Global Orthopaedic Surgery: An Ethical Framework to Prioritize Surgical Capacity Building in Low and Middle-Income Countries

Global Health Inequities in Orthopaedic Care: Perspectives Beyond the US

PURPOSE OF REVIEW

The burden of musculoskeletal disease is increasing globally and disproportionately affecting people in low and middle income countries (LMIC). We sought to review global access to orthopaedic care, burden of trauma, research infrastructure, impact of surgical mission trips, implant availability, and the effect of COVID-19 upon the delivery of orthopaedic care worldwide.

RECENT FINDINGS

The majority of people in LMIC do not have access to safe, quality surgical care, and there are few fellowship-trained orthopaedic traumatologists. Road traffic accidents are the leading cause of long bone fractures in LMIC and result in significant morbidity and mortality. Of the orthopaedic literature published globally in the last 10 years, less than 15% had authors from LMIC. There has been growth in surgical mission trips to LMIC, but few organizations have established bidirectional partnerships. Among the challenges to delivering quality musculoskeletal care in LMIC is timely access to quality orthopaedic implants. Implant options in LMIC are more limited and subjected to less rigorous testing and regulation than high income countries (HIC). The COVID-19 pandemic dramatically reduced elective surgeries but saw the increase in telemedicine utilization which has prevailed in both HIC and LMIC. Awareness of global inequities in orthopaedic care is growing. Much can be learned through collaborations between orthopaedic surgeons from HIC and LMIC to advance patient care worldwide. There is a need for high quality, accurate data regarding incidence and prevalence of musculoskeletal disease, care utilization/availability, and postoperative outcomes so resources can be allotted to make orthopaedic care more equitable globally.

Sociopolitical, clinical, and ethical challenges of sustainable fracture care in Haiti

INTRODUCTION

In low- and middle-income countries such as Haiti, musculoskeletal injuries are the leading cause of morbidity and mortality. Untreated injuries can contribute to decreased mobility, leading to disability and reduced productivity for individuals. The accessibility of timely fracture care poses a substantial challenge in Haiti, where socioeconomic instability and recent surges in gang violence exacerbate an already strained healthcare infrastructure. This manuscript delves into the intricate barriers to sustainable fracture care in Haiti, shedding light on the sociopolitical landscape and clinical challenges that influence the delivery of orthopedic services.

ETHICAL DISCUSSION

The ethical considerations in providing fracture care in Haiti are multifaceted, including classic medical principles, self-preservation in the face of violence, issues of justice in resource and service allocation, and concerns of nonmaleficence in the context of international volunteers. These ethical dilemmas arise from the complex interplay of limited resources, the dangers posed by the current sociopolitical climate, and the involvement of international aid in a vulnerable healthcare system.

CONCLUSION

To address the clinical and ethical conflicts of providing fracture care in Haiti, solutions include education and training of Haitian orthopedic surgeons, capacity building of healthcare facilities, and establishing ethical standards for international volunteers. This comprehensive approach is vital for advancing sustainable fracture care in Haiti and other resource-limited settings.

Implementation of an electronic health record system during global surgical outreach: A prospective evaluation of success and sustainability

BACKGROUND

The burden of musculoskeletal conditions continues to grow in low- and middle-income countries. Among thousands of surgical outreach trips each year, few organizations electronically track patient data to inform real-time care decisions and assess trip impact. We report the implementation of an electronic health record (EHR) system utilized at point of care during an orthopedic surgical outreach trip.

METHODS

In March 2023, we implemented an EHR on an orthopedic outreach trip to guide real-time care decisions. We utilized an effectiveness-implementation hybrid type 3 design to evaluate implementation success. Success was measured using outcomes adopted by the World Health Organization, including acceptability, appropriateness, feasibility, adoption, fidelity, and sustainability. Clinical outcome measures included adherence to essential quality measures and follow-up numerical rating system (NRS) pain scores.

RESULTS

During the 5-day outreach trip, 76 patients were evaluated, 25 of which underwent surgery beforehand. The EHR implementation was successful as defined by: mean questionnaire ratings of acceptability (4.26), appropriateness (4.12), feasibility (4.19), and adoption (4.33) at least 4.00, WHO behaviorally anchored rating scale ratings of fidelity (6.8) at least 5.00, and sustainability (80%) at least 60% follow-up at 6 months. All clinical quality measures were reported in greater than 80% of cases with all measures reported in 92% of cases. NRS pain scores improved by an average of 2.4 points.

