Much of the non-commercial orthopaedic research performed in North America is publicly funded by agencies such as the Canadian Institutes of Health Research (CIHR) or the (US) National Institutes of Health (NIH). In recent years the cogent question has been asked - "if the public is paying for this work, why cannot the public see the results?" The barriers to public access to research results stem mainly from the cost of subscription to orthopaedic journals, the publishers' policies restricting access to the non-paying public and the denial of copyright to the authors.

The root of the issue is that the authors of scientific papers desire readership and citation while the publishers want to make as much profit as possible. Prestigious journals therefore require authors to sign away their intellectual property rights and forbid them to publish' anywhere but in the journal. It wasn't much of an issue before the Internet, as printing was the cheapest way to make multiple copies. But now it is easy to post copies of one's work for free worldwide access and a deep division has arisen between the traditional journals and the advocates for Open Access. These advocates have now persuaded governments around the globe that if the public pays for the research then the public has a right to see the results.

CIHR policy1 was set out on a web page posted in Sept 2007. (slightly amended)

This policy applies to all grants awarded January 1, 2008 and onward, which have received funding in whole or in part from CIHR. While not required, researchers holding grants that were awarded prior to January 1, 2008 are encouraged to adhere to the requirements of this policy.

Grant recipients are now required to make every effort to ensure that their peer-reviewed publications are freely accessible through the Publisher's web site (Option #1) or an online repository as soon as possible and in any event, within six months of publication (Option #2).

Under the second option, grant recipients must archive the final peer-reviewed full-text manuscripts immediately upon publication in a digital archive, such as PubMed Central2 or one of the Canadian Institutional Repositories3,4, digital collections "of an institution's intellectual output". Publications must be freely accessible within six months of publication, where allowable and in accordance with publisher policies. The publisher's policy can be found in the Sherpa/Romeo database of Publisher copyright policies and self-archiving5 (emphasis and references mine).

Some publishers (e.g. Elsevier) have policies consistent with the requirements of the granting agencies. I looked up the publishers' policies of both editions of JBJS6,7, CORR8, JAAOS9, JT10 and JPO11. None are compliant with the policies required by CIHR. All require transfer of the copyright to the journal. Any copying or re-posting requires the permission of the publisher. This effectively bars post-publication in an open archive until the journal policies on this matter change. The unresolved question is whether CIHR will tacitly allow us to publish in these prestigious journals with "business as usual" or will expect us to publish in journals that comply with Open Access requirements, if we can find one. In a conflict between the agencies that fund our research and the institutions that publish our work, it is hard to see how we can come out ahead. Enjoy making "every effort"!

The NIH policy requires that the scientific results of publicly funded research must be available Open Access' to the public within 12 months of publication. There are no loopholes about "accordance with publisher policies" and you must supply NIH with evidence of compliance (PubMed Central number of the deposited article) if you wish to apply for any new grants. The NIH recognises that journals often require that copyright be transferred to the publisher before publication and blandly states12: "Authors should work with the publisher before any rights are transferred to ensure that all conditions of the NIH Public Access Policy can be met. Authors should avoid signing any agreements with publishers that do not allow the author to comply with the NIH Public Access Policy." The Scholarly Publishing and Academic Resources Coalition (SPARC) has prepared an addendum13 to send with your submitted manuscript. It retains copyright for the author and specifically permits posting of a copy of the article on the Internet. Canadians should be relieved that the US policies are tougher, as it seems likely that the battle for OA will be joined south of the border. No one would willingly risk a breach of copyright lawsuit with a US publisher even though the chance of winning would be very high. If that is what it will take, we can hope that one of our American colleagues will volunteer!

Open Access (OA) is defined as "free, immediate, permanent, full-text, online access, for any user, web-wide, to digital scientific and scholarly material, primarily research articles published in peer-reviewed journals.14" The British Medical Journal, Acta Orthopaedica and the Journal of Postgraduate Medicine are prominent examples of long established medical journals which have been Open Access for some time. JBJS-B allows access to articles published more than five years ago. There are now a number of newer online OA orthopaedic journals. Most of them accept wordage to the effect that the material may be copied, quoted and re-posted without infringement of copyright as long as the original source is acknowledged.

The orthopaedic journals are the most experienced institutions when it comes to high quality information. There is really only one cogent argument against Open Access - that it may weaken or destroy the journals that have hitherto provided the best quality information. Some advocates for the current system distort this concern by suggesting that the Open Access journals are unconcerned with quality and reject peer review in favour of an anything goes' attitude. In contrast, Dr Peter Suber, a long time advocate for OA, identified eight major advantages of traditional journals"15 and showed that none of these advantages are inherently sacrificed by Open Access journals (Table 1).

Table 1. Advantages of Traditional Journals

Advantage of Journals

Comment on Open Access

Peer Review

Traditional methods of peer review are used by most OA journals


A function of excellence of authors, editors and reviewers (not access)


A function of long established journals


Archiving may be achieved electronically or by printing paper copies

Intellectual Property

In OA this belongs to the authors not the journal. Copyright still exists


OA journals make a profit by charging authors not readers


OA journals have the option to sell add-ons such as current awareness, reference linking or customization


The journal or the user can print a hard copy of the article at need

Only in the area of prestige do the traditional journals have an advantage that the new Open Access journals cannot meet yet. Eysenbach16 studied the impact of OA publishing by examining the citations of articles in the same journal, some of which were OA and most of which were not. He found that OA articles were twice as likely to be cited compared to non-OA articles. With that kind of advantage, it will not be long before OA journals become highly prestigious.

