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Fig. 1 Average number of years spent in orthopaedic training by geographic region
Courtesy of Andrew R. Jensen, MD, MBE


Published 2/1/2019
Andrew R. Jensen, MD, MBE; Musiliu Odunola, MB, MPH; Faseeh Shahab, MD; Nicholas Bonazza, MD; Christian Carrwik, MD; Verena Schreiber-Frank, MD; Kevin J. Cronin, MD

AAOS Resident Assembly’s Survey Examines Domestic and International Training Trends

Worldwide, orthopaedic educators are tasked with training the next generation of surgeons for their local communities. Every country has different norms and standards for providing this education; however, there is surprisingly little discourse amongst international orthopaedic educators regarding the best ways of teaching their trainees.

With this in mind, the AAOS Resident Assembly surveyed orthopaedic trainees from across the globe to examine regional trends in orthopaedic education and identify particularly effective orthopaedic education practices.

An electronic questionnaire was sent to selected English-speaking senior trainees (also known as residents in many parts of the world) who were identified through local contacts in 2017. Authors from the United States, Sweden, and Nigeria jointly created the electronic questionnaire to minimize geographical survey bias. The questionnaire addressed seven domains related to orthopaedic trainee education, including:

  1. Residency application process
  2. Residency length
  3. Work hours
  4. Tests and evaluations
  5. Educational resources
  6. Surgery case volume
  7. Post-residency training

The survey was open for a period of six weeks. Researchers received 238 responses from trainees in 57 countries. The responses were grouped by country into nine geographic regions according to the Central Intelligence Agency’s “World Factbook”: Africa, Central America and the Caribbean, East and Southeast Asia, Europe, Oceania, Middle East, North America, South America, and South Asia.

The findings, summarized here, highlight the many similarities and some notable differences in the ways orthopaedic education is delivered.

Length of training

Results of the survey revealed that the average time spent in an orthopaedic-specific training program was 4.4 years. There was large variability in length of training, with respondents in Europe reporting the most years (5.4) and those in South America the fewest (3.2) (Fig. 1). The number of years spent in pre-orthopaedic training was also highly variable due to differences in local educational systems.

Work hours

Orthopaedic trainees across the globe work long hours. On average, respondents reported working 71 hours per week. However, in contrast to the longer length of training seen in Europe, European trainees worked fewer hours (51 hours per week) than the rest of respondents (Fig. 2). Many European training programs abide by European Union law, which restricts medical trainee work to 48 hours or fewer per week. Trainees from 22 countries, mostly in Europe and North America, reported some form of restrictions to work hours (38 percent). Many respondents from those countries did note, however, that the restrictions were not frequently enforced.

Trainee evaluations

Most reported that an end-of-residency certification process (88 percent) and standardized surgical case logs (79 percent) were mandatory. The same was not true, however, for annual written examinations. Only 40 percent of non-U.S. respondents reported that they were required to take an annual exam. In the United States, all orthopaedic residents take the Orthopaedic In-training Exam on a yearly basis.

Educational resources

Information is easier to access now than ever before. There is an abundance of resources for modern trainees to utilize, including textbooks, scientific journals, electronic resources, and even surgical simulators. Textbooks remain the most commonly used educational resources worldwide (Fig. 3), particularly in Africa, East and Southeast Asia, and South Asia, where more than 80 percent of trainees reported daily use. The daily use of scientific journals was more common in South America (50 percent) and North America (37 percent) than in other regions of the world (13 percent).

Use of electronic educational resources also demonstrated marked regional variability. For instance, 61 percent of trainees in North America reported using the website Orthobullets (www.orthobullets.com) daily compared to just 17 percent of trainees in Europe and 27 percent in South Asia. Surgical simulators remain rare globally, with only 7 percent of trainees worldwide reporting daily or weekly use. Most trainees stated that surgical simulators (79 percent) or cadaver labs (71 percent) were rarely or never used at their institutions.

Fig. 1 Average number of years spent in orthopaedic training by geographic region
Courtesy of Andrew R. Jensen, MD, MBE
Fig. 2 Average number of orthopaedic surgery trainee work hours per week by geographic region
Courtesy of Andrew R. Jensen, MD, MBE
Fig. 3 Global distribution of orthopaedic educational resource use
Courtesy of Andrew R. Jensen, MD, MBE
Fig. 4 Percentage of respondents reporting more than 100 arthroscopy/sports cases during residency by geographic region
Courtesy of Andrew R. Jensen, MD, MBE

Case distribution

Trauma and fracture care are the most commonly performed procedures for trainees worldwide: Greater than 70 percent of respondents reported performing more than 100 trauma and fracture cases during their training. Tumor and spine cases are rare, with 43 percent of trainees reporting that they performed fewer than 10 cases in each domain during training.

Interesting regional variation in case distribution also was observed. For instance, North American trainees perform far and away the most arthroscopy cases (Fig. 4). Among them, 66 percent reported performing more than 100 arthroscopy cases during training compared to just 14 percent of trainees from other regions of the world.


Orthopaedic training is similar in many ways across the globe: long hours, an emphasis on trauma and fracture care, and a reliance on traditional teaching resources such as textbooks and scientific journals. There are significant differences among training programs, however, and the differences leave us with more questions than answers. What are the optimal length of time, number of cases, and distribution of cases for orthopaedic training? Are annual in-training examinations the best way to prepare trainees for independent practice, particularly if 60 percent of respondents do not take them? Should surgical simulators be encouraged in parts of the world where trainees’ arthroscopic case volume is low?

Although some of these differences exist due to the needs of local populations and cultural standards, understanding worldwide discrepancies is a first step in identifying best practices to enhance surgical training techniques. Training variables such as length in years, work hours per week, distribution of educational resource use, and surgical case volume should be assessed to identify the best and most efficient practices for teaching the next generation of orthopaedic surgeons. Although every individual country has specific training needs, we all can learn from one another to improve orthopaedic education and, ultimately, patient care.

We would like to thank all the survey respondents and, in particular, the following organizations: International Society of Orthopaedic Surgery and Traumatology, SIGN Fracture Care International, and Soddo Christian Hospital.

The complete results of this survey can be found in PowerPoint format for free download and use on the AAOS Resident Assembly webpage at www.aaos.org/residents.

Andrew R. Jensen, MD, MBE, chair of the AAOS Resident Assembly, is with the University of California, Los Angeles Health System.

Musiliu Odunola, MB, MPH, is with the Ahmadu Bello University Teaching Hospital in Zaria, Nigeria.

Faseeh Shahab, MD, is with the Khyber Teaching Hospital in Peshawar, Pakistan.

Nicholas Bonazza, MD, vice chair of the AAOS Resident Assembly, is with Pennsylvania State College of Medicine in Hershey, Pa.

Christian Carrwik, MD, is with the Uppsala University Hospital in Sweden.

Verena Schreiber-Frank, MD, is with NorthShore University Health System in Evanston, Ill.

Kevin J. Cronin, MD, health policy committee chair of the AAOS Resident Assembly, is with the University of Kentucky Hospital in Lexington.