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Zhu Y, Babazadeh-Naseri A, Brake MRW, Akin JE, Li G, Lewis VO, Fregly BJ. Evaluation of finite element modeling methods for predicting compression screw failure in a custom pelvic implant. Front Bioeng Biotechnol 2024; 12:1420870. [PMID: 39234264 PMCID: PMC11372789 DOI: 10.3389/fbioe.2024.1420870] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2024] [Accepted: 08/05/2024] [Indexed: 09/06/2024] Open
Abstract
Introduction: Three-dimensional (3D)-printed custom pelvic implants have become a clinically viable option for patients undergoing pelvic cancer surgery with resection of the hip joint. However, increased clinical utilization has also necessitated improved implant durability, especially with regard to the compression screws used to secure the implant to remaining pelvic bone. This study evaluated six different finite element (FE) screw modeling methods for predicting compression screw pullout and fatigue failure in a custom pelvic implant secured to bone using nine compression screws. Methods: Three modeling methods (tied constraints (TIE), bolt load with constant force (BL-CF), and bolt load with constant length (BL-CL)) generated screw axial forces using functionality built into Abaqus FE software; while the remaining three modeling methods (isotropic pseudo-thermal field (ISO), orthotropic pseudo-thermal field (ORT), and equal-and-opposite force field (FOR)) generated screw axial forces using iterative physics-based relationships that can be implemented in any FE software. The ability of all six modeling methods to match specified screw pretension forces and predict screw pullout and fatigue failure was evaluated using an FE model of a custom pelvic implant with total hip replacement. The applied hip contact forces in the FE model were estimated at two locations in a gait cycle. For each of the nine screws in the custom implant FE model, likelihood of screw pullout failure was predicted using maximum screw axial force, while likelihood of screw fatigue failure was predicted using maximum von Mises stress. Results: The three iterative physics-based modeling methods and the non-iterative Abaqus BL-CL method produced nearly identical predictions for likelihood of screw pullout and fatigue failure, while the other two built-in Abaqus modeling methods yielded vastly different predictions. However, the Abaqus BL-CL method required the least computation time, largely because an iterative process was not needed to induce specified screw pretension forces. Of the three iterative methods, FOR required the fewest iterations and thus the least computation time. Discussion: These findings suggest that the BL-CL screw modeling method is the best option when Abaqus is used for predicting screw pullout and fatigue failure in custom pelvis prostheses, while the iterative physics-based FOR method is the best option if FE software other than Abaqus is used.
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Affiliation(s)
- Yuhui Zhu
- Department of Mechanical Engineering, Rice University, Houston, TX, United States
| | - Ata Babazadeh-Naseri
- Department of Mechanical Engineering, Rice University, Houston, TX, United States
| | - Matthew R W Brake
- Department of Mechanical Engineering, Rice University, Houston, TX, United States
| | - John E Akin
- Department of Mechanical Engineering, Rice University, Houston, TX, United States
| | - Geng Li
- Department of Mechanical Engineering, Rice University, Houston, TX, United States
| | - Valerae O Lewis
- Department of Orthopedic Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Benjamin J Fregly
- Department of Mechanical Engineering, Rice University, Houston, TX, United States
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2
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Feng X, Zhang S, Luo Z, Liang H, Chen B, Leung F. Development and initial validation of a novel thread design for nonlocking cancellous screws. J Orthop Res 2022; 40:2813-2821. [PMID: 35267202 DOI: 10.1002/jor.25305] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Revised: 01/20/2022] [Accepted: 02/21/2022] [Indexed: 02/04/2023]
Abstract
High failure rates have been associated with nonlocking cancellous screws with a typical buttress thread in patients with osteoporotic bone. This study aimed to develop a novel thread design and compare its fixation stability with that of a typical buttress thread. Nonlocking cancellous screws with a novel thread design (proximal flank angle of 120 degrees, a flat crest feature, a tip-facing undercut feature) and nonlocking cancellous screws with a typical buttress thread were manufactured using stainless steel. Fixation stabilities were evaluated individually by the axial pullout and lateral migration tests, and they were evaluated in pairs together with a dynamic compression plate in an osteoporotic bone substitute (10 PCF polyurethane foam per ASTM F1839) under cyclic craniocaudal and torsional loadings. Pullout strength and lateral migration resistance for the individual screw test and the force, torque, and number of cycles required to achieve specific displacement and torsion for the multi-screw test were comparatively analyzed between both screw types. A finite element analysis model was constructed to analyze the stress distributions in the bone tissue adjacent to the threads. The biomechanical test revealed the novel undercut thread had superior axial pullout strength, lateral migration resistance, and superior fixation stability when applied to a dynamic compression plate under cyclic craniocaudal loading and torsional loading than those in the typical buttress thread. The finite element analysis simulation revealed that the novel thread can distribute stress more evenly without high-stress concentration at the adjacent bone tissue when compared to that of a typical buttress thread.
