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.

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.

Surgical Management and Reconstruction Training (SMART) Course for International Orthopedic Surgeons.

BACKGROUND: The burden of complex orthopedic trauma in low- and middle-income countries (LMICs) is exacerbated by soft-tissue injuries, which can often lead to amputations. This study's purpose was to create and evaluate the Surgical Management and Reconstruction Training (SMART) course to help orthopedic surgeons from LMICs manage soft-tissue defects and reduce the rate of amputations. METHODS: In this prospective observational study, orthopedic surgeons from LMICs were recruited to attend a 2-day SMART course taught by plastic surgery faculty in San Francisco. Before the course, participants were asked to assess the burden of soft-tissue injury and amputation encountered at their respective sites of practice. A survey was then given immediately and 1-year postcourse to evaluate the quality of instructional materials and the course's effect in reducing the burden of amputation, respectively. RESULTS: Fifty-one practicing orthopedic surgeons from 25 countries attended the course. No participant reported previously attempting a flap reconstruction procedure to treat a soft-tissue defect. Before the course, participants cumulatively reported 580-970 amputations performed annually as a result of soft-tissue defects. Immediately after the course, participants rated the quality and effectiveness of training materials to be a mean of ≥4.4 on a Likert scale of 5 (Excellent) in all 14 instructional criteria. Of the 34 (66.7%) orthopedic surgeons who completed the 1-year postcourse survey, 34 (100%, P < 0.01) reported performing flaps learned at the course to treat soft-tissue defects. Flap procedures prevented 116 patients from undergoing amputation; 554 (93.3%) of the cumulative 594 flaps performed by participants 1 year after the course were reported to be successful. Ninety-seven percent of course participants taught flap reconstruction techniques to colleagues or residents, and a self-reported estimate of 28 other surgeons undertook flap reconstruction as a result of information dissemination by 1 year postcourse. CONCLUSION: The SMART Course can give orthopedic surgeons in LMICs the skills and knowledge to successfully perform flaps, reducing the self-reported incidence of amputations. Course participants were able to disseminate flap reconstructive techniques to colleagues at their home institution. While this course offers a collaborative, sustainable approach to reduce global surgical disparities in amputation, future investigation into the viability of teaching the SMART course in LMICs is warranted.

Wrong Place, Wrong Time: Coincidental Involvement in the Gujarat Earthquake, India (2001).

Orthopaedic surgeons have traditionally answered the call in times of disaster. Shortly after the devastating earthquake in January 2001, in Gujarat India, that call came from a buffer zone hospital. The Gandhi Lincoln Hospital in Deesa, Gujarat was struggling with an influx of injured survivors. Five days after the initial event, 2 of the traveling American authors met up with the Director of Surgery at the hospital. The clinical load was primarily extremity injuries and wounds. The authors present their assessment of the orthopaedic response highlighting factors of success, barriers, and lessons learned. Despite their published accounts, many of these lessons were not applied to the Haiti earthquake response.

What factors influence the production of orthopaedic research in East Africa? A qualitative analysis of interviews.

BACKGROUND: Research addressing the burden of musculoskeletal disease in low- and middle-income countries does not reflect the magnitude of the epidemic in these countries as only 9% of the world's biomedical resources are devoted to addressing problems that affect the health of 90% of the world's population. Little is known regarding the barriers to and drivers of orthopaedic surgery research in such resource-poor settings, the knowledge of which would help direct specific interventions for increasing research capacity and help surgeons from high-income countries support the efforts of our colleagues in low- and middle-income countries. PURPOSE: We sought to identify through surveying academic orthopaedic surgeons in East Africa: (1) barriers impeding research, (2) factors that support or drive research, and (3) factors that were identified by some surgeons as barriers and others as drivers (what we term barrier-driver overlap) as they considered the production of clinical research in resource-poor environments. MATERIALS: Semistructured interviews were conducted with 21 orthopaedic surgeon faculty members at four academic medical centers in Ethiopia, Kenya, Tanzania, and Uganda. Qualitative content analysis of the interviews was conducted using methods based in grounded theory. Grounded theory begins with qualitative data, such as interview transcripts, and analyzes the data for repeated ideas or concepts which then are coded and grouped into categories which allow for identification of subjects or problems that may not have been apparent previously to the interviewer. RESULTS: We identified and quantified 19 barriers to and 21 drivers of orthopaedic surgery research (mentioned n = 1688 and n = 1729, respectively). Resource, research process, and institutional domains were identified to categorize the barriers (n = 7, n = 5, n = 7, respectively) and drivers (n = 7, n = 8, n = 6, respectively). Resource barriers (46%) were discussed more often by interview subjects compared with the research process (26%) and institutional barriers (28%). Drivers of research discussed at least once were proportionally similar across the three domains. Some themes such as research ethics boards, technology, and literature access occurred with similar frequency as barriers to and drivers of orthopaedic surgery research. CONCLUSIONS: The barriers we identified most often among East African academic orthopaedic faculty members focused on resources to accomplish research, followed by institutional barriers, and method or process barriers. Drivers to be fostered included a desire to effect change, collaboration with colleagues, and mentorship opportunities. The identified barriers and drivers of research in East Africa provide a targeted framework for interventions and collaborations with surgeons and organizations from high-resource settings looking to be involved in global health.

