Publications by authors named "Joseph W Galvin"

39 Publications

Management of Chronic Quadriceps Tendon Rupture: A Critical Analysis Review.

JBJS Rev 2021 05 6;9(5). Epub 2021 May 6.

Boston University School of Medicine, Boston, Massachusetts.

»: Chronic quadriceps tendon (QT) ruptures are uncommon injuries that present treatment challenges due to their complex nature and the limited evidence to guide management.

»: Timely diagnosis and surgical management of acute QT injury are imperative to optimize patient outcomes as delayed diagnosis leads to poorer results regardless of treatment modality.

»: Elements of chronic QT ruptures that may complicate surgical management include patient age, comorbidity, scar-tissue formation, amount of quadriceps muscle/ tendon retraction, and distalmigration of the patella with contraction of the tendon.

»: Treatment options for chronic QT ruptures include primary repair with or without vastus advancement, V-Y tendon lengthening with or without tissue augmentation, and autograft or allograft reconstruction.
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http://dx.doi.org/10.2106/JBJS.RVW.20.00096DOI Listing
May 2021

Shoulder arthroplasty in dwarfism: A case report of pseudoachondroplasia with 17-year follow-up.

Orthop Rev (Pavia) 2021 Mar 31;13(1):8605. Epub 2021 Mar 31.

Shoulder Service, Massachusetts General Hospital, Boston, MA, USA.

The purpose of this case report is to report the long-term outcome following shoulder hemiarthroplasty in a patient with dwarfism. A 60-year old female with pseudoachondroplasia dwarfism presented 17 years post-operative with a Subjective Shoulder Value of 90% and minimal pain. Custom designed implants were critical for surgical success. Preoperative planning with a CT scan was important in assessing glenoid dysplasia and determining the feasibility of glenoid resurfacing. The emergence of 3D CT virtual preoperative planning tools can further assist in the recognition of deformity to determine if custom designed implants are needed. Shoulder arthroplasty in dwarfism can lead to excellent long-term outcomes.
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http://dx.doi.org/10.4081/or.2021.8605DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8082169PMC
March 2021

Generating the American Shoulder and Elbow Surgeons Score Using Multivariable Predictive Models and Computer Adaptive Testing to Reduce Survey Burden.

Am J Sports Med 2021 03 1;49(3):764-772. Epub 2021 Feb 1.

Investigation performed at the Defense Health Agency, Military Health System for the US Military, Rosslyn, Virginia, USA.

Background: The preferred patient-reported outcome measure for the assessment of shoulder conditions continues to evolve. Previous studies correlating the Patient-Reported Outcomes Measurement Information System (PROMIS) computer adaptive tests (CATs) to the American Shoulder and Elbow Surgeons (ASES) score have focused on a singular domain (pain or physical function) but have not evaluated the combined domains of pain and physical function that compose the ASES score. Additionally, previous studies have not provided a multivariable prediction tool to convert PROMIS scores to more familiar legacy scores.

Purpose: To establish a valid predictive model of ASES scores using a nonlinear combination of PROMIS domains for physical function and pain.

Study Design: Cohort study (Diagnosis); Level of evidence, 3.

Methods: The Military Orthopaedics Tracking Injuries and Outcomes Network (MOTION) database is a prospectively collected repository of patient-reported outcomes and intraoperative variables. Patients in MOTION research who underwent shoulder surgery and completed the ASES, PROMIS Physical Function, and PROMIS Pain Interference at varying time points were included in the present analysis. Nonlinear multivariable predictive models were created to establish an ASES index score and then validated using "leave 1 out" techniques and minimal clinically important difference /substantial clinical benefit (MCID/SCB) analysis.

Results: A total of 909 patients completed the ASES, PROMIS Physical Function, and PROMIS Pain Interference at presurgery, 6 weeks, 6 months, and 1 year after surgery, providing 1502 complete observations. The PROMIS CAT predictive model was strongly validated to predict the ASES (Pearson coefficient = 0.76-0.78; = 0.57-0.62; root mean square error = 13.3-14.1). The MCID/SCB for the ASES was 21.7, and the best ASES index MCID/SCB was 19.4, suggesting that the derived ASES index is effective and can reliably re-create ASES scores.

Conclusion: The PROMIS CAT predictive models are able to approximate the ASES score within 13 to 14 points, which is 7 points more accurate than the ASES MCID/SCB derived from the sample. Our ASES index algorithm, which is freely available online (https://osf.io/ctmnd/), has a lower MCID/SCB than the ASES itself. This algorithm can be used to decrease patient survey burden by 11 questions and provide a reliable ASES analog to clinicians.
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http://dx.doi.org/10.1177/0363546520987240DOI Listing
March 2021

Uncomplicated Arthroscopic Rotator Cuff Repair in Chronic Ipsilateral Upper Extremity Lymphedema: A Case Report.

JBJS Case Connect 2020 11 24;10(4):e20.00290. Epub 2020 Nov 24.

Department of Orthopaedic Surgery, Madigan Army Medical Center, Joint Base Lewis-McChord, Washington.

Case: A 69-year-old woman with chronic upper extremity lymphedema secondary to bilateral mastectomy and axillary lymph node dissection for breast cancer 10 years before presented to the clinic with a massive rotator cuff tear. Her shoulder pain and dysfunction persisted despite nonoperative treatment. She underwent left shoulder arthroscopic rotator cuff repair (RCR) and biceps tenotomy. Arm, forearm, and wrist circumference measurements were obtained, preoperatively, immediately postoperatively, and 1-week and 2-weeks postoperatively. No permanent increase in extremity circumference measurements was observed.

