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The Penetrator going through the rotator cuff grabbing a suture.

Keith D. Nord, MD, FAAOS, founded Sports Orthopedics & Spine in Jackson, Tenn. in 1996. Although based in a smaller city, the practice is certainly considered a major league player in sports medicine.

While most fellowships are associated with a major university in a large city, Sports Orthopedics & Spine has offered a sports medicine fellowship for the past four years, and it has received ACGME accreditation. Much of the practice's renown centers on its founder's work refining arthroscopic shoulder surgery and developing tools for his techniques.

Nord routinely teaches arthroscopic shoulder procedures at workshops and conferences and is a master instructor for the Arthroscopy Association of North America. He has been working to refine the procedures to repair rotator cuff injuries, labral and bicep tears for almost 20 years.

"I trained with several very good shoulder surgeons in the past, but typically those shoulder surgeries were done in an open manner," said the board certified orthopaedic surgeon, adding that when he finished training in 1990, his program only offered two arthroscopic shoulder procedures. "A lot of this has developed since I finished training … that's why it is important for doctors to continue learning."

Taking his own admonition to heart, Nord has collaborated with several other well-known names in orthopedic surgery including Stephen Burkhart, MD, Rick Ryu, MD, Scott Powell, MD, and Paul Brady, MD to advance arthroscopic surgical techniques and instrumentation.

Early on, Nord found some of the instrumentation to be awkward in its construction for the tedious work required by arthroscopic shoulder surgery.

"A lot of instruments are straight so you have to come in at the right angle," he noted.

Nord explained that in arthroscopic rotator cuff surgery, anchors are screwed or pounded into the bone with the sutures attached. To sew the tissue to the bone, however, he said surgeons were required to "bite the tissue" and then pass a wire through a turning wheel, pull it out, and then thread a suture through a wire eyelet in another cannula.

To ease the process, Nord developed the reusable Penetrator, which is manufactured by Arthrex.

"It basically is a pointed grasper," he explained. "The point goes through the rotator cuff and then the jaws open up and grasp the suture."

A locking mechanism on the angled head keeps the jaws closed during insertion and extraction, allowing surgeons to retrieve the suture in one step. The instrument comes in a straight version and one with a 30º bend. Developed almost a decade ago, the Penetrator has undergone minor refinements over the years but is still one of the most popular devices used in rotator cuff repair. A few years later, Nord developed a second tool, the Arthrex BirdBeak. The newer instrument has a much sharper bend in the tip and is used for labral repairs, in addition to rotator cuff tears.

Once he had developed improved instrumentation, Nord began looking for the best angles to approach surgery, which led to the discovery of additional portals allowing better access to make even large tears candidates for arthroscopic surgery.

The three portals Nord has developed in collaboration with his colleagues are the subclavian, modified Neviaser and most recently the low posterolateral, which was just published last year. The portals allow an extremely small incision without even using a cannula.

"It hardly even needs a stitch … many people don't put any stitch in at all," Nord said of the tiny opening. "It pokes through the muscle and into the joint. By poking through, you don't do any damage to the muscle."

The subclavian and modified Neviaser portals are typically used for rotator cuff repair. The newer posterolateral portal, Nord explained, allows the surgeon to put anchors in at the six o'clock position at the very inferior portion of the glenoid.

"It's a much safer spot than trying to come from the front of the shoulder," Nord said.

Not content to rest on past achievements, Nord is continually questioning the status quo.

"I have been working on different techniques to repair damage to the bone from shoulder dislocations and doing that arthroscopically," he said, adding that a major issue currently is that the humeral head often gets dented or part of the bone is sheared off from the bottom front of the glenoid … both of which will cause a shoulder to be much more likely to dislocate again in the future.

Nord marveled at how far his field has come over the past two decades and how much more can be achieved in the future.

"One of the quotes I like is 'on the shoulders of giants.' We all learn and benefit from those that went before us," he concluded.

It seems like a particularly apt motto for this innovator who has spent his career dedicated to improving the function of damaged shoulders.

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