The AOSpine study group recently developed a comprehensive thoracolumbar injury classification system that was subsequently used to create the Thoracolumbar AOSpine Injury Score, which helps guide thoracolumbar spine injury management via objective criteria. These scoring systems have been effectively used in clinical practice and allow for a focused and objective assessment of thoracolumbar spine injuries. Both the Thoracolumbar Injury Classification and Severity Score and the Thoracolumbar AOSpine Injury Score should be routinely used in treatment decision making to optimize outcomes and avoid unnecessary surgical treatment in polytrauma patients with a thoracolumbar spine injury.

Discharge Disposition and Clinical Outcomes After Spine Surgery.

OBJECTIVE: Spinal decompression with or without fusion is one of the most commonly performed procedures in spine surgery. However, there is limited evidence on the effect of discharge environment on outcomes after surgery. The purpose of this study is to identify the effects of discharge disposition setting on clinical outcomes after spine surgery. METHODS: Patients who underwent lumbar decompression, lumbar decompression and fusion, or posterior cervical decompression and fusion surgery were retrospectively identified. All clinical and demographic data were obtained from electronic health records. Surgical outcomes included wound complications, revision surgery, "30-day" readmission (0-30 d), and "90-day" readmission (31-90 d). Discharge disposition was stratified into home/self-care, acute inpatient rehabilitation, and subacute rehabilitation. Patient-reported outcome measures including VAS Back, VAS Leg, VAS Neck, VAS Arm, PCS-12 and MCS-12, ODI, and NDI were compared between patient discharge disposition settings using the Mann-Whitney U test. Pearson's chi-square analysis was used to assess for differences in wound complications, revision surgery, 30-day readmission, or 90-day readmission rates. Multivariate logistic regression incorporating age, sex, body mass index (BMI), Charlson Comorbidity Index (CCI), and discharge disposition was used to determine independent predictors of wound complications. RESULTS: A total of 637 patients were included in the study. A significant difference (P = 0.03) was found in wound complication based on discharge disposition, with subacute disposition having the highest proportion of wound complications (6.1%) and home disposition having the lowest (1.5%). There were no significant differences in the rates of revision surgery, 30-day readmission, or 90-day readmission between groups. Subacute rehabilitation (odds ratio: 3.67, P = 0.047) and CCI (odds ratio 1.49, P = 0.01) were independent predictors of wound complications. Significant improvement in PROMs was seen across all postacute discharge dispositions. Baseline (P = 0.02) and postoperative (P = 0.02) ODI were significantly higher among patients discharged to an acute facility (49.4 and 32.0, respectively) compared to home (42.2 and 20.0) or subacute (47.4 and 28.4) environments. CONCLUSION: Subacute rehabilitation disposition and CCI are independent predictors of wound complications after spinal decompression surgery. Patients undergoing spine surgery have similar readmission and revision rates and experience similar clinical improvement across all postacute discharge dispositions.

Artificial Intelligence in Spine Care.

Artificial intelligence is an exciting and growing field in medicine to assist in the proper diagnosis of patients. Although the use of artificial intelligence in orthopedics is currently limited, its utility in other fields has been extremely valuable and could be useful in orthopedics, especially spine care. Automated systems have the ability to analyze complex patterns and images, which will allow for enhanced analysis of imaging. Although the potential impact of artificial intelligence integration into spine care is promising, there are several limitations that must be overcome. Our goal is to review current advances that machine learning has been used for in orthopedics, and discuss potential application to spine care in the clinical setting in which there is a need for the development of automated systems.

The Effect of Obesity on Fluoroscopy-Assisted Direct Anterior Approach Total Hip Arthroplasty.

