Orthopedic screws insertion simulation with immediate feedback enhances surgical skill

Eran Keltz, James Fletcher, Alberto Jorge Mora, Nirit Yavnai, Boyko Gueorguiev-Rüegg, Yaniv Keren

Research output: Contribution to journalArticlepeer-review


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.

Original languageEnglish
Article number105367
JournalClinical Biomechanics
Early online date26 Apr 2021
Publication statusPublished - 30 Apr 2022


  • Feedback
  • Perception
  • Screw
  • Stripping
  • Tactile
  • Training

ASJC Scopus subject areas

  • Biophysics
  • Orthopedics and Sports Medicine


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