there is a large discrepancy between the supply and demand of surgical services in the developing world , especially for nations in sub - saharan africa . in 2008 , of the estimated 235 million surgical procedures performed annually , only 3.5% was performed in developing countries . this inequality also holds true in the field of orthopaedic surgery and the delivery of musculoskeletal care . over the past decade , many countries in africa have experienced economic growth , which has been associated with a marked increase in motor vehicle traffic . this has led to an increase in injuries from road traffic accidents ( rta ) secondary to a lack of concomitant investment in infrastructure , implementation of traffic and safety laws , and noncompliance with the use of seat - belts and helmets . there has been longstanding and growing interest from the developed world in assisting the developing world , including providing surgical services . involvement in the early 19th century began with a religious focus through  mission trips  that commonly had evangelical motives . the mission trip concept has evolved beyond religious goals to include trips geared towards providing medical and surgical care in the developing world during periodic short trips by medical teams . the typical goals of such trips are to treat patients in need , decrease the local burden of disease through direct patient care and to build local capacity through education and training . in 2012 , there were approximately 6000 such medical missions with approximately $ 250 million raised for funding . in recent years , a growing number of teams of well - intentioned international orthopaedic surgeons have volunteered their time and expertise on trips to the developing world . these medical missions are designed to perform a high volume of surgical procedures over a short period of time . during these trips , a large amount of material resources are transferred to the developing world in order to create a functional operating room facility in the target country . such surgical missions are assumed to be effective in achieving their goals , however , this approach to care raises several questions related to the medical , economic , and social state of the target country including : ( 1 ) what happens to patients that develop a post - operative complication after the surgical team returns to their native country ? ( 2 ) are there facilities available for patients to receive treatment for the complication ? ( 3 ) are the intellectual and material resources at the facility adequate to provide the appropriate treatment for complications ? ( 4 ) is the infrastructure suitable for patients to travel from their homes to the facility ? ( 5 ) assuming that a treatment facility and resources are available , is the treatment affordable to the patient ? ( 6 ) is the treatment culturally acceptable to the patient ? intertwined amongst the decision to perform surgical procedures in the developing world are the ethics of doing so  just because one is capable of performing a procedure , should it be done ? is a procedure such as a total hip replacement , which is appropriate in a developed country , also appropriate in a country with fewer resources for postoperative care ? systems limitations locally within the target country may result in patients being left in worse positions than they were prior to treatment . we present a case performed in tanzania that resulted in the development of an untreatable post - operative complication . this testimony highlights the urgent need for a different approach to providing surgical services in the developing world , but also emphasizes the need for open forums for discussion of international morbidity and mortality cases . sm is a woman who at age 31 resided in a small rural village on the outskirts of nairobi , kenya . she lived with her parents and her two younger brothers in a 20  ft    20  ft dwelling . at the age of 5 , she was afflicted with a condition that affected several of her major joints . her condition was not treated medically due to a lack of family resources as well the limited availability of local treatment options . she was fortunate to be well educated and has completed high school after which she obtained a clerical position at a printing a press and was able to work daily , although with severe pain and deformities . the pain was located in the left groin and was present at rest , but exacerbated with motion . by the age of 29 , the left hip was auto - fused to her pelvis resulting in no range of motion and a significant residual deformity . by this point , most of the symptoms were consistent with low back pain and degenerative disk disease due to increased loads experienced across the lumbosacral spine secondary to the auto - fusion of the left hip . in july 2012 , at 33 years of age , the patient sought treatment from a rheumatologist in nairobi and was told that she would need a total hip replacement ( thr ) . however , a thr in nairobi would cost $ 7000 , which was cost - prohibitive . although discouraged , the patient tenaciously sought alternative routes for getting the appropriate treatment . by november 2012 , due to the severe soft - tissue contracture ( e.g. , severe adduction contracture ) surrounding the left hip , she was unable to urinate comfortably and was unable to have children because vaginal delivery would not be possible . in november 2012 , a rheumatology conference was held in nairobi . a rheumatology colleague from one of the authors ( nps ) home university in the united states attended the conference and met the