Rob Hartzler: 

Welcome to a special edition of the Arthroscopy podcast. This is the second of a two-part episode featuring Dr. Stephen Burkhart. Part-one, if you haven’t heard it, should not be missed. We discuss his June 2020 article in Arthroscopy entitled, “The basis of Innovation: Depth, Breath, and Tenacity.” This article was adapted from the planned inaugural AANA innovations lecture. 

Speaker 1: 

Welcome to the Arthroscopy Association's Arthroscopy Journal podcast. The views expressed in this podcast do not necessarily represent the views of the Arthroscopy Association or the Arthroscopy Journal. 

Rob Hartzler: 

Greetings. This is Rob Hartzler with TSAOG Orthopedics in San Antonio. Today on the podcast we have the pleasure of speaking with a man who needs no introduction to our listeners, Dr. Steve Burkhart from San Antonio. 

                Dr. Burkhart is now retired from the practice of orthopedic surgery. He retains his role and title as the chairman of the board of BRIO, The Burkhart Research Institute for Orthopedics. 

                Dr. Burkhart, welcome to the podcast. 

Steve Burkhart: 

Thank you, Rob. I appreciate it. 

Rob Hartzler: 

One of the things that you wrote in the article was about having to determine normal anatomy from pathoanatomy, and how you were communicating with other surgeons who were innovating at that time. Nowadays, if I wanted to ask my buddy what he thought about something, I'd just save a video clip and text it off or something like that. 

                How were y'all communicating about this arthroscopic pathology? 

Steve Burkhart: 

Yeah. You have to remember this was in the days before email and internet. And so you had to just communicate over the telephone or in person or by regular mail. 

                It was actually not that common. I forget when FedEx launched, but I think it may have even been before FedEx. So basically we had to send things through regular mail. 

                So Steve Snyder in Los Angeles came up with this great idea and formed the shoulder arthroscopy study group. I don't know the exact number, I think there were probably seven or eight of us in the United States that were interested in shoulder arthroscopy and were actually doing it. 

                And so we all automatically became members of this shoulder arthroscopy study group. When you did a shoulder scope and you saw something that was either unusual or interesting or you didn't know what it was or you didn't know if it was normal or abnormal or normal variant, you would send a VHS video of that arthroscopy around to each member, like chain mail. You'd send it to one guy, then he'd send it to the next guy, and on down. 

                And so what you would have to do is watch it and then you would have to send a letter to every member of the shoulder arthroscopy study group to tell them what you thought that was. So if you didn't do that, if you didn't send a letter to everyone, then you would be kicked out of the group. I don't think we ever kicked anyone out of the group because we were all fascinated by it and we got so much good feedback by it. 

                Then we'd have a meeting of the shoulder arthroscopy study group every year at the AANA meeting. Seems like we may have had it at the academy as well. But we'd all get together in person once or twice a year, also. 

Rob Hartzler: 

So you had access to record parts of the cases on VHS tape. 

Steve Burkhart: 

Yeah. It was all VHS. It was before we had any CDs or DVDs. So it was kind of a cumbersome way to do it, but it was very effective at time. 

                Well, I mean it was a matter of you have to remember it's we were looking for the first time, looking at the shoulder from inside out. Without destroying tissue as we went in. So, part of it was a matter of just deciding what was normal and what was abnormal. 

                And then we were seeing structures that you couldn't see if you looked from outside in. You would see them in a different way. Things like the comma tissue and that type of thing. And so if you were really going to be able to communicate about them, then you had to have names for them. 

                So typically if you're the one that discovered it and you realized that we needed a name for it, you had the naming rights. Unless you gave those up. 

Rob Hartzler: 

What was your approach to naming things? Were you just trying to describe what you saw or were you trying to come up with a name that would stick and be memorable? What do you think about that? 

Steve Burkhart: 

Yeah. I thought of it in a couple ways. I wanted it to be memorable and I wanted it to be descriptive. From the standpoint of being memorable, it's kind of like having a good hook in the chorus of a country western song. You want it to be almost like a singalong, where everyone's going to remember the words. 

                But you wanted it to be descriptive too, because otherwise you're not going to really make an association between what you see and what its name is. Like the comma tissue is a good example. 

                It was this comma shaped arc at the superolateral border of the upper subscap, that you'd see as much more pronounced when you would have a torn upper subscap. And so it was a comma shaped arc. It was like a real comma in a right shoulder. Of course, it was a reverse comma in the left shoulder. It just made sense to me. 