Volunteer opportunities for orthopaedic surgeons in the developing world.

Orthopaedic surgeons have consistently shown interest in volunteering to aid needy populations throughout the world. Service missions, building surgical capacity, and disaster relief have benefited from the volunteer efforts of orthopaedic surgeons. The burden of musculoskeletal disease is high and will continue to increase as motorization and development reach more people. The increasing burden of musculoskeletal disease requires thoughtful, well-planned, and effectively executed interventions. A framework for action will help orthopaedic surgeons use the many avenues available for involvement in international volunteer work.

The implementation of a pilot femur fracture registry at Komfo Anokye Teaching Hospital: an analysis of data quality and barriers to collaborative capacity-building.

BACKGROUND: Trauma registries are essential for injury surveillance and recognition of the burden of musculoskeletal injury in low- and middle-income countries (LMICs). The purpose of this study was to pilot a femur fracture registry at Komfo Anokye Teaching Hospital (KATH) to assess data quality and determine the barriers to research partnering in LMICs. METHODS: All patients admitted to KATH with a fracture of the femur, or Arbeitsgemeinschaft für Osteosynthesefragen (AO) class 31, 32, 33, were entered into a locally designed, electronic femur fracture database. Patients' characteristics and data quality were assessed by using descriptive statistics. Orthopedic trauma research barriers and opportunities were identified from key informants at the research site and supporting site. RESULTS: Ninety-six femur fracture patients were enrolled into the registry over a 5-week period. The majority of patients resided in the Ashanti region surrounding the hospital (78 %). Most participants were involved in a road traffic crash (58 %) and physiologically stable with a Cape Triage Score of yellow upon admission (84 %). AO class 32 femur fractures represented the majority of femur fractures (78 %). Median times from injury to admission, admission to surgery, and surgery to discharge were 0, 5, and 10 days, respectively. Data quality analysis showed that data collected at admission had higher rates of completion in the database relative to data collected at various follow-up time points. CONCLUSIONS: Data and data quality analyses highlighted characteristics of femur fracture patients presenting to KATH as well as the technological, administrative support, and hospital systems-based challenges of longitudinal data collection in LMICs.

Volunteer orthopedic surgical trips in Nicaragua: a cost-effectiveness evaluation.

BACKGROUND: Injuries account for a substantial portion of the world's burden of disease and require effective surgical care. Volunteer surgical teams that form partnerships with hospitals help build local surgical capacity while providing immediate care. The purpose of the present study was to evaluate the cost-effectiveness of short orthopedic surgical volunteer trips as a method of reducing the global burden of surgical disease through both surgical and educational interventions. METHODS: Data were collected from a scheduled volunteer trip to Leon, Nicaragua, in January 2011 as part of the Cooperación Ortopédica Americano Nicaraguense (COAN), a 501c3 nonprofit organization established in 2002. Costs are from the COAN provider prospective with an additional analysis to include the Nicaraguan provider variable costs. The total burden of musculoskeletal disease averted from the patients receiving surgical intervention was derived using the disability-adjusted-life-years (DALYs) framework and disability weights from the disease control priority project. The cost-effectiveness ratio was calculated by dividing the total costs by the total DALYs averted. RESULTS: A total of 44.78 DALYs were averted in this study, amounting to an average of 1.49 DALYs averted per patient. The average cost per patient from the COAN provider perspective was $525.64, and from both the COAN and Nicaraguan provider perspective it was $710.97. In the base case, cost-effectiveness was $352.15 per DALY averted, which is below twice the Nicaraguan per capita gross national income ($652.40). CONCLUSIONS: Volunteer orthopedic surgical trips are cost-effective in Nicaragua. Further research should be conducted with multiple trips and with different patient populations to test the generalizability of the results.

