Stephen A Parada - Academia.edu (original) (raw)

Papers by Stephen A Parada

Research paper thumbnail of Reliability of the scapular dyskinesis test yes-no classification in asymptomatic individuals between students and expert physical therapists

Clinics in Shoulder and Elbow

Background: Scapular dyskinesis is considered a risk factor for the shoulder pain that may warran... more Background: Scapular dyskinesis is considered a risk factor for the shoulder pain that may warrant screening for prevention. Clinicians of all experience screen scapular dyskinesis using the scapular dyskinesis test yes-no classification (Y-N), yet its reliability in asymptomatic individuals is unknown. We aimed to establish Y-N’s intra- and inter-reliability between students and expert physical therapists.Methods: We utilized a cross-sectional design using consecutive asymptomatic subjects. Six students and two experts rated 100 subjects using the Y-N. Cohen’s kappa (κ) and Krippendorff’s alpha (K-α) were calculated to determine intra- and inter-rater reliability.Results: Intra- and inter-rater values for experts were κ=0.92 (95% confidence interval [CI], 0.91–0.93) and 0.85 (95% CI, 0.84–0.87) respectively; students were κ=0.77 (95% CI, 0.75–0.78) and K-α=0.63 (95% CI, 0.58–0.67).Conclusions: The Y-N is reliable in detecting scapular dyskinesis in asymptomatic individuals regardle...

Research paper thumbnail of Anterior Glenoid Reconstruction With Distal Tibial Allograft: Biomechanical Impact of Fixation and Presence of a Retained Lateral Cortex

Orthopaedic Journal of Sports Medicine, 2021

Background: Glenoid reconstruction with distal tibial allograft (DTA) is a known surgical option ... more Background: Glenoid reconstruction with distal tibial allograft (DTA) is a known surgical option for treating recurrent glenohumeral instability with anterior glenoid bone loss; however, biomechanical analysis has yet to determine how graft variability and fixation options alter the torque of screw insertion and load to failure. Hypothesis: It was hypothesized that retention of the lateral cortex of the DTA graft and the presence of a washer with the screw will significantly increase the maximum screw placement torque as well as the load to failure. Study Design: Controlled laboratory study. Methods: Whole, fresh distal tibias were used to harvest 28 DTA grafts, half of which had the lateral cortex removed and half of which had the lateral cortex intact. The grafts were secured to polyurethane solid foam blocks with a 2-mm epoxy laminate to simulate a glenoid with an intact posterior glenoid cortex. Grafts underwent fixation with 4.0-mm cannulated drills, and screws and washers were...

Research paper thumbnail of Optimizing the Patient Telemedicine Experience in an Orthopaedic Clinic

Cureus, 2021

With the rapid advancements in today's technology, the telemedicine model of healthcare has becom... more With the rapid advancements in today's technology, the telemedicine model of healthcare has become an increasingly useful tool for healthcare providers and patients to interact outside of the confines of a traditional office visit. As a result of the COVID-19 pandemic, many providers have been forced to adopt a component of telemedicine into their practice. In an effort to improve the telemedicine system for continued use, 519 patients in an orthopaedic clinic at a Level One academic system were surveyed on their willingness and confidence to use telemedicine in future orthopaedic visits. Though most patients reported that they had been unwilling to use telemedicine for their current visit, the majority were neutral or willing to use telemedicine in the future. In this study, we present some challenges to the orthopaedic telemedicine visit, patient sentiment towards the current and future use of telemedicine in orthopaedics, as well as possible direction for improvement so that telemedicine can be better incorporated into the orthopaedic clinic.

Research paper thumbnail of Mathematical modeling of glenoid bone loss demonstrate differences in calculations that May affect surgical decision making

Journal of Orthopaedics, 2020

Two glenoid bone loss calculations are compared across a range of anatomic glenoid sizes. Methods... more Two glenoid bone loss calculations are compared across a range of anatomic glenoid sizes. Methods: 20 cadaveric paired glenoid diameters were measured to create glenoid models with bone loss calculated in 1 mm linear increments up to 50% bone loss comparing the linear measurement percentage (LMP) to the circle line method (CLM) gold standard. Results: The LMP overestimates glenoid bone loss at every potential 1 mm increment across each glenoid model until bone loss reaches 50%. Conclusion: The widely-used LMP method overestimates bone loss compared to a gold standard potentially misguiding surgeons towards bony reconstruction in shoulder instability during preoperative planning.