Conclusion: This case suggests that it is possible to perform an arthroscopic RCR in a patient with chronic upper extremity lymphedema without creating further morbidity.
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http://dx.doi.org/10.2106/JBJS.CC.20.00290DOI Listing
November 2020

Ultrasound-Guided Biceps Tendon Sheath Injections Frequently Extravasate Into the Glenohumeral Joint.

Arthroscopy 2021 06 13;37(6):1711-1716. Epub 2021 Jan 13.

Madigan Army Medical Center, Joint Base Lewis-McChord, Washington, U.S.A.

Purpose: To evaluate the frequency of glenohumeral joint extravasation of ultrasound (US)-guided biceps tendon sheath injections.

Methods: Fifty shoulders with a clinical diagnosis of bicipital tenosynovitis pain received a US-guided biceps sheath injection with anesthetic, steroid, and contrast (5.0 mL mixture) followed immediately by orthogonal radiographs to localize the anatomic distribution of the injection. Radiographic evaluation of contrast localization was determined and interobserver reliability calculated.

Results: All 50 postinjection radiographs (100%) demonstrated contrast within the biceps tendon sheath. In addition, 30 of 50 (60%) radiographs also revealed contrast in the glenohumeral joint. Interobserver reliability for determination of intraarticular contrast was good (kappa value 0.87).

Conclusions: US-guided bicipital sheath injections reproducibly result in intrasheath placement of injection fluid. Bicipital sheath injections performed with 5 mL of volume result in partial extravasation into the joint 60% of the time. These data may be useful for surgeons who use the results of diagnostic biceps injections for diagnosis and surgical decision-making.

Level Of Evidence: III, prospective cohort study, diagnosis.
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http://dx.doi.org/10.1016/j.arthro.2020.12.238DOI Listing
June 2021

Response to Letter to the Editor regarding: "Fracture of pyrocarbon humeral head resurfacing implant: a case report".

J Shoulder Elbow Surg 2021 03 24;30(3):e134-e135. Epub 2020 Dec 24.

University Institute for Locomotion and Sports (iULS), Hospital Pasteur 2, University Côte d'Azur, Nice, France.

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http://dx.doi.org/10.1016/j.jse.2020.11.005DOI Listing
March 2021

Biceps Squeeze Tenotomy: Technique to Improve Efficiency of Arthroscopic Biceps Tenotomy.

Arthrosc Tech 2020 Nov 23;9(11):e1851-e1853. Epub 2020 Oct 23.

Department of Orthopaedic Surgery, Madigan Army Medical Center, Joint Base Lewis-McChord, Washington, U.S.A.

Biceps tenotomy is a common procedure performed in arthroscopic shoulder surgery. Numerous studies have demonstrated the effectiveness of both biceps tenotomy and tenodesis to relieve pain and restore function for the diagnoses of bicipital tenosynovitis, SLAP tears, rotator interval pulley lesions, and failed SLAP repairs. It is also frequently performed as a concomitant procedure with arthroscopic rotator cuff repair. We report a technique to improve the efficiency of arthroscopic bicep tenotomy using a biceps squeeze maneuver. This is a simple method of manually squeezing the biceps muscle belly while performing the arthroscopic biceps tenotomy. This shortens and tensions the intra-articular portion of the tendon to facilitate a more safe and efficient procedure.
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http://dx.doi.org/10.1016/j.eats.2020.08.009DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7695749PMC
November 2020

Fractures of the Coracoid Process: Evaluation, Management, and Outcomes.

J Am Acad Orthop Surg 2020 Aug;28(16):e706-e715

From the Department of Orthopaedic Surgery, Madigan Army Medical Center (Dr. Galvin), Tacoma, WA, the Department of Orthopaedic Surgery, Boston University School of Medicine (Dr. Kang and Dr. Li), Boston, MA, and the Department of Orthopaedic Surgery, University of Missouri School of Medicine (Dr. Ma), Columbia, MO.

Fractures of the coracoid process are relatively rare, and current management guidelines remain unclear. Most coracoid fractures occur in conjunction with other shoulder injuries, including dislocations and fractures. Identifying coracoid fractures can be difficult because most fractures are nondisplaced and can be missed on radiographs or may be masked by other injuries. Management is largely guided by fracture location and displacement. Conservative treatment is preferred for fractures that are minimally displaced, whereas indications for surgical fixation include fractures that are displaced (>1 cm), have progressed to a painful nonunion, or are associated with the disruption of the superior shoulder suspensory complex. Although conservative treatment has been historically favored, satisfactory outcomes have been reported for both surgical and nonsurgical treatment. We provide a comprehensive review of diagnosis and management strategies for coracoid fractures.
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http://dx.doi.org/10.5435/JAAOS-D-19-00148DOI Listing
August 2020

Reverse shoulder-allograft prosthesis composite, with or without tendon transfer, for the treatment of severe proximal humeral bone loss.

J Shoulder Elbow Surg 2020 Nov 9;29(11):e401-e415. Epub 2020 Jun 9.

Department of Orthopaedic Surgery, Madigan Army Medical Center, Tacoma, WA, USA.

Background: The treatment of severe proximal humeral bone loss (PHBL) secondary to tumor resection or failed arthroplasty is challenging. We evaluated the outcomes and complications of reconstruction with reverse shoulder-allograft prosthesis composite (RS-APC), performed with or without tendon transfer.

