Dear Editor,

With great interest, we read the article “Off-label use of orthopedical trauma implants in a low-income country [1]” by F. Wichlas et al. Many thanks to the authors for their contribution in studying the use of off-labeled orthopaedic trauma devices in low-income countries. But I have a very important question that I would like to discuss with the author.

In low-income countries, limited resources limit primary surgeons in surgery. One important point is that the surgeon’s skill and teamwork greatly affects the prognosis of the surgery. Therefore, with limited resources, the effectiveness of improvisation depends heavily on the experience and expertise reserve of the lead surgeon. So, how is it possible to ensure the effectiveness of improvisation? I hope to draw some general lessons that can be applied to clinical surgery in low-income countries.