Rockwood and Matsen's "The Shoulder"

Dear CSS Colleagues:

I’d like to share with you my insight into an exceptional, state of the art book on Shoulder Care. I believe this will be an enduring resource for years to come, but it is even more than this.

This seminal work considers the current standards for shoulder surgery as offered by experts in their field. While each chapter is a “gem,” the features which differentiate this book from other textbooks are the Opinion Editorials written by individuals who blend known science with a vision for the future. In fact, Matsen and colleagues have had the creative forethought to attach these insights into the body of the book, connected with Topics on issues of shoulder care. The result is a unique work that belongs in every orthopedic surgeon’s library. Here are the individual Opinion Editorials:

I’d like to offer some insights on the first three Opinion Editorials which I’ve listed above. These are especially interesting to me, as they speak to the important questions of Innovation and Value. Here are a few points I’d like to leave you with as the philosophy of each of these authors could be a framework for your own consideration of priorities in treatment as well as the risk of innovation. You’ll have to buy the book to get the full scope of these author’s collective wisdom.

I have known Christian Gerber for just over 3 decades and this Opinion Editorial reflects a Code by which he lives his life as a surgeon and a physician. His Code is simply expressed in the Figure below which I’ve re-drawn from the chapter:

Gerber gives us this framework for prioritizing the factors which affect the decision-making process for patient care. In his own words “Everyone has a Cartesian Coordinate system in which they move and that defines where they stand. My Cartesian is called the Pyramid.” Simply put, the patient’s interests are at the top of the pyramid. Next is the commitment to Orthopedics. By this, Gerber means that evidence-based decisions must be made when it comes to treating patients, and if the evidence is lacking, then scientific study must provide this. The third level down is the institution in which we work. Here if two treatments work equally well, the lowest cost is the best choice. The lowest level should be ego. Gerber goes on to point out that this concept should be the template upon which all decisions for patient care are made. He further describes how one can also apply this to resident education as well as basic principles of research.

I first met Rick Matsen in 1988 at the ICSES Meeting (International Congress for Surgery of the Elbow and Shoulder) in NYC. He created much of the foundation of knowledge in management of shoulder problems which has guided many in my generation. In his Opinion Editorial, he raises real questions about the dark side of innovation. He reminds us of the truism that “The Surgeon is the Method.” This is a term he has used for years, and it aptly describes how skill developed over years is more important than the implant being used. He goes on to call out the concept of innovation, for it’s not uncommon for an “innovation” to fail to deliver real value to patients. In fact, the exponential growth of “innovation” in arthroplasty, for example, has led to mainly derivative products that provide little value compared to what has been used before. That said, some of you may disagree, as do I, with his position on value of new implants and even digital technology when it comes to the question of value. There is no question that not all innovation creates value, but this is not surprising when one also considers that the average failure rate of medical start-up companies is about 80%. The point is, the definition of value varies depending on who you ask, and the studies required to determine if one implant is better than another are difficult if not impossible to perform. We should continue to try and innovate with the context of Value = Outcome/Cost.

In this last opinion piece, Jon Ticker and I have tried to give insight into the real meaning of the word “Innovation” and to look at this through the lens of history. Who were the great innovators in shoulder surgery?

While I draw on much of what I learned at Harvard Business School, we also consider the approach developed in the Surgical Innovation Program at Stanford. We asked the members of the Codman Shoulder Society to come up with their list of innovations using the framework we provided. Here is what they said:

1. Reverse Shoulder Replacement

2. Anchor technologies (for soft tissue to bone repair)

3. Arthroscopic soft-tissue repair

4. Anatomic total shoulder arthroplasty

5. Functional tendon transfer

6. Latarjet procedure

7. Arthroscopic soft-tissue and bone removal

8. Goutallier Classification of fatty muscle degeneration of the rotator cuff

9. Anatomic plate fixation for fracture care

10. Proximal humerus fracture classification

11. Two/three-dimensional cross-sectional imaging

12. Graft augment/replacement in cuff repair

13. Outcome measurement scoring systems

14. Open transosseous cuff repair

15. Planning tools for shoulder arthroplasty

16. Suture technologies

17. Open instability pathology and repair

18. Shoulder-dedicated education

19. Subscapularis pathology understanding and treatment

In conclusion. I strongly recommend this book and firmly believe it will be a guiding framework for your future approaches to problems affecting the shoulder.

Kind Regards,

“JP” Warner MD

Founder, CSS