Since the arthroscope first enabled surgeons to peer into a joint, the field has advanced beyond merely using it as a diagnostic tool and has progressed to using it as a therapeutic instrument. Initially, the use of the arthroscope was limited to simple procedures such as biopsies and excising meniscal tears; however, with technical advances and instrument-design innovations, much more complex procedures are now performed with regularity. Nowhere is this advancement more evident than in shoulder surgery.
Massive complex rotator cuff tears are severely disabling and are challenging to reconstruct, even with open surgical techniques such as tendon grafts or transfers, some of which have been published in JBJS Essential Surgical Techniques (EST)1. Now, JBJS EST is highlighting the technical mastery attained by the authors of 2 articles in the current JBJS EST issue as they instruct on the use of advanced arthroscopic techniques to reconstruct massive rotator cuff tears, using dermal grafts as the native cuff is insufficient to reconstruct the defect in these massive tears. Through a combination of innovative instruments, multiple portals, elegant knot-tying, controlled suture passaging, and anchoring advances, these authors have managed to perform a complex procedure while utilizing minimally invasive techniques in an effort to improve outcomes for this debilitating condition.
Both groups of surgeon authors have taken different scholarly approaches to demonstrate these skills, with each utilizing 1 of the 2 different article formats provided by JBJS EST. Adams et al. have utilized the traditional Subspecialty Procedures article format to present written text with step-by-step instructions in their technique along with a concise 7-minute video. The authors aptly show the external view of the surgical maneuvers while simultaneously showing the arthroscopic view as an inset window, allowing the viewer to understand what maneuvers are necessary to accomplish the arthroscopic procedure. In contrast, Chahla et al. have utilized the Key Procedures, all-video article format to demonstrate a similar procedure with multiple video segments, again showing both the external surgical view and the arthroscopic camera view in side-by-side windows. The narration greatly enhances the educational value of the series of video clips. Despites utilizing different article formats, both author teams have expended considerable effort to condense and synthesize a complex surgical procedure into a very small treatise that one can readily ingest in a short period of time. This is impressive given the multiplicity of sutures utilized in the procedure, which makes suture tracking a challenge. Indeed, the information is so compact that the option for pausing the video periodically to replay or study it in more detail greatly assists viewers and is quite necessary and valuable. This aspect of a video presentation is one reason that both the Subspecialty Procedures and Key Procedures series of articles are migrating to an all-video format, which further enables the succinct yet richly informative articles that we strive to provide our readership2.
Reconstruction of a massive cuff tear with a dermal graft utilizing arthroscopic techniques is a highly complex procedure that would have truly impressed the founders of arthroscopic surgery were they alive today. We can only imagine what future innovations will take place in the next few decades.
1. Wagner ER, Woodmass JM, Welp KM, Chang MJ, Elhassan BT, Higgins LD, Warner JJP. Novel arthroscopic tendon transfers for posterosuperior rotator cuff tears: latissimus dorsi and lower trapezius transfers. JBJS Essent Surg Tech. 2018 Apr 25;8(2):e12.
2. Cheng EY. Announcing a new video and written abstract format for all Essential Surgical Techniques articles. JBJS Essent Surg Tech. 2020 Jan-Mar;10(1):e0061.