Research paper thumbnail of Comparison of complication types and rates associated with anatomic and reverse total shoulder arthroplasty

Journal of Shoulder and Elbow Surgery, 2020

This is a PDF file of an article that has undergone enhancements after acceptance, such as the ad... more This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

Research paper thumbnail of Terminal Sterilization of Anterior Cruciate Ligament (ACL) Allografts: A Systematic Review of Outcomes

Kansas Journal of Medicine, 2020

Introduction. Anterior cruciate ligament (ACL) injuries are common and reconstruction can be comp... more Introduction. Anterior cruciate ligament (ACL) injuries are common and reconstruction can be completed with either autograft or allograft tissue. However, there is concern about an increased failure rate with allograft tissue. The purpose of this study was to systematically review the available evidence to determine the effect of irradiation and level of dose on the failure rates of allograft in ACL reconstruction. Methods. A literature search was performed using PubMed, Scopus, and Web of Science from January 2000 to September 2013. Inclusion criteria consisted of the following: (1) primary, unilateral, single-bundle allograft ACL procedure, (2) studies with data documenting graft type and terminal sterilization technique, (3) subjective assessments of outcome, and (4) objective assessments of outcome. Studies without reported subjective and objective outcomes and those pertaining to revision ACL reconstruction were excluded. Failures were defined and compared between irradiated an...

Research paper thumbnail of Loop and knot security of a novel arthroscopic sliding-locking knot using high-strength sutures

Journal of Orthopaedics, 2018

We evaluated the loop and knot security of a novel arthroscopic knot, the Wiese knot, using diffe... more We evaluated the loop and knot security of a novel arthroscopic knot, the Wiese knot, using different types of sutures. Methods: The Wiese knot was tied using four different brands of braided sutures (Ethibond, Orthocord, FiberWire, and UltraBraid) with and without a series of three reversing half-hitches (RHAPs) and tested for loop and knot security. Results: Orthocord provided the greatest amount of loop security. FiberWire delivered the highest knot security. UltraBraid had the greatest ultimate force. Three half-hitches increased the maximal load to clinical failure. Conclusion: The biomechanical characteristics of the Wiese knot are affected by suture material qualities.

Research paper thumbnail of Magnetic Resonance Imaging of Pectoralis Major Injuries in an Active Duty Military Cohort: Mechanism Affects Tear Location

Orthopaedic Journal of Sports Medicine, 2020

Background: Pectoralis major (PM) tendon tears are common injuries in athletic patient population... more Background: Pectoralis major (PM) tendon tears are common injuries in athletic patient populations, where operative repair is largely recommended for maximum functional recovery. The repair varies in difficulty and technique based on the location of the tear within the muscle-tendon unit. Magnetic resonance imagining (MRI) has been reported to be sensitive and specific for identifying the tear location, but the effect of injury mechanism on tear pattern has not been previously investigated. Purpose: To examine PM tears in a military patient population and assess the effect of injury mechanism (weightlifting vs high-energy trauma) on the tear pattern and accuracy of MRI interpretation. Study Design: Cohort study; Level of evidence, 3. Methods: Active duty military servicemembers undergoing operative repair of PM tendon tears with corresponding preoperative MRIs from 2 medical centers were identified. Two musculoskeletal fellowship–trained radiologists reviewed imaging studies, report...

Research paper thumbnail of Surgical Implications of the Distal Tibia Morphology at the Incisura for Glenoid Augmentation

Orthopaedic Journal of Sports Medicine, 2018

Objectives: Distal tibia allograft (DTA) glenoid augmentation has been introduced as a viable tre... more Objectives: Distal tibia allograft (DTA) glenoid augmentation has been introduced as a viable treatment approach for glenoid bone loss in conjunction with shoulder instability. An ideal graft has a flat or nearly flat lateral border of the tibia, allowing the surgeon to retain the lateral cortical bone for increased screw fixation (Figure 1A). DTA grafts with a deep concavity are difficult to prepare for fixation, as it is necessary to remove most of the cortical bone to create a flat contour of the graft (Figure 1B). Previous anatomic studies have sought to evaluate the morphology at the incisura as it pertains to syndesmosis fixation. No previous study has assessed the morphologic variation of the distal tibia at the incisura as it relates to graft dimensions for glenoid augmentation. Methods: Magnetic resonance images (MRI) of the ankle were reviewed over a 3 month period. Studies that met inclusionary criteria underwent morphology assessment to characterize the appearance and de...

Research paper thumbnail of Epidemiology of Existing Extensor Mechanism Pathology in Primary Anterior Cruciate Ligament Ruptures in an Active-Duty Population

The American Journal of Orthopedics, 2018

reconstruction. 3 Recent advances in allograft processing, along with improved fixation technique... more reconstruction. 3 Recent advances in allograft processing, along with improved fixation techniques and devices, have improved results following the use of soft-tissue autografts and both bony and soft tissue allografts. 4 Thus, the optimal graft choice for ACL reconstruction has become controversial in light of several studies demonstrating no significant, long-term difference in clinical and/or functional outcomes based on graft selection. 5-7 Given the lack of a clear gold standard in graft selection, multiple patient factors, such as age, activity demands, and patient preference, should be taken into account when considering the choice of graft. In addition, intrinsic factors that could potentially weaken an autograft should be considered. Several extensor mechanism pathological findings that are easily visualized on either plain radiographs or magnetic resonance imaging (MRI) could potentially affect graft selection. Findings such as a multipartite patella, free ossicles about the tibial tuberosity consistent with Osgood-Schlatter's disease, and proximal patella tendon thickening suggestive of patellar tendinopathy are easily identifiable on preoperative imaging and could exert adverse effects on pBTB, QT, and qTB autografts. The purpose of this study is to identify the prevalence of these pre-existing conditions in activeduty military patients presenting with acute ACL tears.

