Stephen Burkhart, MD, recently retired as President of The San Antonio Orthopaedic Group and is currently Chairman of the Board of BRIO (Burkhart Research Institute for Orthopaedics). He has authored more than 200 peer-reviewed articles on arthroscopic shoulder surgery and more than 50 book chapters. Dr. Burkhart has also authored three textbooks on shoulder arthroscopy. He holds 51 US patents, and he is the designer or co-designer of more than 700 shoulder products.
The American physicist and philosopher Thomas Kuhn coined the term paradigm shift in 1962 in his classic book The Structure of Scientific Revolutions. He defined paradigm shift as a fundamental change in the basic concepts and practices of a discipline. Based on that definition, I believe that the transition from open shoulder surgery to arthroscopic shoulder surgery represents a classic paradigm shift.
Thomas Kuhn went on to say that those who initiated a paradigm shift were typically either young and naïve, and therefore oblivious to the consequences of challenging the established power structure; or they were completely outside the hierarchy of the opinion leaders of the status quo; or both. That description certainly fit the upstart arthroscopic shoulder community that coalesced in the 1980s as a group of mostly young (and therefore naïve) orthopedic surgeons who were almost all in private nonacademic practices (outside the academic power structure and therefore relatively immune to hierarchal reprisals against them). I was proud to be a part of this early group of upstarts: surgeons such as Steve Snyder, Jim Esch, Dick Caspari, Lanny Johnson, Eugene Wolf, Doug Harryman, Craig Morgan, Buddy Savoie, Harvard Ellman, and Gary Gartsman. An exception to this private practice profile was Gary Poehling, a talented arthroscopic surgeon who had become Chairman of Orthopaedic Surgery at Wake Forest University at a very young age. Dr. Poehling wholeheartedly embraced arthroscopic shoulder surgery and became editor-in-chief of the journal Arthroscopy . His stellar academic credentials and his tenacity and appetite for hard work transformed Arthroscopy into a world-class journal much sooner than anyone could have anticipated.
It has been amply demonstrated that technology can take one of two forms as an agent of change: enhancement technology or disruptive technology. Enhancement technology provides gradual incremental improvements over time, whereas disruptive technology causes sudden drastic changes in the way things are done. It became obvious at an early stage that shoulder arthroscopy, if it were to succeed, would be a disruptive technology that would result in paradigm shift. However, before that paradigm shift could occur, there were some prerequisite burdens that had to be assumed by the arthroscopic shoulder surgeons who wanted to see the nascent discipline progress and mature.
There was the burden of arthroscopic identification. As we looked in the shoulder from inside-out, without destroying any anatomic structures on the way in, we were seeing the anatomy in an entirely new way. We had to determine what was normal and what was abnormal. We were seeing things such as a thickened cable-like structure subtending a crescent of capsular tissue near the rotator cuff insertion on the greater tuberosity, a sublabral foramen at the midanterior labrum, and a comma-shaped structure at the superolateral border of the subscapularis. We were seeing instability patients with glenoid bone loss in the shape of an inverted pear and Hill-Sachs lesions that would engage the anterior-inferior glenoid rim in varying degrees of abduction and external rotation. We were seeing various patterns of rotator cuff tears; they were not all shaped like crescents. Once we began repairing these various types of cuff tears, we could see whether or not we were accurately restoring the anatomy.
Early shoulder arthroscopists had the burden of developing the language of arthroscopy. The arthroscopic anatomy that we were seeing for the first time required a descriptive language—hence the designation of descriptive terms to these structures, such as rotator cable and rotator crescent, sublabral foramen, comma sign, inverted-pear glenoid, anterior labral periosteal sleeve avulsion (ALPSA), partial articular supraspinatus tendon avulsion (PASTA), engaging Hill-Sachs lesion, partial lesion, and L-shaped and reverse-L rotator cuff tears. Repair techniques, to be described and taught, needed their own language, with new terms such as deadman angle, margin convergence, loop security, linked double row repair, self-reinforcing construct, and load-sharing rip-stop repair.
There was the early burden of disseminating arthroscopic knowledge. The mainstream journals in the 1980s and early 1990s had little interest in publishing arthroscopic articles, so we had no choice but to start our own journal, Arthroscopy , in 1984. As I alluded to, I have special appreciation for the dedication and tenacity of Dr. Gary Poehling, the journal’s second editor-in-chief, for almost singlehandedly taking it from a very basic conduit of arthroscopic information to a world-class publication with a high impact factor. The present editorial staff, led by Editor-in-Chief Dr. Jim Lubowitz, has continued this tradition of excellence and has taken the journal to the next level. Just as the early shoulder arthroscopists were boxed out of mainstream journals, they were also boxed out of podium presentations at mainstream meetings. This situation provided an opportunity to form our own organization, the Arthroscopy Association of North America (AANA), which could put on its own meetings and hands-on cadaver courses. Accessing the media of the time (initially the podium and journals) was crucial to taking the discipline mainstream, but the more successful we became, the more resistance we encountered from some powerful sectors of the shoulder establishment.
