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Medical Journals Should Be a Forum for Disruptive Research

      Abstract

      Disruptive innovation completely changes the traditional way that we operate and may only be realized in retrospect. For example, shoulder superior capsule reconstruction (SCR) is a complete change from the traditional methods of treating massive, irreparable rotator cuff tears and pseudoparalysis. Classic examples of disruptions in orthopaedic surgery include distraction osteogenesis, total hip joint replacement arthroplasty, and modern orthopaedic trauma care. Orthopaedic technologies that promise future disruption include artificial intelligence, surgical simulation, and orthopaedic biologics, including mesenchymal stromal cell (MSC) and gene therapy. Most of all, arthroscopic surgery completely changed the way we operate by using new methods and technology. Many never saw it coming. The challenge going forward is to motivate and foster new ideas and research that result in innovation and progress. Skepticism has a place, but not at the expense of transformative ideas, particularly as medical journals offer the alternative of prospective hypothesis testing using the scientific method, followed by unbiased peer review, and publication. Medical journals should be a forum for disruptive research.
      Disruption (business): “The action of completely changing the traditional way that an industry or market operates by using new methods or technology”--The Cambridge Dictionary
      The term “disruptive innovation” was first popularized by Bower and Christensen, who identified a failure of leading companies to remain at the top as technologies or markets change.
      • Bower J.L.
      • Christensen C.M.
      Disruptive technologies: Catching the wave.
      A contemporary example of disruptive technology could be Web-based video applications, such as Netflix, which have changed the way people experience television and movies. On the other hand, while ride-sharing companies like Uber may eventually displace traditional taxi companies, ride-sharing companies have not completely changed the way the industry operates; rather, the companies have upgraded the technology, but we still summon a car. That said, disruptive innovation occurs stealthily and may only be realized in retrospect.
      As with the examples above, we acknowledge that some may disagree with what we define as disruptive or not disruptive. Bearing in mind this caveat, from our point of view, surgical techniques are frequently modified, but most modifications do not “completely” change how we operate. For example, “new” ACL techniques, such as double-bundle,
      • Kim J.H.
      • Oh E.
      • Yoon Y.C.
      • Lee D.K.
      • Lee S.-S.
      • Wang J.H.
      Remnant-tensioning single-bundle anterior cruciate ligament reconstruction provides comparable stability to and better graft vascularity than double-bundle anterior cruciate ligament reconstruction in acute or subacute injury: A prospective randomized controlled study using dynamic contrast-enhanced magnetic resonance imaging.
      anatomic,
      • Mermerkaya M.U.
      • Büyükdoğan K.
      • Hakyemez Ö.S.
      • Birinci M.
      • Avcı C.C.
      Editorial Commentary: Anatomic or not, the tunnel will get wider!.
      all-inside,
      • Smith P.A.
      • Cook C.S.
      • Bley J.A.
      All-inside quadrupled semitendinosus autograft shows stability equivalent to patellar tendon autograft anterior cruciate ligament reconstruction: Randomized controlled trial in athletes 24 years or younger.
      or new graft options,
      • Smith P.A.
      • Cook C.S.
      • Bley J.A.
      All-inside quadrupled semitendinosus autograft shows stability equivalent to patellar tendon autograft anterior cruciate ligament reconstruction: Randomized controlled trial in athletes 24 years or younger.
      or preparation methods,
      • Lamplot J.D.
      • Liu J.N.
      • Hutchinson I.D.
      • et al.
      Effect of vancomycin soaking on anterior cruciate ligament graft biomechanics.
      seem like refinement rather than disruption. “New” soft tissue-to-bone fixation implants, such as those used in shoulder surgery, may allow us to operate with greater facility, but have not “completely” changed what we accomplish.
      • Frank R.M.
      Editorial commentary: Biceps tenodesis fixation: Screw, button, or none of the above?.
      In contrast, among recent surgical innovations, we find shoulder superior capsule reconstruction (SCR) to be a “disruptive technology”; this new surgical technique is a complete change from the traditional methods of treating massive, irreparable rotator cuff tears and pseudoparalysis like tendon transfer or reverse total shoulder replacement.
      • Smith T.J.
      • Gowd A.K.
      • Kunkel J.
      • Kaplin L.
      • Waterman B.R.
      Superior capsular reconstruction provides sufficient biomechanical outcomes for massive, irreparable rotator cuff tears: A systematic review.
