Please welcome to the stage Dr. Jeffrey S. Abrams and Dr. John M. Tokish. J.T., great honor to stand up here with you as we introduce a new part of the program, and we'd like to thank the program chair, program directors for putting this together. I don't know that any of us would be in this audience if it wasn't for these three individuals in terms of what they have achieved with shoulder arthroscopy. So we have a few slides we'd like to put together if we could start the presentation. And J.T., I think that it's sort of an evolution that's occurring. We want to know what individuals stimulated these three individuals. We will add to what they've done for us. Me being a little bit older, you being past president, we could kind of talk about a timeline with shoulder arthroscopy and what it's meant to our organization and actually internationally what it's done for the shoulder surgical business as well. So it's a great honor to stand up here with you, and even a greater honor to be with the three amigos which were given that title or created that title because of their strength in the education and the innovation business of shoulder arthroscopy. Thanks, Jeff. An honor. I was lucky enough to be Jeff's program chair back when he was president, and I've been lucky enough to follow in his footsteps. And I think one of the things that makes us a little different as an organization is the vertical integration. I've never been a part of an organization or rarely been a part of one where the established members reach out to the younger ones. If you were in the presidential suite last night, there were five or ten young third-year residents chatting with Alan Curtis, president of the society, telling stories back and forth. And that's always been welcoming. The three gentlemen that are here, and we're going to talk a little bit about their legacy, you all know them. They don't need an introduction. But I'll just tell you that when you're putting that scope in the shoulder as a young person, remember struggling with it or maybe you're struggling with it now, keep in mind that you're in there with a blueprint. These guys didn't have a map. There was no trail to follow. They had to blaze their own trail. I've often said this, but many of us are really poor imitations and frauds. The pioneers, what do you do when you're looking in the shoulder and nobody's been there before? Nobody's got there to define it. And these three gentlemen, the three amigos, if you will, really blazed that trail. So we're going to just sort of get out of the way and ask them some questions and maybe get them kind of talking about it, if you will. We do have the mandatory disclosures. Jeff's got all the good ones. I'm much lower without it. We're all trying to become these three with regard to those things, so if you have any ideas, please feel free to give us a call. Actually, Critch is in the audience. He's technically my chair, so Aaron, I didn't say any of that. And then I'll just say these are where these gentlemen stand today, fitting maybe that it's an autumn picture. They've lived through so many seasons of this organization and of the innovation process and really inventing and teaching us the way to go. But I will tell you that you look at this picture and you might not recognize the three decades of friendship and work that go beyond this. And I'll tell you, they weren't always like this, and I thought maybe we'd just take an advantage to go back to the beginning. I'd just like to thank Bob Burks, the keeper of all video, for sending a little bit of video on this. This is a young Steve Burkhardt, 25 years ago, giving one of his first talks on bone loss. Can you roll the tape, please? I'm going to talk about the effect of bone loss on arthroscopic state. The most quoted paper in arthroscopic history. That's the original discussion on that paper. That's a young Steve Snyder in front of a Metcalf meeting talking about the future. Look at those graphics. Look at that. Keynote, you got nothing on him. How's the labral glue going, Steve? The absorbable tacks are all experimental. We hope that in the future we'll have them available, but we certainly know that that is in the future, and we're working now to try to... Look at that graphic, always ahead of the time. You can always tell what's in the shoulder, Steve Snyder. Oh, and here's Esh. Look at the video, so bad. This was color reenactment. Still has that sweater. That's Russ Warren, by the way. Is that Bob Newhart? The talk show, it's like... Not short on words, and like the relationship matures, you're going to see one guy takes the microphone, and then the other guy just kind of sums it all up. It's kind of fitting. Those aren't very common, but you have to be careful when you're looking up front, and you certainly don't want to remove labrum if it has capsule attached to it. That's not a real viable option. When do you think we switch from flannel to wearing sport jackets? I think they're very rare. I