Abstract

Orthopaedic surgery residency programs consistently rank among the most competitive training opportunities for medical school graduates, with demand far exceeding available positions. Additionally, the rising need for musculoskeletal care and the increasing demand for joint replacement surgeries underscore the critical importance of expanding the orthopaedic workforce. Addressing this disparity by increasing the number of residency training positions is vital to meeting the growing demand for care, mitigating orthopaedic surgeon shortages and fostering a culture of research and innovation through the integration of new residents.

This article provides a step-by-step guide on establishing a new orthopaedic surgery residency program, outlining key considerations such as identifying sponsoring institutions, funding, curriculum development, accreditation requirements, marketing and other essential components. Starting a new program is a complex endeavor requiring meticulous planning and collaboration. This guide is a resource for those working to expand GME and address challenges in the orthopaedic workforce.

Keywords: Orthopaedic Surgery; Residency; Graduate Medical Education; Surgical Training; Teaching Hospitals

Introduction

Orthopaedic surgery remains one of the most competitive specialties for medical school graduates [1]. Despite an increasing number of qualified applicants, the availability of residency positions has failed to keep pace [2,3]. Data from the 2022 residency match cycle revealed that approximately 40% of applicants for orthopaedic surgery positions did not successfully match [4]. Between 2008 and 2018, the total number of applicants increased by roughly 15%, while the number of applications submitted per applicant nearly doubled and during the same period, only 11 new orthopaedic surgery residency programs were established [5]. The gap between applicants and available positions may continue to grow as unmatched candidates reapply with additional experience. Only 58% of unmatched orthopaedic applicants from 2016 to 2018 successfully matched on reapplication, highlighting the need to expand residency opportunities [6].

The projected demand for orthopaedic surgeons is rising in tandem with demographic shifts in the United States [7,8]. The shortage is further compounded by rising demand for orthopaedic care, with projections estimating a 174% increase in primary hip arthroplasties by 2030 and a need to double total joint arthroplasty caseloads by 2050 to meet population needs [9,10]. Meeting these future needs will require a robust orthopaedic workforce, highlighting the urgency of expanding residency training programs. This guide offers a practical roadmap for developing, funding and launching new orthopaedic surgery residency programs, addressing key elements such as funding, curriculum, accreditation and marketing.

ACGME Requirements Overview

The Accreditation Council for Graduate Medical Education (ACGME) outlines core standards to ensure high-quality orthopaedic residency training. Programs must span 60 months, with at least 36 months in orthopaedic subspecialty rotations. Multiple participating sites may be used, including hospitals, trauma centers, clinics and ASCs. Each site must have a Program Letter of Agreement (PLA), approved by institutional officials and renewed every 10 years, detailing responsibilities for resident education (Fig. 1). Programs must have at least three core faculty, including an ABOS- or AOBOS-certified Program Director, each dedicating a minimum of 20 hours weekly (Fig. 2). A 1:4 faculty-to-resident ratio is required and each subspecialty must be staffed by at least one certified faculty member.

Resident performance is assessed using the ACGME Milestones, which serve as a developmental framework for tracking progress across the six key competencies: patient care, medical knowledge, professionalism, interpersonal skills, systems-based practice and practice-based learning [11,12]. The milestones are organized into Levels 1 through 5, representing the progression from novice to expert. Advancement through milestone levels is based on demonstrated performance rather than post-graduate year, allowing for variability in individual progress [12]. The Clinical Competency Committee (CCC) conducts semi-annual reviews to evaluate milestone achievement and ensure residents are meeting program expectations [13]. Furthermore, the sponsoring institution must also have ACGME-I-accredited programs in general surgery, internal medicine and pediatrics so that orthopaedic residents can be provided with interprofessional training with other specialties [14].

Figure 1: Clinical training sites affiliated with an orthopaedic residency program. This diagram illustrates the primary clinical training environments that comprise an orthopaedic surgery residency program. Residents rotate across a variety of affiliated sites, including teaching hospitals, trauma centers, outpatient clinics and ambulatory centers, to gain comprehensive exposure to both inpatient and outpatient orthopaedic care.

