The Institute for Global Orthopedics and Traumatology: A Model for Academic Collaboration in Orthopedic Surgery

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.

Complications and Revision Surgery in Orthopedics Focusing on Traumatology

BACKGROUND

Orthopedic traumatology, a vital component of orthopedic surgery, poses significant challenges in managing complications and necessitating revision surgeries. These challenges impact clinical outcomes, healthcare economics, and patient well-being.

OBJECTIVE

This study aimed to provide insights that informed clinical decision-making and improved patient outcomes by thoroughly examining the range of complications encountered in orthopedic traumatology. Specifically, the research focused on the indications, techniques, and outcomes of revision surgeries.

METHODOLOGY

This retrospective cohort research looked at orthopedic traumatology complications and revision procedures over a thorough two-year period from March 2021 to March 2023 at Hayatabad Medical Complex in Peshawar, Pakistan. The following information was gathered from 316 patients receiving orthopedic surgery for traumatic injuries: demographics, kinds of trauma, surgical methods, complications, indications, methods, and results of revision surgery. For data analysis, chi-square tests and descriptive statistics were used, with the goal of finding patterns and correlations within the research population.

RESULTS

The average age of the 316 patients was 42.5 years, and 64.76% of them were male (n = 192). The most frequent kind of trauma (n = 218; 69.01%) was fractures, which were mostly brought on by falls (n = 147; 46.52%). The most common surgical method (n = 138; 43.67%) was found to be internal fixation, which was followed by external fixation (n = 67; 21.20%). The most common complication (n = 78; 24.68%) was surgical site infection, which resulted in revision procedures mostly for infection (n = 68; 21.52%) and implant failure (n = 56; 17.72%). Debridement was the most often used revision approach (n = 95; 30.10%), and it was substantially correlated with surgical outcomes, such as increased function (31%) and full resolution (36%).

CONCLUSION

This research emphasizes the need to maximize patient outcomes for improved well-being and highlights the crucial role that careful care plays in managing complications and revision operations in orthopedic traumatology.

An Analysis of Participant Preferences Regarding Virtual Versus In-person Format of Orthopaedic Surgery Educational Materials in Low- and Middle-Income Countries

INTRODUCTION

The University of California, San Francisco Institute for Global Orthopaedics and Traumatology Surgical Management and Reconstructive Training (SMART) course has instructed orthopaedic surgeons from low-resource countries on soft-tissue reconstruction. Before the COVID-19 pandemic, the course was conducted in-person; however, it was transitioned to a virtual format during the pandemic. The aim of this study was to determine participant preferences regarding a virtual or in-person SMART course format.

METHODS

Survey data were collected via e-mail after each SMART course using RedCap or Qualtrics. Statistical analyses were conducted using Stata.

RESULTS

There were 247 survey respondents from 44 countries representing all world regions, with Africa (125, 51%) the most represented. Of those who attended both an in-person and virtual course, most (82%) preferred the in-person format. In addition, all measured course outcomes were significantly better for participants attending the in-person course. The most common reason for not attending an in-person course was the cost of travel (38, 51%).

DISCUSSION

This study demonstrated a preference toward in-person learning for the SMART course. In addition, those surgeons participating in the in-person course endorsed increased positive outcomes from the course. Increased emphasis should be placed on in-person surgical skills training for low-resource surgeons.

Reliability of artificial intelligence in predicting total knee arthroplasty component sizes: a systematic review

PURPOSE

This systematic review aimed to investigate the reliability of AI predictive models of intraoperative implant sizing in total knee arthroplasty (TKA).

METHODS

Four databases were searched from inception till July 2023 for original studies that studied the reliability of AI prediction in TKA. The primary outcome was the accuracy ± 1 size. This review was conducted per PRISMA guidelines, and the risk of bias was assessed using the MINORS criteria.

