Welcome to a special edition of the Arthroscopy Podcast. This is part one of a two-part episode featuring Dr. Stephen Burkhart. We discuss his June 2020 article in Arthroscopy entitled “The Basis of Innovation: Depth, Breadth, and Tenacity.” This article was adapted from the planned Inaugrual AANA Innovations Lecture.
Rob Hartzler:
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. But 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:
Today we're going to be discussing your article from the June 2020 issue, entitle “The Basis of Innovation: Depth, Breadth, and Tenacity.” Dr. Burkhart, this article was adapted from a lecture that was scheduled to be delivered at AANA specialty day 2020.
It was going to be the inaugural [address of the] AANA Innovations Lecture series. First of all, congratulations for that. I think that's a wonderful honor that AANA is giving to you, remembering your contributions to the field, through that lecture series.
Steve Burkhart:
Well it is a great honor. I really do appreciate the invitation that they gave me. It was disappointing that the lecture couldn't be given, of course, because of the cancellation of specialty day to the COVID virus.
But as a result, I got to publish it in the Arthroscopy Journal and I'm very pleased that that occurred. Thank you for inviting me to be in this podcast.
Rob Hartzler:
Well certainly with over 50 US patents, 700 instruments and implants designed, three textbooks, and over 200 peer reviewed scientific articles, you're well qualified to talk to us about innovation. I thought it was a fantastic article, I enjoyed reading it, and certainly would encourage all of our listeners to go into that article which we're going to be hopefully adding some depth to and some stories.
Again, we just welcome you to the podcast and thank you for your time tonight.
Steve Burkhart:
Certainly.
Rob Hartzler:
Dr. Burkhart, what I was hoping that we could start out with was one of the points that you talked about in the article was a trend of subspecialization, or you called it super-specialization, in medicine, versus having a broader type of experience and practice…those two competing aspects of expertise, depth and breadth.
I was just hoping that you would talk to us a little bit about how that played out in your career as it evolved.
Steve Burkhart:
Yeah. It's very interesting. I think a lot of what happens in many of our careers is sort of an accident and a consequence of running toward daylight. Which is that famous phrase that Vince Lombardi used. He said that the great running backs would always run toward daylight. Which was something they would almost instinctively see out of their peripheral vision, but wasn't so much of a conscious act of going there.
It was sort of an improbable journey from where I started to where I ended, I think. I grew up in a small town in a rural area of central Texas. Both of my grandfathers did farming and ranching, and so there was ... I had exposure to a lot of shade tree mechanic sorts of things, I suppose, where you had to fix things yourself and do all the things yourself. As a kid, had to rely on yourself.
And then in college I decided to major in mechanical engineering, which was not standard at that time as a premed. My whole reason for that was that I wanted to have a good and interesting job in the event that I wasn't able to either get in to or afford medical school. So I had that broad area of education in engineering, which is not something that most surgeons or doctors would have.
Then when I finished my residency at Mayo Clinic in 1981, it was pretty heavily oriented toward total joints at the time. Although I got a good amount of trauma on a trauma rotation that I did. I felt that I was weak in sports medicine and I really was interested in sports medicine, so I did a sports fellowship. That was in Oregon with Dr. Bob Larson and his associates. That was at a time when people seldom did fellowships. Then I had the engineering, I had the total joints, I had the sports medicine.
Knee arthroscopy was in its infancy at that time. In fact, at the Mayo Clinic when I was there, the knee arthroscopy was all done by a rheumatologist, not even an orthopedic surgeon. He would do a diagnostic arthroscopy and then the next week or so, one of the orthopedic surgeons would operate on whatever he had identified.
So if it was a bucket handle tear of a meniscus, then they would do an open meniscectomy the next week. So it was very fascinating, though, for me to see what was going on with the knee and then to start in my practice.
I came through my sports fellowship at a time when my mentors and my teachers were trying to learn knee arthroscopy. Of course, shoulder arthroscopy wasn't even on the horizon. And so they couldn't really teach me to do it, so I was learning along with them on how to do knee arthroscopy and then had to continue learning in the early years of my practice, how to do knee arthroscopy.
So, once I got into my practice, though, a lot of it was I would say the two heaviest areas of orientation in my first five years of practice were total joint replacement, primarily total hip and total knee, and also trauma: so, ORIF and fractures.
