Industry payments to authors of articles on shoulder arthroplasty

Industry payments to authors of Journal of Shoulder and Elbow Surgery shoulder arthroplasty manuscripts are accurately disclosed by most authors and are not significantly associated with better reported treatment outcomes

These authors used data from the Centers for Medicare & Medicaid Services Open Payments Program (OPP) database to analyze articles (2016-2017) in the Journal of Shoulder and Elbow Surgery for (1) discrepancies between the stated conflicts of interest and associated payments recorded in the database, (2) the magnitude and types of payments received, and (3) possible relationships between industry financial support and positive study outcomes.

They found that implant manufacturers provided $16,051,261 to authors of shoulder arthroplasty publications over the 2-year period. Approximately half of senior authors (46%) received royalty payments, more than 90% of which ($14,910,873; 93%) were reported in disclosure statements. Authors of studies that had a positive outcome received a mean of $115,610 (range, $0-$1,752,922). This was almost twice the mean of $62,306 (range, $0- $838,008) for authors of studies that had a nonpositive outcome, but this difference did not attain statistical significance (P=0.11) (see below).

Comment:  This article points to the close financial relationship between authors and industry. The majority (87%) of shoulder arthroplasty publications in the Journal of Shoulder and Elbow Surgery were associated with transfers of value from the manufacturer of the implant reported in the study to the authors of the study in the year prior to publication. 

Although the presence of such conflicts is usually acknowledged in a disclaimer box in the publication, the magnitude of the payments is not included. This article suggests that reporting of approximate dollar amounts directly in publications could help readers to better judge the degree of such a financial conflict of interest. Because the existence of these payments may influence the methods, results, and conclusions of the research, it would seem appropriate to list the type and magnitude of these transfers of value in the ‘‘limitations’’ section of the discussion in manuscripts 

regarding shoulder arthroplasty.

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Are practice guidelines for sale?

An Evaluation of Industry Relationships Among Contributors to AAOS Clinical Practice Guidelines and Appropriate Use Criteria

These authors point out that the long-standing relationship between orthopaedic surgeons and industry has made financial conflicts of interest a concerning issue. Research supports that financial conflicts of interest can influence both medical research and clinical practice. Financial conflicts of interest may also influence clinical practice guideline recommendations and their corresponding appropriate use criteria. Because of the influential nature of these guidelines, it is imperative that care be taken to minimize bias during guideline development.

To investigate these relationships, they retrieved clinical practice guidelines and their corresponding appropriate use criteria from the American Academy of Orthopaedic Surgery that were published or revised between 2013 and 2016. They extracted industry payments received by physicians using the Centers for Medicare & Medicaid Services Open Payments database and evaluated the value and types of these payments. They also used these data to determine whether disclosure statements were accurate and whether guideline development was in adherence with the Institute of Medicine’s (IOM’s) standards.

They found that of the 106 physicians that were evaluated, 85 (80%) received at least 1 industry payment, 56 (53%) accepted >$1,000, and 35 (33%) accepted >$10,000. Financial payments amounted to a mean of $93,512 per physician. Total reimbursement for the 85 clinical practice guideline and appropriate use criteria contributors was $9,912,309. They found that disclosure statements disagreed with the Open Payments data and that the IOM standards were not completely enforced.

They concluded that clinical practice guideline and appropriate use criteria contributors received substantial payments from industry, many disclosure statements were inaccurate, and the IOM standards were not completely met. Clinical practice guidelines and appropriate use criteria are critical for practicing evidence-based medicine. If financial conflicts of interest are present during their development, it is possible that patient care may be compromised.

The authors recommend that:

(1) The chair and cochair of guideline committees not have any financial conflicts of interest (FCOI)

(2) Workgroup members with FCOIs be limited to one third of the group

(3) Disclosure statements should include a broader range of years and a higher degree of detail (e.g., the date of the FCOI, the amount of the FCOI, and whether the relationship is ongoing) and

(4)The AAOS should use Open Payments and Dollars for Docs to verify disclosure statement accuracy and to ensure that workgroups are in compliance with IOM and AAOS standards.

