Fostering International Knowledge Sharing and Clinical Excellence: A Partnership and Inaugural Academic Conference

Introduction

Merging knowledge and experience through international partnerships is key in the movement toward global health equity [33]. This is especially true in musculoskeletal health. Despite being the leading global contributors to disability among noncommunicable diseases, musculoskeletal conditions have been underprioritized globally [9]. Few countries, regardless of income level, have developed overarching strategic policies for addressing musculoskeletal health challenges [46]. To help bridge the gap, institutions are forging international global alliances, with the goal of “facilitating collaborative research and knowledge exchange” in orthopedics [10].

Facilitating these collaborations is a fundamental goal of the Hospital for Special Surgery (HSS) strategic plan. In this spirit, a strategic partnership was launched in September 2021, joining Colombia’s Fundación Santa Fe de Bogotá (FSFB), Hospital Serena del Mar (HSM) in Cartagena, and HSS in New York. (FSFB is responsible for the operation of HSM.) Knowledge sharing is at the core of this partnership, in which HSS is advising on musculoskeletal-related clinical services and facility design, building on HSS’ previous experience in Brazil, South Korea, and China.

Health care benefits from a culture of learning and knowledge exchange [44]. Both a tool for productivity [37] and fuel for organizational growth and innovation [39], knowledge is an institutional asset [59] that creates a competitive advantage [1,40,50]. Undoubtedly, the members of the partnership share a strong belief in the value of education. For example, FSFB is a private organization that oversees the university hospital in Bogota and was the first of its kind in Colombia to be accredited by the Joint Commission International (JCI) as an academic medical center. Currently, 18 of its disease-specific efforts have received clinical care program certification by the JCI. (The orthopedic department was the first to earn certification.)

The HSS-FSFB partnership supports progress toward health equity, defined by the Pan American Health Organization as the “absence of unfair and avoidable differences in health among population groups defined socially, economically, demographically, and/or geographically” [41]. For Colombians, legislation passed in 1993 marked a major commitment to this idea. Recognizing health as a fundamental right, Law 100 created an insurance system that today covers 96% of the population [35]. (Previously, only 4% of low-income residents were covered.) Although 36.6% of its population lives below the poverty line [43], Colombia meets World Bank criteria for an upper-middle income country [56], and its health care system is considered among the best in Latin America. Nonetheless, infrastructure improvements are warranted. In 2016, 15% of the population did not have geographical access to a hospital providing essential and emergency surgery (laparotomy, cesarean section, and open fracture management) within a 2-hour driving distance [23]. Timely access was even less likely for people living in lower socioeconomic municipalities.

Hospital Serena del Mar was designed to remedy such a lack. Before ground was broken on the new facility in 2016, the historic coastline city of Cartagena had insufficient medical infrastructure to serve its growing population [28]. The facility, which opened its doors in March 2022, is a 152-bed public hospital designed to operate with a person-centered comprehensive clinical care model [25]. It supports more than 60 medical specialties and subspecialties, and state-of-the-art technology enables advanced treatments throughout. Orthopedic surgeons are available around the clock. More than 13,000 patients have visited the emergency room since it opened in March 2022. Decisions surrounding hospital management are service-driven and not market-driven.

A principal component of the HSS-FSFB partnership is the provision of education, training, and professional development to medical professionals involved in musculoskeletal health care. In pursuit of this goal, FSFB received remote access to HSS educational programs: spine and joint replacement weekly grand rounds, symposia held between HSS and global partners in China and Germany, rehabilitation grand rounds, a surgical arthritis service monthly lecture series, and content on the HSS eAcademy learning platform on health systems management. In addition, an educational program combining faculty from HSS and FSFB was planned.

Inaugural Academic Conference: “Innovations in Orthopedics”

“Innovations in Orthopedics” took place on September 30, 2023. The conference was designed to reinforce the partnership’s commitment to a culture of learning and knowledge sharing, in itself an example of the exchange of knowledge, skills, and expertise that promote innovation and excellence [45].