BACKGROUND: Obesity has been considered a relative contraindication to performing a direct anterior approach total hip arthroplasty (DAA-THA) since it is hypothesized to lead to component malpositioning and poor outcomes. Fluoroscopy-assisted DAA-THA has been reported to diminish variability in acetabular component positioning. However, fluoroscopy-assisted DAA-THA in the obese patients has not been well described. We report on a single surgeon consecutive series of fluoroscopy-assisted primary DAA-THA's examining the radiographic and perioperative outcomes in obese patients. METHODS: A retrospective review was conducted of 509 consecutive unilateral fluoroscopy-assisted DAA-THAs on a specialized orthopaedic table performed by a single surgeon. All patients were divided into three cohorts according to their body mass index (BMI): Group I (< 30 kg/ m2 ), Group II (≥ 30 to < 35 kg/m2 ), and Group III (≥ 35 kg/ m2 ). Perioperative parameters, outcome scores (EuroQol 5 Dimension and hip disability and osteoarthritis outcome scores), and radiographs were comparatively assessed. Cup position was determined using Widmer's method. RESULTS: A total of 492 DAA-THAs (minimum follow-up: 2.1 years) with appropriate radiographs were analyzed. Of which 356 (72.2%) were in Group I (average: 25.1 kg/m2 ), 105 (21.3%) in Group II (average: 32 kg/m2 ), and 31 (6.5%) in Group III (average: 38.6 kg/m2 ). There were no differences in any parameters between Group II and III. Group I differed in average age and included more female patients than Groups II and III. There was a statistically significant difference in cup anteversion between all groups with average measurements of 20.8°, 19.5°, and 17.6°, respectively. No other differences were identified in radiographic parameters or postoperative outcomes. CONCLUSIONS: There were no clinically relevant differences in component positioning or perioperative parameters between obese and non-obese patients. We do not consider a BMI ≥ 30 kg/m2 to be a contraindication for fluoroscopyassisted DAA-THA when performed by a surgeon experienced in the technique.

Comparing Patient-reported Outcomes to Patient Satisfaction After a Microdiscectomy for Patient's With a Lumbar Disk Herniation.

STUDY DESIGN: A retrospective cohort study. OBJECTIVE: The objective of this study was to determine if patient satisfaction is predicted by improvement in health-related quality of life (HRQOL) metrics. SUMMARY OF BACKGROUND DATA: Patient satisfaction is becoming an increasingly common proxy for treatment quality; however, the correlation between patient satisfaction and HRQOL outcome metrics following a lumbar disk herniation is unclear. METHODS: Patients enrolled in the Spine Patient Outcomes Research Trial (SPORT) study were prospectively enrolled at 13 institutions. A retrospective subgroup analysis of prospectively collected data from the SPORT trial was performed. Receiver operating characteristic curves were used to determine if improvement in HRQOL metrics could accurately identify patient satisfaction. HRQOL metrics included: Short Form-36 (SF-36), Oswestry Disability Index (ODI), Sciatica Bothersomeness Index, Back Pain Bothersomeness Scale, and Leg Pain Bothersomeness Scale. RESULTS: A total of 709 patients who underwent surgery and 319 patients treated without surgery were included. In the surgical cohort, receiver operating characteristic curve analysis demonstrated that SF-36 Physical Component Summary improvement had moderate accuracy [area under the curve (AUC)=0.77 (95% confidence interval, CI: 0.73-0.82)] at predicting satisfaction at 3 months, and it had excellent accuracy at predicting satisfaction at 2 years [AUC=0.81 (95% CI: 0.77-0.85)] and 4 years [AUC=0.81 (95% CI: 0.76-0.85)]. Absolute Physical Component Summary score had excellent accuracy at 3 months [AUC=0.83 (95% CI: 0.79-0.87)], 2 years [AUC=0.87 (95% CI: 0.84-0.9)] and 4 years [AUC=0.84 (95% CI: 0.8-0.89)]. Similarly improvement in the ODI had moderate accuracy of predicting satisfaction at 3 months [AUC=0.77 (95% CI: 0.72-0.81)], 2 years [AUC=0.78 (95% CI: 0.74-0.82)] and 4 years [AUC=0.78 (95% CI: 0.73-0.83)], and the absolute ODI score had excellent accuracy at 3 months [AUC=0.85 (95% CI: 0.82-0.89)], 2 years [AUC=0.89 (95% CI: 0.86-0.92)], and 4 years [AUC=0.88 (95% CI: 0.85-0.92)]. CONCLUSIONS: HRQOL metrics can accurately predict patient satisfaction with symptoms at 3 months, 2 years, and 4 years after surgical intervention for a lumbar disk herniation. Absolute outcome scores were somewhat more predictive than change scores.

Is the Neck Disability Index an Appropriate Measure for Changes in Physical Function After Surgery for Cervical Spondylotic Myelopathy?

