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“Everything that irritates us about others can lead us to an understanding of ourselves.”
~Carl Gustav Jung


It is rare that orthopaedic surgeons know much about medications beyond the 2 antibiotics (Ancef and the other on when they are allergic). We occasionally know several NSAIDS and other post-op pain medication. If a patient is on more than Prevacid, we are likely to get a medicine consult because we have no idea what that new cardiac medication does. So, we rarely are visited by the well dressed pharmacy representative. (Well, ever since the who Vioxx debacle.) Orthopaedic surgeons are a high user of equipment, particularly implants. Therefore, we are always being visited by implant representatives, Zimmer, Styker, Medtronic, Biomet, Depuy. They bring their bagels and their new fancy devices just approved by the FDA through X amount of clinical trials. They keep scheduling you meetings to talk to you about new technology; take you to dinner to wine and dine you with a "special" lecturer. They smile and talk to you like a stripper wanting a 10 dollar tip. So, how should choose your implant company? My opinion is you choose the one with the best representation. Let me explain.

I do spine cases. Spine implants cost a lot of money and the rep gets a percentage of the money from each case. Let me give you an idea of dollars. A pedicle screw costs about ~$400-1000 per screw; a rod cost ~$500; and a cross-link~$1000 . I do scoliosis cases. On average, I will use 15 screws, 2 rods, and 2 cross-links (~$15,000-20,000/case). The rep gets 5-20% of that amount depending on where they are in the food chain (~$750-4,000/case). Because of the amount of money and the number of companies, they are always trying to get you to use their implant.

Now, I can tell you that most of the companies have the same "stuff." The fancy doodad and the whoosie whatsit will be on everyones implant set. The companies have become so big that even patents don't mean much and if they really want something from a small company, they will just buy the company. What separates one company from another, besides having a specific new device, is the representation. The representative must be knowledgeable, courteous, prepared, eager, unbiased, and the all important, not annoying. The rep has to be cautious as not to hurt anyones eqo as well as providing information that is helpful. It is a fine line. Let me tell you what puts a rep on "probation" in my OR. Saying you are prepared and you are not.

Today, I was doing a tibial osteotomy. I decided to use a company that I had used previously but had not for sometime. I was approached by the new reps who where eager an knowledgeable. They even brought their "specialist" in for the case. I check the set the day before, they assured me they had everything.

The day began, same as usual. Talked to patient. Walk the patient to the room. Checked with the rep and my staff to make sure we had all of the equipment. I began the case. Life was good. Pins were in place.

"OK Don, where is the whoosie whatsit?"

"Dr. P it's right over here." Pointing with his laser pointer.


Eve hands me the whoosie whatsit. I place it on the external fixator. I start to use it.


"Hey, Don. Is it says template on it? Is this the right one?"


"Sure is. That's the one you use."

"OK," I say. I put the next pin in place. Wouldn't you know that whoosie whatsit held that pin like a BB in a box car.

"Uh, Don. This doesn't fit. Do you have something else? Another whoosie whatsit? Maybe in you car or at the office?"

"UUhhh no, we don't have any thing else," he says.

Silence.To my scrub tech,"Get me the Ilizarov trays."

I didn't speak to him the rest of the case. My scrub tech, Eve, and I put together a new fixator. And the case turned out beautifully.

The leg looks FFT (Fan-Fu&@*ng-tastic).


For now, he is dead to me.

For all of you going into practice, don't be fooled by the fancy equipment, the nice dinner, or the pretty representative with the low cut dress. When you are choosing a total joint, spine, or fracture implant company, choose them based on the companies equipment and their representative. If you have a good rep, you can make almost any system work; with a bad rep, you may not have the equipment you need even if the company makes it.

Oh and by the way, always have a back up plan.


"Judge a man by his questions rather than by his answers"
~Voltaire
ORTHOPAEDIC RESIDENCY: The attending perspective.  A blog specifically for medical students interested in orthopaedics and orthopaedic residents. It is orthopaedic residency from the attending's perspective.