Available online at www.sciencedirect.

com

Available online at www.sciencedirect.com

ScienceDirect
Available ScienceDirect
online at www.sciencedirect.com
Procedia Manufacturing 00 (2019) 000–000
www.elsevier.com/locate/procedia
ScienceDirect
Procedia Manufacturing 00 (2019) 000–000
www.elsevier.com/locate/procedia
Procedia Manufacturing 46 (2020) 484–490

13th International Conference Interdisciplinarity in Engineering (INTER-ENG 2019)

13th International Conference Interdisciplinarity in Engineering (INTER-ENG 2019)
Torque Control during Bone Insertion of Cortical Screws
Torque Control during Bonea, Insertion of Cortical
a Screws
Flaviu Moldovan *, Tiberiu Bățagă
a, a
a
Flaviu
“George Emil Palade” Moldovan
University *, Tiberiu
of Medicine Pharmacy, Science, Bățagă
and Technology of Târgu Mureș,
38 Gheorghe Marinescu street, 540139 Târgu Mureș, Romania
a
“George Emil Palade” University of Medicine Pharmacy, Science, and Technology of Târgu Mureș,
38 Gheorghe Marinescu street, 540139 Târgu Mureș, Romania

Abstract

Abstract
A critical factor in the biomechanical stability of orthopaedic surgery is tightening of cortical screws which currently are
surgeon's skills based. This paper provides recommendation for better control and optimal insertion of cortical screws.
A critical factor
Experiments in the bones
on animal biomechanical stability of orthopaedic
allowed determination of clampingsurgery
torque islimits
tightening
for an of corticaltight.
efficient screws which currently
Employment are
of digital
surgeon's skills based.
torque screwdrivers This
allows paper
direct provides recommendation
determination for Than
of threshold torque. betterforcontrol and density
any bone optimaland insertion
any typeofofcortical screws.
screw the peak
Experiments
clamping on animal
torque is 1.75 bones allowed
threshold determination
torque. The clamping of torque
clamping torque
limits limits for1.5an....efficient
are between tight.torque.
2 threshold Employment of digital
This is calculated
torque screwdrivers
analytically allowsbydirect
and validated determination
experimental of threshold torque. Than for any bone density and any type of screw the peak
measurements.
clamping torque is 1.75 threshold torque. The clamping torque limits are between 1.5 .... 2 threshold torque. This is calculated
analytically
© 2019 The andAuthors.
validatedPublished
by experimental measurements.
by Elsevier B.V.. This is an open access article under the CC BY-NC-ND license
©(http://creativecommons.org/licenses/by-nc-nd/4.0/)
©2020
2019The Authors.
The Published
Authors. by Elsevier
Published B.V. B.V.. This is an open access article under the CC BY-NC-ND license
Peer-review
This is an openunder
accessresponsibility ofbyCC
article under the
Elsevier
the scientific committee
BY-NC-ND of the 13th International Conference Interdisciplinarity in
license (http://creativecommons.org/licenses/by-nc-nd/4.0/)
(http://creativecommons.org/licenses/by-nc-nd/4.0/)
Engineering
Peer-review under responsibility of the scientific committee of the 13th International Conference Interdisciplinarity in Engineering.
Peer-review under responsibility of the scientific committee of the 13th International Conference Interdisciplinarity in
Engineering
Keywords: cortical screw; bone fractures; threshhold torque; peak clamping torque; peak failure torque.

Keywords: cortical screw; bone fractures; threshhold torque; peak clamping torque; peak failure torque.
1. Introduction
1. Introduction
During bone fracture repair operations, orthopaedic surgeons insert cortical screws directly into the bone or
through the holes of a bone fixation plate. Tightening of screws is done subjectively by applying empirical torques,
During on
depending bone
thefracture
surgeon'srepair
skill. operations, orthopaedic
They must provide surgeons
a good insert
tightened cortical
of the screw screws
withoutdirectly into thewhich
bone crumble, bonecan
or
through the holes of a bone fixation plate. Tightening of screws is done subjectively by applying empirical torques,
compromise the quality of the assembly by destroying the threads that are formed in the bone by driving of the screw
depending
[1]. on the surgeon's skill. They must provide a good tightened of the screw without bone crumble, which can
compromise the quality of the assembly by destroying the threads that are formed in the bone by driving of the screw
[1].

* Corresponding author. Tel.: +40-754-671886.

