I am very honored that Dr. Rob Bell, past president of the American Shoulder and Elbow Surgeons, invited me to give last year’s Neer Lecture. Dr. Bell asked me to specifically address my role in the development of arthroscopic rotator cuff repair and to recount the significant resistance that the early arthroscopic shoulder surgeons faced from the shoulder establishment as we struggled to achieve mainstream acceptance for this new technology. Tasked with such a personal topic, I find myself in a position analogous to that of Winston Churchill at the end of World War II. When a journalist asked him to speculate on how historians would portray his role in the war, he replied without hesitation, “History will be kind to me because I intend to write it.”
So let’s start at the beginning. And for me it makes the most sense to travel back to the year I started my practice: 1981. The world then was very different from today’s world. On January 20, 1981, Ronald Reagan was inaugurated President of the United States. The same day, 52 US hostages in Iran were released after having been held captive for 442 days. In March 1981, Reagan survived an assassination attempt; 3 months earlier, John Lennon had not been so lucky. Lennon’s hit song “Starting Over” garnered the highest musical awards posthumously.
The world of shoulder surgery was also very different in 1981. The arthroscope was the “instrument of the devil,” according to Dr. Rockwood. And shoulder surgery was ruled by the Charlies—Dr. Charles Neer, Dr. Charlie Rockwood, and any other Charlie who felt compelled to marginalize shoulder arthroscopy.
My personal world in the early 1980s was daunting as well. I had just completed my residency at the Mayo Clinic and my sports medicine fellowship in Eugene, Oregon. I had a young son, a new daughter, and a new job with the San Antonio Orthopaedic Group. I had a new house with a 21% mortgage loan and a “new” used car with a 23% car loan.
I was simultaneously energized and intimidated by my new job, where I was doing general orthopedics with a “special interest” in shoulder surgery and sports medicine. I was initially very proud and humbled by the fact that my senior partners had entrusted me with the care of the most difficult shoulder cases within the practice. But that pride got cut down to its appropriate size the day after I had thanked one of my partners, Dr. Lamar Collie, for his confidence in my potential as a shoulder surgeon. Dr. Collie replied matter-of-factly, “Sure … but you need to understand that we always make the new guy the shoulder expert because shoulders never do worth a damn.”
For shoulder arthroscopy, the early 1980s were exciting. Most of us who were scoping shoulders had already been doing knee arthroscopy and were trying to adapt knee instruments to the shoulder. This worked for some simple excisional cases. For example, I recall excising the bucket-handle portion of a type III SLAP (superior labral tear from anterior to posterior) lesion in 1983. In general, however, shoulder problems were different from knee problems and usually involved repair rather than excision of damaged tissues. Therefore, the technology used in knee arthroscopy was often not directly transferable to the shoulder. Furthermore, treatment of the rotator cuff necessitated development of arthroscopic techniques in a virtual space, the subacromial space, and this was an entirely new arthroscopic concept.
Development of Arthroscopic Rotator Cuff Repair
A major mind-expanding turning point for me occurred in 1984 when I attended one of Dr. Jim Esch’s early San Diego shoulder courses. During that course, Dr. Harvard Ellman of Los Angeles demonstrated to me on a cadaver shoulder how he created a virtual subacromial working space that allowed enough visualization for an arthroscopic acromioplasty. At that moment, I knew that arthroscopic rotator cuff repair was just around the corner. Up until then, I had not been able to envision complex extra-articular reconstructive surgery, as all previous arthroscopic surgery had been intra-articular. But now, having realized a virtual working space could always be created, I knew it would be relatively straightforward to develop the portals to approach the cuff as well as the implants and the instruments to repair it. But I also knew that progression to all-arthroscopic repair techniques would have to be stepwise and that the final repair constructs would need to be at least as strong as those of open repair in order to be acceptable. With an undergraduate degree in mechanical engineering, I had a reasonably clear idea of the concepts I wanted to apply to the instrumentation and techniques, though I could never have envisioned how circuitous the route to the end result would be.