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Despite efforts to advance clinical research through collaboration between Latin and North American partners, there remains persistent barriers to performing investigative work. To overcome these obstacles, a team of over 100 surgeon-leaders from 18 Latin American countries founded the Asociación de Cirujanos Traumatólogos de las Américas (ACTUAR). One of ACTUAR's first major collaborative projects, initiated in 2018, was a prospective, observational, multicenter study evaluating quality of life after open tibia fracture management. The current study identified common barriers experienced during the initiation of this study, as exemplified through two sites in Mexico. The study aims to identify obstacles to proactively overcome these in future collaborative work.Two research assistants from University of California, San Francisco and two research coordinators from Mexico were recruited to share their experiences, identify common barriers experienced during site enrollment and on-boarding for the ACTUAR open tibia study, and discuss possible solutions.Barriers were organized into three categories: structural, logistical, and intrapersonal. Structural barriers included differences in patient populations and resources between private and public hospitals. Logistical barriers included ambiguous ethical review processes, internet availability, and low patient follow-up. Primary enrollment as a resident responsibility led to some intrapersonal barriers. Potential solutions were identified for each barrier and agreed upon by all collaborators.Multiple barriers were identified by research personnel who initiated a prospective surgical clinical research study in Mexico. Through collaborative approaches, many potential solutions may help overcome these barriers and build locally led research capacity in Latin America.

INTRODUCTION: There is growing interest in leadership courses for physicians. Few opportunities are available in global regions with limited resources. This study describes orthopaedic trauma surgeons' desired leadership skill acquisition, opportunities, and barriers to course participation in Latin America.METHODS: Latin American orthopaedic trauma surgeons from the Asociación de Cirujanos Traumatólogos de las Americas (ACTUAR) network were surveyed. This survey solicited and gauged the surgeons' level of interest in leadership topics and their relative importance utilizing a 5-point Likert-scale. Additionally, comparisons were calculated between middle-income countries (MICs) and high-income countries (HICs) to ascertain if needs were different between groups. The survey included demographic information, nationality, level of training, years in practice, leadership position, needs assessment, and perceived barriers for leadership educational opportunities.RESULTS: One hundred forty-four orthopaedic surgeons completed the survey, representing 18 countries across Latin America; 15 MICs and 3 HICs. Participants had more than 20 years in practice (49%) and held leadership positions (81%) in hospital settings (62%), national orthopaedic societies (45%), and/or clinical settings (40%). Sixty-three percent had never attended a leadership course due to lack of opportunities/invitations (69%), difficulty missing work (24%), and costs (21%). Ninety-seven percent expressed interest in attending a leadership course. No difference in needs was determined between respondents from MICs and HICs. Professional Ethics, Crisis Management/Organizational Change Management, and High Performing Team-Building were identified as the most important leadership topics.CONCLUSION: Orthopaedic surgeons in Latin America demonstrate an interest in acquiring additional leadership skills but have few opportunities. Identifying interests, knowledge gaps, and core competencies can guide the development of such opportunities.

Background Despite a substantial burden of musculoskeletal injury, orthopaedic trauma studies in Latin America are lacking. The purpose of the present study was to identify research priorities among orthopaedic trauma surgeons in Latin America. Methods Research questions were solicited from members of the Asociacion de Cirujanos Traumatologos de las Americas. Participants rated questions by importance from 1 to 9. All questions were redistributed with an aggregate rating, and participants rerated questions with knowledge of group responses. Results Seventy-eight participants completed the first survey and were included in subsequent surveys. The mean age was 51.8 years, and most participants were male (92%), had completed an orthopaedic trauma fellowship (60.3%), and participated in research (80.8%). Seventeen countries were represented; 5 respondents were from a high-income country, 67 were from an upper middle-income country, and 6 were from a lower middle-income country. Sixty-five questions were identified. Six questions were rated from 1 to 3 ("more important") by >70% of participants: (1) What is the optimal treatment protocol for elderly patients with hip fracture? (2) What is the most effective initial and definitive management of musculoskeletal injury, including timing and surgical strategy, for the polytraumatized patient? (3) What is the ideal state of open fracture treatment, including timeliness and method of antibiotics, debridement, surgical fixation, and closure or coverage, at each hospital level in the health-care system? (4) What patient and fracture characteristics predict infection after musculoskeletal injury? (5) What is the current state of treatment for fracture-related infection, including timeliness and method of antibiotics and surgical intervention, at each hospital level in the health-care system? (6) What is the optimal protocol for temporary management for the hemodynamically unstable patient with a pelvic or acetabular fracture? Conclusions This modified Delphi study of orthopaedic trauma surgeons in Latin America identified geriatric hip fractures, polytrauma, open fractures, musculoskeletal infection, and pelvic and acetabular fractures as top research priorities. This information is important for resource allocation and goal setting for orthopaedic trauma in the region.

