2025 Great Debates: Every cup deserves a good screw

Great Debate: To Screw or Not to Screw in Hip Arthroplasty

🎙️ Join host Joe Schwab for the thrilling finale of the AHF podcast's Great Debates series! In this episode, we're diving into the contentious topic of acetabular fixation with Dr. Michael Blankstein and Dr. Nicholas Mast. 💥 Dr. Blankstein argues that every cup deserves a good screw, emphasizing their safety, ease, and crucial role in complex surgeries. Meanwhile, Dr. Mast contends that modern implant designs make screws obsolete, likening their use to reinforcing a sturdy bridge with duct tape. 🤔 Who's right in this orthopedic face-off? Tune in to find out! Don't forget to like, subscribe, and share your thoughts in the comments. 🧠🔧 #AHFPodcast #GreatDebates #AnteriorHipFoundation

Transcript

Joseph M. Schwab: 0:00

Hi, this is Joe Schwab and if you recognize my voice, it's probably because you've heard another episode of the AHF podcast, which means you're listening again, and I can't tell you how much I appreciate that. And because you're listening, again, I want to ask you a favor, if you could share this podcast with a colleague or a friend or somebody you think might be interested in this type of content. Or better yet, leave us a review on your podcast platform or give us five stars, or you could do all of those things. We really appreciate it and it helps us grow. Anyway, thank you so much for being a listener and a subscriber to the AHF podcast. Now let's get on with the show. Hello, and welcome to the AHF podcast. I'm your host, Joe Schwab. Well, welcome to our sixth and final great debate where the topics are serious, the arguments are passionate, and the innuendo is well kind of unavoidable. Today's debate is titled to Screw or Not to Screw, which means two things. One. Yes, this is about acetabular fixation and two, no, there was absolutely no chance this was going to stay. PG 13. Taking the pro position that every cup deserves a good screw is Dr. Michael Blankstein, who arrived the morning of this debate. Absolutely furious. I took away his AI generated slide deck. Imagine waking up hungover in Nashville, Tennessee only to discover you can't show the world. The machine made screw slides. You were so proud of a tragedy. Really opposing him is Dr. Nicholas mast who believes screws in primary total hip arthroplasty are basically the orthopedic equivalent of a rotary phone. Charming, nostalgic, but unnecessary unless you're reenacting history. What follows is a debate about fixation stability and bone biology wrapped in the energy of two surgeons who absolutely knew what they were getting into with a title like this. Well buckle up, or I should say screw in. We've got Dr. Michael Blankstein and Dr. Nicholas Mast talking about every cup deserves a good screw In the pro position. We've got Michael Blankstein. You get to go first in the con position. We've got Dr. Nicholas Mast. Gentlemen, keep it clean. No, don't.

Michael Blankstein: 3:06

Just so you guys know, I went out drinking last night and I woke up this morning at 8:00 AM from a text from Joe Schwab who said, you have too many slides and I'm, you only get to use one slide. And I woke up angry and all I did is text him why you should be using slides for this. 'cause I made this AI generate slides that I was so happy about and I can't use them. Well, thanks Joe. So, um, so I just wanna let you know, an orthopedic surgeon's best friend is the screw who has taken an AO course here before. What's the first lecture you take? What's the first thing you learn about in the AO course? You learn about the screw. The Screw is our best friend. Neil, what's the best feeling you get during the case when you do a revision case? Can you just show me, show me, get up that you know that, that feeling, the best feeling that we experience as surgeons right there. How often can one stand up here and say, guys, what I promote is safe? Easy, cheap and quick. How often, what's exactly what it is, what's happening here? When you put a screw in, it literally takes a couple minutes For Charlie DeCook, it means 12 by 1230 maybe instead of 12 by 12, but literally it's easy. It's safe. The anatomy it just so easy. Now here's the, here's the kicker here. If you're worried about the safety of this screw trajectory, then you should definitely practice putting in these screws so you know the anatomy. So when you need it for your tough cases, post-traumatic, dysplastic, osteoporotic, et cetera. Um, who doesn't like additional stability? Now let's talk about the pressfit cup that doesn't get the screw. What do you have to do? You need to rely on good bone. You need to under ream and head harder. These are things that you only get once in a while. Who does complex hip surgeries here? Most of us, right? We need those screws. 'cause many of us will do these complex cases. If you guys wanna quote me, I wanna be quoted for this for the rest of my life. Every screw matters. It's an opportunity to master, refine, sharpen, and perfect the technique that is critical for every hip surgeon. So my last slide here. I got one. You guys. I would say that you don't always need a screw, but when you do, it can save the case. So you should definitely stay sharp, my friends,

