Top screw pullout is a significant problem in anterior scoliosis correction, with rates of 5-15% reported in the literature. The Mater Misericordiae Hospital in Brisbane currently has a series of 125 patients with scoliosis treated by thoracoscopic anterior fusion, instrumentation and correction between April 2000 and August 2007. In this series 11 top screws are known to have pulled out (a rate of 8.8%), with six occurring in the first week, and all within 6 weeks, suggesting that the problem is one of excessive static force rather than fatigue. This thesis describes a biomechanical investigation into the mechanics of vertebral body screw pullout in anterior scoliosis surgical constructs. Previous biomechanical studies of vertebral body screws have evaluated their resistance to either straight pullout or cephalo-caudad compression forces, however the aim of this study was to assess screw resistance to more realistic loading conditions, namely pullout of initially angled screws, and pullout where the motion path is an arc rather than a straight axial pullout, as would be expected in a single rod anterior construct. The first series of experiments involved straight and angled pullout tests using synthetic bone. In the angled tests, both locked and free-to-pivot configurations were tested. The second series of experiments tested the effect of cephalo-caudad pre-compression (the actual deformity correction step performed during surgery) on subsequent axial pullout strength. A third series of experiments performed arc pullouts using synthetic bone, and the final series of experiments tested the pullout resistance of a newly proposed screw position configuration against the standard screw positioning using ovine lumbar vertebrae. Synthetic bone testing revealed that for initially angled pullout, resistance is greatest as the screw angle approaches 0 (ie a direct axial pullout). Cephalo-caudad pre-compression reduced subsequent pullout strength for cases where a staple was not used under the screw head, but if a staple was used the pre-compression did not decrease pullout force significantly. Arc pullout resistance was greatest when the screw was angled at 10 cephalad, and the mean pullout strength for the proposed screw configuration using ovine lumbar vertebrae (1864N) was almost double that of the standard screw positioning (993N). The clinical implication of this study is that top screw pullout resistance can be maximised by placing the top screw as close as possible to the top endplate and the bottom screw as close as possible to the bottom endplate, although this will have detrimental effects on the pullout of the second screw should the top screw pull out. Screw angulation is a less important factor but any angulation should be in a cephalad direction and around 10º in magnitude. The experimental results also suggest that the use of a staple may play a role in preventing cephalo-caudad pre-compression forces from reducing screw resistance to subsequent pullout forces.

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