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Affiliation(s)
- Xiaoreng Feng
- Department of Orthopaedics and Traumatology, Yangjiang People's Hospital, Yangjiang, China.,Division of Orthopaedics and Traumatology, Department of Orthopaedics, Nanfang Hospital, Guangzhou, China
| | - Sheng Zhang
- Division of Orthopaedics and Traumatology, Department of Orthopaedics, Nanfang Hospital, Guangzhou, China
| | - Zhaopei Luo
- Department of Orthopaedics and Traumatology, Yangjiang People's Hospital, Yangjiang, China
| | - Hongfeng Liang
- Department of Orthopaedics and Traumatology, Yangjiang People's Hospital, Yangjiang, China
| | - Bin Chen
- Division of Orthopaedics and Traumatology, Department of Orthopaedics, Nanfang Hospital, Guangzhou, China
| | - Frankie Leung
- Department of Orthopaedics and Traumatology, Queen Mary Hospital, The University of Hong Kong, Pok Fu Lam, Hong Kong
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3
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Fletcher JWA, Neumann V, Silva J, Burdon A, Mys K, Panagiotopoulou VC, Gueorguiev B, Richards RG, Whitehouse MR, Preatoni E, Gill HS. Augmented screwdrivers can increase the performance of orthopaedic surgeons compared with use of normal screwdrivers. Sci Rep 2022; 12:20076. [PMID: 36418373 PMCID: PMC9684403 DOI: 10.1038/s41598-022-24646-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Accepted: 11/17/2022] [Indexed: 11/24/2022] Open
Abstract
Orthopaedic screws insertion can be trivialised as a simple procedure, however it is frequently performed poorly. Limited work exists defining how well surgeons insert screws or whether augmented screwdrivers can aid surgeons to reduce stripping rates and optimise tightness. We aimed to establish the performance of surgeons inserting screws and whether this be improved with screwdriver augmentation. 302 orthopaedic surgeons tightened 10 non-locking screws to what they determined to be optimum tightness into artificial bone sheets. The confidence in the screw purchase was given (1-10). A further 10 screws were tightened, using an augmented screwdriver that indicated when a predetermined optimum tightness was reached. The tightness for unstripped insertions under normal conditions and with the augmented screwdriver were 81% (95% CI 79-82%)(n = 1275) and 70% (95% CI 69-72%)(n = 2577) (p < 0.001). The stripping rates were 58% (95% CI 54-61%) and 15% (95% CI 12-17%) respectively (p < 0.001). The confidences when using the normal and augmented screwdrivers respectively were 7.2 and 7.1 in unstripped insertions and 6.2 and 6.5 in stripped insertions. Performance improved with an augmented screwdriver, both in reduced stripping rates and greater accuracy in detecting stripping. Augmenting screwdrivers to indicate optimum tightness offer potentially enormous clinical benefits by improving screw fixation.
