A COMPARATIVE STUDY ON EVALUATING THE OUTCOME OF DISPLACED ISOLATED MEDIAL MALLEOLUS FRACTURE MANAGED WITH TENSION BAND WIRING (TBW) VERSUS MALLEOLAR SCREWS FIXATION

Objective: The Ankle fractures are becoming more prevalent as a result of increased road traffic accidents and sports injuries. There are various modalities of treatment available for Medial Malleolus fractures. Undisplaced fractures are managed conservatively with slab or cast and displaced fractures are fixed with screws, k wires, anchors, tension wiring and plates. The main objective of the study is to compare the clinical outcomes of Tension band wiring versus Malleolar screws in managing Displaced Isolated Medial Malleolus fractures.Methods: This is a cross-sectional study conducted in the Department of Orthopaedics in Kurnool Medical College with 35 patients from November 2022 to November 2023 over one year with displaced isolated Medial Malleolus fractures. Postoperatively the patients are evaluated based on clinical and radiological examinations at one, three, and six months, respectively.Results: The patients are evaluated with Baird and Jackson scoring system postoperatively, where Excellent score: 8(47%) in group 1 and 7(38.8%) in group 2; Good score: 8(47%) in group 1 and 8(44.4 %) in group 2; Fair score: 1(5.8%) in group 1 and 2(11.1%) in group 2; Poor score: 0 in group 1 and 1(5.5%) in group 2. Hence excellent and good results are obtained in 16(94%) patients in group 1(TBW) and 15(82.2) patients in group 2(Malleolar Screws).Conclusion: Tension band wiring can be a better option than Malleolar screws in fixation of Displaced Isolated Medial Malleolus fractures.

Wide-Awake Olecranon Tension Band Wiring with Ipsilateral Zone 6 Extensor Tendon Repair: A Case Report

@#Wide-awake local anaesthesia, no tourniquet (WALANT) continues to gain popularity and has been adapted for various fracture fixations proximal to the hand. A case of olecranon tension band wiring with concomitant extensor tendon repair is presented. The procedure was done with the patient awake in a lateral decubitus position 30min after the injection of WALANT solution at the intended surgical sites. Pain and discomfort were felt by the patient towards the end of the procedure mainly on his volar forearm where the bolster was placed. Olecranon fixation under WALANT is a viable alternative for patients who prefer to be awake or those with contraindications to general or regional anaesthesia. Alternative patient positioning may be considered, and perioperative pain control should not be overlooked.

Tension Band Wiring Technique for Distal Radius Fracture with a Volar Articular Marginal Fragment: Technical Note

Most distal radius fractures are currently being treated with anterior plating using anatomical precontoured locking compression plates via the anterior approach. However, it is difficult to fix the volar articular marginal fragment because these anatomical plates should be placed proximally to the watershed line. There were just a few methods of fixation for this fragment on medical literature. Herein, we introduced a tension band wiring technique for fixation of a volar articular marginal fragment in the distal radius.

Treatment of Isolated Lateral Malleolar Fractures Using Locking Compression Plate Fixation and Tension Band Wiring Fixation

PURPOSE: The purpose of this study was to compare the clinical and radiological outcomes of locking compression plate (LCP)-screw fixation and tension band wiring (TBW) fixation in isolated lateral malleolar fractures.MATERIALS AND METHODS: From May 2016 to August 2018, 52 patients with isolated lateral malleolar fracture were retrospectively reviewed. They were divided into 30 cases of the LCP fixation group (Group I) and 22 cases of the TBW fixation group (Group II). The clinical and radiological results of those groups were compared. Pearson chi-square tests and independent t-tests were used in the statistical analysis.RESULTS: The mean length of the surgical incision was 8.3 cm in Group I and 4.9 cm in Group II. Radiological union was obtained at a mean of 8.4 weeks in both groups. The mean American Orthopaedic Foot and Ankle Society score was 90 (range, 85–97) and 92 (range, 85–100) in Groups I and II, respectively, at the last follow up.CONCLUSION: Both the LCP-screw and TBW techniques revealed excellent results in isolated lateral malleolar fractures. The tension band technique may be a fine alternative method of fixation in the treatment of isolated lateral malleolar fracture.

