First Steps
I sketched out my ideas for arthroscopic suture passers and knot-tying instruments and presented them to a couple of the major arthroscopy companies in the United States, but the companies were not interested. They did not believe arthroscopy would have any meaningful applications in the shoulder. So, I enlisted the services of a local San Antonio aircraft machinist to fabricate instruments for me. By 1987, I was doing arthroscopic side-to-side margin convergence1 cuff repairs for U-shape tears on a regular basis. And I was doing these at the most hostile point in the universe for arthroscopic shoulder surgery: San Antonio, Texas.
Only a few surgeons were doing arthroscopic shoulder surgery in the 1980s and early 1990s, and without exception these surgeons became the leader-pioneers in the new discipline. In general, these were young surgeons who were in private practice and removed from academia and professional organizations, and thus relatively sheltered from the actions of the shoulder rule-makers of the day. They accepted their status as pariahs as they developed their techniques out of the view of mainstream orthopedics. These leaders included Jim Esch, Steve Snyder, Dick Caspari, Lanny Johnson, Gene Wolf, Gary Gartsman, Rob Bell, and Howard Sweeney. We shared our techniques and our ideas with one another, encouraged one another, and generally became good friends.
Thomas Kuhn, in his classic book The Structure of Scientific Revolutions,2 observed that paradigm shifts within a given field were usually achieved by practitioners who were either very young (naïve) or outside the established hierarchy in the field. The surgeons who contributed most to the shift of shoulder surgery from open to arthroscopic techniques were generally young men who were in private practice and had little to lose by inciting the disdain of the shoulder establishment. Predictably, resistance from the mainstream open shoulder surgeons increased as arthroscopic techniques became more successful and more threatening to the primacy of the open shoulder surgeons. The disdain yielded to disruption and finally to transformation as the paradigm shift occurred. The conflict between the open shoulder surgeons and the arthroscopic shoulder surgeons passed through all the phases that Mahatma Gandhi had described many years before. “First they ignore you; then they laugh at you; then they fight you; then you win.”
Building a Ship in a Bottle
At the start of the 1990s, I recognized that my progress in arthroscopic rotator cuff repair would be extremely slow unless I could find an industry partner who shared my vision for full-scale conversion to arthroscopic means of repair and would be willing to help make it a reality. In 1991, I happened to meet Reinhold Schmieding, the owner of Arthrex, a small arthroscopic device company in Naples, Florida. Reinhold invited me to visit him to discuss the feasibility of developing arthroscopic repair systems for the shoulder. At the time, the world headquarters of Arthrex was a 20×30-ft storage room in an office service center, and there were 2 employees. One employee, Don Grafton, was a talented engineer without medical experience. By the end of my first day there, Reinhold and Don and I had agreed that developing arthroscopic repair systems for shoulder instability and rotator cuff repair would become a top priority for Arthrex.
My initial bias toward arthroscopic cuff repair was that a transosseous bone tunnel technique not only would be possible but would be superior to suture anchor fixation. In fact, my first 2 patents with Arthrex were for instrumentation for an arthroscopic transosseous repair technique. I tested my hypothesis with 2 successive biomechanical studies. The first examined cyclic loading of bone tunnel repairs, and the second examined cyclic loading of anchor-based repairs.3,4 Evaluating the data from these 2 studies, I was surprised to find that anchor-based repairs were significantly stronger than bone tunnel repairs. In addition, anchors shifted the weak link from the bone–suture interface to the tendon–suture interface; in essence, anchors optimized bone fixation by shifting the weak link in the construct to the tendon. I was then completely convinced of the superiority of suture anchors over bone tunnels, and that conviction has become even stronger over the years. After these 2 cyclic loading studies, I shifted my focus, and that of Arthrex, toward arthroscopic suture anchor repair of the rotator cuff.
Reconciling Technique and Instrumentation With Anatomy and Biomechanics
Having recognized the importance of the rotator cable attachments both anatomically5 and biomechanically,6,7 I thought it important to reinforce them as a routine part of performing rotator cuff repairs. Our anatomical and biomechanical studies had had great translational implications in the development of our techniques and instrumentation.