The burden of developing safe arthroscopic instruments and implants was assumed by a few surgeons in conjunction with even fewer companies, because most of the major orthopedic companies in the 1980s and early 1990s voiced their opinion that there would never be a market for shoulder arthroscopy. We had no choice initially but to try to adapt arthroscopic knee instruments to the shoulder. However, there was very little functional crossover of instrumentation between knee arthroscopy and shoulder arthroscopy because the early knee procedures were mostly excisional in nature, whereas shoulder arthroscopy required repair and reconstruction techniques. A number of shoulder surgeons came up with some very ingenious techniques and instruments and implants to effectively “build a ship in a bottle,” and each generation of devices became more reliable and more user friendly.
As the techniques and devices were being developed to accomplish arthroscopic rotator cuff repair and arthroscopic instability repair, the early arthroscopic surgeons faced the burden of proving that the new technology was biomechanically as good as or better than the old technology. Because I had an undergraduate degree in mechanical engineering, I took it upon myself to do much of this early biomechanical work. I performed biomechanical studies on knot security and loop security for knots that were tied arthroscopically. I also devised a series of experiments to compare cyclic loading strength of arthroscopic anchor-based rotator cuff repairs to the strength of open cuff repairs with fixation through bone tunnels (the gold standard at the time). These studies showed that arthroscopic anchor-based cuff repairs were stronger than bone tunnel repairs and furthermore demonstrated that the anchors shifted the weak link of the construct from bone to the suture-tendon interface. These studies, by proving the biomechanical superiority of arthroscopic repair constructs, enabled conscientious and ethical advancement of arthroscopic surgical techniques. This biomechanical superiority, coupled with the lower morbidity associated with minimally invasive shoulder surgery, heralded the beginning of the paradigm shift from open to arthroscopic surgery. All that remained to be done was to teach these techniques to enough surgeons to create a critical mass of patients that would demand arthroscopic rather than open shoulder surgery. The inevitability of this paradigm shift was rapidly becoming apparent by the mid-1990s.
The two faces of craft
To have a meaningful discussion on craft, it is essential to first define the term. Strictly speaking, craft is a skill that relies on and maximizes manual competence. By this definition, surgery is clearly a craft . As surgeons, we have a unique burden of craft, and that burden is the obligation to provide the best possible care to our patients.
Beyond the burden of craft, there are two distinctly different components to every craft: expertise and problem solving. These two components of craft are the direct consequence of the two faces of craft: depth and breadth.
The first face of craft is depth of expertise. Depth optimizes results in a specific patient or in a specific field. The need for depth is best met by superspecialists such as dedicated shoulder surgeons.
The second face of craft is breadth of experience for problem solving. Breadth is achieved by individuals with experience in multiple fields. Breadth of experience optimizes the possibility of combining knowledge from different domains to obtain a creative solution. Breadth maximizes the ability to solve problems, thereby providing the potential to advance the level of the entire craft.
Simply put, depth optimizes the chance for achieving an excellent result in an individual patient, whereas breadth optimizes the chance for advancing the discipline and potentially achieving a paradigm shift.
Malcolm Gladwell discussed depth of experience in his book Outliers . He first postulated the “10,000-hour rule,” which suggested that the attainment of an elite status in a craft (particularly music, art, or sports) requires at least 10,000 hours of practice and participation.
Obviously, surgeons cannot possibly spend 10,000 hours practicing rotator cuff repairs, then another 10,000 hours performing instability repairs, as well as the requisite time required to achieve elite status in all the other operative procedures in the field of shoulder surgery. Fortunately, there are some shortcuts. Dr. Christopher Ahmad has written a book entitled Skill: 40 Principles That Surgeons, Athletes, and Other Elite Performers Use to Achieve Mastery . This book describes targeted drills and practice that the surgeon can use to achieve excellence in a compressed timeframe.
The counterpoint of depth is breadth . Breadth is the other face of craft, the one that facilitates problem solving. Author David Epstein examined this issue in his book Range: Why Generalists Triumph in a Specialized World . Epstein asserted that there is a technologic trend toward specialization not only in medicine but also in large companies and academic institutions, where there has been elevation of narrowness to an ideal. Research is done at these institutions by groups of individuals with expertise in a single domain, a condition called vertical thinking . Vertical thinking can lead to technical advancements but not to paradigm shifts.
Dr. Arturo Casadevall, Chairman of Immunology at the Johns Hopkins School of Public Health, has a theory of parallel trenches . As quoted in David Epstein’s book Range , Dr. Casadevall explains that, with narrow expertise, we keep digging deeper in our own trench in search of a solution, never recognizing that the answer may lie in the trench next to ours. This theory highlights the need for broad experience within individuals and groups. Such broad experience facilitates lateral thinking , which can provide unique insights that lead to paradigm shifts.