RESULTS

A total of four observational studies comprised of at least 34,547 patients were included in this review. A mean MINORS score of 11 out of 16 was assigned to the review. All included studies were published between 2021 and 2022, with a total of nine different AI algorithms reported. Among these AI models, the accuracy of TKA femoral component sizing prediction ranged from 88.3 to 99.7% within a deviation of one size, while tibial component sizing exhibited an accuracy ranging from 90 to 99.9% ± 1 size.

CONCLUSION

This study demonstrated the potential of AI as a valuable complement for planning TKA, exhibiting a satisfactory level of reliability in predicting TKA implant sizes. This predictive accuracy is comparable to that of the manual and digital templating techniques currently documented in the literature. However, future research is imperative to assess the impact of AI on patient care and cost-effectiveness.

LEVEL OF EVIDENCE III

PROSPERO registration number: CRD42023446868.

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.

Scientometric analysis of Indian Orthopaedic Research in the last two decades

PURPOSE

This study aimed to examine India's orthopaedic research output during 2002-2021 to analyze the research characteristics and publication performances of leading organizations, authors, and cities, the core journals publishing research, broad subject areas, sub-specialties, and the classification by anatomical location, the subject areas of research using major keywords and the sources of funding and the extent of international collaboration.

METHODS

India's orthopaedic publications data was identified and downloaded from the Scopus database ( https://www.scopus.com ) using a well-defined search strategy and keywords.

RESULTS

India's 4606 publications grew at a 20.8% annual growth rate and averaged 11.3 citations per paper. The 10.4% and 16.3% share of India's papers received external funded support and were involved in international collaboration. The USA and UK (31.8% and 21.3%) represent the highest collaborative share in India's international collaborative publications. AIIMS-New Delhi and PGIMER-Chandigarh produced a larger proportion of articles (5.2% and 4.3%) among contributing organizations. In terms of authors, R. Vaishya and S. Rajasekaran are the most productive ones, contributing 1.6% and 1.1% share respectively. Clinical studies, paediatric sub-specialty, and knee & leg anatomical location accounted for the largest share of papers (32.2%, 10.8%, and 7.5%).The most frequent keywords co-occurrences were "Orthopaedic Surgery," "Hydroxyapatite," "Biocompatibility," "Orthopaedic Procedures," "Bone," "Surgical Techniques," "Biomaterials," and "Osteosynthesis."

CONCLUSION

This study revealed the characteristics and trends of research and core publications from Indian authors and organizations identified in the last two decades. This research should provide useful insights into the research hotspots of India in the present, past, and future.

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.

A world away and here at home: a prioritisation framework for US international patient programmes

Programmes serving international patients are increasingly common throughout the USA. These programmes aim to expand access to resources and clinical expertise not readily available in the requesting patients' home country. However, they exist within the US healthcare system where domestic healthcare needs are unmet for many children. Focusing our analysis on US children's hospitals that have a societal mandate to provide medical care to a defined geographic population while simultaneously offering highly specialised healthcare services for the general population, we assume that, given their mandate, priority will be given to patients within their catchment area over other patients. We argue that beyond prioritising patients within their region and addressing inequities within US healthcare, US institutions should also provide care to children from countries where access to vital medical services is unavailable or deficient. In the paper, we raise and attempt to answer the following: (1) Do paediatric healthcare institutions have a duty to care for all children in need irrespective of their place of residence, including international patients? (2) If there is such a duty, how should this general duty be balanced against the special duty to serve children within a defined geographical area to which an institution is committed, when resources are strained? (3) Finally, how are institutional obligations manifest in paradigm cases involving international patients? We start with cases, evaluating clinical and contextual features as they inform the strength of ethical claim and priority for access. We then proceed to develop a general prioritisation framework based on them.

Pattern of Orthopedic Injuries Related to Road Traffic Accidents Among Patients Managed at the Emergency Department in Black Lion Hospital, Addis Ababa, Ethiopia, 2021

Background

Studies showed that each year people lose their life on the road and many people are disabled. The majority of this disability was caused by orthopedic injury related to road traffic accidents. However, in the context of Ethiopia, studies ascribed to orthopedic injuries related to road traffic accidents are limited. The study aimed to assess the pattern of orthopedic injuries related to road traffic accidents among patients managed at the emergency department of Black Lion Hospital.

