• Daniel Mahr, Viola Freigang, Himanshu Bhayana, Maximilian Kerschbaum, Borys Frankewycz, Markus Loibl, Michael Nerlich, and Florian Baumann.
• Department of Trauma Surgery, Regensburg University Medical Center, Regensburg, Germany.
• Eur J Trauma Emerg Surg. 2021 Jun 1; 47 (3): 713-718.

BackgroundAtlanto-axial rotatory fixation (AARF) is an uncommon condition in children presenting with torticollis. Many studies have elaborated on the diagnostic sequence of AARF. However, there is no consensus for the algorithm of management of AARF.MethodsThis study proposes to provide a comprehensive step-by-step guideline which aims to achieve and retain anatomic reduction of the atlanto-axial joint (AAJ). We recommend a 'therapeutic crescendo': closed reduction and immobilization in a rigid cervical collar (step I). In cases of re-dislocation, a second attempt of closed reduction and immobilization in a Halo-jacket (step II). Cases of recurrent dislocations due to persistent instability require open reduction and internal fixation. We present a new surgical technique of transverse suture transfixation (TSF) of C1/C2 (step III). Alternatively, a dorsal stabilization of C1/C2 is indicated after open reduction (step IV). 13 patients with radiologically confirmed AARF were included in this study. These patients were treated as per the above mentioned algorithm. All these patients were serially evaluated with a minimum follow-up of 1 year.ResultsClinical data of 10/13 patients were available for follow-up evaluation at mean 4.6 years after the onset of symptoms. Two patients were managed surgically. We recorded good clinical results in all patients treated according to the algorithm.ConclusionsAARF is a subacute pediatric emergency. Reduction and maintenance of joint congruency of the AAJ are the treatment goals. The comprehensive therapeutic algorithm presented in this study is applicable in patients with AARF to achieve excellent long-term results.Level Of EvidenceIV, Retrospective cohort study.Trial Registration NumberClinical Trial Registry University of RegensburgZ-2014-0453-4. Registered 01 December 2014.

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