Saturday, November 29, 2025

Five stemless humeral arthroplasty components - design differences and regional humeral bone density

Stemless humeral arthroplasty depends on fixation of the humeral component to the proximal humeral metaphysis. The article referenced below maps the typical bone density of this region from the article Spatial mapping of humeral head bone density

Stemless components consist of (a) the humeral head and (b) a fixation device that connects the humeral head to the bone of the humeral metaphysis - we'll call that the "nucleus".

The first stemless humeral head component was the TESS (Total Evolutive Shoulder System), developed by Zimmer Biomet and introduced around 2004-2005. The TESS used a nucleus consisting of central peg with metaphyseal fins for fixation.

The TESS had a relatively short clinical lifespan - it was discontinued after several years due to concerns about loosening and suboptimal outcomes. The device struggled with achieving reliable fixation, particularly in patients with poor bone quality.

In spite of this initial failure, many shoulder arthroplasty surgeons are currently successfully using newer stemless humeral components because of their ability to position the articular surface where the surgeon desires, rather than having it positioned as dictated by a humeral stem.

For many patients the cancellous bone of the humeral metaphysis is sufficient for secure fixation of the implant. Thus, as long as the head cut is made properly and the bone is of good quality, things usually work out well.

The challenge is that in older patients or patients with diminished quality of the cancellous bone in the humeral metaphysis, the fixation may not be adequate.

Some surgeons advocate preoperative CT imaging to examine local bone density. However, because the quality of fixation depends not only on bone quality but also on the design of the fixation device - the nucleus - that links the humeral head component to the humeral bone it seem more practical to insert the trial nucleus to assess fixation quality; if it's insufficient the surgeon can switch to a stemmed component.

Below I've endeavored to present five stemless shoulder arthroplasty systems arranged in chronological order of U.S. FDA clearance, examining their design philosophy, and mechanical advantages for osteoporotic bone quality.

N.B. Please note that I have no conflict of interest with any of the companies selling these implants. Note also that I used Claude.ai to help in the analysis and preparation of this post. As such there may be errors and I'd welcome any evidence-based corrections/comments. Finally, this analysis does not present clinical outcome, radiographic followup data, or complexity of revision among these options - such a comparison would require a very large number of patients and careful control of bone density and surgical technique.

1. Simpliciti (Wright Medical/Stryker)

FDA CLEARANCE: March 10, 2015

Design Geometry

Three central fins (~10mm length) arranged in a star pattern with central contact through a nucleus. While the nucleus provides broad cancellous contact with minimal risk cortical perforation, the central fin placement relies on cancellous bone which is weaker in patients with diminished bone desitity.

[Churchill RS et al. J Bone Joint Surg Am. 2016;98(7):552-560 (prospective two-year multicenter FDA IDE study, n=149). Churchill RS. J Shoulder Elbow Surg. 2014;23(9):1409-1414 (stemless shoulder arthroplasty current status review). First stemless system cleared in the United States, with clinical use in France beginning in 2010.]

2. Comprehensive Nano (Zimmer Biomet)

FDA CLEARANCE: April 2019

Design Geometry

Single central peg (15-20mm length, 8-10mm diameter) with tapered profile plus modular metaphyseal shells. Load concentrated in cancellous bone without peripheral bone engagement.

[Razmjou H et al. J Shoulder Elbow Surg. 2012;21(10):1-9 (early TESS/stemless design study). IDE study began with first U.S. implant in October 2013 at University of Virginia. Built on clinical heritage of Biomet T.E.S.S. stemless shoulder available in Europe since 2004. Comprehensive Nano IDE clinical trial data on file, Zimmer Biomet.]

3. Eclipse (Arthrex)

FDA CLEARANCE: August 1, 2019 (510(k) K183194)

Design Geometry

Fenestrated central screw (6.5mm diameter, 35mm length) penetrates into cancellous bone. A collar-bearing baseplate is compressed against cancellous bone and the cortical rim. The degree of compression depends on the purchase achieved by the screw in the central cancellous bone which can be weak.