E-mail: [email protected]
* Corresponding author. Tel.: +40-754-671886.
E-mail: [email protected]
2351-9789© 2019 The Authors. Published by Elsevier B.V.. This is an open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/by-nc-nd/4.0/)
2351-9789© 2019 The
Peer-review under Authors. Published
responsibility by Elsevier
of the scientific B.V..of
committee This
theis13th
an open access article
International under the
Conference CC BY-NC-NDinlicense
Interdisciplinarity Engineering
(http://creativecommons.org/licenses/by-nc-nd/4.0/)
Peer-review under responsibility of the scientific committee of the 13th International Conference Interdisciplinarity in Engineering

2351-9789 © 2020 The Authors. Published by Elsevier B.V.

This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/)
Peer-review under responsibility of the scientific committee of the 13th International Conference Interdisciplinarity in Engineering.
10.1016/j.promfg.2020.03.070
 Flaviu Moldovan et al. / Procedia Manufacturing 46 (2020) 484–490 485
2 Flaviu Moldovan and Tiberiu Bățagă / Procedia Manufacturing 00 (2019) 000–000

This problem is a critical factor in the biomechanical stability of orthopaedic surgery [2]. For this research issue,
in the scientific literature there is a limited number of studies revealing that the current values applied by surgeons
are 66-92% of the maximum tightening moments that lead to the assembly destroy [3-6].
Orthopaedic surgeons want better control for optimal insertion of cortical screws in absence of evolved devices
[7, 8]. From this perspective, the research subject is clinically important [9].
This paper has the following objectives:
 to determine the Peak Clamping Torque (PCT) and Peak Failure Torque (PFT) achieved by orthopaedic
surgeons in the bone fracture repair;
 to determine the cortical screw clamping torque limits which provides a good clamping;
 to determine if screw dimensional characteristics influence screw insertions measurements.

Nomenclature

PCT Peak Clamping Torque

PFT Peak Failure Torque
TT Threshold Torque
D Thread diameter
d Drill bit for threaded hole
L Screw length

2. Material and Method

The experiment is performed on fresh bovine bones received from a local slaughterhouse. It is ensured that the
bones used in experiment have same mechanical properties as regards: moisture content, lubrication factor, bone
mineral density which is a condition for conclusive results. The screws having four different diameters [10], shown
in table 1, are to be inserted in bones [11]. In the first stage of the experiment, bone conduction holes (Fig. 1) are
performed. For this purpose, the bone specimens are measured to determine the place where the screws are inserted.
Due to the geometric variability of the biological bone properties, it is necessary to determine and use relatively
similar locations for the same type of test on all bone specimens [12], following the rule:

Relative position of the hole = hole distance from one end of the bone / bone length (1)

The place where the screws are to be inserted is drawn with a pencil. Then, it is chosen the appropriate drill bit
size “d” which depend on the diameters of the screws “D” (Table 1). As a rule, this is recommended by the
manufacturer depending on the diameter of the bolt, but the selection of an optimal bit requires knowledge of the
material being drilled, the force applied, the rate of feed and the speed of the drill bit, the cutting end and the spiral
(or helix) of the shaft [13].

Fig. 1. Pilot Holes.

486 Flaviu Moldovan et al. / Procedia Manufacturing 46 (2020) 484–490
Flaviu Moldovan and Tiberiu Bățagă / Procedia Manufacturing00 (2019) 000–000 3

Bone specimens are fixed in a vice with the insertion point positioned directly under the drill bit. The drill
advances slowly until it perforates the bone surface at the insertion point of the screw. The frontal flute and the tool
geometry are the main factors for positioning the hole.
Than it is remove the bone from the vice and it is measured the thickness of the cortical wall by means of a
calliper with rod.
In the next step, the bone cortical screw insertion tests are performed by means of a torque wrench. Cortical
screws are manually inserted through the holes, and the clamping is done until they are fixed, under conditions
similar to those during orthopaedic operations. During the experiment the tightening torque values are read on the
torque wrench (Fig. 2). The measured parameters of the intervention, registered in table 1 are:
 Threshold Torque (TT) – the value of the torque when the screw starts to get tight in the bone;
 Peak Failure Torque (PFT) – the value of the torque when the screw assembly starts to be failed.

Table 1. Raw data for biological bone screw insertion tests.

Peak Peak Peak Clamping

Thread Drill bit for Screw Surface Threshold Clamping
Screw Failure TT Clamping Torque limits
diameter threaded length Area Torque Torque -
No. Torque PFT Torque 1,5-2,25 TT
D [mm] hole d [mm] L [mm] [mm2] [Nmm] normalized
[Nmm] [Nmm] [Nmm]
[N/mm]
1 1.5 1.1 14 65.94 150 380 0.39 265 4.00 225…337
2 2.7 2 14 118.69 280 700 0.4 490 4.12 420…630
3 3.5 2.5 14 153.86 390 980 0.39 685 4.45 585…877
4 4.5 3.2 14 197.82 520 1300 0.4 910 4.60 780…1170

Then, the screws are tightened until damage at the screw-to-bone interface occurs, which simulates an accidental
overload of the screw during operation. It is measured the Threshold Torque and the Peak Failure Torque.

