Characterizing Physical Intimate Partner Violence-Associated Injuries Among Adults in Low- and Middle-Income Countries: A Systematic Review.

Forty-two percent of women who experienced intimate partner violence (IPV) reported that their experience of IPV resulted in an injury. This review aims to review the existing literature from low- and middle-income countries (LMICs) on IPV-related injuries as well as identify IPV-related injury patterns and locations. A systematic electronic database search was conducted between August and September 2021 (Prospero ID: CRD42021281519). Five databases yielded 408 articles; 328 remained for title and abstract screening after duplicates were removed. Of the 59 eligible for full-text review, 19 articles were eligible for extraction. After quality assessment, 18 articles were included in the study. Most (56%) studies were observational studies. Studies represented 15 different countries. The majority of the studies (89%) had authors whose institutional affiliation was located in the country where the study took place. Soft tissue injuries were the most commonly reported injury type followed by fractures and burns. The most common injury locations were the head, neck, and face followed by both upper and lower limbs. The most commonly cited injury mechanism was bodily force. The findings of this study echo what has been written in the literature regarding IPV-related injury patterns from high-income countries (HICs). One limitation of this study is that the search only included literature published in English. The injury patterns identified in this article confirm the need for awareness and action on the part of both medical and surgical providers in order to best address IPV in LMICs.

The Current State of International Academic Partnerships in Orthopaedic Surgery Between High-Income and Low and Middle-Income Countries: A Systematic Review.

Background: Orthopaedic academic partnerships between high-income countries (HICs) and low and middle-income countries (LMICs) are an effective method to increase research and scholarly support. The purpose of this study was to perform a systematic literature review of the current state of partnerships worldwide and assess the quality, quantity, and content of their research output. Methods: A systematic review was conducted using 4 academic databases: PubMed, MEDLINE, Embase, and CENTRAL. Article eligibility criteria included articles published between January 2017 and 2022, with orthopaedic authors from at least 1 HIC and LMIC. Articles related to global orthopaedic surgery with exclusively HIC or LMIC authors were excluded. Results: The database search yielded 25,928 articles, and after deduplication, 21,145 articles were included in the screening. After title and abstract screening, 408 articles underwent full-text review for eligibility. The final list of eligible articles for extraction included 310 publications in 127 journals. Published articles increased over time (46 in 2017 to 88 in 2021) and were most commonly published in the Journal of Bone and Joint Surgery (20, 6.5%). Open-access articles (203, 65.5%) had a significantly greater Journal Citation Indicator (p = 0.024) than non-open-access articles. Most studies (40.7%) were observational, with few (3.6%) randomized controlled trials. Orthopaedic trauma (38.1%) was the most common subspecialty, followed by spine (14.8%) and pediatrics (14.2%). Most partnerships were sponsored by North American authors in 65 LMICs, primarily China, India, and the sub-Saharan African region. Conclusion: This study identified 310 articles published by orthopaedic international academic partnerships in 106 countries over the past 5 years, demonstrating that collaborations between LMIC/HIC partners nearly doubled over the study period. Sixty-five percent of the articles were published in open-access journals.

Critical elements of international academic partnerships in orthopaedic surgery: a modified Delphi approach.

Background: Despite the recent emphasis on promoting international collaborations within orthopaedic surgery, criteria for determining the strengths of such partnerships has not been established. The purpose of this study was to evaluate orthopaedic experts' perceptions of the most valuable characteristics of international academic partnerships. Methods: This study was conducted using a modified Delphi methodology. Experts were identified through the Consortium of Orthopaedic Academic Traumatologists (COACT). Responses were collected from February to September 2022. Three rounds of surveys listing possible topics on a 5-point Likert scale were used to develop consensus among a group of experts. Consensus criteria for topic inclusion in the final scale was determined as a rating of "strongly agree" or "agree" by ≥70% of the participants in the third survey. Results: The Round 1 survey was distributed to 96 invited participants within the COACT network, of which 50 experts (52.1%) completed the first survey. Consensus was reached on 54 topics organized into the following 5 categories: Research, Advocacy/Leadership, Training/Surgical Skills, Education/Knowledge Exchange, and Sustainability and Safety (RATES Criteria). Conclusions: Determining the most valuable characteristics of successful international academic partnerships can lead to more sustainable, mutually beneficial collaborations. The criteria identified in this study can provide the foundation for developing new partnerships and assessing existing ones.

Predictors of quality of life, economic impact, and loss to follow-up after open tibial shaft fractures in Ghana.