Clinical Evidence

[Habermeyer P et al. J Shoulder Elbow Surg. 2015;24(9):1463-1472 (midterm results). Habermeyer P et al. JSES Open Access. 2019;3(4):234 (9-13 year results). Gallacher S et al. J Shoulder Elbow Surg. 2018;27(12):2191-2197 (independent 2-year study). Uschok S et al. J Shoulder Elbow Surg. 2017;26(2):225-232 (Eclipse vs Univers II RCT). Over 20,000 successful implantations in Europe and Canada prior to U.S. FDA clearance. Longest clinical track record of any stemless system (2005-present)].

4. CS EDGE (DJO/Enovis)

FDA CLEARANCE/LAUNCH: September 30, 2020

Design Geometry

Three peripheral serrated fins arranged in tripod configuration (~15mm length, 2-3mm thickness) plus a short central peg. Fins engage peripheral bone (greater tuberosity, calcar region). Insertion needs to avoid fin perforation of cortex.

Clinical Evidence

Product launch announcement September 30, 2020 (DJO/Enovis). No published peer-reviewed clinical studies available to date.

5. OsseoFit (Zimmer Biomet)

FDA CLEARANCE: December 13, 2024

Design Geometry

Asymmetric 3-4 peripheral fins with variable lengths (12-18mm) scaled to engage the asymmetrical peripheral bone in humeal head. Posterior-inferior fin longest, medial fin engages calcar, superior fins engage greater tuberosity. Requires precise surgical technique for correct rotational alignment

Clinical Evidence

FDA clearance announcement December 13, 2024 (Zimmer Biomet). No published peer-reviewed clinical studies available to date.

Fundamental Principle: Humeral head bone architecture exhibits a shell-and-core structure with peripheral bone density significantly exceeding central metaphyseal bone quality, especially in elderly patients and those with osteoporosis. Peripheral fixation designs theoretically exploit the strongest available bone, while central fixation systems depend on the bone that may be compromised in typical arthroplasty candidates.

It's all about fixation

Acorn Woodpecker

Madera Canyon, AZ

2020

Follow on twitter/X: https://x.com/RickMatsen
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Here are some videos that are of shoulder interest
Shoulder arthritis - what you need to know (see this link).
How to x-ray the shoulder (see this link).
The ream and run procedure (see this link)
The total shoulder arthroplasty (see this link)
The cuff tear arthropathy arthroplasty (see this link).
The reverse total shoulder arthroplasty (see this link).
The smooth and move procedure for irreparable rotator cuff tears (see this link)
Shoulder rehabilitation exercises (see this link).

Wednesday, November 26, 2025

TXA and Shoulder Arthroplasty - what we wish we knew

For shoulder surgeons it's not so much about reducing total blood loss (which is usually <400cc and rarely requires transfusion) but rather it's about minimizing hematoma/brusing/swelling - especially when it is a priority to get the shoulder moving soon after arthroplasty, such as in anatomic arthroplasty for a preoperatively stiff shoulder.

Tranexamic acid (TXA) is a synthetic lysine derivative that competitively inhibits plasminogen activation, preventing its conversion to plasmin, and stabilizing fibrin clots; this is its anti-fibrinolytic effect. It can be administered intravenously, topically, or orally.

Much of what we have learned about TXA comes from hip and knee arthroplasty. Here's a summary of what can be pulled from that literature:

1. Interestingly, more is not better - low dose IV TXA (total of 1 or 2 grams) is as effective as higher doses.

2. Pre-incision administration is more effective than post incision administration.

3. A common protocol is1 gram pre-incision and 1 gram at closure. A protocol of 2 grams IV at incision plus 2 grams IV at closure (total 4 grams) is NOT standard and exceeds what most studies have investigated.

4. The 2021 TRAC-24 Trial revealed that in addition to intraoperative IV TXA, postoperative oral TXA reduced blood loss in total knee arthroplasty as well as reduced length of stay, lower readmission rates, ER visits and need for transfusion.