Peer review has its critics. Fister's scathing summary (2005)17 was "We now have plenty of evidence to support the contention that peer review is "expensive, slow, subjective and biased, open to abuse, patchy at detecting important methodological defects, and almost useless at detecting fraud or misconduct.18" The Cochrane Review of the subject19 concluded that "little empirical evidence is available to support the use of editorial peer review as a mechanism to ensure quality of biomedical research." Peer review on the Internet has the potential for being more immediate, open and productive because alteration and updating of electronic material in response to critique is faster and easier.

There are now many Open Access Journals20 in the orthopaedic field (Table 2) posting articles on the Internet without charging for access to the material21. By and large they offer a traditional approach to peer review and, disappointingly, do not take full advantage of the electronic medium and hypertext. Some only publish online. Online publishers' include Bentham, Biomed Central (BMC), Public Library of Science (PLOS) and Internet Scientific Publications (ISPUB). Bioline specializes in journals from developing medical systems. Most of the journals published by the CMA are Open Access and so is the COA Bulletin. In about half of these journals, authors (or their institutions) are responsible for an Article Processing Fee (APF) to cover the costs of the web site and editorial activities. APFs are also charged by some print journals. Funding agencies expect grant applications to include these fees. NIH budgets $30m annually for APFs.

Table 2. Online Open Access Journals in Orthopaedics and Related Subjects

Journal Name

Address (URL)

Acta Orthopaedica*

Acta Orthopaedica et Traumatologica Turcica*

Acta Ortopdica Brasileira

Arthritis Research & Therapy*

BMC Musculoskeletal Disorders*

Indian Journal of Orthopaedics

International Journal of Shoulder Surgery

The Internet Journal of Hand Surgery

The Internet Journal of Minimally Invasive Spinal Technology

The Internet Journal of Orthopaedic Surgery

The Internet Journal of Rheumatology

The Internet Journal of Spine Surgery

The Iowa Orthopaedic Journal*

Journal of Orthopaedic Surgery*

Journal of Orthopaedic Surgery and Research*

Journal of Orthopaedics

Journal of Trauma Management & Outcomes*

Open Orthopaedics Journal

Open Sports Medicine Journal


In Table 2, journals marked with * are indexed in Medline (9/20). With the exception of Acta Orthopaedica, these are not high profile journals. Comparison by Impact Factor (IF)22 is hazardous. IF is the ratio between the number of citations to a journal's complete set of articles, and the number of articles. Calculation of IF is highly dependant on the period over which the data was collected. Bosker & Verheyen (2006)23 calculated mean IF for 15 high profile orthopaedic journals between 2000 and 2004. They found values between 2.20 (Spine) and 0.66 (Foot and Ankle). JBJS-A had an IF value of 2.06 and Acta Orthopaedica Scandanavica (the predecessor of Acta Orthopaedica) a value of 1.00 in that study. BMC Musculoskeletal Disorders states it has an Impact Factor of 1.4624 which would put it in the top six if the calculations had been equivalent. A more defensible conclusion is that this journal's impact factor is in the same range as many of the more highly prestigious journals. If Eysenbach's observations16 can be extrapolated to other OA journals, we should expect them to have relatively high impact. At present all this means is that articles in OA journals reward their authors with high readership. This may eventually be translated into prestige.

What conclusions can be drawn from this account of Open Access in orthopaedics? The first is that the landscape is changing. Ten years ago the Internet was ignored by the journals; now they are under heavy pressure to provide free access to all their articles on the Internet and may need to adopt new financial models as a result. This may mean that the costs of publication will fall on authors and their funding sources. If you want the advantage of publishing in Open Access journals, it may already do so. If you are doing publicly funded research work, you are under an obligation to provide Open Access to the results but the most prestigious journals currently refuse to allow this. Perhaps the only certainties are that you should be aware of this situation and that the situation itself will continue to change unpredictably.

If you do wish to push the orthopaedic community in the direction of Open Access, here are some suggestions.

  1. Discuss the issue with your colleagues and your medical librarian.
  2. Make Acta Orthopaedica your current first choice of publishing journal.
  3. Write to the editors of non-compliant journals asking them to adopt Open Access policies and explaining why you have published your research elsewhere. There would need to be institutional or profession-wide solidarity on this one to avoid reprisals in the form of refusal to consider your work in the future.
  4. Publish in OA journals regardless of prestige. You probably care more about how many people read the article. Use letters to the editor' in other journals to publicise OA articles.
  5. Cite OA articles and include the web site in the citation.
  6. Publish in a traditional journal, but sign the SPARC-CARL Authors' Addendum25,26 in addition to the copyright transfer form.
  7. Peer review only for journals that comply with CIHR policies.
  8. Discover your institution's policies about reimbursing APFs for authors who do not have a grant to cover them.

Acknowledgement: The author would like to thank Heather Morrison for her comments on the first draft of this article and for suggesting many valuable additional resources and recommendations for action.


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