patient . intrigued by her story , she contacted the author upon her return and asked him to engage in her care . in february 2013 , the author was scheduled to travel to a hospital in arusha , tanzania for a short teaching trip , which is approximately 250 miles from the patient s home . it was agreed upon to meet the patient in arusha , along with new radiographs of the pelvis and left hip as well baseline labs including a sedimentation rate ( esr ) and c - reactive protein ( crp ) . in february 2013 tuk ( an open air carriage so named because of the sound of the motor ) for 9  h to meet the surgeon and the orthopaedic team at the arusha lutheran medical center in tanzania . the patient s esr and crp were 33 ( range 020 ) and 3.2 ( range 06 ) , respectively . the mildly elevated esr ( normal crp ) , although not specific for any given inflammatory process , was consistent with a diagnosis of rheumatoid arthritis , but inconsistent with an infectious process . based on her normal crp the patient stated that the problems she had with her hip permeated her entire life . there was a chronic rheumatoid nodule present at the superolateral aspect of her left hip projecting through the skin . the hip was in a fixed position of 40 of flexion , 20 of adduction , and 10 of internal rotation . this case presented a challenging ethical problem  the patient had a problem that could be addressed with a technically challenging thr , but what if there was a complication post - operatively ? did the benefit of changing this woman s status in her village outweigh the risk associated with the surgical procedure ? the local hospital offered a prosthesis that the surgical team had left behind from a surgical mission the previous year . since there was no surgical or implantation fee for the patient , her only financial responsibility would be the post - operative hospital costs amounting to $ 1000 us , which was feasible for her due to donations by relatives and friends . the decision was made to proceed with the surgical procedure after a detailed informed consent process . the patient was made aware of and demonstrated understanding of the alternatives , risks and benefits of a thr . a pre - operative consent form was signed by the patient and witnessed by the surgeon ( nps ) . the morning of surgery , the patient received pre - operative antibiotics and underwent spinal anesthesia . there was no gross evidence of intraarticular infection at the time of surgery . due to the unique anatomic considerations of the patient  a small pelvis with very poor bone quality secondary to disuse osteopenia  a combination of components from different orthopaedic implant manufacturers were mixed and matched in order to achieve a stable final construct ( fig . her host bone was extremely osteoporotic and was unable to accept the only cementless acetabular device that was available for implantation given her size ; having no other options , this cup was cemented in place . the patient tolerated the procedure well and was brought back to the recovery room in stable condition . her leg length had been restored , and soft - tissue contractures had been adequately addressed ( fig . 3a and b ) . however , due to scant persistent serosanguinous wound drainage for several days , she was placed on intravenous antibiotic treatment . while this was associated with diminution of the drainage , it also added to her total cost burden . the patient s wound eventually healed , and she was discharged to home after a 3-week hospital stay . once back at home in nairobi , kenya , the patient completed an extensive self - directed physical therapy program outlined by the operative surgeon , since therapy services were not readily available due to high cost . the patient maintained contact with the surgeon via email with periodic updates on a monthly basis . she had been doing extremely well and was very happy with her surgical outcome . in october 2013 , approximately 7 months following the index surgical procedure , the patient sent an email stating that she had new onset left hip pain . the pain began insidiously , and had become constant , both at rest as well as with activity . an x - ray of her hip that was reviewed by the operative surgeon ( nps ) demonstrated no interval change in component position and no peri - prosthetic fracture ( fig . it was recommended that the patient obtain a new esr and crp to rule - out deep space peri - prosthetic infection . a set of inflammatory markers was obtained ( esr 136 and crp 12 , respectively ) which was suggestive of a deep space peri - prosthetic infection . accordingly , she was advised to seek evaluation by an orthopaedic surgeon for a hip aspiration , as obtaining synovial fluid from her left hip would be the only way to definitively diagnose the presence of a deep space infection around her left thr , which is potentially very severe . effective treatment of a deep space peri - prosthetic infection typically requires using several expensive resources ( e.g. , 6 weeks of intravenous antibiotic therapy through a peripherally inserted central catheter ) , a multi - disciplinary team approach ( i.e. , orthopaedic surgery with expertise in revision surgery , infectious disease , and a pathologist ( needed for evaluation for intra - operative specimen obtained for final microbiology ) , and one or more additional operations . in kenya , this treatment would cost several thousand us dollars , assuming that the full complement of intellectual and material resources are available at a given hospital facility . prior to surgical intervention , the patient