Stephen S Burkhart’s research while affiliated with The University of Texas at San Antonio and other places

Full-thickness rotator cuff tears are commonly encountered and can be a substantial source of pain and overall shoulder dysfunction. Normal shoulder function is largely predicated on functioning, coupled anterior and posterior forces that are balanced across the glenohumeral joint, and full-thickness rotator cuff tears derange the reciprocal relationship between these force couples. Rotator cuff repair healing is critical to restoring shoulder strength, and a linked double-row repair construct maximizes healing at the tendon-to-bone interface. The keys to successful arthroscopic rotator cuff repair include achieving adequate visualization of all relevant pathology, accurately characterizing tear pattern morphology, mobilizing retracted tendon tissues, and performing an anatomic, tension-free repair. Post-operatively, a conservative approach to advancing patients’ activity should be undertaken so as to maximize the likelihood of healing, with active strengthening deferred until at least 3 months post-operative.KeywordsFull thicknessForce couplesFoot print restorationLinked double-row repair

Purpose: To characterize the outcomes and range of motion at a minimum 5-year follow-up in patients undergoing arthroscopic rotator cuff repair (ARCR) with simultaneous manipulation under anesthesia (MUA) and capsular release (CR) for concurrent RC and adhesive capsulitis and to compare active range of motion of the operative and nonoperative shoulder. Methods: Patients undergoing ARCR with MUA and CR by a single surgeon were retrospectively reviewed and prospectively evaluated at a minimum of 5 years postoperatively. Standardized surveys, examinations, and patient-reported outcomes were recorded pre- and postoperatively. Outcome measures included range of motion, American Shoulder and Elbow Surgeon Score (ASES), visual analog score (VAS) for pain, Simple Shoulder Test (SST), subjective shoulder value (SSV), functional level, and satisfaction. Results: Fourteen consecutive patients were evaluated at 7.5 ± 1.6 years' follow-up. At final follow-up, the affected shoulder had substantial improvements in ASES (P < .001), VAS (P < .001), SST (P = .001), and SSV (P < .001), with similar ASES, VAS, SST, and SSV compared with the contralateral side. Range of motion was also similar to the contralateral side at final follow-up for forward elevation and internal rotation, but external rotation was noted to be 10.77 ± 17.06° (95% confidence interval 0.46-21.08, P = .042) more limited. Two patients (14%) underwent revision MUA and CR for stiffness at 6 months and 12 months' postoperatively. Conclusions: This study highlights significantly improved and maintained patient-reported outcomes and range of motion at minimum 5-year follow-up in patients undergoing concomitant ARCR, MUA, and CR. These results provide further evidence that preoperative stiffness in the setting of rotator cuff tear can be managed concurrently; however, patients may remain at an increased risk for recurrent stiffness and external rotation loss. Level of evidence: Level IV, therapeutic case series.

Purpose: The purposes of this study were to investigate the difference in value (benefit to cost ratio) of dermal allograft superior capsular reconstruction (SCR) versus reverse total shoulder arthroplasty (rTSA) for the treatment of massive rotator cuff tears (MRCTs) without arthritis; to compare the patient populations selected for the operations and report pre- and postoperative functional data; and to understand other characteristics of the 2 operations, including operating time, use of institutional resources, and complications. Methods: A retrospective, single-institution analysis during the study period 2014-2019 with MRCT treated with SCR or rTSA by 2 surgeons with complete institutional cost data and minimum 1-year clinical follow-up with American Shoulder and Elbow Surgeons (ASES) score. Value was defined as ΔASES/(total direct costs/$10,000). Results: Thirty patients underwent rTSA and 126 patients SCR during the study period with significant differences noted in patient demographics and tear characteristics between the groups (patients who underwent rTSA were older, less male, had more pseudoparalysis, had greater Hamada and Goutallier scores, and had more proximal humeral migration). Value was 25 and 29 (ΔASES/$10,000) for rTSA and SCR, respectively (P = .7). The total costs of rTSA and SCR were $16,337 and$12,763, respectively (P = .7). Both groups experienced substantial improvements in ASES scores: 42 for rTSA vs 37 for SCR (P = .6). The operative time for SCR was much longer (204 vs 108 minutes, P < .001) but complication rate lower (3% vs 13%, P = .02) versus rTSA. Conclusions: In a single institutional analysis of the treatment of MRCT without arthritis, rTSA and SCR demonstrated similar value; however, the value calculation is highly dependent on institution specific variables and duration of follow-up. The operating surgeons demonstrated different indications in selecting patients for each operation. rTSA had an advantage over SCR in shorter operative time, whereas SCR demonstrated a lower complication rate. Both SCR and rTSA are demonstrated to be effective treatments for MRCT at short-term follow-up. Level of evidence: III, retrospective comparative study.

