title: Surgeon perception of cancellous screw fixation.
abstract: OBJECTIVE
  The ability of surgeons to optimize screw insertion torque in nonlocking fixation constructs is important for stability, particularly in osteoporotic and cancellous bone. This study evaluated screw torque applied by surgeons during synthetic cancellous fixation. It evaluated the frequency with which screws were stripped by surgeons, factors associated with screw stripping, and ability of surgeons to recognize it.
  
  
  METHODS
  Ten surgeons assembled screw and plate fixation constructs into 3 densities of synthetic cancellous bone while screw insertion torque and axial force were measured. For each screw, the surgeon recorded a subjective rating as to whether or not the screw had been stripped. Screws were then advanced past stripping, and stripped screws were identified by comparing the insertion torque applied by the surgeon to the measured stripping torque.
  
  
  RESULTS
  Surgeons stripped 109 (45.4%) of 240 screws and did not recognize stripping 90.8% of the time when it occurred. The tendency to strip screws was highly variable among individual surgeons (stripping ranging from 16.7% to 83.3%, P < 0.0001) and did not correlate with synthetic bone density in the range tested (P = 0.186) nor with the ranking of surgeons as resident or attending surgeon (P = 0.437). Screws that were correctly recognized as stripped retained a mean 55.0% of maximum torque, less than when stripping was not recognized (79.6%, P = 0.005).
  
  
  CONCLUSIONS
  Surgeon perception is not reliable at preventing and detecting screw stripping at clinical torque levels in synthetic cancellous bone. Less aggressive insertion or standardized methods of insertion may improve the stability of nonlocking screw and plate constructs.
authors.affiliation: *Department of Orthopaedic Surgery, Western Michigan University School of Medicine, Kalamazoo, MI; and †Department of Mechanical and Aeronautical Engineering, Western Michigan University, Kalamazoo, MI.
authors.forename: Michael J
authors.initials: MJ
authors.lastname: Stoesz
authors.forename: Peter A
authors.initials: PA
authors.lastname: Gustafson
authors.forename: Bipinchandra V
authors.initials: BV
authors.lastname: Patel
authors.forename: James R
authors.initials: JR
authors.lastname: Jastifer
authors.forename: Joseph L
authors.initials: JL
authors.lastname: Chess
mesh_terms: D001860:Bone Plates; D001863:Bone Screws / Q000009:adverse effects*; D002983:Clinical Competence; D008962:Models, Theoretical; D019637:Orthopedic Procedures / Q000009:adverse effects*; D019415:Torque