Removal of cement-augmented screws in distal femoral fractures and the effect of retained screws and cement on total knee arthroplasty: a biomechanical investigation

J Orthop Traumatol. 2021 Feb 27;22(1):5. doi: 10.1186/s10195-021-00568-w.


Background: Given the increasing number of osteoporotic fractures of the distal femur, screw augmentation with bone cement is an option to enhance implant anchorage. However, in implant removal or revision surgeries, the cement cannot be removed from the distal femur without an extended surgical procedure. Therefore, the aims of this study were to investigate (1) whether cement augmentation has any influence on screw removal and removal torque, and (2) whether the implantation of a femoral component of a knee arthroplasty and its initial interface stability are affected by the remaining screws/cement.

Material and methods: Eight pairs of fresh-frozen human female cadaveric distal femurs (mean age, 86 years) with a simulated AO/OTA 33 A3 fracture were randomized in paired fashion to two groups and fixed with a distal femoral locking plate using cannulated perforated locking screws. Screw augmentation with bone cement was performed in one of the groups, while the other group received no screw augmentation. Following biomechanical testing until failure (results published separately), the screws were removed and the removal torque was measured. A femoral component of a knee arthroplasty was then implanted, and pull-out tests were performed after cement curing. Interference from broken screws/cement was assessed, and the maximum pull-out force was measured.

Results: The mean screw removal torque was not significantly different between the augmented (4.9 Nm, SD 0.9) and nonaugmented (4.6 Nm, SD 1.3, p = 0.65) screw groups. However, there were significantly more broken screws in in the augmented screw group (17 versus 9; p < 0.001). There was no significant difference in the pull-out force of the femoral component between the augmented (2625 N, SD 603) and nonaugmented (2653 N, SD 542, p = 0.94) screw groups.

Conclusion: The screw removal torque during implant removal surgery does not significantly differ between augmented and nonaugmented screws. In the augmented screw group, significantly more screws failed. To overcome this, the use of solid screws in holes B, C, and G can be considered. Additionally, it is possible to implant a femoral component for knee arthroplasty that retains the initial anchorage and does not suffer from interference with broken screws and/or residual cement.

Level of evidence: 5.

Keywords: Biomechanics; Distal femoral fracture; Osteoporosis; Screw augmentation; Total knee arthroplasty.

MeSH terms

  • Aged, 80 and over
  • Arthroplasty, Replacement, Knee / methods*
  • Biomechanical Phenomena
  • Bone Cements*
  • Bone Plates
  • Bone Screws*
  • Cadaver
  • Device Removal / methods*
  • Female
  • Femoral Fractures / physiopathology
  • Femoral Fractures / surgery*
  • Fracture Fixation, Internal / methods*
  • Humans
  • Reoperation


  • Bone Cements

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