Methods

An institutional-based cross-sectional study was conducted on 354 victims of road traffic accidents with orthopedic injuries who were visiting the Emergency department of Black Lion Hospital. Patient charts were selected by systematic random sampling technique and the data was entered into Epi-data version 4.4.2.2 and exported to the static package for social science window version 26, and descriptive statistics were used for analysis.

Results

The study reveals that males were mostly injured persons (71.7%) with the age group of 13-24 were the most injured. Passenger car accounts 36.3% of causes of injury followed by motorbikes (27.4%) and lower limbs were the most common anatomic site of injuries (47.9). Of all injury types, a fracture is the most common one with 71.1%, especially lower limb fracture (42.1%). More than half victims (59.5%) had open wounds, and almost half of the study subjects (51.8%) experience Road traffic accidents while they are crossing or walking along the way.

Conclusion

Orthopedic injuries related to road traffic accidents are the main cause of death and disability in many individuals, especially in reproductive age groups. Therefore, policy-makers should be aware of different patterns of orthopedic injuries associated with a victim of road traffic accidents to have an appropriate and sustainable capacity to manage the orthopedic injuries.

Collaborative healthcare education programmes for continuing professional education in low and middle-income countries: A Best Evidence Medical Education (BEME) systematic review. BEME Guide No. 65

BACKGROUND

Large discrepancies exist between standards of healthcare provision in high-income (HICs) and low and middle-income countries (LMICs). The root cause is often financial, resulting in poor infrastructure and under-resourced education and healthcare systems. Continuing professional education (CPE) programmes improve staff knowledge, skills, retention, and practice, but remain costly and rare in low-resource settings. One potential solution involves healthcare education collaborations between institutions in HICs and LMICs to provide culturally appropriate CPE in LMICs. To be effective, educational partnerships must address the challenges arising from differences in cultural norms, language, available technology and organisational structures within collaborating countries.

METHODS

Seven databases and other sources were systematically searched on 7 July 2020 for relevant studies. Citations, abstracts, and studies were screened and consensus was reached on which to include within the review. 54 studies were assessed regarding the type of educational programme involved, the nature of HIC/LMIC collaboration and quality of the study design.

RESULTS

Studies varied greatly regarding the types and numbers of healthcare professionals involved, pedagogical and delivery methods, and the ways in which collaboration was undertaken. Barriers and enablers of collaboration were identified and discussed. The key findings were: 1. The methodological quality of reporting in the studies was generally poor. 2. The way in which HIC/LMIC healthcare education collaboration is undertaken varies according to many factors, including what is to be delivered, the learner group, the context, and the resources available. 3. Western bias was a major barrier. 4. The key to developing successful collaborations was the quality, nature, and duration of the relationships between those involved.

CONCLUSION

This review provides insights into factors that underpin successful HIC/LMIC healthcare CPE collaborations and outlines inequities and quality issues in reporting.

COVID-19 and Orthopaedic International Humanitarianism

As the world continues to adjust to life with COVID-19, one topic that requires further thought and discussion is whether elective international medical volunteerism can continue, and, if so, what challenges will need to be addressed. During a pandemic, the medical community is attentive to controlling the disease outbreak, and most of the literature regarding physician involvement during a pandemic focuses primarily on physicians traveling to areas of need to help treat the disease. As a result, little has been written about medical volunteerism that focuses on medical treatment unrelated to the disease outbreak. In a world-wide pandemic, many factors are to be considered in determining whether, and when, a physician should travel to another region to provide care and training for medical issues not directly related to the pandemic.

Leaders of humanitarian committees of orthopaedic surgery subspecialties engaged with one another and host orthopaedic surgeons and a sponsoring organization to provide thoughtful insight and expert opinion on the challenges faced and possible pathways to provide continued orthopaedic support around the globe. Although this discussion focuses on international orthopaedic care, these suggestions may have a much broader application to the international medical community as a whole.