CONCLUSIONS

We demonstrate successful implementation of an EHR for real-time clinical use on a surgical outreach trip. Benefits of EHR utilization on surgical outreach trips may include improved documentation, minimization of medical errors, and ultimately improved quality of care.

Defining a Framework and Evaluation Metrics for Sustainable Global Surgical Partnerships: A Modified Delphi Study

OBJECTIVE

The aim of this study was to use expert consensus to build a concrete and realistic framework and checklist to evaluate sustainability in global surgery partnerships (GSPs).

BACKGROUND

Partnerships between high-resourced and low-resourced settings are often created to address the burden of unmet surgical need. Reflecting on the negative, unintended consequences of asymmetrical partnerships, global surgery community members have proposed frameworks and best practices to promote sustainable engagement between partners, though these frameworks lack consensus. This project proposes a cohesive, consensus-driven framework with accompanying evaluation metrics to guide sustainability in GSPs.

METHODS

A modified Delphi technique with purposive sampling was used to build consensus on the definitions and associated evaluation metrics of previously proposed pillars (Stakeholder Engagement, Multidisciplinary Collaboration, Context-Relevant Education and Training, Bilateral Authorship, Multisource Funding, Outcome Measurement) of sustainable GSPs.

RESULTS

Fifty global surgery experts from 34 countries with a median of 9.5 years of experience in the field of global surgery participated in 3 Delphi rounds. Consensus was achieved on the identity, definitions, and a 47-item checklist for the evaluation of the 6 pillars of sustainability in GSPs. In all, 29% of items achieved consensus in the first round, whereas 100% achieved consensus in the second and third rounds.

CONCLUSIONS

We present the first framework for building sustainable GSPs using the input of experts from all World Health Organization regions. We hope this tool will help the global surgery community to find noncolonial solutions to addressing the gap in access to quality surgical care in low-resource settings.

One World Surgery: The Evolution of a Locally Run Surgical Mission in Honduras

ABSTRACT

One World Surgery (OWS) is a medical mission organization that treats a variety of orthopaedic conditions and focuses on local partnerships, education, capacity-building, and high-quality care. OWS runs a Honduran ambulatory surgery center (ASC) with >50 full-time local staff; it operates year-round and accommodates visiting surgical teams bimonthly. Across its 12-year history, 8,703 surgical procedures have been performed and 54,940 total consults have been completed, with increasing autonomy of the local medical staff. From 2009 through 2021, OWS has provided 74 million U.S. dollars in surgical and consult patient care. By addressing global surgical disparities via life-enhancing surgical care in low- and middle-income country (LMIC) settings, the OWS ASC mission model may be a useful blueprint for other medical missions.

An Analysis of Global Orthopedic Organizations Through the Lens of the Four Pillars of Global Surgery

Introduction The mortality of orthopedic trauma is very high, however, a large proportion is considered preventable. Global orthopedics was historically centered around the direct delivery of nonsurgical and surgical medical care. There has been an evolution towards increased sustainability. Purpose The purpose of this paper is to evaluate the accomplishment of the four pillars of global surgery by five commonly referenced orthopedic global surgery organizations. Methods This institutional review board (IRB)-exempt cross-sectional data studied Global Orthopedic Alliance, Operation Rainbow, the Institute for Global Orthopaedics and Traumatology (IGOT), One World Surgery (OWS), and the Canadian Orthopedic Association for Global Surgery (COAGS) through the lens of the four pillars of global surgery: knowledge exchange, advocacy, research initiative, surgical education. The knowledge exchange pillar was examined through the three most popular online knowledge exchange platforms in orthopedics. The advocacy pillar was examined through each organization's individually created website. The research initiative was examined through a comprehensive literature search. The surgical education pillar was examined through resident-level educational resources. The data was summarized descriptively. Results A total of four organizations demonstrated activity within the pillar of knowledge exchange. A total of three organizations demonstrated activity with the pillar of advocacy. A total of three groups demonstrated activity within the pillar of the research initiative. A total of two groups had activity within the pillar of surgical education. Conclusions The landscape regarding global orthopedic surgery programs has evolved greatly to encompass the four pillars of global surgery. Within the past 10 years, there has been increased emphasis on the knowledge exchange and research initiative pillars. Surgical education remains the pillar with the least emphasis. As global orthopedic surgery programs continue to evolve, increasing emphasis should be placed on all four of these pillars to increase sustainability.

