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Editorial Commentary: The Surgeon Is the Method: Be Thoughtful and Methodical When Adopting New Techniques

      Abstract

      Arthroscopic and open Latarjet procedures can achieve similar results with similar complication rates and a low risk of recurrent instability, but these results may not be generalizable to every surgeon or practice. When considering a new procedure, surgeons should thoughtfully consider a stepwise approach to acquiring new skills and avoiding complications.
      A mentor of mine, and of many shoulder surgeons and arthroscopists before and after me, Dr. Frederick Matsen, was famous for saying, “The surgeon is the method.” The article “Open Versus Arthroscopic Latarjet Procedure for the Treatment of Chronic Anterior Glenohumeral Instability With Glenoid Bone Loss” by Ali, Altintas, Pulatkan, Boykin, Aksoy, and Bilsel
      • Ali J.
      • Altintas B.
      • Pulatkan A.
      • et al.
      Open versus arthroscopic Latarjet procedure for the treatment of chronic anterior glenohumeral instability with glenoid bone loss.
      is an excellent example of what I have come to call Matsen’s dictum.
      In this retrospective series of 48 patients by a single surgeon, the authors found overall similar clinical results between open and arthroscopic approaches. This group is interesting to me because all patients had what would be considered “subcritical” glenoid bone loss (less than 17%). This is relevant since these patients would receive a primary arthroscopic Bankart repair in my practice, and likely with many other surgeons in the United States. I do acquiesce the case for primary Latarjet ever since Dr. Tokish published diminished functional results with subcritical bone loss after arthroscopic Bankart repair
      • Shaha J.S.
      • Cook J.B.
      • Song D.J.
      • et al.
      Redefining “critical” bone loss in shoulder instability: Functional outcomes worsen with “subcritical” bone loss.
      and since other studies have supported primary Latarjet over Bankart repair in this subset of patients.
      • Jeon Y.S.
      • Jeong H.Y.
      • Lee D.K.
      • Rhee Y.G.
      Borderline glenoid bone defect in anterior shoulder instability: Latarjet procedure versus Bankart repair.
      Exploring my own bias, I think I continue to perform arthroscopic Bankart repairs because I feel comfortable with a technique that has been effective for me and my specific patient population, but I suspect that in part it is the familiar trap that arthroscopy seems like “less surgery” with smaller incisions and a faster recovery.
      In regards to the Latarjet procedure, a recent systematic review and meta-analysis comparing open and arthroscopic approaches suggested similar clinical outcomes, recurrence rates, and revision rates.
      • Hurley E.T.
      • Lim Fat D.
      • Farrington S.K.
      • Mullett H.
      Open versus arthroscopic Latarjet procedure for anterior shoulder instability: A systematic review and meta-analysis.
      ,
      • Randelli P.
      • Fossati C.
      • Stoppani C.
      • Evola F.R.
      • De Girolamo L.
      Open Latarjet versus arthroscopic Latarjet: Clinical results and cost analysis.
      Therefore, I was not surprised when these authors replicated those results. They did not assess early postoperative range of motion or early visual analog scale pain scores, where we would expect to see the advantages of the arthroscopic approach. Much like arthroscopic versus open rotator cuff repair, the final results are the same. This paper confirms the noninferiority of the arthroscopic approach to complete the procedure effectively.
      I was surprised, however, that the Rowe scores in this series were somewhat different than those published in that meta-analysis because this cohort seems to represent a best-case scenario of minimal glenoid bone loss. This may be because this was early in the surgeon’s conversion from open to arthroscopic treatment or to unknown factors specific to this surgeon or this cohort of patients. Either way, it is an important reminder that individual surgeons and individual patients are just that, individuals, and not means or medians.
      Whenever we are considering a new procedure or approach, we need to ask ourselves how a specific procedure applies to our practice and whether we have what it takes to truly adopt it. Adopt is a powerfully appropriate word here because it can either mean (1) to take up, follow, or use, or (2) to legally take (another’s child) and bring it up as one’s own. With technically difficult and potentially dangerous procedures, we should consider using the second meaning.
      The “learning curve” for the arthroscopic Latarjet has been described as 10 cases to stop converting to open and 20 cases required to achieve similar operative time.
      • Cunningham G.
      • Benchouk S.
      • Kherad O.
      • Lädermann A.
      Comparison of arthroscopic and open Latarjet with a learning curve analysis.
      However, that is not the whole story. In that same series complications, screw placement inaccuracy, and apprehension remained greater in the arthroscopic group even though the functional outcomes were equivalent. If these problems remain, perhaps the “curve” is not really over.
      This reminds me of one of my favorite Arthroscopy editorials of all time, when Dr. Ochiai encouraged us to abandon the term “steep learning curve” altogether because it can equally mean that a new procedure is either difficult or easy.
      • Ochiai D.H.
      Editorial commentary: A steep learning curve for hip arthroscopy? I literally don't know what this means anymore.
      In the future, we will still need studies on how arthroscopic skills are acquired successfully before they are implemented, and this is happening in residency programs all across the country.
      • Gilmer B.B.
      • Guerrero D.M.
      • Coleman N.W.
      • Chamberlain A.M.
      • Warme W.J.
      Orthopaedic residents improve confidence and knot-tying speed with a skills course.
      ,
      • Hodgins J.
      • Veillette C.
      • Biau D.
      Quantitative assessment of surgical competence: The arthroscopic learning curve (SS-58).
      However, it is not happening among practicing surgeons. For those of us in practice, we seem slow to acknowledge that arthroscopic technology is advancing rapidly while our residency training grows dimmer in the rearview with time. What we need is a learning bridge: a smooth and reliable way to cross a knowledge gap.
      Which brings me back to Dr. Matsen. I cannot imagine performing shoulder arthroplasty without having first had his invaluable instruction and patient guidance. As practicing surgeons, we still need mentors to help us navigate the perilous and stressful waters of learning something new. And we need practice, both in the laboratory and in the classroom. The good news is that increasingly, these resources exist. Arthroscopy Association of North America APEx courses and laboratory courses make these opportunities available to anyone committed enough to sign up. We owe it to ourselves and our patients to genuinely “adopt” new techniques because any operation will only be as good as the surgeon performing it.