Most attendees were orthopedic surgeons, but the event also drew radiologists, general surgeons, endocrinologists, nurses, and orthopedic residents. In all, 96 participants traveled from around Colombia, representing cities including Barranquilla, Bogotá, Cali, Cartagena, Medellín, Montería, and Pereira. The conference was not streamed, and enrollment was limited to 100. By keeping attendance compact and focusing on emerging topics, the planners sought to create a vibrant atmosphere of interaction and debate, with continuous engagement throughout the program.

There were 4 sessions of presentations led by speakers from all 3 institutions. Each session focused on a specific “hot” topic: (1) basic science of musculoskeletal tissues, (2) innovation in orthopedics, (3) enabling technologies, and (4) musculoskeletal infections.

Session 1: Basic Science

An update on current concepts of pathophysiology of the intervertebral disk (IVD) was presented by Matthew Cunningham, MD, PhD (HSS). Disk degeneration represents a “vicious cycle” that can progress slowly (normal aging) or rapidly (pathological degeneration) associated with interrelated processes that involve biomechanical, cellular, and matrix components [55]. Several gene mutations predispose patients to pathological degenerative disk disease (DDD), and other substances including proinflammatory cytokines have been identified as mediating the process (such as tumor necrosis factor-α and interleukin-1β). Experimental approaches to reverse degeneration suggest that bone morphogenetic protein-2, 7, and 14 and stem cell injections into the IVD may help restore or repair DDD [19,51]. There is also clinical evidence for injection of platelet-rich plasma into the IVD [12,38,53].

The role of cell therapy in tendon repair was presented by Claire D. Eliasberg, MD (HSS). The complex processes implicated in the development of tendinopathy were reviewed. Given its heterogeneous clinical presentation, reviews of research and treatment of tendinopathy are not easily summarized. Cell therapy for the treatment of tendon disease has become a topic of interest to both the orthopedic research community and the general public. While tissue regeneration requires a combination of the appropriate cells, scaffold materials, and molecular environment, cells are essential to the healing response. Cell therapies have demonstrated some promise in both preclinical and clinical trials. Currently available autologous, minimally manipulated, connective tissue progenitors include bone marrow aspirate concentrate (BMAC), adipose-derived cells, and subacromial bursal cells. Numerous experimental models have been developed, suggesting promise for augmentation of healing, but definitive clinical results are still lacking [13,15,42].

Exciting new work suggests that subacromial bursal cells may include a source of progenitor cells as well as important signaling molecules and inflammatory modulators [32]. A subpopulation of subacromial bursal cells has been found to have some characteristics of mesenchymal stromal cells, including key cell surface markers, differentiation capacity, and the ability to grow out colony-forming units [5,34]. Although results from experimental models show promise [36], clinical evidence of efficacy of these cells is needed. More standardized characterization of cell surface markers, gene expression, and biologic performance will be necessary to determine the efficacy of these novel treatments.

Advancements in bone healing and osseointegration were presented by Mathias P. Bostrom, MD (HSS). An understanding of bone biology is important in both fracture healing and bone-to-implant healing. The concept of direct bone healing that requires complete rigidity of the bone fragments and is difficult to achieve has been supplanted by renewed interest in indirect bone healing. Indirect healing involves formation of hematoma and granulation tissue that leads to a combination of endochondral and intramembranous ossification and remodeling. Growth factors involved in mesenchymal stem cell differentiation are expressed during bone healing and include transforming growth factor (TGF)-β, platelet-derived growth factor (PDGF), and fibroblast growth factor (FGF). Aseptic loosening of prosthetic components remains a top reason for implant failure. Investigations of the pathologic mechanisms of these failures are underway focusing on the role of parathyroid hormone analogues as a treatment [49].