BACKGROUND: The Neck Disability Index (NDI) is a 10-item questionnaire about symptoms relevant to cervical spine pathology, originally validated in the physical therapy literature. It is unclear if all of the items apply to spine surgery. The purpose of this study was to determine if improvements in the composite NDI score or specific NDI domains are appropriate measures for tracking changes in physical function after surgical intervention for cervical spondylotic myelopathy (CSM). METHODS: A retrospective cohort review of patients treated at a major academic medical center was undertaken. Baseline and postoperative standardized outcome measurement scores, including composite NDI, NDI subdomain, and SF-12 physical component score (PCS), were collected. Wilcoxon signed-rank test was used to determine whether patients exhibited improvement in each of the outcome measures included. Multiple linear regression was performed to determine whether change in NDI composite or subdomain scores predicted change in physical function after surgery for CSM-compared with the well-validated PCS score-controlling for factors such as age, sex, etc. RESULTS: Baseline data were collected on 118 patients. All outcome measures exhibited significant improvement after surgery based on the Wilcoxon signed-rank test. On linear regression, work (ß = -2.419 [-3.831, -1.006]; P = .001) and recreation (ß = -1.354 [-2.640, -0.068]; P = .039), as well as the NDI composite score (ß = -0.223 [-0.319, -0.127]; P < .001), were significant predictors of change in physical function over time. CONCLUSIONS: Although the NDI composite score did predict change in PCS over time, only 2 of the 10 NDI subdomains were found to be associated with change in physical function over time. Based on these results, the item bank and composite scoring of the NDI are inappropriate for evaluating quality of life in studies of surgically treated cervical spondylotic myelopathy patients. CLINICAL RELEVANCE: NDI may not be a valid tool in the determination of physical function changes after surgery for CSM. LEVEL OF EVIDENCE: III.

Does an Uninstrumented Level Increase the Rate of Revision Surgery in a Multilevel Posterior Cervical Decompression and Fusion?

STUDY DESIGN: This was a retrospective cohort study. OBJECTIVE: The goal of this study is to determine if skipping a single level affects the revision rate for patients undergoing multilevel posterior cervical decompression and fusion (PCDF). SUMMARY OF BACKGROUND DATA: A multilevel PCDF is a common procedure for patients with cervical spondylotic myelopathy. With advanced pathology, it can be difficult to safely place screw instrumentation at every level increasing the risk of intraoperative and perioperative morbidity. It is unclear whether skipping a level during PCDF affects fusion and revision rates. PATIENTS AND METHODS: A cervical spine surgeries database at a single institution was used to identify patients who underwent ≥3 levels of PCDF. Inclusion criteria consisted of patients who had screws placed at every level or if they had a single level without screws bilaterally. Patients were excluded if the surgery was performed for tumor, trauma, or infection, and age below 18 years, or if there was <1 year of follow-up. RESULTS: A total of 157 patients met inclusion criteria, with 86 undergoing a PCDF with instrumentation at all levels and 71 that had a single uninstrumented level. Overall mean follow-up was 46.5±22.8 months. In patients with or without a skipped level, the revision rate was 25% and 26%, respectively (P<1.00). Univariate regression analysis demonstrated that proximal fixation level in the upper cervical region, having the fusion end at C7, prior surgery, and myelopathy were significant predictors of revision. Skipping a single level, however, was not predictive of revision. CONCLUSIONS: When performing a multilevel PCDF, there is no increase in the rate of revision surgery if a single level is uninstrumented. Conversely, other surgical factors, including the cranial and caudal levels, affect revision rates. In contrast to other reports, the C2 sagittal vertical axis did not affect reoperation rates. LEVEL OF EVIDENCE: Level IV.

The Effect of Hospital Ownership on Health Care Utilization in Orthopedic Surgery.

PURPOSE: To determine if ownership of a specialty hospital or ambulatory surgery centers (ASC) affects surgical volume. MATERIALS AND METHODS: All surgeries performed by 75 orthopedic surgeons at a single practice between January 1, 2010 and March 1, 2015 were identified. During this time, the practice purchased an ownership stake in 1 hospital and 3 ASC. The total surgical volume by partnership status and location was collected and analyzed. RESULTS: A total of 104,661 surgical surgeries were performed by 75 surgeons. Over the 62 months, there was an average increase in the number of surgical cases performed per surgeon per year of 2.82±0.48 cases; however, the average increase in cases per year was lower for equity partners by 1.51 cases per year (P<0.0001). In the 2 years before purchasing the specialty hospital, the increase in the number of surgical cases per surgeon per month was 0.093±0.087 cases. In the 2 years after investing in the physician-owned specialty hospital, there was a decrease in the number of cases performed per surgeon per month by 0.027±0.110 (P=0.92). CONCLUSIONS: In a well-established large orthopedic practice, surgeon ownership of a hospital or ASC does not lead to an increase in surgical volume. LEVEL OF EVIDENCE: Level 4.

