Orthoplastic Surgery 9 (2022) 29–30

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Orthoplastic Surgery
journal homepage: www.journals.elsevier.com/orthoplastic-surgery

Letter to the Editor

Orthoplastic surgery in low- and middle-income countries: A discipline that needs to be

studied and disseminated through medical education

Dear Editor,
Orthopedics and plastic surgery are two of the most sought after surgical disciplines in low- and middle-income countries, due to the high incidence
of trauma, ergonomic disorders, occupational accidents, and chronic musculoskeletal diseases [1,2]. Evidence has found that there are innumerable
barriers to timely access to specialized surgical services, resulting in a high burden of surgical disease, which is reflected in mortality, morbidity,
disability and high health care costs [1]. Generally, due to the reduced number of high complexity hospital centers, the distances between these centers
and rural areas, economic barriers for transportation and home health care, the definitive approach to a disease is made by a single specialty, with few
patients accessing rehabilitation services to improve their quality of life.
Orthoplastic surgery is a relatively new discipline, which involves applying theoretical bases of orthopedics, as well as plastic and reconstructive
surgery, which are materialized through vascular, neural and other microsurgery techniques. High levels of evidence has proven that the ortho-
plastic vs. non-orthoplastic approach to pathologic conditions decreases time to fixation of structures, the use of negative pressure therapy, and risk
of surgical site infection or osteomyelitis (p < 0.001) [3]. This approach also encourages greater use of free flaps (p ¼ 0.01) [3]. Institutional
experiences in trauma-related limb salvage have found that collaboration with orthoplastic surgery is associated with a higher number of free flaps,
and this in turn is associated with a lower risk of therapeutic failure (p ¼ 0.03) and reoperation (p ¼ 0.001) [4]. By estimating odds ratios (OR), the
authors of this study found that involving an orthoplastic surgical team in the management of trauma cases, especially in military settings with a
severe injury, generally reduces flap failure (OR 0.4, CI 95%; 0.2 to 0.9, p ¼ 0.02) [4]. The authors concluded that it was essential to train
orthoplastic surgeons for trauma management, an aspect to consider in regions hit by armed conflict and high rates of violence, such as in low- and
middle-income countries, where the risk of amputation and permanent disability is substantially increased, and access to quality prostheses is
extremely difficult [5].
The current pandemic of COVID-19 has encouraged the use of social media by medical students, residents, teachers and specialists [6]. It is
essential to introduce orthoplastic concepts and quality evidence from orthopedics and plastic surgery that disseminate the results achieved by the
orthoplastic approach. Generally, the undergraduate student from underserved countries has limited exposure to specialties and subspecialties
developed in more prosperous countries [6]. The possibility of developing interest in studying orthoplastics and contributing to the progress of
orthoplastic techniques and educational programs in countries where this new speciality is needed is criticial. Similarly, there are many clinical
problems that could be solved once orthoplastic surgery programs in underserved countries are established. Equal access must be guaranteed by
gender, race, socioeconomic status, among many other aspects [7,8]; and also take into account the professionalism of the specialist who is part of
an emerging field.
The establishment of this specialty in low- and middle-income countries would solve problems that exist regarding the burden of care of some cases
and the dilemma between which specialists should be in charge, knowing that in some countries the volume of specialists is not high. Holler et al. [9]
conducted a study in which they identified the limited availability of plastic surgeons, difficulties in accessing specialized instruments, and support from
senior specialists as the main barriers to soft tissue reconstruction and orthopedic training in low- and middle-income countries [9]. Complications with
a higher incidence in the non-orthoplastic approach, such as postoperative infection site, carry costs of up to $34,000 [10]. The gap in the production of
new knowledge about orthoplastic surgery is immense between first and third world countries [11]. Graham et al. [11] conducted a bibliometric study
with the aim of determining the production of evidence on orthoplastic surgery, observing that less than 10% of the available evidence corresponded to
levels I or II, and the participation of third world countries was almost nonexistent [11]. Therefore, it can be concluded that the knowledge and scientific
production coming from low- and middle-income countries on orthoplastic surgery is very low. This discipline should be studied and disseminated
widely, taking into account the demand required in the management of certain conditions that produce reduction of functional capacity, morbidity and
mortality. We believe that the introduction of orthoplastic surgery interest groups in medical schools could be a good strategy to recruit medical
students and deepen their knowledge in this discipline, through workshops, seminars, research and creation of new knowledge products. In the same
way, it is possible to create specialized knowledge networks and make use of social media to disseminate the results of the activities and share useful
theoretical concepts for the undergraduate student.