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Affiliation(s)
- James W. A. Fletcher
- grid.418048.10000 0004 0618 0495AO Research Institute Davos, Clavadelerstrasse 8, 7270 Davos Platz, Switzerland ,grid.7340.00000 0001 2162 1699Department for Health, University of Bath, Bath, UK
| | - Verena Neumann
- grid.418048.10000 0004 0618 0495AO Research Institute Davos, Clavadelerstrasse 8, 7270 Davos Platz, Switzerland
| | - Juan Silva
- grid.418048.10000 0004 0618 0495AO Research Institute Davos, Clavadelerstrasse 8, 7270 Davos Platz, Switzerland
| | - Abigail Burdon
- grid.7340.00000 0001 2162 1699Department of Mathematical Sciences, University of Bath, Bath, UK
| | - Karen Mys
- grid.418048.10000 0004 0618 0495AO Research Institute Davos, Clavadelerstrasse 8, 7270 Davos Platz, Switzerland ,grid.5596.f0000 0001 0668 7884Biomechanics Section, Department of Mechanical Engineering, KU Leuven, Leuven, Belgium
| | - Vasiliki C. Panagiotopoulou
- grid.418048.10000 0004 0618 0495AO Research Institute Davos, Clavadelerstrasse 8, 7270 Davos Platz, Switzerland
| | - Boyko Gueorguiev
- grid.418048.10000 0004 0618 0495AO Research Institute Davos, Clavadelerstrasse 8, 7270 Davos Platz, Switzerland
| | - R. Geoff Richards
- grid.418048.10000 0004 0618 0495AO Research Institute Davos, Clavadelerstrasse 8, 7270 Davos Platz, Switzerland
| | - Michael R. Whitehouse
- grid.416201.00000 0004 0417 1173Musculoskeletal Research Unit, Bristol Medical School 1St Floor Learning & Research Building, Translational Health Sciences, Southmead Hospital, Bristol, UK ,grid.5337.20000 0004 1936 7603National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol NHS Foundation Trust and University of Bristol, Bristol, UK
| | - Ezio Preatoni
- grid.7340.00000 0001 2162 1699Department for Health, University of Bath, Bath, UK
| | - Harinderjit S. Gill
- grid.7340.00000 0001 2162 1699Department of Mechanical Engineering, University of Bath, Bath, UK ,grid.7340.00000 0001 2162 1699Centre for Therapeutic Intervention, University of Bath, Bath, UK
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Moreno CR, Santschi EM, Janes J, Liu J, Kim DG, Litsky AS. Compression generated by cortical screws in an artificial bone model of an equine medial femoral condylar cyst. Vet Surg 2022; 51:833-842. [PMID: 35394080 PMCID: PMC9321887 DOI: 10.1111/vsu.13814] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Revised: 03/11/2022] [Accepted: 03/19/2022] [Indexed: 11/29/2022]
Abstract
Objective Determine compression generated by lag and neutral screws over 12 h using two bone analogs. Study design Experimental study. Sample population Bone analogs were made of composite synthetic bone (CSB) or three‐dimensional printed polylactic acid (PLA). Analogs had a 2 mm exterior shell with a 10 mm thick internal layer of open‐cell material. Methods Bone analogs were opposed, making a 4‐sided box with open ends. A central channel contained the sensor and the screws passed through it to engage both paired analogs. Four screw/analog conditions were tested: neutral and lag screw with bicortical engagement, neutral and lag screw with unicortical engagement. All screws were tightened to 2 Nm torque and compression values recorded at 0, 0.5, 1, 2, 6, and 12 h (six trials per condition). Medians were compared across groups for statistical significance. Results There was no difference in median compression between lag and neutral bicortical screws. For PLA, greater median compression was generated by neutral (median 437 N) and lag (median 379 N) bicortical screws compared to neutral unicortical screws (median 208 N, p < .001); lag bicortical screws generated greater median compression than lag unicortical screws (median 265 N, p = .012). For CSB, lag bicortical screws (median 293 N) generated greater median compression than neutral unicortical screws (median 228 N, p = .008). Conclusion Lag and neutral screws generated similar compression. Bicortical screws had higher median compression than unicortical screws in bone analogs. Clinical significance Neutral screws generate compression in cancellous bone analogs that can be increased with bicortical bone engagement.