Osteosynthesis in Lower Pole of Patella Fracture: A Follow up Study in Churu District of Rajasthan

Introduction: Patella is an important component of extensorapparatus and it has a major role in making the extension ofknee efficient. Patella fracture accounts for 1% of all fractures.Treatment options for fracture of lower pole of patella areTension Band Wiring, Circumferential Wiring or with screw ifthe fragment is large enough. Tension Band Fixation involvesboth static and dynamic forces.Objectives: To assess the functional outcome ofosteosynthesis in fracture of lower pole of patella usingTension band Wiring technique.Materials and Methods: The present study was a follow-upstudy conducted in Churu Multispecialty Hospital and ResearchCenter, Churu during Sept 2017 to April 2019. All the patientswith lower pole of patella fracture and whose age was 16 ormore were included in the study. Tension Band wiring is donein all the 15 patients under spinal anesthesia. Patients werefollowed at 1, 6 and 12 weeks after the date of surgery.Patients were evaluated according to Bostman’s method ofclinical grading of knee scoring system and patients weregraded as excellent, poor or unsatisfactory depending on thescore obtained.Results: In present study maximum patellar fractures were inage group 31 to 50 years. Most of the patients in our studywere males. All the variables like flexion loss, extension loss,pain, quadriceps atrophy, effusion, giving way andstair climbing improved in all the cases at final follow-up. Onepatient was lost to follow-up at 12 weeks. Clinical grading alsoimproved and 12 out of 14 patients had excellent scoring atfinal follow-up. Superficial infection developed in one patientand that was recovered fully after antibiotic coverage. Onepatient developed kneeling discomfort and that was alsorecovered at 12 week of follow-up.Conclusion: Osteosynthesis using tension band wiringtechnique is a viable treatment option lower pole fracture ofpatella with good functional results despite the technicaldifficulty associated with this procedure.

A Comparative Study between Double Tension Band Wiring and Reconstruction Plate and Screws for the Treatment of Displaced Bicondylar Intra-Articular Fractures of the Distal Humerus

Objective: In this study our main goal is to evaluatetheoutcome of double tension band wiring and reconstructionplate and screws for the treatment of displaced bicondylar intraarticular fractures of the distal humerus.Methodology: This perspective and randomized study wasconducted at the National Institute of Traumatology andOrthopaedic Rehabilitation (NITOR), Dhaka from July 2003 to2005. Where out of 24 patients 12 were selected for operativetreatment by reconstruction plate and screws (Group –I), and12 were selected for operative treatment by double tensionband wiring (Group-II) as on random basis.Results: During the study, in group-1 and group-2 most of thepatients belongs to 18-30 age group., 75% patients’ injury inleft limb whereas, 35% had injury in left limb in group-2.33.33% patients with reconstruction Plate and Screw, hadexcellent recovery after treatment where as 25% had excellentrecovery when they had double Tension Band Wiring.Conclusion: From our study we can conclude that, operativetreatment of displaced bicondylar intra-articular fractures of thedistal humerus by reconstruction plate and screws gives amore rigid fixation with better functional outcome than bydouble tension band wiring.

Management of displaced transverse fractures of the patella using tension band wiring with or without circumferential cerclage wiring: A comparative study

Background: Transverse fractures of body of the patella are by far the most common fractures of this bone. Surgical fixation is the recommended treatment in displaced fractures with extensor lag. Although, tension band wiring (TBW) technique is the gold standard for these fractures, few surgeons recommend augmentation with circumferential cerclage wiring to improve the strength of the fixation. We compared the results of the internal fixation of displaced transverse fractures of the patella using TBW and circumferential cerclage wiring with those treated with TBW alone. Methods: We treated 54 displaced transverse fractures of the patella at our institution. We segregated the patients into two groups: Group 1 (n=23) included fractures treated with tension band wiring (TBW) along with augmented circumferential cerclage wiring while as Group 2 (n=31) included fractures treated by TBW alone. Outcome was studied, graded and compared on the basis of knee pain, knee stiffness, quadriceps wasting, loss of flexion and loss of extension. Results: 73.90% patients among group 1 and 70.96% among group 2 showed excellent to good results (P value < 0.1). Fixation failure and need for revision surgery among group 1 and group 2 was found to be 8.69% and 9.67%, respectively (P value < 0.6). Infections and non union occurred among 4.34% patients in group 1 whereas in group 2 it was 6.45% of the patients who encountered the same (P value < 0.6). Conclusions: The use of circumferential cerclage wiring along with tension band wiring for displaced transverse fractures of patella seems to have no added advantage over fixation with tension band wiring alone. Keywords: Patella fracture, Tension band wiring, cerclage wiring

