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A problem shared is a problem halved

The International Carousel Report 2012

Dias JJ*, Schemitsch Ev, Dirschl D¢, Mercer G¤, Thorn B, Le Roux Tu, Berry D§, Peabody T¢, Johnston Gv

British Orthopaedic Association*, Canadian Orthopaedic Associationv, American Orthopedic Association¢, Australian Orthopaedic Association ¤, New Zealand Orthopaedic Association, South African Orthopedic Associationu, American Academy of Orthopedic Surgeons§

Corresponding Author:  Professor Joseph Dias, British Orthopaedic Association, 35-43 Lincoln’s Inn Fields, London, WC2A 3PA. Email:

The carousel is formed by the group of presidents of Orthopaedic Associations from the United States of America (AAOS, AOA), Canada, United Kingdom, South Africa, Australia and New Zealand who meet at each associations annual congresses in order to share problems and exchange solutions. This has enabled the sharing of successful initiatives across our nations for the common good of surgeons, training surgeons and patients in each country. This group has allowed the sharing of good practice across the carousel nations. In the recent past issues surrounding the national joint registries, resident’s work hours, and sharing of educational content from each other’s meetings have been discussed.

The Carousel was formed by the Presidents of these associations in 1991 when Mike Freeman, the then British Orthopaedic Association President coined the term the “Carousel” at the dinner in Sydney when attending the Australian Orthopaedic Association.  This reflected the change in the membership of the carousel at each associations meeting as the new President took on the reins of his or her association and joined the Carousel while the past President stepped off the carousel.

In the current year (2012/13) the carousel presidents have discussed many issues sharing solutions between our countries. Some of these are presented below.

Fellowships: Each of the Carousel nations has a substantial number of trainees who pursue subspecialty fellowship training; most seek the additional training in their own nation, but many seek training in other nations. Estimates from both the SAOA and the BOA indicate that about 15% of their trainees pursue fellowships in other countries, while the NZOA reports that the majority of their trainees pursue such training, often after they have already completed a domestic fellowship and accepted a faculty position in New Zealand. In the UK, a trainee from outside the UK occupies nearly one fellowship position in three. In New Zealand, the number appears to be about one in two; while in South Africa it is estimated to be less than one in twenty positions are used by overseas fellows. There is general agreement between our countries on the importance and value of having one’s own trainees go outside of one’s home nation and of hosting fellows from other nations. The NZOA reports that the ‘exchange’ adds quite a lot in terms of bringing different approaches and ideas and also fostering international friendships. Additionally, having New Zealand trainees go away is particularly valuable given the geographical isolation of the country; while technology has decreased the isolation, there is still no electronic substitute for the hands on, face-to-face experience that these fellowships offer. The BOA finds these fellowships extremely important as strong clinical links and wide education in different systems of care help advance care for UK patients and ensure that doctors have access to the best systems in other parts of the world. The SAOA finds the exchange highly important for the same reasons, and believes that a much larger proportion of their trainees would pursue training outside of South Africa if there were fewer barriers to obtaining posts in other nations.

Requirements necessary to obtain a fellowship in another nation vary widely among the Carousel nations. The very strict requirements in the United States for foreign doctors to pursue training in an ACGME (Accreditation Council for Graduate Medical Education) -accredited fellowship are viewed by many of the other Carousel nations as making it highly difficult for their trainees to come to the US for clinical fellowship. Studying for and completing the USMLE examinations are the most difficult of these requirements, but obtaining a training visa and medical staff privileges can also be substantial barriers. There are variations of requirements in each state and this adds to the complexity. Canadian requirements, while not dissimilar to those in the US, are perceived as being a bit more relaxed. However, in Canada, too, there are provincial variations. Carousel nations report that the fact that requirements may be different from one Canadian province to another can lead to confusion and can make the process more difficult.  While all of the Carousel nations require a visa, verification of medical training and competence, registration with a medical board, and letters of recommendation, the perception is that South Africa, the UK, and New Zealand are more “accessible” to foreign fellows seeking training. Australia is a unique example for their highly organized and centralized approach to the matter. The AOA endorses the majority of fellowship positions in Australia and has a highly organized, rigorous, and very well communicated set of steps prospective international fellows must follow to pursue their clinical fellowship. While the requirements are rigorous and the entire process of approval and registration takes a few months, the centralized approach appears to offer a consistency and clarity that the remaining carousel countries should aspire to.