Session 2: Innovations in Delivery of Orthopedic Care

The concepts of value-based care were presented by Catherine MacLean, MD, PhD (HSS). She began by citing the fact that in 2021, health care expenditures reached $4.3 trillion in the United States [11], suggesting that poor management and waste are a significant part of this cost. For US employers, high health insurance costs mean wages erode and product costs increase. For orthopedic patients, high health care costs have resulted in delayed or reduced care. In value-based care, the solution is focusing on each overall episode of care and population costs, rather than unit costs. This means incorporating value principles into care delivery and business operations. At HSS, the focus is on delivering the highest quality care in the most cost-effective way by providing evidence-based care through clinical pathways. Clinical decisions are based on the best available evidence and unnecessary care is avoided. This is accomplished through an extensive program involving perioperative clinical pathways, analytics monitoring, and coordination across each episode of care. For joint replacement, delivering greater value and lowering costs involve proper diagnosis and timing of surgical treatment, preferred discharge to home, reduced readmissions due to fewer infections, fewer complications, and need for fewer revisions. These new approaches have led to significant cost savings ($11,085) over an episode of care for a hip or knee replacement.

The challenge of innovations in orthopedic surgery was presented by Adolfo Llinás, MD (FSFB). Dr Llinás stressed that the responsible adoption of innovation and technology in orthopedics requires an organization in which decisions are based on a clearly delineated model of care. This model’s characteristics should be easily identifiable and regularly expressed in the actions of the administration and the care team reflecting a therapeutic expression of culture. The foundations of the FSFB model include 4 ideals. First is a devotion to evidence-based interventions. Next is person-centered care (an approach that began with the institution’s founding 50 years ago), followed by continuity of care, which prioritizes prevention of complications as much as cure. Finally, surgical care should follow well-defined algorithms that support high-quality outcomes across the entire organization. Treatment decisions are based on a definition of value that balances outcomes that matter to the patient with the cost of delivering results. Innovations that cost more but have little effect on the patient’s interests are not of value. In this idealized relationship between cost and value, every peso or dollar invested in clinical activity should produce better, tangible, results. At FSFB, and by extension HSM, even new innovations or technologies that have been validated are not incorporated into practice if they do not meet this value proposition.

Guillermo Bonilla, MD (FSFB), discussed the challenges of adopting new technology, which include balancing clinical responsibility to the patient with the need for innovation. An ethical approach might begin with asking whether the innovation is addressing a serious problem; efforts should benefit patients and not, for example, fulfill a surgeon’s desire to use a new device. The risk/benefit ratio should be in the patient’s favor. Patients must understand that they have a choice when new approaches are offered. Vigilant and systematic measurement of outcomes should follow implementation of any innovation that includes early detection of failures and long-term outcomes in sufficient numbers of cases. Surgeons must assess their own outcomes when implementing unproven technologies to ensure an ethical framework for innovation.

Jorge Rojas Liévano, MD, MSc (FSFB), addressed the impact of artificial intelligence (AI) in orthopedic surgery, illustrating how it might evolve. As one study shows, 72% of publications involving AI in orthopedics have been published in the last 3 years [27]. As AI changes clinical practice and research in orthopedics, orthopedists must understand its capabilities and risks. Artificial intelligence works through machine learning, which allows computers to “learn” without being explicitly programmed. Examples of the application of AI in orthopedic surgery include robotic surgery and navigation systems that are being used in preoperative planning and surgical execution. Artificial intelligence–guided interpretation of clinical imaging is rapidly becoming a tool for diagnosis and risk assessment of fractures, tumors, developmental dysplasia of the hip, and prediction of the risk of post-total hip arthroplasty dislocation. Natural language processing and electronic medical records are being used to aggregate and analyze large databases. AI is also being used in rehabilitation, surgical training, and research. Its potential limitations include high costs, compromised confidentiality, validation by users, and assessment of data quality and generalizability with associated legal issues and liability. How these issues are addressed will determine how AI will facilitate orthopedic practice.

