Opinion editorial—a framework for innovation in shoulder surgery


Jon J.P. Warner, MD, is a Professor of Orthopedic Surgery at Harvard Medical School and Chief of the Massachusetts General Hospital Shoulder Service. He is a graduate of Harvard Business School (Executive Program). Dr. Warner has broad interests in all aspects of shoulder care and has been involved in innovation and design of many devices, implants, and software used to treat shoulder problems.

Jonathan B. Ticker, MD, is in private practice at Orlin & Cohen Orthopaedic Group on Long Island, New York, where his clinical care is devoted to the shoulder with emphasis on arthroscopic approaches. Dr. Ticker’s training shaped his passion; he held a research fellowship in shoulder biomechanics at the New York Orthopaedic Hospital and a clinical fellowship in sports medicine and the shoulder at the University of Pittsburgh. His interests are reflected in his books and other publications, academic endeavors, national organization volunteerism, and continued discovery of the shoulder.


Simply put, innovation is “a new device, idea, or method.” A more comprehensive definition is “Innovation is production or adoption, assimilation, and exploitation of a value-added novelty in economic and social spheres; renewal and enlargement of products, services, and markets; development of new methods of production; and the establishment of new management systems. It is both a process and an outcome.” In a more practical approach, Joe Dwyer, a Kellogg Professor and entrepreneur, has suggested the following definition: “Innovation is the process of creating value by applying novel solutions to meaningful problems.” Although innovation and invention are related and both present with novelty, not all innovations require an invention.

Regina Herzlinger defined six forces which affect a health care innovation: industry players, funding, public policy, technology, customers, and accountability. She made the point that separately or in combination these can either facilitate an innovation or block it. Moreover, most innovations fail because they are not clear on what type they are. For example, is the innovation a technological advancement, a consumer innovation, or something which integrates technology with a method and its delivery? We will not go into depth in applying this framework to shoulder surgery, although we will use elements in our discussion to follow. Clayton Christensen and colleagues introduced the concept of disruptive innovation and suggested that it is more of a “disruptive process” which occurs over time. In this regard we might consider that many of the initial great innovations of the masters in our field (e.g., Blundell Bankart, Ernest Amory Codman, Harrison McLaughlin, and Charles S. Neer II) formed the basis for what we now understand as modern innovations in shoulder surgery.

In further detail, innovation can be appreciated in a number of forms, with differing impact. A sustaining innovation is additive to maintain position or growth in an existing market. Certain recent suture and anchor technologies can be considered in this regard. A disruptive innovation differs in that it creates a new market sometimes with a lower cost solution than that promoted by incumbent businesses. Although initially not perceived as useful or valuable, the disruptive technology, once evolved, expands and replaces the existing market. Examples would be the reverse shoulder prosthesis, as well as arthroscopic Bankart and rotator cuff repairs with initial development of anchors for tissue to bone repair. Although arthroscopic repair and the reverse shoulder prosthesis offered disruptive alternatives to the status quo of care at the time, they were generally more expensive. These could be considered hybrid disruptions. Such innovations take longer to develop and incur greater risk; if successful, the disruptive innovation can rapidly change dominance in an industry. An enabling technology leads to dramatic change in a field from the subsequent technologies. Examples include the arthroscope and the suture anchor, which enabled further innovation. Incremental innovations build upon existing technology, without dramatic advancement in subsequent technology, and include, for example, certain modifications to anchor design, arthroplasty implant design, and fracture fixation. Herzlinger made the point that, in addition to having advocates, an innovation should lower health care cost and be profitable to the business to be sustainable. In the case of any new technology, the initial costs are high, but as new entrants provide an alternative, competition will drive costs down and the technology will, indeed, be sustainable. While a better-performing alternative at the same price or a similar-performing alternative at a lower price is advantageous, the goal is a better-performing alternative at a lower price. It is now increasingly difficult to sustain better performance at a higher price.

Innovation in the field of medicine has been dramatic in the 20th century, and some advances have been beneficial to all fields, not just shoulder. For example, in one review of 10 greatest medical innovations over a 50-year period, cross-sectional imaging with magnetic resonance imaging and computed tomography was the #1 innovation and has made significant positive impact on the lives of the patients we treat. Although we all recognize that innovation is essential to progress in medicine, many so-called innovations do not produce lasting value and introduce significant risk and harm to patients. While we might suppose that the current regulatory climate offers an added barrier into innovation and its adoption, consider past deterrents to innovation: “In the Ptolemaic era, the Greek historian Diodorus Siculus . . . records legislative penalties for methodological innovation by state-supported physicians in the army.” If a physician deviated from the prescribed rules of medicine and the patient did not survive (presumably whether or not the deviation caused the patient’s demise), the physician would be subjected “to a trial with death as the penalty.” This approach governed the rendering of medical treatment for millennia. Fortunately, as noted by a lifelong innovator, Jesse Jupiter, “Innovation in surgery has a rich tradition, and the interest and enthusiasm to innovate has never been greater.”