      Classic examples of disruptions in orthopaedic surgery
      • Gerber C.
      What’s important: Disruption in research.
      may include the technique described by Ilizarov for distraction osteogenesis,
      • Gubin A.V.
      • Borzunov D.Y.
      • Marchenkova L.O.
      • Malkova T.A.
      • Smirnova I.L.
      Ilizarov to bone reconstruction: Historical achievements and state of the art.
      innovations leading to successful total hip joint replacement arthroplasty credited primarily to Charnley,
      • Gomez P.F.
      • Morcuende J.A.
      A historical and economic perspective on Sir John Charnley, Chas. F. Thackray Limited, and the early arthroplasty industry.
      and the introduction of modern orthopaedic trauma care and education by the AO Group founded by Müller, Allgöwer, and Willenegger.
      • Heim U.F.A.
      Geschichte der Entstehung und erste Jahre der Arbeitsgemeinschaft für Osteosynthesefragen 1952-1963.
      Examples of orthopaedic technologies that hold promise for future disruption include artificial intelligence,
      • Ramkumar R.N.
      • Kunze K.N.
      • Haeberle H.S.
      • et al.
      Clinical and research medical applications of artificial intelligence.
      surgical simulation,
      • Richard L.
      • Angelo R.L.
      • St Pierre P.S.
      • Tauro J.
      • Gallagher A.G.
      Shoulder PBP Instructional Faculty
      A proficiency-based progression simulation training curriculum to acquire the skills needed in performing arthroscopic Bankart and rotator cuff repairs—Implementation and impact.
      and orthopaedic biologics, including mesenchymal stromal cell (MSC)
      • Branch E.A.
      • Matuska A.M.
      • Plummer H.A.
      • Harrison R.M.
      • Anz A.W.
      Platelet-rich plasma devices can be used to isolate stem cells from synovial fluid at the point of care.
      and gene therapy.
      • Lee Y.-S.
      • Kim J.-Y.
      • Ki S.-Y.
      • Chung S.W.
      Influence of smoking on the expression of genes and proteins related to fat infiltration, inflammation, and fibrosis in the rotator cuff muscles of patients with chronic rotator cuff tears: A pilot study.
      Again, here, time will tell.
      And “time will tell” is telling. Innovators responsible for critically disruptive medical breakthroughs were initially ridiculed by their peers. Gruntzig, the German cardiologist responsible for developing the concept of balloon angioplasty produced the initial device in his kitchen.
      • Zeitler E.
      Zur Geschichte der Katheterbehandlung der arteriellen Verschlusskrankheit.
      ,
      • Barton M.
      • Grüntzig J.
      • Husman M.
      • Rösch J.
      Balloon angioplasty—The legacy of Andreas Gruntzig, M.D. (1939-1985).
      When he first presented his idea to his peers, he was told “it will never work” and “never happen in my hospital.”
      • Zeitler E.
      Zur Geschichte der Katheterbehandlung der arteriellen Verschlusskrankheit.
      When Warren and Marshall announced that, in addition to stress, Helicobacter pylori infection could lead to peptic ulcer disease, Marshall was pushed to infect himself and undergo gastric biopsy to finally prove his point; ultimately, he was awarded the Nobel Prize.
      • Ahmed N.
      23 years of the discovery of Helicobacter pylori: Is the debate over?.
      This brings us to Arthroscopy, our journal; arthroscopy, our field; and AANA, the Arthroscopy Association of North America. The complete history of AANA; arthroscopy; and Arthroscopy (not to mention Arthroscopy Techniques, and Arthroscopy, Sports Medicine, and Rehabilitation) is for another day and will fill volumes. The names and accomplishments of arthroscopic disruptors are too numerous to mention, and attempting to do so risks failing to be comprehensive. Thus, in brief: In Japan, Watanabe initiated a revolution when he adapted and introduced the “Number 22 Arthroscope,” the first ultrathin, fiberoptic endoscope, into the knee joint.
      • Jackson R.W.
      A history of arthroscopy.
      Jackson, of Toronto, visited Watanabe, and both figuratively and literally brought arthroscopy to North America.
      • Jackson R.W.
      A history of arthroscopy.
      Jackson and his colleagues eventually formed AANA, promulgated arthroscopy as a result of their founding teaching mission, and established the Arthroscopy journal. Their efforts were met with criticism and scorn every step of the way.
      • Jackson R.W.
      A history of arthroscopy.