Figure 2: Core faculty leadership in an orthopaedic surgery residency program. Example of core faculty leadership structure within an orthopaedic surgery residency program. Core faculty typically include the department chair, program director and associate program director, all of whom are required to be certified by the American Board of Orthopaedic Surgery (ABOS) or the American Osteopathic Board of Orthopaedic Surgery (AOBOS). Core faculty are expected to dedicate a minimum of 20 hours per week to the residency program in accordance with ACGME requirements.

Building the Infrastructure

Establishing an Institutional Affiliation and Primary Training Site

The institutional affiliation of a residency program plays a critical role in shaping its clinical and operative experiences, reputation and mission. Partnering with a high-volume medical center that serves a diverse patient population offers residents extensive exposure to complex orthopaedic cases and hands-on surgical training [15]. Alternatively, affiliations with renowned academic institutions emphasizing research and education cultivate a program culture focused on innovation, scholarly activity and leadership development [16]. Programs based at community hospitals in underserved or rural areas appeal to applicants seeking comprehensive clinical training with a strong emphasis on community health [17]. These partnerships not only shape the training environment but also impact the program’s reputation and its ability to attract applicants aligned with its values and goals. (Fig. 3).

Collaborating with Additional Training Sites

While the primary site serves as the foundation for the program, partnerships with additional training sites are often essential to meet case exposure and subspecialty training requirements [18]. These sites may include trauma centers, Ambulatory Surgical Centers (ASCs), VA hospitals and private orthopaedic practices. The program must ensure consistency in orthopaedic education across all participating sites by monitoring the clinical learning environment and appointing a site director at each location to oversee resident education and collaborate with the program director [14].

Partnerships between the sponsoring institution and community training sites should be mutually beneficial. For community hospitals, participating as a training site increases surgical capacity, reduces staff workload and needs, while enhancing patient care [19]. For example, rotations at the VA expose residents to the single-payer healthcare model, while rotations at ambulatory care centers provide experience in a private-practice setting [20]. These varied training environments offer residents exposure to various healthcare systems and diverse patient populations and musculoskeletal pathologies, equipping them to navigate unique clinical challenges across different practice settings [21].

Figure 3: What do you want your residency to be known for?. Key institutional priorities influencing orthopaedic residency program selection. This example highlights major areas of emphasis that shape residency training, including community service, research, surgical volume, academic affiliation and other mission-driven components. These institutional focuses help define the residency experience and guide applicants in aligning their personal and professional goals with a program’s strengths.

Developing a Budget and Securing Funding for an Orthopaedic Residency Program

Initial Start-up Cost

Launching an orthopaedic residency program requires significant upfront investment in program development, including ACGME application preparation, infrastructure, faculty recruitment across subspecialties and acquisition of training facilities such as simulation labs and skills centers. Application-related costs include a one-time ACGME application fee of $7,380 and an annual accreditation fee ranging from $5,125 to $6,200, depending on program size [21]. These fees are billed through the Sponsoring Institution, which also incurs an additional 2.5% charge based on total program fees [21].

Faculty recruitment is a major expense, often requiring relocation support, start-up compensation and incentives to attract American Board of Orthopaedic Surgery (ABOS) or American Osteopathic Board of Orthopaedic Surgery (AOBOS) certified surgeons. Hiring a full-time program coordinator is essential to manage daily operations, scheduling and accreditation compliance [22]. Additional investments are needed for resident call rooms, conference space, offices and skills training facilities to create a robust educational environment.

Strategic Planning for Medicare GME Funding

Under the Balanced Budget Act of 1997, Medicare sets a resident cap based on the hospital’s initial five-year training period. During this “cap-building” window, hospitals should maximize resident enrollment to optimize long-term funding. Medicare GME payments currently average approximately $140,000 to $160,000 per resident annually, although the exact amount varies by institution [23]. Institutional factors that influence GME funding include the hospital’s Medicare patient volume, resident-to-bed ratios, PRA and geographic adjustments [22,24]. Once a hospital’s cap and PRA are set, they generally cannot be changed, except under specific conditions such as expansion into rural or underserved areas [25].

Ongoing Costs

Sustaining program quality requires careful management of ongoing operational expenses. Resident salaries and benefits, typically ranging from $66,000 to $90,000 annually per resident, represent a significant recurring cost, along with faculty compensation for teaching, supervision and mentorship [26]. Programs should allocate funding for visiting lecturers, subspecialty education and scholarly activity, including research staff, statistical support and resident stipends for conferences and workshops, while also maintaining skills labs, surgical instruments, implants and models to support ACGME requirements and hands-on training.