Are Patients Undergoing an Anterior Cervical Discectomy and Fusion Treated Differently at a Physician-owned Hospital?

STUDY DESIGN: Retrospective case-control study. BACKGROUND: Physician-owned specialty hospitals focus on taking care of patients with a select group of conditions. In some instances, they may also create a potential conflict of interest for the surgeon. The effect this has on the surgical algorithm for patients with degenerative cervical spine conditions has not been determined. METHODS: A retrospective review of all patients who underwent a 1- or 2-level anterior cervical discectomy and fusion between October 2009 and December 2014 at either a physician-owned specialty hospital or an independently owned community hospital were identified. Demographic information, the time course for treatment and the nonoperative treatment regimen were evaluated. RESULTS: In total, 115 patients undergoing surgery at a physician-owned specialty hospital and 149 patients undergoing surgery at an independent community hospital were identified. Demographic data between the groups including the presence of 12 medical comorbidities and insurance status was similar between the groups. The only difference that was identified was that patients at the surgeon-owned hospital were marginally younger than patients who had surgery at the independent hospital (49.7 vs. 50.0, P=0.048). No difference in the median number of months from the onset of symptoms to surgery (6.51 vs. 7.53 mo, respectively; P=0.55), from the onset of symptoms to the preoperative visit (6.02 vs. 6.02, P=0.64), or from the initial surgical consultation to surgery (0.99 vs. 1.02, P=0.31) was identified. No difference in the number of patients who underwent formal physical therapy (72.2% vs. 67.1%, P=0.42) or who had a cervical steroid injection (55.6% vs. 50.3%, P=0.25%) was identified between patients who had surgery at a physician-owned or independent hospital; however, patients who underwent surgery at the physician-owned hospital were more likely to have taken oral anti-inflammatories (93.0% vs. 83.9%, P=0.04). CONCLUSIONS: When comparing hospitals with similar resources, surgeons do not preferentially select younger, healthier patients with higher paying insurance to be treated at the physician-owned hospital. Furthermore, both the time from the onset of symptoms to surgery and the nonoperative treatment regimen were similar between patients treated at the 2 facilities.

Utilization of Time-driven Activity-based Costing to Determine the True Cost of a Single or 2-level Anterior Cervical Discectomy and Fusion.

STUDY DESIGN: This is a prospective case series. OBJECTIVE: To determine the actual cost of performing 1- or 2-level anterior cervical discectomy and fusion (ACDF) using actual patient data and the time-driven activity-based cost methodology. SUMMARY OF BACKGROUND DATA: As health care shifts to use value-based reimbursement, it is imperative to determine the true cost of surgical procedures. Time-driven activity-based costing determines the cost of care by determining the actual resources used in each step of the care cycle. MATERIALS AND METHODS: In total, 30 patients who underwent a 1- or 2-level ACDF by 3 surgeons at a specialty hospital were prospectively enrolled. To build an accurate process map, a research assistant accompanied the patient to every step in the care cycle including the preoperative visit, the preadmission testing, the surgery, and the postoperative visits for the first 90 days. All resources utilized and the time spent with every member of the care team was recorded. RESULTS: In total, 27 patients were analyzed. Eleven patients underwent a single-level ACDF and 16 underwent a 2-level fusion. The total cost for the episode of care was $29,299±$5048. The overwhelming cost driver was the hospital disposable costs ($13,920±$6325) which includes every item used during the hospital stay. Intraoperative personnel costs including fees for the surgeon, resident/fellow, anesthesia, nursing, surgical technician, neuromonitoring, radiology technician and orderlies, accounted for the second largest cost at $6066±$1540. The total cost excluding hospital overhead and disposables was $9071±$1939. CONCLUSIONS: Reimbursement for a bundle of care surrounding a 1- or 2-level ACDF should be no less than $29,299 to cover the true costs of the care for the entire care cycle. However, this cost may not include the true cost of all capital expenditures, and therefore may underestimate the cost.

Which Domains of the ODI Best Predict Change in Physical Function in Patients After Surgery for Degenerative Lumbar Spondylolisthesis?

