Iran's Orthopaedic Landscape: Distribution, Per-capita Ratios, Female Inclusion, and Academic Standing among Residents and Surgeons

Document Type : RESEARCH PAPER

Authors

1 International Center for Limb Lengthening, Rubin Institute for Advanced Orthopaedic s, Sinai Hospital of Baltimore, Baltimore, Maryland, USA

2 School of Medicine, Tehran University of Medical Sciences, Tehran, Iran -Neuromusculoskeletal Research Center, Iran University of Medical Sciences, Tehran, Iran

3 School of Medicine, Tehran University of Medical Sciences, Tehran, Iran

4 Student Research Committee, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran

5 Sina University Hospital, Tehran University of Medical Sciences, Tehran, Iran

10.22038/abjs.2025.82716.3767

Abstract

Objectives: Iran's orthopaedic surgery care is facing significant challenges due to an aging population and the increasing prevalence of chronic medical conditions such as osteoarthritis, fractures, and trauma. These challenges underscore the pressing need for a more equitable distribution of the orthopaedic workforce. This study aimed to assess the per capita ratios and geographical distribution of orthopaedic surgeons (OSs) in Iran, as well as their distribution in academic and non-academic settings. Additionally, the involvement and scientific productivity of women in orthopaedic s were examined.
Methods: This study investigated the distribution, per-capita ratios, and academic status of OSs and trainees in Iran, and compared these parameters with those in Turkey and the UK. This study used data from the Islamic Republic of Iran Medical Council, the Iranian Scientometrics Information Database, and the population census to indicate an uneven distribution of OSs across Iran.
Results: The per capita ratio of OSs in Iran (3.13) is lower than in Turkey (4.00) and the United Kingdom (8.00), highlighting disparities in healthcare infrastructure and economic resources in low-income countries. Notably, 33.6% of Iranian OSs reside in Tehran, contributing to unequal access to care. Furthermore, female representation in orthopaedic s remains limited, with only 3.5% of OSs being women. These academic surgeons have a median H-index of 4, which is lower than that of their counterparts in Canada and the United States.
Conclusion: The study emphasized the significance of governmental reforms and incentives in promoting equitable distribution, gender diversity, and academic progress within Iran's orthopaedic workforce. Financial incentives, advanced facilities, and career advancement opportunities could enhance academic involvement and diversity. Improving the distribution of surgeons, increasing support for women in orthopaedic, and fostering academic interests are essential steps toward achieving equitable healthcare and boosting scientific output in Iran.
        Level of evidence: IV