Methods: An RS-APC procedure was performed in 25 consecutive patients with severe PHBL (>4 cm): 12 after failed reverse shoulder arthroplasty, 5 after failed hemiarthroplasty for fracture, 6 after failed mega-tumor prosthesis placement, and 2 after tumor resection. The median length of humeral bone loss or resection was 8 cm (range, 5-23 cm). Humeral bone graft fixation was obtained with a long monobloc reverse stem and a "mirror step-cut osteotomy," without plate fixation. Nine infected shoulders underwent a 2-stage operation with a temporary cement spacer. In addition, 9 patients (36%) underwent an associated L'Episcopo procedure. The median follow-up duration was 4 years (range, 2-11 years).

Results: Overall, 76% of patients (19 of 25) were satisfied. In 8 patients (32%), a reoperation was needed. At last follow-up, we observed incorporation at the allograft-host junction in 96% of the cases (24/25); partial graft resorption occurred in 3 cases and severe in 1. The median adjusted Constant score was 53% (range 18-105); Subjective Shoulder Value, 50% (range 10%-95%). Additional tendon transfers significantly improved active external rotation (20° vs. 0°, P < .001) and forward elevation (140° vs. 90°, P = .045).

Conclusions: (1) Shoulder reconstruction with RS-APC provides acceptable shoulder function and high rates of graft survival and healing. (2) Additional L'Episcopo tendon transfer (when technically possible) improves active shoulder motion. (3) The use of a long monobloc (cemented or uncemented) humeral reverse stem with mirror step-cut osteotomy provides a high rate of graft-host healing, as well as a limited rate of graft resorption, and precludes the need for additional plate fixation. (4) Although rewarding, this reconstructive surgery is complex with a high risk of complications and reoperations. The main advantages of using an allograft with a reverse shoulder arthroplasty (compared with other reconstruction options) are that this type of reconstruction (1) allows restoration of the bone stock, thus improving prosthesis fixation and stability, and (2) gives the possibility to perform a tendon transfer by fixing the tendons on the bone graft to improve shoulder motion.
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http://dx.doi.org/10.1016/j.jse.2020.03.016DOI Listing
November 2020

Fracture of pyrocarbon humeral head resurfacing implant: a case report.

J Shoulder Elbow Surg 2020 Aug 9;29(8):e306-e312. Epub 2020 Jun 9.

University Institute for Locomotion and Sports (iULS), Hospital Pasteur 2, 30 Voie Romaine, University Côte d'Azur, Nice, France.

We report a case of a pyrocarbon humeral head resurfacing implant fracture, occurring 6 years after its implantation, without any obvious trauma or dislocation. Initial radiographs showed a proud and oversized pyrocarbon resurfacing implant. On clinical examination, the patient had a painful and pseudoparalyzed shoulder with subscapularis insufficiency. Imaging studies confirmed implant fracture and severe fatty infiltration (Goutallier, grade 4) of the subscapularis muscle. Intraoperatively, the implant was found to be fractured with multiple pyrocarbon debris in the glenohumeral joint. The implant was loose, and gross inspection showed no visible bony adhesion or ongrowth. Histologic analysis showed multiple seats of metallosis in the synovial tissue and cancellous bone of the humeral head. Successful management of this complication was managed with a thorough débridement and irrigation and revision to reverse shoulder arthroplasty. Our observation put into question the use of pyrocarbon as a humeral head resurfacing implant. The material seems to be too fragile to be used as a resurfacing implant and cannot achieve fixation of the implant to bone.
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http://dx.doi.org/10.1016/j.jse.2020.02.028DOI Listing
August 2020

Analysis of glenohumeral joint intraarticular pressure measurements in volume-limited MR arthrograms in patients with shoulder-instability compared to a control group.

J Orthop 2020 Jan-Feb;17:63-68. Epub 2019 Aug 13.

Department of Orthopaedics, Medical University of South Carolina, Charleston, SC, USA.

Purpose: Compare intraarticular pressure of the glenohumeral joint in patients with and without shoulder instability after a volume-limited arthrogram.

Materials And Methods: Patients aged 18-45 years with shoulder instability or pain were included. After injecting 10 cc of contrast-mixture, intraarticular pressure was recorded using an arterial-line pressure-transducer connected to a portable monitor.

Results: 14/16 (86%) patients were included - 7/14 (50%) had instability. Post-injection pressure measurement averaged 59.9 ± 44.0 mmHg (range 15-181). Instability patients averaged 60.8 ± 37.6 (range 15-117) versus 41.9 ± 14.0 mmHg (range 30-64) for non-instability (p > 0.1).

Conclusion: Glenohumeral pressure measurements are variable when utilizing standardized volume-limited arthrograms.
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http://dx.doi.org/10.1016/j.jor.2019.08.016DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6919372PMC
August 2019

The Impact of Socioeconomic Status on Outcomes in Orthopaedic Surgery.

J Bone Joint Surg Am 2020 Mar;102(5):428-444

Boston University School of Public Health, Boston, Massachusetts.

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http://dx.doi.org/10.2106/JBJS.19.00504DOI Listing
March 2020

Insurance status affects access to physical therapy following rotator cuff repair surgery: A comparison of privately insured and Medicaid patients.

Orthop Rev (Pavia) 2019 May 23;11(2):7989. Epub 2019 May 23.

Boston University School of Medicine, Boston, MA, USA.