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.

Purpose: This study examined soft-tissue coverage techniques of open tibia fractures, described soft-tissue treatment patterns across income groups, and determined resource accessibility and availability in Latin America. Methods: A 36-question survey was distributed to orthopaedic surgeons in Latin America through two networks: national orthopaedic societies and the Asociación de Cirujanos Traumatólogos de las Américas (ACTUAR). Demographic information was collected, and responses were stratified by income groups: high-income countries (HICs) and middle-income countries (MICs). Results: The survey was completed by 469 orthopaedic surgeons, representing 19 countries in Latin America (2 HICs and 17 MICs). Most respondents were male (89%), completed residency training (96%), and were fellowship-trained (71%). Only 44% of the respondents had received soft-tissue training. Respondents (77%) reported a strong interest in attending a soft-tissue training course. Plastic surgeons were more commonly the primary providers for Gustilo Anderson (GA) Type IIIB injuries in HICs than in MICs (100% vs. 47%, p

Argentina is a country with varying access to orthopedic surgical care. The Argentine Association of Trauma and Orthopedics (AATO) "Interior Committee" was developed to address potential regional differences and promote standardization of orthopedic trauma care. The paper assesses the level of national standardization of the management of open tibia fractures across 9 provinces in Argentina.Utilizing a matched-comparison group design, management of these injuries were assessed and compared between 3 groups: an "AATO Exterior Committee" consisting of surgeons that practice in Buenos Aires, and 2 "Interior Committees," comprising surgeons that practice in outlying provinces, 1 of which is affiliated with the AATO, and 1 that is not affiliated with the AATO. The study was conducted in 2 phases: phase 1 assessed open tibia fracture management characteristics, and phase 2 evaluated the management of soft-tissue wound coverage following open fractures.Soft-tissue coverage procedures for Gustilo Anderson Type IIIB fractures were more commonly performed by orthopedic surgeons in Interior Committees than the AATO Exterior Committee. Greater rates of definitive wound coverage within 7 days post-injury were reported in both Interior Committees compared to the Exterior Committee. Plastic surgeons were reported as more available to those in the AATO Exterior Committee group than in the AATO Interior Committees.While treatment patterns were evident among groups, differences were identified in the management and timing of soft-tissue coverage in Gustilo Anderson Type IIIB fractures between the Exterior Committee and both Interior Committees. Future targeted educational and surgical hands-on training opportunities that emphasize challenges faced in resource-limited settings may improve the management of open tibia fractures in Argentina.

Leadership development programs are integral to the future success of public health and healthcare organisations. Despite low-and middle-income countries (LMICs) bearing a greater burden of unmet medical needs, fewer professional development opportunities exist in these settings. This study aims to provide a comprehensive understanding of available leadership development programs for healthcare professionals in LMICs.This study conforms to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis-P systematic review and traditional meta-analyses guidelines. Articles were identified through five academic databases: Embase, PubMed, Web of Science, ERIC, and Business Source Complete. Eligibility criteria included original research published in peer-reviewed journals on non-clinical, leadership development programs offered to healthcare professionals in LMICs worldwide.Forty-one peer-reviewed articles met inclusion criteria, of which physicians, nurses, and public health professionals were the most common types of providers to attend leadership development programs; no programs exclusively targeted surgeons. The greatest proportion of programs were short-term interventions (ranging from 1 day to 12 weeks). Communication, organizational structure and leadership, and personal development were identified as the three most common leadership themes in the review. Regionally, leadership programs were reported most commonly in Africa, specifically in Anglophone countries. Other regions worldwide, including Latin America and the Caribbean, were underrepresented in the review.The findings from this review identify gaps in leadership development programs for certain groups of healthcare professionals from certain geographical regions, supporting the need for further provision of and participation in these opportunities in LMICs.

Background:. 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.

ObjectiveOperating duties for orthopaedic surgeons decreased during the COVID-19 pandemic, while Emergency Department (ED) cases surged. Orthopaedic Walk-In Clinics (OWICs) were implemented to manage urgent musculoskeletal cases.MethodsOWICs, organized in three days, were staffed by one orthopaedic surgeon, one triage person, three medical assistants, and a physician assistant/nurse practitioner.ResultsMusculoskeletal non-emergency ED referrals decreased by 40.6% (p&nbsp