The Impact of Inadequate Soft-tissue Coverage following Severe Open Tibia Fractures in Tanzania

Managing lower extremity fractures complicated by large soft-tissue defects is challenging for surgeons in low- and middle-income countries, and long-term quality of life (QOL) for these patients is unclear.

METHODS

We examined QOL, surgical complications, and longitudinal outcomes in 10 patients with Gustilo-Anderson Classification Type IIIB open tibia fractures seen at an orthopedic institute in Tanzania, from December 2015 to March 2017. Patients completed follow-up at 2-, 6-, 12-, 26-, and 52-week time points, and returned for qualitative interviews at 2.5 years. The primary outcome was QOL, as measured using EuroQoL-5D scores and qualitative semi-structured interview responses. The secondary outcome was rate of complication, as defined by reoperation for deep infection or nonunion.

RESULTS

Ten patients enrolled in the study and 7 completed 1-year follow-up. All fractures were caused by road traffic accidents and treated by external fixation. No patients received initial soft-tissue (flap) coverage of the wound. All patients developed an infected nonunion. No patients returned to work at 6 weeks, 3 months, or 6 months. EQ-5D index scores at 1 year were poor (0.71 ± 0.09). Interview themes included ongoing medical complications, loss of employment, reduced income, and difficulty with activities of daily living.

CONCLUSIONS

Patients in low- and middle-income countries with IIIB open tibia fractures not treated with appropriate soft-tissue coverage experience poor QOL, high complication rates, and severe socioeconomic effects as a result of their injuries. These findings illustrate the need for resources and training to build capacity for extremity soft-tissue reconstruction in LMICs.

Motivations and impact of international rotations in low- and middle-income countries for orthopaedic surgery residents: Are we on the same page?

BACKGROUND

Despite interest among North American orthopaedic residents to pursue rotations in resource-limited settings, little is known regarding resident motivations and impact on host surgeons.

METHODS

Surveys were distributed to North American orthopaedic surgeons and trainees who participated in international rotations during residency to assess motivations for participation and to orthopaedic surgeons at partnering low- and middle-income country (LMIC) institutions to assess impact of visiting trainees.

RESULTS

Responses were received from 136 North American resident rotators and 51 LMIC host surgeons and trainees. North American respondents were motivated by a desire to increase surgical capacity at the LMIC while host surgeons reported a greater impact from learning from residents than on surgical capacity. Negative aspects reported by hosts included selfishness, lack of reciprocity, racial discrimination, competition for surgical experience, and resource burdens.

CONCLUSIONS

The motivations and impact of orthopaedic resident rotations in LMICs need to be aligned. Host perceptions and bidirectional educational exchange should be incorporated into partnership guidelines.

Resident Rotations in Low- and Middle-Income Countries: Motivations, Impact, and Host Perspectives

Interest in clinical rotations in low- and middle-income countries (LMICs) has grown among high-income country (HIC) orthopaedic residents. This study addresses the following questions: (1) What motivates HIC surgical residents to rotate in LMICs? (2) What is the impact of rotations on HIC residents? (3) What are the LMIC partner perceptions of HIC collaboration?

MATERIALS AND METHODS

A search strategy of multiple databases returned 3,740 unique articles pertaining to HIC surgical resident motivations for participating in rotations in LMICs or the LMIC host perspective. Data extraction was dually performed using meta-ethnography, the qualitative equivalent of meta-analysis.

RESULTS

Twenty-one studies were included in the final analysis. HIC residents were primarily motivated to rotate in LMICs by altruistic intent, with greatest impact on professional development. LMIC partners mostly valued HIC sustained investment and educational opportunities for LMIC partners. From LMIC's perspective, potential harm from collaboration arose from system-level and individual-level discordance between HIC and LMIC expectations and priorities. HIC priorities included the following: (1) adequate operative time, (2) exposure to varied pathology, and (3) mentorship. LMIC priorities included the following: (1) avoiding competition with HIC residents for surgical cases, (2) that HIC groups not undermine LMIC internal authority, (3) that HIC initiatives address local LMIC needs, and (4) that LMIC partners be included as authors on HIC research initiatives. Both HIC and LMIC partners raised ethical concerns regarding collaboration and perceived HIC residents to be underprepared for their LMIC rotation.