Comment: Financial payments can influence the decisions that people make. Buying influence is one of the reasons that industry makes "general payments" to physicians. When such payments are made to individual practitioners, they may influence the implants they use. When such payments are made to surgeons who review articles for publication, they may influence which articles get published. When such payments are made to speakers at symposia or instructional courses, they may alter how information is presented. And when such payments are made to the authors of practice guidelines, they may influence the recommendations forwarded. While the effect of these payments is a substantial concern, an even greater concern is when the receipt of such payments is not openly and completely acknowledged in a way that the conflict of interest is readily apparent to the persons consuming the information. 

We can do better. Consider this example of an informative disclosure, "the authors of these recommendations have received a total of X dollars in payment from these companies (A, B, C) over the years during which the recommendations were being formulated. It is possible that these payments have biased the recommendations."
Finally, we need to recall that the money that goes to these financial payments adds to the cost of the implants, driving up the cost of care. This effect is compounded if the purchased influence drives us to use more expensive treatments than are necessary for the welfare of the patient.

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Why does industry give money to surgeons for research?

Increasing Industry Support Is Associated with Higher Research Productivity in Orthopaedic Surgery

These authors point out that orthopaedic surgeons receive a disproportionately small share of funding from the National Institutes of Health, but they receive the largest amount of funding from industry sources. They sought to examine the association between payments from industry partners and research productivity among orthopaedic research authors, as well as to identify predictors of high research productivity.

United States-based physicians who published an article in 2016 in The Journal of Bone & Joint Surgery or The American Journal of Sports Medicine were included in this study. These authors were queried in the Centers for Medicare & Medicaid Services Open Payments database (OPD) to determine the amount of industry payments received, and on Scopus, a bibliometric web site, to assess the quantity (total publication count) and quality (Hirsch index [h-index]) of each author’s research.

Of the 766 included authors, 494 (64.5%) received <$10,000 per year, 162 (21.1%) received between $10,000 and $100,000, and 110 (14.4%) received >$100,000 in total payments. The h-index increased significantly from a mean (and standard deviation) of 13.1 ± 12.9 to 20.9 ± 14.4, and to 32.3 ± 16.7, from the lowest to highest payment cohorts, as did total publication count. 

When authors were stratified by academic position (assistant professor, associate professor, full professor, and nonacademic), those who received more industry payments (>$100,000) had a higher h-index and total publication count at all academic levels relative to lower-earning (<$10,000) authors. 

Independent predictors of a high h-index included industry payments of between $10,000 and $100,000 (odds ratio [OR], 1.63; p = 0.048), payments of >$100,000 (OR, 5.87), associate professorship (OR, 6.53), full professorship (OR, 33.38), and last authorship (OR, 2.22) (p < 0.001 for all comparisons unless otherwise noted).

The authors point out that in addition to direct research funding, industry payments to orthopaedic surgeons include nonresearch financial payments for fellowship funding, consulting, speaking engagements, product development, and royalties. 1.7% of the number of payments directed toward orthopaedic  surgeons were for royalties (i.e. not for research support), but these payments accounted for 69.5% of the total monetary value that orthopaedic surgeons received. 

Comment: This article indicates that orthopaedic companies support publications by "thought leaders". It does not discuss why industry might do this and what effect this research support may have on the type of research or the conclusions of this research conducted by these investigators.  For example, is industry more likely to support (a) investigation of a non-operative approach to managing chronic cuff tears or (b) investigation of a new cuff repair technique using multiple suture anchors made by the supporting company? As another example, is industry likely to continue much desired research and personal support for a surgeon (a) if the surgeon's research reveals a relatively high complication rate for a new prosthesis or (b) if the surgeon's research reveals that osseous ingrowth by CT scan is better for this new component? What effect might this have on the direction of the surgeon's research?

We recognize the value of industrial support for orthopaedic research. We also recognize that

We're talking real money here (see this link): data from 2016

and see this link (link), where two of the top three recipients are orthopaedic surgeons

As discussed in Demographics of Disclosure of Conflicts of Interest at the AAOS, industrial payments to physicians may also affect the work presented at national meetings.

This article might well have included a discussion of these important aspects of the industry-investigator relationship. 

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The reader may also be interested in these posts:

Healing through joint replacement

Supporting progress in shoulder surgery

Consultation for those who live a distance away from Seattle.

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Information about shoulder exercises can be found at this link.

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Deep Throat: "Follow the money" - financial relationships of orthopaedic surgeons

Industry Financial Relationships in Orthopaedic Surgery: Analysis of the Sunshine Act Open Payments Database and Comparison with Other Surgical Subspecialties

These authors sought to describe the industry relationships in orthopaedic surgery using the information now publicly reported in the Sunshine Act Open Payments database.