Objectives: Open tibia fractures are associated with substantial morbidity and impact on quality of life. Despite increasing incidence in low-resource settings, most open tibia fracture research comes from high-resource settings. This study aimed to assess the impact of socioeconomic status on treatment modality and evaluate predictors of health-related quality of life following open tibia fractures in Ghana. Design: A single-center prospective observational study was conducted in Kumasi, Ghana, from May 2020 to April 2022. Adults with open tibial shaft fractures presenting within 2 weeks of injury were eligible. Demographics, comorbidities, socioeconomic factors, and hospital course were collected at enrollment. Follow-up was scheduled at 8, 12, 26, and 52 weeks. A telephone survey assessing reasons for loss to follow-up was initiated on enrollment completion. Results: A total of 180 patients were enrolled. Most patients were employed before injury (79.9%), had government insurance (67.2%), and were from rural areas (59.4%). Fracture classification was primarily Gustilo-Anderson type 3A (49.1%). No relationship between socioeconomic predictors and treatment modality was identified. The largest barriers to follow-up were preference for bonesetter treatment (63.1%), treatment cost (48.8%), and travel cost (29.8%). Of the lost to follow-up patients contacted, 67 (79.8%) reported receiving traditional bonesetter care. Reasons for seeking traditional bonesetter care included ease of access (83.6%), lower cost (77.6%), and familial influence (50.7%). Conclusion: No association was identified between socioeconomic predictors and choice of treatment. Bonesetter treatment plays a substantial role in the care of open tibia fractures in Ghana, largely because of ease of access and lower cost.

The economic impact of infection and/or nonunion on long-bone shaft fractures: a systematic review.

Background: Long-bone fractures are a major cause of morbidity worldwide. These injuries are often complicated by infection or nonunion, which significantly affect patient quality of life and economic costs. Although studies have quantified the impact of these fractures, there is not a comprehensive review summarizing their economic and lifestyle costs. Study Objective: This review summarized the impact of long-bone fracture infection and nonunion on health-related quality of life, as measured by utility scores, and both direct and indirect economic costs. Methods: A systematic review was conducted using the following databases: PubMed, EMBASE, Web of Science, and the Cochrane Library. The search included terms related to long-bone fractures, infection, nonunion, cost, and utility. The search yielded 1267 articles, and after deduplication, 1144 were screened, yielding 116 articles for full-text review. Screening was conducted using Covidence and extraction using REDCap. Results: Twenty-two articles met inclusion criteria, with the majority being from the United States and Europe. Most articles were retrospective studies, predominantly regarding the tibia. Fifteen articles contained cost data and 8 contained utility data, with 1 article containing both. Ten cost articles and 1 utility article contained infection data. 8 cost and all utility articles contained nonunion data. Infection ranged from 1.5 to 8.0 times the cost of an uncomplicated fracture. Nonunion ranged from 2.6 to 4.3 times the cost of an uncomplicated fracture. Utility data were variable and ranged from 0.62 to 0.66 for infection and 0.48-0.85 for nonunion. Conclusions: Infection and nonunion after long-bone fractures are associated with large decreases in health-related quality of life and incur substantial costs to both patients and health care systems. The data presented in this review quantify these impacts and may serve useful for future economic analyses. In addition, this study highlights the dearth of high-quality literature on this important topic.

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.

Estimating the economic impact of complications after open tibial fracture: A secondary analysis of the pilot Gentamicin Open Tibia trial (pGO-Tibia).

Objectives: To estimate the indirect economic impact of tibial fractures and their associated adverse events (AEs) in Tanzania. Design: A secondary analysis of the pilot Gentamicin Open (pGO)-Tibia randomized control trial estimating the indirect economic impact of suffering an AE, defined as a fracture-related infection (FRI) and/or nonunion, after an open tibial fracture in Tanzania. Setting: The pGO-Tibia trial was conducted from November 2019 to August 2021 at the Muhimbili Orthopaedic Institute in Dar es Salaam, Tanzania. Patients/Participants: One hundred adults with open tibial shaft fractures participated in this study. Intervention: Work hours were compared between AE groups. Cost data were analyzed using a weighted-average hourly wage and converted into purchasing power parity-adjusted USD. Main Outcome Measurements: Indirect economic impact was analyzed from the perspective of return to work (RTW), lost productivity, and other indirect economic and household costs. RTW was analyzed using a survival analysis. Results: Half of patients returned to work at 1-year follow-up, with those experiencing an AE having a significantly lower rate of RTW. Lost productivity was nearly double for those experiencing an AE. There was a significant difference in the mean outside health care costs between groups. The total mean indirect cost was $2385 with an AE, representing 92% of mean annual income and an increase of $1195 compared with no AE. There were significantly more patients with an AE who endorsed difficulty affording household expenses postinjury and who borrowed money to pay for their medical expenses. Conclusions: This study identified serious economic burden after tibial fractures, with significant differences in total indirect cost between those with and without an AE. Level of Evidence: II.