      Rockwood is credited with asking: “Why look through the keyhole when you can open the door?” and denouncing arthroscopy as an “instrument of the devil.” Later, in more measured tones, Dr. Rockwood did not hesitate to publish that “the use of the arthroscope for operative procedures is still in the developing stages; its use should be considered as a research tool and remains controversial.
      • Rockwood Jr., C.A.
      Editorial: Shoulder arthroscopy.
      This was in the Journal of Bone & Joint Surgery in 1988; talk about failing to recognize disruption!
      The rest is history—our history. Arthroscopic surgery is a classic example of disruptive innovation. Without a doubt, arthroscopy “completely” changed the traditional way we operate by using new methods and technology. Andrews identifies the arthroscope as “the major milestone” that “revolutionized sports medicine”.
      • Andrews J.
      Andrews Institute for Orthopaedics & Sports Medicine
      How the arthroscope revolutionized sports medicine; biologics next revelation.
      And, to be fair to Dr. Rockwood, many never saw it coming. Thank goodness for AANA and our visionary, unapologetic, unrelenting, founding, disruptive leaders.
      • Field L.D.
      AANA: Education, innovation, and the power of volunteerism.
      Recently our Swiss colleagues have created the Meyer Award to support “disruption in orthopedics” and to award those who forswear “me too” research in favor of research that truly “change(s) the destiny of musculoskeletal patients.”
      • Gerber C.
      What’s important: Disruption in research.
      The challenge is to motivate and foster new ideas and research that result in innovation, progress, and new and better methods and technology. We fully support this intention that honors and continues the Arthroscopy, arthroscopy, and AANA tradition.
      • Field L.D.
      AANA innovations lecture. Introduction of the inaugural AANA innovations lecture by Stephen S. Burkhart, M.D.
      Let us learn from the errors of the past. Healthy skepticism has a place, but not at the expense of potentially transformative ideas. There is no place for ridicule, particularly as medical journals offer as an alternative, prospective hypothesis testing using the scientific method, followed by unbiased peer review and publication.
      National Library of Medicine
      Quality in peer review.
      While many fail to recognize disruption and are “late to the party,” we are eager to provide a forum for future paradigm shifts.
      • Petty N.J.
      • Thomson O.P.
      • Stew G.
      Ready for a paradigm shift? Part 1: Introducing the philosophy of qualitative research.
      Medical journals should be a forum for disruptive research.
      • Bublitz F.M.
      • Oetomo A.
      • Sahu K.S.
      • et al.
      Disruptive technologies for environment and health research: An overview of artificial intelligence, blockchain, and internet of things.

      References

      1. Cambridge dictionary.
        (Available at)
        • Bower J.L.
        • Christensen C.M.
        Disruptive technologies: Catching the wave.
        Harvard Bus Rev. 1995; (;Jan-Feb:43-53. Available online at)
        • Kim J.H.
        • Oh E.
        • Yoon Y.C.
        • Lee D.K.
        • Lee S.-S.
        • Wang J.H.
        Remnant-tensioning single-bundle anterior cruciate ligament reconstruction provides comparable stability to and better graft vascularity than double-bundle anterior cruciate ligament reconstruction in acute or subacute injury: A prospective randomized controlled study using dynamic contrast-enhanced magnetic resonance imaging.
        Arthroscopy. 2021; 37: 209-221
        • Mermerkaya M.U.
        • Büyükdoğan K.
        • Hakyemez Ö.S.
        • Birinci M.
        • Avcı C.C.
        Editorial Commentary: Anatomic or not, the tunnel will get wider!.
        Arthroscopy. 2020; 36: 1112-1113
        • Smith P.A.
        • Cook C.S.
        • Bley J.A.
        All-inside quadrupled semitendinosus autograft shows stability equivalent to patellar tendon autograft anterior cruciate ligament reconstruction: Randomized controlled trial in athletes 24 years or younger.
        Arthroscopy. 2020; 36: 1629-1646
        • Lamplot J.D.
        • Liu J.N.
        • Hutchinson I.D.
        • et al.
        Effect of vancomycin soaking on anterior cruciate ligament graft biomechanics.
        Arthroscopy. 2020; 37: 953-960
        • Frank R.M.
        Editorial commentary: Biceps tenodesis fixation: Screw, button, or none of the above?.
        Arthroscopy. 2020; 36: 1261-1263
        • Smith T.J.
        • Gowd A.K.
        • Kunkel J.
        • Kaplin L.