5. A 2024 randomized controlled trial showed that for total knees, 1 gram IV before and at closure plus1.95 grams orally daily on post operative days 1, 2 and 3 resulted in improved motion, less pain and better functional scores at 2 and 6 weeks in comparison to those receiving only the IV perioperative TXA. The authors suggested that the benefit resulted from an anti-inflamatory effect rather than diminished blood loss. This postoperative regimen significantly reduced CRP and IL-6 levels in TKA patients

Tranexamic acid attenuates inflammatory effect and modulates immune response in primary total knee arthroplasty: a randomized, placebo-controlled, pilot trial

The antifibrinolytic and anti‐inflammatory effects of multiple doses of oral tranexamic acid in total knee arthroplasty patients: a randomized controlled trial

Anti-inflammatory effect of multi-dose tranexamic acid in hip and knee arthroplasty: a systematic review and meta-analysis of randomized controlled trials

Safety Considerations

1. The 2018 guidelines provide STRONG evidence that TXA administration (IV, topical, and oral) does not increase the risk of venous thromboembolism in patients without known history of VTE. Direct meta-analysis of 77 high-quality and 1 moderate-quality randomized clinical trials (92% of which excluded patients with history of thromboembolic events) demonstrated no significant difference in VTE rates between TXA and placebo.

2. For high-risk patients - those with a history of VTE, myocardial infarction, cerebrovascular accident, or vascular stent placement - the guidelines provide only MODERATE support that TXA does not increase thromboembolic risk.

Extrapolating the hip and knee evidence to shoulder arthroplasty, a reasonable approach to the use of TXA in shoulder arthroplasty may be:

(1) One gram IV at the time of incision and one gram at closure (alternative: two grams IV at incision).

(2) For patients with a history of prior VTE, myocardial infarction, cerebrovascular accident, or vascular stent placement, avoid IV TXA and, after the wound has been irrigated, topically administer 2 grams TXA in 50 mL normal saline and close the wound without further irrigation.

(3) Consider oral tranexamic acid: three 650mg tablets once daily on postoperative days 1, 2, and 3 in an attempt to reduce postoperative brusing, improve motion, reduce pain and improve function. Check with patient's insurance company to be sure it is covered for this use.

Staying on top of the situation

Nesting Grebe

Montlake Fill

2024

REFERENCES

1. Fillingham YA, Ramkumar DB, Jevsevar DS, Yates AJ, Bini SA, Clarke HD, Schemitsch E, Johnson RL, Memtsoudis SG, Sayeed SA, Sah AP, Della Valle CJ. Tranexamic Acid Use in Total Joint Arthroplasty: The Clinical Practice Guidelines Endorsed by the American Association of Hip and Knee Surgeons, American Society of Regional Anesthesia and Pain Medicine, American Academy of Orthopaedic Surgeons, Hip Society, and Knee Society. J Arthroplasty. 2018 Oct;33(10):3065-3069.

2. Fillingham YA, Ramkumar DB, Jevsevar DS, Yates AJ, Shores P, Mullen K, Bini SA, Clarke HD, Schemitsch E, Johnson RL, Memtsoudis SG, Sayeed SA, Sah AP, Della Valle CJ. The Efficacy of Tranexamic Acid in Total Hip Arthroplasty: A Network Meta-Analysis. J Arthroplasty. 2018;33(10):3083-3089.

3. Fillingham YA, Ramkumar DB, Jevsevar DS, Yates AJ, Shores P, Mullen K, Bini SA, Clarke HD, Schemitsch E, Johnson RL, Memtsoudis SG, Sayeed SA, Sah AP, Della Valle CJ. The Efficacy of Tranexamic Acid in Total Knee Arthroplasty: A Network Meta-Analysis. J Arthroplasty. 2018;33(10):3090-3098.

4. Magill P, Hill JC, Bryce L, Martin U, Dorman A, Hogg R, Campbell C, Gardner E, McFarland M, Bell J, Benson G, Beverland D. Oral tranexamic acid for an additional 24 hours postoperatively versus a single preoperative intravenous dose for reducing blood loss in total knee arthroplasty: results of a randomized controlled trial (TRAC-24). Bone Joint J. 2021 Oct;103-B(10):1595-1603.