                And then we had things like cable-crescent. That actually had kind of a double origin, I guess, because it looks like a cable. The cable crescent, as you know, is the portion of the supraspinatus and part of the infraspinatus tendon, where you have this thinner area we call the rotator crescent that's subtended by this arc of a thick cable-like structure we call the rotator cable. 

                So, I had done an early biomechanical study on that and we came up with some data that indicated that the rotator crescent was stress shielded by the rotator cable. This went along with this whole concept that I had had a few years earlier that the function that ... well, that it sort of explained why the function of someone with a crescent shaped rotator cuff tear could be entirely normal, even though they had a big tear, a reasonably big tear in the cuff, because that rotator cable functioned like a cable on a suspension bridge. 

                And so that was initially a hypothesis, but then we got to look at that in the lab and showed it to be true. And then later Shawn O’Driscoll and his associates confirmed it again in another study. 

                Those kinds of things were fun to have the naming rights for something like that. It looked like a cable and it also acted like a cable biomechanically. So that one made perfect sense to me. 

Rob Hartzler: 

You mentioned that there were fun times. But obviously from the article, you wrote a lot about how much grit it took and tenacity to overcome the powers that were of shoulder surgery at that time. I was just wondering if you thought that there was any time when you were close to maybe giving up the mission or something like that, or maybe if you thought about what maybe the worst time was in terms of thinking about the paradigm shift failing. 

Steve Burkhart: 

Well, I think first of all the conflict in retrospect shouldn't have been a surprise to us. Although at the time it was. But conflict is a consequence of any paradigm shift. I think we didn't initially realize that we were involved in the early stages of the paradigm shift, though. 

                What we realized early on, there was a group of very talented arthroscopic surgeons that could repair the rotator cuff and repair instability, with very rudimentary implants and suture passing devices. They were just naturally gifted at this particular skillset. 

                I think that's what kept it alive. It sort of was the spark, in a way. We saw it could be done, but then that kept it alive when there were reports coming out by other surgeons who said, “Oh, the failure rates for these arthroscopic instability repairs are so high you should never do them. There must be something different about them.” But then you would see certain guys that really were skilled at it that had much better results. So it became apparent that we just needed to develop techniques and tools for the masses of shoulder surgeons, basically, so that you would have something that everyone could do a good job with. 

                You needed something that you could teach people, even if they were doing only the occasional rotator cuff repair, that type of thing, teach them to do a good, competent, solid job of it. And of course that was going to be years in the making and it implied that we were going to obligate ourselves to developing not only instruments, but teaching techniques. And then gradually improving the techniques and the instruments so that everyone could learn to do this. 

                There was a time maybe in the early '90s, I guess, where there were a few of us that were doing quite a few rotator cuff repairs arthroscopically, and we would commiserate at some of the meetings and say, “Gosh, you know, it just doesn't seem like we're reaching all that many people yet. Is this ever going to really catch on?” 

                And then we would kind of make this small group of people, make each other feel good, by saying, "Well, I guess the very worst that could happen is that if nobody else learns to do it, we have job security because we know how to do it and patients want it." There's the demand because patients were just knocking the doors down to get it done. They just couldn't find surgeons who could do it. 

                That would've been probably in the early '90s, '93, '94, maybe into the mid '90s. I would say is when things really started to take off probably was by the late '90s. Late '90s to early 2000s, it became obvious at that point because there was this exponential growth and the interest in shoulder arthroscopy, the number of papers that were being submitted, the number of studies that were being done, the number of podium presentations. 

                And if you were to look at sales as an indicator for the popularity of the procedures, then the company sales were beginning to really go up. Maybe not quite exponentially at that point, but going up very fast. 

Rob Hartzler: 

I was just chuckling to myself a little bit earlier today because the Arthroscopy Journal put out this video on Twitter that was demonstrating the comma. So I was just thinking that that was an interesting coincidence, that we might talk about new media today and that we had the comma being demonstrated in that way on the media of our time, I guess you would say. 

Steve Burkhart: 

Yeah. I've tried to make this point over and over too, is that if you're going to really make a difference, if you think you have a really good idea and you want to reach a lot of people with that idea, you've got to create a critical mass. Because there was the demand, as I said, for arthroscopic shoulder procedures. 

                We didn't have the critical mass of surgeons to satisfy that demand. So for it to really become mainstream, that's what had to be done. And so you had to reach those surgeons through the media of the time. Which in those days, the media were basically podium presentations and journal articles. 

                We didn't really have access to the mainstream podium or the mainstream journals. They weren't really interested in publishing anything or having podium presentations on anything to do with shoulder arthroscopy for a long long time. 