Ethical approval

Not applicable.

https://doi.org/10.1016/j.orthop.2022.04.001
Received 11 February 2022; Received in revised form 20 April 2022; Accepted 29 April 2022
2666-769X/© 2022 The Author(s). Published by Elsevier Ltd on behalf of IJS Publishing Group Limited. This is an open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/by-nc-nd/4.0/).
Letter to the Editor Orthoplastic Surgery 9 (2022) 29–30

Funding source

This manuscript was funded by the authors.

Author contribution

All authors equally contributed to the analysis and writing of the manuscript.

Conflict of interest statement

The authors declare that they have no conflicts of interest.

Guarantor

Corresponding author at: School of Health & Life Sciences, Northsouth University, Dhaka, Bangladesh. E-mail address: rubaya.rashid@northsouth
.edu (R. Rashid).

Research Registration Number

1. Name of the registry: Not applicable.

2. Unique Identifying number or registration ID: Not applicable.
3. Hyperlink to your specific registration (must be publicly accessible and will be checked): Not applicable.

Consent

Not applicable.

References

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[2] L.M. García-Henao, J.C. Gallego-Uribe, Epidemiología de lesiones ortop
edicas de origen laboral en un hospital de Manizales, Rev. Colomb. Ortop. Traumatol. 33 (3–4) (2019) 73–81.
[3] K.M. Klifto, S.C. Azoury, S. Othman, C.S. Klifto, L.S. Levin, S.J. Kovach, The Value of an Orthoplastic Approach to Management of Lower Extremity Trauma: Systematic Review and
Meta-analysis, Plast. Reconstr. Surg. Glob. Open 9 (3) (2021), e3494.
[4] B.W. Hoyt, S.M. Wade, C.J. Harrington, B.K. Potter, S.M. Tintle, J.M. Souza, Institutional Experience and Orthoplastic Collaboration Associated with Improved Flap-based Limb
Salvage Outcomes, Clin. Orthop. Relat. Res. 479 (11) (2021) 2388–2396.
[5] J. Shaw, S. Challa, D. Conway, M. Liu, B. Haonga, E. Eliezer, et al., Quality of life and complications in lower limb amputees in Tanzania: results from a pilot study, Lancet Global
Health 6 (2018) S18.
[6] I. Lozada-Martínez, M. Bola~ no-Romero, L. Moscote-Salazar, D. Torres-Llinas, Letter to the Editor: 'Medical Education in Times of COVID-19: What's New in Neurosurgery?', World
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[7] P. Zuluaga-Ramírez, I. Lozada-Martínez, L. Moscote-Salazar, L. Cabrera-Vargas, Sexual harassment and racism in surgery: A latent problem, Int. J. Surg. 86 (2021) 13–14.
[8] M.P. Herrera-Martinez, E. García-Ballestas, I. Lozada-Martinez, D. Torres-Llin
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[9] J.T. Holler, P. Albright, S. Challa, S.H. Ali, D. Martins, K. Keys, et al., Barriers to Performing Soft Tissue Reconstruction Procedures among Orthopedic Surgeons in Low- and Middle-
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[10] M. Monahan, S. Jowett, T. Pinkney, P. Brocklehurst, D.G. Morton, Z. Abdali, et al., Surgical site infection and costs in low- and middle-income countries: A systematic review of the
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[11] S.M. Graham, C. Brennan, M. Laubscher, S. Maqungo, D.G. Lalloo, D.C. Perry, et al., Orthopaedic research in low-income countries: A bibliometric analysis of the current literature,
SICOT-J. 5 (2019) 41.

Ivan David Lozada-Martinez

Medical and Surgical Research Center, Future Surgeons Chapter, Colombian Surgery Association, Bogot
a, Colombia
Grupo Prometheus y Biomedicina Aplicada a las Ciencias Clínicas, School of Medicine, Universidad de Cartagena, Cartagena, Colombia
Jos
e Luis Moscoso-Organista
Department of Medicine, Fundaci
on Universitaria Juan N. Corpas, Bogot

a, Colombia
Yamit Eutimio Cossio-Giraldo
Department of Medicine, Corporaci
on Universitaria Remington, Medellín, Colombia
Anderson Fabian Guerrero-Ceron
Department of Medicine, Universidad del Cauca, Popayan, Colombia
Cesar Mauricio Arango-Ospina
Department of Medicine, Universidad de Ciencias Aplicadas y Ambientales, Bogot

a, Colombia
Rubaya Rashid*
School of Health & Life Sciences, Northsouth University, Dhaka, Bangladesh

*
Corresponding author. School of Health & Life Sciences, Northsouth University, Dhaka, Bangladesh.
E-mail address: rubaya.rashid@northsouth.edu (R. Rashid).

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