Modified Tension Band Wiring Using FiberWire for Patellar Fractures

In comminuted patellar fractures, we performed modified tension band wiring using a FiberWire (Arthrex) instead of the conventional methods. From March 2016 to March 2018, 63 patients with patellar fractures who needed surgical treatment were treated with modified tension band wiring using two Kirschner wires (K-wires) and FiberWire. We inserted two 1.6-mm K-wires perpendicular to the fracture line after accurate reduction. With the knee flexed over 90°, we sutured around the patella using a FiberWire. Visual analog scale score and Levack's score were improved postoperatively. The mean bone union time was 5.6 months. None of the patients had breakage of wires, and nonunion with deformity occurred in one patient. We think that our method can be easier to handle and reduce irritation or breakage of the wires than conventional methods. In addition, early rehabilitation can be allowed. Therefore, we suggest that this method could be a useful method for the treatment of patellar fractures.

A Functional And Radiological Outcome Of Surgical Management Of Bimalleolar And Trimalleolar Ankle Fractures

BACKGROUND: Ankle joint is one of the unstable joints in the body due to its anatomic position and is more prone to injury during daily activities. Malleolar fractures are one of the most common fractures in orthopedic traumatology. OBJECTIVES : The aim of this study was to evaluate the clinical and functional results of patients with ankle fractures treated with Open reduction and internal fixation with different modalities. Method and Materials:Aprospective study was conducted from April 2016 to April 2018 over a period of 2 years . Total 50 patients were treated by various techniques of open reduction and internal fixation. Result :According to Baird and Jackson scoring system, 23 (51 %) patients had excellent outcome, 14 (31%) had good outcome,6 (13 %) had fair outcome and 2 ( 4 %) had poor outcome. Supination External Rotation injury is the commonest mechanism of injury. CONCLUSION : We concluded that early treatment , anatomical reduction and fracture fixation, stringent postoperative mobilization and rehabilitation should help improve Functional outcome in ankle fractures.

To Evaluate the Clinical Outcome of Transverse Fractures of Patella Treated with Modified Tension Band Wiring A Prospective Study

Background: Patella is the largest sesamoid bone in the body situated in the quadriceps tendon1. The main function of patella is to improve the efficiency of quadriceps muscle by improving the mechanical leverage of the quadriceps muscle. Patellar fractures are common and it constitutes about 1% of all skeletal injuries resulting from either direct or indirect trauma2.The subcutaneous location of the patella makes it vulnerable to direct trauma.Aims of the study were to evaluate the clinical outcome of Transverse fractures of patella treated with modified tension band wiring. The objectives of the study are to study the advantages of modified tension band wiring fixation in patellar fracture, the complications associated with this method of fixation and to assess the role of early mobilization with this technique. Methods: This prospective study is done in Department of Orthopaedics at R L Jalappa Hospital and Research Center, attached to Sri DevarajUrs Medical College, Kolarduring the period from December 2010 to June 2012. This study consists of 30 cases of displaced transverse fracture patella treated by modified tension band wiring. The cases were selected based on inclusion and exclusion criteria. After pre anaesthetic fitness patient, patient was operated (tension band wiring). Operatedknee was immobilized in extension in an above knee posterior slab, and advised to do straight leg raising test.Weight bearing was started from 3rd post-operative day. Sutures were removed on 12th to 14thpost operative day. The discharged patients were advised to report for follow up every month, during each follow up the patients were examined for both subjective symptoms and objective signs which was recorded. The patients were questioned about subjective complaints like pain, difficulty in walking, squatting, climbing and getting down stairs and ability to perform routine work. The patient’s objective assessment was done for Extensor lag, Range of knee movement, circumference of thigh (wasting) and Efficacy of quadriceps (power).Results: The range of age of fracture of patella in our series was between 19-70 years, the mean age was 42 years and the incidence was high in the age group of 31-40 years. In a total of 30 cases, 24 fractures were in men and 6 fractures were in females.22 fractures were as a result of indirect mechanism and 8 cases were due to direct trauma to the patella as in RTA. 17 patients had fracture on the right side and 13 patients had fracture on the left side.Average duration between injuries to hospital admission was about 1.16 days. The average duration between the days of admission to the day of surgery is about 2.93 days and the average duration of stay in hospital is about 13.2 days (ranging from 11 to 22 days).No intra operative complications like fragmentation at wiring, difficulty in closure were encountered. Results were excellent in 26 cases, good in 3 cases and bad in 1 caseasper west’s criteria. Conclusion: Thus we conclude that anatomical reduction and stable fixation in patellar fracture is necessary for the normal integrity and stability of the joint.Early post-operative physiotherapy plays an important role in final outcome, which helps in reducing complication like stiffness of knee and in providing good functional. Our outcome was not influenced by the associated injuries. Long-term follow up is necessary to assess late complications like osteoarthritis and late functional outcome.