They found that 12,320 orthopaedic surgeons (50%) had 58,127 industry financial relationships with a total value of $80.2 million. They compared this percentage to other surgical specialties:

Royalties or licensing fees, which were received by 1.7% of U.S. orthopaedic surgeons, accounted for 69.5% of the total monetary value of payments to orthopaedic surgeons. The number of reported relationships and the percent value for the five specialties are shown in the charts below.

Comment: "Follow the money" is a phrase attributed to Deep Throat (aka Mark Felt) the Watergate Scandal informant as portrayed in the film, All The President's Men.

The data shown in this study indicate that there is a major financial incentive for orthopaedic surgeons to develop new implants and new technologies, to speak about them, or to get 'free' food and drink while hearing about them. These new products almost always cost more that their predecessors, yet it is not often clear whether or not these 'advances' lead to better outcomes for the patient. The question 'is the incremental cost offset by the incremental value?" often goes unanswered.

This point is made clearly in the Congressional Budget Office report on "Technological Change and the Growth of Health Care Spending":

"The health care system’s rapid adoption of emerging medical technologies has, in many instances, provided enormous clinical benefits, such as prolonged life and improved quality of life. However, the added clinical benefits of new medical services are not always weighed against the added costs before those services enter common clinical practice. Newer, more expensive diagnostic or therapeutic services are sometimes used in cases in which older, cheaper alternatives could offer comparable outcomes for patients. And expensive services that are known to be highly effective in some patients are occasionally used for other patients for whom clinical benefits have not been rigorously demonstrated.

These findings suggest that some medical services could be used more selectively without a substantial loss in clinical value. Research on comparative effectiveness could provide a basis for applying costly new technologies only when they are likely to confer added benefits that are significantly greater than the benefits conferred by less expensive technologies. If placing greater emphasis on providing evidence-based care (encouraged, for example, by appropriate financial incentives for providers and consumers) resulted in the more selective use of some costly services, future spending levels would probably be lower than they would otherwise be—perhaps substantially so. Attaining significant cost savings, however, may require difficult changes to the ways in which providers and patients make decisions concerning medical care."

Shoulder surgeons have invented systems for 3-dimensional surgical planning, patient specific instruments, bone ingrowth implants, short stemmed humeral implants, stemless humeral implants, resurfacing humeral implants, partial resurfacing humeral implants, humeral implants with adjustable neck shaft angles, metal backed glenoids, augmented glenoid components, pain pump infusion of local anesthetics, patches for augmenting cuff repair, viscosupplementation, laser surgery, radio frequency surgery, and many more (you can see some of the 'advanced' glenoid designs here). We need to assure that these 'technological changes' are cost effective and that they are used appropriately.

Let's make sure that the ways in which we are making decisions concerning medical care is not because we are 'following the money' rather than following the best interests of our patients.

You can find financial relationship information for any U.S. orthopaedic surgeon as shown here.

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Industry payments to doctors revealed - the 'Sunshine' act

Docs fear Sunshine Act data may be misread

The Sunshine Act appears as Section 6002 of the Patient Protection and Affordable Care Act has as its goal to create a national transparency program for payments made to physicians and teaching hospitals by drug and medical-device manufacturers and group purchasing organizations. The Centers for Medicare and Medicaid Services (CMS) reports that more than 90% of physicians have some type of business relationship with industry sources. Pharmaceutical companies are reported to have spent $15.7 billion in 2011 on sales and promotional activities.

Beginning Aug. 1, drug and device companies will need to start keeping track of transfers of value worth more than $10 to physicians and teaching hospitals. Physicians will have the opportunity to review what is reported about them in the second quarter of next year, and the reports will be made public on Sept. 30, 2014.

The Act attempts to address concerns regarding conflicts of interest, noting that 60% of physicians reporting an industry relationship are involved in medical education and 40% are involved in creating clinical practice guidelines.

While the prospect of these relationships being made public is troubling for some physicians, their revelation is important be cause fiscal conflicts of interest can affect the way doctors practice, do research and teach. See here, here and here.

