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History of the Orthopedic Screw

Article  in  Orthopedics · January 2013

DOI: 10.3928/01477447-20121217-02 · Source: PubMed

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n guest editorial

History of the Orthopedic Screw

Timothy T. Roberts, MD; Christoph M. Prummer, BS; Dean N. Papaliodis, MD;
Richard L. Uhl, MD; Theodore A. Wagner, MD

F ew inventions compare with the wheel—an elegant, simple

device that has had a profound effect on human develop-
ment. Perhaps worthy of comparison, the screw is a machine of
simplicity and near-universal application; however, for all of its
uses and ubiquity, few appreciate the story behind the screw’s
evolution.
Considered the father of the screw, Archimedes of Syracuse
is widely regarded as having invented the screw in the third
century BCE. His published treatises on geometry were a math-
ematical milestone.1 However, beyond mathematical theory,
Archimedes’ discovery had a remarkable application. His water
screw consisted of a long wooden pole that was 2 to 3 meters in 1
length; this core supported a continuous double or triple helical
Figure 1: The water screw was used as a conveyer for transferring wa-
thread of wood strips that were sealed with pitch resin. Wooden ter to higher ground. Image in public domain: http://etc.usf.edu/clipart/
planks placed lengthwise around its circumference completed 15000/15042/archimedean_15042.htm
the tubular construct, which could rotate as a single piece. With
1 end submerged in low-lying water reservoirs, water screws
provided a pulsatile lift of water, a process famously responsible Recently, similar designs of water screws have been pro-
for providing irrigation to the Greek city of Alexandria.2 Some posed by archeologists to have existed in Mesopotamia as early
surviving representations of the water screw depict an individual as the seventh century BCE. These cast bronze water screws are
treader balanced atop the cylinder and running in place to spin thought to have had a rotating helix mechanism, which turned
the massive helix. by hand crank within a stationary tube (Figure 1). Purportedly,
they helped irrigate the Hanging Gardens of Babylon—one of
the Seven Wonders of the Ancient World.2 Although the true
origins of the water screw are disputed, it is clear that the first
The authors are from the Department of Orthopaedic Surgery (TTR, application of the screw was for irrigation. Amazingly, over a
DNP, RLU), Albany Medical Center, Albany, New York; and the Department millennium would pass before the screw was used for its more
of Orthopaedic Surgery (TAW), Sports Medicine & Spine Surgery, and
the Department of Neurological Surgery (TAW), University of Washington
familiar purpose: a fastener.
School of Medicine (CMP), Seattle, Washington. In the 15th century, shoulder-supported firearms such as
The authors have no relevant financial relationships to disclose. Harquebusses were common among soldiers of Europe and
Correspondence should be addressed to: Timothy T. Roberts, MD, Asia. These light, muzzle-loaded weapons contained match-
Department of Orthopaedic Surgery, Albany Medical Center, 43 New
Scotland Ave, Albany, NY 12208 (robertt3@mail.amc.edu).
locks, which allowed for superior accuracy because operators no
doi: 10.3928/01477447-20121217-02 longer had to relinquish a hand to light the chamber. However,

