Orthopedic Surgical Case Volume is Low at Foreign Military Hospitals and Often Insufficient for Board Eligibility

INTRODUCTION: Military hospitals located outside the continental United States (OCONUS) have been frequently cited as environments where operative demand may be limited. Low case volumes adversely impact surgical readiness within the Military Health System (MHS) and place a particular strain on newly trained orthopedic surgeons, who must complete 35 operative cases in a 6-month period to be eligible to sit for board certification. The primary objective of this study is to characterize orthopedic surgical case volume at foreign OCONUS military hospitals relative to assigned surgeon staffing. We hypothesized that several of these hospitals would be unable to support the case volume necessary for newly trained surgeons to meet board eligibility requirements. MATERIALS AND METHODS: We performed a retrospective review of hospital records by generating reports within the Electronic Health Record which detail (1) the quantity of orthopedic surgical cases, (2) the procedures which were performed, and (3) the case volume per operating orthopedic surgeon at eleven foreign OCONUS military hospitals within three 6-month windows (January 2024 through June 2025). From the collected data, we calculated the total number of cases performed during each study window, mean 6-month case volume, mean case volume per number of assigned orthopedic surgeons, and both the number and percentage of surgeons achieving a mean of 35 cases or more per 6-month period at each facility. This study was classified as exempt human subjects research by the authors' Institutional Review Board (IRB). RESULTS: Total orthopedic case volume at each facility over the study window was greatest at Landstuhl (n = 1,610), followed by Okinawa (n = 624), Camp Humphreys (n = 459), Yokosuka (n = 368), Guam (n = 343), Lakenheath (n = 218), Rota (n = 185), Osan (n = 160), Yokota (n = 107), Naples (n = 103), and Misawa (n = 54). When accounting for number of allocated orthopedic surgeon slots at each facility, the 6-month mean number of cases per surgeon was: Camp Humphreys, 76.5; Guam, 57.2; Landstuhl, 53.7; Osan, 53.3; Okinawa, 41.6; Yokota, 35.7; Rota, 30.8; Yokosuka, 30.7; Lakenheath, 24.2; Misawa, 18; and Naples, 17.2. Percentage of allocated surgeons achieving a mean of 35 cases or more per 6-month period at each facility includes: Landstuhl (100%, n = 10 of 10), Camp Humphreys (100%, n = 2 of 2), Guam (100%, n = 2 of 2), Osan (100%, n = 1 of 1), Yokota (100%, n = 1 of 1), Okinawa (60%, n = 3 of 5), Rota (50%, n = 1 of 2), Yokosuka (25%, n = 1 of 4), Misawa (0%, n = 0 of 1), Naples (0%, n = 0 of 2), Lakenheath (0%, n = 0 of 3). CONCLUSIONS: Orthopedic surgical volume at multiple foreign OCONUS military hospitals is low, with several facilities failing to accommodate sufficient case volume for newly trained surgeons to meet board certification benchmarks. Overall case volume also appears inadequate relative to assigned surgeon staffing, raising concerns regarding skill sustainment and efficient resource utilization. Although low-intensity surgical environments have long been recognized as a readiness risk, this study is the first to quantify operative exposure at overseas facilities, demonstrating clear volume gaps. These findings provide objective data to guide personnel distribution and policy decisions aimed at optimizing surgical proficiency and healthcare delivery.