Clinical Review

The Burden of Craft in Arthroscopic Rotator Cuff Repair: Where We Have Been and Where We Are Going

Am J Orthop. 2015 August;44(8):353-358

References

1. Burkhart SS, Athanasiou KA, Wirth MA. Margin convergence: a method of reducing strain in massive rotator cuff tears. Arthroscopy. 1996:12(3):335-338.

2. Kuhn TS. The Structure of Scientific Revolutions. Chicago, IL: University of Chicago Press; 1962.

3. Burkhart SS, Johnson TC, Wirth MA, Athanasiou KA. Cyclic loading of transosseous rotator cuff repairs: tension overload as a possible cause of failure. Arthroscopy. 1997;13(2):172-176.

4. Burkhart SS, Diaz Pagàn JL, Wirth MA, Athansiou KA. Cyclic loading of anchor-based rotator cuff repairs: confirmation of the tension overload phenomenon and comparison of suture anchor fixation with transosseous fixation. Arthroscopy. 1997;13(6):720-724.

5. Burkhart SS, Esch JC, Jolson RS. The rotator crescent and rotator cable: an anatomic description of the shoulder’s “suspension bridge.” Arthroscopy. 1993;9(6):611-616.

6. Burkhart SS, Nottage WM, Ogilvie-Harris DJ, Kohn HS, Pachelli A. Partial repair of irreparable rotator cuff tears. Arthroscopy. 1994;10(4):363-370.

7. Halder AM, O’Driscoll SW, Heers G, et al. Biomechanical comparison of effects of supraspinatus tendon detachments, tendon defects, and muscle retractions. J Bone Joint Surg Am. 2002;84(5):780-785.

8. Lo IK, Burkhart SS, Chan KC, Athanasiou K. Arthroscopic knots: determining the optimal balance of loop security and knot security. Arthroscopy. 2004;20(5):489-502.

9. Lo IK, Ochoa E Jr, Burkhart SS. A comparison of knot security and loop security in arthroscopic knots tied with newer high-strength suture materials. Arthroscopy. 2010;26(9 suppl):S120-S126.

10. Lo IK, Burkhart SS, Athanasiou K. Abrasion resistance of two types of nonabsorbable braided suture. Arthroscopy. 2004;20(4):407-413.

11. Park MC, ElAttrache NS, Tibone JE, Ahmad CS, Jun BJ, Lee TQ. Part I: footprint contact characteristics for a “transosseous-equivalent” rotator cuff repair technique compared to a double-row technique. J Shoulder Elbow Surg. 2007;16(4):461-468.

12. Park MC, Tibone JE, ElAttrache NS, Ahmad CS, Jun BJ, Lee TQ. Part II: biomechanical assessment for a footprint-restoring transosseous-equivalent rotator cuff repair technique compared with a double-row repair technique. J Shoulder Elbow Surg. 2007;16(4):469-476.

13. Burkhart SS, Athanasiou KA. The twist-lock concept of tissue transport and suture fixation without knots: observations along the Hong Kong skyline. Arthroscopy. 2003;19(6):613-625.

14. Tenner E. Why Things Bite Back. New York, NY: Random House; 1996.

15. Denard PJ, Jiwani AZ, Lädermann A, Burkhart SS. Long-term outcome of arthroscopic massive rotator cuff repair: the importance of double-row fixation. Arthroscopy. 2012;28(7):909-915.

16. Denard PJ, Lädermann A, Jiwani AZ, Burkhart SS. Functional outcome after arthroscopic repair of massive rotator cuff tears in individuals with pseudoparalysis. Arthroscopy. 2012;28(9):1214-1219.

17. Lädermann A, Denard PJ, Burkhart SS. Revision arthroscopic rotator cuff repair: systematic review and authors’ preferred surgical technique. Arthroscopy. 2012;28(8):1160-1169.

18. Randelli P, Castagna A, Cabitza F, Cabitza P, Arrigoni P, Denti M. Infectious and thromboembolic complications of arthroscopic shoulder surgery. J Shoulder Elbow Surg. 2010;19(1):97-101.

19. Zumstein MA, Pinedo M, Old J, Boileau P. Problems, complications, reoperations, and revisions in reverse total shoulder arthroplasty: a systematic review. J Shoulder Elbow Surg. 2011;20(1):146-157.

20. Adams CR, Schoolfield JD, Burkhart SS. The results of arthroscopic subscapularis tendon repairs. Arthroscopy. 2008;24(12):1381-1389.

21. Denard PJ, Jiwani AZ, Lädermann A, Burkhart SS. Long-term outcome of a consecutive series of subscapularis tendon tears repaired arthroscopically. Arthroscopy. 2012;28(11):1587-1591.

22. Lo IK, Burkhart SS. Arthroscopic repair of massive, contracted, immobile rotator cuff tears using single and double interval slides: technique and preliminary results. Arthroscopy. 2004;20(1):22-33.