Patellar Fractures Treated by Modified Tension Band Wiring: A Clinical Study in a Teaching Hospitals.

Background: Patellar fractures are more common in country like India due to the activity of daily life and constitute 1% of all skeletal injuries by direct or indirect mechanism. Direct injuries due to the subcutaneous location of patella and indirect injuries because of forceful contraction of quadriceps with knee in flexed position are common. Thus, improper operative procedure can lead to disability in the patient. Therefore, this study was conducted to assess of advantages and complications associated with fixation technique so as to manage the fracture of patella. Methods: The study was conducted on 60 cases of transverse patellar fracture treated by Modified tension band wiring. All patients who had closed and open type I displaced transverse patellar fractures, acute fractures and who were medically fit for operative procedures were included in the study. Results: The most common age group in our study was 41-50 years. Male patients were 46 (76.7%) and female patients were 14(23.3%). Fracture due to direct injury was seen in 12(20%) patients and 48(80%) cases were with indirect trauma. Right side injury was seen in 26(43.3%) patients while 34 (56.7%) patients had injuries on the left side. The outcome of our study was excellent in 90% of cases, 8.3% was good and only 1.7% was poor. Conclusion: According to our study modified tension band wiring showed better outcome for the early mobilization and management of displaced transverse patellar fracture.

Patellar Fractures Treated by Cannulated Cancellous Screw and Tension Band Wiring – A prospective study in a Teaching Hospital, Sangareddy

Background: Country like India patellar fractures is more common due to the activity of daily life. 1% of all skeletal injuries due to patellar fracture by direct or indirect mechanism. Aim: This present study focus on advantages and complications associated with fixation technique for the management of patellar fracture. Material and Methods: 50 patients with patellar fractures treated by cannulated cancellous screw with tension band wiring. Result: The most common age group in our study was 41-50 years. Among 50 patients 37 were male and 13 were female. Fracture due to indirect injury was 64% and direct trauma was 36%. Outcome of our study was 90% as excellent, 8% as good and 2% poor. Conclusion: According to our study management and early mobilization of displaced transverse patellar fracture by cannulated cancellous screw and tension band wiring showed better result.

Tension band wiring of the olecranon: A biochemical study

@#<p style="text-align: justify;"><strong>OBJECTIVE:</strong> Hardware prominence is the most common cause of reoperation in patients who have undergone tension band wiring for fractures of the olecranon. The study was conducted to compare the strength of four different constructs of tension band wiring of the olecranon.<br /><strong>METHODS:</strong> A transverse fracture was created in twenty cadaveric ulnas which were equally divided into four groups according to the method of fixation: 1-Single tension band, transcortical k-wire fixation; 2-Single tension band, intramedullary k-wire fixation; 3-Double tension band, transcortical k-wire fixation; 4-Double tension band, intramedullary k-wire fixation. All specimens were mounted on a universal testing machine using a custom-made fixation jig. They were tested under a single cycle load to failure. The maximum failure load was measured for all specimens.<br /><strong>RESULTS:</strong> There was no significant difference in the maximum load to failure among the four treatment groups.<br /><strong>CONCLUSION:</strong> No differences in the maximum load to failure noted in between treatment groups, regardless if single or double tension band wiring was done, and regardless if k-wire fixation was transcortical or medullary. These findings would support the argument that any of the desired fixation methods may be used.</p>

Usefulness of the Additional K-Wire Fixation and Suture for Reinforce the Treatment of Distal Clavicle Fracture Using Modified Tension Band Wiring