While the overwhelming value of international fellowships is recognized by all the Carousel nations, individual nations have differing perspectives on some of the potential negatives of these fellowships. The SAOA expressed some concern that facilitating foreign fellowships for their own trainees can increase the risk that those individuals may choose not to return to South Africa and will practice orthopaedic surgery in other nations. The NZOA expressed some concern that having trainees pursue highly specialized fellowship training in other nations may lead to poor distribution of orthopaedic expertise in New Zealand. These individuals may feel they must pursue practice in an urban center in order to make use of their highly specialized training, while more orthopaedic surgeons are needed in rural areas of that nation. The BOA reports that, in some cases, foreign training is not as highly applicable to orthopaedic practice in the UK as is ‘domestic’ fellowship training; case mix, case volume, and treatment approach in some foreign fellowship may not best prepare the fellow for orthopaedic practice in the UK. In the US, some have expressed a fear that foreign surgeons training in the US may remain in the US for practice, competing with US physicians for available positions and for patients.

There is clearly consensus that there is a great deal of value in international exchange of ideas and practice in the training of orthopaedic surgeons. Barriers and negatives, however, differ substantially among the Carousel nations. Existing and future developments in technology provide many opportunities for extending orthopaedic training, exchange of ideas, and perhaps quality of care and outcome measures, beyond national borders. It is a worthy discussion to engage in in an effort to identify ways that the advantages of international training can be amplified, while minimizing the barriers and concerns.  It is a global orthopaedic community and the International Presidents Council is an effective vehicle to identify and explore issues of potential collaboration and cooperation that our individual associations can, perhaps, investigate and pursue.

Road Traffic accidents: January 1st, 2011 marked the beginning of the United Nations and World Health Organization’s (WHO) collaboration on improving education, reducing mortality and developing preventative strategies for road traffic injuries worldwide. The WHO’s Global Road Traffic Safety Report1 provides a roadmap for decreasing mortality globally from accidents. The report recommends a major focus of education and intervention in developing nations given that “over 90% of the world’s fatalities on the roads occur in low-income and middle-income countries”.  Approximately 1.3 million people die each year on the world's roads, and between 20 and 50 million sustain non-fatal injuries. The Global Status Report on Road Safety is the first broad assessment of the road safety situation in 178 countries, using data drawn from a standardized survey. The international community must play its part in halting and reversing the current global trend of increasing traffic injuries as an important health and development problem and by intensifying education and support. In direct response to the 2011 United Nations/World Health Organization’s global campaign to increase awareness of road traffic safety in low and middle income nations, the English speaking Associations are well positioned to define priorities, articulate global challenges, propose practical education and research action plans, and mobilize both the and our members in orthopaedic surgery towards action. The members of the various English-speaking associations have an obligation to understand and appreciate the global nature of this issue. We have a unique opportunity to engage in the challenge of reducing mortality from road traffic accidents worldwide.

Metal-on-Metal hip replacements: Metal-on-metal bearings for hip replacements were introduced to increase the survival of implants and to reduce the dislocation rate as using metal permitted the use of a larger diameter head. However the tolerance of the biomechanics was narrow and for some implants this led to excessive loading and wear of metal releasing Cobalt and Chromium ions not only within the hip operated but also into the whole body. This unintended impact of the wear of the metal on metal bearing has caused much fear and anxiety in the huge population of patients who have hip replacements world wide as the media has become involved.

One of the great successes of the Carousel is how the registries in the United Kingdom, Australia and New Zealand have collaborated to review and share experiences working with the other large registry in Sweden. The Australian Registry identified the failure of the DePuy ASR metal-on-metal implant. The UK registry confirmed this and worked with the regulator the United Kingdom, Medicines and Healthcare Regulatory Agency (MHRA) to issue an alert and then a recall of the DePuy ASR implant.2,3

This collaboration has now identified that as a class the large head metal on metal implants were performing significantly worse than implants that used the traditional metal on polyethylene bearing. Recent papers from the UK joint registry have confirmed this and led to the alert issued by the MHRA in February this year.4,5 These registries have formed a safety network around patients by identifying both good and poor implants. Working together, in the carousel countries in particular, has allowed findings in one country to be confirmed or rejected by analysis of data in another permitting good regulatory decisions. In the USA, the FDA has contributed by facilitating the formation of ICOR chaired at present by Dr. Steve Graves from Australia.

The registries in the carousel countries have also worked together to establish that at present there is no increased risk of malignant change in spite of very small datasets from some centers in the UK showing that the rate of problems identified raised this question. This analysis is ongoing, alongside investigation into the biological effects of Cobalt and Chromium causing muscle necrosis locally and probably having a systemic effect in high concentrations.

