Orthopaedic resources available on the internet

by Ian Robertson

June 2011


Now that the internet is available to almost everybody and broard band connectios are common, the internet is becoming almost a more important source of orthopaedic information then traditional print media such as books and periodicals.

Not only are a significant proportion of articles online as text, a few minutes browsing will locate videos of operative technique. Pod cast lectures and blogs are available at the click of the mouse.

Only a few years ago if you did not personally subscribe to a variety of journals, a trip to the medical library was usually necessary to find an article, or verify a fact for research. Today the web enabled doctor is able to download most of this information from the comfort of his office or study.  

The downside is the plethora of information available online. In addition the searcher will have to avoid frustrations such as password protected sites, pay sites and references of dubious authenticity.

Characteristics of a quality Orthopaedic Web Site


The orthopaedic surgeon will have to avoid the many Orthopaedic sites that are of are of poor quality. Besides sloppy presentation, there may be untruths or bias towards a product or technique. This is often caused by conflicts of interest, the site may be commercially driven towards selling you a product, or to advertise a particular individual or group's practice.  Others sites exist for patient education, and are over simplified rather than being educational at the level of an orthopaedic surgeon.

How does the Orthopaedic surgeon recognize a quality site with reliable information?

Silberg 1 notes the following criteria for assessing a quality website.

Table I: Silberg’s Quality Web Criteria





Authors and contributors, their affiliations, and relevant

credentials should be provided


References and sources for all content should be listed

clearly, and all relevant copyright information noted



Web site “ownership” should be prominently and fully

disclosed, as should any sponsorship, advertising,



Dates that content was posted and updated should be



Quality Orthopaedic sites should be controlled by someone or who is an Orthopaedic surgeon. He need not necessarily be the webmaster , but should have control over what content is published. He ideally should be preferably also known as an author of peer reviewed journal articles. Popular sites of value to the academic are often large and have appreciable running costs; do not begrudge the fact that you may have to pay to gain access. As with paper journals the cost of running a large web site, of several thousand pages, may have to be offset by sponsorship or subscriptions by the users. 

Of many Orthopaedic web sites the following are of a good standard, comprehensive and are particularly useful to the postgraduate studying Orthopaedics.

Popular academic orthopaedic sites

Of the thousands of orthopaedic websites available, only a few are dedicated to academic orthopaedic surgery. The rest are either commercial, or are for patient education.


1)      Orthogate 2 is a site dedicated to providing verified and approved web references and also has a search facility. The site was begun in 1995 by Dr Myles Clough3, an Orthopaedic surgeon in Kamloops, Canada .

2) Orthoteers: 4. This site was started by three registrars,  Jonathan Borill, Lennard Frank and Susan Deakin. It has now developed into a major site containing a significant portion of the knowledge an Orthopaedic registrar needs to acquire. It has a large advisory board to vet the content. Unfortunately it requires an annual subscription if the user wants more than a cursory glimpse of its content.  

3)      Wheeless Textbook5. This site, at Duke University is edited by Clifford Wheeless,   and has 11000 pages of Orthopaedic information. Most information is didactic, being in a bullet list type point listings.

4)     Intute: 6Is a UK based organization with similar ideals of providing a search facility to approved quality sites and references. It does not uniquely deal with Orthopaedic material, but medical articles can be specified.

5)      Book and journal publishers.  Major publishers, including such sites as the Journal of Bone and Joint Surgery7 use software that allows the user to search not only their site material but other relevant medical and basic science journals.



Passive methods: Receiving your knowledge by mail


It is not always necessary to actively search for information. If you know what type of orthopaedic information interests you, the patient orthopaedic surgeon can have it sent to his mailbox or his mail aggregator program.  There are two methods to arrange this - joining a mailing list, or subscribing to a feed.


1)      Mailing Lists

Subscribing to a mailing list allows the Orthopaedic surgeon to keep abreast of his topic of interest. He will receive regular e mails on his chosen field of interest and can also become active by replying to the thread thus making himself a member of a discussion group. The downside of a mailing list is that all mail, not just the headlines, is sent to your mailbox. This can result in a large volume of post to sift through.

The quality of the mailing list is even more difficult to assess than that of a web page. G. McLauchlan8 in his assessment of the Orthopod9 mailing felt that a mailing list could be a medium of good quality Orthopaedic information.


2)      RSS Feeds


Another method of receiving mail or blogs is through subscribing to a RSS feed. RSS stands for Really Simple Syndication and overcomes the biggest problem of mail lists, which is the volume of unwanted information and its concomitant waste of bandwidth.

