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

doi:10.1302/2058-5241.5.180066

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 journal › Article › peer-review

23 Citations (SciVal)

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. The aims of this study were 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.
Twelve studies were included, with 260 surgeons inserting a total of 2793 screws; an average of 11 screws each, although only 1510 screws have been inserted by 145 surgeons where tightness was measured – average tightness was 78±10% for cortical (n = 1079) and 80±6% for cancellous screw insertions (n = 431).
An average of 26% of all inserted screws irreparably damaged and stripped screw holes, reducing the construct pullout strength. Furthermore, awareness of bone stripping is very poor, meaning that screws must be considerably overtightened before a surgeon will typically detect it.
Variation between individual surgeons’ ability to optimally insert screws was seen, with some surgeons stripping more than 90% of samples and others hardly any. Contradictory findings were seen for the relationship between the tightness achieved and bone density.
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 language	English
Pages (from-to)	26-36
Number of pages	11
Journal	EFORT Open Reviews
Volume	5
Issue number	1
Early online date	3 Jan 2020
DOIs	https://doi.org/10.1302/2058-5241.5.180066
Publication status	Published - 31 Jan 2020

Bibliographical note

Funding Information:
This study was performed with the assistance of the Royal College of Surgeons of England, Surgical Research Fellowship. This study was supported by the NIHR Biomedical Research Centre at University Hospitals Bristol NHS Foundation Trust and the University of Bristol. The views expressed in this publication are those of the authors and not necessarily those of the NHS, the National Institute for Health Research or the Department of Health and Social Care.

Funding Information:
JWAF reports a Research Fellowship with the Royal College of Surgeons of England for the submitted work. LW reports she is the Chair of the ‘Junges Forum O und U’ - the political board of young trauma and orthopaedic surgeons in Germany; research funding from Forschungsförderungsfond der Paracelsus Medizinischen Privatuniversität, PMU Rise Projekt, Kategori: Newcomerprojekt (research funding of the Paracelsus Medical Private University, Rise project in the category ‘newcomer project’), all outside the submitted work. RGR reports support for travel to meetings for the study or other purposes from AO Research Institute Davos for the submitted work. HSG reports a grant covering first author from the Royal College of Surgeons for the submitted work. The author reports consultancy to Zimmer Biomet and an educational grant from Smith & Nephew; and membership of the BJJ Editorial Board, with expenses for attending meetings reimbursed outside the submitted work. EP reports they are a co-investigator in the fellowship application of the corresponding author from David Telling Charitable Trust and Royal College of Surgeons for the submitted work. MRW reports grant salary costs from the National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol NHS Foundation Trust and University of Bristol, National Joint Registry Lot 2 contract, Stryker (Triathlon); royalties for being editor of an orthopaedic textbook from Taylor & Francis; undertaking teaching on basic sciences for orthopaedic trainees preparing for the FRCS for which the author’s institution receives market-rate payment from Heraeus; undertaking teaching on total hip replacement for orthopaedic consultants and trainees for which the author’s institution receives market rate payment from DePuy, all outside the submitted work. The other authors declare no conflict of interest relevant to this work.

Publisher Copyright:
© 2020 The author(s).

Keywords

Bone screws
Fracture fixation
Internal fixation
Screw insertion
Screw tightness
Stripping torque
Surgical technique

ASJC Scopus subject areas

Surgery
Orthopedics and Sports Medicine

Access to Document

10.1302/2058-5241.5.180066Licence: CC BY-NC

Cite this

@article{8a1e1189f91a443ba94ac2069761aeef,

title = "Surgical performance when inserting non-locking screws – a systematic review",

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. The aims of this study were 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.Twelve studies were included, with 260 surgeons inserting a total of 2793 screws; an average of 11 screws each, although only 1510 screws have been inserted by 145 surgeons where tightness was measured – average tightness was 78±10% for cortical (n = 1079) and 80±6% for cancellous screw insertions (n = 431).An average of 26% of all inserted screws irreparably damaged and stripped screw holes, reducing the construct pullout strength. Furthermore, awareness of bone stripping is very poor, meaning that screws must be considerably overtightened before a surgeon will typically detect it.Variation between individual surgeons{\textquoteright} ability to optimally insert screws was seen, with some surgeons stripping more than 90% of samples and others hardly any. Contradictory findings were seen for the relationship between the tightness achieved and bone density.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.",