5. Magill P, Hill JC, Bryce L, Martin U, Dorman A, Hogg R, Campbell C, Gardner E, McFarland M, Bell J, Benson G, Beverland D. Oral tranexamic acid for an additional 24 hours postoperatively versus a single preoperative intravenous dose for reducing blood loss in total hip arthroplasty: results of a randomized controlled trial (TRAC-24). Bone Joint J. 2021 Jul;103-B(7):1197-1205.

6. Karayiannis PN, Agus A, Bryce L, Hill JC, Beverland D. Using tranexamic acid for an additional 24 hours postoperatively in hip and knee arthroplasty saves money: a cost analysis from the TRAC-24 randomized control trial. Bone Jt Open. 2022 Jul;3(7):536-542.

7. Mihalko WM, Brimmo O, Siddiqi A, Mannava S, Kremers HM, Sierra RJ. The AAHKS Clinical Research Award: Extended Postoperative Oral Tranexamic Acid in Total Knee Arthroplasty: A Randomized Controlled Pilot Study. J Arthroplasty. 2024 Sep;39(9S):S2-S8.

8. Yuenyongviwat V, Dissaneewate K, Iamthanaporn K. Efficacy of Extended Oral Tranexamic Acid on Blood Loss in Primary Total Knee Arthroplasty. Acta Ortop Bras. 2022 Jul-Aug;30(4):e245411.

9. Lloyd TD, Deakin AH, Gregg-Smith SJ, Melling L, Dall GF, Yates P, Hui ACW, et al. Perioperative administration of tranexamic acid in lower limb arthroplasty: a multicentre, prospective cohort study. Anaesthesia. 2020 Aug;75(8):1050-1058.

10. Grosso MJ, Boddapati V, Cooper HJ, Geller JA, Shah RP, Neuwirth AL, Rubin LE. One Dose Versus Two Doses of Intravenous Tranexamic Acid in Total Joint Arthroplasty. J Bone Joint Surg Am. 2021 Jun 2;103(11):e45.

11. Box HN, Tisano BS, Khazzam M. Tranexamic acid administration for anatomic and reverse total shoulder arthroplasty: a systematic review and meta-analysis. JSES Open Access. 2018 Feb 15;2(1):28-33.

12. Kirsch JM, Bedi A, Horner N, Wiater JM, Pauzenberger L, Koueiter DM, Miller BS, Bhandari M, Khan M. Tranexamic Acid in Shoulder Arthroplasty: A Systematic Review and Meta-Analysis. JBJS Rev. 2017 Sep;5(9):e3.

13. Friedman RJ, Gordon E, Butler RB, Mock L, Dumas B. Tranexamic acid decreases blood loss after total shoulder arthroplasty. J Shoulder Elbow Surg. 2016 Apr;25(4):614-8.

14. Pauzenberger L, Domej MA, Heuberer PR, Hexel M, Grieb A, Laky B, Blasl J, Anderl W. A single dose of tranexamic acid reduces blood loss after reverse and anatomic shoulder arthroplasty: a randomized controlled trial. J Shoulder Elbow Surg. 2021 Mar;30(3):e55-e67.

15. Sun C, Zhang X, Ma J, Jiang C, Xia Y, Xiong Y, Pan Z. Oral and intravenous tranexamic acid are equivalent at reducing blood loss following shoulder arthroplasty: A multicenter, double-blinded, randomized, placebo-controlled trial. J Shoulder Elbow Surg. 2022 May;31(5):907-915.

16. Abildgaard JT, McLemore R, Hattrup SJ. Tranexamic acid decreases blood loss in total shoulder arthroplasty and reverse total shoulder arthroplasty. J Shoulder Elbow Surg. 2016 Oct;25(10):1643-8.

17. Koutserimpas C, Chamakos E, Raptis K, Samoladas E. Tranexamic Acid in Shoulder Arthroplasty. A Comprehensive Review. Acta Biomed. 2021 Jun 7;92(3):e2021213.