See also Baucus-Grassley Investigation into Medtronic Reveals Manipulated Studies, Close Financial Ties with Researchers from the U.S. Senate Committee on Finance. Here's a quote from that report, "Without public disclosure of their roles, Medtronic employees collaborated with physician authors to edit – and in some cases, write – segments of published studies on its bone-growth product InFuse. The studies as published may have inaccurately represented InFuse’s risks and may have placed added weight on side effects of alternative treatments. Medtronic, which describes itself as “the world's largest independent medical technology company,” also maintained significant, previously-undisclosed financial ties with physicians who authored studies about InFuse, making $210 million in payments to physicians over a 15-year period"


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Disclosure of conflict of interest - acknowledging influence

Podium Disclosures at the 2012 AAOS Meeting: An Exercise in Going Through the Motions

This article is a nice partner to our article from earlier this year, Demographics of Disclosure of Conflicts of Interest at the 2011 Annual Meeting of the American Academy of Orthopaedic Surgeons in which we point out the high and increasing degree to which orthopaedic companies influence what is presented in orthopaedic educational venues, such as the AAOS. In our article, we advocated inclusion of disclosures in the section of presentation that discusses the limitations of the investigation, recognizing that conflicts of influence can influence the design, results and conclusions of an investigation.

In the new article, the authors studied slide-based disclosure of potential conflicts of interest prior to presentations during the 2012 American Academy of Orthopaedic Surgeons (AAOS) Annual Meeting to determine if the process is accomplishing its primary goal.

The authors observed 139 disclosures were observed across a range of subspecialties including adult reconstruction, hand and wrist, pediatrics, shoulder and elbow, sports medicine, trauma, and oncology. While 90% of the presentations included the required disclosure slide, only half noted whether the author disclosures were related to the data presented and over half of the presenters failed to mention the relationship of the disclosure to the topic of the presentation. 

As you can see from prior posts on this blog, the process of disclosure is voluntary, irregular, often incomplete, and often inaccurate.

One of the goals upgrading the standards of disclosure is to assure that the investigators themselves recognize and acknowledge that, for example, receiving payment as a speaker on behalf of a product is likely to influence how the investigators study and present the results with that product.  This is not to be confused with a mea culpa statement, rather it is an expression of the candor that we owe ourselves, our colleagues, our students, and our patients.

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Conflict of interest and liability - a cautionary tale

Medicolegal sidebar: corporate relationships and increased surgeon liability risk.

This article bridges two of our recent articles, one on conflicts of interest and the other on orthopaedic malpractice.

This is a very timely reminder that conflicts of interest may complicate malpractice defense. The authors discuss a case in which a cold therapy device was prescribed to a patient after need surgery.  The result was that the patient sustained severe cold injury requiring multiple surgeries and leaving permanent scarring. The complicating issue is that the device was sold and rented by the surgeon's office, creating a de facto conflict of interest. The case came to trial with a verdict for the plaintiff totaling $12,696,220, including negligence, economic damages and punitive damages shared by Breg, Inc (the manufacturer) and the surgeon.

In the opinion of the authors, the size and nature of the verdict were influenced by the financial relationship between the manufacturer and the surgeon that had the potential to interfere with optimal patient care.

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Demographics of Disclosure of Conflicts of Interest

Demographics of Disclosure of Conflicts of Interest at the 2011 Annual Meeting of the American Academy of Orthopaedic Surgeons


There is growing concern regarding conflicts of interest in orthopaedic research and education. Because of their potential influence on orthopaedic practice, conflicts of interest among participants in the educational programs of the American Academy of Orthopaedic Surgeons (AAOS) are of particular interest.Methods:

We analyzed the voluntarily disclosed conflicts of interest listed in the Final Program of the 2011 Annual Meeting of the AAOS for the relevant program committees as well as for presentations in the disciplines of pediatric orthopaedic surgery, spine, and sports medicine/arthroscopy.

Conflicts of interest were disclosed by participants for each of the program committees and for over 75% of the presentations. Conflicts of interest were disclosed for 100% of the featured symposia, 80% of the scientific exhibits, 76% of the podium presentations, and 75% of the posters. Over half (53%) of the disclosures were for paid consultancy, 51% were for research support for the principal investigator, 41% were for paid presentations, 39% were for royalties, and 39% were for stock. The highest number of disclosures for an individual author was thirty-seven. The number of disclosures per author was significantly (p < 0.001) correlated to the number of presentations per author. Disclosures were associated with 379 different companies; relationships with a relatively small number (twenty-six, 7%) of these companies were listed in the disclosures for 67% of the presentations.