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Affiliation(s)
- Caitlin R Moreno
- Department of Clinical Sciences, Kansas State University, Manhattan, Kansas, USA
| | - Elizabeth M Santschi
- Department of Clinical Sciences, Kansas State University, Manhattan, Kansas, USA
| | - Jennifer Janes
- Equine Programs, University of Kentucky, Lexington, Kentucky, USA
| | - Jie Liu
- Division of Orthodontics, The Ohio State University, Columbus, Ohio, USA
| | - Do-Gyoon Kim
- Division of Orthodontics, The Ohio State University, Columbus, Ohio, USA
| | - Alan S Litsky
- Departments of Orthopaedics and Biomedical Engineering, The Ohio State University, Columbus, Ohio, USA.,Orthopaedic BioMaterials Laboratory, The Ohio State University, Columbus, Ohio, USA
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Keltz E, Fletcher J, Mora AJ, Yavnai N, Gueorguiev-Rüegg B, Keren Y. Orthopedic screws insertion simulation with immediate feedback enhances surgical skill. Clin Biomech (Bristol, Avon) 2022; 94:105367. [PMID: 34088527 DOI: 10.1016/j.clinbiomech.2021.105367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Revised: 04/19/2021] [Accepted: 04/23/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Screw insertion to bones is a fundamental skill in orthopedic, spine and cranio-maxillofacial surgery. Applying the correct tightening torque is critical when compressing and fixating bone fragments. Overtightening yields in plastic deformation of the bone and destruction of the screw-bone interface, damaging the construct's stability. The surgeon is required to achieve sufficient hold and compression without stripping the bone. Several studies have investigated these skills, demonstrating much potential to enhance the future surgeons' capabilities. This study presents a novel training module, combining direct tightening followed by deliberate striping with immediate feedback suggested to enhance the surgeon's tactile perception and improve skill. METHODS A prospective single-blinded cohort study was run. Twenty surgeons from various disciplines, excluding orthopedic and maxillo-facial surgeons, were trained using an orthopedic screws insertion model, comprised of synthetic bones. Training sessions considered inserting 40 screws into normal and osteoporotic bone models, experiencing deliberate stripping of the screws and feedback for their performance in three different sessions. FINDINGS Success rate increased between sessions - by 24% to 48% in normal bone, and by 37% to 52% in osteoporotic bone. Stripping rate decreased between sessions - by 37.5% to 18.5% in normal bone, and by 29% to 14% in osteoporotic bone. Average ratio between tightening torque and maximum possible torque before bone stripping improved gradually and consistently from 67.3% to 81.6% in normal bone (p < 0.001), and slightly from 76.4% to 77.5% in osteoporotic bone (p = 0.026). INTERPRETATION Immediate feedback with deliberate stripping and external feedback using a digital torque measuring screwdriver may improve cortical screw insertion technique in the surgeons' community.
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Affiliation(s)
- Eran Keltz
- Division of Orthopedic Surgery, Rambam Health Care Campus, Ruth Rappaort Faculty of Medicine, Technion Institute of Technology, Haifa, Israel.
| | | | - Alberto Jorge Mora
- Division of Traumatology & Institute IDIS, Servicio Galego de Saúde, Santiago University Clinical Hospital, Santiago de Compostela, Musculoskeletal Pathology Group, Institute IDIS Lab 18, Santiago, Spain
| | | | | | - Yaniv Keren
- Division of Orthopedic Surgery, Rambam Health Care Campus, Ruth Rappaort Faculty of Medicine, Technion Institute of Technology, Haifa, Israel
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6
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Fletcher JWA, Neumann V, Wenzel L, Gueorguiev B, Richards RG, Gill HS, Whitehouse MR, Preatoni E. Screw tightness and stripping rates vary between biomechanical researchers and practicing orthopaedic surgeons. J Orthop Surg Res 2021; 16:642. [PMID: 34702320 PMCID: PMC8549396 DOI: 10.1186/s13018-021-02800-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Accepted: 10/18/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Screws are the most frequently inserted orthopaedic implants. Biomechanical, laboratory-based studies are used to provide a controlled environment to investigate revolutionary and evolutionary improvements in orthopaedic techniques. Predominantly, biomechanical trained, non-surgically practicing researchers perform these studies, whilst it will be orthopaedic surgeons who will put these procedures into practice on patients. Limited data exist on the comparative performance of surgically and non-surgically trained biomechanical researchers when inserting screws. Furthermore, any variation in performance by surgeons and/or biomechanical researchers may create an underappreciated confounder to biomechanical research findings. This study aimed to identify the differences between surgically and non-surgically trained biomechanical researchers' achieved screw tightness and stripping rates with different fixation methods. METHODS Ten orthopaedic surgeons and 10 researchers inserted 60 cortical screws each into artificial bone, for three different screw diameters (2.7, 3.5 and 4.5 mm), with 50% of screws inserted through plates and 50% through washers. Screw tightness, screw hole stripping rates and confidence in screw purchase were recorded. Three members of each group also inserted 30 screws using an augmented screwdriver, which indicated when optimum tightness was achieved. RESULTS Unstripped screw tightness for orthopaedic surgeons and researchers was 82% (n = 928, 95% CI 81-83) and 76% (n = 1470, 95% CI 75-76) respectively (p < 0.001); surgeons stripped 48% (872/1800) of inserted screws and researchers 18% (330/1800). Using washers was associated with increased tightness [80% (95% CI 80-81), n = 1196] compared to screws inserted through plates [76% (95% CI 75-77), n = 1204] (p < 0.001). Researchers were more accurate in their overall assessment of good screw insertion (86% vs. 62%). No learning effect occurred when comparing screw tightness for the first 10 insertions against the last 10 insertions for any condition (p = 0.058-0.821). Augmented screwdrivers, indicating optimum tightness, reduced stripping rates from 34 to 21% (p < 0.001). Experience was not associated with improved performance in screw tightness or stripping rates for either group (p = 0.385-0.965). CONCLUSIONS Surgeons and researchers showed different screw tightness under the same in vitro conditions, with greater rates of screw hole stripping by surgeons. This may have important implications for the reproducibility and transferability of research findings from different settings depending on who undertakes the experiments.