                So fortunately, in combination with the knee arthroscopy people, the shoulder arthroscopy guys, we all got together and started our own journal, the Arthroscopy Journal. And we started our own organization, AANA. 

                That helped us really get the word [out]. Then we used those media to create, I guess, sort of new ancillary means of teaching. So for example, through AANA we were able to be instrumental in starting the Orthopedic Learning Center, which we shared the burden of the expense for that with the academy. 

                But it was essentially a new way of teaching things. Then beyond that, once we were able to do remote learning and remote teaching by means of video, and it's incrementally and gradually improved over the years, but starting probably in the late '90s was when we began to do these remote transmissions of surgeries. Whether they were cadaver surgeries or live surgeries from the OR. So that was something that was new. 

                And then of course now you have Twitter, you have the Facebook. I don't have a Facebook account, I wouldn't know how to Tweet anything if my life depended on it. So I'm not an expert on that, but you guys know how to do that. 

Rob Hartzler: 

Podcasts. 

Steve Burkhart: 

Well, I'm being walked through this podcast. 

Rob Hartzler: 

Well, I just wanted to take the opportunity to congratulate again on an absolutely amazing career. It's really mind boggling the number of contributions that you made to orthopedic surgery and shoulder surgery, and really just helping countless numbers of patients to improve their lives through all of these things. I hope that you've had - even though we've had the COVID crisis - just a great start to a well-deserved retirement. Congratulations again and strong work, Steve. 

                Any closing thoughts for us? 

Steve Burkhart: 

I would really like to end this by talking a little bit about craft. If you think to the definition of craft, it's a skill that relies on and maximizes manual competence. I think one of the most important crafts in the world is surgery. As surgeons, we're all craftsmen. 

                And then there are basically these two faces of craft. One of which is expertise. Expertise requires depth, depth of expertise so that you're really good at doing something over and over again. And that's led to super-specialization. 

                But then there's problem solving. That's the other face of craft. You have to be able to solve problems as you encounter them in surgery. That certainly is benefited by breadth of experience, breadth of knowledge, and what you'd call lateral thinking. 

                I think that we need to think about that in terms of how we prepare young surgeons for their practices. I think there's a tendency now to have super-specialists and I think that's good for patients. But along the way you need to have that breadth that gives you the ability to take information from one domain to solve a problem in another domain. 

                I think that's an educational challenge that AANA is really leading the way in at this point. 

Rob Hartzler: 

Do you think that ... so that breadth question, it made me wonder about my own career because I've already gotten to a pretty specialized shoulder-only practice. Even though it's somewhat broad in doing arthroplasty and fracture care and arthroscopy. So it's broad in that way, but it's very narrow in terms of the anatomical distribution. So I've felt almost a little bit guilty about lack of breadth in my own practice. Is it that as a surgeon that has my sort of practice, where does the breadth come from? Is it within orthopedic surgery to keep in touch with what's going on in other areas? Is it other surgical disciplines? Is it outside of medicine where the breadth comes from? What do you think about that? 

Steve Burkhart: 

I think that's a great question, Rob. I think it's not only training and vocational. For example, I had a broad experience early in my practice with a lot of different types of trauma. I was doing foot surgery, hand surgery, total joints, total hips, total knees, total shoulders. 

                So I had all those things, so I might see a problem in the shoulder where I would sort of harken back to something that I learned from doing total hips. So there is that, but then there's also I think just the ... I think there's avocation and there's also just kind of thinking about how you can apply something from one part of your life to another part of your life. 

                One of the great things that ... I guess the great analogy that I use is the analogy of solutions around the ranch to solutions in surgery. Some of the things that we would use to solve problems, just simple problems on the ranch, would have application with solving similar problems in surgery. 

                Whether that's a type of knot that you might use, or how do you keep a loop tight while you're trying to add more half hitches to it. Just think in simplistic terms, gosh, how I would solve this same problem with a rope at the ranch versus a suture in the operating room. 

                I think that's also another aspect of it. Things in your everyday life. 

Rob Hartzler: 

Thanks again for being on tonight with us, Steve. We wish you well and I hope that we'll get you on again for something similar. 

Steve Burkhart: 

Thank you, Rob. I appreciate it. 

Rob Hartzler: 

This article, entitled The Basis of Innovation: Depth, Breadth, and Tenacity, was published in the June 2020 issue of the Arthroscopy Journal and can be found on the journal's website at ArthroscopyJournal.org