Rotator cuff repair (RCR) is an effective procedure to relieve shoulder pain and dysfunction. Postoperative physical therapy (PT) plays an integral role in the overall success of RCR. Insurance status has been shown to be an important predictor of postoperative PT utilization. This study evaluated the effect of insurance status on access to PT services following RCR. One hundred thirty-eight PT clinics were contacted in the Greater Boston metropolitan area. Clinics were contacted on two separate occasions and presented with a fictitious acutely postoperative RCR patient in need of PT. Insurance status was reported as Medicaid or private insurance. Overall, 133 (96.4%) accepted private insurance, whereas only 71 (51.4%) accepted Medicaid (P=0.019). Medicaid patients were offered a first available appointment at a mean of 8.3 days (95% CI: 7.13-9.38, range: 0-31) versus a mean of 6.3 days (95% CI: 5.3-7.22, range: 0-19, P=0.001) for private patients. Clinic location was not associated with access to PT or time to first appointment. Insurance status affects access to PT services and time to first available appointment in patients following RCR surgery in a major metropolitan area.
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http://dx.doi.org/10.4081/or.2019.7989DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6551457PMC
May 2019

Return to Sport After the Surgical Treatment of Superior Labrum Anterior to Posterior Tears: A Systematic Review.

Orthop J Sports Med 2019 May 6;7(5):2325967119841892. Epub 2019 May 6.

Department of Orthopaedic Surgery, Boston University School of Medicine, Boston, Massachusetts, USA.

Background: Controversy exists as to the optimal treatment of superior labrum anterior to posterior (SLAP) tears in athletes. There are no systematic reviews evaluating return-to-sport (RTS) rates after arthroscopic SLAP repair and biceps tenodesis.

Purpose: To compare the overall RTS rates in patients with primary type 2 SLAP tears who were managed with arthroscopic SLAP repair versus biceps tenodesis.

Study Design: Systematic review; Level of evidence, 4.

Methods: A review was performed according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines by searching the MEDLINE (PubMed), Embase (Elsevier), and Cochrane Library databases. Inclusion criteria were clinical studies that evaluated RTS rates after arthroscopic SLAP repair, arthroscopic SLAP repair with partial rotator cuff debridement, and biceps tenodesis. The studies were analyzed for quality and inclusion in the final analysis. Data relevant to RTS rates were then extracted and compiled, and outcomes were compared.

Results: Of the 337 studies initially identified, 15 (501 patient-athletes) met inclusion criteria. These consisted of 195 patients who underwent isolated arthroscopic SLAP repair (mean age, 31 years; mean follow-up, 3.2 years), 222 patients who underwent arthroscopic SLAP repair with partial rotator cuff debridement (mean age, 22 years; mean follow-up, 5.1 years), and 84 patients who underwent biceps tenodesis (mean age, 42 years; mean follow-up, 3.3 years). The overall RTS rates were high for all 3 procedures (SLAP repair, 79.5%; SLAP repair with rotator cuff debridement, 76.6%; biceps tenodesis, 84.5%), with biceps tenodesis having the highest overall rate. Biceps tenodesis also had the highest RTS rate at the preinjury level (78.6%) compared with SLAP repair (63.6%) and SLAP repair with rotator cuff debridement (66.7%).

Conclusion: Primary arthroscopic SLAP repair, arthroscopic SLAP repair with partial rotator cuff debridement, and biceps tenodesis all provide high RTS rates. Biceps tenodesis as an operative treatment of primary SLAP lesions may demonstrate an overall higher RTS rate when compared with traditional SLAP repair in older athletes. More, higher level studies are needed that control for age, level of activity, and type of sport (overhead vs nonoverhead) to determine the efficacy of biceps tenodesis as a primary alternative to arthroscopic SLAP repair in young athletes who present with type 2 SLAP tears.
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http://dx.doi.org/10.1177/2325967119841892DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6506928PMC
May 2019

The Effect of Race on Early Perioperative Outcomes After Shoulder Arthroplasty: A Propensity Score Matched Analysis.

Orthopedics 2019 Mar 27;42(2):95-102. Epub 2019 Feb 27.

There is a paucity of data on how racial disparities may affect early outcomes following shoulder arthroplasty. The purpose of this study was to evaluate differences in 30-day complications and readmission rates after shoulder arthroplasty based on race. White and black patients who underwent hemiarthroplasty, anatomic or reverse total shoulder arthroplasty (Current Procedural Terminology codes 23470 and 23472) between 2006 and 2015 were identified in the American College of Surgeons National Surgical Quality Improvement Program database. Black patients were propensity score matched 1:4 based on preoperative demographics and comorbidities to white patients. Multivariable analysis was performed to assess postoperative complications based on race. Of the 12,663 patients with shoulder arthroplasty identified, 10,717 (84.6%) were white and 559 (4.4%) were black. Overall, 557 black patients were matched to 2228 white patients, for a total cohort of 2785 patients (mean age, 63.9±11.7 years; female, 61.0%). Surgical indications were similar between black and white patients. The 2 races had similar rates of overall complications, major complications, minor complications, readmissions, and discharge to facility. Mortality was significantly higher among black patients compared with white patients (0.6% vs 0.05%; P=.033). Black patients also experienced longer operative time (mean, 126.4 vs 112.5 minutes; P<.001) and length of stay (mean, 2.4 vs 2.1 days; P<.001). There was a significant disparity with underutilization of shoulder arthroplasty for black patients in the American College of Surgeons National Surgical Quality Improvement Program database. Black and white patients undergoing shoulder arthroplasty experienced similar rates of 30-day complications, readmissions, and discharge to facility. However, black patients experienced greater operative time, total length of stay, and mortality compared with white patients. [Orthopedics. 2019; 42(2):95-102.].
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http://dx.doi.org/10.3928/01477447-20190221-01DOI Listing
March 2019

Thirty-day Complications and Readmission Rates in Elderly Patients After Shoulder Arthroplasty.