Objective To evaluate the outcomes of arthroscopic superior capsular reconstruction (SCR) augmentation of complete, massive rotator cuff repair (RCR). Methods A retrospective study of dermal allograft SCR augmented RCR by single surgeon from June 2016 - December 2017 was performed with inclusion criteria as follows: massive rotator cuff tear amenable to complete repair but with poor quality native rotator cuff tissue. Radiographic follow-up was performed at 1-year, and clinical follow up at both 1-year and minimum 2 years after surgery. Clinical follow up included the American Shoulder and Elbow Surgeons (ASES) score, the Visual Acuity Scale (VAS) for pain, the Subjective Shoulder Value (SSV), active forward elevation (aFE), and external rotation (aER). Radiographs and MRI scans were assessed for muscle quality using the Goutallier classification, and graft and cuff integrity according to Sugaya’s classification. Results Twenty-four patients met inclusion criteria at one-year and 18 (75%) at minimum 2 years postoperative. Patient reported outcomes were improved versus preoperative and maintained at minimum 2-year follow-up: median (IQR) ASES 42.5 (30.8-58.7) to 93.9 (82.4-100), p < .001; SSV 30 (20-50) to 90 (86.2-97.2), p < .001; VAS pain 5.5 (1-9) to 0 (= 0-0.8), p = .001. Evaluation of graft and tendon healing on postoperative MRI had poor interobserver agreement and showed 10 (42%) completely healed grafts, 9 (38%) partially healed, and 5 (21%) completely disrupted grafts with 42% and 54% of supraspinatus and infraspinatus tendons healed. Conclusions Superior capsular reconstruction with dermal allograft augmentation of complete rotator cuff repairs with poor quality tissue demonstrates very good clinical outcomes at minimum 2-year follow-up. Poor interobserver agreement in postoperative graft and rotator cuff integrity by MRI was found. The healing rate for the SCR grafts was 79%. Rates of healing of the native supraspinatus, and infraspinatus tendons were 42% and 54% respectively.

This article constitutes the text of the Codman Lecture, delivered by the author to the attendees of the International Congress of Shoulder and Elbow Surgeons on September 19, 2019, in Buenos Aires, Argentina.

The transition from open shoulder surgery to arthroscopic shoulder surgery represents a classic paradigm shift. In order for that paradigm shift to have occurred, the early pioneers in this discipline had to assume several burdens of their new craft: the burden of “arthroscopic identification”; the burden of developing the language of arthroscopy; the burden of disseminating arthroscopic knowledge; the burden of developing safe arthroscopic instruments and implants; and the burden of proving biomechanical and structural equivalency between arthroscopic and open constructs. Embracing these obligations, they were able to produce the paradigm shift to arthroscopic shoulder surgery through a spirited mix of depth, breadth, and tenacity, defying long odds and conventional wisdom while creating a major breakthrough in shoulder surgery. The American physicist and philosopher Thomas Kuhn coined the term paradigm shift in 1962 in his classic book The Structure of Scientific Revolutions (Ref 1). He defined paradigm shift as a fundamental change in the basic concepts and practices of a discipline. Based on that definition, I believe that the transition from open shoulder surgery to arthroscopic shoulder surgery represents a classic paradigm shift.