Research News

More than 10 years have passed since the World Health Assembly and the Lancet Commission on Global Surgery issued concurrent statements focused on improving surgical availability and equity across the world. The guidelines included a list with 44 “essential surgeries,” but the only orthopaedic representation was related to traumatic injuries.

Today, musculoskeletal conditions, including osteoarthritis, are the second leading cause of years lived with disability. With the spectrum of disease burden shifting away from communicable diseases like HIV, tuberculosis and malaria, Nicolas Piuzzi, MD, Vice Chair of Research, Orthopaedic Surgery, and Peter Delaney, MD, a resident in Cleveland Clinic’s Orthopaedic Program, see an opportunity to shift attention and address an unmet need.

Here, they discuss their recent article in the Bulletin of the World Health Organization, focused on advocating for the global surgery community to consider arthroplasty an essential surgery.

What motivated you to write this article and propose this consideration from the front line?

Nicolas Piuzzi (NP): In my clinical work, I see firsthand the experiences and suffering of patients with osteoarthritis. My grandmother and grandfather both had bilateral hip replacements. Seeing their experiences with the surgery shaped my early understanding of the disease’s limitations and the profound, transformative impact of arthroplasty on restoring mobility and quality of life. Although these musculoskeletal conditions often do not take a person’s life abruptly or in a short period of time, they do steal your life, silently and over time.

I recently became the Vice Chair of Research for Orthopaedics, overseeing Cleveland, Florida and London. I am also co-director of the Musculoskeletal Research Center. The question at the top of my mind is, “How do we tackle the global problem of osteoarthritis?”

Peter Delaney (PD): As an EMT and Red Cross first aid instructor during my undergraduate studies at Washington University in St. Louis, I had an opportunity to go to Uganda in 2016 to conduct global health research. I was shocked to see communities lacking emergency medical services (like dedicated 9-1-1 lines, ambulances or trained personnel), and partnered with a professor and local Ministry of Health officials to train existing motorcycle taxi drivers as first responders. Through this training, we helped them create a basic EMS system.

Since then, my research has been focused on trauma system development in the prehospital setting of resource-limited countries, primarily in Sub-Saharan Africa. This snowballed into a nonprofit (LFR International), which has provided training for 8,000 first responders across projects in seven countries, including Chad, Sierra Leone, Nigeria, Cameroon, Guatemala, the Philippines and Kenya.

While at the University of Michigan Medical School, I was also a researcher at the Michigan Center for Global Surgery under Krishnan Raghavendran, MBBS, which prompted the shift in my global health interest toward the surgical setting.

What are the global effects of excluding arthroplasty from the list of “essential surgeries”?

NP: Arthroplasty is currently considered an “elective surgery,” and that classification unintentionally denies life-saving treatment to millions of people. Nearly 600 million people have osteoarthritis, and that number is expected to grow to nearly one billion by 2050. We’re entering an era of chronic disability, as the population ages and people are living longer, and we need to devote attention to improving their quality of life.

PD: In many low- and middle-income countries, especially in Sub-Saharan Africa, arthroplasty is not widely available. Where it is, implants can oftentimes be hard to acquire. Some areas do not have orthopaedic surgeons, either—and that shortage is only going to grow as demand increases.

What do you see as the first steps toward addressing these problems?

NP: We’re working with colleagues and international societies, and hope to build a consensus statement and strategic program over the next few years. This effort will position us to formally propose arthroplasty as a topic for discussion at a future World Health Organization meeting. Ideally, that statement would include a framework that demonstrates how arthroplasty is cost-effective, is reproducible with predictable outcomes and has standard pathways suitable for implementation in countries of all means and income levels.

Cleveland Clinic’s Orthopaedic Outcome Measurement and Evaluation (OME) Program, which includes more than 1 million data points for over 250,000 knee or hip arthroplasty patients, will help redefine what is often labeled as “elective.” By better understanding patient needs, severity and outcomes, we can distinguish procedures that are “optional” from those that are essential to restoring mobility, independence and quality of life.

PD: We need to define a “minimum arthroplasty package” as part of this framework. In other words, what are the bare essentials needed (luxury of choice aside) to safely and ethically perform arthroplasty? This could include the implants, anesthesia, antibiotics, operating table, number of retractors and so on. We can learn so much from surgeons across the world about how they do these procedures under all conditions—and that’s the benefit of working with a global team.  

How could Cleveland Clinic serve as a contributing leader institution to work toward this change?

PD: Cleveland Clinic’s large global footprint and reputation provide a strong platform for jumpstarting this work and forming partnerships that will help it grow.

I am in my third year of residency here, and am so fortunate to work with physicians and researchers like Nico. Writing this article with a mentor and colleague who shares my vision makes this goal feel more achievable. I think orthopaedics has lagged behind the amazing work of our general surgery colleagues in the global surgery space, and this is a crucial opportunity to step up and do something that could help a lot of people.

NP: This effort is not about prioritizing one condition over another, but about aligning attention and resources with the true burden of disease. Osteoarthritis represents a leading cause of disability worldwide, and access to effective interventions remains uneven. I love taking care of patients; this advocacy work, no matter how long it takes, will ensure that high-value, evidence-based care is accessible to patients across the world.