      Supplementary Data

      References

        • Ali J.
        • Altintas B.
        • Pulatkan A.
        • et al.
        Open versus arthroscopic Latarjet procedure for the treatment of chronic anterior glenohumeral instability with glenoid bone loss.
        Arthroscopy. 2020; 36: 940-949
        • Shaha J.S.
        • Cook J.B.
        • Song D.J.
        • et al.
        Redefining “critical” bone loss in shoulder instability: Functional outcomes worsen with “subcritical” bone loss.
        Am J Sports Med. 2015; 43: 1719-1725
        • Jeon Y.S.
        • Jeong H.Y.
        • Lee D.K.
        • Rhee Y.G.
        Borderline glenoid bone defect in anterior shoulder instability: Latarjet procedure versus Bankart repair.
        Am J Sports Med. 2018; 46: 2170-2176
        • Hurley E.T.
        • Lim Fat D.
        • Farrington S.K.
        • Mullett H.
        Open versus arthroscopic Latarjet procedure for anterior shoulder instability: A systematic review and meta-analysis.
        Am J Sports Med. 2019; 47: 1248-1253
        • Randelli P.
        • Fossati C.
        • Stoppani C.
        • Evola F.R.
        • De Girolamo L.
        Open Latarjet versus arthroscopic Latarjet: Clinical results and cost analysis.
        Knee Surg Sports Traumatol Arthrosc. 2016; 24: 526-532
        • Cunningham G.
        • Benchouk S.
        • Kherad O.
        • Lädermann A.
        Comparison of arthroscopic and open Latarjet with a learning curve analysis.
        Arthroscopy. 2015; 31: e4-e5
        • Ochiai D.H.
        Editorial commentary: A steep learning curve for hip arthroscopy? I literally don't know what this means anymore.
        Arthroscopy. 2017; 33: 1810-1811
        • Gilmer B.B.
        • Guerrero D.M.
        • Coleman N.W.
        • Chamberlain A.M.
        • Warme W.J.
        Orthopaedic residents improve confidence and knot-tying speed with a skills course.
        Arthroscopy. 2015; 31: 1343-1348
        • Hodgins J.
        • Veillette C.
        • Biau D.
        Quantitative assessment of surgical competence: The arthroscopic learning curve (SS-58).
        Arthroscopy. 2013; 29: e28