Funding Sources

To ensure long-term financial sustainability, programs should consider leveraging multiple funding sources. Primary funding is typically derived from Medicare GME payments, which are composed of Direct and Indirect GME adjustments (DGME and IME, respectively) [22,23]. The DGME payments cover direct training costs (resident stipends, faculty teaching time and GME office operations), whereas the IME payments compensate hospitals for increased patient care costs in the teaching setting [27]. These payments, however, are contingent on resident caps and the proportion of Medicare inpatient volume. Hospitals training residents beyond their Medicare cap must secure other institutional or alternative sources of funding, including through VA affiliations, other health systems and private donations or grants (Table 1) [27,28].

Table 1: Funding sources for starting an orthopaedic surgery residency program.

Faculty Recruitment and Development

Selecting a Program Director (PD)

The ACGME outlines specific qualifications for the program director of orthopaedic surgery to ensure effective leadership, educational oversight and resident development. The program director must have at least three years of documented educational or administrative experience and other qualifications deemed acceptable by the Review Committee [29]. Additionally, the director is required to hold current certification from the ABOS or AOBOS as well as an active medical license [14]. Further details for program director and program coordinator qualifications are provided in Table 2.

Table 2: Qualifications for program director and program coordinator selection. ABOS = American Board of Orthopaedic Surgery; AOBOS = American Osteopathic Board of Orthopaedic Surgery; GME = Graduate Medical Education; ACGME = Accreditation Council for Graduate Medical Education; ADS = Accreditation Data System.

Selecting Faculty Members

Establishing clearly defined faculty roles and responsibilities is essential to the success of an orthopaedic surgery residency program.  Faculty should be selected based on their ability to fulfill key roles such as:

• Clinical Education: Faculty who supervise residents during clinical rotations, providing hands-on training in orthopaedic procedures and patient care
• Research: Faculty who mentor residents in orthopaedic research and guide them in producing high-quality scholarly work
• Academic Teaching: Faculty who deliver educational lectures and lead discussions on orthopaedic topics during grand rounds and resident conferences

Recruitment qualifications should emphasize board certification, significant clinical experience in orthopaedic subspecialties, a history of teaching and academics and research expertise. Faculty may be recruited from private practice orthopaedic surgeons with teaching or academic affiliations, as well as from traditional academic and university-based orthopaedic surgeons.

To recruit faculty, programs can:

• Post openings on orthopaedic boards, journals and society platforms (e.g., AAOS, AOA)
• Network at conferences, online platforms and through mentorship or alumni channels
• Partner with local medical schools and teaching hospitals to identify qualified educators

Faculty Compensation and Advantages to Serving as a Faculty Member

Faculty compensation should be competitive with industry standards to attract qualified candidates. According to a 2023 Medscape survey, the average salary for orthopaedic surgeons was $573,000 [30]. Faculty salaries should align with or exceed this benchmark, considering regional and institutional factors. Benefits may include insurance, research support, CME and leadership opportunities. Employed faculty may receive dedicated support for teaching, whereas private practice surgeons typically require additional financial and time accommodations, which should be factored into the program budget.

Subspecialty Departments

Creating subspecialty departments is essential to provide residents with comprehensive training across orthopaedic disciplines. It involves recruiting board-certified faculty to lead clinical care, didactics and research; developing focused curricula around outpatient, inpatient and surgical management; structuring rotations to balance operative experience and academic learning; equipping each department with essential tools, imaging and facilities; and securing funding to support both initial setup and ongoing operations. This approach ensures residents acquire the knowledge and skills needed across all orthopaedic subspecialties.

Educational Development

Content and Curriculum

The orthopaedic surgery residency curriculum should follow ACGME guidelines, focusing on subspecialty competency-based goals that prepare residents for independent practice. Key components of the curriculum include:

• Responsibilities for patient care, safety and management under graded supervision by credentialed attending physicians
• Consistent clinical teaching from supervising physicians
• Emphasis on mentee-mentor relationships between junior and senior level residents
• Objective evaluations based on resident performance and milestones
• Structured didactic activities integrated into the schedule

Beyond clinical and operative experiences, the didactic curriculum forms the foundation of orthopaedic knowledge. Program developers must decide on a schedule for didactics, balancing daily one-hour sessions or weekly 2–3-hour blocks of protected time. Didactic sessions are critical for preparing residents for the Orthopaedic In-Training Exam (OITE), which serves as a predictor of board readiness. Sessions can be resident-led, faculty-led or a hybrid model based on the program director’s preference.