By joining a feed, the subscriber may selectively download the articles he is interested in. The feed initially sends headlines only to the subscriber. This is done on a regular basis (hourly for news feeds, but weekly or monthly for most Orthopaedic feeds). These are selected by clicking on the headline which will download the full text (blog), or audio talk (Pod cast). Most modern web browsers allow the user to join a feed, but, in addition, there are many specialized RSS aggregator program such as  FeedReader10 and SharpReader.11 Many of these software programmes are free ware.

Advantages of a RSS feed over a Website12

·            Users can be notified of new content without having to actively check for it.

·            Content updates can be sourced from many modalities (news, journals, portals and PubMed) can be tracked and easily managed in one central location.

·            No time wasted navigating complex sites.

 There are many excellent text-based and Pod cast feeds available on Orthopaedic topics. Orthopaedic Web Links13 maintains a list of feeds of Orthopaedic interest.  

Video pod casts or Vodcasts have an important role in the education of a practical profession such as ours. Many excellent videos of operative technique on the internet, including the video library maintained by the Journal of Bone and Joint Surgery14 exist. Video files tend to be large, and a broadband connection is recommended for shortened download times.



Archive sites

A reliable way to find scholarly articles is to visit an archive site. These respected sites such as PubMed and Medline 18 do not publish themselves, but invite other publishers to deposit either hard copy or digital versions of their publications with them. They do not own copyright over the articles they store. PubMed Central19 serves such a function. Besides peer reviewed journal articles they also store unpublished articles and data, considered of value in the opinion of   publishers, to researchers they trust.  .

 PubMed is an archive of biomedical and life sciences journal literature at the U.S. National Institutes of Health.  PubMed is well supported by all major publishers.  A search from PubMed web site will link the user to most of the Orthopaedic (and other biomedical) literature  ever published.  Currently most journals, have an online presence, and will be referenced by PubMed. In many cases only the abstract of an article and not the full text will be available.  PubMed maintains links  to the actual publisher’s site where, the full version of the article can be read, albeit often - only after paying a fee.


Cost Considerations

Many publishers now have digitalized their entire paper archives and these can be accessed online. The Journal of Bone and Joint Surgery, for example has PDF (Portable Document Format file) copies available from the date of first publication in 1948.20

These articles need to be paid for; publishers are often for profit commercial organizations and will expect to extract a fee for these. After searching for and finding the article, the user typically will be allowed to read the abstract for free, but is then required to pay $30 or more to download the PDF or full text version of the article.


There are more cost effective ways of legitimately obtaining these articles. Journals you personally subscribe to will allow you to login on their website and download whatever is available, after signing up using your subscription number.    If you are a member of an academic library they probably already have subscriptions to many popular Orthopaedic journals. This right of access to the full text versions is also transferred to you as a member. It is not necessary visit the library in order to exercise this right; all that is necessary is access to the internet from a University computer. Many publisher’s sites take note of the referrer’s unique IP (internet Protocol) address, and if this packet comes from a subscribing academic institution, the remote host computer will sign the user in automatically and honor him with the privileges of a paid subscriber.

 Many universities also allow a students and staff to log on to their library site from outside the university. After verifying the user via login passwords, he is then allowed to log into publishers’ sites to which the University has subscription rights. License agreements pay a role here: some publishers do not allow away from campus access, but most do.

A University also has finite means and, most likely, does not have subscriptions to all Orthopaedic journals. If you still cannot get the full text of your reference free online, consider asking the librarian for an inter library loan. In many cases all that will have to be paid for is the cost of photostating the article. Ironically, because of license agreements, the paper version may be more freely available for inter-lending than a digital copy. This is because libraries are bound by treaties on interlibrary loans. The conference on fair use (CONFU)21 agreement determines fair use, its main aim is to allow fair academic use, and also to prevent the borrowing library from being able to redistribute it again as if they had a subscription. This agreement was more biased towards Photostat (paper) copies, but recently digital copies are becoming regarded as an equivalent.

If you need the copy for teaching purposes, for example to distribute to a class your University may already own a blanket copyright agreement. For example the University of Stellenbosch pays a levy to the Dynamic Artistic and Literary Rights Organisation (DALRO22) to allow unlimited copies (with certain provisos, such as only one article per journal) to your class. The university requires to be notified retrospectively of your use of the article.

Privatly funded electronic libraries

Medical and paramedical practitioners, who are often not affiliated with a medical school and it's library have to take out individual subscriptions to each journal and join many pay sites. MELISA (Medical electronic library of South Africa) was set up to allow communal access to it's members to these existing subscriptions and online resources. It asked the pharmaceutical companies to sponsor costs. Melisa recently closed its services due to lack of funding. The feeling in the industry was that "doctors did not read", and that Melisa did not warrant sponsorship because industry would not get a return on its investment.