Voluntarily disclosed conflicts of interest were common at the 2011 AAOS Annual Meeting, especially for the featured symposia. In view of the previously documented frequency of undisclosed conflicts of interest, as well as the previously documented effects of conflicts of interest on research design, conduct, and conclusion, it may be time to consider improved strategies for ensuring the accuracy and completeness of disclosure and for managing the biasing effects of conflicts of interest.

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Blood clots after total joints - thromboembolic prophylaxis - conflict of interest - JBJS

The JBJS recently published an article by Lee et al entitled: Conflict of Interest in the Assessment of Thromboprophylaxis After Total Joint Arthroplasty: A Systematic Review. Although problems with deep venous thrombosis and pulmonary emboli are not common after shoulder surgery, they do occur. As mentioned in a previous post, it is a question of balancing the risk of blood clots versus the risk of bleeding.

The article by Lee et al takes a look at the recent published evidence regarding thromboprophylaxis with special regard to the relationship between industrial funding and the results of the study. 52 of the 71 articles were funded by industry. They found a significant association was observed between the funding source and qualitative conclusions. Only two (3.8%) of the fifty-two industry-sponsored studies had unfavorable conclusions, whereas three (21.4%) of the fourteen non-industry-sponsored studies indicated that, depending on the clinical scenario, the modality examined was neither effective nor safe.

They concluded that most studies on thromboprophylaxis after total joint arthroplasty are sponsored by industry and that  qualitative conclusions in those studies are favorable to the use of the sponsored prophylactic agent.

The lesson here is clear. Identifying conflict of interest is essential to the interpretation of the results of studies. As we have pointed out in previous posts, it is unfortunate that uncovering this critical information can be difficult. 

Our position is that a discussion of all conflicts of interest and their possible effects on study design, results and conclusions should be a part of the "limitations" paragraph of the Discussion section of each paper.

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Chondrolysis - JBJS "current concepts review" - questions left unanswered

Those interested in chondrolysis of the shoulder may enjoy reading a letter by Benjamin Busfield, entitled "Questions left unanswered".

Some of the key points in his letter are summarized here:

(1) Apples and Oranges "Review articles tend to review existing literature, not re-classify the data. Why group pediatric hip chondrolysis cases with PAGCL patients? This is very likely two different pathologies presenting in vastly different patient populations. This also begs the issue of the authors merging of the terms chondrolysis and PAGCL. The term PAGCL, as I correctly stated in my initial letter to the editor that was disputed in the author reply, was indeed a term coined by Beck and Hansen.PAGCL was a new diagnosis in the shoulder at that time that occurred after arthroscopy and was associated with use of intra-articular pain pumps with local anesthetics. Numerous subsequent retrospective studies have confirmed this association in both the knee and the shoulder, and numerous laboratory studies have demonstrated the chondrotoxicity of local anesthetics. For obvious reasons, no prospective study can ethically be performed for patients receiving intra-articular pain pumps and local anesthetics to give us the highest level of evidence."

(2) The Evidence: "I find the inconsistent conclusion of this article and the grouping of all chondrolysis cases to be questionable, which creates significant concern as it has been published in our most respected journal. The advent of intra-articular pain pumps with local anesthetics in the 1990’s directly correlated with the development of PAGCL cases. All recent authors on this topic recommend against the use of intra-articular pain pumps and local anesthetics." See our post on "res ipsa".

(3) Disclosure: "It seems that both the “Joint Chondrolysis” CCR and the Solomon et al. paper were both co-authored by members of this corporation (Advance Health Solutions).  Regarding Advance Health Solutions, what is the nature of this corporation that is now co-authoring articles in our Orthopedic literature? .. I am concerned about possible bias on the part of Advance Health Solutions. Clearly an article that minimizes the role of pain pumps and local anesthetics as a cause of PAGCL would be looked upon favorably by the defense counsels of the pain pump manufacturers and could assist in deflecting blame toward their products. As the Orthopedic literature has committed to do with changes in the author disclosure forms, it is appropriate that we have complete transparency with regards to potential bias. The disclosure statement for the “Joint Chondrolysis” CCR states that none of the authors “received payments or services, either directly or indirectly (i.e., via his or her institution)” but there is disclosure of a “financial relationship” in the “thirty-six months prior to submission of this work, with an entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work.” There were no conflicts of interest reported in the Solomon et al. paper in 2009, the other paper on chondrolysis with contributions from Advance Health Solutions and largely the same authors as the “Joint Chondrolysis” CCR. If Advance Health Solutions has had pain pump manufacturers as clients with confidentiality agreements, are the company and Dr. Maryam Navaie held to our literature standard of full disclosure for publications? Are corporations also subject to the disclosure standards?" See also our post regarding disclosure in the CCR.