Session 3: Enabling Technology in Orthopedics

The implementation of robotics and navigation in total joint replacement was addressed by Alberto Carli, MD, MSc, FRCSC (HSS). Since 2017, the use of robotics in hip replacement surgery has more than doubled and its use in knee procedures has grown to over 10% in 2022 [2]. Use is expanding internationally as well [3]. However, the clinical benefits and cost-effectiveness of this innovation has yet to be proven [17]. Dr Carli believes there are clear benefits to use of robotics in complex procedures, but more research is needed to determine benefit in routine cases. Longer operative times and additional incisions that are required theoretically put patients at greater risk for complications. It is unclear whether the enormous capital costs for equipment and training required for navigation and robotics can be recouped through improving clinical outcomes. Ultimately, well-powered randomized controlled trials are needed to answer these questions.

Klaus Mieth Alviar, MD, MSc (FSFB), presented on risk and preventive measures in sport medicine. In this field, there is a tremendous opportunity to help prevent injuries through public education. Injury during sports is associated with the possibility of prolonged disability, subsequent injury, loss of performance, as well as a risk of developing osteoarthritis. Understanding mechanisms of injury has been identified as a key to prevention [4]. Intrinsic risk factors include age, sex, body composition, history of injuries, ability, and psychological factors. Extrinsic risk factors include team dynamics and atmosphere. Environmental risk factors include cold climate, artificial grass, and a dry environment. More than 70% of injuries are non-contact, caused by sudden changes of direction, deceleration, and jumping with knee hyperextension [4]. Risk of injury can be addressed by neuromuscular training following programs such as FIFA 11 and FIFA Junior. Injury prevention demands education at all levels of sport including leadership, coaching, and athletes of all ages.

Advances in imaging for orthopedic trauma were presented by William M. Ricci, MD (HSS). Advanced imaging is critical for orthopedic trauma care. Today, a combination of low- and high-tech imaging modalities are available. Traditional x-rays and picture archiving and communication systems (PACS) enable computer-assisted preoperative planning. Advanced imaging can be used to advance fracture fixation permitting patient-specific reconstruction [7]. Given that there is no significant difference between a patient’s right and left, low-tech comparisons using x-rays or computed tomography (CT) scans of the patient’s injured and uninjured sides can provide an accurate template for trauma reconstructions. Two-dimensional CT reconstructions have proven useful, especially for pelvic reconstruction. Finally, intraoperative 3D fluoroscopy is presenting unique advantages [16,24].

Matthew Cunningham, MD (HSS), explored the role of computer navigation and robotics in spine surgery. Research suggests that computer-assisted navigation in spine surgery may lead to significant reductions in operative and fluoroscopy times and hardware-related complications [8,54]. Robotics may lead to improved accuracy in screw placement and allow for a significant increase in screw diameter and length [47]. It may also significantly decrease high-grade breaches of the pedicle into the spinal canal [48]. Considering the emerging evidence, practitioners who accept the learning curve should critically evaluate how the new technology works in their hands, get buy-in from everyone involved, and drive its use according to their experience.

Session 4: Musculoskeletal Infection

A discussion of the current challenges of diagnosis of periprosthetic joint infection (PJI) was presented by Guillermo Bonilla, MD (FSFB). Diagnosis of PJI can be challenging, but it is imperative. One recent study found that at 2 years after revision, total knee arthroplasty patients with undiagnosed PJI had an infection-free implant survival rate of 88%, compared with 98% in patients without a PJI [29]. Periprosthetic joint infection can be identified by combining 2 diagnostic elements: clinical likelihood (including clinical history and physical examination) and diagnostic tests. C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) are the most commonly used serum markers with proven sensitivity and specificity [26,57]. While patients without clinical signs of infection and negative serum markers are cleared for aseptic revision, patients with high clinical suspicion or positive markers should undergo joint aspiration and culture. Patients with clinical evidence of infection but negative synovial fluid test results require additional testing including intraoperative synovial biopsy and fluid culture. Future challenges include improving the clinical evidence supporting diagnosis of PJI, adding clinical presentation to diagnostic criteria, moving from dichotomous to continuous interpretation of test results, understanding the best combination of tests, and adoption of genomic assays into routine practice.

