Development of Orthopaedic Clinical Practice in Emerging Countries: Innovation, Adaptation, and Reciprocal Collaboration for Global Excellence

Tania Alvarado, MD , Prof., ECUADOR Túlio V.O. Campos, MD, MsC, PhD, Prof., BRAZIL Oyoo O. Were, MMed, IOC Dip Sp Phy, KENYA Phob Ganokroj, MD, THAILAND

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Introduction

The critically important symposium on “Orthopaedics in Developing Countries” at the 2025 ISAKOS Congress in Munich addressed a topic that profoundly shapes much of global orthopaedic practice, highlighting the immense responsibility that we share in advancing care globally. Our perspective, drawn from regions such as Ecuador, confirms that orthopaedics in emerging nations, while facing significant barriers, is also a fertile ground for innovation, resilience, and the cultivation of pragmatic solutions.

It was both an honor and a profound responsibility to lead a dialogue on a topic that shapes much of global orthopaedic practice. My own experience, honed as an orthopaedic trauma surgeon within the context of an emerging nation (Ecuador), has allowed me to witness first-hand that orthopaedics in these regions faces numerous challenges (e.g., a shortage of professionals, limited access to necessary implants and supplies, and inadequate funding), leading to high patient morbidity and mortality. Solutions involve international collaboration through organizations such as the NOGs (Non-Governmental Organizations )or foreign aid programs, training local staff (often facilitated by academic partners and NGOs), expanding the role of other healthcare providers (such as community health workers, nurses, and private clinics), and improving access to information and technology (by engaging the private sector and specialized tech organizations). Other solutions include increasing public funding, developing local research capacity, and focusing on cost-effective trauma-related surgeries¹.

The context of orthopaedic care in developing countries is defined by a disproportionate burden of musculoskeletal trauma, often compounded by limited access to essential surgical resources, including reliable implants, modern arthroscopic equipment, and specialized training pathways. This lack of resources forces surgeons to constantly adapt, innovate, and prioritize highly pragmatic treatment solutions to prevent long-term disability and restore function across vast, underserved populations.

Our symposium challenged the traditional unidirectional view of aid and instead focused on the core concept of reciprocal collaboration. In this collaborative article, we move beyond discussing limitations to showcase how clinicians in resource-limited settings are driving surgical innovation, adapting complex techniques to achieve global excellence, and generating high-impact research with minimal funding. We will explore the key takeaways from our presenters—Dr. Oyoo Were, Dr. Tulio Campos, and Dr. Phob Ganokroj—in order to demonstrate that lessons learned in the most challenging environments hold immense value for the entire ISAKOS community, regardless of resource availability.

The Reality of Orthopaedic Care in Emerging Countries

Orthopaedics and Traumatology, as a medical specialty, aims to restore function and improve the quality of life for patients affected by musculoskeletal pathologies. However, the capacity to provide optimal care varies drastically across the globe. In emerging or low- and middle-income countries (LMICs), orthopaedic clinical practice unfolds in an environment of structural and resource limitations that extend beyond mere funding. These limitations include the scarcity of allografts for complex reconstructions, the lack of cutting-edge technology due to regulatory barriers or industrial distribution issues, limited access to subspecialized training, and the absence of rehabilitation infrastructure in rural areas^2,3.

Research with Resources: Maximizing Impact with Minimal Funding in Orthopaedics

Dr. Phob Ganokroj (Bangkok, Thailand, in his presentation on “Research with Limited Resources: Maximizing Impact with Minimal Funding in Orthopaedics,” emphasized how evidence generation is possible and crucial, even with economic limitations. Research in orthopaedics plays a pivotal role in improving surgical techniques, implant design, and rehabilitation strategies. However, many clinician-researchers face the challenge of conducting meaningful investigations with minimal funding. Competitive grants are limited, and institutional budgets often prioritize clinical operations over academic development.