Many innovators are driven by personal or professional reasons to solve practical problems. We owe much to the user innovator who recognizes an unmet need and has the skill and resources to develop a solution. This does not need to be disruptive and can be incremental and still be of value. In fact, experienced surgeons innovate in the operating room case by case often using evidence-based medicine and insight to change an operation as needed. In some instances, pattern recognition of pathology and unsuccessful treatment allows surgeons to develop alternative methods which are more successful. An example would be the latissimus dorsi transfer for irreparable rotator cuff tear as originally described by Gerber. This is very much consistent with Malcolm Gladwell’s definition of an expert after 10,000 hours of practice, as experts have developed insight and perspective allowing them to innovate novel approaches to difficult problems.

In the field of shoulder surgery, we have a long tradition of recognizing and developing innovations. A reasonable starting point would be with Codman ( Fig. 69.1 ). He recognized the value of Roentgen’s discovery of x-rays and studied this in detail. In 1899, Codman became the first skiagrapher ( skia is Greek for shadow), or radiologist, at Boston Children’s Hospital. Along with C.F. Painter, he used x-rays to combine the diagnosis and surgical treatment of a case of a calcified deposit of the shoulder. As one other example of his many innovative ideas and methods, Codman performed the first rotator cuff repair in 1909 and published his findings in 1911. Codman’s innovative ideas in shoulder, and in the study of outcomes in medicine, are presented in his classic book The Shoulder: Rupture of the Supraspinatus Tendon and Other Lesions In or About the Subacromial Bursa published in 1934.

Fig. 69.1

Ernest Amory Codman.

While Codman is referred to as the father of the field of shoulder, Neer has been described as the father of modern shoulder surgery ( Fig. 69.2 ). His credits cover the spectrum of innovation, including new devices, ideas, and methods. These include the development of shoulder arthroplasty, advancing understanding subacromial impingement and glenohumeral instability, expanding Codman’s ideas on proximal humeral fracture pathology, and developing methods and techniques in these and other areas of shoulder pathology and care. Neer summarized his concepts and contributions to the field of shoulder surgery in his timeless book Shoulder Reconstruction , published in 1990.

Fig. 69.2

Charles S. Neer II.

Another integral part to the advancement in medicine is the diffusion of innovations. It is not enough to have the right idea, the right device, and/or the right method. An innovation needs to be introduced at a fortuitous time in the evolution of our understanding of diagnosis and treatment to have the greatest chance of being recognized and adopted. Ultimately, adoption is multifactorial. If an innovation can be proven successful by rigorous scientific methods, it has a chance. In this vein, Tom Krummel, Director of the Surgical Innovation Program at Stanford, described Rodney Perkins’ perspective on how important and efficacious innovation can be and how such an innovation can diffuse into the market. This model describes leveraging of medical knowledge. In our interpretation, consider that one doctor treats “X” patients over his or her career. One teacher trains “Y” doctors over his or her career. And, just one innovation adopted by “Z” teachers has a geometric effect, as “X” × “Y” × “Z”. The power of an innovation and its value to health care are unmistakably apparent.


We have hypothesized that the field of shoulder surgery has been enriched by a multitude of innovations across a wide spectrum of areas in our field. To assess these aspects of innovation as it relates to the field of shoulder surgery over the past 120 years, we queried members of the Codman Shoulder Society ( www.codman-shoulder-society.com ) to provide thoughtful input to identify those meaningful innovations which have advanced the art and craft in the field of shoulder. No examples were noted in our initial query, and each respondent provided a list of 10 innovations, be it a device, an idea, and/or a method. These were then collated and ranked, with the top-mentioned selected for further consideration. These are listed in Table 69.1 .

TABLE 69.1

Innovation in Shoulder Surgery

  • Reverse shoulder prosthesis

  • Anchor technologies

  • Arthroscopic soft tissue repair

  • Anatomic total shoulder arthroplasty

  • Functional tendon transfer

  • Latarjet transfer

  • Arthroscopic soft tissue and bone removal

  • Goutallier classification of fatty muscle degeneration of the rotator cuff

  • Anatomic plate fixation for fracture care

  • Proximal humerus fracture classification

  • Two-/three-dimensional cross-sectional imaging

  • Graft augment/replacement in cuff repair

  • Outcome measurement scoring systems

  • Open transosseous cuff repair

  • Planning tools for shoulder arthroplasty

  • Suture technologies

  • Open instability pathology and repair

  • Shoulder-dedicated education

  • Subscapularis pathology understanding and treatment

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Aug 21, 2021 | Posted by in ORTHOPEDIC | Comments Off on Opinion editorial—a framework for innovation in shoulder surgery
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