Surgical performance when inserting non-locking screws – a systematic review

James Fletcher, Lisa Wenzel, Verena Neumann, R. Geoff Richards, Boyko Gueorguiev, Harinderjit Gill, Ezio Preatoni, Michael Whitehouse

Research output: Contribution to journalArticle

Abstract

• Billions of screws are inserted by surgeons each year, making them the most commonly inserted implant. When using non-locking screws, insertion technique is decided by the surgeon including how much to tighten each screw. This choice typically dictated by the surgeon’s experience, alongside subjective assessment of the screw and bone properties. The aim of this study is to assess, through a systematic review, the screw tightness and rate of material stripping produced by surgeons and the effect of different variables related to screw insertion.
• In studies measuring subjectively chosen tightness in comparison to the maximum tightness for the material, combined average tightness was 77.9±10.1% for cortical (n=1079) and 80.0±6.4% for cancellous screw insertions (n=431).
• An average of 26% of all inserted screws irreparably damage and strip the bone around their threads, reducing the pullout construct strength. Furthermore, awareness of bone stripping is very poor, meaning that screws must be considerably overtightened before a surgeon will typically detect it.
• There is great variation between individual surgeons' abilities to optimally insert screws, with some surgeons stripping in more than 90% of samples and others hardly ever. No consistent associations are seen with experience nor bone density and optimal screw insertion.
• The optimum tightness for screws remains unknown, thus subjectively chosen screw tightness, which varies greatly, remains without an established target to generate the best possible construct for any given situation. Work is needed to establish these targets, and to develop methods to accurately and repeatably achieve them.
Original languageEnglish
JournalEFORT Open Reviews
Publication statusAccepted/In press - 1 Aug 2019

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Bone Screws
Bone and Bones
Surgeons
Bone Density

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Fletcher, J., Wenzel, L., Neumann, V., Richards, R. G., Gueorguiev, B., Gill, H., ... Whitehouse, M. (Accepted/In press). Surgical performance when inserting non-locking screws – a systematic review. EFORT Open Reviews.

Surgical performance when inserting non-locking screws – a systematic review. / Fletcher, James; Wenzel, Lisa; Neumann, Verena; Richards, R. Geoff; Gueorguiev, Boyko; Gill, Harinderjit; Preatoni, Ezio; Whitehouse, Michael.

In: EFORT Open Reviews, 01.08.2019.

Research output: Contribution to journalArticle

Fletcher, James ; Wenzel, Lisa ; Neumann, Verena ; Richards, R. Geoff ; Gueorguiev, Boyko ; Gill, Harinderjit ; Preatoni, Ezio ; Whitehouse, Michael. / Surgical performance when inserting non-locking screws – a systematic review. In: EFORT Open Reviews. 2019.
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AB - • Billions of screws are inserted by surgeons each year, making them the most commonly inserted implant. When using non-locking screws, insertion technique is decided by the surgeon including how much to tighten each screw. This choice typically dictated by the surgeon’s experience, alongside subjective assessment of the screw and bone properties. The aim of this study is to assess, through a systematic review, the screw tightness and rate of material stripping produced by surgeons and the effect of different variables related to screw insertion. • In studies measuring subjectively chosen tightness in comparison to the maximum tightness for the material, combined average tightness was 77.9±10.1% for cortical (n=1079) and 80.0±6.4% for cancellous screw insertions (n=431).• An average of 26% of all inserted screws irreparably damage and strip the bone around their threads, reducing the pullout construct strength. Furthermore, awareness of bone stripping is very poor, meaning that screws must be considerably overtightened before a surgeon will typically detect it.• There is great variation between individual surgeons' abilities to optimally insert screws, with some surgeons stripping in more than 90% of samples and others hardly ever. No consistent associations are seen with experience nor bone density and optimal screw insertion.• The optimum tightness for screws remains unknown, thus subjectively chosen screw tightness, which varies greatly, remains without an established target to generate the best possible construct for any given situation. Work is needed to establish these targets, and to develop methods to accurately and repeatably achieve them.

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