DISCUSSION

This study synthesizes the available literature on HIC surgical resident motivations for and impact of rotating in LMICs and the LMIC host perception of collaboration. Three improvement categories emerged: that residents (1) receive site-specific preparation before departure, (2) remain in country long enough to develop site-specific skills, and (3) cultivate flexibility and cultural humility. Specific suggestions based on synthesized data are offered for each concept and can serve as a foundation for mutually beneficial international electives in LMICs for HIC orthopaedic trainees.

Traumatic Spine Injury: Which Discrepancy Between the Research Output and the Actual Burden of the Disease?

OBJECTIVE

Traumatic spinal injury (TSI) is a global health issue contributing to morbidity and mortality, especially in low- and middle-income countries. The aim of this study is to compare the epidemiological estimates of TSI with the corresponding amount of published papers for different regions.

METHODS

A bibliometric analysis was performed by collecting the number of publications concerning TSI from the PubMed database. Results were sorted according to the different geographical World Health Organization regions. A "publication-to-volume ratio" was obtained by comparing the average number of documents per year with the number of TSI cases across each region.

RESULTS

A total of 2304 articles were detected from 2008 to 2018. The major publishing regions were North America (AMR-US/Can: 843 articles, 36.6%) and Europe (EUR: 833, 36.2%), then Western Pacific (WPR: 410, 17.8%), Eastern Mediterranean (EMR: 73, 3.2%), South-East Asia (SEAR: 71, 3.1%), Latin America (AMR-L: 55, 2.4%), Africa (AFR: 19, 0.8%). The United States is the most publishing country in AMR-US/Can (86.0%), and Germany in EUR (22.4%). In 2018, EUR published 36.6% of papers versus AMR-US/Can 26.5% and WPR 25.7%, thanks to an increase in Chinese publications. The highest publication ratios of 4.63 and 2.68 were found for AMR-US/Can and EUR, respectively. The other were EMR (0.22), WPR (0.18), AMR-L (0.07), SEAR (0.03), and AFR (0.01).

CONCLUSIONS

A marked divide is currently found between countries with a high burden of TSI and those where there is most research interest, estimated as amount of publications. Data demonstrate the need for increased inclusiveness in guidelines generation from high-income countries including collection and analysis from low- and middle-income countries.

Impact of North American Institutions on Orthopedic Research in Low- and Middle-Income Countries

There exists an unmet need for locally relevant and sustainable orthopedic research in low- and middle-income countries. Partnerships between high-income countries and low- and middle-income countries can bridge gaps in resources, knowledge, infrastructure, and skill. This article presents a select list of models for high-income countries/low- and middle-income countries research partnerships including academic partnerships, international research consortia, professional society-associated working groups, and nongovernmental organization partnerships. Models that produce research with lasting legacy are those that promote mutually beneficial partnerships over individual gains.

Knowledge deficits and barriers to performing soft-tissue coverage procedures: An analysis of participants in an orthopaedic surgical skills training course in Mexico

Background:

An increasing number of traumatic injuries in low- and low-middle-income countries (LICs/LMICs) have coexisting injuries requiring soft-tissue coverage (flaps). Yet, there is a lack of subspecialty care and flap training in Latin America. This study assesses the effectiveness of a surgical skills training course in improving rotational and free flap knowledge and identifies barriers to performing these types of flaps.

Methods:

Participants attending a surgical skills training course in Guadalajara, Mexico completed a pre/postcourse flaps knowledge survey consisting of 15 questions from the plastic surgery in-training examination and also completed a 7-point Likert survey regarding perceived barriers to performing flaps at their institution.