Block Diagram

Block diagrams are essential for mapping resident schedules. A sample block diagram is available on the ACGME website and has been adapted for Fig. 4. The diagram should include:

• Clinical Rotations
• Didactic Education, including lectures, workshops, simulations and grand rounds
• Research time
• Evaluation and Feedback (See milestone section below).

Figure 4: Sample block diagram for orthopaedic surgery residency. A sample core block diagram for orthopaedic surgery residency rotations across all five postgraduate years (PGY1–PGY5), detailing rotation durations and scheduling limitations such as restrictions on rotations shorter than 6 weeks.

Resident Schedule (Summarized in Table 3)

PGY-1

During the intern year, residents must complete six months of non-orthopaedic surgery rotations, with at least three months focused on basic surgical skills, perioperative care, medical management and airway management. These six months are divided into:

• Specific surgical rotations (3 months): General surgery, trauma surgery, plastic/burn surgery, surgical/medical ICU or vascular surgery
• Additional rotations (3 months): Options include anesthesiology, emergency medicine, radiology, neurosurgery, pediatric surgery, physical medicine and rehabilitation, rheumatology and other approved specialties. No single non-orthopaedic rotation may exceed two months

Basic surgical skills training typically is included in intern year and can be a dedicated rotation or longitudinal throughout the year, covering initial management of injuries (splinting, casting, traction, immobilization) and basic operative skills (soft tissue management, arthroscopy, fluoroscopy and use of orthopaedic equipment).

Residents must also complete six months of orthopaedic surgery rotations to develop proficiency in basic surgical skills, learn fundamental patient care, treat orthopaedic emergencies and expand their orthopaedic knowledge base. Additionally, there are rotation services recommended but not required, including plastic surgery, physical medicine and rehabilitation, rheumatology and neurological surgery.

Table 3: Orthopaedic surgery resident schedule by Postgraduate Year (PGY). All non-orthopaedic rotations in PGY-1 are limited to a maximum of 2 months per specialty. Orthopaedic rotations emphasize progressive responsibility, subspecialty exposure and continuity of clinical education from PGY-2 to PGY-5. PGY, Postgraduate Year; ICU, Intensive Care Unit.

PGY 2-5

For the remainder of residency, each clinical rotation must be at least six weeks in length. The final 24 months of education must be obtained in a single program. The core rotations in a resident’s clinical experience typically include joint reconstruction, orthopaedic trauma, spine, hand, foot and ankle, sports medicine, pediatric orthopaedics and orthopaedic oncology. Additionally, the delivery of education to the residents must be limited to no more than 80 hours per week with one day a week off averaged over a four-week period, with no work periods exceeding 24 hours of continuous scheduled clinical assignments. A minimum of 6 months of pediatric orthopaedic surgery is also required for all residents. 

Ensure Appropriate Case Volume and Surgical Load

PGY-2 to PGY-5 residents must complete at least 36 months of orthopaedic service rotations, with a minimum of one half-day per week dedicated to outpatient clinical care. Proper planning is essential to ensure residents achieve adequate case volume. Per ACGME guidelines, clinical experiences must encompass the diagnosis and management of:

• Adult and pediatric disorders
• Joint reconstruction
• Trauma including multisystem trauma
• Surgery of the spine
• Athletic injuries
• Hand and upper extremity surgery
• Foot and ankle surgery
• Orthopaedic oncology

Residents are required to log cases in the ACGME case log system, completing 1,000 to 3,000 cases over the five-year program.31 Minimum case requirements for specific procedures are listed with their CPT codes are outlined in Fig. 5 and provide a benchmark for evaluating progress.

To ensure sufficient case volume for residents, a program should consider:

• Recruiting Skilled Faculty: Attract faculty with established reputations, particularly by building relationships with large orthopaedic groups in the community. This strategy is advantageous for community-based programs without access to nearby academic centers
• Optimizing Surgical Workflow: Address barriers such as long operating room turnover times and equipment shortages to maximize efficiency and case numbers. Choose facilities with sufficient personnel and resources to support high-volume surgical care
• Monitoring Case Volume: Regularly review residents’ case logs during evaluations

The ACGME publishes an annual national report of case logs for all orthopaedic residents, highlighting the number of cases completed compared to the required minimums.31 This report serves as a valuable benchmark to evaluate case volume and types, ensuring your proposed program can provide sufficient surgical experience for each resident.

