Editor's Spotlight/Take 5: Mapping the Diffusion of Technology in Orthopaedic Surgery: Understanding the Spread of Arthroscopic Rotator Cuff Repair in the United States.

Why are some technologies adopted quickly, while others are not? Why are some surgical procedures adopted wholeheartedly and others simply dismissed? Why does this vary from place to place? In this month’s Editor’s Spotlight/Take 5, Daniel C. Austin MD, MS and his team from Dartmouth-Hitchcock Medical Center, already known for their work on surgical variation [2], show profound differences in adoption of arthroscopic repair of rotator cuff tears between hospital referral regions across the United States [1]. Why might this be so? Providers may surmise that a patient in Paris, TX, USA and one in Rome, GA, USA (to borrow half a line from a country song) both will receive the same surgical recommendation if they present with the same clinical problem. But while variation is typically quite low for straightforward problems— surgery is appropriate for almost all patients with hip fractures—the degree of variation for other diagnoses is surprising. For example, coils are used to treat cerebral aneurysms in 99% of patients covered byMedicare in Tacoma, WA, USA, while less than 40% of patients treated for unruptured aneurysms received coiling in Modesto, CA, USA, Madison, WI, USA and Manchester, NH, USA [2]. What about when new procedures or approaches are introduced? Presumably, we’re all reading the same studies and getting the same information on the risks and benefits of a new technique. It’s reasonable to think that adoption would occur with similar patterns, and over the same amount of time. But this is almost never the case. There are notable differences in how individuals approach technological novelty. The first systematic assessment on how to incorporate new practice into daily life dates back to the early 20th century. Ryan and Gross [7] looked at how Iowa farmers used hybrid seed corn and found features that resonate even today: There was a time lag of about 5 years between first knowledge and first adoption; those who tried the approach earliest were somewhat tentative in incorporating new seed; late adopters were more likely to carry out a full conversion, and “almost all had heard of the new trait before more than a handful were planting it” [7]. Farmers fell into several categories: Innovators, early adopters, early majority, late majority, and laggards—familiar territory for surgeons. In the early 1960s, Everett Rogers developed the theory of diffusion of innovations, and proposed four elements that influence the spread of a new idea: (1) The innovation itself, (2) communication channels, (3) time, and (4) a social system [6]. Although Rogers did not write specifically about medical or surgical techniques, his model resonates with providers trying out new forms of therapy. A note from the Editor-In-Chief: In “Editor’s Spotlight,” one of our editors provides brief commentary on a paper we believe is especially important and worthy of general interest. Following the explanation of our choice, we present “Take 5,” in which the editor goes behind the discovery with a oneon-one interview with an author of the article featured in “Editor’s Spotlight.” The author certifies that neither he, nor any members of his immediate family, have any commercial associations (such as consultancies, stock ownership, equity interest, patent/licensing arrangements, etc.) that might pose a conflict of interest in connection with the submitted article. All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research editors and board members are on file with the publication and can be viewed on request. The opinions expressed are those of the writer, and do not reflect the opinion or policy of CORR or The Association of Bone and Joint Surgeons. This comment refers to the article available at: DOI: 10.1097/CORR.0000000000000860. P.A. Manner MD, FRCSC (✉), Clinical Orthopaedics and Related Research, 1600 Spruce St., Philadelphia, PA 19013 USA, Email: sleopold@clinorthop.org P. A. Manner, Senior Editor, Clinical Orthopaedics and Related Research Philadelphia, PA, USA