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Affiliation(s)
- James W A Fletcher
- Applied Biomechanics Suite, Department for Health, University of Bath, Claverton Down, Bath, BA2 7AY, UK.
- AO Research Institute Davos, Davos, Switzerland.
| | | | - Lisa Wenzel
- AO Research Institute Davos, Davos, Switzerland
- Department of Trauma Surgery, Trauma Center Murnau, Professor-Küntscher-Str. 8, 82418, Murnau, Germany
| | | | | | - Harinderjit S Gill
- Department of Mechanical Engineering, University of Bath, Bath, UK
- Centre for Therapeutic Innovation, University of Bath, Bath, UK
| | - Michael R Whitehouse
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, Southmead Hospital, 1st Floor Learning & Research Building, Bristol, UK
- National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol NHS Foundation Trust and University of Bristol, Bristol, UK
| | - Ezio Preatoni
- Applied Biomechanics Suite, Department for Health, University of Bath, Claverton Down, Bath, BA2 7AY, UK
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Feng X, Qi W, Zhang T, Fang C, Liang H, Chen B, Leung F. Lateral migration resistance of screw is essential in evaluating bone screw stability of plate fixation. Sci Rep 2021; 11:12510. [PMID: 34131183 PMCID: PMC8206340 DOI: 10.1038/s41598-021-91952-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Accepted: 05/31/2021] [Indexed: 11/09/2022] Open
Abstract
Conventional evaluation of the stability of bone screws focuses on pullout strength, while neglecting lateral migration resistance. We measured pullout strength and lateral migration resistance of bone screws and determined how these characteristics relate to screw stability of locking plate (LP) and dynamic compression plate (DCP) fixation. Pullout strength and lateral migration resistance of individual bone screws with buttress, square, and triangular thread designs were evaluated in polyurethane foam blocks. The screw types with superior performance in each of these characteristics were selected. LP and DCP fixations were constructed using the selected screws and tested under cyclic craniocaudal and torsional loadings. Subsequently, the association between individual screws’ biomechanical characteristics and fixation stability when applied to plates was established. Screws with triangular threads had superior pullout strength, while screws with square threads demonstrated the highest lateral migration resistance; they were selected for LP and DCP fixations. LPs with square-threaded screws required a larger force and more cycles to trigger the same amount of displacement under both craniocaudal and torsional loadings. Screws with triangular and square threads showed no difference in DCP fixation stability under craniocaudal loading. However, under torsional loading, DCP fixation with triangular-threaded screws demonstrated superior fixation stability. Lateral migration resistance is the primary contributor to locking screw fixation stability when applied to an LP in resisting both craniocaudal and torsional loading. For compression screws applied to a DCP, lateral migration resistance and pullout strength work together to resist craniocaudal loading, while pullout strength is the primary contributor to the ability to resist torsional loading.