Research paper thumbnail of Magnetic Resonance Imaging Correlates With Computed Tomography for Glenoid Version Calculation Despite Lack of Visibility of Medial Scapula

Arthroscopy: The Journal of Arthroscopic & Related Surgery, 2020

Purpose: To assess the accuracy of measuring glenoid version on magnetic resonance imaging (MRI) ... more Purpose: To assess the accuracy of measuring glenoid version on magnetic resonance imaging (MRI) in the presence of varying amounts of the medial scapula body as compared with the gold standard of glenoid version measured on computed tomography (CT) imaging, including the entire scapula in a cohort of young patients with shoulder instability and without glenohumeral arthritis. Methods: A retrospective review was performed on instability patients with preoperative MRI and CT imaging. Measurements of available scapular width and glenoid version were performed using the Cobb angle method to measure the angle between the plane of the glenoid fossa to Friedman's line on axial images. Intra-and interrater reliability analysis was performed using intraclass correlation coefficients to assess agreement between MRI and CT measurements. Paired t tests were used to compare measurement differences between MRI and CT. Results: Thirty-two patients with both MRI and CT scans were assessed. Intra-and inter-rater assessment revealed strong agreement for scapular width measurement. For glenoid version measurement, intra-rater agreement was excellent and inter-rater agreement was moderate on CT and good on MRI. The mean available scapular body width was 24.7 mm longer on CT as compared with MRI (95% confidence interval 17.5-31.9, P < .0001; 109.8 AE 8.2 mm vs 85.1 AE 16.9 mm, respectively), with MRI having an average of 78.2% (AE17.6%) of the CT scapular width shown on CT. No significant difference in glenoid version was found between MRI and CT (95% confidence interval À0.87 to 1.75, P ¼ .499; MRI À2.57 vs CT À2.13). Conclusion: MRI provided significantly shorter available scapular widths when compared with CT imaging in a cohort of patients with glenohumeral instability and without arthritis. However, this failed to produce a significant difference of !5 in measured glenoid version compared with CT measurements when 75% (8 cm) of the scapular width was present on MRI. Measuring glenoid version on MRI does not appear to be significantly affected when the entirety of the medial border of the scapula is not included in the imaging field. Level of Evidence: Level III; study of diagnostic test. See commentary on page 106 G lenoid morphology is a topic of increasing importance for orthopaedic shoulder surgeons, as it has significant implications on surgical indications in various shoulder pathologies. Glenoid version has a wide range of "normal" and can vary by both race and sex. 1 In the normal patient population, glenoid version

Research paper thumbnail of Survey of shoulder arthroplasty surgeons’ methods for infection avoidance of Propionibacterium

Journal of Orthopaedics, 2018

Introduction: Propionibacterium acnes infection after shoulder arthroplasty remains a source of m... more Introduction: Propionibacterium acnes infection after shoulder arthroplasty remains a source of morbidity. Determining practices amongst shoulder surgeons is the first step in developing infection-prevention bestpractices. Methods: A survey was sent to a shoulder fellowship alumni group to determine their arthroplasty infection prevention methods Results: 74% completed the survey. Cefazolin (90%), vancomycin (50%) and clindamycin (18%) were the most commonly used antibiotics, 61% utilized more than one antibiotic. Most (76%) reported using an experiencebased protocol learned during residency/fellowship. Discussion and conclusion: There are no clear standards for prevention of Propionibacterium acnes infections in shoulder arthroplasty. There is a general non-scientific approach to the prevention of shoulder arthroplasty infection. 2. Materials and methods An on-line survey (Appendix A) was distributed via e-mail invitation

Research paper thumbnail of Outcomes of Subacromial Balloon Spacer Implantation for Massive and Irreparable Rotator Cuff Tears: A Systematic Review

Orthopaedic Journal of Sports Medicine, 2019

Background:Selection of optimal treatment for massive to irreparable rotator cuff tears (RCTs) en... more Background:Selection of optimal treatment for massive to irreparable rotator cuff tears (RCTs) entails a challenging decision-making process in which surgeons must consider several factors, including duration of symptoms, tear pattern, tear size, and muscle quality, as well as patient characteristics such as age, comorbidities, shoulder dominance, and activity level. Unfortunately, no clear consensus has been reached regarding optimal management.Purpose:To systematically review the published literature assessing outcomes after subacromial balloon spacer implantation for treatment of massive and irreparable RCTs.Study Design:Systematic review; Level of evidence, 4.Methods:A comprehensive literature search was performed in September 2018 through use of MEDLINE and the Cochrane Library electronic databases. Studies were assessed for multiple outcomes of interest including Constant score, Oxford Shoulder Score (OSS), University of California Los Angeles (UCLA) Shoulder Score, complicati...