J Am Acad Orthop Surg Glob Res Rev 2018 Nov 2;2(11):e068. Epub 2018 Nov 2.

Department of Orthopaedic Surgery, Boston Medical Center, Boston University School of Medicine, Boston, MA (Dr. Koh, Dr. Sing, Ms. Curry, and Dr. Li), and the Department of Orthopaedic Surgery, Blanchfield Army Community Hospital, Orthopedic Clinic, Fort Campbell, KY (Dr. Galvin).

Introduction: Shoulder arthroplasty procedures are increasingly being performed in older patients despite an increased perioperative risk. The purpose of this study is to determine the complications and 30-day readmission rates in the elderly population after shoulder arthroplasty and hemiarthroplasty.

Methods: Total shoulder arthroplasty, reverse total shoulder arthroplasty, and hemiarthroplasty cases were collected from the National Surgical Quality Improvement Program database from 2006 to 2015. The 30-day complication and readmission rates, surgical time, discharge destination, and total hospital length of stay were calculated, comparing patients by age (elderly: ≥80 years; older: 65 to 79 years; younger: <65 years). Multivariable logistic regression analysis was performed to identify variables associated with any complication within 30 days of surgery.

Results: Of 11,450 patients, 1,956 (17.1%) underwent shoulder hemiarthroplasty and 9,494 (82.9%) underwent total shoulder arthroplasty. By age group, 1,708 (14.9%) were ≥80, 6,073 (53.0%) were 65 to 79, and 3,669 (32.0%) were <65. The overall 30-day postoperative complication rate was significantly higher in elderly patients (15.3% versus 8.2% versus 6.8%; < 0.001), length of stay (2.6 versus 2.1 versus 1.8 days; < 0.001), and unplanned readmissions (5.5% versus 2.6% versus 2.3%; < 0.001). The strongest independent variables significantly associated with any complication included revision arthroplasty indication (odds ratio [OR], 4.34; < 0.001), fracture indication (OR, 4.14; < 0.001), and history of cardiac disease (OR, 2.33; < 0.001), followed by elderly age (OR, 2.01; < 0.001).

Conclusions: The 15.3% complication rate (major, 4.8%; minor, 10.7%), 2.6 days of average length of stay, and 5.5% unplanned readmission among elderly patients (>80) are significantly higher than younger patients. Although surgical indications and comorbidities are higher-quality predictors of complications, elderly patients should be appropriately counseled and medically optimized according to the perioperative risk profile before surgery.
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http://dx.doi.org/10.5435/JAAOSGlobal-D-18-00068DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6324900PMC
November 2018

A Guide to Understanding Reimbursement and Value-Based Care in the Military Health System.

Mil Med 2019 03;184(3-4):e205-e210

Bureau of Medicine and Surgery, U.S. Navy, 7700 Arlington Blvd Falls Church, VA.

Introduction: With the continued rise in the cost of U.S. health care, there is an increased emphasis on value-based care methodologies. Value is defined as health outcomes achieved per dollar spent. Few studies have evaluated the role of value-based care in the Military Health System (MHS), especially in a format which physicians and providers can understand. The purpose of this article is to provide a guide to understanding current reimbursement systems and value-based care in the MHS and discuss potential strategies for improving value and military readiness.

Materials And Methods: We outlined the current value-based care methodologies in the MHS, and by using musculoskeletal care as an example, offer strategies for further improvement.

Results: The MHS has been a leader in the health care industry in adopting value-based care strategies. Current value-based systems in the MHS are primarily designed to incentivize process measure compliance. Initial steps toward measurement and reporting health outcomes have been made, however, with the military's use of the Integrated Resourcing and Incentive System (IRIS), National Surgical Quality Improvement Program (NSQIP) database, and the Joint Outpatient Experience Survey (JOES).

Conclusion: As this article will describe, universal reporting of health outcomes, adoption of integrated practice units, and a focus on determining outcomes of illness over the entire care cycle offer a significant opportunity to accelerate the MHS journey to providing true value-based care. The universal measurement and systematic improvement of outcomes based on this measurement will contribute to military medical readiness and warfighter effectiveness.
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http://dx.doi.org/10.1093/milmed/usy206DOI Listing
March 2019

Relationship Between the Critical Shoulder Angle and Shoulder Disease.

JBJS Rev 2018 Aug;6(8):e1

Medical University of South Carolina, Charleston, South Carolina.

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http://dx.doi.org/10.2106/JBJS.RVW.17.00161DOI Listing
August 2018

Snapping Biceps Femoris Tendon.

Am J Orthop (Belle Mead NJ) 2018 Jul;47(7)

Blanchfield Army Community Hospital, Fort Campbell, KY.

A 23-year-old male active duty soldier presented with a biceps femoris tendon snapping over the fibular head with flexion of the knee beyond 90°. Surgical release of anomalous anterolateral tibial and lateral fibular insertions provided relief of snapping with no other repair or reconstruction required. The soldier quickly returned to full running and active duty. Snapping biceps femoris tendon is a rare but potential cause of pain and dysfunction in the lateral knee. The possible anatomical variations and the cause of snapping must be considered when determining the operative approaches to this condition.
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http://dx.doi.org/10.12788/ajo.2018.0055DOI Listing
July 2018

Return to Sport After Surgical Treatment for Anterior Shoulder Instability: A Systematic Review.