keywords = "Bone screws, Fracture fixation, Internal fixation, Screw insertion, Screw tightness, Stripping torque, Surgical technique",

author = "James Fletcher and Lisa Wenzel and Verena Neumann and Richards, {R. Geoff} and Boyko Gueorguiev and Harinderjit Gill and Ezio Preatoni and Michael Whitehouse",

note = "Funding Information: This study was performed with the assistance of the Royal College of Surgeons of England, Surgical Research Fellowship. This study was supported by the NIHR Biomedical Research Centre at University Hospitals Bristol NHS Foundation Trust and the University of Bristol. The views expressed in this publication are those of the authors and not necessarily those of the NHS, the National Institute for Health Research or the Department of Health and Social Care. Funding Information: JWAF reports a Research Fellowship with the Royal College of Surgeons of England for the submitted work. LW reports she is the Chair of the {\textquoteleft}Junges Forum O und U{\textquoteright} - the political board of young trauma and orthopaedic surgeons in Germany; research funding from Forschungsf{\"o}rderungsfond der Paracelsus Medizinischen Privatuniversit{\"a}t, PMU Rise Projekt, Kategori: Newcomerprojekt (research funding of the Paracelsus Medical Private University, Rise project in the category {\textquoteleft}newcomer project{\textquoteright}), all outside the submitted work. RGR reports support for travel to meetings for the study or other purposes from AO Research Institute Davos for the submitted work. HSG reports a grant covering first author from the Royal College of Surgeons for the submitted work. The author reports consultancy to Zimmer Biomet and an educational grant from Smith & Nephew; and membership of the BJJ Editorial Board, with expenses for attending meetings reimbursed outside the submitted work. EP reports they are a co-investigator in the fellowship application of the corresponding author from David Telling Charitable Trust and Royal College of Surgeons for the submitted work. MRW reports grant salary costs from the National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol NHS Foundation Trust and University of Bristol, National Joint Registry Lot 2 contract, Stryker (Triathlon); royalties for being editor of an orthopaedic textbook from Taylor & Francis; undertaking teaching on basic sciences for orthopaedic trainees preparing for the FRCS for which the author{\textquoteright}s institution receives market-rate payment from Heraeus; undertaking teaching on total hip replacement for orthopaedic consultants and trainees for which the author{\textquoteright}s institution receives market rate payment from DePuy, all outside the submitted work. The other authors declare no conflict of interest relevant to this work. Publisher Copyright: {\textcopyright} 2020 The author(s).",

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N2 - 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. The aims of this study were 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.Twelve studies were included, with 260 surgeons inserting a total of 2793 screws; an average of 11 screws each, although only 1510 screws have been inserted by 145 surgeons where tightness was measured – average tightness was 78±10% for cortical (n = 1079) and 80±6% for cancellous screw insertions (n = 431).An average of 26% of all inserted screws irreparably damaged and stripped screw holes, reducing the construct pullout strength. Furthermore, awareness of bone stripping is very poor, meaning that screws must be considerably overtightened before a surgeon will typically detect it.Variation between individual surgeons’ ability to optimally insert screws was seen, with some surgeons stripping more than 90% of samples and others hardly any. Contradictory findings were seen for the relationship between the tightness achieved and bone density.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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Surgical performance when inserting non-locking screws – a systematic review

Abstract

Bibliographical note

Keywords

ASJC Scopus subject areas

Access to Document

Other files and links

Fingerprint

Fellowship for James Fletcher - Optimal surgical techniques to reduce screw failure in fragility fractures

Improving Fracture Fixation - The Role of Insertion Forces on Construct Stability

Data for "Juvenile bovine bone is an appropriate surrogate for normal and reduced density human bone in biomechanical testing"

Dataset for "Non-locking screw insertion: no benefit seen if tightness exceeds 80% of the maximum torque"

Cite this

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

Abstract

Bibliographical note

Keywords

ASJC Scopus subject areas

Access to Document

Other files and links

Fingerprint

Projects

Fellowship for James Fletcher - Optimal surgical techniques to reduce screw failure in fragility fractures

Improving Fracture Fixation - The Role of Insertion Forces on Construct Stability

Datasets

Data for "Juvenile bovine bone is an appropriate surrogate for normal and reduced density human bone in biomechanical testing"

Dataset for "Non-locking screw insertion: no benefit seen if tightness exceeds 80% of the maximum torque"

Cite this