Critically assessing the Haiti earthquake response and the barriers to quality orthopaedic care.

BACKGROUND: Although numerous authors have described surgical experiences following major disasters, little is known regarding the needs of and barriers to care faced by surgeons during such disasters. QUESTIONS/PURPOSES: We therefore (1) identified and compared recurrent interview themes essential to the disaster response following the 2010 Haiti earthquake; (2) determined the difference in reported disaster equipment management task difficulty between disaster-trained and untrained volunteers; and (3) approximated the quantity of various procedures performed. METHODS: We conducted 14 interviews with selected orthopaedic surgeon volunteers. We also invited the 504 members of the American Academy of Orthopaedic Surgeons (AAOS), who registered as Haiti earthquake volunteers, to complete an online survey; 174 (35%) completed the survey and 131 (26%) were present in Haiti during the 30 days after the earthquake. Recurrent interview themes were identified, quantified, and compared using Poisson regression analysis. The difference in disaster equipment management difficulty scores was determined with a Wilcoxon rank-sum test. RESULTS: Of 10 recurrent interview themes, group organization (31 occurrences) was mentioned much more often than all but two of the remaining nine themes. Compared with disaster-untrained respondents, equipment management tended to be less challenging for disaster-trained respondents. Transporting to the treatment site and security during storage at the site were less challenging (19.5% and 16.5% decreases, respectively). Revision surgeries, guillotine amputations, fasciotomies, and internal fixations, suggestive of inappropriate disaster care, were frequently reported. CONCLUSIONS: Organizational and training barriers obstructed orthopaedic care delivery immediately after the Haiti earthquake. Disaster training and outcomes require further study to improve care in future catastrophes.

Estimating the healthcare burden of osteomyelitis in Uganda.

Chronic osteomyelitis is a considerable healthcare burden in many developing countries, but this burden is poorly quantified. To estimate the clinical burden of osteomyelitis we systematically sampled the medical records of orthopaedic clinics at five hospitals in Uganda. To estimate the surgical burden of osteomyelitis we reviewed the diagnosis in 9354 operations conducted during a 1 year period at the same five hospitals. Of 1844 outpatients with a documented diagnosis sampled over 1 year, 187 (10%) had osteomyelitis. Only 20% of those with osteomyelitis were older than 20 years, whereas this age group accounted for 52% of patients with another orthopaedic diagnosis or no diagnosis (P<0.001). Osteomyelitis was diagnosed in 325 (3.5%) of the surgical operations; in 32% of these operations the patients were children aged between 10 and 14 years. The tibia was the bone most frequently involved (31%), and sequestrectomy was the most frequent surgical procedure (60%). These findings suggest that osteomyelitis disproportionately affects the young, and is a burden on both clinical and surgical services. To decrease this burden in populations with limited resources, improved diagnosis and more timely treatment of acute osteomyelitis is needed.

Orthopaedic Outreach Program in Uganda: A Strategy to Improve Inequality in Service Delivery between Rural and Urban Communities

Background: Musculoskeletal diseases are on the increase worldwide. Greater than 80of Ugandans live in rural areas; facing formidable barriers to specialized care. In 1991 the Orthopedics Outreach Program (OOP) was initiated as a plausible solution to the inequity of orthopedic care between the urban and rural disadvantaged populations. This investigation was conducted to evaluate the output; effectiveness; and barriers to access; of the OOP over 13 years. Methods: This was a retrospective analysis to quantify surgical output and effectiveness of the OOP using the outreach record and a cross-sectional analysis to assess access and efficacy of the program. Semi-structured and key informant interviews targeted to key actors involved in the OOP were conducted to provide a qualitative assessment of the program. Results: Sixty seven outreach visits were completed; 6;653 patients seen; and 1;071 surgeries performed; at a total cost of US$12;701.00. The cost per patient seen was US$1.91 and US$11.86 per surgery performed. Poverty was uniformly cited as barrier to access; others were; transportation; and lack of awareness. There was unanimous opinion on the worthiness and effectiveness of the OOP; but many operational issues and constraints were cited. Conclusion: The OOP may provide a short and medium term solution to equity and access for orthopedic care in Uganda. There is need to quantify the burden of specific orthopedics conditions. A follow-up analysis assessing operational efficacy and output from 2004 to date; under the African Medical and Research Foundation (AMREF) and Ministry of Health funding is recommended

Topics in global public health.