Am J Sports Med 2019 05 27;47(6):1507-1515. Epub 2018 Jun 27.

School of Medicine, Boston University, Boston, Massachusetts, USA.

Background: For athletes, a return to preinjury activity levels with minimal time away is a metric indicative of successful recovery. The knowledge of this metric would be helpful for the sports medicine specialist to advise patients on appropriate expectations after surgery.

Purpose: To evaluate the rate and amount of time needed for athletes to return to sport (RTS) after different surgical treatments for anterior shoulder instability.

Study Design: Systematic review and meta-analysis.

Methods: The MEDLINE, EMBASE, and Cochrane databases were searched for articles relevant to athletes' RTS after surgical anterior shoulder stabilization with variants of the Latarjet and Bankart procedures. Article selection was based on relevant inclusion and exclusion criteria. After the articles were reviewed, the data pertinent to rates of and time to RTS were extracted, compiled, and analyzed.

Results: Sixteen articles met the inclusion criteria. Based on these articles, the rate of RTS was 97.5% after arthroscopic Bankart, 86.1% after open Bankart, 83.6% after open Latarjet, 94.0% after arthroscopic Latarjet, and 95.5% after arthroscopic Bankart with remplissage. Among the athletes who did RTS, arthroscopic Bankart had the highest rate of return to preinjury levels (91.5%), while arthroscopic Latarjet had the lowest rate (69.0%). The time to RTS was 5.9 months after arthroscopic Bankart, 8.2 months after open Bankart, 5.07 months after open Latarjet, 5.86 months after arthroscopic Latarjet, and 7 months after arthroscopic Bankart with remplissage.

Conclusion: Of the pooled data, patients who underwent arthroscopic Bankart showed the highest rate of RTS, while patients who underwent open Latarjet showed the shortest time to RTS. Return to preinjury level was highest in the arthroscopic Bankart group and lowest in the arthroscopic Latarjet group. Physicians can utilize these data to set expectations for their patient-athletes regarding RTS after anterior shoulder stabilization procedures.

Clinical Relevance: When treating an athlete, many factors must be taken into account to weigh treatment options. Two important factors to consider with the patient-athlete are the rate of return to the previous activity level and the timeline for this to occur. This study provides a guide for physicians and a time frame for athletes with respect to the mean percentage and time for return to sport after different surgical procedures for anterior shoulder instability.
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http://dx.doi.org/10.1177/0363546518780934DOI Listing
May 2019

Shoulder adhesive capsulitis: epidemiology and predictors of surgery.

J Shoulder Elbow Surg 2018 Aug 25;27(8):1437-1443. Epub 2018 May 25.

Department of Orthopaedic Surgery, Boston Medical Center/Boston University School of Medicine, Boston, MA, USA. Electronic address:

Background: Adhesive capsulitis is characterized by a gradual, painful loss of shoulder motion. This study evaluated patient variables significantly associated with developing adhesive capsulitis compared with a sex-matched control group without adhesive capsulitis. We also sought to determine those factors associated with adhesive capsulitis patients requiring surgical intervention.

Methods: All patients presenting to our hospital with adhesive capsulitis between 2004 and 2014 were identified. Demographic characteristics were collected, and a sex-matched control group was randomly generated from the electronic medical record and used for comparison. Patients who underwent surgical intervention for adhesive capsulitis were also identified, and factors associated with surgical intervention were identified with logistic regression analysis.

Results: Included were 2190 adhesive capsulitis patients with a normal age distribution of 56.4 ± 13.1 years. Most were classified as overweight (30.7%) or obese (27.0%). Compared with controls, adhesive capsulitis patients were more likely to be younger (<50 vs. ≥50 years; odds ratio [OR], 0.69; P < .001), obese (OR, 1.26; P < .001), black/African American (OR, 1.71; P < .001), Hispanic/Latino (OR, 4.85; P < .001), or diabetic (OR, 1.12; P < .001) and less likely to have hypertension (OR, 0.93; P = .006). Overall, 361 subsequently underwent surgical intervention. Older patients, racial minorities, and government-sponsored/uninsured patients were significantly less likely to have surgery for adhesive capsulitis (P < .01), whereas workers' compensation patients were 8 times more likely to receive surgery compared with privately insured patients (P < .001).

Conclusions: Obesity and diabetes were significantly associated with adhesive capsulitis and should be considered modifiable patient factors. Additionally, younger patients and racial minorities were also significantly more likely to be diagnosed with adhesive capsulitis. Younger, white, and workers' compensation patients were more likely to receive surgery, whereas patients with government-sponsored or no insurance status were more likely to receive nonoperative treatment.
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http://dx.doi.org/10.1016/j.jse.2018.04.004DOI Listing
August 2018

Pectoralis Major Tendon Insertion Anatomy and Description of a Novel Anatomic Reference.

J Surg Orthop Adv Spring 2018;27(1):39-41

Department of Surgery, Madigan Army Medical Center, Tacoma, Washington.

Pectoralis major rupture is an uncommon injury often treated surgically, requiring anatomic knowledge of the tendon insertion. This study defines the pectoralis major tendon insertion footprint and a novel anatomic relationship. Twelve cadaver shoulders were evaluated andmeasured using a standard surgical ruler to demonstrate the normal anatomic footprint. Measurements were taken from the anterior medial margin of the articular surface of the humeral head to the superior margin of the pectoralis major insertion and its relation to the latissimus dorsi tendon insertion. The average length and width of the pectoralis major insertion were 73.3 ± 10.0 mm and 3.3 ± 0.54 mm, respectively, consistent with previous publications. On average, the superior margin of the pectoralis tendon was within 1 mm of the latissimus dorsi insertion and 41.2 ± 9.27 mm from the articular margin. These points form a new anatomic reference of the latissimus dorsi, providing an intraoperative reference point when performing pectoralis major muscle tendon repair. (Journal of Surgical Orthopaedic Advances 27(1):39-41, 2018).
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July 2018

Trends in Surgical Management of Anterior Shoulder Instability: Increased Utilization of Bone Augmentation Techniques†.

