Orthopaedic Surgeons and the Orthopaedic Device Industry Benefit from a Symbiotic Partnership

There has been a long and mutually beneficial partnership between orthopaedic surgeons and the orthopaedic industry. The partnership has produced value to each side and most importantly has brought improved devices to orthopaedic patients.

As Callaghan et al identified in their 2010 article in the Iowa Orthopaedic Journal on orthopaedic surgeons and industry, this unique relationship creates two types of value. First are the development and sales of orthopaedic devices. Second is the value to patients and society when product advancements improve outcomes of orthopaedic surgeries. However, it is the surgeon’s responsibility to disclose conflicts and discuss how conflicts may influence outcomes and options for patients.

Many orthopaedic devices and advances would not have been possible without partnerships between surgeons and industry. The modern hip replacement evolved from a partnership between Sir John Charnley, CBE, FRS, and Charles F. Thackray. In the 1960s, Charnley pioneered modern total hip arthroplasty (THA) and spent the next two decades refining aspects of the procedure, working with the commercial firm of Charles F. Thackray Limited, now a subsidiary of DePuy Orthopaedics, a Johnson & Johnson Company. He was demanding of the company, and the team combined to develop the modern THA. Remarkably, none of their early products was patented.

Another important surgeon-industry partnership is the AO/ASIF line of products. In 1958, a group of Swiss surgeons established the AO organization to transform fracture care in Switzerland, revolutionizing the development of implants for fracture fixation. The company Synthes was established in 1960 as a trademark for AO/ASIF products and was later spun off to focus on fracture fixation products. In 2011, Johnson & Johnson merged with Synthes to create the world’s largest orthopaedic corporation.

Celebrity endorsements have become a common advertising tool. When Michael Jordan or Tom Brady endorse a product, they may have no input into the design or manufacturing process. In contrast, surgeons are often actively involved in the design of orthopaedic products. It is a very different relationship than the relationship between physicians and drug companies, as it is less common for physicians to be involved in developing new drugs. Orthopaedic products are unique in that many products arise from the ideas and persistence of individual orthopaedic surgeons who develop and improve their ideas in partnership with industry.

The Physician Payments Sunshine Act, officially named the Open Payments database, reports all payments made to physicians by industry. It details the substantial ties between industry and the orthopaedic surgery community. Orthopaedic surgeons receive a larger percentage of payments compared to other specialties. Interestingly, in 2018, the top 10 percent of orthopaedic surgeons accounted for more than 92 percent of all payments. The largest share of payments (more than 67 percent) was royalties. The database illustrates the intertwined nature of the relationship between private industry and surgeons.

AAOS established Standards of Professionalism to protect patient welfare and guide appropriate behavior regarding relationships between physicians and industry. The guidelines include disclosure of any financial arrangements that relate to patient treatment, including receipt of royalties or paid consulting arrangements. Direct financial inducements for using a specific product are forbidden.

The relationship between orthopaedic surgeons and industry is best described as symbiotic. Physicians need industry to produce new and reliable products and to bring innovation to the marketplace. The industry needs physicians to use their products, provide new ideas, and explore new avenues to improve orthopaedic care. The orthopaedic market in the United States is estimated to be greater than $10 billion annually. Increasing sophistication and complexity of implants have provided opportunities to improve and streamline care.

In response to the growing diversity and complexity of procedures, orthopaedic manufacturers have responded by financially supporting a range of orthopaedic learning and research opportunities. Specifically, manufacturers have generously supported the Orthopaedic Learning Center, the Orthopaedic Research and Education Foundation, and other educational and research organizations. Contributions from industry are the single largest source of income for AAOS and are used to support advocacy and the continued financial health of orthopaedic organizations.

Additionally, orthopaedic companies fund research projects, clinical trials, and studies related to orthopaedic treatments, devices, and techniques. This funding is crucial to advance scientific knowledge and patient outcomes.

Many orthopaedic companies provide educational opportunities, sponsor CME workshops and seminars, and provide grants to professionals to further orthopaedic knowledge. Industry research and development efforts continue to drive the creation of new implants, instruments, and technologies, leading to improved treatment options for patients. Additionally, orthopaedic companies collaborate with a range of research and training institutions on combined research projects, educational programs, and clinical trials, which accelerate the translation of research findings into clinical practice. Overall, the orthopaedic industry’s contributions are essential for advancing the field of orthopaedics, from research and education to clinical practice and patient care.

The specific amount of money that the orthopaedic industry contributes each year toward education and research can vary widely and is not always easy to quantify precisely.

Several factors influence this, including:

1. Size and scope of the industry: The orthopaedic industry encompasses a wide range of companies, from multinational corporations to smaller firms specializing in orthopaedic devices, implants, pharmaceuticals, and biotechnology.
2. Types of contributions: Contributions can take various forms, such as direct funding for research grants, sponsorship of academic conferences and workshops, endowments for academic chairs or professorships, support for fellowships and scholarships, and in-kind donations of equipment and technologies.
3. Geographic variation: Contributions may vary by region and country due to differences in healthcare systems, research priorities, and regulatory environments.
4. Transparency and reporting: Not all contributions are publicly disclosed or easily accessible in consolidated reports. Some companies may report their philanthropic activities separately, making it challenging to compile a comprehensive total.

The orthopaedic industry invests significantly in education and research to advance the field. Industry leaders recognize the importance of supporting scientific advancements, fostering innovation, and educating healthcare professionals to improve patient care and outcomes.

Thomas Fleeter, MD, MBA, FAAOS, is in private practice in Reston, Virginia, with Town Center Orthopaedics. He is a member of the AAOS Now Editorial Board and chair of the AAOS Committee on Professionalism.