Research paper thumbnail of Graft Transfer Technique in Arthroscopic Posterior Glenoid Reconstruction With Distal Tibia Allograft

Arthroscopy Techniques, 2017

Posterior glenoid reconstruction using distal tibia allograft is an available technique for the t... more Posterior glenoid reconstruction using distal tibia allograft is an available technique for the treatment of posterior shoulder instability with glenoid bone loss. A key aspect to this procedure relies on maintaining complete control of the graft during insertion and securement to the posterior glenoid. Although there are commercially available products to aid with graft control, we describe a novel graft transfer technique that is compatible with all cannulated systems for maintaining positive graft control. This technique allows the surgery to be performed in an arthroscopic manner using current instrumentation for open glenoid reconstruction.

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

Journal of Orthopaedics, 2019

Compare intraarticular pressure of the glenohumeral joint in patients with and without shoulder i... more 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.

Research paper thumbnail of A Guide to Understanding Reimbursement and Value-Based Care in the Military Health System

Military Medicine, 2018

Introduction: With the continued rise in the cost of U.S. health care, there is an increased emph... more 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.

Research paper thumbnail of Current Practices in Anterior Cruciate Ligament Reconstruction in the U.S. Military: A Survey of the Society of Military Orthopaedic Surgeons

Military Medicine, 2018

Introduction: The subject of anterior cruciate ligament reconstruction (ACLR) contains a large vo... more Introduction: The subject of anterior cruciate ligament reconstruction (ACLR) contains a large volume of research but very little consensus for ideal surgical technique, graft implementation, and fixation strategy for improved clinical outcome. Previous studies have assessed surgeon preferences for ACLR in civilian populations, but no study to date has examined ACLR trends in military surgeons caring for a unique, high functional demand population. Materials and Methods: A 20 question survey was distributed to all members of the Society of Military Orthopaedic Surgeons (SOMOS) practicing orthopedic surgery at an Army medical treatment facility. Questions focused on graft preferences for ACLR according to age and gender groups, and fixation strategies for the femoral and tibial components. Responses were recorded via a survey application and statistical analysis of the responses was done to exam for trends. This study was exempt from IRB approval. Results: Of the identified 131 surgeons, 56 were excluded, leaving 75 providers for study inclusion, with a 100% response rate. Surgeons preferred autograft for younger patients (80.5%) (patients ≤25 yr), whereas they relied on patient choice more commonly for older patients (51.9%). Surgeons preferred bone-patellar tendon-bone autograft for males ≤25 yr of age (51.3%) compared with 34.2% for females in the same age range. Independent femoral drilling was performed by 96.0% of surgeons for primary soft tissue ACL reconstructions. Suspensory fixation was the preferred fixation for soft tissue grafts (87.7%). Knee position for graft tensioning during tibial fixation varied between surgeons with the majority tensioning with the knee in 15-30 degrees of flexion (63.8%), following by <15 degrees (18.8%), and full extension (15%). Conclusion: There was a general consensus in the technical components for ACLR performed among military orthopedic surgeons. Multicenter studies in the military are necessary to examine how these technical aspects of reconstruction are affecting the functional outcome of military service members undergoing ACLR.

Research paper thumbnail of Trends in Surgical Management of Anterior Shoulder Instability: Increased Utilization of Bone Augmentation Techniques†

Military Medicine, 2018

The purpose of this study is to evaluate the trends in surgical management for anterior shoulder ... more 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.

Research paper thumbnail of The Epidemiology and Natural History of Anterior Shoulder Instability

Current Reviews in Musculoskeletal Medicine, 2017

Purpose of Review The purpose of this review is to outline the natural history and best clinical ... more 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. Summary 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.

Research paper thumbnail of Low Rate of Return to Impact Activity Following Core Decompression for Femoral Head AVN in Military Servicemembers

Military medicine, Jan 3, 2018

Femoral head avascular necrosis (AVN) is a debilitating disease with core decompression commonly ... more Femoral head avascular necrosis (AVN) is a debilitating disease with core decompression commonly performed for early stage disease. However, the ability to return to high-activity levels following treatment is largely unknown. Active military patients undergoing core decompression for femoral head AVN were reviewed. Demographic variables were identified and visual analog pain data was collected at a minimum of 2-year post-surgery or prior to total hip arthroplasty (THA). Patient outcomes, need for THA, and ability to remain on active service were recorded from chart review. Imaging studies were reviewed to classify the lesion stage and size for correlation with progression to THA or discharge from military service. A total of 29 active duty patients met inclusion criteria (22 male, 7 female; 32.3 years). Seven patients (24%) progressed to THA and they were more likely to have bilateral disease (86%) and be older (35.4 years versus 31.2 years). At final follow-up, 86% of patients had...

