Are Research Publications Original and True?
Vernon T. Tolo, MD

Clinical and basic research has driven the advances in orthopaedics to a level only dreamed about a few decades ago, with major benefits for patients with musculoskeletal disorders. However, the picture is not perfect. Since I have been Editor-in-Chief of JBJS, I have become aware that some negative trends threaten the quality and veracity of some research being reported today. In this final issue for which I am Editor-in-Chief, I will address some of these threats.

Conflicts of interest have been a prominent topic among orthopaedic surgeons for many years, with the lay press focusing public attention on the relationships between industry and the clinical practice and research work of individual orthopaedists. Despite the disclosures of potential conflicts by JBJS and other journals, the impact of these disclosures remains small. My sense is that few of our readers look at the conflict-of-interest forms that are attached to all JBJS articles and that most accept some conflicts of interest as being the norm among those doing and reporting research. The trust that orthopaedic surgeons place in their colleagues to be free of influence from potential conflicts is concerning, as there is clear evidence that biases can and do result from conflicts of interest. We need to educate our readers to be more alert to these conflicts and to devise a better way to communicate the magnitude of the relationships that authors may have.

The pressure in American and international academic communities to publish can be intense, with publications in journals with higher impact factors constituting a major component for academic promotion. Over the past few years, several manuscripts representing attempts at duplicate publication or simultaneous submission have been identified by the software used at JBJS to detect some of these unethical publication practices, including less obvious sorts of plagiarism. While the publication of the same data in different languages was once considered acceptable, this is no longer the case, and the technology now available can more easily detect attempts at duplicate publication. When duplicate submission or plagiarism is identified, the manuscript is rejected and the authors are precluded from submitting to JBJS for a time. As a result of duplicate submission and plagiarism, as well as for other reasons, the number of retractions of scientific articles has exploded, as evidenced by a look at www.retractionwatch.com. Our authors need to abide by the principles of publication ethics (www.publicationethics.org) and ensure the originality of the research submitted to our journals.

Randomized controlled trials (RCTs) remain at the top of the pyramid for the highest level of evidence. An important component of RCTs is the clinical trial registration on a national/international data site. Trial parameter registration is best accomplished prior to the start of the trial. This registration includes the protocol of the study, particularly important in multicenter studies, and the primary and secondary outcomes being evaluated. While JBJS requires this registration, <50% of submitted RCTs are registered at the start of the study. More than half are registered at a later stage, allowing manipulation of the protocol and primary or secondary outcomes based on the early results of the unregistered study. If one of the secondary outcomes appears more favorable than the primary outcome initially proposed, those outcomes can be flipped, increasing the likelihood that the paper will report favorable results. All RCTs submitted to JBJS should have been registered prior to the recruitment of any patients.

Pre-publication peer review must continue to be the standard for publishing articles that may affect orthopaedic patient care. Experiments in which journals rely on peer review by readers post-publication worry me. We know that our readers use information from our articles to guide their patient care. Rigorous pre-publication peer review needs to remain a cornerstone of JBJS so that we can continue to provide trusted information.

Open-access journals for which author fees are the main or only source of revenue for the publisher also concern me. Fortunately, these types of open-access journals in orthopaedics remain poorly developed and infrequently used to date.

JBJS has been a leader in publishing high-quality orthopaedic research for 125 years. I have no doubt that this will continue after I am no longer Editor-in-Chief. However, ongoing attention must be given to the threats to accuracy and originality of research reports published across all of our journals as we continue to be a mainstay of education for orthopaedic surgeons globally.

I am grateful for the privilege of serving as Editor-in-Chief of JBJS for the past several years.