Results:

Of the course participants, 17 (44.7%) completed the precourse knowledge survey, 24 (63.2%) completed the postcourse survey, and 37 (97.4%) completed the barriers survey. Scores improved from pre- to postcourse knowledge surveys (39.6% to 53.6%, P = .005). Plastic surgery subsection scores also improved (39.0% to 60.4%, P = .003). Twenty-five percent of attendees received prior flap training and had plastic surgeons available to perform flaps. Few participants (38.9%) reported flap procedures being commonly completed at their hospitals. Participants stating that flaps were uncommon in their hospital reported more institutional barriers and less access to dermatomes. These participants also reported lack of operating room and surgical personnel availability.

Conclusion:

A surgical skills training course may be useful in improving knowledge of soft-tissue coverage procedures. There are also modifiable physician and institutional barriers that can improve the ability to perform rotational and free flaps as identified by the course participants.

Is Insurance Status Associated with the Likelihood of Operative Treatment of Clavicle Fractures?

BACKGROUND

Most closed clavicle fractures are treated nonoperatively. Research during the past decade has reported differences in the treatment of clavicle fractures based on insurance status in the US and may highlight unmet needs in a vulnerable population, particularly because new data show that surgery may lead to improved outcomes in select populations. Large-scale, national data are needed to better inform this debate.

QUESTIONS/PURPOSES

(1) Does the likelihood of operative fixation of closed clavicle fractures vary among patients with different types of insurance? (2) What demographic and socioeconomic factors are associated with the likelihood of clavicle fracture surgery? (3) Has the proportion of operative fixation of clavicle fractures changed over time?

METHODS

A retrospective analysis of the Nationwide Inpatient Sample 2001-2013 database was performed. This database is the largest publicly available all-payer inpatient database in the US that provides pertinent socioeconomic data on a nationwide scale. Data were queried for patients with closed clavicle fractures using International Classification of Diseases, Ninth Revision (ICD-9) diagnostic codes, and surgery was determined using ICD-9 procedural codes. A total of 252,109 patients were included in the final analysis after 158,619 patients were excluded because of missing demographic or insurance data, ambiguous fracture location, or age younger than 19 years. Of the 252,109 included patients, 21,638 (9%) underwent surgical fixation of clavicle fractures. A chi-square analysis was performed to determine variables to be included in a multivariable analysis. A binary logistic regression analysis was used to examine demographic and other important variables, with a significance level of p < 0.01. Poisson's regression and a t-test were used to analyze trends over time. Results were recorded as odds ratios (OR) and incidence rate ratios.

RESULTS

After controlling for demographic and potentially relevant variables, such as the median income and fracture location, we found that patients with Medicare, Medicaid, and no insurance had a lower likelihood of undergoing operative fixation of clavicle fractures than did those with private insurance. Patients without insurance were the least likely to undergo surgery (OR, 0.63; 95% CI, 0.60-0.66; p < 0.001), followed by those with Medicare (OR, 0.73; 95% CI, 0.70-0.78; p < 0.001) and those with Medicaid (OR, 0.74; 95% CI, 0.69-0.78; p < 0.001). Women, black, and Hispanic patients were also less likely to undergo surgery than men and white patients (OR, 0.95; p = 0.003; OR = 0.67; p < 0.001; and OR = 0.82; p < 0.001, respectively) There was an increase in the overall proportion of patients undergoing surgery, from 5% in 2001 to 11% in 2013 (incidence rate ratio, 2.99; p < 0.001).

CONCLUSIONS

We believe that the greater use of surgery among adult patients with clavicle fractures who have private insurance than among those with nonprivate or no insurance-as well as among men and white patients compared with women and patients of color-may be a manifestation of important health care disparities in the inpatient population. This may be owing to variable access to care or a difference in the likelihood that a surgeon will offer surgery based on a patient's insurance status. Because operative fixation of closed clavicle fractures increases in the adult population, future research should elucidate conscious and subconscious motivations of patients and surgeons to better inform the discussion of health care disparities in orthopaedics.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Orthopaedic Trauma in Low-resource Settings: Measuring Value

