Political stability. If a country is currently at war or otherwise politically unstable, the most pressing need is for first-tier orthopaedics.

Socioeconomic stability. This may be the most influential factor in determining when to introduce arthroscopy and other second-tier orthopaedic technologies. This assessment includes whether or not the country is able to address the first-tier orthopaedic need adequately and whether second-tier orthopaedics would be helpful.

Number of orthopaedists. There should be enough trained orthopaedists to adequately address the trauma and infection burden prior to introducing new tiers of orthopaedics. Admittedly, meeting this need may be a problem in many countries, including Eritrea, and even in some local areas of the United States.

Level of orthopaedic knowledge and sophistication. Examples of markers that would indicate appropriate technical knowledge among local orthopaedists are postgraduate training (in an existing residency program or in a high-income country) or a relationship with a nongovernmental organization such as Orthopaedics Overseas. Our Eritrean colleagues were technically proficient with intraoperative fluoroscopy and with internal and external fixation. They had Internet access to medical literature and were able to prescreen a large number of patients who had appropriate indications for arthroscopy including meniscal tears, ACL tears, and rotator cuff tears.

Capacity for postoperative rehabilitation. In sports medicine, the ultimate outcome of many procedures is nearly as dependent on the postoperative rehabilitation course as on the actual surgical procedure. Thus, appropriate and well-functioning postoperative follow-up with physical therapy is also important.

Low infection rates. For simple, low-cost elective surgery to be safe, infection rates for open procedures should be as low as possible.