Using Artificial Intelligence for Rheumatic Heart Disease Detection by Echocardiography: Focus on Mitral Regurgitation.

BACKGROUND: Identification of children with latent rheumatic heart disease (RHD) by echocardiography, before onset of symptoms, provides an opportunity to initiate secondary prophylaxis and prevent disease progression. There have been limited artificial intelligence studies published assessing the potential of machine learning to detect and analyze mitral regurgitation or to detect the presence of RHD on standard portable echocardiograms. METHODS AND RESULTS: We used 511 echocardiograms in children, focusing on color Doppler images of the mitral valve. Echocardiograms were independently reviewed by an expert adjudication panel. Among 511 cases, 229 were normal, and 282 had RHD. Our automated method included harmonization of echocardiograms to localize the left atrium during systole using convolutional neural networks and RHD detection using mitral regurgitation jet analysis and deep learning models with an attention mechanism. We identified the correct view with an average accuracy of 0.99 and the correct systolic frame with an average accuracy of 0.94 (apical) and 0.93 (parasternal long axis). It localized the left atrium with an average Dice coefficient of 0.88 (apical) and 0.9 (parasternal long axis). Maximum mitral regurgitation jet measurements were similar to expert manual measurements (P value=0.83) and a 9-feature mitral regurgitation analysis showed an area under the receiver operating characteristics curve of 0.93, precision of 0.83, recall of 0.92, and F1 score of 0.87. Our deep learning model showed an area under the receiver operating characteristics curve of 0.84, precision of 0.78, recall of 0.98, and F1 score of 0.87. CONCLUSIONS: Artificial intelligence has the potential to detect RHD as accurately as expert cardiologists and to improve with more data. These innovative approaches hold promise to scale echocardiography screening for RHD.

Cutaneous Histiocytosis in an Eastern Gray Squirrel (Sciurus carolinensis).

A free-ranging Eastern gray squirrel (Sciurus carolinensis) was presented for ulcerated cutaneous masses at the base of both pinnae in July 2021. Diagnosis of cutaneous histiocytosis was achieved by histologic and immunohistochemical examination of one excised mass and supported by spontaneous resolution of the contralateral mass before the squirrel's release.

Combined Anterior Thoracic Vertebral Body Tethering and Posterior Lumbar Tethering Results in Quicker Return to Sport and Activity Compared to Posterior Spinal Instrumented Fusion in Patients with Adolescent Idiopathic Scoliosis.

STUDY DESIGN: Retrospective comparative study. OBJECTIVE: To compare patient-reported physical activity between anterior thoracic vertebral body tethering and posterior lumbar spine tethering (ATVBT/PLST) and posterior spinal instrumentation and fusion (PSIF) with minimum 2 year follow-up. METHODS: Consecutive skeletally immature patients with idiopathic scoliosis and a thoracic and lumbar curve magnitude ≥40° who underwent either ATVBT/PLST or PSIF from 2015-2019 were included. The primary outcome was rate of returning to sport. Secondary outcomes included ability to bend and satisfaction with sport performance as well as weeks until return to sport, school, physical education (PE) classes, and running. RESULTS: Ten patients underwent ATVBT/PLST and 12 underwent PSIF. ATVBT/PLST patients reported significantly faster return to sport (13.5 weeks vs 27.9 weeks, P = .04), running (13.3 weeks vs 28.8 weeks, P = .02), and PE class (12.6 weeks vs 26.2 weeks, P = .04) compared to PSIF patients. ATVBT/PLST patients reported that they had to give up activities due to their ability to bend at lower rates than PSIF patients while reporting "no changes" in their ability to bend after surgery at higher rates than PSIF patients (0% vs 4% giving up activities and 70% vs 0% reporting no changes in bending ability for ATVBT/PLST and PSIF, respectively, P = .01). Compared to PSIF patients, ATVBT/PLST patients experienced less main thoracic and thoracolumbar/lumbar curve correction at most recent follow-up (thoracic: 41 ± 19% vs 69 ± 18%, P = .001; thoracolumbar/lumbar: 59 ± 25% vs 78 ± 15%, P = .02). No significant differences in the number of revision surgeries were observed between ATVBT/PLST and PSIF patients (4 (40%) and 1 (8%) for ATVBT/PLST and PSIF, respectively, P = .221). CONCLUSIONS: ATVBT/PLST patients reported significantly faster rates of returning to sport, running, and PE. In addition, ATVBT/PLST patients were less likely to have to give up activities due to bending ability after surgery and reported no changes in their ability to bend after surgery more frequently than PSIF patients. However, the overall rate of return to the same or higher level of sport participation was high amongst both groups, with no significant difference observed between ATVBT/PLST and PSIF patients.