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Affiliation(s)
- Xiaoreng Feng
- Department of Orthopaedics and Traumatology, Queen Mary Hospital, the University of Hong Kong, Pok Fu Lam, Hong Kong, SAR, China.,Division of Orthopaedics and Traumatology, Department of Orthopaedics, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, China.,Yangjiang People's Hospital, Yangjiang, 529500, China
| | - Weichen Qi
- Department of Orthopaedics and Traumatology, Queen Mary Hospital, the University of Hong Kong, Pok Fu Lam, Hong Kong, SAR, China
| | - Teng Zhang
- Department of Orthopaedics and Traumatology, Queen Mary Hospital, the University of Hong Kong, Pok Fu Lam, Hong Kong, SAR, China
| | - Christian Fang
- Department of Orthopaedics and Traumatology, Queen Mary Hospital, the University of Hong Kong, Pok Fu Lam, Hong Kong, SAR, China
| | | | - Bin Chen
- Division of Orthopaedics and Traumatology, Department of Orthopaedics, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, China.
| | - Frankie Leung
- Department of Orthopaedics and Traumatology, Queen Mary Hospital, the University of Hong Kong, Pok Fu Lam, Hong Kong, SAR, China.
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8
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Fletcher JWA, Neumann V, Wenzel L, Gueorguiev B, Richards RG, Gill HS, Whitehouse MR, Preatoni E. Variations in non-locking screw insertion conditions generate unpredictable changes to achieved fixation tightness and stripping rates. Clin Biomech (Bristol, Avon) 2020; 80:105201. [PMID: 33158573 DOI: 10.1016/j.clinbiomech.2020.105201] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Revised: 10/15/2020] [Accepted: 10/19/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Screws are the most commonly inserted orthopaedic implants. However, several variables related to screw insertion and tightening have not been evaluated. This study aimed firstly to assess the effect of insertion variables on screw tightness, secondly to improve methodologies used by researchers when testing screw insertion techniques and thirdly to assess for any learning or fatigue effects when inserting screws. METHODS Two surgeons tightened a total of 2280 non-locking, 3.5 mm cortical screws, with 120 screws inserted to what they felt to be optimum tightness whilst varying each of the following factors: different screwdrivers for measuring torque, screwdriver orientation, gloves usage, dominant/non-dominant hand usage, awareness to the applied torque (blinded, unblinded and re-blinded), four bone densities and seven cortical thicknesses. Screws were tightened to failure to determine stripping torque, which was used to calculate screw tightness - ratio between stopping and stripping torque. FINDINGS Screw tightness increased with glove usage, being blinded to the applied torque and with denser artificial bone and with thinner cortices. Considering all the insertions performed, the two surgeons stopped tightening screws at difference values of tightness ((77% versus 66% (p < 0.001)). A learning effect was observed with some parameters including sterile gloves usage and non-dominant hand application. INTERPRETATION Different insertion conditions frequently changed screw tightness for both surgeons. Given the influence of screw tightness on fixation stability, the variables investigated within this study should be carefully reported and controlled when performing biomechanical testing alongside practicing screw insertion under different conditions during surgical training.
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Affiliation(s)
- James W A Fletcher
- Department for Health, University of Bath, Bath, UK; AO Research Institute Davos, Davos, Switzerland.
| | | | - Lisa Wenzel
- AO Research Institute Davos, Davos, Switzerland; Department of Trauma Surgery, Trauma Center Murnau, Professor-Küntscher-Str. 8, 82418 Murnau, Germany
| | | | | | | | - Michael R Whitehouse
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, 1st Floor Learning & Research Building, Southmead Hospital, Bristol, UK; National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol NHS Foundation Trust and University of Bristol, Bristol, UK
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9
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Fletcher JWA, Zderic I, Gueorguiev B, Richards RG, Gill HS, Whitehouse MR, Preatoni E. Stripping torques in human bone can be reliably predicted prior to screw insertion with optimum tightness being found between 70% and 80% of the maximum. Bone Joint Res 2020; 9:493-500. [PMID: 32922757 PMCID: PMC7469512 DOI: 10.1302/2046-3758.98.bjr-2019-0318.r1] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
AIMS To devise a method to quantify and optimize tightness when inserting cortical screws, based on bone characterization and screw geometry. METHODS Cortical human cadaveric diaphyseal tibiae screw holes (n = 20) underwent destructive testing to firstly establish the relationship between cortical thickness and experimental stripping torque (Tstr), and secondly to calibrate an equation to predict Tstr. Using the equation's predictions, 3.5 mm screws were inserted (n = 66) to targeted torques representing 40% to 100% of Tstr, with recording of compression generated during tightening. Once the target torque had been achieved, immediate pullout testing was performed. RESULTS Cortical thickness predicted Tstr (R2 = 0.862; p < 0.001) as did an equation based on tensile yield stress, bone-screw friction coefficient, and screw geometries (R2 = 0.894; p < 0.001). Compression increased with screw tightness up to 80% of the maximum (R2 = 0.495; p < 0.001). Beyond 80%, further tightening generated no increase in compression. Pullout force did not change with variations in submaximal tightness beyond 40% of Tstr (R2 = 0.014; p = 0.175). CONCLUSION Screw tightening between 70% and 80% of the predicted maximum generated optimum compression and pullout forces. Further tightening did not considerably increase compression, made no difference to pullout, and increased the risk of the screw holes being stripped. While further work is needed for development of intraoperative methods for accurate and reliable prediction of the maximum tightness for a screw, this work justifies insertion torque being considerably below the maximum.Cite this article: Bone Joint Res 2020;9(8):493-500.
