Editorial discretion

The gold standard for publication remains the blinded peer review process where authors’ manuscripts are judged in quality and scientific worth by their peers (usually two but often more). The process itself adds weight to the findings of the paper as does the journal in which the paper, has been published. This process is often talked about as a key marker of quality, both of the paper and of the journal, however, it is only part of a larger picture.

Often ignored, or indeed perhaps simply less well publicised, is the effect of editorial discretion and bias in the publication process. In truth, the decision to publish is much more complex than it appears. Editors are ultimately responsible for the decision to accept or reject a manuscript. This decision is necessary but not always transparent, taking into account factors other than reviews, such as likelihood of citation, interest, suitability for the readership and what other papers are about to be published in the journal. The Editor also considers quality, both objectively such as use of PRISMA and CONSORT guidelines and often less satisfactorily the Editor’s own standards. We have included an editorial in the Roundup from the Journal of Hand Surgery (Europe) that illustrates how these editorial decisions are vital in pushing up research standards. Despite the revolution in academic publishing, the ‘make or break’ decision still ends with editorial discretion. I welcome the open approach taken by the editor of the Journal of Hand Surgery (Europe) in openly setting his own editorial standards.

There is, however, another facet to editorial bias – the ‘author effect’ and ‘unit effect’. Responses to reviewers’ comments and justification of methodology and results following a review are necessarily decided upon by the Editor. A ‘big name author’ from a large centre will carry more weight with their comments than the same response from a less well known individual. There is one significant paper missing from this month’s 360 Roundup,¹ a paper by two esteemed authors, one previously chief executive of the NHS, and the other a UK government special advisor and member of the House of Lords. Both are big names, but neither is an orthopaedic surgeon. How could 360 fail to pick up on perhaps the most talked about paper of the past five years in orthopaedic circles? Quite simply, it has no scientific merit, provides no new findings, and completely lacks the insight that a senior author should apply to such a piece. How then has such a paper made headlines in the major newspapers of the UK? Quite simply due to ‘household name’ senior authors.

The paper describes a retrospective case series based on serious untoward incident reports from a national reporting framework. This tiny case series describes the outcomes of 62 patients, of whom 41 died over a seven-year period. There is no comparison group or indeed any real attempt to establish causation during a period when around 200,000 patients underwent surgery for their neck of femur fracture. The authors assert a causal relationship between the reports of ‘bone cement implantation syndrome’ and death without actually reviewing any patient records or information. They know nothing of the patients’ comorbidities, pre- and post-hospital care; simply that the event surrounding their on-table death or peri-arrest occurred during or after the insertion of the femoral stem. There is no discussion of those discarded reports in the study (numbering 298) which presumably could have described on table death associated with an uncemented stem. This retrospective case series with no known denominator or comparison group has caused more harm to patients than any recent academic papers. The general press has seized on these comments, despite better and more complete publications identifying a lower mortality rate associated with cemented rather than uncemented implants (7.4% vs 8.9%, respectively). Like another previous controversial² (and subsequently withdrawn) paper the authors of this paper had not seen the patient nor their notes. We would recommend reading and sharing the BOA’s position statement on the topic.³

In light of all of this it is probably worth revisiting how the structure of 360 works; the digest journal is perhaps the ultimate ‘editorial discretion’ journal. On a background of increasing open access and an explosion in the number of published papers (in 2013 13,367 indexed papers were added to the PubMed index with an orthopaedic subject title - up from 5973 back in 2003), the role of the digest is ever more important. How else is the orthopaedic surgeon to manage to keep abreast of this massive volume of published papers? In 2013 I included just 480 papers in the 360 reviews representing 1:27 published orthopaedic papers (still a substantial volume of information to ‘digest’ in the six hours it would take to read all of those issues of 360). Bone & Joint 360 sets out to include the major and most interesting papers from all over the globe. Our distinguished editorial board select papers from within their own area of specialty and provide a brief commentary on the value (or otherwise) of the paper, attempting to distil their expert opinion and views into just a few lines. From those submitted, as Editor-in-Chief I then select the most significant papers, around 80 each issue. Those papers are summarised into plain English in an easy to read format. This is not intended to replace reading the paper (or abstract), but to provide the substance and sense of an article and set its value within the experience of our editorial board.

In addition to the Roundup section, 360 covers updates from the Cochrane Collaboration, general interest orthopaedic feature articles, medicolegal features and Roundups of the latest information from meetings. This month I would particularly draw attention to the superb summary of the AAOS meeting from Mark Hammerberg in Denver, Colorado.