The study by Liang et al. evaluated a total of 12,553 articles worldwide, with the USA accounting for the highest proportion of studies (35.4%) and with 90% of the studies originating from high-income countries The study by Hohmann et al. showed that the USA also had the highest publication and impact factors When adjusted for population size, Switzerland has the highest publication rate (1 article per $ 15,300). When adjusted by Gross Domestic Product (GDP)—which represents the total market value of all finished goods and services produced within a country's borders and serves as a fundamental measure of its economic health, Croatia has the highest rate (1 publication per $772,000). However, when adjusted for both economic status and population, only two countries had publication rates at the same level as the USA (benchmark) Many factors (e.g., income, population, language, policy, funding, and internal collaboration) are related to the impact and number of publications. Despite these limitations, many opportunities still exist for impactful, low-cost research. Smart design, open-access resources, and strategic teamwork can produce high-quality results with minimal investment. The presentation of Dr. Ganokroj offers a framework for conducting orthopaedic research with limited resources, emphasizing feasibility, innovation, and sustainability.

There are five key steps to maximize research impact with a low budget, as outlined below.

1. Recognize Fixed and Growth Mindsets. The first and most crucial step in developing a sustainable research career—especially in limited-resource environments—is to understand one’s own mindset. Some surgeons pursue research to improve patient outcomes, advance surgical techniques, or advance their academic careers. Others hesitate to do so because of a lack of time, fear of failure, or uncertainty about methodology. Recognizing these beliefs helps one to shift from avoidance to purposeful engagement. Developing a growth mindset requires immersion in learning. Take advantage of free online educational opportunities, such as the ISAKOS webinars, attending the conference, or applying for the fellowship.
2. Prioritize the Research Question. A well-formulated question provides the foundation for all subsequent research design, data collection, and analysis. In low-resource environments, clarity and focus are even more important because time, personnel, and funding must be directed efficiently toward the most impactful problems. Apply the “3I Test” —Interesting, Important, and Innovative — to create strong research questions. By applying this test and focusing on well-defined, relevant questions, surgeons can ensure that their limited resources produce meaningful, high-impact research.
3. Leverage Open-Access and Low-Cost Resources. In resource-limited environments, the ability to maximize output while minimizing cost is essential for sustainable research productivity. Fortunately, the growing global movement toward open science has democratized access to knowledge, tools, and technologies that allow orthopaedic surgeons to conduct high-quality research without large financial investment. Certain study types inherently offer high scientific value at low cost, such as cadaveric, image-based, or systematic review stu
4. Create a Program Collaboration Plan. In limited-resource environments, collaboration transforms individual research efforts into sustainable, high-impact programs. Partnering with institutions or research teams that possess advanced equipment, laboratories, or established databases allows access to resources and expertise that would otherwise be unavailable. Participation in structured mentorship initiatives, such as the ISAKOS Mentorship Program or AO Foundation Fellowships, accelerates skill development and connects early-career surgeons to experienced global researchers. Building a multidisciplinary team by engaging medical students, residents, and postgraduate trainees fosters continuity, supports task delegation, and nurtures future clinician-scientists.
5. Publish Smart and Boost Visibility with Minimal Cost. Maximize research impact through strategic, low-cost publication. Choose reputable open-access or high-impact journals that offer fee waivers for low-income countries—remember, open access is not the same as low quality. Avoid predatory journals that compromise credibility. Present your work at local or virtual conferences to expand recognition affordably. Enhance global visibility by sharing results on ResearchGate, LinkedIn, and X (Twitter), as well as through institutional blogs and visual abstracts. These platforms connect you with collaborators and amplify reach. By publishing wisely and promoting effectively, orthopaedic researchers can achieve high visibility and academic impact without the financial burden.

The impact of orthopaedic research is shaped by many factors—not merely funding, but also mindset, strategy, and planning. Success begins with cultivating a growth mindset, asking meaningful questions, leveraging open-access tools, and building strong collaborations. Even in limited-resource environments, impactful research is achievable through creativity, efficiency, and persistence. Applying SWOT analysis helps to identify strengths, overcome weaknesses, seize opportunities, and manage threats, guiding researchers toward smarter and more sustainable approaches. Ultimately, meaningful research is not defined by the size of the budget, but by the clarity of purpose and the strength of strategy behind it.

Arthroscopy Without Borders

Dr. Alvarado’s presentation on “The Travelling Arthroscope: Arthroscopy Without Borders,” based her experience as an orthopaedic traumatologist in Guayaquil, Ecuador, serves as a powerful case study in developing and maintaining sustainable subspecialized surgical care in resource-constrained environments. Her work deliberately shifts the focus from the absence of resources to the creative deployment of available technology and expertise to meet critical clinical needs in previously underserved populations.

The core of this strategy lies in the following.