Fig. 2. Cortical screw insertion test is performed using a torque wrench.

3. Results

The numerical values recorded with the help of a torque wrench allow the torque variation curve to be represented
(Fig. 3). It increases linearly from zero as the friction between the spirals and the bone appears, up to a Threshold
Torque value when the screw head comes into contact with the bone / washer / fracture plate. After that there is a
Peak Clamping Torque that allows for sufficient clamping, and the continuation of the clamping results in a Peak
Failure Torque over which the screw assembly is completely failed. The screw-bone assembly is totally deteriorated
and continuing tightened the screw is done with a low torque, different from zero, due to the friction between the
screw threads and the bone. The value of this moment depends on several factors that influence the friction
coefficient [14]: screw shape, lubrication caused by synovial fluid, marrow, blood, etc.
 4 Flaviu
Flaviu Moldovan and Moldovan et al./ /Procedia
Tiberiu Bățagă ProcediaManufacturing
Manufacturing00
46(2019)
(2020)000–000
484–490 487

PFT-Peak
Torque failure
[Nmm] torque
PCT-Peak
clamping
torque
mw Screw-bone coupling
total deteriorated

TT-Threshold
torque
Residual friction
between screw and
bone

Screw turns
[Number]

Fig. 3. Torque variation curve depending on the number of screw turns.

(a) (b)

Fig. 4. (a) Desinsertion of cortical screw; (b) Threaded hole.

Images with mounts and threaded hole are presented in figure 4.

Graphical representation in figure 5 of the experimental data for biological bone screw insertion tests for the 4
screws in table 1, are the raw torques variation curves.

1400
1300
1200

1000 980
910
800 Threshold Torque
700 685 Peak Clamping Torque
600
490 520 Peak Failure Torque
400 380 390
265 280
200
150
0
Screw 1 Screw 2 Screw 3 Screw 4

Fig. 5. Row torques variation curves [Nmm].

488 Flaviu Moldovan et al. / Procedia Manufacturing 46 (2020) 484–490
Flaviu Moldovan and Tiberiu Bățagă / Procedia Manufacturing00 (2019) 000–000 5

Analysis of numerical data from table 1, reveals the following findings of the research:
 The report: Threshold Torque (TT) / Peak Failure Torque (PFT) has an approximate value of 0.4 (Fig. 6).

0.8

0.6
TT / PFT
0.4

0.2

0
Screw 1 Screw 2 Screw 3 Screw 4

Fig. 6. The report between Threshold Torque and Peak Failure Torque.

 Clamping Torque limits = 1.5 TT .... 2.25 TT

This allows definition of Peak Clamping Torque as mid value between Threshold Torque and the Peak Failure
Torque:

(PCT) = (TT + PFT) / 2 = 1.75 TT (2)

The contact surface between the screw and the bone is:

SA = DL (3)

This is calculated in table 1 considering an active thrust portion of 14 mm in the bone wall. By taking into
account the approximate surface engaged at the screw-bone interface the Peak Clamping Torque should be
normalized by geometry:

PCTn = PCT/ SA (4)

Graphical representation of the normalized Peak Clamping Torque in figure 7, demonstrates that the pressure at
the interface between screw and bone is increasing with the diameter of the screw.

4.7
4.6
4.5
4.4
4.3
4.2
PCTn
4.1
4
3.9
3.8
3.7
Screw 1 Screw 2 Screw 3 Screw 4

Fig. 7. The normalized Peak Clamping Torque.

 Flaviu Moldovan et al. / Procedia Manufacturing 46 (2020) 484–490 489
6 Flaviu Moldovan and Tiberiu Bățagă / Procedia Manufacturing 00 (2019) 000–000

Clamping visualisation as function of the Threshold Torque significant values is shown in figure 8. After reaching
the Trashold Torque the clamping starts but the screw is not sufficiently tight and can spread over time. Above
tightening torque, for the values ranging from 1.5, ..., up to, 2.25 TT, there is a good clamping, represented in green
on the figure. Above 2.25 TT there is a risk of clamping failure which certainly occurs at the value of 2.5 TT - Peak
Failure Torque, represented in red on the figure.

PFT =2,5 TT

Clamping failure
2,25 TT

Good clamping
1,5 TT
Clamping
1 TT

Screw insertion

Fig. 8. Efficient clamping visualization.