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Affiliation(s)
- James W. A. Fletcher
- Department for Health, University of Bath, Bath, UK
- AO Research Institute Davos, Davos, Switzerland
| | - Ivan Zderic
- AO Research Institute Davos, Davos, Switzerland
| | | | | | | | - Michael R. Whitehouse
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, Southmead Hospital, Bristol, UK
- National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol NHS Foundation Trust and University of Bristol, Bristol, UK
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10
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Märdian S, Schmölz W, Schaser KD, Duda GN, Heyland M. Locking plate constructs benefit from interfragmentary lag screw fixation with decreased shear movements and more predictable fracture gap motion in simple fracture patterns. Clin Biomech (Bristol, Avon) 2019; 70:89-96. [PMID: 31445402 DOI: 10.1016/j.clinbiomech.2019.08.008] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Revised: 08/10/2019] [Accepted: 08/15/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND A mechanical characterisation of lag screw fixation plus locking plate - although clinically widely used as either "mixed fixation concept" or absolutely stable fixation - is so far missing. This study aimed to evaluate the influence of an interfragmentary lag screw on the resulting motion at the fracture site of locking plate constructs using a simple fracture at the distal femur. METHODS Human cadaver femora were in vitro loaded in torsion and axial bending-compression with and without lag screw fixation next to a locking plate fixation. In addition, two plate working lengths were tested. Interfragmentary movement was measured optically. FINDINGS Axial interfragmentary movement is reduced with lag screw (102 mm plate working length, 1000 N, mean): 0.28 mm versus 0.82 mm. With lag screw, the fracture gap stays closed with mean normal interfragmentary movement ≤0.03 mm. Fracture gap tends to open without lag screw: normal interfragmentary movement up to -0.29 mm. Reduction of shear interfragmentary movement was observed throughout all tested loads and groups. Mean true shear remains generally low with lag screw (≤0.42 mm) compared to without lag screw (≤1.46 mm). We also found that interfragmentary movement variance decreases with lag screw, especially for longer plate working length. INTERPRETATION An interfragmentary lag screw next to locking bridge plating reduces fragment motion in vitro for a simple fracture pattern and provides a sufficient tool to decrease detrimental shear movements. Prospective clinical trials with interfragmentary lag screw fixation should prove these findings in wide clinical use to treat simple fracture patterns.
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Affiliation(s)
- Sven Märdian
- Centre for Musculoskeletal Surgery, Charité-Universitätsmedizin Berlin, Augustenburger Platz 1, 13353 Berlin, Germany.
| | - Werner Schmölz
- Department of Trauma Surgery, Medical University Innsbruck, Anichstraße 35, 6020 Innsbruck, Austria
| | - Klaus-Dieter Schaser
- UniversitätsCentrum für Orthopädie & Unfallchirurgie, Universitätsklinikum Carl Gustav Carus Dresden, Fetscherstraße 74, 01307 Dresden, Germany
| | - Georg N Duda
- Julius Wolff Institute for Biomechanics and Musculoskeletal Regeneration, Charité - Universitätsmedizin Berlin, Augustenburger Platz 1, 13353 Berlin, Germany
| | - Mark Heyland
- Julius Wolff Institute for Biomechanics and Musculoskeletal Regeneration, Charité - Universitätsmedizin Berlin, Augustenburger Platz 1, 13353 Berlin, Germany
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