Other Articles

AAOS Political Action Committee
Active players in the orthopedic field know the importance of the AAOS Political Action Committee (PAC). On the cusp of hot topics affecting physicians and patients, the AAOS PAC works diligently to provide data to members of Congress and improve the present and future of orthopedics.

Who ARE These Guys?
Every 60 seconds or so a surgeon tears the cover off an Integra LifeSciences package. Quietly, this company has become the seventh largest medical implant manufacturer serving orthopedic surgeons in the world. Where to now? Would you believe $1 billion in two years? How about $2 billion by 2015?

Redemption in a Mechanism of Failure: The TOPS™ Story
Impliant’s TOPS™ System had a “squeaker” in its clinical study. After a voluntary suspension of the study by the company and finding the mechanism of failure, the FDA has approved a resumption of the study. What insider lessons were learned? Class starts here.

What Complaint is Numero Uno in the PearlDiver Database?
The answer may surprise you. Is it sore backs, aching hips, sore knees, fingers? PearlDiver details 3.8 million spine related complaints—complete with demographic information and charging information. But that’s not #1. PearlDiver also lists 3.5 million large joint complaints. Sorry, still not #1. What could the most common orthopedic complaint possibly be? To get the surprising answer…read on.

What the Knees Need: Baby Boomers and Their Options
Knee patients often show up at the doctor’s office with recurrent mechanical symptoms. It is up to the orthopedist, says Dr. Giles R. Scuderi, Director and orthopedic surgeon with the Insall, Scott & Kelly Institute in Manhattan, to thoroughly assess the patient and then determine if nonoperative treatment will do, or if the person needs a unicompartmental or total knee procedure.

Physician: Report Thyself
The government says its healthcare anti-fraud efforts are working and it wants to encourage physicians to self-report possible fraud. How well did the government do in 2007 and what about those deferred-prosecution deals with undisclosed evidence? Read about it here.

Revising the Statistics
The word that orthopedic patients least want to hear is “revision.” Who, in the universe of large joint patients, do we expect to see on the receiving end of this news? If you guessed “the elderly” you would have been wrong. The reality of who is hearing “revision” may come as a surprise. Read what we found when probing PearlDiver’s database.

Where Is Ben Now? Trends in Venture Capital
What is being funded by VCs and why? First of all, spine is having to share the spotlight, says Gary Stevenson, Managing Partner at MB Venture Partners, LLC. Here Stevenson outlines what constitutes an attractive investment…he also highlights issues that are affecting the distribution of VC funding.

The Hounds of Wall Street
Conventional wisdom on Wall Street is that ArthroCare is in a bare-knuckle fight to the finish with short sellers. Which leaves us with the dominating question: If ArthroCare is essentially a “lame duck” growth stock, then why are sales, earnings, and the stock price contradicting the short seller’s dire predictions and even outperforming consensus analyst forecasts? We have the answer.

The Era of “Tell Me Right Now” Dawns at FDA
The FDA wants the next phase of post-market oversight to change from self reporting to proactive surveillance. How? Through the Sentinel Initiative. Read what it means to device manufacturers here.

The Day After Tomorrow: Complication Rates and Instrumentation Trends in Posterior Lumbar Fusion
Could PearlDiver be the Nostradamus of spinal instrumentation? This most commonly performed surgery on the lumbar region of the spine increases fusion rates and improves spinal stability—but what about complications? Using PearlDiver’s database we find the answers. Are you ready for some quatrains about what happens next?

You Try It. No You Try It First: New Technology Adoption
What are the forces working for and against new technology adoption? Youth versus age, risk taking versus conservatism, and the economic realities of the day, says Dr. Rick Guyer, President of the Texas Back Institute.

Cheaper, Thinner, Faster, Stronger
In this, the second of our series of three articles on innovation, we tackle the question: How do you measure medical technology innovation? While difficult, measuring innovation is NOT impossible. Why? Well to start, and in the immortal words of Supreme Court Justice Potter Stewart, “We know it when we see it.”

SAS Crosses the Rubicon in Miami Beach
The SAS 8th Annual Global Symposium in Miami Beach may have crossed the Rubicon. How? Read about the Society’s opportunities for growth and collaboration as its new President lays out a vision for the future.

Arthroscopic Treatment for Tennis Elbow: Coming on Strong
“Tennis elbow” or lateral epicondylitis is, according to our PearlDiver database, one of the most reported diagnosis for problems with the elbow. Lately clinical evidence has shown that arthroscopic treatment for tennis elbow can provide long-term stability and, in most cases, return of the elbow to its optimal function. Check out the data from PearlDiver.

Do Republicans Make Better Orthopedic Surgeons?
A recent Nature Neuroscience journal study of the decision making differences between liberals and conservatives appears to argue in favor of Republican surgeons! Which, frankly, explains a lot—to BOTH sides and, to stretch an analogy almost to its breaking point, it may also explain why McCain’s health care plan is different from Obama’s. Read OUR take here.

"Sound of Music" Turns to Greek Tragedy for Smith & Nephew
Smith & Nephew’s Swiss (mis)adventure with Plus Orthopaedics is turning into a Greek Tragedy. The company’s whole acquisition strategy is being called into question. Read how CEO Illingworth explained it to the brutal British press.