Best Practices for Developing International Academic Partnerships in Orthopaedics.

ABSTRACT: Traumatic and nontraumatic orthopaedic conditions are major contributors to global morbidity and account for the majority of life-years lived with disability worldwide. Additionally, the burden of musculoskeletal injuries has increased substantially over the past 3 decades. Unfortunately, in low and middle-income countries (LMICs), access to orthopaedic care is limited, leading to a disproportionate burden of disease. The Lancet Commission on Global Surgery has emphasized the urgent need for unified international commitment and research collaboration to achieve universal access to safe and affordable surgical care. However, conducting high-quality orthopaedic research in LMICs remains challenging as a result of disparities in training, access to resources, infrastructure, and equipment availability. Partnerships between high-income countries (HICs) and LMICs have emerged in recent decades as an effective approach to combatting some of these challenges. These partnerships aim to bridge the gaps by facilitating collaborative research and knowledge exchange. The establishment of successful partnerships requires a collaborative and reciprocal approach that starts with a clear understanding of mutual research aims and the availability of resources. Despite the potential benefits, various factors can make establishing such partnerships difficult. However, these partnerships can have a substantial impact in delivering quality orthopaedic education and research training, thus improving access to care in resource-limited environments. This paper represents the collaborative effort of multiple international academic orthopaedic surgeons with extensive experience in HIC-LMIC partnerships. Our aims were to outline the best practices for conducting orthopaedic research within these relationships and to provide guidance for future successful collaborations.

Responses to Reduced Feeding Frequency in Captive-Born Cheetahs (Acinonyx jubatus): Implications for Behavioural and Physiological Stress and Gastrointestinal Health.

Unnatural diet composition and frequent feeding regimes may play an aetiological role in the multiple diseases prevalent in captive cheetahs. This study investigated the responses of captive-born (hand-reared) cheetahs (n = 6) to a reduced feeding frequency schedule distinguished by offering larger quantities of food less frequently. The study cheetahs were fed four once-daily meals per week during the 3-week treatment period, followed by a 3-week control period in which they were fed two daily rations six days a week. Total weekly food intake was maintained throughout the study. Variations in behaviour, faecal consistency score (FCS), and faecal glucocorticoid metabolite concentration were measured. Less frequent feeding resulted in higher FCS (p < 0.01) and locomotory behaviour (p < 0.05) among the studied cheetahs. Faecal glucocorticoid metabolite concentration demonstrated an initial acute stress response to the change in feeding frequency (p < 0.05) and subsequent adaptation. The results of the FCS analysis suggest that the more natural feeding pattern could have benefited the studied cheetahs' gastrointestinal health without a significant behavioural or physiological stress response overall to the change in feeding frequency.

A pilot, masked, randomized controlled trial to evaluate local gentamicin versus saline in open tibial fractures (pGO-Tibia).

Background: Open tibial fractures have a high risk of infection that can lead to severe morbidity. Antibiotics administered locally at the site of the open wound are a potentially effective preventive measure, but there are limited data evaluating aminoglycoside antibiotics. The objective of this study was to assess the feasibility of a clinical trial to test the efficacy of local gentamicin in reducing the risk of fracture-related infection after open tibial fracture. Methods: This study is a single-center, pilot, masked, randomized controlled trial conducted at the Muhimbili Orthopaedic Institute. Participants were randomized intraoperatively after wound closure to receive gentamicin solution or normal saline solution injected at the fracture site. Follow-ups were completed at 2 weeks, 6 weeks, 3 months, 6 months, 9 months, and 1 year postoperatively. The primary feasibility outcomes were the rate of enrollment and retention. The primary clinical outcome was the occurrence of fracture-related infection. Results: Of 199 patients screened, 100 eligible patients were successfully enrolled and randomized over 9 months (11.1 patients/month). Complete data were recorded at baseline and follow-up for >95% of cases. The rate of follow-up at 6 weeks, 3 months, 6 months, 9 months, and 1 year were 70%, 68%, 69%, 61%, and 80%, respectively. There was no difference in adverse events or any of the measured primary and secondary outcomes. Conclusion: This pilot study is among the first to evaluate locally administered gentamicin in open tibial fractures. Results indicate a rigorous clinical trial with acceptable rates of enrollment and follow-up to address this topic is possible in this setting.