        • Waterman B.R.
        Superior capsular reconstruction provides sufficient biomechanical outcomes for massive, irreparable rotator cuff tears: A systematic review.
        Arthroscopy. 2020; 37: 402-410
        • Gerber C.
        What’s important: Disruption in research.
        J Bone Joint Surg. 2021; 103: 646-647
        • Gubin A.V.
        • Borzunov D.Y.
        • Marchenkova L.O.
        • Malkova T.A.
        • Smirnova I.L.
        Ilizarov to bone reconstruction: Historical achievements and state of the art.
        Strateg Trauma Limb Reconstr. 2016; 11: 145-152
        • Gomez P.F.
        • Morcuende J.A.
        A historical and economic perspective on Sir John Charnley, Chas. F. Thackray Limited, and the early arthroplasty industry.
        Iowa Orthop J. 2005; 25: 30-37
        • Heim U.F.A.
        Geschichte der Entstehung und erste Jahre der Arbeitsgemeinschaft für Osteosynthesefragen 1952-1963.
        OP J. 2012; 28 ([in German]): 98-106
        • Ramkumar R.N.
        • Kunze K.N.
        • Haeberle H.S.
        • et al.
        Clinical and research medical applications of artificial intelligence.
        Arthroscopy. 2020; 37: 1694-1697
        • Richard L.
        • Angelo R.L.
        • St Pierre P.S.
        • Tauro J.
        • Gallagher A.G.
        • Shoulder PBP Instructional Faculty
        A proficiency-based progression simulation training curriculum to acquire the skills needed in performing arthroscopic Bankart and rotator cuff repairs—Implementation and impact.
        Arthroscopy. 2020; 37: 1099-1106.e5
        • Branch E.A.
        • Matuska A.M.
        • Plummer H.A.
        • Harrison R.M.
        • Anz A.W.
        Platelet-rich plasma devices can be used to isolate stem cells from synovial fluid at the point of care.
        Arthroscopy. 2020; 37: 893-900
        • Lee Y.-S.
        • Kim J.-Y.
        • Ki S.-Y.
        • Chung S.W.
        Influence of smoking on the expression of genes and proteins related to fat infiltration, inflammation, and fibrosis in the rotator cuff muscles of patients with chronic rotator cuff tears: A pilot study.
        Arthroscopy. 2019; 35: 3181-3191
        • Zeitler E.
        Zur Geschichte der Katheterbehandlung der arteriellen Verschlusskrankheit.
        in: Husfeldt K.J. Roth F.J. Kokurrierende Verfahren in der Gefässchirurgie.Ed. 1. Springer, New York1995: 5-11
        • Barton M.
        • Grüntzig J.
        • Husman M.
        • Rösch J.
        Balloon angioplasty—The legacy of Andreas Gruntzig, M.D. (1939-1985).
        Front Cardiovasc Med. 2014; 1: 15
        • Ahmed N.
        23 years of the discovery of Helicobacter pylori: Is the debate over?.
        Ann Clin Microbiol Antimicrob. 2005; 4: 17
        • Jackson R.W.
        A history of arthroscopy.
        Arthroscopy. 2010; 26: 91-103
        • Rockwood Jr., C.A.
        Editorial: Shoulder arthroscopy.
        J Bone Joint Surg Am. 1988; 70: 639-640
        • Andrews J.
        • Andrews Institute for Orthopaedics & Sports Medicine
        How the arthroscope revolutionized sports medicine; biologics next revelation.
        (Available at)
        • Field L.D.
        AANA: Education, innovation, and the power of volunteerism.
        Arthroscopy. 2020; 36: 1781-1787
        • Field L.D.
        AANA innovations lecture. Introduction of the inaugural AANA innovations lecture by Stephen S. Burkhart, M.D.
        Arthroscopy. 2020; 36: 1502
        • National Library of Medicine
        Quality in peer review.
        Commun Biol. 2019; 2: 352https://doi.org/10.1038/s42003-019-0603-3
        • Petty N.J.
        • Thomson O.P.
        • Stew G.
        Ready for a paradigm shift? Part 1: Introducing the philosophy of qualitative research.
        Man Ther. 2012; 17: 267-274
        • Bublitz F.M.
        • Oetomo A.
        • Sahu K.S.
        • et al.
        Disruptive technologies for environment and health research: An overview of artificial intelligence, blockchain, and internet of things.
        Int J Environ Res Public Health. 2019; 16: 3847