4. Conclusion

The conclusion can be formulated in the interdisciplinary context of clinical, biomedical and technological
considerations, starting from the observation that during orthopaedic operations surgeons use manual surgical
screwdrivers and apply empirical tightening torques without accurately measuring the stopping torque. Frequently
the screws are under or over tightened which may lead to unnecessary or compromised assembly.
In order to avoid screw assembly failure it is recommended to use digital torque screwdrivers which allow
measurement of torque during insertion.
For any bone density and any type of screw the clamping torque can be predetermined: first it is determined the
Threshold Torque and then the Peak Clamping Torque (PCT) = 1.75 Threshold Torque. This is calculated
analytically and validated by experimental measurements, as a midway between the Threshold Torque and the Peak
Failure Torque. For a good clamping of the screw the Clamping Torque limits are between 1.5,...,2 Threshold
Torque.

References

[1] R. Zdero, Experimental methods in orthopaedic biomechanics. Elsevier, Academic Press, London, United Kingdom (2017) 101-116.
[2] K. M. Rose, C. M. Nelson, A. L. Ogden, M. Morandi, The Relationship Between Insertional Torque and Pullout
Strength of Surgical Screws, Techniques in Orthopaedics, 31(2) (2016) 137-139.
[3] T. Cleek, K. Reynolds, T. Hearn, Effect of screw torque level on cortical bone pullout strength, Journal of Orthopaedic Trauma, 21(2) (2007)
117-123.
[4] M. Tsuji, M. Crookshank, M. Olsen, E. H. Schemitsch, R. Zdero, The biomechanical effect of artificial and human bone density on stopping
and stripping torque during screw insertion. Journal of the Mechanical Behavior of Biomedical Materials, 22 (2013) 146-156.
[5] B. Nicayenzi, M. Crookshank, M. Olsen, E. Schemitsch, H. Bougherara, R Zdero. Biomechanical measurements of cortical screw stripping
torque in human versus artificial femurs. Proceedings of the Institution of Mechanical engineers. Part H: Journal of Engineering in Medicine,
226(8) (2012) 645-651.
[6] M. S. Aziz, M. R. Tsuji, B. Nicayenzi, M. C. Crookshank, H. Bougherara, E.H. Schemitsch, R Zdero, Biomechanical measurements of
stopping and stripping torques during screw insertion in five types of human and artificial humeri. Proceedings of the Institution of
Mechanical Engineers (Part H): Journal of Engineering in Medicine, 228(5) (2014) 446-55.
[7] K. J. Reynolds, A. A. Mohtar, T. M. Cleek, M. K. Ryan, T. C. Hearn, Automated Bone Screw Tightening to Adaptive Levels
of Stripping Torque, Journal of Orthopaedic Trauma, 31(6) (2017) 321-325.
[8] M. K. Ryan, A. A. Mohtar, T. M. Cleek, K. J. Reynolds, Time-elapsed screw insertion with microCT imaging. Journal of Biomechanics,
49(2) (2016) 295-301.
490 Flaviu Moldovan et al. / Procedia Manufacturing 46 (2020) 484–490
Flaviu Moldovan and Tiberiu Bățagă / Procedia Manufacturing00 (2019) 000–000 7

[9] A. Herman, E. Keener, C. Dubose, J.A. Lowe, Simple mathematical model of sacroiliac screws safe-zone Easy to implement by pelvic inlet
and outlet views, Journal of Orthopedic Research, 35(7) (2017) 1478-1484.
[10] *** Orthomed. Bone screws and plates. Online available at: http://www.orthomedinc.com/wp-content/uploads/2017/08/T-Bone-Screws-and-
Plates.pdf
[11] F. Moldovan, T. Bățagă, Optimal fixation of cortical screws in bone fracture repair. International Congress for Students, Young Physicians
and Pharmacists Marisiensis, Targu Mures, Romania, (2019).
[12] S.C. Thakkar, E.R. Langdale, S.C. Mears, S.M. Belkoff, Can the "Turn-of-the-Nut" Method Improve Cortical Screw Fixation? Journal of
Orthopaedic Trauma, 28(4) (2014) 195-199.
[13] C. Natali, P. Ingle, J. Dowell, Orthopaedic bone drills – can they be improved?. The journal of bone and joint surgery, 78-B(3) (1996) 357-
362.
[14] J. Seebeck, J. Goldhahn, H. Stadele, P. Mesmer, M.M. Morlock, E. Schneider, Effect of cortical thickness and cancellous bone density on
the holding strength of internal fixator screws, Journal of Orthopaedic Research, 22(6) (2004) 1237-1242.