There is increasing recognition of both the impact and value of trauma care in low- and middle-income countries (LMICs). However, data supporting the value of musculoskeletal trauma care specifically are lacking. This review discusses methods of economic analysis relevant to low-resource settings and provides a review of cost studies related to orthopaedic trauma care in these settings. In general, microcosting methods are preferred in LMICs because of the lack of databases with aggregate cost data. It is important that studies use a societal perspective that includes the indirect costs of treatment in addition to direct costs of medical care. Cost-effectiveness studies most commonly report cost per disability-adjusted life year, particularly in LMICs, but quality-adjusted life years are an acceptable alternative that is based on more empiric data. There are solid economic data supporting potential cost savings and improved outcomes with intramedullary nailing for femoral shaft fractures. Trauma care hospitals and educational initiatives have also been found to be highly cost-effective. However, very little data exist to support other interventions in orthopaedic trauma. Orthopaedic surgeons should strive to understand these methodologies and support the conduct of rigorous economic analysis to better establish the value of musculoskeletal trauma care in LMICs.

Barriers to Performing Soft Tissue Reconstruction Procedures among Orthopedic Surgeons in Low- and Middle-income Countries: Results of a Surgical Skills Training Course

Appropriate management of soft tissue injury associated with orthopedic trauma is challenging in low- and middle-income countries (LMICs) due to the lack of available reconstructive surgeons. The Surgical Management and Reconstructive Training (SMART) course teaches orthopedic surgeons reconstructive techniques aimed at improving soft tissue management. This study aims to identify additional barriers to implementing these techniques for surgeons in LMICs who have attended SMART courses.

The physical, psychological and social impact of long bone fractures on adults: A review

Background

Long bone fractures are common injuries caused by trauma and are a common cause for referral to hospitals. Little consideration has been given to the impact of long bone fractures in adults despite the World Health Organization’s statement that such injuries cause substantial morbidity in low- and middle-income countries.

Aim

This review targeted published studies conducted from 1990 to 2017 that examined the impact of long bone fractures on the psychological, social, financial, occupational and physical health of adults.

Method

This scoping review involved a systematic literature search using key terms in Science Direct, Cochrane Library, BMJ Online, PubMed, Jstor, SpringerLink, Emerald Insight and Ebscohost Research databases and Google Scholar.

Results

From a total of 297 publications, 19 met the inclusion criteria: four publications focused on the impact of fractures of the humerus, one publication looked at ulna fractures, six publications focused on distal radius fractures, five looked at femur fractures and three focused on tibial fractures.

Conclusion

Long bone fractures have a considerable impact on many facets of a patient’s life. In some cases, the fracture prevents patients from working and meeting financial obligations. The injury limited previously normal social interactions and pre-injury functioning. Future research should examine the impact of long bone fractures in Africa, as there were very limited studies, which were identified.

Availability of global health opportunities in North American Paediatric Orthopaedic Fellowship Programmes

PURPOSE

Orthopaedic residents are increasingly seeking international health electives (IHEs) during training, many of which involve providing paediatric orthopaedic care. However, little is known about the availability of IHEs during orthopaedic fellowship training. Our study sought to assess the global health opportunities available to North American paediatric orthopaedic fellows.

METHODS

We conducted an online, REDCap-based survey of paediatric orthopaedic fellowship programme directors (PDs) in the United States and Canada. The survey link was sent by the Pediatric Orthopaedic Society of North America (POSNA) Evidence-Based Medicine Committee to all POSNA-approved paediatric orthopaedic fellowship PDs. Follow-up reminder emails were delivered at set time intervals.

RESULTS

The overall response rate was 55% (26/47). Only three of 26 responding programmes (11.5%) offered a structured global health programme but 42.3% of programmes (11/26) reported fellow IHE participation within the last ten years. In all, 91% of PDs reported that fellows were extremely satisfied with their IHE, and 91% agreed that IHEs are valuable for trainees. Perceived barriers to fellow participation in IHEs included lack of funding, lack of established partner sites, lack of interest among fellows and concerns related to time away compromising clinical/call coverage. In all, 65.4% of PDs agree that IHE participation during training plays a major role in shaping fellows' future volunteer activities.