Nicholas Mast: 5:37

well to my, uh, esteemed colleague. Um, I as a man enjoy a good screw as much as anybody, but, um. The acetabular screw for routine primaries, the orthopedic equivalent of a, of a rotary phone in the age of smartphones, um, well considered a necessary crutch in the days of old, uh, Harris-Galante cups, it was important for stability of the total hip. Um, the unquestioned used is less about sound biomechanics, and more about nostalgia. It is the orthopedic equivalent of reinforcing a sturdy bridge with duct tape If the engineering is sound, why do you need to do that? Implant designs have advanced, we have high friction coatings. There's no need for additional supplemental fixation. Uh, it's kind of like clinging to the same decade old scrubs. A closer look at clinical outcomes and surgical risk makes it clear. Screws add unnecessary complexity, potential complications. They make the revision harder and they do not add any additional longevity to the prosthesis. But it's understandable that my opponent here continues to cling to the idea that screws are necessary. 'cause remember, I believe he trained in a place where I think the mullet is still the men's. Premier fashion. So I posit to you that the same thing in that AO course that they teach about putting that first screw in. You learn that from the plate, that every screw hole is an opportunity, not an obligation. So thank you.

Joseph M. Schwab: 7:26

One minute rebuttal.

Michael Blankstein: 7:29

I do love that. Last point. Good for you again, guys. Two options. Get in the cup. Two minutes put on a screw. Perfect. It know what you're doing when you need it. You have that trajectory in the back of your mind. You know you're three dimensionally oriented. It's a no brainer. The alternative is one day you're gonna under ream. One day you're gonna hit too hard. One day you're gonna have a cup inside the pelvis, and gonna think I should have listened to Dr. Blankstein.

Joseph M. Schwab: 7:54

One minute rebuttal.

Nicholas Mast: 7:57

Alright, so we're scientists here. Please show my slide. So after Joe assigned us our topic, a timely paper came out. And in this paper, the conclusion on a very large retrospective series showed that actually in this cohort, the largest, the longevity, the least risk of aseptic loosening, least risk of complications of the implant failing were those without screws. Thank you.

Joseph M. Schwab: 8:24

Go to your Hova app and vote, and we need your votes in because we're gonna hand out the awards. Well, there you have it. Two seasoned surgeons passionately debating an issue that has divided orthopedics since the dawn of press. Fitt, whether the humble acetabular screw is the anchor of stability or the mullet of arthroplasty. Dr. Blankstein reminded us that screws are quick, they're cheap, they're safe, and bring unparalleled joy, especially if you learn the craft at an AO course where screws are practically a love language. Dr. Mass reminded us that modern day cup designs don't really need screws, and that adding one is kind of like putting duct tape on a well engineered bridge technically possible, but. A bit eyebrow raising and somewhere in the middle is the truth. We all know some cases need them, some don't, and all of us have one revision nightmare burned into our memory where the screw absolutely saved the case or made the revision twice as hard. Thank you for listening to this final episode of the AHF Great debates. As always, please take a moment to like and subscribe so we can keep the lights on and keep sharing great content just like this. Please also drop any topic ideas or feedback in the comments below. You can find the AHF podcast on Apple Podcasts, Spotify, or in any of your favorite podcast apps, as well as in video form on YouTube slash at anterior hip foundation. All one word episodes of the AHF Podcast come out on Fridays. I'm your host, Joe Schwab, asking you to keep those hips and screws happy and healthy.