(4)  Disclosure: Dr. Busfield is a medicolegal consultant for plaintiffs in chondrolysis litigation

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"Sunshine rule" conflict of interest disclosure required for doctors

The Centers for Medicare and Medicaid Services has proposed a 'sunshine rule' to publicize relationships between doctors and manufacturers that may affect the decisions that physicians make regarding patient care.

The full proposal can be found here.

The summary is " This proposed rule would require applicable manufacturers of drugs, devices, biologicals, or medical supplies covered by Medicare, Medicaid or the Children's Health Insurance Program (CHIP) to report annually to the Secretary certain payments or transfers of value provided to physicians or teaching hospitals ("covered recipients"). In addition, applicable manufacturers and applicable group purchasing organizations (GPOs) are required to report annually certain physician ownership or investment interests. The Secretary is required to publish applicable manufacturers' and applicable GPOs' submitted payment and ownership information on a public website."

Public comments will be accepted by the Centers for Medicare and Medicaid Services until 2/17/12. Data collection will begin after the rule is finalized.

Since it is widely recognized that financial conflicts of interest can affect not only clinical decisions, but also the way research is done, it is important that the public be aware of these conflicts.

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Conflicts of interest in orthopaedics and medicine in general

Dear Readers,

Recently there has been a surge in interest and concern regarding conflicts of interest in our field. The primary responsibilities of surgeons, physicians and scientists are to the patient and to the integrity of publications and presentations. When relationships exist with for-profit organizations, these relationships may affect the way patient care and research decisions are made. My friend, colleague and editor of the Journal of Bone and Joint Surgery, Vern Tolo, has written an editorial on this topic entitled "Interest in Conflicts" which is highly recommended reading.

Part of the way conflicts of interest are managed is through public disclosure. My disclosures can be found here.

Questions remain, however. How can we be sure that the voluntary disclosure of conflicts are complete and accurate? How can we manage the biasing effects of conflicts of interest in a way that assures the integrity of educational programs and published research? And, fundamentally, how can we be assured that the interests of patients are always served above all other interests?

More on this important topic to come!

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This blog

Greetings.

This blog is intended to be a living, dynamic resource dedicated to all those interested in shoulder arthritis. It will provide basic information on shoulder arthritis and it will provide updates on recent important published articles related to the topic of shoulder arthritis.

Throughout this blog you will find links that are indicated like this - these links take you to related content.

You may also wish to visit www.orthop.washington.edu/shoulderarthritis.

You should be aware of our colleagues at the Arthritis Foundation who do so much to support individuals who live with arthritis!

Steve Lippitt, my good friend in Akron, has provided the art work for almost all the figures in this blog, including the one at the bottom indicating (cleverly) the safe side and the 'suicide' for shoulder surgery.

You might like to see the countries from where our visitors come.

Finally, thanks to Nidhi Shah who has done so much to help develop this site, including the handy index of contents you see at your right.


Best wishes
rick matsen

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                                    Disclosure Statements and Conflict of Interest

                                    Dr. Matsen is a full-time tenured professor at the University of Washington. All of his patient care, research and teaching activities are within the Department of Orthopaedics and Sports Medicine. He is the inaugural holder of the Douglas T. Harryman II/DePuy Endowed Chair for Shoulder Research at the University of Washington.  This permanent endowment has been the sole source of support for his investigations.  DePuy/Johnson and Johnson has no role in the direction, conduct, or publication of his research.

                                    Dr. Matsen receives no royalties and has no equity related to any implant or prosthesis used in his practice or described in this blog.  

                                    Dr. Matsen does receive royalties from The Shoulder, a textbook published by Elsevier.

                                    In the past, Dr. Matsen has received payment for legal consultation on the topic of chondrolysis, but no longer provides legal consultation except as required by his own patients

The author regularly reviews manuscripts for the Journal of Bone and Joint Surgery, the Journal of Shoulder and Elbow Surgery, and the Journal of Orthopaedic Research, but receives no compensation for these services.