title: Impact of academic collaboration and quality of clinical orthopaedic research conducted in low- and middle-income countries.
abstract: BACKGROUND
  Little is known about the quality of orthopaedic investigations conducted in low- and middle-income countries (LMICs). Academic collaboration is one model to build research capacity and improve research quality. Our study aimed to determine (1) the quality of clinical orthopaedic research conducted in LMICs, (2) the World Bank Regions and LMICs that publish the highest quality studies, (3) the pattern of collaboration among investigators and (4) whether academic collaboration between LMIC and non-LMIC investigators is associated with studies that have higher levels of evidence.
  
  
  METHODS
  Orthopaedic studies from 2004 to 2014 conducted in LMICs were extracted from multiple electronic databases. The World Bank Region, level of evidence and author country-affiliation were recorded. Collaboration was defined as a study that included an LMIC with non-LMIC investigator.
  
  
  RESULTS
  There were 958 studies that met inclusion criteria of 22,714 searched. Ninety-seven (10.1%) of included studies achieved Level 1 or 2 evidence, but case series (52.3%) were the most common. Collaboration occurred in 14.4% of studies and the vast majority of these (88.4%) were among academic institutions. Collaborative studies were more likely to be Level 1 or 2 (20.3% vs. 8.4%, p < 0.01), prospective (34.8% vs. 22.9% p = 0.04) and controlled (29.7% vs. 14.4%, p < 0.01) compared to non-collaborative studies.
  
  
  CONCLUSIONS
  Although orthopaedic studies in LMICs rarely reach Level 1 or 2 evidence, studies published through academic collaboration between LMIC and non-LMIC investigators are associated with higher levels of evidence and more prospective, controlled designs.
authors.affiliation: Department of Orthopaedic Surgery, Orthopaedic Trauma Institute, Institute for Global Orthopaedics and Traumatology, University of California, San Francisco, San Francisco, CA 94110, USA.
authors.forename: Hao-Hua
authors.initials: HH
authors.lastname: Wu
authors.affiliation: Department of Orthopaedic Surgery, Orthopaedic Trauma Institute, Institute for Global Orthopaedics and Traumatology, University of California, San Francisco, San Francisco, CA 94110, USA.
authors.forename: Max
authors.initials: M
authors.lastname: Liu
authors.affiliation: Department of Orthopaedic Surgery, University of Illinois College of Medicine, Chicago, IL 60612, USA.
authors.forename: Kushal R
authors.initials: KR
authors.lastname: Patel
authors.affiliation: Department of Orthopaedic Surgery, Orthopaedic Trauma Institute, Institute for Global Orthopaedics and Traumatology, University of California, San Francisco, San Francisco, CA 94110, USA.
authors.forename: Wes
authors.initials: W
authors.lastname: Turner
authors.affiliation: Department of Orthopaedic Surgery, Orthopaedic Trauma Institute, Institute for Global Orthopaedics and Traumatology, University of California, San Francisco, San Francisco, CA 94110, USA.
authors.forename: Lincoln
authors.initials: L
authors.lastname: Baltus
authors.affiliation: Department of Orthopaedic Surgery, Orthopaedic Trauma Institute, Institute for Global Orthopaedics and Traumatology, University of California, San Francisco, San Francisco, CA 94110, USA.
authors.forename: Amber M
authors.initials: AM
authors.lastname: Caldwell
authors.affiliation: Department of Orthopaedic Surgery, Orthopaedic Trauma Institute, Institute for Global Orthopaedics and Traumatology, University of California, San Francisco, San Francisco, CA 94110, USA.
authors.forename: Jesse C
authors.initials: JC
authors.lastname: Hahn
authors.affiliation: Department of Orthopaedic Surgery, Orthopaedic Trauma Institute, Institute for Global Orthopaedics and Traumatology, University of California, San Francisco, San Francisco, CA 94110, USA.
authors.forename: Ralph Richard
authors.initials: RR
authors.lastname: Coughlin
authors.affiliation: Department of Orthopaedic Surgery, Orthopaedic Trauma Institute, Institute for Global Orthopaedics and Traumatology, University of California, San Francisco, San Francisco, CA 94110, USA.
authors.forename: Saam
authors.initials: S
authors.lastname: Morshed
authors.affiliation: Department of Orthopaedic Surgery, Orthopaedic Trauma Institute, Institute for Global Orthopaedics and Traumatology, University of California, San Francisco, San Francisco, CA 94110, USA.
authors.forename: Theodore
authors.initials: T
authors.lastname: Miclau
authors.affiliation: Department of Orthopaedic Surgery, Orthopaedic Trauma Institute, Institute for Global Orthopaedics and Traumatology, University of California, San Francisco, San Francisco, CA 94110, USA.
authors.forename: David W
authors.initials: DW
authors.lastname: Shearer