CONCLUSION

There are limited global health opportunities among North American paediatric orthopaedic fellowship programmes, with only 11.5% offering a structured global health programme. Greater efforts to establish sustainable funding and international partnerships may increase opportunities for IHEs during paediatric orthopaedic fellowship training.

LEVEL OF EVIDENCE

Level II.

Consortium of Orthopaedic Academic Traumatologists: A Model for Collaboration in Orthopaedic Surgery

In March 2016, North American academic leaders with an interest in and commitment to the field of global orthopaedics met in Orlando, Florida, to gauge each institution's clinical, research, and educational programs in developing countries, establish the main limitations to participating in global health efforts, and assess areas of need for both the participating institutions and their international partners. After this inaugural meeting, a needs assessment survey was distributed to the group to better understand how to organize and unify the individual institutional global efforts. The results revealed that surgeons believed there was a vital need for improved communication, mentorship, and infrastructural support between North American universities. To this end, the Consortium of Orthopaedic Academic Traumatologists (COACT) was founded. The COACT seeks to promote a novel framework geared toward improving trauma care capacity by building collaborative partnerships among leading academic centers across the United States and Canada. The consortium represents a comprehensive partnership that promotes communication, collaboration, and advocacy through a central network to facilitate investigative, educational, and clinical services. Academic partners share best practices, resources, and opportunities in their international outreach projects in low- and middle-income countries in the field of orthopaedic trauma. Over the course of the past 2 years, the COACT has grown to more than 80 faculty, fellow, resident, and student members, representing over 20 orthopaedic institutions across North America.

Pediatric Trauma Care in Low Resource Settings: Challenges, Opportunities, and Solutions

Trauma constitutes a significant cause of death and disability globally. The vast majority -about 95%, of the 5.8 million deaths each year, occur in low-and-middle-income countries (LMICs) 3-6. This includes almost 1 million children. The resource-adapted introduction of trauma care protocols, regionalized care and the growth specialized centers for trauma care within each LMIC are key to improved outcomes and the lowering of trauma-related morbidity and mortality globally. Resource limitations in LMICs make it necessary to develop injury prevention strategies and optimize the use of locally available resources when injury prevention measures fail. This will lead to the achievement of the best possible outcomes for critically ill and injured children. A commitment by the governments in LMICs working alone or in collaboration with international non-governmental organizations (NGOs) to provide adequate healthcare to their citizens is also crucial to improved survival after major trauma. The increase in global conflicts also has significantly deleterious effects on children, and governments and international organizations like the United Nations have a significant role to play in reducing these. This review details the evaluation and management of traumatic injuries in pediatric patients and gives some recommendations for improvements to trauma care in LMICs.

Surgical Navigation in Orthopedics: Workflow and System Review

Orthopedic surgery is a widely performed clinical procedure that deals with problems in relation to the bones, joints, and ligaments of the human body, such as musculoskeletal trauma, spine diseases, sports injuries, degenerative diseases, infections, tumors, and congenital disorders. Surgical navigation is generally recognized as the next generation technology of orthopedic surgery. The development of orthopedic navigation systems aims to analyze pre-, intra- and/or postoperative data in multiple modalities and provide an augmented reality 3-D visualization environment to improve clinical outcomes of surgical orthopedic procedures. This chapter investigates surgical navigation techniques and systems that are currently available in orthopedic procedures. In particular, optical tracking, electromagnetic localizers and stereoscopic vision, as well as commercialized orthopedic navigation systems are thoroughly discussed. Moreover, advances and development trends in orthopedic navigation are also discussed in this chapter. While current orthopedic navigation systems enable surgeons to make precise decisions in the operating room by integrating surgical planning, instrument tracking, and intraoperative imaging, it still remains an active research field which provides orthopedists with various technical disciplines, e.g., medical imaging, computer science, sensor technology, and robotics, to further develop current orthopedic navigation methods and systems.