PURPOSE: We attempted to evaluate the clinical results of modified tension band wiring (MTBW) with additional K-wire fixation and suture for distal clavicle fracture. MATERIALS AND METHODS: Fifty-nine patients with a distal clavicle fracture from May 2009 to December 2013 treated with MTBW were enrolled in this study. Their fracture types were type 2, 12; and type 3, 33; type 4, 8; and type 5, 6 according to Craig classification group II; average age was 47.2 years with a mean follow-up period of 27.9 months. The operations were performed within a mean of 3.1 days a fter t rauma. The c linical results were evaluated u sing University of California at Los Angeles scores (UCLA), American Shoulder and Elbow Surgeons scores (ASES) and Korean Shoulder Society scores (KSS) at 1 year after surgery. RESULTS: Radiographic bone union was achieved at a mean of 3.7 months after the operation. In the last observation, their range of motion was forward flexion 159.0°, external rotation 59.8°, and internal rotation 4.3 points, and there were 2 cases of nonunion. Each average functional score was UCLA 31.3 points, KSS 91.6 points, and ASES 93.0 points. CONCLUSION: For the surgical treatment of distal clavicle fractures, MTBW with additional K-wire fixation and suture is a useful technique allowing early range of motion exercises, minimizing soft tissue damage, and preserving the acromio-clavicular joint.

Tension band wiring fixation for the treatment of young patients with lumbar spondylolysis / 第二军医大学学报

Objective: To summarize the cable tension band fixation for the treatment of the clinical effect of lumbar spondylolysis, to explore the feasibility and effectiveness of the cable tension band fixation. Methods: in 2011 May to 2013 May received a total of 12 cases of L4 and L5 in patients with lumbar spondylolysis. 12 cases were male; age 18---22 year old, average age is 19.5 years old. Were not associated with lumbar spondylolisthesis. All the patients were Ai Wentai cable tension band fixation and isthmic bone grafting treatment, after 3, 6, 9, 12 months of follow-up. Results: there were no operation complications and sequelae, no secondary lumbar spondylolisthesis was found. Reached the standard of bone healing in 11 cases, bone healing rate was 91.7%, 9 cases achieved healthy players training intensity. At the last follow-up evaluation of curative effect, excellent in 9 cases, good in 2 cases, 1 cases, the excellent and good rate was 91.7%. Conclusion: the cable tension band fixation for the treatment of lumbar spondylolysis is effective, simple operation, little injury and good biological compatibility method. On the prevention of lumbar spondylolisthesis, promote the local fracture of lumbar spondylolysis Union, has a positive meaning to improve the symptoms of waist.

Transosseous fixation of intercondylar fracture of lower end humerus by tension band wiring technique.

Background: Intercondylar fractures of lower end of humerus is a challenge for orthopedic surgeon to fix rigidly for early mobilization. We hereby have devised a novel technique of fixing an intercondylar fracture of lower end of humerus by transosseous route utilizing the Tension band wiring. We successfully obtained a rigid, stable reconstruct without affecting the anatomy of the region. Aims & Objective: To study the effect of transosseous fixation of intercondylar fracture of lower end humerus by tension band wiring technique. Materials and Methods: We have followed a novel technique for treating intercondylar fracture of lower end of humerus. Till date we have treated 10 patients of supracondylar fracture of humerus with intercondylar extension. All patients were selected randomly the only criteria was a supracondylar fracture of lower end of humerus with intercondylar extension. This method gave us four cortices fixation in the lower intercondylar region which was not possible till date by other methods of fixation. So now T-Y elbow type of fracture is converted into a supracondylar fracture. Rest fixation of supracondylar fracture was done with perpendicular plating and k wire TBW in case of osteoporotic bones. Results: Out of 10 treated cases with this method all get rigid fixation and radiological union at average of 8 weeks. Average ROM was 5-100. One case had postoperative stitch infection, one had k wire impinging on skin and two patients lost follow up after 3 months. Conclusion: Complicated fractures of intercondylar region of distal humerus can be successfully managed by interosseous TBW technique. We recommend such technique and further research regarding it.