I would do some knee, some shoulder, but it was open shoulder and there wasn't very much of it at the time. My group wanted me to do the more difficult shoulders because I had done the shoulder rotation at Mayo Clinic and they, for that reason, wanted me to do total shoulders. And since I'd done the sports fellowship, they thought I should also do instabilities and rotator cuffs.
So that's-
Rob Hartzler:
It’s amazing that there was not much shoulder work to do, because there's so much shoulder surgery now. Is it that the operations weren't thought of as being good? Was it that surgeons weren't offering them? Is it that patients didn't trust them and so they didn't sign up for them? Why do you think that that was?
Steve Burkhart:
Well, that's a very interesting question. You kind of take some of these things for granted when you think of it as having been in your own history. But you tried your best not to operate on instability.
In fact, the conventional wisdom at the time was you could just reduce the dislocation and send the patient back into play and let him continue doing that and it didn't matter how many times they dislocated. There were always so many examples of the 45-year-old high school football coach who had been dislocating for 25 years and he never had surgery. Of course he had an arthritic shoulder by then, but the conventional wisdom was you seldom had to operate on instabilities. But the big thing was the rotator cuff.
When you think about now how the volumes of rotator cuff surgery dwarf volumes for instability surgery. Well, rotator cuff surgery was considered to be somewhat risky. Not for the patient so much as for the doctor, for the surgeon. Because you never knew when someone was going to get stiff.
Once they got stiff, there was nothing you could do about it. And so open acromioplasty, open rotator cuff repair, the surgeons would be ... they'd go into those with a great deal of trepidation because even though the surgery might go perfect and even if they started in early motion, a lot of those people get so stiff. And if they got stiff, they'd be upset.
There was nothing you could do because that was the days before arthroscopic capsular release. So there was no minimally invasive way to correct the stiffness, if you got it. And certainly the open releases which were written about in the textbook, nobody really did those because that was just a huge operation.
And then the other thing, if you look at another category, would be adhesive capsulitis. You know, the refractory adhesive capsulitis now we'll do arthroscopic releases on. But there was no surgery that anyone would do for adhesive capsulitis back then. Of course, kind of the narrative on that was that if you gave them two to three years, they would all regain their motion. Which wasn't true. But that was what you'd hear a lot from the podium.
Once people found out that I was doing arthroscopic capsular releases in the early years, the ones that had been kind of hiding their stiff patients started sending them to me. I was operating on people who had had stiff shoulders for five plus years. And they would do great.
Rob Hartzler:
In the early days, you said that shoulder arthroscopy wasn't even on the horizon in the early '80s. I was just wondering how did that dawning happen? If you can take us through how you got started in it.
Steve Burkhart:
The first shoulder arthroscopy I did in my practice was after two years of being in practice. It was in 1983, I started in 1981. It was a high school baseball player who was a pitcher.
He was brought in by his dad. He had what they called then a dead arm. That was really very poorly understood. That was early in the days of diagnostic arthroscopy. I talked to them about people that I knew of that had done a few diagnostic arthroscopies and offered to -- because I wasn't the first one to do a diagnostic arthroscopy in the United States -- but I talked about sending him to someone who had.
The dad said, "Why don't you just do it?" And I told him, "Well, you know I've never done a shoulder arthroscopy. I do a lot of knee arthroscopy now but I haven't ever done a shoulder arthroscopy." He said, "Well, I expect you to be just about as good as anybody. Why don't you go ahead and do it?"
So, not only did he give me permission, he sort of pressured me into scoping his son's shoulder. So, I scoped this, he was a 17 year old boy. Dominant arm, high school pitcher. Scoped him and amazingly enough, he had a type three buck handled tear of the superior labrum.
And I thought wow, this is going to be easy. It's like a partial meniscectomy. We'll just cut out the bucket handle, I used knee instruments, and the kid did pretty well. He didn't become a professional baseball player or anything, but it sort of emboldened me then to start doing some other cases.
The problem is that I had discovered some pathology in that case, it was one of the few things you could deal with with knee instruments. Because it was excisional. I mean you think about what you do arthroscopically, it's almost all repair and reconstruction.
So there was nothing in the knee instrument repertoire where you could actually repair or reconstruct anything at that time. So all excisional. At any rate, then I realized that, “Gosh, we're going to have to have some instruments to repair things. It's a whole different set of issues than what we've got in the knee.”
Rob Hartzler:
In that time, you were only looking intraarticular and dealing intraarticular pathology. Talk to us about the evolution of dealing with that to the rotator cuff, where you have to be in a whole different space.