Research paper thumbnail of Reliability of the scapular dyskinesis test yes-no classification in asymptomatic individuals between students and expert physical therapists

Clinics in Shoulder and Elbow

Background: Scapular dyskinesis is considered a risk factor for the shoulder pain that may warran... more Background: Scapular dyskinesis is considered a risk factor for the shoulder pain that may warrant screening for prevention. Clinicians of all experience screen scapular dyskinesis using the scapular dyskinesis test yes-no classification (Y-N), yet its reliability in asymptomatic individuals is unknown. We aimed to establish Y-N’s intra- and inter-reliability between students and expert physical therapists.Methods: We utilized a cross-sectional design using consecutive asymptomatic subjects. Six students and two experts rated 100 subjects using the Y-N. Cohen’s kappa (κ) and Krippendorff’s alpha (K-α) were calculated to determine intra- and inter-rater reliability.Results: Intra- and inter-rater values for experts were κ=0.92 (95% confidence interval [CI], 0.91–0.93) and 0.85 (95% CI, 0.84–0.87) respectively; students were κ=0.77 (95% CI, 0.75–0.78) and K-α=0.63 (95% CI, 0.58–0.67).Conclusions: The Y-N is reliable in detecting scapular dyskinesis in asymptomatic individuals regardle...

Research paper thumbnail of Anterior Glenoid Reconstruction With Distal Tibial Allograft: Biomechanical Impact of Fixation and Presence of a Retained Lateral Cortex

Orthopaedic Journal of Sports Medicine, 2021

Background: Glenoid reconstruction with distal tibial allograft (DTA) is a known surgical option ... more Background: Glenoid reconstruction with distal tibial allograft (DTA) is a known surgical option for treating recurrent glenohumeral instability with anterior glenoid bone loss; however, biomechanical analysis has yet to determine how graft variability and fixation options alter the torque of screw insertion and load to failure. Hypothesis: It was hypothesized that retention of the lateral cortex of the DTA graft and the presence of a washer with the screw will significantly increase the maximum screw placement torque as well as the load to failure. Study Design: Controlled laboratory study. Methods: Whole, fresh distal tibias were used to harvest 28 DTA grafts, half of which had the lateral cortex removed and half of which had the lateral cortex intact. The grafts were secured to polyurethane solid foam blocks with a 2-mm epoxy laminate to simulate a glenoid with an intact posterior glenoid cortex. Grafts underwent fixation with 4.0-mm cannulated drills, and screws and washers were...

Research paper thumbnail of Optimizing the Patient Telemedicine Experience in an Orthopaedic Clinic

Cureus, 2021

With the rapid advancements in today's technology, the telemedicine model of healthcare has becom... more With the rapid advancements in today's technology, the telemedicine model of healthcare has become an increasingly useful tool for healthcare providers and patients to interact outside of the confines of a traditional office visit. As a result of the COVID-19 pandemic, many providers have been forced to adopt a component of telemedicine into their practice. In an effort to improve the telemedicine system for continued use, 519 patients in an orthopaedic clinic at a Level One academic system were surveyed on their willingness and confidence to use telemedicine in future orthopaedic visits. Though most patients reported that they had been unwilling to use telemedicine for their current visit, the majority were neutral or willing to use telemedicine in the future. In this study, we present some challenges to the orthopaedic telemedicine visit, patient sentiment towards the current and future use of telemedicine in orthopaedics, as well as possible direction for improvement so that telemedicine can be better incorporated into the orthopaedic clinic.

Research paper thumbnail of Mathematical modeling of glenoid bone loss demonstrate differences in calculations that May affect surgical decision making

Journal of Orthopaedics, 2020

Two glenoid bone loss calculations are compared across a range of anatomic glenoid sizes. Methods... more Two glenoid bone loss calculations are compared across a range of anatomic glenoid sizes. Methods: 20 cadaveric paired glenoid diameters were measured to create glenoid models with bone loss calculated in 1 mm linear increments up to 50% bone loss comparing the linear measurement percentage (LMP) to the circle line method (CLM) gold standard. Results: The LMP overestimates glenoid bone loss at every potential 1 mm increment across each glenoid model until bone loss reaches 50%. Conclusion: The widely-used LMP method overestimates bone loss compared to a gold standard potentially misguiding surgeons towards bony reconstruction in shoulder instability during preoperative planning.