Objective The impact of new pedagogical methods such as case-based learning (CBL) rather than traditional lectures in graduate medical education is poorly defined. We hypothesized that using CBL in lieu of lectures in an orthopedic surgery residency anatomy course would lead to increased resident engagement, improved resident satisfaction, and similar knowledge acquisition. Design A prospective, observational study design was used. CBL sessions were developed for an orthopedic surgery residency anatomy course. Content was delivered in 6 sessions (3 traditional lecture-based and 3 CBL) taught by the same attending surgeon. Engagement was measured every 10 minutes by 2 trained observers using a standardized protocol. Resident satisfaction was surveyed and knowledge acquisition tested. Data from the course were scored separately for CBL verses lectures and compared statistically. Setting Orthopedic surgery residency program at the University of California, San Francisco. Participants Orthopedic surgery interns and residents (n = 35). Results No significant differences were measured in resident engagement (83% vs 85%, p = 0.664) or in knowledge acquisition (84% vs 78%, p = 0.056) in CBL verses lecture sessions, respectively. CBL sessions were judged equally valuable compared to lectures with high satisfaction rates across all survey measures. Conclusions Residents demonstrated similar engagement and satisfaction with CBL compared to lectures with equivalent knowledge acquisition, suggesting both pedagogical methods are effective for a highly motivated group of learners.

Incidence rates of hip fractures in Latin America continue to rise. These fractures are associated with factors such as health, education, and socioeconomic status. Although there are many well-developed public and private healthcare systems available, the quality and consistency in the management of patients with hip fractures varies substantially. This article provides a summary review of national hip fracture care guidelines in 4 of the largest countries in Latin America (Mexico, Colombia, Brazil, and Argentina), describing national guidelines, audits, standard treatment approaches in each country and regional policies; with the goal of understanding and comparing the different guidelines, identifying the main problems in each country, learning from the policies of the other countries, and developing improvement projects.

© 2020 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license Background: The Lancet Commission on Global Surgery established the Three Delays framework, categorising delays in accessing timely surgical care into delays in seeking care (First Delay), reaching care (Second Delay), and receiving care (Third Delay). Globally, knowledge gaps regarding delays for fracture care, and the lack of large prospective studies informed the rationale for our international observational study. We investigated delays in hospital admission as a surrogate for accessing timely fracture care and explored factors associated with delayed hospital admission. Methods: In this prospective observational substudy of the ongoing International Orthopaedic Multicenter Study in Fracture Care (INORMUS), we enrolled patients with fracture across 49 hospitals in 18 low-income and middle-income countries, categorised into the regions of China, Africa, India, south and east Asia, and Latin America. Eligible patients were aged 18 years or older and had been admitted to a hospital within 3 months of sustaining an orthopaedic trauma. We collected demographic injury data and time to hospital admission. Our primary outcome was the number of patients with open and closed fractures who were delayed in their admission to a treating hospital. Delays for patients with open fractures were defined as being more than 2 h from the time of injury (in accordance with the Lancet Commission on Global Surgery) and for those with closed fractures as being a delay of more than 24 h. Secondary outcomes were reasons for delay for all patients with either open or closed fractures who were delayed for more than 24 h. We did logistic regression analyses to identify risk factors of delays of more than 2 h in patients with open fractures and delays of more than 24 h in patients with closed fractures. Logistic regressions were adjusted for region, age, employment, urban living, health insurance, interfacility referral, method of transportation, number of fractures, mechanism of injury, and fracture location. We further calculated adjusted relative risk (RR) from adjusted odds ratios, adjusted for the same variables. This study was registered with ClinicalTrials.gov, NCT02150980, and is ongoing. Findings: Between April 3, 2014, and May 10, 2019, we enrolled 31 255 patients with fractures, with a median age of 45 years (IQR 31–62), of whom 19 937 (63·8%) were men, and 14 524 (46·5%) had lower limb fractures, making them the most common fractures. Of 5256 patients with open fractures, 3778 (71·9%) were not admitted to hospital within 2 h. Of 25 999 patients with closed fractures, 7141 (27·5%) were delayed by more than 24 h. Of all regions, Latin America had the greatest proportions of patients with delays (173 [88·7%] of 195 patients with open fractures; 426 [44·7%] of 952 with closed fractures). Among patients delayed by more than 24 h, the most common reason for delays were interfacility referrals (3755 [47·7%] of 7875) and Third Delays (cumulatively interfacility referral and delay in emergency department: 3974 [50·5%]), while Second Delays (delays in reaching care) were the least common (423 [5·4%]). Compared with other methods of transportation (eg, walking, rickshaw), ambulances led to delay in transporting patients with open fractures to a treating hospital (adjusted RR 0·66, 99% CI 0·46–0·93). Compared with patients with closed lower limb fractures, patients with closed spine (adjusted RR 2·47, 99% CI 2·17–2·81) and pelvic (1·35, 1·10–1·66) fractures were most likely to have delays of more than 24 h before admission to hospital. Interpretation: In low-income and middle-income countries, timely hospital admission remains largely inaccessible, especially among patients with open fractures. Reducing hospital-based delays in receiving care, and, in particular, improving interfacility referral systems are the most substantial tools for reducing delays in admissions to hospital. Funding: National Health and Medical Research Council of Australia, Canadian Institutes of Health Research, McMaster Surgical Associates, and Hamilton Health Sciences.

