Effect of Surgical Tightening Torque on the Pull-Out Strength of Screws in Vertebral Body Tethering

Background/Objectives: Screw loosening and vertebral fractures remain common after vertebral body tethering (VBT). Because tightening torque sets screw preload, its biomechanical effect warrants explicit modeling. In this paper, a Finite Element (FE) model, supported by ex vivo porcine vertebral tests, was developed and validated that incorporates torque-induced pre-tension to quantify vertebral stress, aiming toward customizable VBT planning. Methods: An FE model with pre-tension and axial extraction failure was parameterized using ex vivo tests on five porcine vertebrae. A laterally inserted surgical screw in each specimen was tightened to 5.9±0.80 Nm. Axial extraction produced failure loads of 2.1±0.31 kN. This is also considered in the FE model to validate the failure scenario. Results: Torque alone generated peak von Mises stresses of 16.1±0.86 MPa (cortical bone 1) and 2.1±0.13 MPa (trabecular), lower than prior reports. With added axial load, peaks rose to 141.1±0.70 MPa and 19.7±0.23 MPa, exceeding typical ranges. However, predicted failure agreed with experiments, showing 0.58 mm displacement and a conical displacement distribution around the washer. Conclusions: Modeling torque-induced pre-tension is essential to reproduce realistic stress states and anchor failure in VBT. The framework enables patient-specific assessment (bone geometry/density) to recommend safe tightening torques, potentially reducing screw loosening and early fractures.