Keywords

Main Subjects

References

  1. Hogan MV, Ahn J, Egol KA, Mittwede PN. Research During Orthopaedic Training. J Am Acad Orthop Surg. 2022;30(4):e461-e469. doi:10.5435/jaaos-d-21-00455.
  2. Vail TP. What's Important: A Musculoskeletal Moonshot: Accelerating Orthopaedic Innovation. J Bone Joint Surg Am. 2018;100(7):627-628. doi:10.2106/jbjs.17.01486..
  3. Poacher AT, Bhachoo H, Weston J, Shergill K, Poacher G, Froud J. Undergraduate education of trauma and orthopaedic surgery in the UK : a systematic review. Bone Jt Open. 2022;3(7):549-556. doi:10.1302/2633-1462.37.Bjo-2022-0044.R1.
  4. Rohrer F, Farokhnia A, Nötzli H, et al. Profit-Influencing Factors in Orthopaedic Surgery: An Analysis of Costs and Reimbursements. Int J Environ Res Public Health. 2022;19(7). doi:10.3390/ijerph19074325.
  5. Yu S, Zuckerman JD. Orthopaedic s in US Health Care. Am J Orthop (Belle Mead NJ). 2015;44(12):538-41.
  6. Wibulpolprasert S, Pengpaibon P. Integrated strategies to tackle the inequitable distribution of doctors in Thailand: four decades of experience. Hum Resour Health. 2003;1(1):12. doi:10.1186/1478-4491-1-12.
  7. Okike K, Utuk ME, White AA. Racial and ethnic diversity in orthopaedic surgery residency programs. J Bone Joint Surg Am. 2011;93(18):e107. doi:10.2106/jbjs.K.00108.
  8. Day MA, Owens JM, Caldwell LS. Breaking Barriers: A Brief Overview of Diversity in Orthopaedic Surgery. Iowa Orthop J. 2019;39(1):1-5.
  9. Amiresmaili M, nekoeimoghadam M, Goudarzi R, Yazdi-Feyzabadi V, Karimi Mobarakeh M, Jahad Sarvestani A. Epidemiological study of Total Knee Arthroplasty in Iran. Health Management & Information Science. 2021;8(3):210-216. doi:10.30476/jhmi.2022.92476.1096.
  10. Aslani H, Nourbakhsh ST, Lahiji FA, et al. Iranian Joint Registry (Iranian National Hip and Knee Arthroplasty Registry). Arch Bone Jt Surg. 2016;4(2):192-6.
  11. Bastian S, Ippolito JA, Lopez SA, Eloy JA, Beebe KS. The Use of the h-Index in Academic Orthopaedic Surgery. J Bone Joint Surg Am. 2017;99(4):e14. doi:10.2106/jbjs.15.01354.
  12. Casciato DJ, Cravey KS, Barron IM. Scholarly Productivity Among Academic Foot and Ankle Surgeons Affiliated With US Podiatric Medicine and Surgery Residency and Fellowship Training Programs. J Foot Ankle Surg. 2021;60(6):1222-1226. doi:10.1053/j.jfas.2021.04.017.
  13. Appelbaum NP, Lee N, Amendola M, Dodson K, Kaplan B. Surgical Resident Burnout and Job Satisfaction: The Role of Workplace Climate and Perceived Support. J Surg Res. 2019:234:20-25. doi: 10.1016/j.jss.2018.08.035.
  14. Lases LSS, Arah OA, Busch ORC, Heineman MJ, Lombarts K. Learning climate positively influences residents' work-related well-being. Adv Health Sci Educ Theory Pract. 2019;24(2):317-330. doi:10.1007/s10459-018-9868-4.
  15. Christmas C, Durso SC, Kravet SJ, Wright SM. Advantages and challenges of working as a clinician in an academic department of medicine: academic clinicians' perspectives. J Grad Med Educ. 2010;2(3):478-84. doi:10.4300/jgme-d-10-00100.1.
  16. Chen RE, Kuhns BD, Kaupp S, Voloshin I, Mannava S. Diversity among academic orthopaedic shoulder and elbow surgery faculty in the United States. J Shoulder Elbow Surg. 2020;29(4):655-659. doi:10.1016/j.jse.2019.11.035.
  17. Onuoha AC, Meadows AM, Faraj MT, Skinner MM, Day C, Ravi K. Comparative analysis of racial and gender diversity in orthopaedic surgery applicants and residents from 2007 and 2019. Journal of Orthopaedic Experience & Innovation. 2022;3(1).
  18. Lum ZC, Dennison S, Le HV, Bayne CO, Lee CA. Trends in Orthopaedic Surgery Workforce Diversity: Analyzing Changes Over Time. J Am Acad Orthop Surg Glob Res Rev. 2024;8(4)doi:10.5435/JAAOSGlobal-D-24-00038.
  19. Van Heest AE, Fishman F, Agel J. A 5-Year Update on the Uneven Distribution of Women in Orthopaedic Surgery Residency Training Programs in the United States. J Bone Joint Surg Am. 2016;98(15):e64. doi:10.2106/jbjs.15.00962.