Mil Med 2018 05;183(5-6):e201-e206

Department of Orthopaedic Surgery, Wake Forest University School of Medicine, Medical Center Boulevard, Winston-Salem, NC 27157.

Purpose: The purpose of this study is to evaluate the trends in surgical management for anterior shoulder instability in the U.S. Military.

Methods: A retrospective analysis of military service members undergoing arthroscopic or open shoulder stabilization from 2012 to 2015 within the U.S. Military Health System was conducted. Demographic and surgical variables were extracted from the medical record. Chi-square and linear regression analysis were performed to identify temporal trends by surgical procedures and concomitant surgery. Associations between demographic variables and surgical procedure were evaluated using logistic regression analysis with odds ratios and 95% confidence intervals.

Results: Eight thousand five hundred and eighty nine surgeries were performed for anterior shoulder instability. The arthroscopic Bankart procedure remained the dominant surgical procedure over time (n = 8177, 95.2%), whereas the open Bankart procedure (n = 172, 2.0%) demonstrated a diminishing trend, which was significant on univariate analysis (p = 0.0009), but not statistically significant on linear regression (p = 0.12). Additionally, there was a significant trend toward increased utilization of the Latarjet procedure over the period studied (n = 33, 1.7% - n = 81, 3.56%) (p = 0.009). During the same time period, concomitant superior labrum anterior/posterior repairs decreased (n = 980, 11.4%; p = 0.0045), whereas rates of biceps tenodesis (n = 741, 8.6%; p = 0.05) increased significantly. When analyzing patient age as a continuous variable, increasing age was associated with a significantly higher likelihood of arthroscopic treatment (odds ratio 1.02, 95% confidence interval 1.00-1.03, p = 0.05).

Conclusion: The rate of performing an arthroscopic Bankart repair has remained relatively stable as the dominant surgical procedure for shoulder instability in the military patient population. There was a significant trend of increased use of the Latarjet procedure, which likely reflects the recognition of bone loss through use of preoperative advanced imaging and computed tomography with three-dimensional reconstructions. Additionally, there was a significant decrease in adjacent superior labrum anterior/posterior repairs over the study period, followed by a corresponding rise in biceps tenodesis. Level of evidence: level IV.
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http://dx.doi.org/10.1093/milmed/usx077DOI Listing
May 2018

Proximal to Distal Exostectomy for the Treatment of Insertional Achilles Tendinopathy.

Foot Ankle Spec 2018 Aug 17;11(4):362-364. Epub 2018 Jan 17.

Department of Orthopaedics, Madigan Army Medical Center, Tacoma, Washington (ZLM, JR).

When insertional Achilles tendinopathy is addressed surgically via a central-Achilles splitting approach, the calcaneal osteotomy has classically been performed from distal to proximal. We describe a simple proximal to distal technique that allows optimal resection of both the calcaneal exostosis and Achilles enthesophyte, minimizes risk to the soft tissues and skin, provides a bony attachment surface parallel to the axis of the Achilles tendon, and avoids the risk of osteotomy extension into the subtalar joint.

Levels Of Evidence: Level V: Technique tip.
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http://dx.doi.org/10.1177/1938640017751187DOI Listing
August 2018

The Epidemiology and Natural History of Anterior Shoulder Instability.

Curr Rev Musculoskelet Med 2017 Dec;10(4):411-424

Eisenhower Army Medical Center, 300 E Hospital Rd, Augusta, GA, 30905, USA.

Purpose Of Review: The purpose of this review is to outline the natural history and best clinical practices for nonoperative management of anterior shoulder instability.

Recent Findings: Recent studies continue to demonstrate a role for nonoperative treatment in the successful long-term management of anterior glenohumeral instability. The success of different positions of shoulder immobilization is reviewed as well. There are specific patients who may be best treated with nonoperative means after anterior glenohumeral instability. There are also patients who are not good nonoperative candidates based on a number of factors that are outlined in this review. There continues to be no definitive literature regarding the return to play of in-season athletes. Successful management requires a thorough understanding of the epidemiology, pathoanatomy, history, physical examination, diagnostic imaging modalities, and natural history of operative and nonoperative treatment.
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http://dx.doi.org/10.1007/s12178-017-9432-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5685954PMC
December 2017

Arthroscopic treatment of posterior shoulder instability in patients with and without glenoid dysplasia: a comparative outcomes analysis.

J Shoulder Elbow Surg 2017 Dec 19;26(12):2103-2109. Epub 2017 Jul 19.

Department of Orthopaedics, Medical University of South Carolina, Charleston, SC, USA. Electronic address:

Background: The purpose of this study was to evaluate the influence of glenoid dysplasia on outcomes after isolated arthroscopic posterior labral repair in a young military population.