Research paper thumbnail of Comparison of complication types and rates associated with anatomic and reverse total shoulder arthroplasty

Journal of Shoulder and Elbow Surgery, 2020

This is a PDF file of an article that has undergone enhancements after acceptance, such as the ad... more This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

Research paper thumbnail of Terminal Sterilization of Anterior Cruciate Ligament (ACL) Allografts: A Systematic Review of Outcomes

Kansas Journal of Medicine, 2020

Introduction. Anterior cruciate ligament (ACL) injuries are common and reconstruction can be comp... more Introduction. Anterior cruciate ligament (ACL) injuries are common and reconstruction can be completed with either autograft or allograft tissue. However, there is concern about an increased failure rate with allograft tissue. The purpose of this study was to systematically review the available evidence to determine the effect of irradiation and level of dose on the failure rates of allograft in ACL reconstruction. Methods. A literature search was performed using PubMed, Scopus, and Web of Science from January 2000 to September 2013. Inclusion criteria consisted of the following: (1) primary, unilateral, single-bundle allograft ACL procedure, (2) studies with data documenting graft type and terminal sterilization technique, (3) subjective assessments of outcome, and (4) objective assessments of outcome. Studies without reported subjective and objective outcomes and those pertaining to revision ACL reconstruction were excluded. Failures were defined and compared between irradiated an...

Research paper thumbnail of Loop and knot security of a novel arthroscopic sliding-locking knot using high-strength sutures

Journal of Orthopaedics, 2018

We evaluated the loop and knot security of a novel arthroscopic knot, the Wiese knot, using diffe... more We evaluated the loop and knot security of a novel arthroscopic knot, the Wiese knot, using different types of sutures. Methods: The Wiese knot was tied using four different brands of braided sutures (Ethibond, Orthocord, FiberWire, and UltraBraid) with and without a series of three reversing half-hitches (RHAPs) and tested for loop and knot security. Results: Orthocord provided the greatest amount of loop security. FiberWire delivered the highest knot security. UltraBraid had the greatest ultimate force. Three half-hitches increased the maximal load to clinical failure. Conclusion: The biomechanical characteristics of the Wiese knot are affected by suture material qualities.

Research paper thumbnail of Magnetic Resonance Imaging of Pectoralis Major Injuries in an Active Duty Military Cohort: Mechanism Affects Tear Location

Orthopaedic Journal of Sports Medicine, 2020

Background: Pectoralis major (PM) tendon tears are common injuries in athletic patient population... more Background: Pectoralis major (PM) tendon tears are common injuries in athletic patient populations, where operative repair is largely recommended for maximum functional recovery. The repair varies in difficulty and technique based on the location of the tear within the muscle-tendon unit. Magnetic resonance imagining (MRI) has been reported to be sensitive and specific for identifying the tear location, but the effect of injury mechanism on tear pattern has not been previously investigated. Purpose: To examine PM tears in a military patient population and assess the effect of injury mechanism (weightlifting vs high-energy trauma) on the tear pattern and accuracy of MRI interpretation. Study Design: Cohort study; Level of evidence, 3. Methods: Active duty military servicemembers undergoing operative repair of PM tendon tears with corresponding preoperative MRIs from 2 medical centers were identified. Two musculoskeletal fellowship–trained radiologists reviewed imaging studies, report...

Research paper thumbnail of Surgical Implications of the Distal Tibia Morphology at the Incisura for Glenoid Augmentation

Orthopaedic Journal of Sports Medicine, 2018

Objectives: Distal tibia allograft (DTA) glenoid augmentation has been introduced as a viable tre... more Objectives: Distal tibia allograft (DTA) glenoid augmentation has been introduced as a viable treatment approach for glenoid bone loss in conjunction with shoulder instability. An ideal graft has a flat or nearly flat lateral border of the tibia, allowing the surgeon to retain the lateral cortical bone for increased screw fixation (Figure 1A). DTA grafts with a deep concavity are difficult to prepare for fixation, as it is necessary to remove most of the cortical bone to create a flat contour of the graft (Figure 1B). Previous anatomic studies have sought to evaluate the morphology at the incisura as it pertains to syndesmosis fixation. No previous study has assessed the morphologic variation of the distal tibia at the incisura as it relates to graft dimensions for glenoid augmentation. Methods: Magnetic resonance images (MRI) of the ankle were reviewed over a 3 month period. Studies that met inclusionary criteria underwent morphology assessment to characterize the appearance and de...

Research paper thumbnail of Epidemiology of Existing Extensor Mechanism Pathology in Primary Anterior Cruciate Ligament Ruptures in an Active-Duty Population

The American Journal of Orthopedics, 2018

reconstruction. 3 Recent advances in allograft processing, along with improved fixation technique... more reconstruction. 3 Recent advances in allograft processing, along with improved fixation techniques and devices, have improved results following the use of soft-tissue autografts and both bony and soft tissue allografts. 4 Thus, the optimal graft choice for ACL reconstruction has become controversial in light of several studies demonstrating no significant, long-term difference in clinical and/or functional outcomes based on graft selection. 5-7 Given the lack of a clear gold standard in graft selection, multiple patient factors, such as age, activity demands, and patient preference, should be taken into account when considering the choice of graft. In addition, intrinsic factors that could potentially weaken an autograft should be considered. Several extensor mechanism pathological findings that are easily visualized on either plain radiographs or magnetic resonance imaging (MRI) could potentially affect graft selection. Findings such as a multipartite patella, free ossicles about the tibial tuberosity consistent with Osgood-Schlatter's disease, and proximal patella tendon thickening suggestive of patellar tendinopathy are easily identifiable on preoperative imaging and could exert adverse effects on pBTB, QT, and qTB autografts. The purpose of this study is to identify the prevalence of these pre-existing conditions in activeduty military patients presenting with acute ACL tears.

