Four years ago a group of top orthopedic implant makers agreed to pay $310 million in fines to settle federal accusations that they funneled kickbacks to surgeons to get the doctors to use their products.

But, according to a a new study, manufacturers of artificial hips and knees have kept giving millions of dollars every year to orthopedic surgeons. “There is a lot of money flowing back and forth,” said the lead researcher, Jason Hockenberry, a health policy expert now at Emory University.

As Reuters reports, the payments come through such avenues as consulting fees, royalties and research support. Supporters of the financial ties say the money often supports medical innovations, but critics counter that the money may induce doctors to use implants from a particular manufacturer or to downplay the side effects of those products when they conduct research.

The new study comes amid a U.S. Senate investigation into whether surgeons paid by Medtronic, a medical device maker not included in the new analysis, failed to report sterility and other complications stemming from the company’s bone-growth implant Infuse.

According to Hockenberry’s study, the five top hip and knee implant companies paid more than $198 million to 939 orthopedic surgeons in 2007. The following year, after the federal settlement, the companies made payments to 526 surgeons totaling more than $228 million, although $109 million of that amount was a one-time royalty buyout.

The five companies tracked over those years were Biomet Orthopedics, DePuy Orthopedics, Smith & Nephew, Stryker Orthopedics and Zimmer. All but Stryker paid into the $310 million federal settlement in 2007, and Striker agreed at the time to submit to government supervision.

As Bloomberg reports, for 2009 and 2010, only three of the companies — DePuy, Smith & Nephew and Stryker — continued, on a voluntary basis, to provide information on payments made to surgeons. Using that information, the researchers found that the three companies increased the amount of money they paid to doctors by more than 40 percent between 2008 and 2010.

The study appeared in the Archives of Internal Medicine.

STUART SILVERSTEIN

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