Steve Burkhart:
A really pivotal event as far as my career, occurred in 1984. This was in the early days of Dr. Jim Esch’s shoulder course out in San Diego. I was at that course in 1984 and Dr. Harv Elman had talked to me about how he had been doing some arthroscopic acromioplasties.
I really hadn't been looking up in the subacromial space. I'd put a scope in there a couple of times and I just saw kind of your classic mass of soft tissue, from being too far posterior with my scope. So he showed me how he created a virtual space in the subacromial space. Basically, making as much space as he needed to see the acromion.
But in the process of showing me that, I realized he could really see the rotator cuff well too. So it immediately dawned on me that that's the key. Now we'll be able to repair the rotator cuff. It's just a matter of time, we need to have the instruments.
But Dr. Elman had just showed me how we could visualize whatever pathology we needed to see in the subacromial space. So, that was really a pivotal moment for me.
Rob Hartzler:
What about instrument design? You designed so many instruments over the course of your career. What do you think about dipping your toe into that water? Describe that to us.
Steve Burkhart:
In terms of instrument design and developing ways to repair things, by about 1987, I was doing arthroscopic side to side rotator cuff repairs. You have to remember that suture anchors didn't come on the market until 1991. So anything we would repair before 1991 would've been a soft tissue repair. And so these were a pretty small number of cases. They were typically side to side cases.
But in order to repair them, you had to have ways to pass the suture and you had to have ways to tie knots. And so I designed a couple of rudimentary knot pushers and suture passers, and showed my ideas to the major instrument companies, the device companies of the time, and nobody was interested.
So I was kind of left to my own devices, so to speak. I identified an aircraft machinist in San Antonio. The reason I wanted an aircraft machinist to make these for me is it's well known among machinists that these guys can make small instruments, do very fine work. They have special lathes, so they have higher tolerances. And so they can make much smaller instruments and a little more intricate than anything else we could have at the time.
The other thing is that you need to remember this was back in the day before any computer assisted design or CAD programs for engineers. Everything we had to use or any instrument we made in those early days had to be straight, because it was made out of straight round or square tubular bar stock. And so it was just stainless steel bar stock and it had to all be straight.
They were very simple designs, but that's how I got started. We used the same grade of steel that surgical instruments were made of. I didn't design anything that was going to be left in the shoulder, these were just for passing instruments, tying knots.
So then fast forward to the suture anchor era. So now we're getting to the point now where we're doing reconstructive and repair types of techniques. Really, I think, became imperative at that point that we feel like we were conscientiously doing this and I felt this moral obligation to prove that what we were going to be able to do arthroscopically was going to be biomechanically and structurally equivalent to the open repair constructs.
Once we had the suture anchors and I became adept at placing those, we did bench work and biomechanical testing, cyclic loading tests, on the transosseous repairs compared to the anchor repairs. And actually, showed suture anchor repairs were superior and they shifted the weak leak from the bone to the suture tendon interface.
Knots were very important. It's interesting that even before I started doing the suture anchor repairs, probably the first arthroscopic project that I became involved in was I developed a jig system and a suture passing system for doing transosseous arthroscopic cuff repairs.
Tying an arthroscopic knot over a bone bridge is very difficult, because part of what we depended on if you had a sliding knot was bringing it down over soft tissue and sort of bunching up the soft tissue to hold the first part of it. When you're tying over bone, whatever you put down initially would invariably slip back a couple of millimeters at least, or maybe more.
And so I was having trouble solving that problem of how we were going to get that to hold. So then I thought well, it's just like a kid that's tying a shoelace. When you teach them to tie a shoelace, which they don't really do I guess anymore, but the first half hitch and they put their finger over it and then they tie the bow over top of that.
So, I thought of how we could basically copy that with an instrument, and came up with this sixth finger design so that we would have a slidable plastic tube outside of a cannulated metal tube. And what I did was I just happened to think of it one day, went to the hardware store, and got a piece of copper tubing. Which was going to be my metal tube. And then I bought a caulking gun and I cut the nozzle off with a hole in it where it would be the plastic sleeve over the top of the copper tubing.
And then I got some fishing line and I found I could just tie knot after knot that was very secure and it wouldn't slip. So that was the ... we called it the surgeon's sixth finger, because it gave you an extra finger to tie, to push down on the knot inside the joint.
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.
This concludes part one of this two part episode on the Inaugrual AANA Innovations Lecture. Please join us in the future for part 2 of this podcast.