12 ORTHOPEDICS | Healio.com/Orthopedics

repeated firing of the weapon would quickly loosen the small
nails used to fasten matchlocks to the stocks. Small screws were
substituted for their superior holding power.3 However, despite
their clear advantages, the complexities and high costs associated
with producing screws made them an impractical option for most
types of fixation. It was not until the 19th century that screws
would be manufactured in industrial quantities and made avail-
able for everyday purposes.
By the late 18th century, European and American craftsmen had
developed and patented effective screw-cutting lathes (Figure 2).
The inventions created a rapid increase in threaded fasteners, and
with the introduction of standardized thread forms, a highly mecha-
nized industry evolved in which millions of screws were produced
per year by the mid-19th century. Accompanying the evolution of
standardized forms, self-tapping screws with gimlet points were
introduced in 1832, eliminating the need for pilot holes.3 Similar
revolutions occurred with the development of new alloys and drives,
and with the development of the turret lathe in 1840, diminishing
production costs established the ubiquity of screws.
History of the Orthopedic Screw
The 19th century saw similar revolutions in the field of ortho-
pedic surgery. In 1850, French surgeons Cucel and Rigaud per-
formed the first internal fixation procedure by reducing an olec-
ranon fracture with 2 transcutaneous screws fastened by string.4
Perhaps more famously, German surgeon Carl Hansmann per-
formed the first internal plate fixation using a removable steel
plate and nickel-plated screws in 1886.5 Hansmann’s screws were
pre-welded to his screwdrivers, and the driver handles remained
attached to the plate and protruded through the skin upon fixa-
tion. After 6 to 8 weeks, the entire construct was removed—often
a necessary second procedure given the lack of aseptic technique
and the impurities inherent to 19th century metallurgy.
By 1912, William O. Sherman, surgeon to the Carnegie Steel
Company, published recommendations on the most effective
properties of orthopedic screws. Among his many recommenda-
tions—which concerned everything from alloy composition to
the width of drive heads—Sherman advocated self-tapping, fully
threaded vanadium machine screws instead of the customary
tapered soft-steel screws that were intended for use in carpen-
try.4 In addition, Sherman produced his own plate design, which
remained the international gold standard for 50 years until the
advent of the AO screw.
Despite significant advances in the principles of fixation and
the development of devices such as Sherman’s plates, orthope-
dic screws remained relatively indistinct from their metal- and
wood-working counterparts. However, by the 1940s, many sur-
geons were advocating for the development of screws adapted
specifically to human bone. Most famously, Belgian surgeon
Robert Danis6 proposed 3 key screw design features tailored spe-
JANUARY 2013 | Volume 36 • Number 1 13
n guest editorial
2
Figure 2: Screw-cutting lathe, circa 1870. Image in public domain: http://
runeberg.org/tektid/1871/0050.html
cifically to bone: a ratio of exterior diameter to core diameter of
3:2, not 4:3 as is typical of metal screws; a reduction of thread
surface area to one-sixth that of metal screws because bone is ap-
proximately one-sixth the strength of metal; and a buttress thread
design to replace standard V-shaped threads because buttress
threads had greater holding power.7
With retooled screws and the addition of compression plates
(another of his creations), Danis was able to achieve precise ana-
tomical fracture reductions with rigid fixation.8 This allowed for
both early mobilization of the patient and primary bone healing
(Haversian remodeling) that characteristically lacked external
callus formation. So impressive were the results that Swiss sur-
geon Maurice Müller, himself one of Danis’ students, assembled
a team of fellow Swiss surgeons to study the process of bone
healing and the influence of rigid fixation on fractures. Meeting
first in Chur, Switzerland, in 1958, they called themselves Ar-
beitsgemeinschaft für Osteosynthesefragen (AO)—German for
the Association for the Study of Internal Fixation. “The AO was
soon joined by additional surgeons, manufacturers, and metallur-
gists. The influential group would subsequently develop the lag
screw, tension band wires, articulated tensioning devices, pow-
ered equipment, and specialized instruments for implant inser-
tion.4 In the same year as the AO’s founding, George Bagby and
Joseph Janes, surgeons at the Mayo Clinic in Rochester, Min-
nesota, published their design of a new “impacting” bone plate.9
The American plate, which had a lower profile than many of its
European counterparts, bore unique oval-shaped holes that al-
lowed eccentrically placed screws to provide intrafragmentary
compression upon tightening.9 Their design, with relatively little
modification, remains in use today.
Subsequently, research and innovation continued to change
the course of the orthopedic screw. From the introduction of
stainless steel in 1926 to the testing of titanium alloys in the
n guest editorial
1970s, screw strength and biological inertness improved to a
point at which metal composition was no longer a significant
factor for potential screw pullout. Likewise, the introduction of
Phillips and Woodrugg screw heads made slippage at the driver–
head interface a rare event. Over the following decades, screw
composition, thread count, shape, pitch, and diameter continu-
ally advanced with designs optimized for a variety of bone types,
qualities, and pathologies.7
Role in Modern Orthopedic Surgery
Similarly to general orthopedics, research in spine surgery is
currently exploring the biomechanics of screws. Central study
questions concern the role of techniques, such as tapping vs non-
tapping, and the biomechanical qualities of screw features, such as
cannulation, tread depth, pitch, and single- vs double-lead threads.
In 1996, Chapman et al10 explored how factors such as screw
thread geometry, tapping, and cannulation affected the holding
power of screws in cancellous bone. Using polyurethane models,
they demonstrated that tapping a hole prior to screw insertion
reduced the maximum pullout strength by 8%. Tapping of a po-
rous material results in removal of excess supportive material,
thus reducing the area of its interface with the screw threads. In
addition, increasing the thread shape factor (the ratio of thread
depth to pitch) increases the pullout strengths. Therefore, can-
nulated screws, which have a relatively low thread shape factor
to accommodate the central bore, have weaker pullout strength
than noncannulated screws.
In a similar study, the pullout strength of double-lead or fast
drive screws was compared with that of single-lead screws.
Using cadaveric thoracolumbar and lumbar vertebrae, Jacob et
al11 were unable to find a significant difference between the pull-
out strengths of either lead type, despite the double-lead screw
having a faster insertion time.
14 ORTHOPEDICS | Healio.com/Orthopedics
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As our understanding of biomechanics, medicine, and mate-
rial science continues to evolve, so too will the role of the screw
in orthopedics. From Archimedes’ water screw to matchlock fas-
tening and from Hansmann’s fortuitous fixation to dual-lead tita-
nium pedicle screws, innovation continues to drive the screw’s
progression, one revolution after another. 
References
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lenistic third century B.C., II: Archimedes to Diocles. Calinger RS. ed. A
Contextual History of Mathematics: To Euler. Upper Saddle River, NJ:
Prentice Hall, 1999; 150-169.
2. Dalley S, Oleson JP. Sennacherib, Archimedes, and the water screw: the con-
text of invention in the ancient world. Technology and Culture. 2003; 44:1-26.
3. Rybczynski W. One Good Turn: A Natural History of the Screwdriver
and the Screw. New York, New York: Simon & Schuster, 2000.
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Kingdom: The Royal Society of Medicine; 2002.
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6. Danis R. Théorie et Pratique de L’Ostéosynthèse. Paris, France: Masson;
1949.
7. Sehlinger TE, Selingson D. History and development of the orthopedic
screw. Harvey JP, Games RF. eds. Clinical and Laboratory Performance
of Bone Plates. Philadelphia, Pennsylvania: ASTM; 1994:2-9.
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site. http://www.aofoundation.org/Structure/the-ao-foundation/about/
Pages/history.aspx. Accessed December 13, 2012.
9. Bagby GW, Janes JM. The effect of compression on the rate of fracture
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10. Chapman JR, Harrington RM, Lee KM, Anderson PA, Tencer AF,
Dowalski D. Factors affecting the pullout strength of cancellous bone
screws. J Biomech Eng. 1996; 118:391-398.
11. Jacob AT, Ingalhalikar AV, Morgan JH, et al. Biomechanical comparison
of single and dual-lead pedicle screws in cadaveric spine. J Neurosurg
Spine. 2008; 8:52-57.