  20. Van Heest AE, Agel J. The uneven distribution of women in orthopaedic surgery resident training programs in the United States. J Bone Joint Surg Am. 2012;94(2):e9. doi:10.2106/jbjs.J.01583.
  21. Klyce W, Nhan DT, Dunham AM, El Dafrawy MH, Shannon C, LaPorte DM. The Times, They Are A-Changing: Women Entering Academic Orthopaedic s Today Are Choosing Nonpediatric Fellowships at a Growing Rate. J Surg Educ. 2020;77(3):564-571. doi:10.1016/j.jsurg.2019.12.007.
  22. Van Heest AE, Agel J, Samora JB. A 15-Year Report on the Uneven Distribution of Women in Orthopaedic Surgery Residency Training Programs in the United States. JB JS Open Access. 2021;6(2)doi:10.2106/jbjs.Oa.20.00157.
  23. Rohde RS, Wolf JM, Adams JE. Where Are the Women in Orthopaedic Surgery? Clin Orthop Relat Res. 2016;474(9):1950-6. doi:10.1007/s11999-016-4827-y.
  24. Alomar AZ, Almonaie S, Nagshabandi KN, AlGhufaili D, Alomar M. Representation of women in orthopaedic surgery: perception of barriers among undergraduate medical students in Saudi Arabia. J Orthop Surg Res. 2023;18(1):19. doi:10.1186/s13018-022-03487-6.
  25. Agaronnik N, Xiong GX, Uzosike A, et al. The role of gender in academic productivity, impact, and leadership among academic spine surgeons. Spine J. 2022;22(5):716-722. doi: 10.1016/j.spinee.2021.1
  26. Hoof MA, Sommi C, Meyer LE, et al. Gender-related Differences in Research Productivity, Position, and Advancement Among Academic Orthopaedic Faculty Within the United States. J Am Acad Orthop Surg. 2020;28(21):893-899. doi: 10.5435/JAAOS-D-19-00408.
  27. Parhizkari K, Kuehnel S. Comparing Modernization in Iran and Turkey. International Journal of Social Sciences and Humanity Studies. 2011;3(1):207-15.
  28. Liu S, Wang B, Fan S, Wang Y, Zhan Y, Ye D. Global burden of musculoskeletal disorders and attributable factors in 204 countries and territories: a secondary analysis of the Global Burden of Disease 2019 study. BMJ Open. 2022;12(6):e062183. doi:10.1136/bmjopen-2022-062183.
  29. Al-Ajlouni YA, Al Ta'ani O, Mushasha R, et al. The burden of musculoskeletal disorders in the Middle East and North Africa (MENA) region: a longitudinal analysis from the global burden of disease dataset 1990-2019. BMC Musculoskelet Disord. 2023;24(1):439. doi:10.1186/s12891-023-06556-x.
  30. Grosios K, Gahan PB, Burbidge J. Overview of healthcare in the UK. EPMA J. 2010;1(4):529-34. doi:10.1007/s13167-010-0050-1.
  31. Adams R, Branthwaite H, Chockalingam N. Prevalence of musculoskeletal injury and pain of UK-based podiatrists and the impact of enforced altered working practices. J Foot Ankle Res. 2021;14(1):53. doi:10.1186/s13047-021-00491-7.
  32. IRIMC. Islamic Republic of Iran Medical Council, Membersearch. Available at: https://membersearch.irimc.org/. Accessed May 15, 2024.
  33. ISID. Iranian Scientometrics Information Database. Available at: https://isid.research.ac.ir/Index.php. Accessed May 15, 2024.
  34. Sanjesh. Iran's Medical Education Assessment Center Accessed. Available at: https://sanjeshp.ir/Content.aspx?click=12. Accessed May 15, 2024.
  35. Statistical Center of Iran. Available at: https://amar.org.ir/. Accessed May 15, 2024.
  36. Madanat R, Mäkinen TJ, Ryan D, Huri G, Paschos N, Vide J. The current state of orthopaedic residency in 18 European countries. Int Orthop. 2017;41(4):681-687. doi:10.1007/s00264-017-3427-0.
  37. Peterson BE, Jiwanlal A, Della Rocca GJ, Crist BD. Orthopaedic Trauma and Aging: It Isn't Just About Mortality. Geriatr Orthop Surg Rehabil. 2015;6(1):33-6. doi:10.1177/2151458514565663.
  38. Alqarni MM, Alaskari AA, Al Zomia AS, et al. Epidemiology and Pattern of Orthopaedic Trauma in Children and Adolescents: Implications for Injury Prevention. Cureus. 2023;15(5):e39482. doi:10.7759/cureus.39482.
