Global Orthopaedic Trauma Care: Where We Stand

A new Current Concepts Review performed at Massachusetts General Hospital and appearing in the December edition of The Journal of Bone and Joint Surgery highlights aspects of global orthopedic trauma care. The consensus? The needs are growing.

Kiran Agarwal-Harding, M.D. is in the Combined Orthpaedic Residency Program at Harvard University and is affiliated with Mass General. He told OTW, “Global disparities in available orthopaedic care are immense. A higher burden and poorer access to care is shouldered by the poorest patients, for whom disability can plunge patients and their families deeper into poverty. Shifting our focus to improving care for the poorest patients can help make orthopaedic care cheaper and of higher quality for all, representing a new frontier for device and systems innovation in orthopedics.”

Regarding service missions, Dr. Agarwal-Harding noted, “Without local integration, surgical missions can disrupt local health-care economies, providing free services that unintentionally undermine local surgeons who depend on payments to maintain their practices.”

“About five billion people worldwide have inadequate access to surgical care, with affordability remaining as one of the biggest barriers. While rife with challenges, cost-effective orthopaedic interventions can help patients return to work, feed their families, contribute positively to their local and national economies, and avoid falling into a vicious cycle of poverty.”

“Even in high-income countries, some patient populations have higher relative rates of trauma and inadequate access to orthopaedic care. In several low- and middle-income countries, high quality and cost-effective orthopaedic care is available to the extent that patients from high-income countries are preferentially seeking care overseas. Achieving musculoskeletal health equity means thinking globally but acting locally; and several promising innovations exist that are beginning to extend the reach of orthopaedic surgeons, reduce costs, and subsidize care for the poorest patients.”

“Two examples from India, ” says Dr. Agarwal-Harding, “Aravind Eye Care System and Narayana Health, have established a practical model that utilizes cross-subsidization, where patients who cannot pay for care are supported by profits generated from patients paying the market rate, and additional profits earned by charging for personal amenities.”

Dr. Agarwal-Harding added, “There are several innovations by which we can lower costs. In terms of manpower, training and deploying non-physician clinicians as well as using telemedicine can extend the reach of surgeons and cut costs. In terms of devices, the Relligo splint designed by Stanford India Biodesign has low production costs and is manufactured locally in India. Then there is the SIGN nail, which is designed specifically for the low resource setting, can be used without electricity or intraoperative fluoroscopy. SIGN as an organization distributes these nails for free in the developing world as part of their model to provide education to local surgeons about fracture care and donate instruments and implants to treat the poor. The SIGN nail may also facilitate task-shifting of fracture care to community health centers. The SIGN nail is an example of a technology designed specifically for a resource-poor context, but with much broader applicability and potential to improve orthopaedic care globally.”

“Further investigation of many of the innovations we discuss is planned in coming years, to determine their broader applicability, both in high- and low-resource settings, to make care more cost-effective and accessible to the poor and in low resource settings.”