Capacity Building During Short-Term Surgical Outreach Trips: A Review of What Guidelines Exist

INTRODUCTION

While short-term surgical outreach trips improve access to care in low- and middle-income countries (LMIC), there is rising concern about their long-term impact. In response, many organizations seek to incorporate capacity building programs into their outreach efforts to help strengthen local health systems. Although leading organizations, like the World Health Organization (WHO), advocate for this approach, uniform guidelines are absent.

METHODS

We performed a systematic review, using search terms pertaining to capacity building guidelines during short-term surgical outreach trips. We extracted information on authorship, guideline development methodology, and guidelines relating to capacity building. Guidelines were classified according to the Global-QUEST framework, which outlines seven domains of capacity building on surgical outreach trips. Guideline development methodology frequencies and domain classifications frequencies were calculated; subsequently, guidelines were aggregated to develop a core guideline for each domain.

RESULTS

A total of 35 studies were included. Over 200 individual guidelines were extracted, spanning all seven framework domains. Guidelines were most frequently classified into Coordination and Community Impact domains and least frequently into the Finance domain. Less than half (46%) of studies collaborated with local communities to design the guidelines. Instead, guidelines were predominantly developed through author trip experience.

CONCLUSION

As short-term surgical trips increase, further work is needed to standardize guidelines, create actionable steps, and promote collaborations in order to promote accountability during short-term surgical outreach trips.

Host Perspectives of High-Income Country Orthopaedic Resident Rotations in Low and Middle-Income Countries

BACKGROUND

International orthopaedic resident rotations in low and middle-income countries (LMICs) are gaining popularity among high-income country (HIC) residency programs. While evidence demonstrates a benefit for the visiting residents, few studies have evaluated the impact of such rotations on the orthopaedic surgeons and trainees in LMICs. The purpose of this study was to further explore themes identified in a previous survey study regarding the local impact of visiting HIC resident rotations.

METHODS

Using a semistructured interview guide, LMIC surgeons and trainees who had hosted HIC orthopaedic residents within the previous 10 years were interviewed until thematic saturation was reached.

RESULTS

Twenty attending and resident orthopaedic surgeons from 8 LMICs were interviewed. Positive and negative effects of the visiting residents on clinical care, education, interpersonal relationships, and resource availability were identified. Seven recommendations for visiting resident rotations were highlighted, including a 1 to 2-month rotation length; visiting residents at the senior training level; site-specific prerotation orientation with an emphasis on resident attitudes, including the need for humility; creation of bidirectional opportunities; partnering with institutions with local training programs; and fostering mutually beneficial sustained relationships.

CONCLUSIONS

This study explores the perspectives of those who host visiting residents, a viewpoint that is underrepresented in the literature. Future research regarding HIC orthopaedic resident rotations in LMICs should include the perspectives of local surgeons and trainees to strive for mutually beneficial experiences to further strengthen and sustain such academic partnerships.

Patient Follow-up After Orthopaedic Outreach Trips - Do We Know Whether Patients are Improving?

Background

The burden of traumatic musculoskeletal injuries falls greatest on low- and middle-income countries (LMICs). To help address this burden, organizations host over 6,000 outreach trips annually, 20% of which are orthopaedic. Monitoring post-surgical outcomes is critical to ensuring care quality; however, the implementation of such monitoring is unknown. The purpose of this review is to identify published follow-up practices of short-term orthopaedic surgery outreach trips to LMICs.

Methods

We completed a systematic review of Pubmed, Web of Science, EMBASE, and ProQuest following PRISMA guidelines. Follow-up method, rate, duration, and types of outcomes measured along with barriers to follow-up were collected and reported.