  39. Chalupa RL, Hooker RS. The education, role, distribution, and compensation of physician assistants in orthopaedic surgery. JAAPA. 2016;29(5):1-7. doi:10.1097/01.JAA.0000482318.38700.d1.
  40. Agaronnik N, Xiong GX, Uzosike A, et al. The role of gender in academic productivity, impact, and leadership among academic spine surgeons. Spine J. 2022;22(5):716-722. doi:10.1016/j.spinee.2021.12.003.
  41. Mock C, Cherian M, Juillard C, et al. Developing priorities for addressing surgical conditions globally: furthering the link between surgery and public health policy. World J Surg. 2010;34(3):381-5. doi:10.1007/s00268-009-0263-4.
  42. Ozgediz D, Jamison D, Cherian M, McQueen K. The burden of surgical conditions and access to surgical care in low- and middle-income countries. Bull World Health Organ. 2008;86(8):646-7. doi:10.2471/blt.07.050435.
  43. Marks IH, Thomas H, Bakhet M, Fitzgerald E. Medical equipment donation in low-resource settings: a review of the literature and guidelines for surgery and anaesthesia in low-income and middle-income countries. BMJ Glob Health. 2019;4(5):e001785. doi:10.1136/bmjgh-2019-001785.
  44. Grimes CE, Henry JA, Maraka J, Mkandawire NC, Cotton M. Cost-effectiveness of surgery in low- and middle-income countries: a systematic review. World J Surg. 2014;38(1):252-63. doi:10.1007/s00268-013-2243-y.
  45. Meliala A, Hort K, Trisnantoro L. Addressing the unequal geographic distribution of specialist doctors in indonesia: the role of the private sector and effectiveness of current regulations. Soc Sci Med. 2013;82:30-4. doi:10.1016/j.socscimed.2013.01.029.
  46. Nair A, Jawale Y, Dubey SR, Dharmadhikari S, Zadey S. Workforce problems at rural public health-centres in India: a WISN retrospective analysis and national-level modelling study. Hum Resour Health. 2022;19(Suppl 1):147. doi:10.1186/s12960-021-00687-9.
  47. Rawal LB, Joarder T, Islam SM, Uddin A, Ahmed SM. Developing effective policy strategies to retain health workers in rural Bangladesh: a policy analysis. Hum Resour Health. 2015;13:36. doi:10.1186/s12960-015-0030-6.
  48. Sriram V, Hariyani S, Lalani U, Buddhiraju RT, Pandey P, Bennett S. Stakeholder perspectives on proposed policies to improve distribution and retention of doctors in rural areas of Uttar Pradesh, India. BMC Health Serv Res. 2021;21(1):1027. doi:10.1186/s12913-021-06765-x.
  49. Thoresen SH, Fielding A. Inequitable distribution of human resources for health: perceptions among Thai healthcare professionals. Qual Prim Care. 2010;18(1):49-56.
  50. Dell AJ, Gray S, Fraser R, Held M, Dunn R. Orthopaedic Surgeon Density in South Africa. World J Surg. 2018;42(12):3849-3855. doi:10.1007/s00268-018-4709-4.
  51. Brouillette MA, Kaiser SP, Konadu P, Kumah-Ametepey RA, Aidoo AJ, Coughlin RC. Orthopaedic surgery in the developing world: workforce and operative volumes in Ghana compared to those in the United States. World J Surg. 2014;38(4):849-57. doi:10.1007/s00268-013-2314-0.
  52. Moradi R, Olyaeemanesh A, Mosadeghrad AM, Harirchi I, Larijni B. Measuring Equity of Geographical Distribution of Specialist Physicians in Iran's Health System. Int J Prev Med. 2023;14:60. doi:10.4103/ijpvm.ijpvm_542_21.
  53. Rabbanikhah F, Moradi R, Mazaheri E, Shahbazi S, Barzegar L, Karyani AK. Trends of geographic distribution of general practitioners in the public health sector of Iran. J Educ Health Promot. 2018;7:89. doi:10.4103/jehp.jehp_14_18.
  54. Weintraub M, Ahn D, Herzog I, et al. Retainment of U.S. OSs in Academia from 2016 to 2022. JB JS Open Access. 2024;9(1). doi:10.2106/jbjs.Oa.23.00111.
  55. Atwan Y, Charron BP, Sidhu S, Cavanagh J, Degen R. Publication Productivity Among Academic OSs in Canada. Cureus. 2020;12(6):e8441. doi:10.7759/cureus.8441.
  56. Ence AK, Cope SR, Holliday EB, Somerson JS. Publication Productivity and Experience: Factors Associated with Academic Rank Among Orthopaedic Surgery Faculty in the

