title: Screw orientation and plate type (variable- vs. fixed-angle) effect strength of fixation for in vitro biomechanical testing of the Synthes CSLP.
abstract: BACKGROUND
  Two common justifications for orienting cervical screws in an angled direction are to increase pullout strength and to allow use of longer screws. This concept is widely taught and has guided implant design. Fixed- versus variable-angle systems may offer strength advantages. Despite these teachings, there is a paucity of supporting biomechanical evidence. The purpose of our study is to test the influence of screw orientation and plate design on the maximum screw pullout force.
  
  
  OBJECTIVE
  This study evaluates the effect of screw orientation and plate type (fixed- vs. variable-angle) on screw pullout strength.
  
  
  METHODS
  Anterior cervical plates of both a fixed- and variable-angle CSLP, were tested for peak pullout strength in a direct plate pullout model using polyurethane foam bone, which models osteoporotic bone.
  
  
  METHODS
  Self-tapping, locking screws (4.0x14mm and 4.0x16mm) were used. Screws were oriented in the fixed-angle plate in the standard fashion. In the variable plate, screws were instrumented in three different orientations. Biomechanical testing was performed on an Instron DynaMight 8841 servohydraulic testing machine, measuring maximum pullout force under a displacement-controlled pullout rate of 1mm/min. Five samples were tested per group.
  
  
  RESULTS
  When all screws were placed 90 degrees to the plate, there was a significantly increased peak pullout strength (412.8+/-22.2N) compared with when all screws were placed 12 degrees "up and in" (376.2+/-24.3N, p less than or equal to .03). When the 90 degrees construct was reproduced using 14-mm screws and compared with 16-mm screws oriented 12 degrees "all up and in," there was still significantly higher pullout strength with the all 90 degrees construct (434.2+/-28.7N vs. 376.2+/-24.3N, p less than or equal to .009). The fixed-angle plate had a significantly decreased peak pullout strength (288.2+/-15.7N) compared with the variable-angle plate (416.6+/-12.6N) (p less than .00001) when the screws were placed in the same orientation. Overall, the variable-angle plate, regardless of the orientation of screws, had a significantly greater pullout strength than the fixed-angle plate (p less than .001).
  
  
  CONCLUSIONS
  In this system, a variable-angle plate has greater pullout strength than a fixed-angle plate, regardless of the orientation of screws. With the variable-angle plate, a construct of all screws 12 degrees "up and in" is the weakest configuration. We found that with the 90 degrees construct, both 16- and 14-mm screws performed significantly better than 16-mm convergent screws. These findings are remarkable because they contradict the current doctrine. This may be a function of plate-dependent factors and should not be applied universally to all plate systems. Further study of screw orientation in additional plating systems is warranted.
authors.affiliation: University of Rochester Medical Center, Rochester, NY 14642, USA. cpd62@yahoo.com
authors.forename: Christian P
authors.initials: CP
authors.lastname: Dipaola
authors.forename: Justin A
authors.initials: JA
authors.lastname: Jacobson
authors.forename: Hani
authors.initials: H
authors.lastname: Awad
authors.forename: Bryan P
authors.initials: BP
authors.lastname: Conrad
authors.forename: Glenn R
authors.initials: GR
authors.lastname: Rechtine
mesh_terms: D001696:Biomechanical Phenomena; D001860:Bone Plates; D001863:Bone Screws; D002574:Cervical Vertebrae / Q000601:surgery; D019544:Equipment Failure Analysis; D008422:Materials Testing; D019637:Orthopedic Procedures / Q000295:instrumentation*