Sarcina sp. as a presumptive cause of fatal acute gastric dilation and gastric emphysema in rhesus macaques.

A 4-y-old female and 3-y-old male rhesus macaque (Macaca mulatta), both housed in the same facility, died unexpectedly within 2 wk. Postmortem examination revealed severe gastric dilation in both macaques and gastric emphysema in the female macaque. Histologically, bacteria consistent with Sarcina sp. were present in both macaques within the lungs and lumen of the trachea, esophagus, and gastrointestinal (GI) tract without associated inflammation. Additionally, in the female macaque, the bacteria were found in the gastric mucosa and associated with emphysematous spaces in the gastric wall without associated inflammation. PCR and Sanger sequencing of amplicons were subsequently performed on GI contents and non-alimentary tissues from the 2 affected monkeys and on comparative samples from unaffected rhesus monkeys in the same facility and an adjacent primate facility. The cases were compared using the 2-tailed Fisher exact test (p-value at 95% confidence). PCR identified Sarcina in GI contents of both affected and unaffected monkeys (p = 0.6084) and in non-alimentary tissues of affected monkeys only (p = 0.0083). These results suggest that the presence of Sarcina sp. in non-alimentary tissues is associated with gastric distension, gas accumulation, and unexpected death in nonhuman primates.

Predictors of nonunion for transverse femoral shaft fractures treated with intramedullary nailing: a SIGN database study.

Introduction: Nonunion is a common postfracture complication resulting in decreased quality of life for patients in resource-limited settings. This study aims to determine how age, sex, injury mechanism, and surgical intervention affect the rate of nonunion in transverse femur fractures treated with a SIGN intramedullary nail (IMN). Methods: A retrospective study was conducted using the SIGN online surgical database. All patients older than 16 years with simple transverse (<30 degrees), open or closed, femur fractures treated using a SIGN IMN between 2007 and 2021 were included. Our primary outcome of nonunion was measured with the modified Radiographic Union Scale for Tibial fractures (mRUST); scores ≤9 of 16 defined nonunion. The secondary outcome was squat depth. Outcomes were evaluated at follow-up appointments between 240 and 365 days postoperatively. Univariate and multivariate analysis were used for statistical comparison. Results: Inclusion criteria were met for 182 patients. The overall radiographic union rate was 61.0%, and a high proportion (84.4%) of patients could squat with their hips at or below the level of their knees. Older age, retrograde approach, and fracture distraction were associated with nonunion, but sex, injury mechanism, and other surgical variables were not. Conclusion: Poor reduction with fracture distraction was associated with a higher rate of nonunion. Loss of follow-up may have contributed to our overall union rate; however, we observed high rates of functional healing using the SIGN IMN. Level of evidence: IV.

Epidemiology of Ankle Dislocations in the United States: 2009 to 2018.

BACKGROUND: Injuries to the ankle joint are common and often sustained during participation in athletic activities. There is little information regarding the overall epidemiology of ankle dislocation, both with and without associated fracture. DESIGN AND METHODS: The National Electronic Injury Surveillance System (NEISS) database was queried to characterize ankle dislocation presentations to U.S. Emergency Departments (ED) from 2009-2018. Ankle dislocations were analyzed by age, sex, mechanism, and race. RESULTS: From 2009-2018, 30,477 patients with ankle dislocations presented to U.S. EDs with a majority (59.8%) occurring in male patients. The overall incidence of ankle dislocations increased by 54% from 2009-2018 (p = 0.017). Over half (53%) of ankle dislocations occurred in association with sports. Ankle dislocations peaked in the third decade of life at 16.94 per million person-years. For male, the age at which ankle dislocation peaked was 33.33, whereas for females, ankle dislocations peaked at 39.27. CONCLUSION: Preventive strategies are necessary to decrease the risk of sustaining ankle dislocations in the adult population participating in jumping sports.