Circumferential Wiring Combined with Tension Band Wiring in the Operative Treatment of Patella Fracture

PURPOSE: The purpose of this study is to evaluate the radiographic and clinical results of patella fractures using a circumferential wiring combined with tension band wiring. MATERIALS AND METHODS: Between January 2005 and June 2012, 22 (male 14, female 8) patients with patella fracture treated with circumferential wiring combined with tension band wiring were analyzed retrospectively. The mean age of patients was 51 years (range, 28 to 72 years). Controlled passive range of motion exercise was started at three weeks from the postoperative day. The patients were evaluated using radiographs, clinical examination, and Levack's scoring system. RESULTS: All fractures healed and mean time elapsed for union was 11.5 weeks (range, 10 to 14 weeks). Complete union without displacement and full range of motion was achieved in all cases. Clinical results according to Levack's scoring system were excellent in 20 cases and good in two cases. We found broken wire in one case. In this case, results of clinical evaluation after reoperation were good. CONCLUSION: Circumferential wiring combined with tension band wiring is appropriate for patella fractures.

Tension Band Wiring for Distal Clavicle Fracture: Radiologic Analysis and Clinical Outcome

PURPOSE: The purpose of this study is to evaluate the radiologic and clinical outcomes after tension band wire fixation of Neer type II distal clavicle fractures. MATERIALS AND METHODS: Twenty-six patients with Neer type II distal clavicle fractures who underwent tension band wire fixation from March 2002 to May 2011 were included in the study. Fifteen cases were classified as Neer type IIa and 11 cases as type IIb. The postoperative mean follow-up period was 14.3 months. Clinical and radiologic evaluation was performed at two weeks, six weeks, three months, six months, and 12 months postoperatively. RESULTS: Bony union on X-rays was observed at an average of 11.7 weeks (range 8-20 weeks) postoperatively. The overall visual analogue scale score for pain was 1.23+/-2.75 postoperatively. The overall postoperative University of California at Los Angeles score increased to 33.5+/-2.15 from the preoperative score of 21.6+/-1.91 (p<0.05). CONCLUSION: Among various methods of treatment for Neer type II distal clavicle fracture, K-wire and tension band fixation was used and relatively satisfactory radiological and clinical results were obtained. This surgical method yields excellent clinical results, owing to its relatively easy technique, fewer complications, and allowance of early rehabilitation.

Results of Tension Band Wiring and Additional Circumferential Wiring in Treatment of Comminuted Patella Fracture

PURPOSE: The purpose of this study is to evaluate the results of tension band wiring and additional circumferential wiring in treatment of comminuted patella fractures. MATERIALS AND METHODS: A retrospective study of 67 patients with follow-up period longer than six months who underwent tension band wiring and additional circumferential wiring for comminuted patellar fracture from January 2004 to December 2012 was conducted. Analysis was based on radiological evaluation of bony union and articular surface displacement, and clinically by evaluating the postoperative function of the knee joint using the Levack scoring system. RESULTS: Only one case out of 67 (1.5%) showed nonunion without metal breakage while good bone union was achieved in all other cases. Excluding the nonunion case, range of motion was 90 degrees minimum, 135 maximum, 129 on average. Average displacement was less than 2 mm, and 64 out of 67 cases showed satisfactory outcome with excellent functional score according to the Levack scoring system. CONCLUSION: Tension band wiring and additional circumferential wiring technique for treatment of comminuted patella fractures can be considered as an effective treatment for achievement of good bone union and restoration of normal knee function.

Treatment of Fifth Metatarsal Base Fracture Using Tension Band Wiring / 대한족부족관절학회지

PURPOSE: To evaluate the clinical and radiological results of internal fixation with tension band wiring for the fracture at the base of fifth metatarsal bone. MATERIALS AND METHODS: From January 2008 to December 2009, 15 cases with displaced fracture at the base of fifth metatarsal were analyzed and average follow up period was 13.8 months. Lawrence classification was used to classify fracture type. We evaluated clinical results by American Orthopedic Foot Ankle Society (AOFAS) midfoot score and radiological results by union time. Complications was also checked. RESULTS: According to classification, zone I fracture were 11 cases and zone II fracture were 4 cases. Bony union was achieved in all cases after 7 weeks. In the final follow-up, average AOFAS score was 94. There were no complications except hardware irritation. CONCLUSION: Satisfactory results were obtained after tension band wiring for the fifth Metatarsal base fracture in zone I fracture or comminuted zone II fracture for which it is not easy to be fixed with screw.