“Dear John Letter” for Hip Resurfacing?
“Dear John H. Resurfacing: I hope this little note finds you well. We certainly have had some great times and, gosh, I’ll never forget those wonderful moments when the FDA approved your PMA. We’ve just celebrated our second anniversary together and, well, I’m just not feeling the magic anymore….” Two years after FDA approval, how happy are orthopedists with hip resurfacing? Read our analysis here.

In the Beginning, There Was the End: Manuscripts 101
Dr. Paul Manske, Professor of Orthopaedic Surgery at Washington University School of Medicine in St. Louis and Editor-in-Chief of The Journal of Hand Surgery, shares his thoughts and experience on the details of shepherding a manuscript through publication.

Did ConMed Get Re-Wired?
Ever hear about the neurosurgeon who used an $80 Bosch power drill to do brain surgery? It really happened. Surgeons like their power tools. Increasingly they also like a particular line of sterilizeable power tools from ConMed’s Linvatec unit. Did ConMed get re-wired? We have the details here.

In some respects, the trajectory of a medical career is fairly clear—medical school, residency, fellowship. And you always know where you want to end up...at graduation. Oh that the same clarity could be found in research. Says Dr. Paul Manske, Professor of Orthopaedic Surgery at Washington University School of Medicine in St. Louis and Editor-in-Chief of The Journal of Hand Surgery, “The most important thing in writing a good research manuscript—and the area that gives people the most trouble—is knowing where they’re going. They don’t keep the end in mind...and they don’t get published.”

But if a beginning investigator has a navigator, the chances of doing solid research and getting published are increased. “Have a seasoned mentor who is familiar with all the elements of writing a manuscript, as well as the potential landmines. This person would start out with the important basics, such as the fact that one must have done an adequate research project in order to write it up. If it doesn’t have a clear purpose or scientific question that it’s trying to address or you’re not using the proper methodology for addressing that purpose, you will be off track. And you should definitely have an investigative question that is relevant to the audience. For example, if hand surgeons are your audience, then a manuscript concerning hand therapy techniques might not be directly relevant.”

Dr. Manske, a master of systematic inquiry, lays out the path to publishing a manuscript. “A researcher can ease into the process with the cover letter,” says Dr. Manske. “Nowadays the letter is simplified for most journals as it is submitted online with numerous prompts. While some researchers think it is good to be convincing in the letter as to the value of a project, the bottom line is that if the study and its presentation don’t live up to it, then the cover letter doesn’t add anything. And the letter doesn’t go to the reviewers anyway; it is read by the editor.”

The next step involves putting some portion of one’s career on display. Dr. Manske: “A standard part of manuscript submission is a statement of potential conflicts of interest. This should include any vested interests the author(s) may have in the product they are studying, as well any financial interest in the success of that product. That doesn’t necessarily mean that the manuscript isn’t appropriate, but anything of this nature must be disclosed. One must also indicate what kind of support the project received from, for example, the National Institutes of Health, organizations, and hospitals. Any goods and materials, including grants, must also be disclosed. Additionally, any ties that the authors have with the manufacturer, such as consulting fees or shares of stock, should be indicated here. With all of this information in hand, the reader may decide whether the manuscript seems overly biased.”

Appearing next will be the abstract. And although some readers may pass over this summary, those who take the time to peruse it should find a logical thread running through it, as it does through the manuscript. Dr. Manske: “In the abstract section, the identification of the purpose comes first, followed by the methodology, pertinent data, and the conclusions. Some journals have moved to ‘structured abstracts’ which elicit specific information from researchers. This was instituted because in many cases investigators were providing too much irrelevant information.”

According to Dr. Manske, the abstract is a good place to begin with the end in mind. “Write the manuscript first, then the abstract,” advises Dr. Manske, “because at first you don’t always know where you’re going. As you move through the process the purpose of the manuscript will most likely change. The question you initially set out to address may get sidelined because the data lends itself to addressing a different question than the one you began with. Once I was doing a study on flexor tendons and evaluating different kinds of tendon repairs. As time went on I saw that the more pertinent question was not specific tendon repair but the changes that occur in the healing process with movement of these tendons.”

As in all writing, you have to keep the reader interested. With manuscripts, the most important way to ‘grab’ the reader is to have a research question whose purpose is well defined. States Dr. Manske, “Following the abstract is the introduction. The whole rest of the manuscript revolves around how well the author(s) have laid out exactly what they will be studying. Unfortunately, many investigators never take the time to ferret out the details. Let’s say there is a senior and a junior orthopedist and the former says, ‘Look, I’ve done 20 of these xyz procedures and haven’t reported on them.’ So he has the junior person look them up, but the guy never actually identifies a purpose for the study or a scientific question to address. It would work, however, if the junior person were to sift through the data and determine exactly what it says. In many cases, however, someone just writes something up hoping a brilliant idea will come to them along the way. But it never does.”