Such nobile initiatives must be encouraged, as a way to promote reading and study, especially in the South African context, where underpaid junior doctors are sent to do community service in rural areas. Libraries and other physical access to books and periodicals are virtually non existent at these places.


Free Journal Sites

Many are concerned by the fact that commercial publishers make their profit from selling articles generated from research funded by public money. To counter this commercialization, many Open Access (OA) electronic resources have been established. There is an advantage to the author too in using OA  journals.  Alma Swan23  has shown that a publication is more likely to be cited from an OA journal than from a subscription equivalent. The reason is that the OA journal is easier to find and retrieve on the internet. 


Below is a selection of the better known OA sites.


·    BioMed Central.24 is an independent online publishing house committed to providing free access to the peer-reviewed biological and medical research it publishes.

·         Directory of Open Access Journals 25 Here the reader can find 8 journals in the field of Orthopaedic Surgery. These journals include Acta Orthopaedica and Orthopaedic Research and Reviews.

·        Free Medical Journals.com 26 Links to many OA medical journals. The site allows the user to download (full text) copies of articles from 18 Orthopaedic Journals.


Reference manager software

The personal computer will generate many useful links and downloads from your academic quest for knowledge. Reference managers allow the user to create order with this data.

These handy programmes allow the user to compile a reference of articles read, even if the user does not wish to become an author. The software allows a user to download a citation, with a few clicks of the mouse, and keep a database of the downloaded reference. Links to a copy of the PDF (or any other file) you download to your own PC (Personal Computer) can be added including a field for a graphic. There is a field allowing the user to add his notes and annotations. Many citation managers interface with popular word processors such as MS Word, and can automatically add and maintain a list of references as a footnote to the article. The program will correctly order the articles and keep the style of the references uniform and in accordance with that wanted from a selection of well known journals. Alternatively the writers own style can be formatted.  

There are many commercial reference manager programmes such as EndNote27 and Procite28. In addition there are public domain (free ware) alternatives such as JabRef 29distributed under the GNU30 (General public license). Most of these public domain managers make use of  the BibTex notation. This is a simple text based format that can easily be hand written.


Example: Reference 15 in BibTex format:-


   author = {Priscilla Caplan, William Arms},

   title = {Reference linking for journal articles},

   journal = {D-Lib Magazine},

   volume = {5},

   number = {7/8},

   year = {1999}



 This formatted paragraph of text needs to be copied from the host site and merely pasted into your BibTex compatible browser.

The commercial reference mangers are even more automatic. The host site’s software will allow the user to “download to citation manager.” Once the manager type is selected the reference is downloaded in a format such as RIS31 (a standardized tag format developed by Research Information Systems ). This file can either be saved to disk on the user’s machine or will activate your citation manager automatically to include the reference in its library - as ‘RIS’ will be a file type associated by your operating system with your favorite citation manager.  The whole process is thus semi automatic and the user can with minimal effort, build up a large and ordered, library of the articles he has read. Most reference managers also allow the user to link to a local, on disk, copy the user may have saved from his web search.




The internet has changed the way we deal with and acquire knowledge. Not only is more information available, it can be effectively stored and referenced on one’s own personal computer. Search engines that can index the entire internet and produce a search results in microseconds are both a boon and a curse as they have difficulty in distinguishing pearls of wisdom from pornography. The advent of search engines dedicated to scholarly work and archival sites such as Pub Med has helped to improve the quality of their results for the academic.

 It is still up to the individual to verify the quality of the information returned from such searches. All these sophisticated searches do is filter out some of the dirt. The spam producers and unscrupulous businessmen will always be able to keep ahead of these efforts.


A practical knowledge of how to obtain copies of references not available directly through your web connection to your internet provider is necessary. Use your local medical libraries’ online service and if this fails ask for an old fashioned interlibrary loan on paper!


Online information is growing in quantity but is much shorter lived than the paper documents it replaces. The life span of information on a hard disk is unknown30, but probably only slightly longer than flash disks and non gold plated CD ROM disks. Joe Iraci 40 has demonstrated in accelerated ageing tests, reliably store information for less than 10 years.  In addition to the concern about degradation of the data itself  there are other concerns online as a result of the basic building blocks of web pages- the HTML (Hypertext Markup Language); the  hyper links themselves. Online references are liable to ‘link rot’, and vendor obsolescence. Services such as PubMed and other archival sites are helping keep references pointing towards viable sites. The DOI initiative promises to grow and provide a system of valid links to much more scholarly output than just formal journal articles. 