1. Prioritizing Portability and Efficiency. Her approach emphasizes using portable, robust arthroscopic equipment capable of deployment in various clinical settings with hostile scenarios. This “Travelling Scope” approach bypasses infrastructural deficits by making specialized care accessible to patients in decentralized, often rural locations.
2. Adaptive Surgical Planning. She focuses on high-impact, minimally invasive procedures (arthroscopy) that minimize hospital stay and reliance on complex and expensive postoperative facilities. This restriction is crucial for long-term patient success in settings where consistent access to physiotherapy is a known challenge.
3. Educational and Logistical Bridges. She underscores the need to train local staff and establish strong logistical chains to support the specialized equipment. This ensures that the introduction of advanced surgical techniques contribute to the permanent growth of local surgical capacity, rather than being a transient effort.

Dr. Alvarado’s experience demonstrates that arthroscopic excellence is achievable through adaptative protocols, strategic equipment investment, and a profound commitment to making subspecialized care geographically available, setting a new standard for orthopaedic surgeons globally.

Summary and Future Perspectives

The choice of this topic and the structure of this symposium reflect a fundamental conviction: namely, that limitations are not merely obstacles but also are catalysts for frugal innovation and adaptive thinking (Mok et al., 2021). The work of Mok et al. , 2021 seeks to move beyond merely diagnosing deficiencies by analyzing how the development of clinical practice in emerging countries can enrich the global perspective of orthopaedics and foster reciprocal collaboration with orthopaedists from the developed world. It also explores the variables that define and the strategies that drive this evolution, offering a guide for a more inclusive, sustainable, and globally relevant practice.

Building on the enthusiastic response, we are excited about the potential for a follow-up symposium to continue this crucial dialogue at the ISAKOS 2027 Congress in Australia. Our aim is to provide an environment to promote the exchange of knowledge among orthopaedic surgeons from low- and limited-income countries and to create a workgroup that will collaborate to define priorities and produce articles tailored to address issues related to orthopaedic and arthroscopy practice in those scenarios.

Fig. 1. Dr. Oyoo Were, Dr. Marco Tulio, Dra. Tania Alvarado. Preliminary meeting (ISAKOS, Munich, 2025).

Fig. 2. Symposium presentation (ISAKOS, Munich, 2025).

Fig. 3. Symposium presentation (ISAKOS, Munich, 2025).

Fig. 4. From left to right: Dr. Ivan Vallejo (SEOT President), Dr. Santiago Tamayo (Ecuador), Dr. Diego Rubio (Ecuador), Dr. Marco Tulio , Dra. Tania Alvarado (Ecuador), Dr. Phob Ganokroj (Thailand), Dr. OyooWere (Kenya), Dr. Diego Esquivel (Paraguay) (ISAKOS, Munich 2025).

References

1. Doughty K, Rothman L, Johnston L, Le K, Wu J, Howard A. Low-income countries' orthopaedic information needs: challenges and opportunities. Clin Orthop Relat Res. 2010 Oct;468(10):2598-603. doi: 10.1007/s11999-010-1365-x. PMID: 20431972; PMCID: PMC3049618.
2. Gosselin RA, Gialamas G, Atkin DM. Comparing the cost-effectiveness of short orthopedic missions in elective and relief situations in developing countries. World J Surg. 2011 May;35(5):951-5. doi: 10.1007/s00268-010-0947-9. PMID: 21350899; PMCID: PMC3071471.
3. Noordin S, Wright J, Howard A. Global access to literature on trauma. Clin Orthop Relat Res. 2008;466:2418–2421. doi: 10.1007/s11999-008-0375-4.
4. Kupczik F, Schiavon MEG, Vieira LA, Tenius DP, Fávaro RC. Knee Dislocation: Descriptive Study of Injuries. Rev Bras Ortop. 2013 Jun 20;48(2):145-151. doi: 10.1016/j.rboe.2012.10.002. PMID: 31211120; PMCID: PMC6565857.
5. Pinheiro IN, Pedrinha ISM, Maia PAV, Cortes ARO, Albuquerque RPE, Barretto JM. Epidemiological Study on Multiligament Knee Injuries. Rev Bras Ortop (Sao Paulo). 2022 Mar 11;57(4):675-681. doi: 10.1055/s-0041-1731798. PMID: 35966442; PMCID: PMC9365474.

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