Not an advocate of the shot in the dark method of research, Dr. Manske states, “At The Journal of Hand Surgery we receive a lot of submissions which involve subjects which were previously investigated. I recommend that researchers first read the literature on their subject to see what exactly has been published. Look for a niche where there is a lack of clarity on something and focus on addressing that question. For example, let’s say someone wants to do a study on the compression of the radial nerve in the proximal forearm. There have been a lot of studies on this topic so to do yet another study would be pointless. A differentiating topic would be an in-depth look at the specific structures that might be compressing the nerve or an investigation of the relationship between the compression of the radial nerve and the anatomy of the elbow. When you dig deeper into the data, you can find these nuanced topics that can lead to a successful manuscript.”

Moving down the page, we find the methodology section. Explains Dr. Manske, “While it may seem easy to list the research methods, the methodology section is actually the most challenging portion of the manuscript. Done correctly, it properly explains what you did to address the study question; i.e., what did you study and what data did you gather. Related to that are the measures you carried out to evaluate the purpose. If the procedure involves repairing nerves in the finger and the purpose is to look at the outcome of a certain type of nerve repair, then the measurement parameters must be related to the evaluation of the sensation of the nerves in the finger—not how much motion is in the wrist or finger because motion is not related to nerve repair.”

And how do people go astray with the methodology section? States Dr. Manske, “Many people feel compelled to write everything down because they put a lot of work into their project. What is needed, however, is to debride content from the methodology section that is not related to the purpose. During the writing you may alter the purpose to broaden the scope but the content of this section does need to focus back on the purpose. Let’s say you have a researcher who looks up 20 cases, reviews charts and collects reams of data on all sorts of things including height, weight, etc., and then describes them in the methodology section. The problem is that much of this collected information may not be relevant to the purpose of the study. Again, it’s not hard to describe the methodology; the difficulty is in getting rid of those things that are superfluous.”

Getting to the finished product took so much time and energy that it would seem the results section would be the most taxing part of the manuscript. Not so, says Dr. Manske. “If you have constructed a good purpose and described the methodology thoroughly, your job in this section is basically to fill in the blanks. If you are having trouble writing the results section, the problem is most likely that the purpose is not well defined or that the methodology is not clearly spelled out. I have found that authors sometimes don’t include in the methodology section exactly what they studied and what specific parameters they established. If this is the case, they are going to have trouble with the results section.”

If there is a logical thread running through the manuscript, however, and you have made it through the results unscathed, it is time for the discussion section. Explains Dr. Manske, “The discussion puts the study in perspective for the reader. All good studies, like all good stories, have a beginning, middle, and an end. Here is your chance to summarize your findings and state how they are related to the rest of the literature on the subject. And then there is the humbling part…when you shed light on the study’s deficiencies.”

Also humbling is receiving a letter that begins, “We regret to inform you….” “Corrections and rejections are part of being a researcher,” says Dr. Manske. “After a manuscript is received the editor sends it to the reviewers, who are authorities in that particular area of research. They read it, criticize it and develop a list of problems that should be addressed. Some issues are easier to address than others, of course. The editor then reviews the problem list and, if it makes sense then sends it to the authors with the option of addressing the issues and submitting a revised manuscript. Or, if the reviewers reject the submission, the editor conveys that to the author(s). If you get a rejection letter, my advice is to seek out another journal that might accept the manuscript. While you can appeal the rejection, a letter of appeal usually doesn’t go anywhere. All of that being said, it is unusual for an article to be accepted the first time around. The author(s) often receive a letter with points to address, sometimes as few as three, other times as many as 50. Although researchers don’t have to accept all of the reviewers’ criticisms, they should take the comments seriously. Sometimes it is only a matter of changing the emphasis of a sentence.”

So what type of manuscript is likely to be rejected? One that is irrelevant, says Dr. Manske. “The topic must be one that merits investigation. Also unappealing is a manuscript with a methodology that is so poorly structured that it can’t address the question at hand; or, the question it addresses isn’t relevant. Or, it might be a potentially good study but the authors haven’t presented it in an acceptable way. Speaking on my experience with The Journal of Hand Surgery, one-third of our manuscripts are rejected outright, one-third are eventually accepted, and in one-third the comments of reviewers are things that the authors can’t address, so they abandon their effort.”

Elaborating on presentation, Dr. Manske notes, “I have seen instances where the methodology was completely unintelligible or the results go from paragraph to paragraph with no real focus and no underlying theme. In essence, it is just a bunch of unrelated information on paper. In manuscripts such as this, researchers discuss the methodology, surgical technique, opinions (‘we like this…’) in the results section. These types of papers will always be rejected.”

And in some cases, there are just misunderstandings. “Sometimes,” notes Dr. Manske, “authors don’t realize that the review process is more than a thumbs-up/thumbs-down. They don’t understand that the reviewers volunteer their time to improve the quality of the submission. Unfortunately, some authors take a disdainful stance toward reviewers and say, ‘Well, they don’t know what they are talking about. They’re biased.’ Nothing could be further from the truth.”

So begin with the end, be open to suggestions, and look for a topic that hasn’t been studied to death. Then you will find yourself at the intersection of “contributing to the field” and “personal glory.”