The international collaboration between our countries has demonstrated that our communities of orthopaedic surgeons have worked effectively together to ensure that our patients get the best possible care.

Disaster Management and Emergency Preparedness: The Haitian earthquake was an immense disaster in a country with little infrastructure and limited resources.  Orthopaedic injuries were common. Orthopaedic surgeons from all over the world volunteered, came to Haiti and tried their best to help. Five hundred AAOS fellows volunteered and 500 more were “waiting to go”.  However, the earthquake was eye opening and showed the shortcomings of the orthopaedic community’s preparedness to respond to disaster.  It became clear that there was no predesignated coordinating body in orthopaedics nor was there an established coordinating system and governmental and non-governmental organization resources were available but were overwhelmed.  The disaster also demonstrated the wide spectrum of orthopaedic experience related to orthopaedic care in an austere environment. This experience in Haiti was similar to the response to other disasters such as the Pakistan earthquake and the earthquake in New Zealand.

Dr. Berry presented the project of the AAOS6 on Disaster Management and Preparedness and the Disaster Response course.  Following the Haitian earthquake the AAOS, Orthopaedic Trauma Association (OTA), Society of Military Orthopaedic Surgeons (SOMOS), along with several government agencies and other specialty societies, formed a joint task force to evaluate future disaster response efforts.  This taskforce identified a need for a trained credentialed workforce to be in place before a disaster and recognized a need for credentialing groups who will ultimately provide “on the ground” organizational support.  Finally, the AAOS explicitly acknowledged that almost no orthopaedic association or subspecialist society were disaster relief organisations. 

As part of disaster preparedness, a disaster response course was developed.  The overarching intent of the course was to provide disaster specific and austere environment training, to generate a register of trained attendees in a central database and to provide connection between prepared surgeons and non-government organizations, government organizations and military groups likely to respond to disasters.  The Disaster Response course was developed as a fundamental building block to deliver required training for disaster preparedness.  Following completion of the Disaster Response course, attendees can register in the AAOS disaster responder database as either trauma-trained surge responders, acute phase responders who can be deployed after the disaster, or sustained phase responders to help maintain and perform reconstructive surgery.7  Additional opportunities of being registered include the ability to obtain supplemental training  (such as Disaster Management and Emergency Preparation courses and National Disaster Life Support courses) from a variety of government and non-government organizations and also pre-credentialing for international/national service from other responding organizations.

Disaster Response Course:  The Disaster Response course was created as a cooperative effort between SOMOS, OTA and the AAOS.  It was launched in December 2011 in San Diego and repeated in February of 2012 in San Francisco.  Both courses were immediately oversubscribed.  The plan is to run at least two courses annually.  The first day of the course has only didactic sessions, the second day contains a half-day cadaver-based lab.  The faculty is derived from the AAOS and Orthopaedic Trauma Association (6), Pediatric Orthopaedic Society of North America (1), Society Of Military Orthopaedic Surgeons (12) and a vascular surgeon.  The course content includes orthopaedic knowledge about working in an austere environment, a checklist of materials to bring, credentialing and immunizations that one should have completed or have available prior to deployment in the event of a disaster, and talks on ethics of working in an austere environment.  The feedback of the course has been encouraging: registration targets were exceeded, very high satisfaction rates declared by attendees, and the course was highly praised by government and non-government organizations as well as military surgeons.  The carousel discussed this and identified a need to have similar systems in their nations.  Individuals nominated by carousel nations may register for the future disaster preparedness courses .


1. Global Status Report on Road Safety. Time for Action., 2009, World Health Organisation: Switzerland.
2. DePuy ASR™ acetabular cups used in hip resurfacing arthroplasty and total hip replacement, in Medical Device Alert 2010, Medicines and Healthcare Products Regulatory Agency (MHRA): London.
3. DePuy ASR™ hip replacement implants., in Medical Device Alert 2010, Medicines and Healthcare Products Regulatory Agency (MHRA): London.
4. All metal-on-metal (MoM) hip replacements, in Medical Device Alert 2012, Medicines and Healthcare Products Regulatory Agency (MHRA): London.
5. All metal-on-metal (MoM) hip replacements, in Medical Device Alert 2010, Medicines and Healthcare Products Regulatory Agency (MHRA): London.
6. Born C, Teuscher D. Final Report and Recommendations for the AAOS Disaster Preparedness Plan, 2012, American Academy of Orthopaedic Surgeons: Rosemont, Illinois, USA.
7. Born CT, Teuscher D, Dowling L. AAOS approves disaster preparedness plan. AAOS Now, 2011. 5(8).