don't think that these flap tears are quite that common, unless they're part of a degenerative shoulder. Russ, I have two concerns about... And there's Rich Gaspari. ...labral debridement. Steve is absolutely right. There's some people who have lesions of the labrum that are from the function of the shoulder very much as a menis... So we just thought that would be fun to show you a little video as we sit up here and talk about that history, huh? And maybe I'll just start the questions by asking you... Maybe, Jim, we start with you. This has been a relationship that's gone on 30 years. Just tell us a little bit the origin story. How is it that the three of you guys came together to do this stuff? Well, I was running a meeting in San Diego. And I met a guy at London. I gave a talk on... Or he gave a talk, and I told him it was a great talk. And I think Steve can answer that. Steve. Yeah, it was such a great talk. It was called The 15-Point Arthroscopic Evaluation of the Shoulder. And this was for, I think, the England-British Shoulder Society or something like that. We were both about 19... Actually, Charlie was also speaking when we were there. Yeah, yeah, we were both about 19 years old. And I finished my talk, and I was ready for the applause, and nobody clapped. Not one clap. So I hung my head, walked down the aisle, out, and I'm looking for a warm beer. And out of the door on the far end of the lobby comes this crazy guy. And he's screaming and yelling to get my attention. And I said, Who are you? He says, I'm Jim Esch. I'm starting a course in San Diego. I want you to be part of it. That was my introduction, and it was one of my greatest bad talks I've ever given. Well, wait a minute. How many of you have read Steve Snyder, The 15-Point Arthroscopic Examination? So that's not a bad talk, Steve. That's about 80% of the audience. When I showed up as a fellow at Vail, I was starting on my first scope with Rich Hawkins, and so I go through. Here's the biceps, the SJHL, blah, blah, blah. And he goes, JT, what are you doing? And I said, Oh, sir, I'm trying to do the Steve Snyder 15-Point Arthroscopic Examination of the shoulder. And he goes, JT, here in Vail, we do a 16-Point Arthroscopic Evaluation. And I thought, Oh, shit. I missed a paper. I didn't read that. I said, I'm sorry, Dr. Hawkins, I don't know the 16-Point. He said, Neither do I, but I want to be one better than Steve Snyder. True story. And we never were. We never were. And, you know, from there, the Esch course took off, the program that's a premier shoulder course. How many people in the audience have been to the San Diego Shoulder Institute course? Look at that. Again, almost universal. So I think that your shoulder program in San Diego, your annual course, how many are we up to? Forty-two? Forty-three? Just give us a couple statements maybe on how you put together the shoulder course and how it has grown over the years. Well, it evolved out of a San Diego knee study group we had where we would scope knees and look at videos together. And then we scoped shoulders and started to share about what that thing was called, called the labrum. And then I wanted to run a course. And the first course was at this place called Vacation Village. And 80 people signed up for it. And then 110 showed up. And so the fire guy came by, kicked a bunch of guys out, and then fortunately he left. And then later some person from the hotel said, can I help you with anything? I said, yeah, put those chairs back in the room. So I knew we had a hot subject. And then we did cadaver surgery. This was the first course where the residents could do cadaver surgery. Initially we did dissections to find the axillary nerve. And actually in this one place we used the kitchens of the condo for our dissections. And then I was a volunteer at UCSD Anatomy Lab, and they wanted to somehow reach out to the community. But actually I wanted to see meetings run on time. And then I wanted to make, like these guys, the speakers all-stars. And I was always looking for younger people who had a new idea. Somebody asked me at a church meeting last week, who would I like to interview? And I said, I'd like to interview Socrates. And just there's always questions. So in the process of that, we taught labrum repair. Dr. Snyder pointed out all those rivets and anchors and everything that was used. So I also noticed that on today's schedule there's a talk on Bankyard failed, now what? So 43 years ago we were working on fixing the labrum, initially trans-osso sutures. So now we're sitting here today saying, you know, why did they fail? Yeah, well, we're still asking the same questions. We might be asking the same questions, but Steve, you've been quiet and we've got to get to you. You may have been really what exemplified really the transition in history from open surgery to arthroscopic surgery, much to your credit. You go to the Mayo Clinic, you get instructed by some of the most famous open surgeons, and then you