Methods: Thirty-seven male patients who underwent arthroscopic posterior labral repair for symptomatic posterior shoulder instability were evaluated at a mean duration of 3.1 years. A comparative analysis was performed for those with glenoid dysplasia and without dysplasia. Additional factors analyzed included military occupational specialty (MOS), preoperative mental health clinical encounters and mental health medication use, and radiographic characteristics (version, posterior humeral head subluxation, and posterior capsular area) on a preoperative standard shoulder magnetic resonance arthrogram. The groups were analyzed with regard to shoulder outcome scores (subjective shoulder value [SSV], American Shoulder and Elbow Surgeons [ASES] rating scale, Western Ontario Shoulder Instability Index [WOSI]), need for revision surgery, and medical separation from the military.

Results: Of 37 patients, 3 (8.1%) underwent revision surgery and 6 (16%) underwent medical separation. Overall outcome assessment demonstrated a mean SSV of 67.9 (range, 25-100) ± 22.1, mean ASES of 65.6 (range, 15-100) ±  22, and mean WOSI of 822.6 (range, 5-1854) ± 538. There were no significant differences in clinical outcome scores between the glenoid dysplasia and no dysplasia groups (SSV, P = .55; ASES, P = .57; WOSI, P = .56). MOS (P = .02) and a history of mental health encounters (P = .04) were significantly associated with diminished outcomes.

Conclusions: The presence or absence of glenoid dysplasia did not influence the outcome after arthroscopic posterior labral repair in a young military population. However, a history of mental health clinical encounters and an infantry MOS were significantly associated with poorer clinical outcomes.
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http://dx.doi.org/10.1016/j.jse.2017.05.033DOI Listing
December 2017

Return to Duty Rates Following Meniscal Repair Surgery in an Active Duty Military Population.

Mil Med 2016 11;181(11):e1661-e1665

Orthopaedic Surgery Service, Madigan Army Medical Center, 9040 Jackson Avenue, Tacoma, WA, 98431.

Meniscal injury is a common knee injury in a young athletic population. Maintaining the integrity of the meniscus is critical to reducing contact pressures on the tibiofemoral articulation. The purpose of this study is to analyze the outcomes of meniscal repair in a young military population. We conducted a retrospective review of all meniscal repairs performed on active duty Army personnel at a Military Medical Center from January 2002 to December 2012. One hundred seventy-eight active duty patients, mean age 28 (19-48) years underwent 178 meniscal repairs. Postoperatively, 33 (18.5%) patients were medically separated from the military at an average time of 29 months. Fifty (28%) patients required a permanent duty restricting profile. Ninety-five (53.5%) patients required no profile after meniscal repair at an average follow-up of 5 (1.5-12.3) years. Meniscal repair in this young military population allowed 81.5% of patients to return to duty; however, 34% of those required a permanent duty restricting profile. Approximately 20% of patients required medical separation from the military after meniscal repair. Older age was significantly associated with the ability to remain on active duty (p = 0.01).
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http://dx.doi.org/10.7205/MILMED-D-15-00589DOI Listing
November 2016

Critical Findings on Magnetic Resonance Arthrograms in Posterior Shoulder Instability Compared With an Age-Matched Controlled Cohort.

Am J Sports Med 2016 Dec 15;44(12):3222-3229. Epub 2016 Aug 15.

Orthopaedic Surgery Service, Madigan Army Medical Center, Tacoma, Washington, USA.

Background: Posterior shoulder instability is less common and potentially more difficult to diagnose clinically and radiographically compared with anterior shoulder instability. Radiographic findings including posterior labral tears, increased retroversion, presence of glenoid dysplasia, and increased capsular area are associated with symptomatic recurrent posterior shoulder instability.

Purpose: This study aimed to determine the prevalence and severity of associated radiographic parameters found on magnetic resonance arthrograms (MRAs) in patients with arthroscopically confirmed isolated posterior labral tears and symptomatic recurrent posterior shoulder instability, compared with an age-matched cohort of patients without posterior instability or labral injury confirmed with shoulder arthroscopy.

Study Design: Cross-sectional study, Level of evidence, 3.

Methods: Patients who received a preoperative standard shoulder MRA at an academic institution over a 5-year period and had symptomatic posterior instability and received a repair of an arthroscopically confirmed posterior labral tear (n = 63) were identified. These patients were compared with an age-matched control group of patients without posterior instability (n = 49) who underwent an isolated arthroscopic distal clavicle resection that included an arthroscopic glenohumeral joint evaluation. Glenoid version, posterior humeral head subluxation, glenoid dysplasia, and linear and capsular area measurements were evaluated between the 2 groups. Interobserver reliability for continuous and categorical variables was assessed for all measurements.

Results: Multivariate logistic regression revealed that the presence of increased glenoid retroversion (P = .0018), glenoid dysplasia (P = .03), and increased axial posterior capsular cross-sectional area (P = .05) were significantly associated with posterior labral tears and symptomatic posterior shoulder instability compared with the age-matched control group. Posterior humeral head subluxation was found to be a statistically significant variable with univariate analysis (P = .001) for posterior shoulder instability but not with multivariate logistic regression (P = .53). Interobserver reliability was good to very good for all measurements (intraclass correlation coefficient [ICC] = 0.74-0.85; κ = 0.64) but was moderate for total capsular area and sagittal capsular area measurements (ICC = 0.43-0.56).

Conclusion: The presence of increased glenoid retroversion, glenoid dysplasia, and increased posterior capsular area on MRA are significantly associated with posterior labral tears and symptomatic posterior shoulder instability. Identification of these critical radiographic variables on magnetic resonance arthrography assists in the accurate diagnosis and management of clinically significant posterior shoulder instability.
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http://dx.doi.org/10.1177/0363546516660076DOI Listing
December 2016
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