STUDY DESIGN: A retrospective review. OBJECTIVE: The purpose of this study is to determine the differential improvement of the various individual items of the Oswestry Disability Index (ODI) and to determine their relationship to other measures of Health Related Quality of Life (HRQOL). SUMMARY OF BACKGROUND DATA: The ODI is an easily scored, common, 10-item questionnaire about symptoms relevant to lumbar spine pathology. It is not clear if all of the items can be reliably applied to spine surgery. The purpose of this study is to determine the differential improvement of the various individual items of the ODI and to determine their relationship to other measures of HRQOL. METHODS: Analysis of a prospective registry of patients treated at an academic medical center was undertaken. At baseline, standardized outcome measures including ODI and SF12 PCS were collected on all patients undergoing elective fusion surgery for degenerative spondylolisthesis. Multiple linear regressions were performed using change in SF12 PCS as the dependent variable and change in ODI components as the independent variables. RESULTS: Baseline and 1-year follow-up data were collected on 196 patients (mean age 60.4 years). There were statistically significant differences in improvement among ODI items. Surprisingly, the most improvement after surgery was noted in the standing, sex life, and social life domains. The least improvement was noted in the personal care, sleeping, and sitting domains. Linear regression for change in ODI components versus change in SF-12 PCS revealed a significant correlation (R = 0.353, P ≤ 0.001). The only retained domains in the final model were change in lifting, standing, and traveling as predictors for ΔPCS. CONCLUSION: All domains of the ODI do not improve equally after surgery for degenerative spondylolisthesis. Some of the domains that improve most (e.g., sex life) have no discernible relationship to the known pathophysiology of degenerative spondylolisthesis. Based upon these results, we conclude that the item bank and composite scoring of the ODI are inappropriate for evaluating quality of life in studies of surgically treated degenerative spondylolisthesis patients. LEVEL OF EVIDENCE: 3.

Bias in cervical total disc replacement trials.

PURPOSE OF REVIEW: Cervical disc replacement (CDR) has emerged as a motion-preserving alternative to anterior cervical discectomy and fusion in selected cases. Despite favorable literature, CDR is not universally accepted because of concerns regarding bias in the existing literature. The purpose of this review is to identify the possible biases in the disc replacement literature. RECENT FINDINGS: Recent studies that compare CDR and ACDF have demonstrated equivalent or superior outcomes, lower rates of secondary surgery, and equivalent safety at medium- and long-term follow-up. In our review, we identified four types of bias that may affect the CDR literature: publication bias, external validity, confounding bias, and financial conflicts of interest. Bias, whether intentional or unintentional, can impact the interpretation and outcome of CDR studies. Recognition of this issue is critical when utilizing the existing literature to determine the efficacy of CDR and designing future studies.

Management of Hangman's Fractures: A Systematic Review.

BACKGROUND: Traumatic spondylolisthesis of the axis, is a common cervical spine fracture; however, to date there is limited data available to guide the treatment of these injuries. The purpose of this review is to provide an evidence-based analysis of the literature and clinical outcomes associated with the surgical and nonsurgical management of hangman's fractures. METHODS: A systematic literature search was conducted using PubMed (MEDLINE) and Scopus (EMBASE, MEDLINE, COMPENDEX) for all articles describing the treatment of hangman's fractures in 2 or more patients. Risk of nonunion, mortality, complications, and treatment failure (defined as the need for surgery in the nonsurgically managed patients and the need for revision surgery for any reason in the surgically managed patients) was compared for operative and nonoperative treatment methods using a generalized linear mixed model and odds ratio analysis. RESULTS: Overall, 25 studies met the inclusion criteria and were included in our quantitative analysis. Bony union was the principal outcome measure used to assess successful treatment. All studies included documented fracture union and were included in statistical analyses. The overall union rate for 131 fractures treated nonsurgically was 94.14% [95% confidence interval (CI), 76.15-98.78]. The overall union rate for 417 fractures treated surgically was 99.35% (95% CI, 96.81-99.87). Chance of nonunion was lower in those patients treated surgically (odds ratio, 0.12; 95% CI, 0.02-0.71). There was not a significant difference in mortality between patients treated surgically (0.16%; 95% CI, 0.01%-2.89%) and nonsurgically (1.04%; 95% CI, 0.08%-11.4%) (odds ratio, 0.15; 95% CI, 0.01-2.11). Treatment failure was less likely in the surgical treatment group (0.12%; 95% CI, 0.01%-2.45%) than the nonsurgical treatment group (0.71%; 95% CI, 0.28%-15.75%) (odds ratio 0.07; 95% CI, 0.01-0.56). CONCLUSION: Hangman's fractures are common injuries, and surgical treatment leads to an increase in the rate of osteosynthesis/fusion without significantly increasing the rate of complication. Both an anterior and a posterior approach result in a high rate of fusion, and neither approach seems to be superior.