18. StatPearls. Tranexamic Acid. Treasure Island (FL): StatPearls Publishing; 2024 Jan. Available from: https://www.ncbi.nlm.nih.gov/books/NBK532909/

19. Hill J, Magill P, Dorman A, et al. Assessment of the effect of addition of 24 hours of oral tranexamic acid post-operatively to a single intraoperative intravenous dose of tranexamic acid on calculated blood loss following primary hip and knee arthroplasty (TRAC-24): a study protocol for a randomised controlled trial. Trials. 2018 Jul 31;19(1):422.

20. Jones AM, Greenwood R, Bochert M, Gibbons M. Effectiveness of oral versus intravenous tranexamic acid in primary total hip and knee arthroplasty: a randomised, non-inferiority trial. Br J Anaesth. 2023 Feb;130(2):234-242.

21. Budge M, et al. Topical and Intravenous Tranexamic Acid Are Equivalent in Decreasing Blood Loss in Total Shoulder Arthroplasty. J Shoulder Elbow Surg 2019.

Tuesday, November 25, 2025

The $30 approach for optimizing perioperative nutrition for patients having shoulder surgery

50% of patients having rotator cuff repair, shoulder arthroplasty, and fracture surgery are deficient in Vitamin D. While 10% of patients having shoulder surgery are protein deficient before surgery, as many as 40% have insufficient protein reserve to mount the necessary healing response. Insufficient Vitamin D and protein place the patient at increase risk for complications including delayed healing and infection.

For this reason we provide our patients scheduled for surgery with the following letter:

"Dear Patient

Good nutrition plays an important role in how your body heals after surgery. Unfortunately, many people don't get optimal levels of key nutrients through diet alone, especially during recovery from an operation when you need extra support.

To give your body the best chance to heal well, I recommend two simple supplements starting 2 weeks before your surgery and continuing for 4-6 weeks afterward:

Vitamin D: 4000 IU daily

Most people have low vitamin D levels, particularly in the Pacific Northwest. Vitamin D supports bone healing and may reduce infection risk. This dose is safe and well below levels that could cause any problems.

Protein Powder: 25-30 grams daily

Your body needs protein to heal surgical wounds, maintain muscle mass, and recover strength. A scoop of whey protein ensures you're getting enough even if your appetite is reduced after surgery. Use a plant-based alternative if you prefer.

You can find both supplements at any pharmacy or grocery store. Generic or store brands work fine—you don't need expensive formulations. The cost of this program is usually only $30 - a great investment in your recovery.

When to start: 2 weeks before surgery if possible

How long to continue: 4-6 weeks after surgery

If you have kidney disease, are on blood thinners, or have concerns about these supplements, please let me know.

Taking these simple steps won't guarantee a perfect outcome, but they address common nutritional gaps that can interfere with healing. Think of this as giving your body the raw materials it needs to do its job.

Please email me if you have any questions."

Thanks to Hafiz Kassam for making this plan doable for patients.

The "Secret Sauce" for Optimizing Rotator Cuff Outcomes: Biologics or nutrition?

and

The "secret sauce" for optimizing arthroplasty outcomes: nutrition

Thursday, November 20, 2025

Avoiding the appearance of conflict of interest for orthopaedic surgeons.

Orthopaedic surgeons commonly have relationships with companies that sell the devices used in the practice of orthopaedic surgery. These relationships create both opportunity and risk for both the surgeons and the companies.

These complexities are on display in a November 11, 2025 article in the Columbus Dispatch, the headline of which is presented here as it appeared in the newspaper without any judgement on the accuracy of the article or the appropriateness of the actions of either party.

I asked Claude.ai for some context regarding surgeon-company relationships. This is a bit long, but may be useful to some of our readers, especially those having or considering relationships with industry. The text below is directly from Claude; I've not verified its accuracy.