The case for breadth as the basis for creativity
There is a clear case to be made for the value of breadth. Modern life requires breadth, with the ability to make connections across far-flung domains and ideas. Multitasking has become a way of life.
On close examination, breadth appears to be the basis of creativity. It favors lateral thinking over vertical thinking . What some authors have called thinking outside the box is simply lateral thinking: applying a solution from one domain to a problem in another domain. Perhaps the most striking example of lateral thinking was the series of thought experiments that led to Einstein’s Theory of Special Relativity in 1905.
If bridging between domains is so important, why is it not more common? Uzzi et al. published an article on this topic in Science in 2013 that reached some surprising conclusions. They found that scientific work that bridges between disparate domains is:
- 1.
Less likely to be funded;
- 2.
Less likely to be accepted into high-impact journals; and
- 3.
More likely to be ignored upon publication.
These are three powerful reasons not to conduct research between domains. However, their fourth conclusion highlighted the main incentive in favor of participation in domain-bridging research:
- 4.
It is more likely in the long term to have a high impact on human knowledge.
Simply stated, breadth-enhanced research is more likely to make a difference, even to the point of disruption and paradigm shift.
The end point: Depth versus breadth in technologic advancement
In view of the foregoing discussion, it is imperative that we ask ourselves, “What is the end point of depth and of breadth in technologic advancement? And are these end points the same or different?”
Depth, with its concentration on extensive but narrow expertise, is likely to lead to incremental improvements, or enhancement technology. There is certainly a strong case to be made for this type of technological advancement, with steady progress over time.
In contrast, the end point of breadth-based research, with a broad base of experience and the ability to connect unrelated domains, is the unpredictable but very real potential for disruptive technologic advancement resulting in paradigm shift. Therefore it is essential that we recognize the importance of breadth and never abandon it.
Perhaps the most eloquent case for breadth was articulated by Robert Heinlein, the noted science fiction author:
A human being should be able to change a diaper, plan an invasion, butcher a hog, conn a ship, design a building, write a sonnet, balance accounts, build a wall, set a bone, comfort the dying, take orders, give orders, cooperate, act alone, solve equations, analyze a new problem, pitch manure, program a computer, cook a tasty meal, fight efficiently, die gallantly. Specialization is for insects.
David Epstein noted a recent Nobel Prize phenomenon. In Range, he stated that, almost annually, a Nobel Prize recipient explains that his or her breakthrough could not have occurred today. We might ask ourselves if shoulder arthroscopy could have developed in the 21st century from scratch, particularly because we currently have such strong headwinds as evidence-based medicine, Level I studies, and progressively restrictive US Food and Drug Administration policies. My belief is that yes, shoulder arthroscopy could have developed in today’s world, but such a paradigm shift would require a dedicated group of surgeons, scientists, and engineers willing to take on all the burdens of the new craft.
The invisible engine: Tenacity
When I was a young boy growing up in a rural area of central Texas, my dad would often try to encourage me to work hard to achieve meaningful goals by repeating wisdom-packed Texas adages and aphorisms such as “Hard work never killed anybody,” “No man ever drowned in his own sweat,” or “If the horse bucks you off, you’ve got to get back on and ride him.” Such comments were clearly intended to help a youngster develop grit and determination. Despite the fact that these two terms are frequently used together or even interchangeably, there is a vast difference between them. Grit begins with determination and then adds a layer of courage, resolve, and strength of character to give it a nobility that determination alone does not possess. Grit manifests itself through tenacity, a relentless refusal to give up. Depth and breadth are essential to disruptive pioneers in a new discipline, but tenacity is the human engine that powers paradigm shift.
The early arthroscopic shoulder surgeons held to their belief in the new discipline of shoulder arthroscopy despite strong opposition from powerful forces in the shoulder establishment. Without their persistent demonstration of grit and tenacity, nothing would have changed. However, the paradigm shifted, and the elation among the early pioneers was almost too great for words. Almost, but not quite. The immortal words that best describe the thrill of paradigm shift in shoulder surgery, against all odds, and after long struggles, were composed decades ago by Mahatma Gandhi:
First they ignore you. Then they laugh at you. Then they fight you. Then you win.
And we won. Even so, my greatest hope for the future is that another generation of tenacious lateral thinkers will create a positive disruption of shoulder surgery and end another struggle with the next great win.
Portions of this article were adapted from The Codman Lecture, entitled “Shoulder Arthroscopy: A Bridge from the Past to the Future,” presented by the author on September 19, 2019, in Buenos Aires, Argentina, at the 14th International Congress of Shoulder and Elbow Surgery; and from The First Annual AANA Innovations Lecture, entitled “The Basis of Innovation: Depth, Breadth, and Tenacity,” presented by the author on March 28, 2020, in Orlando, Florida at the AOSSM/AANA Combined Specialty Day Program.
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