23. Lo IK, Burkhart SS. The interval slide in continuity: a method of mobilizing the anterosuperior rotator cuff without disrupting the tear margins. Arthroscopy. 2004;20(4):435-441.

24. Denard PJ, Burkhart SS. Techniques for managing poor quality tissue and bone during arthroscopic rotator cuff repair. Arthroscopy. 2011;27(10):1409-1421.

25. Burkhart SS, Denard PJ, Konicek J, Hanypsiak BT. Biomechanical validation of load-sharing rip-stop fixation for the repair of tissue-deficient rotator cuff tears. Am J Sports Med. 2014;42(2):457-462.

First Steps

I sketched out my ideas for arthroscopic suture passers and knot-tying instruments and presented them to a couple of the major arthroscopy companies in the United States, but the companies were not interested. They did not believe arthroscopy would have any meaningful applications in the shoulder. So, I enlisted the services of a local San Antonio aircraft machinist to fabricate instruments for me. By 1987, I was doing arthroscopic side-to-side margin convergence¹ cuff repairs for U-shape tears on a regular basis. And I was doing these at the most hostile point in the universe for arthroscopic shoulder surgery: San Antonio, Texas.

Only a few surgeons were doing arthroscopic shoulder surgery in the 1980s and early 1990s, and without exception these surgeons became the leader-pioneers in the new discipline. In general, these were young surgeons who were in private practice and removed from academia and professional organizations, and thus relatively sheltered from the actions of the shoulder rule-makers of the day. They accepted their status as pariahs as they developed their techniques out of the view of mainstream orthopedics. These leaders included Jim Esch, Steve Snyder, Dick Caspari, Lanny Johnson, Gene Wolf, Gary Gartsman, Rob Bell, and Howard Sweeney. We shared our techniques and our ideas with one another, encouraged one another, and generally became good friends.

Thomas Kuhn, in his classic book The Structure of Scientific Revolutions,² observed that paradigm shifts within a given field were usually achieved by practitioners who were either very young (naïve) or outside the established hierarchy in the field. The surgeons who contributed most to the shift of shoulder surgery from open to arthroscopic techniques were generally young men who were in private practice and had little to lose by inciting the disdain of the shoulder establishment. Predictably, resistance from the mainstream open shoulder surgeons increased as arthroscopic techniques became more successful and more threatening to the primacy of the open shoulder surgeons. The disdain yielded to disruption and finally to transformation as the paradigm shift occurred. The conflict between the open shoulder surgeons and the arthroscopic shoulder surgeons passed through all the phases that Mahatma Gandhi had described many years before. “First they ignore you; then they laugh at you; then they fight you; then you win.”

Building a Ship in a Bottle

At the start of the 1990s, I recognized that my progress in arthroscopic rotator cuff repair would be extremely slow unless I could find an industry partner who shared my vision for full-scale conversion to arthroscopic means of repair and would be willing to help make it a reality. In 1991, I happened to meet Reinhold Schmieding, the owner of Arthrex, a small arthroscopic device company in Naples, Florida. Reinhold invited me to visit him to discuss the feasibility of developing arthroscopic repair systems for the shoulder. At the time, the world headquarters of Arthrex was a 20×30-ft storage room in an office service center, and there were 2 employees. One employee, Don Grafton, was a talented engineer without medical experience. By the end of my first day there, Reinhold and Don and I had agreed that developing arthroscopic repair systems for shoulder instability and rotator cuff repair would become a top priority for Arthrex.

My initial bias toward arthroscopic cuff repair was that a transosseous bone tunnel technique not only would be possible but would be superior to suture anchor fixation. In fact, my first 2 patents with Arthrex were for instrumentation for an arthroscopic transosseous repair technique. I tested my hypothesis with 2 successive biomechanical studies. The first examined cyclic loading of bone tunnel repairs, and the second examined cyclic loading of anchor-based repairs.^3,4 Evaluating the data from these 2 studies, I was surprised to find that anchor-based repairs were significantly stronger than bone tunnel repairs. In addition, anchors shifted the weak link from the bone–suture interface to the tendon–suture interface; in essence, anchors optimized bone fixation by shifting the weak link in the construct to the tendon. I was then completely convinced of the superiority of suture anchors over bone tunnels, and that conviction has become even stronger over the years. After these 2 cyclic loading studies, I shifted my focus, and that of Arthrex, toward arthroscopic suture anchor repair of the rotator cuff.

Reconciling Technique and Instrumentation With Anatomy and Biomechanics

Having recognized the importance of the rotator cable attachments both anatomically⁵ and biomechanically,^6,7 I thought it important to reinforce them as a routine part of performing rotator cuff repairs. Our anatomical and biomechanical studies had had great translational implications in the development of our techniques and instrumentation.