Legal and Regulatory Framework

Several federal laws govern financial relationships between physicians and medical device companies, particularly when those relationships may influence institutional purchasing decisions that affect Medicare and Medicaid patients:

The Anti-Kickback Statute

The Anti-Kickback Statute (42 U.S.C. § 1320a-7b(b)) is a criminal statute that prohibits knowingly and willfully offering, paying, soliciting, or receiving remuneration to induce or reward referrals of items or services reimbursable by federal healthcare programs. "Remuneration" includes anything of value and takes many forms beyond cash, including consulting fees, speaking honoraria, research grants, and travel expenses. Violations constitute a felony punishable by up to ten years imprisonment and $100,000 in fines per violation. The statute covers both payers and recipients of kickbacks, and importantly, requires proof of intent to induce referrals or business.

A critical aspect of the Anti-Kickback Statute is that even if one purpose of the payment is to influence referrals or purchasing decisions, the statute is violated—it need not be the only purpose. When a physician receives substantial payments from a device manufacturer and then influences institutional purchasing decisions in that manufacturer's favor, prosecutors may argue this creates an inference of improper intent.

The Physician Self-Referral Law (Stark Law)

The Physician Self-Referral Law (Stark Law, 42 U.S.C. § 1395nn) prohibits physicians from referring Medicare patients for designated health services to entities with which they have a financial relationship, unless an exception applies. While the Stark Law is more limited in scope than the Anti-Kickback Statute—applying only to physicians, only to Medicare, and only to "designated health services"—it operates as strict liability, requiring no proof of intent. Penalties include denial of payment, refund of monies received, civil monetary penalties up to $15,000 per service, and treble damages.

The False Claims Act

The False Claims Act permits the government to recover damages when false claims are submitted to federal healthcare programs. Critically, violations of the Anti-Kickback Statute or Stark Law can render submitted claims "false" for purposes of the False Claims Act, even without specific intent to defraud. This provision significantly amplifies enforcement, as whistleblowers can file qui tam suits and receive 15-30% of any recovery.

The Physician Payments Sunshine Act

The Physician Payments Sunshine Act (part of the Affordable Care Act) requires manufacturers of drugs, medical devices, and biologicals to report payments to physicians and teaching hospitals. These payments are disclosed in the Open Payments database, a searchable public resource maintained by the Centers for Medicare & Medicaid Services. This transparency mechanism allows patients, institutions, and regulators to examine financial relationships between industry and physicians.

Ethical Dimensions

The American Medical Association's Code of Medical Ethics addresses physician relationships with industry, emphasizing that such relationships must not compromise professional judgment or prioritize physician interests over patient welfare. The AMA specifically addresses medical device representatives, emphasizing that their presence and involvement should be subject to facility policies and should never substitute for appropriate physician training.

The American College of Physicians has articulated similar principles, noting that while industry partnerships can advance medical knowledge, they create opportunities for bias. ACP emphasizes that the distinguishing feature of true professionalism is "effacement of self-interest"—placing patient welfare above personal financial gain.

Academic medical centers have particular obligations because of their educational, research, and patient care missions. The Institute of Medicine (now National Academy of Medicine) issued comprehensive recommendations in its 2009 report "Conflict of Interest in Medical Research, Education, and Practice. The report called for academic medical centers to prohibit faculty from accepting items of material value from industry except in specified situations, to require written consulting contracts paid at fair market value, and to establish robust conflict of interest review committees.

Patient Welfare: The fundamental obligation of healthcare professionals is patient welfare. Financial conflicts risk prioritizing cost, physician convenience, or industry relationships over optimal patient outcomes.

Industry Relationships and Academic Medicine: Medical device development requires physician input—surgeons provide essential feedback on implant design, surgical techniques, and clinical applications. However, when physicians receive substantial payments and then influence institutional purchasing, the line between legitimate collaboration and improper inducement blurs.

Institutional and Systemic Implications

• Commonness of Industry Payments: Open Payments data reveals that physician-industry financial relationships are widespread. Between 2014 and 2018, over $8.7 billion was transferred from industry to physicians.

• Dual Roles and Conflicts: Physicians increasingly occupy dual roles—clinician and administrator—creating complex conflict landscapes. When a department chair who receives industry payments also controls purchasing, the conflict intensifies. Academic medical centers must carefully structure decision-making to insulate procurement from individual financial interests.

• Conflict Management: Effective conflict management requires not just policies but enforcement mechanisms, monitoring, and accountability. Institutions need conflict of interest committees with authority to review arrangements, require recusals, and impose consequences for violations.