return to Texas, which could have a story or two about a hostile environment, and you decide arthroscopy is an option. Give us a little bit of that transition in your life, your mentors, and when you got back home how you changed your practice. So in 25 words or less, right? You could go longer. I went up. Yeah, I did my residency at Mayo Clinic, and, you know, I didn't actually. That was kind of a culture shock as well, just going that far north. I'd never had to survive in the snow or the cold or anything like that, but really appreciated the opportunity because there were some very well-known, very talented open shoulder surgeons there. The number one role model at that time actually was Mark Coventry. He was the first orthopedic surgeon to have done a total hip replacement in the United States, and he was very scientific in the way that he went about things. And he said, you know, even though he did his first total hip when he was 55 years old, I think, he wasn't afraid to try something new if it made sense. And so he sort of instilled that as a role model, I think, and as a mentor that, you know, don't be afraid to try something new, but be sure that it seems like it's reasonable first, and then do it in kind of a controlled way. Don't go out there like a wild man and start trying crazy things. So I think that was part of it. The shoulder, of course, was still open. I didn't really agree with everything that was being done in the shoulder. It didn't make sense to me with my engineering background because there was a very popular procedure that was being done at the Mayo Clinic and other places then called the subscapularis transfer to cover the hole in the rotator cuff over the top of the shoulder. But to do that, they would take down the upper two-thirds of the subscap, transfer it from a position below the center of rotation of the humerus, and move it to a position above the center of rotation, so totally reverse the moment of that, so that you basically destroyed the biomechanics in trying to make the hole go away. I thought, that doesn't make any sense. And then that kind of led to, I was intrigued to think about the possibility of debriding some of these functional cuff tears and looked at this balance of force couples or the equipollent forces, as the engineers would call them, and that made more sense to me if it was a small tear. And those actually did pretty well, but it was before we had any instruments to repair them. But I thought, you know, they'll do a lot better if we could repair these arthroscopically. So that was the next thing was to think about how to repair it. And it wasn't like the knee. The knee had become instantly popular for arthroscopy because it was all excisional. The shoulder was going to be repair and reconstruction. And we had no instruments available from the knee that you could translate over into the shoulder. So there again, with my engineering background, I had a lot of ideas. I couldn't get anybody interested in them. I was able to engage the services of an aircraft machinist in San Antonio to make the things that I had envisioned. And so I would use those for a while, not implants, just the instruments to pass sutures. And then I had nobody willing to make them until I went to all the major companies, they all said, this will never be a thing. Shoulder arthroscopy is never gonna take off, we're not interested. Until then, you know, it's no secret, I worked with Arthrex for many years and Arthrex was a company then that had very few products. I had lots of ideas that were just itching to be products, but I didn't, I needed a company. So you had a company with few products and a guy with potentially a lot of products, but no company, so it was a good match, I think. You know, fortunately, you went to a community, San Antonio, where you had a great supporter down the street, and I believe he referred you a patient that if you could tell us in short terms what that patient was like. Dr. Rockwood, so you know, I go into practice, I'm in the most hostile single point in the universe to do shoulder arthroscopy, right across town from Charlie Rockwood. And he is just fighting me tooth and nail, and I know that he wanted to destroy me. Thank God I didn't have an infection for a number of years, it would have been in his office and he would have destroyed me. But Charlie one day calls me up, I'm at the office, and he says, hey, I have a patient I want to refer you, and can you see him today? I was in clinic, and I said, well, I guess so. I said, how come you're referring me a patient? He said, well, he's kind of an unusual guy, he's gonna, he's gonna, but he's a little stranger, he's a good guy, and you know, he's got a real problem. So he didn't show up, didn't show up, got his name, and my secretary finally, you know, after he was two hours late or something like that, he called the guy's house, we had the number, and the family said, no, he committed suicide about two hours ago. This