Alberto Carli, MD (HSS), presented on the utility of sequencing in the diagnosis of PJI. In spite of consensus statements published by the Musculoskeletal Infection Society (2011), the Infectious Disease Society of America (2013), the 2nd International Consensus Meeting on Musculoskeletal Infection (2018), and the European Bone & Joint Infection Society (EBJIS) (2021), there is no universally accepted consensus definition for the diagnosis of PJI. This is not for lack of attention to the issue. Yet despite the evident benefit of these consensus statements, 887 articles on diagnosing PJI (representing 26% of the total literature on the subject) have been published since the release of the 2021 EBJIS statement. Diagnosing PJI continues to be complicated when traditional culture methods fail to grow an organism (referred to as a “culture negative infection”) [31] or when an absence of PJI needs to be verified, such as in the setting of reimplantation during a 2-stage procedure.

A potential aid in these complex situations is next-generation sequencing (NGS), in which fragments of bacterial DNA (separated by a process called “shotgun sequencing”) found in joint fluid are meticulously matched to bacterial genome libraries through complex bioinformatic processes that can identify the pathogen as well as underlying genetic mutations that could confer virulence or antibiotic resistance [52]. Additional benefit may arise from analysis of bacterial RNA products (instead of DNA), through a process referred to as meta-transcriptomics [22]. It is important to note that despite their impressive performances, NGS and related molecular techniques remain expensive and require large bioinformatic databases that currently preclude their use on a wider basis across the United States. Nevertheless, interest in these techniques will persist and they will remain a popular target of future PJI diagnostic studies for years to come.

Alberto Carli, MD, and Guillermo Bonilla, MD, addressed the treatment of musculoskeletal infection in North and South America. They emphasized that choosing the best treatment for PJI remains a continuing debate among arthroplasty surgeons. The least morbid option, in which infected tissue is debrided, antibiotics are administered, and implants are retained (referred to as a DAIR procedure), is unfortunately associated with the poorest rate of success. Removing implants, although substantially more morbid, is associated with better treatment success rates, but the debate as to whether a new implant should be immediately placed (single-stage surgery) or in a separate surgery once the infection is fully treated (2-stage surgery) remains vigorously debated. A recent long-term study of single-stage exchange describes eradication of infection in 94% of cases with 76% implant survival at 10 years [58]. The authors also describe the contraindications for single-stage exchange including the presence of enterococcal infections and of specific patient comorbidities [14]. Despite these encouraging results, the orthopedic community will benefit from the results of a multicenter randomized control trial currently taking place in the United States. The 2-stage procedure remains the gold standard in many parts of the world [6,18,20,21,30] and is more commonly performed (by a ratio of 9 to 1) at HSS, FSFB, and HSM. A perceived issue in Latin America is administration of broad-spectrum antibiotics alone as the first action following suspicion of PJI without appropriate surgical management. Modern management of PJI and improved stewardship of antibiotics is needed throughout Latin America.

Conclusion

This inaugural meeting of the HSS-FSFB partnership provided a novel learning format for creating synergy between different institutions with a common goal. With speakers from HSS, HSM, and FSFB, the conversation explored differences in US and Colombian medical models, geographies, health systems, and economies, seeking to identify what will be of greatest value in the future of patient-centered care.

With a multidisciplinary audience of just 100 attendees, this closed meeting allowed for emerging topics of interest in musculoskeletal care to be discussed, with attention to creating therapeutic approaches that will exceed patient expectations. Transparent debate allowed for understanding to be reached among professionals dedicated to incorporating the best available evidence. At the conclusion of the academic session, an action plan was drafted to capitalize on the insights of the debate. The publication of this document is part of that commitment. We hope it may be of use to those who share our vision.