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.

Trauma continues to be a leading cause of mortality and morbidity in lower to middle-income countries. To meet the ever-growing need of musculoskeletal care in trauma patients, orthopaedic surgeons play an instrumental role in providing care, guided by relevant clinical research studies. Promoting research and publishing results are both crucial to influencing trauma-related skeletal injury treatment in lower to middle-income countries. Currently, few opportunities exist for trauma surgeons in Latin America to participate in clinical research or to contribute to academic publications, thereby limiting their ability to address potentially critical treatment questions faced by their specific patient populations. In response to these obstacles, in 2017, a group of 60 surgeon leaders representing 18 countries throughout Latin America developed the Asociación de Cirujanos Traumatólogos de las Américas (ACTUAR; www.actuarla.org). The ACTUAR supports investigative opportunities for Latin American orthopaedic trauma surgeons who want to contribute through collaborative research work. This pioneering initiative aims to improve trauma-related research, clinical care, and health care policies through the development of an international network across the Americas.

Globally, the burden of musculoskeletal conditions continues to rise, disproportionately affecting low and middle-income countries (LMICs). The ability to meet these orthopaedic surgical care demands remains a challenge. To help address these issues, many orthopaedic surgeons seek opportunities to provide humanitarian assistance to the populations in need. While many global orthopaedic initiatives are well-intentioned and can offer short-term benefits to the local communities, it is essential to emphasize training and the integration of local surgeon-leaders. The commitment to developing educational and investigative capacity, as well as fostering sustainable, mutually beneficial partnerships in low-resource settings, is critical. To this end, global health organizations, such as the Consortium of Orthopaedic Academic Traumatologists (COACT), work to promote and ensure the lasting sustainability of musculoskeletal trauma care worldwide. This article describes global orthopaedic efforts that can effectively address musculoskeletal care through an examination of 5 domains: clinical care, clinical research, surgical education, disaster response, and advocacy.

BACKGROUND Open tibial shaft fractures are an important source of disability in Latin America. High-income countries (HICs) worldwide have established standardized treatment protocols for open tibial fractures, but less is known about their treatment in middle-income countries (MICs) in Latin America. This survey of Latin American orthopaedic surgeons characterizes open tibial fracture treatment patterns. METHODS Orthopaedic surgeons from 20 national orthopaedic societies throughout Latin America completed an online survey assessing their treatment of open tibial fractures. Demographic information was collected. Treatment patterns were queried according to 2 groupings of Gustilo-Anderson (GA) fracture types: treatment of type-I and type-II fractures (GA-I/II) and treatment of type-III fractures (GA-III). Treatment patterns were evaluated across 4 domains: antibiotic prophylaxis, irrigation and debridement, fracture stabilization, and wound management. Summary statistics were reported; analysis was performed using the Fisher exact test (p < 0.05). RESULTS There were 616 survey participants from 20 Latin American countries (4 HICs and 16 MICs). Initial external fixation followed by staged internal fixation was preferred for GA-I/II (51.0%) and GA-III fractures (86.0%). Nearly one-third (31.5%) of GA-IIIB fractures did not receive a soft-tissue coverage procedure. Stratifying by country socioeconomic status, surgeons in MICs more commonly utilized delayed internal fixation for GA-I/II (53.3% versus 22.0%, p < 0.001) and GA-III fractures (94.0% versus 80.4%, p = 0.002). Surgeons in MICs more commonly used primary closure for GA-I/II (88.9% versus 62.8%, p < 0.001) and GA-III fractures (32.6% versus 9.8%, p < 0.001). CONCLUSIONS This survey reports Latin American orthopaedic surgeons' treatment patterns for open tibial shaft fractures. Surgeons in MICs reported higher delayed internal fixation use for all fracture types, while surgeons in HICs more routinely avoid primary closure. Soft-tissue coverage procedures are not performed in nearly one-third of GA-IIIB fractures because of a lack of operative personnel and training.

Enhancing health research capacity in developing countries is a global health priority. Understanding the orthopaedic burden of disease in Latin America will require close partnership between more developed and less developed countries. To this end, the Osteosynthesis and Trauma Care Foundation assembled a research consortium of Latin American orthopaedic leaders. Prior to the meeting, we surveyed attendees on perceived barriers to conducting research at their institutions. During the event, working groups discussed these barriers, developed strategies for addressing them, and planned future steps for collaboration. The participants established the need for global relationships that allow colleagues from Latin America to access to training and established investigational infrastructure of North American centers to address research questions relevant to their communities. As a result of the discussion, the International Orthopaedic Multicenter Study (INORMUS) in Fracture Care was initiated. Since then, an expanded international working group, Associacion de Cirujanos Traumatologicos en las Americas (ACTUAR), has been created with the purpose of promoting increased global partnership for research capacity development.

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.