is, it's a horrible story, but it's crazy, it's like, so the only patient, is this the one you're talking about, right? Yeah, that would be. Yeah, that'll do. Well, I hope it is. Yeah. So the only patient. That would be the only suicide that I knew about, but there could be others, so. Oh. Oh. Which is before. So the only patient he ever referred to me, so I had to see Dr. Burkhardt, and he took the easy way out, you know? Fortunate the waiting list got shorter. Steve, you, Steve, you know, inventing instruments, as Steve Burkhardt has said, became something that was relatively natural to you. Tell me a little bit about your inventor, were you like Mr. Roberts, running into there and coming up with your things in your lab, or what motivated you to be involved as Steve was and Jim was with industry and developing technique and instruments? Yeah, Steve talked about having all these ideas in his head that he needed help with, and eventually found a company that he could work with that would listen to some of this crazy stuff. I started putting things together in the garage when I was actually an intern. And in residency, I had a lot of opportunity to make external fracture fixators and things like that, and I made a passive motion machine for the knee and all this stuff, but nothing really sold. So, actually, when I got to work with Dr. Esch, it gave me a, which was, I think, the second year you did your course, right? We were in, yeah, and it gave me an opportunity to test things, because he had cadavers, I mean, who else would have those? And we started putting together some of these crazy ideas, and some of the first labral fixation devices and rotator cuff stitchers, and Lanny Johnson was so generous. He gave me the first synovial resector prototypes, which I used on my hemophilia clinic at Orthopedic Hospital, and I just was so interested, because now that we could see, essentially, everything in the shoulder and the bursa, we needed tools, and there just weren't any. So, every harebrained idea that kept me awake at night, in those days, it was much easier to get something in the operating room. You basically make it and sterilize it, and some of the things worked, and so we started putting together protocols. Jeff, you know I'm like a military guy, excuse me, JT, but I believe in step-by-step-by-step. That's the way you do it, and that's the way I would outline these things. So, we got into braces, we got into anchors, different types of resectors, and this and that, and I didn't like working with just one company. If I had an idea for a biologic patch, graft jacket, I would work with the graft jacket company. If I had an idea for an electrosurgical tool, I'd work with the electrosurgery company, and just on and on, and it was so much fun, and I got this crazy itch in my brain from my dad, who also had a bunch of patents, and it's something that one of my sons has, too, God bless him, you know, it'll cost you a lot of money and a lot of time and sleepless nights, but boy, it's worth it. And then you're able, if it works out, you're able then to share it, and that's just a wonderful gift. We're gonna probably fire a few questions quickly, go ahead. I was gonna say, you mentioned the complete meticulousness by which a military approach to this is, so I just call Jim Esch's attention, him in Vietnam there, as a meticulous surgeon with no shirt, barely any socks, and some flip flops on coming out of the operating room. Jim was kind enough to send me this picture of him from Vietnam, and many of you guys maybe don't know this about him, but many of you in the audience have a military background, as do I, and I think I'd be remiss, I wanted to just say thank you for your service back then in Vietnam, Jim, and for your time in serving and then coming forth with that. JT, one of the pictures that he sent is in that lower left, you may not be able to see it, but he sent home, himself recorded with Dickens' A Christmas Carol to send home to his kids over the time of his deployment, which is a tape picture that you sent me, and then that's the letterbox that it came in, and those were different days back then. That was the old Dropbox, right? That's right, Dropbox back then, yeah. Yeah, so you've seen, what, that's 50 years, 60 years of time between those two times. Tell us a little bit about where you were back practicing in those tents, all the way up to getting finished with an arthroscopy practice. What'd he say? What it was like to? Don't worry, Jim, I'm used to asking questions. Nobody understands our shitty questions to begin with. It's a gift I have. That accent is too much. Going back, you had to be innovative, so going back to Vietnam, we couldn't order from whoever we ordered stuff from, a needle driver or anything like that, but what they had a lot of were amputation knives, so I quickly found out that amputation knives are good for salami, so we had a lot of good salami knives, and then running the course, so certain surgeons