1. Verena Schreiber-Frank
The International Orthopaedic Trainee Survey AAOS Resident Assembly
Andrew R. Jensen
Musiliu Odunola
Faseeh Shahab
Nicholas Bonazza
Christian Carrwik
Verena Schreiber-Frank
Kevin Cronin

2. Background
The AAOS Resident Assembly surveyed orthopaedic trainees from across the globe to assess regional similarities and differences in international orthopaedic educational practices.
An electronic questionnaire addressing seven domains related to orthopaedic education (see table) was sent to selected English-speaking senior trainees worldwide.

3. The survey was open for a period of six weeks.
Survey Results
The survey was open for a period of six weeks.
238 responses were received from trainees in 57 countries.
These responses were grouped into nine geographic regions according to the CIA’s World Factbook:
Africa
Oceania
Central America & the Caribbean
Middle East
North America
East & Southeast Asia
South America
Europe
South Asia

4. Survey Respondents by Region
Region (N)
Country (N)
Africa (51)
Cameroon (1)
Central America & Caribbean (5)
Costa Rica (1)
Europe (36)
Austria (2)
Egypt (2)
Dominican Republic (1)
Belarus (1)
Ethiopia (10)
El Salvador (1)
Belgium (1)
Ghana (1)
Haiti (2)
Denmark (1)
Kenya (7)
Middle East (6)
Iraq (1)
France (2)
Malawi (1)
Qatar (1)
Germany (5)
Nigeria (20)
Saudi Arabia (1)
Iceland (1)
Somalia (1)
Syria (1)
Italy (3)
South Africa (1)
Turkey (1)
Latvia (2)
South Sudan (1)
Yemen (1)
Luxembourg (1)
Sudan (2)
North America (38)
Canada (1)
Netherlands (1)
Tanzania (3)
Mexico (3)
Poland (1)
Tunisia (1)
North America (34)
Romania (5)
East & Southeast Asia (12)
Malaysia (1)
Oceania (11)
New Zealand (11)
Serbia (1)
Myanmar (Burma) (4)
South Asia (73)
Afghanistan (1)
Span (2)
Philippines (3)
Bangladesh (3)
Sweden (3)
Singapore (1)
India (53)
United Kingdom (4)
South Korea (1)
Nepal (3)
South America (6)
Brazil (2)
Taiwan (2)
Pakistan (13)
Chile (3)
Colombia (1)

5. Residency Length - Findings
In terms of the length of training, the average time spent in orthopaedic-specific training programs worldwide was 4.4 years.
There was a large range in reported lengths according to geographic region, with trainees in Europe reporting the most years (5.4) and those in South America the least (3.2).
The number of years spent in pre-orthopaedic training was highly variable due to differences in local educational systems.

6. Residency Length

7. The average number of work hours was 71 per week worldwide.
Work Hours - Findings
The average number of work hours was 71 per week worldwide.
European trainees reported significantly fewer work hours (51 per week) than all other regions.
Many training programs adhere to a 48 hour work week according to EU law (European Working Time Directive)
38% of respondents, mostly from Europe and North America, reported that work hour restrictions are in place.
Trainees from most other regions reported no work hour restrictions.

8. Work Hours

9. Tests and Evaluations - Findings
An end-of-residency certification process prior to become a practicing orthopaedic surgeon was common (88%) throughout all regions.
The use of standardized case logs was also common (79%).
60% of respondents reported that they were not required to take an annual orthopaedic examination.
The majority of respondents who did take an annual orthopaedic examination were from North America.

10. Educational Resources - Findings
Textbooks were the most commonly used educational resource worldwide
Particularly in Africa, East and Southeast Asia, and South Asia, where over 80% of trainees reported daily textbook use.
The daily use of scientific journals was most common in North America (37%) and South America (50%).
61% of trainees in North America reported using the website Orthobullets ( daily.
Didactics were most commonly delivered on a weekly basis in all regions.
Surgical simulators remain rare globally.
Only 7% of trainees worldwide reported daily or weekly use.

11. Educational Resources

12. Educational Resources

13. Educational Resources

14. Educational Resources

15. Educational Resources

16. Educational Resources

17. Educational Resources

18. Educational Resources

19. Educational Resources

20. Educational Resources

21. Surgery Case Volume - Findings
Trauma and fracture cases were the most commonly performed surgeries for trainees worldwide.
More than 70% of respondents reported that they perform over 100 trauma/fracture cases during training.
Tumor and spine cases were rare, with 42-43% of residents reporting that they perform fewer than 10 cases in each domain during training.
66% of North American trainees reported performing over 100 arthroscopy cases during training
Compared to just 14% of trainees from all other regions.

22. Surgery Case Volume

23. Surgery Case Volume

24. Surgery Case Volume

25. Surgery Case Volume

26. Surgery Case Volume

27. Post-Residency Training - Findings
Half of respondents stated that trainees in their country leave the country for fellowship.
Only 6% of respondents stated that trainees don’t pursue fellowship in their country.

28. Summary
There are more similarities than differences between international orthopaedic training programs:
Long work hours and 4-5 years of specialty training.
An emphasis on trauma and fracture cases.
Heavy use of orthopaedic textbooks and scientific journals.
The differences between training programs should be further investigated to determine optimal educational practices:
What is the optimal number and distribution of cases for orthopaedic training?
Should electronic educational resources be promoted?
Are annual in-training examinations beneficial?

29. Thank you to the survey respondents
Thank you to the survey respondents! Please visit the AAOS Resident Assembly website