 

       United States. J Bone Joint Surg Am. 2016;98(10):e41. doi:10.2106/jbjs.15.00757.

  1. Ashfaq A, Kalagara R, Wasif N. H-index and academic rank in general surgery and surgical specialties in the United States. J Surg Res. 2018;229:108-113. doi:10.1016/j.jss.2018.03.059.
  2. Lopez J, Susarla SM, Swanson EW, Calotta N, Lifchez SD. The Association of the H-Index and Academic Rank Among Full-Time Academic Hand Surgeons Affiliated With Fellowship Programs. J Hand Surg Am. 2015;40(7):1434-41. doi:10.1016/j.jhsa.2015.03.026.
  3. Kuhns B, Haws BE, Kaupp S, Maloney MD, Carmody EE, Mannava S. Academic Orthopaedics As a Driver of Gender Diversity in the Orthopaedic Workforce: A Review of 4,519 Orthopaedic Faculty Members. J Am Acad Orthop Surg Glob Res Rev. 2022;6(2). doi:10.5435/JAAOSGlobal-D-21-00028.
  4. Flanagan CD, Schmidt CM, Amin MJ, et al. Academic productivity metrics correlate positively with industry funding amongst orthopaedic shoulder and elbow surgeons. JSES Int. 2023;7(3):372-375. doi:10.1016/j.jseint.2023.02.011.
  5. Flanagan CD, Walson FT, Schmidt CM, Frankle MA, Mir HR. The Association Between Orthopaedic Surgeon Academic Productivity Metrics and Compensation from Medical Industry. J Am Acad Orthop Surg. 2023;31(3):141-147. doi:10.5435/jaaos-d-22-00453.
  6. Haislup BD, Trent S, Sequeira S, Murthi AM, Wright MA. The relationship between academic influence, NIH funding, and industry payments among academic shoulder and elbow surgeons. J Shoulder Elbow Surg. 2022;31(11):2431-2436. doi:10.1016/j.jse.2022.06.019.
  7. Rodgers BM, Moore ML, Mead-Harvey C, et al. How Does Orthopaedic Surgeon Gender Representation Vary by Career Stage, Regional Distribution, and Practice Size? A Large-Database Medicare Study. Clin Orthop Relat Res. 2023;481(2):359-366. doi:10.1097/corr.0000000000002176.
  8. Kocjan K, Safavi KS, Flaherty B, et al. Current Gender Diversity and Geographic Trends Among Orthopaedic Sports Medicine Surgeons in the United States. Orthop J Sports Med. 2022;10(11):23259671221134091. doi:10.1177/23259671221134091.
  9. Kroin E, Garbarski D, Shimomura A, Romano J, Schiff A, Wu K. Gender Differences in Program Factors Important to Applicants When Evaluating Orthopaedic Surgery Residency Programs. J Grad Med Educ. 2019;11(5):565-569. doi:10.4300/jgme-d-18-01078.1.
  10. Jurenovich KM, Cannada LK. Women in Orthopaedic s and their Fellowship Choice: What Influenced their Specialty Choice? Iowa Orthop J. 2020;40(1):13-17.

 

 

 

The Archives of Bone and Joint Surgery
Volume 13, Issue 9
September 2025
Pages 586-594

Files

History

  • Receive Date: 27 September 2024
  • Revise Date: 01 September 2025
  • Accept Date: 22 January 2025

Share

How to cite

Statistics