• Transparency Gaps: While the Sunshine Act improved transparency, significant gaps remain. Patients rarely know about their physicians' industry relationships. Hospital boards and administrators may not fully understand the extent of conflicts within their institutions.

• Cultural Factors: Academic medicine has historically tolerated—even celebrated—industry relationships, viewing them as markers of expertise and influence. This culture can normalize conflicts and create pressure on junior faculty to develop similar relationships. Changing this culture requires leadership commitment, clear policies, and willingness to forgo lucrative arrangements when they create unmanageable conflicts.

Claude.ai's Recommendations and Best Practices

"Several recommendations emerge for academic medical centers:

• Strict Separation of Purchasing and Industry Relationships: Physicians with substantial industry financial relationships should be categorically excluded from institutional procurement decisions involving those companies. This separation should be absolute, not merely advisory. Procurement should be managed by committees that include physicians without conflicts, purchasing professionals, and patient representatives.

• Enhanced Conflict Screening: Institutions should proactively screen conflict of interest disclosures against procurement activities. When a physician with industry relationships is involved in decisions that could benefit those companies, automatic triggers should require review and potential recusal.

• Transparent Governance: Procurement decisions should be documented, including who participated, how decisions were made, and whether conflicts were identified and managed. Minutes should be retained and subject to audit.

• Accountability Mechanisms: Violations of recusal commitments should trigger serious consequences, potentially including suspension from administrative roles, financial penalties, or termination. Without accountability, policies lack teeth.

• Education and Culture Change: Institutions should provide regular training on conflicts of interest, emphasizing not just legal compliance but ethical obligations. Leaders should model appropriate behavior and create cultures where physicians feel empowered to decline problematic industry relationships.

• Patient and Public Engagement: Patients and the public should have input into conflict of interest policies. Patient representatives should serve on conflict of interest committees and procurement committees.

• Limitation of Industry Payments: Academic medical centers should consider limiting industry payments to faculty. Some institutions prohibit speaking fees and restrict consulting to narrow circumstances. While legitimate collaboration is valuable, broad consulting arrangements create pervasive conflicts.

• Use of Open Payments Data: Institutions should routinely query Open Payments to identify undisclosed relationships and verify accuracy of disclosures. Compliance programs should integrate Open Payments monitoring into routine audits.

Ultimately, trust in academic medicine depends on physicians and healthcare leaders acting with integrity, managing conflicts transparently, and prioritizing patient welfare above personal financial interests.

Food for thought

Common Yellowthroat

Union Bay Natural Area

2022

Anchor arthropathy - an avoidable cause of arthritis in young folks.

The first shoulder article I ever published was with my friend and former resident, Joe Zuckerman.

Complications about the glenohumeral joint related to the use of screws and staples. We reported "Twenty-one patients had problems related to the use of screws for affixing a transferred coracoid process to the glenoid. Sixteen patients had problems related to the use of staples: ten had undergone capsulorrhaphy, four had had advancement of the subscapularis, and two had had repair of a rotator cuff tear. The complaints at examination were shoulder pain, decreased glenohumeral motion, crepitus with glenohumeral motion, and radiating paresthesias. The time between placement of the implant and the onset of symptoms ranged from four weeks to ten years. The screws or staples had been incorrectly placed in ten patients, had migrated or loosened in twenty-four, and had fractured in three."

While surgeons rarely use staples these days, issues related to suture anchors are not infrequent. Here are number of blog posts have pointed to the problem:

Ream and run: excellent outcome for a sports-active young man with severe anchor arthropathy

35 year old man with a painful, stiff shoulder after three prior arthroscopic labral surgeries -anchor arthropathy

Shoulder MRIs and anchor arthropathy

Ream and run for anchor arthropathy

The problem with suture anchors: anchor arthropathy

Arthritis from a prominent suture anchor - anchor arthropathy

Total shoulder for anchor arthropathy

A recent case shows the progression of anchor arthropathy in a young man with three prior arthroscopic "stabilization procedures".