Results

The initial search yielded 1,452 articles, 18 of which were eligible. The mean follow-up time was 5.4 months (range: 15 days-7 years). The mean follow-up rate was 65.8% (range: 22%-100%), the weighted rate was 57.5%. Fifteen studies reported follow-up at or after 3 months while eight studies reported follow-up at or after 9 months. Fifteen studies reported follow-up in person, three reported follow-up via phone call or SMS. Outcome reporting varied among mortality, complications, and patient-reported outcomes. The majority (75%) outlined barriers to follow-up, most commonly noting transportation and costs of follow-up to the patient.

Conclusions

There is minimal and heterogeneous public reporting of patient outcomes and follow-up after outreach trips to LMICs, limiting quality assessment and improvement. Future work should address the design and implementation of tools and guidelines to improve follow-up as well as outcome measurement to ensure provision of high-quality care.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00268-022-06630-w.

Training low-middle-income (LMIC) pediatric surgeons in a high-income country (HIC) program

BACKGROUND

A popular paradigm to support surgical education for low- and middle-income countries (LMICs) is partnering with high-income country (HIC) surgeons. These relationships may, however, be asymmetric and fail to optimally address the most pressing curricular needs. We explored the effectiveness of our LMIC-HIC educational partnership.

METHODS

Through a partnership between a HIC (Canada) and a LMIC (Uganda), three candidate surgeons were commissioned for a custom designed 1-year training experience at our HIC accredited pediatric surgical training centre as part of their overall formal education. The training curriculum was developed in collaboration with the LMIC pediatric surgeon and utilized competency-based medical education principles. A Likert and short-answer survey tool was administered to these trainees upon completion of their training.

RESULTS

All prescribed milestones as well as specialty certification by examination of the College of Surgeons of East, Central and Southern Africa was achieved by participating fellows, each of whom have begun clinical practice, leadership and teaching roles in their home country. Although several obstacles were identified by fellows, all agreed that the experience boosted their clinical and teaching abilities, and was worth the effort.

CONCLUSION

This endeavour in global pediatric surgical training represents a significant innovation in surgical education partnerships and would be reproducible across different surgical subspecialties and contexts. Such collaborative efforts represent a feasible upskilling opportunity towards addressing global surgical service capacity.

LEVEL OF EVIDENCE

V.

Establishing Sustainable Arthroscopy Capacity in Low- and Middle-Income Countries (LMICs) through High-Income Country/LMIC Partnerships

Disparities exist in treatment modalities, including arthroscopic surgery, for orthopaedic injuries between high-income countries (HICs) and low- and middle-income countries (LMICs). Arthroscopy training is a self-identified goal of LMIC surgeons to meet the burden of musculoskeletal injury. The aim of this study was to determine the necessary “key ingredients” for establishing arthroscopy centers in LMICs in order to build capacity and expand training in arthroscopy in lower-resource settings.

Candidate Quality Measures for Orthopaedic Surgery Outreach Trips: A Systematic Review

INTRODUCTION

Up to 30% of the global burden of disease is secondary to surgical conditions, most of which falls on those in low- and middle-income countries (LMICs). Ensuring that the quality of care delivered during outreach trips to address these conditions is foundational. Limited work has been done to develop and implement tools to assess and improve the quality of care for these trips. The purpose of this study was to identify candidate quality measures that address orthopaedic surgery outreach trips in LMICs.

METHODS

We conducted a systematic review of MEDLINE/PubMed, EMBASE, Web of Science, Google Scholar, and other databases to identify candidate quality measures relevant to orthopaedic surgery outreach to LMICs. Quality measures were then categorized by system management, sustainability, or both system management and sustainability according to the framework and structures, processes, and outcomes of Bido et al according to the Donabedian domains.

RESULTS

Our initial search yielded 3,891 articles, 22 of which met the inclusion criteria. Seventy-nine candidate quality measures were identified. Regarding the framework of Bido et al, 55 of 79 (70%) were related to system management, 8 (10%) were related to sustainability, and 16 (20%) were related to both system management and sustainability. According to Donabedian domains, 43 of 79 (54%) were structure measures, 25 (32%) were process measures, and 11 (14%) were outcome measures.

