Does Malpositioning of Pedicle Screws Affect Biomechanical Stability in a Novel Quasistatic Test Setup?

Pedicle screw fixation is a common spinal surgery technique, but concerns remain about stability when screws are malpositioned. Traditional in vitro pull-out tests assess anchorage but lack physiological accuracy. This study examined the stability of correctly placed and intentionally malpositioned pedicle screws on forty vertebrae from five cadavers. Optimal screw paths were planned via CT scans and applied using 3D-printed guides. Four malposition types-medial, lateral, superior, and superior-lateral-were created by shifting the original trajectory. A custom setup applied three consecutive cycles of tensile and compressive load from 50 N to 200 N. Screw inclination under load was measured with a 3D optical system. The results showed increasing screw inclination with higher forces, reaching about 1° at 50 N and 2° at 100 N, similar in both load directions. Significant differences in inclination were only found at 100 N tensile load, where malpositioned screws showed a lower inclination. Overall, malpositioning had no major effect on screw loosening. These findings suggest that minor deviations in screw placement do not significantly compromise mechanical stability. Clinically, the main concern with malpositioning lies in the potential for injury to nearby structures rather than reduced screw fixation strength.