Date of Award


Document Type

Open Access Thesis

Degree Name

Medical Doctor (MD)



First Advisor

Adrienne Socci

Second Advisor

Theodore Miclau


Abstract: INTERNATIONAL ACADEMIC PARTNERSHIPS IN ORTHOPAEDIC SURGERY. Michael J. Flores. Department of Orthopaedics & Rehabilitation, Yale University, School of Medicine, New Haven, CT.

Introduction: Orthopaedic-related disease (ORD) is one of the leading health challenges faced worldwide and is a significant cause of global morbidity and mortality, especially in low- and middle-income countries (LMICs). In recent years, international orthopaedic outreach to address the global burden of ORD has received greater attention due to initiatives such as the Lancet Commission on Global Surgery (LCGS). Many strategies have been considered to address the global burden of ORD, most commonly though volunteer trips by orthopaedic surgeons from high-income countries (HICs) to underserved areas. However, volunteerism often does not deliver on many of the principles outlined in the LCGS required for sustainable improvements in the availability of safe, affordable surgical care. Orthopaedic international academic partnerships (O-IAPs) are established on the pillars of clinical care, research, education, advocacy, and humanitarianism, as outlined in the LCGS. The purpose of this thesis is to increase understanding of the current state of O-IAPs worldwide though describing the current global quality, quantity, and location of O-IAPs as well as the quality, quantity, and content of their research output.

Methods: The current study is a three-phase comprehensive overview of O-IAPs worldwide. Phase one involved a systematic review of the literature published by O-IAPs to identify current partnership characteristics and locations as well as research quantity, quality, and content. A systematic search was conducted within 4 databases using a librarian-curated search based on orthopaedic-related terms AND LMIC-related terms. Phase two involved developing a rating scale for evaluating O-IAPs through expert consensus in the form of a modified Delphi approach. Three rounds of surveys listing possible topics on a 5-point Likert scale were used to develop consensus. Closing consensus criteria for topic inclusion in the final scale was determined as a rating of “Strongly Agree” or “Agree” by ≥70% of the participants in the third survey. Phase three was a cross-sectional survey sent to the corresponding authors identified in phase one to rate their own O-IAP level of engagement. Author emails identified in phase one were sent a survey with the rating scale from phase two and questions regarding demographic information and partnership barriers they have faced. In all phases, descriptive data was analyzed using Microsoft Excel and Stata 17 and inferential statistics were analyzed using Stata 17. Survey data was created and stored on REDCap.

Results: In phase one, there were 21,145 articles screened and 310 publications extracted, published in 127 journals. The weighted average journal impact factor was 2.98. The most common study design was retrospective. There were 41 HICs and 65 LMICs represented in the O-IAPs. The most common subspecialty was trauma, and the most common article subject was related to injury. In phase two, there were 50 experts who participated in the modified Delphi, who found consensus on 54 topics for the scale organized into 5 general categories: Research, Advocacy/Leadership, Training/Surgical Skills, Exchange of Knowledge/Education, and Sustainability and Safety (RATE-Scale). In phase three, there were 445 emails identified and 60 participants completed the survey. There were 27 HICs and 41 LMICs represented in the partnerships, as some partnerships involved multiple countries. The overall mean RATE-Scale total was 67.8 points (level III engagement). The categories with the highest percentages of mean total points were Research (81.9%) and Advocacy (81.1%). Nearly half of the partnerships rated their engagement level at a level IV (48.3%). The most common barrier identified was lack of funding (13, 28.3%), followed by political unrest (6, 13.0%) and COVID-19 (4, 8.7%). Most participants indicated that their O-IAP barriers were not or only partially resolved (40, 66.7%).

Conclusion: The current thesis is a comprehensive overview of the current state of O-IAPs worldwide. It identified partnerships in 106 countries in all the orthopaedic subspecialties. This thesis can provide information to help simplify and facilitate the needed expansion of O-IAPs worldwide.


This is an Open Access Thesis.

Open Access

This Article is Open Access