Novel e-learning platform for orthopaedic training in LMICs: A descriptive review of the IGOT portal.

Background: While e-learning has been written about extensively within the context of orthopaedics in the United States, there are few articles describing e-learning initiatives geared towards low-and middle-income countries (LMICs). The Institute for Global Orthopaedics and Traumatology (IGOT) at the University of California, San Francisco (UCSF) developed the IGOT Learning Portal to meet this need. Methods: The IGOT Learning Portal was designed to address knowledge gaps in patient care by increasing access to high-quality orthopaedic education for surgeons and trainees worldwide. It offers 10 distinct, asynchronous courses, which are divided into a modular format. Course enrollment is free and accessible to any surgeon or trainee with a web-browsing capable device and internet connection. Results: There are more than 2700 registered users and 300 active learners enrolled in IGOT Learning Portal courses. The Surgical Management and Reconstructive Training (SMART) program is the most commonly taken course. Learners represent 32 different countries across six continents. The IGOT portal also has surgical videos available on YouTube. The IGOT Portal YouTube channel has over 2000 subscribers and over 143,000 total views. Conclusions: The IGOT Learning Portal is an innovative approach to address the global disparity in orthopaedic trauma care by improving access to high-quality surgical education for surgeons and trainees both in the US and internationally. The development of an interactive online forum may be a beneficial addition to the Portal. Future directions include assessing content retention, participant interaction, and expanding existing content to other orthopaedic subspecialties.

Simple design and analysis strategies for solving problems in observational orthopaedic clinical research.

Randomized controlled trials are the gold standard to establishing causal relationships in clinical research. However, these studies are expensive and time consuming to conduct. This article aims to provide orthopaedic surgeons and clinical researchers with methodology to optimize inference and minimize bias in observational studies that are often much more feasible to undertake. To mitigate the risk of bias arising from their nonexperimental design, researchers must first understand the ways in which measured covariates can influence treatment, outcomes, and missingness of follow-up data. With knowledge of these relationships, researchers can then build causal diagrams to best understand how to control sources of bias. Some common techniques for controlling for bias include matching, regression, stratification, and propensity score analysis. Selection bias may result from loss to follow-up and missing data. Strategies such as multiple imputation and time-to-event analysis can be useful for handling missingness. For longitudinal data, repeated measures allow observational studies to best summarize the impact of the intervention over time. Clinical researchers familiar with fundamental concepts of causal inference and techniques reviewed in this article will have the power to improve the quality of inferences made from clinical research in orthopaedic trauma surgery.

Opportunities for International Orthopaedic Volunteerism: An Exploration of United States and Canada-Based Nonprofit Organizations.

BACKGROUND: In low and middle-income countries (LMICs), there are often not enough orthopaedic surgeons to treat musculoskeletal conditions. International volunteerism is 1 way that the orthopaedic community seeks to meet this need. This study explored the opportunities available for orthopaedic surgeons to volunteer overseas as offered by nonprofit organizations in the United States and Canada. METHODS: A systematic internet search was conducted using 2 distinct search strategies. A website was considered a "hit" if it was that of a U.S. or Canada-based nonprofit, volunteer, or non-governmental organization that had opportunities for international orthopaedic volunteerism. Duplicate hits were eliminated to identify distinct organizations. Data regarding the work and geographical reach of the organization, as well as changes to its volunteer programs as a result of COVID-19, were extracted from each hit. RESULTS: Of the 38 distinct organizations identified in the U.S. and Canada, the most common orthopaedic subspecialties represented were pediatrics (37%), hand (24%), and arthroplasty (18%). Foot and ankle (4 organizations; 11%), sports medicine (2 organizations; 5%), and oncology (1 organization; 3%) were the least represented subspecialities. The most common regions for volunteer trips included Latin America and the Caribbean, followed by West and East Africa. Twelve organizations (32%) were identified as having a religious affiliation. For most organizations, the trip duration was a minimum of 1 week. All volunteer organizations included operative or clinical experiences as part of their trips, and the majority of organizations (58%) reported that their trips included opportunities for training local surgeons. Many organizations (71%) reported having resumed trips after halting them during the COVID-19 pandemic. CONCLUSIONS: Many opportunities exist for orthopaedic surgeons to volunteer their time and skills abroad. Future directions for the improvement of international volunteer efforts among the orthopaedic community could include expanding the number of existing volunteer opportunities and assessing the ethics, safety, efficacy, and longevity of these programs.