DISCUSSION

Quality measures addressing orthopaedic surgery outreach trips are lacking in quantity and breadth, limiting the ability to assess and improve the safety and quality of care provided. The candidate quality measures identified disproportionately focus on systems management and structures, with few related to sustainability and few addressing outcomes. Patients receiving care on outreach trips would benefit from the implementation of the measures identified in this review and from the development of quality measures that capture all domains of care and emphasize outcomes.

LEVEL OF EVIDENCE

Level III.

Ethical considerations in global surgery: a scoping review

Introduction

An unmet burden of surgical disease exists worldwide and is disproportionately shouldered by low-income and middle-income countries (LMICs). As the field of global surgery grows to meet this need, ethical considerations need to be addressed. Currently, there are no formal guidelines to help inform relevant stakeholders of the ethical challenges and considerations facing global surgical collaborations. The aim of this scoping review is to synthesise the existing literature on ethics in global surgery and identify gaps in the current knowledge.

Methods

A scoping review of relevant databases to identify the literature pertaining to ethics in global surgery was performed. Eligible articles addressed at least one ethical consideration in global surgery. A grounded theory approach to content analysis was used to identify themes in the included literature and guide the identification of gaps in existing literature.

Results

Four major ethical domains were identified in the literature: clinical care and delivery; education and exchange of trainees; research, monitoring and evaluation; and engagement in collaborations and partnerships. The majority of published literature related to issues of clinical care and delivery of the individual patient. Most of the published literature was published exclusively by authors in high-income countries (HICs) (80%), and the majority of articles were in the form of editorials or commentaries (69.1%). Only 12.7% of articles published were original research studies.

Conclusion

The literature on ethics in global surgery remains sparse, with most publications coming from HICs, and focusing on clinical care and short-term surgical missions. Given that LMICs are frequently the recipients of global surgical initiatives, the relative absence of literature from their perspective needs to be addressed. Furthermore, there is a need for more literature focusing on the ethics surrounding sustainable collaborations and partnerships.

Development of a Global Pediatric Orthopedic Outreach Program in Ecuador Through Project Perfect World: Past, Present, and Future Directions

Global health delivery is a complex initiative requiring dedicated personnel to achieve a successful program. To be most beneficial, global health delivery should focus on cultural competence, bidirectional education, and capacity building through direct and purposeful means. The authors present the expansion of their global health delivery program in Ecuador focusing on the evolution of the program from a medical mission trip to a multilayered program that helps foster engagement, education, and learning while helping children who might not otherwise have access to care, along with future directions and potential methods to decrease the need for such initiatives in Ecuador.

International Collaboration in Total Joint Arthroplasty: A Framework for Establishing Meaningful International Alliances

Despite the increase in utilization of total joint arthroplasty (TJA) throughout high-income countries, there is a lack of access to basic surgical care, including TJA, in low- and middle-income countries (LMICs). Multiple strategies, including short-term surgical trips, establishment of local TJA centers, and education-based international academic collaborations, have been used to bridge the gap in access to quality TJA. The authors review the obstacles to providing TJA in LMICs, the outcomes of the 3 strategies in use to bridge gaps, and a framework for the establishment and maintenance of meaningful international collaborations.

The Development of a Surgical Mission in the Peruvian Amazon: A 15-Year Expedition

Musculoskeletal disorders and injuries represent a substantial proportion of the global burden of disease. This burden is particularly prevalent in low and middle-income countries that already have insufficient health-care resources. The purpose of this paper is to highlight the vision, the history, the implementation, and the challenges in establishing an orthopaedic surgical mission in a developing nation to help address the epidemic of musculoskeletal trauma.Scalpel At The Cross (SATC) is a nonprofit Christian orthopaedic surgical mission organization that sends teams of 10 to 20 members to Pucallpa, Peru, a rural town in the Amazon, to evaluate patients with musculoskeletal conditions, many that require surgery. The organization employs 4 full-time staff members and has included over 400 medical volunteers in 32 surgical campaigns since 2005. SATC has provided approximately 8.1 million U.S. dollars in total medical care, while investing approximately 2.2 million U.S. dollars in implementation and overhead.Given the projected increase in trauma in low and middle-income countries, the SATC model may be increasingly relevant as a possible blueprint for other medical professionals to take on similar endeavors. This paper also highlights the importance of continued research into the effectiveness of various organizational models to advance surgical services in these countries.