Research paper thumbnail of Magnetic Resonance Imaging Correlates With Computed Tomography for Glenoid Version Calculation Despite Lack of Visibility of Medial Scapula

Arthroscopy: The Journal of Arthroscopic & Related Surgery, 2020

Purpose: To assess the accuracy of measuring glenoid version on magnetic resonance imaging (MRI) ... more Purpose: To assess the accuracy of measuring glenoid version on magnetic resonance imaging (MRI) in the presence of varying amounts of the medial scapula body as compared with the gold standard of glenoid version measured on computed tomography (CT) imaging, including the entire scapula in a cohort of young patients with shoulder instability and without glenohumeral arthritis. Methods: A retrospective review was performed on instability patients with preoperative MRI and CT imaging. Measurements of available scapular width and glenoid version were performed using the Cobb angle method to measure the angle between the plane of the glenoid fossa to Friedman's line on axial images. Intra-and interrater reliability analysis was performed using intraclass correlation coefficients to assess agreement between MRI and CT measurements. Paired t tests were used to compare measurement differences between MRI and CT. Results: Thirty-two patients with both MRI and CT scans were assessed. Intra-and inter-rater assessment revealed strong agreement for scapular width measurement. For glenoid version measurement, intra-rater agreement was excellent and inter-rater agreement was moderate on CT and good on MRI. The mean available scapular body width was 24.7 mm longer on CT as compared with MRI (95% confidence interval 17.5-31.9, P < .0001; 109.8 AE 8.2 mm vs 85.1 AE 16.9 mm, respectively), with MRI having an average of 78.2% (AE17.6%) of the CT scapular width shown on CT. No significant difference in glenoid version was found between MRI and CT (95% confidence interval À0.87 to 1.75, P ¼ .499; MRI À2.57 vs CT À2.13). Conclusion: MRI provided significantly shorter available scapular widths when compared with CT imaging in a cohort of patients with glenohumeral instability and without arthritis. However, this failed to produce a significant difference of !5 in measured glenoid version compared with CT measurements when 75% (8 cm) of the scapular width was present on MRI. Measuring glenoid version on MRI does not appear to be significantly affected when the entirety of the medial border of the scapula is not included in the imaging field. Level of Evidence: Level III; study of diagnostic test. See commentary on page 106 G lenoid morphology is a topic of increasing importance for orthopaedic shoulder surgeons, as it has significant implications on surgical indications in various shoulder pathologies. Glenoid version has a wide range of "normal" and can vary by both race and sex. 1 In the normal patient population, glenoid version

Research paper thumbnail of Survey of shoulder arthroplasty surgeons’ methods for infection avoidance of Propionibacterium

Journal of Orthopaedics, 2018

Introduction: Propionibacterium acnes infection after shoulder arthroplasty remains a source of m... more Introduction: Propionibacterium acnes infection after shoulder arthroplasty remains a source of morbidity. Determining practices amongst shoulder surgeons is the first step in developing infection-prevention bestpractices. Methods: A survey was sent to a shoulder fellowship alumni group to determine their arthroplasty infection prevention methods Results: 74% completed the survey. Cefazolin (90%), vancomycin (50%) and clindamycin (18%) were the most commonly used antibiotics, 61% utilized more than one antibiotic. Most (76%) reported using an experiencebased protocol learned during residency/fellowship. Discussion and conclusion: There are no clear standards for prevention of Propionibacterium acnes infections in shoulder arthroplasty. There is a general non-scientific approach to the prevention of shoulder arthroplasty infection. 2. Materials and methods An on-line survey (Appendix A) was distributed via e-mail invitation

Research paper thumbnail of Outcomes of Subacromial Balloon Spacer Implantation for Massive and Irreparable Rotator Cuff Tears: A Systematic Review

Orthopaedic Journal of Sports Medicine, 2019

Background:Selection of optimal treatment for massive to irreparable rotator cuff tears (RCTs) en... more Background:Selection of optimal treatment for massive to irreparable rotator cuff tears (RCTs) entails a challenging decision-making process in which surgeons must consider several factors, including duration of symptoms, tear pattern, tear size, and muscle quality, as well as patient characteristics such as age, comorbidities, shoulder dominance, and activity level. Unfortunately, no clear consensus has been reached regarding optimal management.Purpose:To systematically review the published literature assessing outcomes after subacromial balloon spacer implantation for treatment of massive and irreparable RCTs.Study Design:Systematic review; Level of evidence, 4.Methods:A comprehensive literature search was performed in September 2018 through use of MEDLINE and the Cochrane Library electronic databases. Studies were assessed for multiple outcomes of interest including Constant score, Oxford Shoulder Score (OSS), University of California Los Angeles (UCLA) Shoulder Score, complicati...