Deficiencies in the delivery of musculoskeletal trauma care in low- and middle-income countries can be attributed to a variety of causes, all of which can be linked to failure of the health system to deliver the necessary services to prevent death and disability. As such, a "systems" approach will be required to improve the delivery of services. The goal of this review is to familiarize the orthopaedic surgeon with selected topics in public health, including health systems, burden of disease, disability adjusted life year (DALY), cost-effective analysis, and related concepts (eg, met versus unmet need, access, utilization, effective coverage).

Nongovernmental organizations in musculoskeletal care: Orthopaedics Overseas.

Injuries are a major worldwide contributor to morbidity and mortality. The negative impact caused by such injuries is disproportionately heavy in developing countries. Such disparities are caused by a complex array of problems, including a lack of physical resources, poor infrastructure, and a shortage of trained health professionals. Overcoming such deficits in care will require the involvement of organizations that can offer broad-based solutions. These organizations must bridge the gap between private and public institutions to establish a systems-based approach to program development and institution-building. They must provide not just an adequate level of care, but a transfer of knowledge that leads to sustainable and cost-effective intervention. Orthopedics Overseas is an example of such an organization. We examine the development of Orthopedics Overseas and describe their interventions in Uganda as a case-study to show the unique position they have to affect change.

The University of California at San Francisco international orthopaedic elective.

International volunteerism helps remedy global inequities in orthopaedic care and provides relief for increasing professional disillusionment experienced by many orthopaedic surgeons in the United States. From 1992 to 1998, 41% of residents from the Department of Orthopaedic Surgery at the University of California, San Francisco volunteered overseas. Approximately one half of those have continued volunteering internationally after residency, including many who led later trips with residents. Based on the success of these trips, the University of California, San Francisco Department of Orthopaedic Surgery established a 1-month elective rotation in Umtata, South Africa in conjunction with Orthopaedics Overseas. Seventy-six percent of residents have chosen this opportunity since the program's inception in 1998. The University of California, San Francisco experience suggests that early exposure to international volunteerism during residency promotes continued participation in volunteer activities after graduation. By providing residents with the opportunity to volunteer overseas, the University of California, San Francisco hopes to enhance resident education, foster a lifelong spirit of volunteerism, and serve as a model for other orthopaedic training programs.

The Gujarat earthquake (2001) experience in a seismically unprepared area: community hospital medical response.

BACKGROUND: At 08:53 hours on 26 January 2001, an earthquake measuring 6.9 on the Richter scale devastated a large, drought-affected area of northwestern India, the state of Gujarat. The known number killed by the earthquake is 20,005, with 166,000 injured, of whom 20,717 were "seriously" injured. About 370,000 houses were destroyed, and another 922,000 were damaged. METHODS: A community health worker using the local language interviewed all of the patients admitted to the Gandhi-Lincoln hospital with an on-site, oral, real-time, Victim Specific Questionnaire (VSQ). RESULTS: The census showed a predominance of women, children, and young adults, with the average age being 28 years. The majority of the patients had other family members who were also injured (84%), but most had not experienced deaths among family members (86%). Most of the patients (91%) had traveled more than 200 kilometers using their family cars, pick-ups, trucks, or buses to reach the buffer zone hospitals. The daily hospital admission rate returned to pre-event levels five days after the event, and all of the hospital services were restored by nine days after the quake. Most of the patients (83%) received definitive treatment in the buffer zone hospitals; 7% were referred to tertiary-care centers; and 9% took discharge against medical advice. The entrapped village folk with their traditional architecture had lesser injuries and a higher rescue rate than did the semi-urban townspeople, who were trapped in collapsed concrete masonry buildings and narrow alleys. However, at the time of crisis, aware townspeople were able to tap the available health resources better than were the poor. There was a low incidence of crush injuries. Volunteer doctors from various backgrounds teamed up to meet the medical crisis. International relief agencies working through local groups were more effective. Local relief groups needed to coordinate better. Disaster tourism by various well-meaning agencies took a toll on the providers. Many surgeries may have contributed to subsequent morbidity. CONCLUSIONS: The injury profile was similar to that reported for most other daytime earthquakes. Buffer zone treatment outcomes were better than were the field and damaged hospital outcomes.