was suffering from significant pain , deformity , limitations with activities of daily living , as well as the social stigma associated with her condition . however , she now is not only in pain , but also likely has a deep - space infection , with an organism with unknown virulence , which can result in a general deterioration of her health , systemic sepsis , and possibly death without appropriate timely treatment . this case demonstrates the ethical challenges that can be created from performing surgical procedures in the developing world without concomitant access to appropriate patient follow - up or resources for treating post - operative complications . while the current system is inadequate to manage the burden of disease , these inadequacies may be exacerbated at times by post - operative complications resulting from well - intentioned surgical missions . consequently , there is need for a new paradigm which provides a more sustainable solution with increased local capacity to treat complications associated with surgical procedures . arguably , this should be considered prior to medical missions and discussed with local personnel and communities as trips are being planned . in addition , until an adequate infrastructure is developed , the informed consent process for surgery in this setting should include a frank discussion about not only potential surgical complications , but also the possibility that they may not be able to be managed appropriately given constrained local resources . this care also raises the very compelling argument , that in retrospect , a total hip replacement may not have been the best choice for this patient . although her preoperative labs were not suggestive of a septic process , the possibility exists that a total hip was done in the setting of an indolent tuberculous infection . moreover , other , more simple surgical procedures , more in - line with the current local standards of care may have been more appropriate for this patient . one could argue , that in this case a simple left femoral subtrochanteric osteotomy with tenotomies and a period of plaster of paris immobilization , could have allowed for the correction of her deformity , improvement of her status , while minimizing the risks that are inherent in a total hip arthroplasty . surgeons across the globe strive to better themselves and optimize patient care . in an ideal world unfortunately , complications are very real and a legitimate concern of every surgery performed . when a complication does occur , it is paramount to critically evaluate the problem , rectify it , and to attempt to prevent future events from occurring . they have been used since the early 1900s as a means to learn from complications and have been a cornerstone in medical education . they were first implemented in surgical departments and later spread to internal medicine and other specialties . as the focus on quality assurance has grown , the core purpose of mmcs should be to call attention to the shortcomings in an organization or patient care that potentially contributed to a complication or the death of a patient and to implement actions aimed at avoiding the reoccurrence of such events . as more resources and opportunities arise to provide medical assistance in the developing world , it is critical to evaluate the impact this is having . for example , there have been calls to ensure that long - term outcomes from mission - based surgeries are measured to help ensure that there are indeed net benefits to patients and communities . nonetheless , even with the best of intentions , complications can and will happen . in the developed world , mmcs are typically held in a grand rounds type forum and allow discussions amongst people involved directly in the case and those who are third party observers . in the international forum , our ability to convene as a group is difficult , but this should not preclude our ability to conduct mmcs . in the electronic age , a written forum such as this will allow an open forum to discuss our complications and to develop solutions and potentially a network of qualified individuals to assist in managing these complex issues . moreover , a collection of these cases will likely be a rich source of data to drive policy improvement as well as education and training . in addition , consideration should be given to developing other means to promote productive conversations regarding such cases . this might include a secure wiki or similar web - based platform that does not require broad bandwidth in which surgeons and other stakeholders , both locally and internationally , could comment on cases thereby creating an opportunity to elicit important perspectives . the presented case illustrates many of the difficulties in caring for individuals in the developing world , raising several important questions : ( 1 ) how can such complications be prevented in the future ? ( 2 ) what are the possible ways of managing a complication with the resources at hand once it occurs ? while , the answers to these questions may not be evident at this point in time , ideally a forum such as a written mmc can help provide rich descriptions of the issues and problems that are encountered so as to increase awareness of them so that appropriate solutions can be identified . in this way , those engaged in well - intentioned medical missions can meet their obligations to help and minimize potential harms in a world that is characterized by marked disparities of resources . all edits / alteration are assured that not to distort scientific meaning of the information presented .