The internet will continue to evolve. Orthopaedic websites will proliferate and search engines will become more attuned to the needs of the academic searcher. On the other hand spam producers, and con artists will continue to keep abreast of these developments. While the future of publishing will undoubtedly be more web-based, the Orthopaedic surgeon will always have to exercise judgment before accepting all online information as gospel truth.











1. Silberg WM, Lundberg GD, Musacchio RA. Assessing, Controlling, and Assuring the Quality of Medical Information on the Internet: Caveant Lector et Viewor--Let the Reader and Viewer Beware. JAMA 1997;277(15):1244-45.

2. Orthogate: http://www.orthogate.org/.

3. Oliver CW. Trauma an orthopaedic surgery on the internet. J Bone Joint Surg Br 1999;81-B(1):3-6.

4. James Carmichael DA. Orthoteers, http://www.orthoteers.org/.

5. Wheeless CR. Wheeless Textbook of Orthopaedics, http://www.wheelessonline.com/.

6. Intute search engine:  http://www.intute.ac.uk.

7. Journal of Bone and Joint - American:  http://www.ejbjs.org.

8. George J McLauchlan, Mike Cadogan, Oliver CW. Assessment of an orthopaedic mailing list, http://www.rcsed.ac.uk/journal/vol44_1/4410040.htm.

9. Orthopod mailing list:  http://groups.google.com/group/orthopod.

10. FeedReader: http://www.feedreader.com/.

11. SharpReader: http://www.sharpreader.net/.

12. Advantages of a RSS feed:  http://www.orthogate.org/workshops/software/using-google-reader-and-rss-feeds.html.

13. Orthopaedic Web Links:  http://www.orthopaedicweblinks.com/sitemap.html.

14. JBJS Video Library:  http://www2.ejbjs.org/misc/vid_archive.dtl. JBJS video library.

15. Priscilla Caplan WA. Reference linking for journal articles. D-Lib Magazine 1999;5(7/8).

16. Digital Object Identifier:  http://www.doi.org/.

17. Rosenblatt W. The digital object identifier: The dilemma of copyright protection online. Journal of elecronic publishing 1997;3(No 2).

18. Rozental TD, Lonner JH, Parekh SG. The Internet as a Communication Tool for Academic Orthopaedic Surgery Departments in the United States. J Bone Joint Surg Am 2001;83(7):987-91.

19. PubMed information:  http://www.ncbi.nlm.nih.gov/pmc/about/intro.html.

20. Scott J. Journal of Bone and Joint Surgery online 1948 to 2006. J Bone Joint Surg Br 2006;88-B(1):1-.

21. Interlibrary loans: http://www.copyright.com/Services/copyrightoncampus/content/ill.html.

22. Golladay GJ, Kirschenbaum IH, Matthews LS, Biermann JS. Current Concepts Review - Internet Resources for Orthopaedic Surgeons. J Bone Joint Surg Am 1998;80(10):1525-32.

23. Swan A. The Open Access citation advantage: Studies and results to date : http://eprints.ecs.soton.ac.uk/18516/, 2010.

24. BioMed Central: http://www.biomedcentral.com/.

25. Directory of Open Access Journals: http://www.doaj.org/.

26. Free Medical Journals.com: http://www.freemedicaljournals.com/.

27. EndNote: http://www.endnote.com/.

28. ProCite: http://www.procite.com/.

29. Beredjiklian PK, Bozentka DJ, Steinberg DR, Bernstein J. Evaluating the Source and Content of Orthopaedic Information on the Internet : The Case of Carpal Tunnel Syndrome. J Bone Joint Surg Am 2000;82(11):1540-.

30. Simonite T, LePage M. Now we know it... New Scientist 2010;January 30 2010:36-39.

31. RIS File format:  http://en.wikipedia.org/wiki/RIS.

32. Google Search Engine:  http://google.co.za.

33. Bing search engine: http://www.bing.com.

34. Yahoo Search Engine:  http://www.yahoo.co.za.

35. Wootton JC. New generation search engines. J Womens Health Gend Based Med 2000;9(1):79-80.

36. Siva N. Search engines continue to advertise rogue online pharmacies. BMJ 2009;339(aug27_3):b3457-.

37. Google Scholar:  http://www.scholar.co.za.

38. Simpson P, Oliver CW. Searching the Internet for orthopaedic knowledge. J Bone Joint Surg Br 2004;86-B(8):1105-07.

39. Scirius: http://www.scirius.com

40. Iraci J. 'The relative stabilities of optical disc formats'. Restaurator: international journal for the preservation of library and archival material 2005;26(No 2):134 - 50.