Research paper thumbnail of Graft Transfer Technique in Arthroscopic Posterior Glenoid Reconstruction With Distal Tibia Allograft

Arthroscopy Techniques, 2017

Posterior glenoid reconstruction using distal tibia allograft is an available technique for the t... more Posterior glenoid reconstruction using distal tibia allograft is an available technique for the treatment of posterior shoulder instability with glenoid bone loss. A key aspect to this procedure relies on maintaining complete control of the graft during insertion and securement to the posterior glenoid. Although there are commercially available products to aid with graft control, we describe a novel graft transfer technique that is compatible with all cannulated systems for maintaining positive graft control. This technique allows the surgery to be performed in an arthroscopic manner using current instrumentation for open glenoid reconstruction.

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

Journal of Orthopaedics, 2019

Compare intraarticular pressure of the glenohumeral joint in patients with and without shoulder i... more 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.

Research paper thumbnail of A Guide to Understanding Reimbursement and Value-Based Care in the Military Health System

Military Medicine, 2018

Introduction: With the continued rise in the cost of U.S. health care, there is an increased emph... more 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.

Research paper thumbnail of Current Practices in Anterior Cruciate Ligament Reconstruction in the U.S. Military: A Survey of the Society of Military Orthopaedic Surgeons

Military Medicine, 2018

Introduction: The subject of anterior cruciate ligament reconstruction (ACLR) contains a large vo... more Introduction: The subject of anterior cruciate ligament reconstruction (ACLR) contains a large volume of research but very little consensus for ideal surgical technique, graft implementation, and fixation strategy for improved clinical outcome. Previous studies have assessed surgeon preferences for ACLR in civilian populations, but no study to date has examined ACLR trends in military surgeons caring for a unique, high functional demand population. Materials and Methods: A 20 question survey was distributed to all members of the Society of Military Orthopaedic Surgeons (SOMOS) practicing orthopedic surgery at an Army medical treatment facility. Questions focused on graft preferences for ACLR according to age and gender groups, and fixation strategies for the femoral and tibial components. Responses were recorded via a survey application and statistical analysis of the responses was done to exam for trends. This study was exempt from IRB approval. Results: Of the identified 131 surgeons, 56 were excluded, leaving 75 providers for study inclusion, with a 100% response rate. Surgeons preferred autograft for younger patients (80.5%) (patients ≤25 yr), whereas they relied on patient choice more commonly for older patients (51.9%). Surgeons preferred bone-patellar tendon-bone autograft for males ≤25 yr of age (51.3%) compared with 34.2% for females in the same age range. Independent femoral drilling was performed by 96.0% of surgeons for primary soft tissue ACL reconstructions. Suspensory fixation was the preferred fixation for soft tissue grafts (87.7%). Knee position for graft tensioning during tibial fixation varied between surgeons with the majority tensioning with the knee in 15-30 degrees of flexion (63.8%), following by <15 degrees (18.8%), and full extension (15%). Conclusion: There was a general consensus in the technical components for ACLR performed among military orthopedic surgeons. Multicenter studies in the military are necessary to examine how these technical aspects of reconstruction are affecting the functional outcome of military service members undergoing ACLR.

Research paper thumbnail of Trends in Surgical Management of Anterior Shoulder Instability: Increased Utilization of Bone Augmentation Techniques†

Military Medicine, 2018

The purpose of this study is to evaluate the trends in surgical management for anterior shoulder ... more 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.

Research paper thumbnail of The Epidemiology and Natural History of Anterior Shoulder Instability

Current Reviews in Musculoskeletal Medicine, 2017

Purpose of Review The purpose of this review is to outline the natural history and best clinical ... more 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. Summary 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.

Research paper thumbnail of Low Rate of Return to Impact Activity Following Core Decompression for Femoral Head AVN in Military Servicemembers

Military medicine, Jan 3, 2018

Femoral head avascular necrosis (AVN) is a debilitating disease with core decompression commonly ... more Femoral head avascular necrosis (AVN) is a debilitating disease with core decompression commonly performed for early stage disease. However, the ability to return to high-activity levels following treatment is largely unknown. Active military patients undergoing core decompression for femoral head AVN were reviewed. Demographic variables were identified and visual analog pain data was collected at a minimum of 2-year post-surgery or prior to total hip arthroplasty (THA). Patient outcomes, need for THA, and ability to remain on active service were recorded from chart review. Imaging studies were reviewed to classify the lesion stage and size for correlation with progression to THA or discharge from military service. A total of 29 active duty patients met inclusion criteria (22 male, 7 female; 32.3 years). Seven patients (24%) progressed to THA and they were more likely to have bilateral disease (86%) and be older (35.4 years versus 31.2 years). At final follow-up, 86% of patients had...