have a certain way of doing things, including my brother here, Dr. Snyder, but then somebody else would show up and say, well, I wanna learn to fix the labrum, but I'm not gonna do it his way. I'm gonna do it my way, and so I found out that in trying to teach, everybody has their own way to the point where every orthopedic surgeon is their own image of an expert in their own image, but this made me look for people that had different ways to do things, and even though Dr. Snyder and Dr. Burke are friends, they have very different ways of fixing the labrum and of fixing the rotator cuff, so I felt my forte was to somehow teach people how to fix the rotator cuff, and one of the most difficult things is everybody wants to do advanced stuff, and they have trouble just doing beginning stuff, and it takes them a lot of experience, so they're all gray-haired experts who realize the importance of the little stuff, so looking for new faculty in All-Stars was, again, was the thing I was looking for, and I go back, I see you got some talks on, after we fixed those bank cards, after about 25 years, somebody actually saw a bone loss. It took a little while for us to observe bone loss, and then Dr. Wolfe came up with this ladder jamb, procedure, and not the ladder jamb, the remplissage procedure that somehow didn't make any sense to me, but it works, and going back on the bone graft, I think it's 30 years ago, Ettore Taverna was taking bone graft and suturing into the glenoid that I noticed is becoming popular 30 years later, and in the meantime, we were teaching people early on how to fix a bank card, and then somebody said, well, maybe, and you go to Europe, they do a ladder jamb procedure, and just that word struck fear in the arthroscopists that, my God, I gotta make an incision, and what do I have to do? Yeah, amazing perspective. In the little time we have left, maybe each of you would share just a, maybe a pearl to the young members in the audience if you're maybe early career or mid-career now, what little bit of wisdom you might impart upon that young person who's hot and in pursuit and wants to go at it? Maybe start with you, Uncle Steve. You know, I guess I would say, you know, kind of the wisdom that I took from Dr. Coventry was to study the new technologies, study the, you know, kind of question them even if they're accepted, the older ones, and if it makes sense, begin to adopt them, you know, and if you feel like, you know, you want to provide your patients with whatever's best for them, and I think you're always trying to do that, and if it's the new technology and you're convinced, then go ahead and do that. So I think that's the main thing, is you want to embrace the new technologies, but do it selectively. There, Steve? Yeah, my most important thing, and these guys are both gonna agree with it, is have a good woman by your side, because if you've got children, if you've got an office work, if you've got papers to write, books to help with, that's a lot of stress. You do it because you enjoy it and you think it's worthwhile, but if you don't have someone with you along the road, I think it would be very lonesome and very difficult, so I just want to have the three ladies in the front row there that have been putting up with us for 50-plus years to stand up and... Thank you. You know, JT, stay tuned. We could have the Legends Wives Symposium as well. Way better stories. We actually might get the accurate stories. Yeah, so in the presidential suite tonight, sorry, Alan, 1030, we're going to get the gals liquored up and they're going to tell us all the real stuff that's going on here. Thank you. Listen, I think we're running short on time. We could go all afternoon. These gentlemen are kind enough to be here with us at the meeting and we'll be available for some of your questions. If you haven't had a chance to meet these guys, man, come up and soak up some of the wisdom that some of us have been blessed to be around. Gentlemen, thank you so much for your time and your candor. JT, this has been an honor to be sharing as a moderator with you. I'd like to invite our president and our program chair to appropriately gift our legends. It looks suspiciously like a suture anchor, brand new, we're going to pound it in there. We've had our time. I didn't get to show these, but that's, I visited Steve and that's, oh, I don't know if you can pick that up there. So that's me sitting at his desk in his house in San Antonio before they moved to the ranch, sitting at the table that he wrote the bone loss papers and the dead man's ankle and the suspension bridge theory of rotator cuff surgery. My ass is literally sitting in the chair that contributed all that science, I'll just tell you, an amazing thing. They stole the name Congressional Library for this town, but in reality, that might have been the library they were referring to.

shoulder arthroscopy

pioneers

collaboration

innovation

mentorship

surgical tools

orthopedic surgery