Figure 5: Sample orthopaedic case schedule log. A sample case schedule log used in orthopaedic surgery residency programs to document the distribution of surgical procedures across different training sites, helping ensure residents meet case requirements at each location. Original Source: Accreditation Council for Graduate Medical Education. Program Accreditation Council for Graduate Medical Education (ACGME).

Orthopaedic Milestones

ACGME-I outlines the updated milestones for orthopaedic surgery training programs [12]. The milestones are a framework to assess the development of residents and fellows in key competencies essential for practicing orthopaedics and are divided into sub-competencies.

Key Components of the Milestones Include

• Patient Care: Evaluates the ability to provide care that is compassionate, appropriate and effective for treating health problems and promoting health
• Medical Knowledge: Assesses mastery of musculoskeletal anatomy, biomechanics, pathology and clinical sciences, with a focus on their application to patient care
• Systems-Based Practice: Focuses on navigating and utilizing healthcare systems to deliver cost-effective, high-quality orthopaedic care, including perioperative planning and collaboration with multidisciplinary teams
• Practice-Based Learning and Improvement: Involves evaluating outcomes in orthopaedic procedures, integrating new evidence into practice and improving surgical techniques and patient care protocols
• Professionalism: Emphasizes ethical decision-making and sensitivity to diverse populations, particularly in the context of orthopaedic care and patient advocacy
• Interpersonal and Communication Skills: Assesses the ability to effectively exchange information and collaborate with patients, their families and other health professionals

Resident Wellness

Creating a resident wellness component is an ACGME requirement to prevent burnout and support resident success. A previous study revealed a 56% burnout rate among PGY-2 orthopaedic residents, with higher rates observed in larger programs and among female residents [32]. To prioritize resident wellness and foster a supportive environment, the following steps can be implemented [33]:

• Adhere to the ACGME resident 80-hour work week-limit [33]
• Design rotations and schedules to ensure reasonable work hours and adequate time off and to attend personal appointments [33]
• Provide access to confidential mental health services at the request of the resident and offer resident resources for stress management, mindfulness and resilience training [33,34]
• Promote exercise by providing access to a gym facility as part of resident benefits [35]
• Organize workshops on time management, financial planning and career development [36]
• Implement policies that prevent and address burnout, harassment and discrimination [37]
• Host regular social events and team-building activities to foster camaraderie and support [38]
• Allow for flexibility in the schedule to accommodate for personal and family needs

Initiate Curriculum and Program Design 

Using the educational vision alongside ACGME and ABOS requirements will be used to create a defined curriculum. Once rotation directors are established, a preliminary timeline should be made for the different educational aspects you want included in the curriculum such as policies, didactic sessions and board review. Other important steps to be prepared for are program evaluations, clinical competency evaluations and creating a quality and safe learning environment.

Faculty Development and Alignment

After faculty have been hired, there should be a comprehensive orientation that covers the program’s curriculum, policies and expectations. This should be done well in advance to the start of the program, to ensure that all faculty understand the goals and are well-integrated into the program and its culture. Faculty collaboration is key to achieving consensus on teaching methods and educational objectives, particularly when integrating their varied orthopaedic specialties.

Steps To Program Accreditation

1. Application:

An initial application to start an orthopaedic residency program must be submitted to the ACGME in order to receive accreditation. The application will consist of the following portions: 1) Duration of resident education, 2) Sponsoring Institution and participating sites, 3) PLA with rotating institutions and outpatient surgery sites  4) Program director, faculty information and other resources, 5) Educational curriculum and specialty-specific educational program, ensuring the ACGME competencies are met, 6) Patient safety, quality improvement, supervision of residents, professionalism and resident well-being and on-call activities, 7) Case log with total number of orthopaedic cases to be completed at each participating institution (Fig. 6).  A sample application could be viewed on the ACGME website [39]. A similar application will have to be submitted to receive continued accreditation for the program.

Once submitted, the application undergoes a site visit, during which the ACGME provides feedback. After revisions, the RRC, typically reviewing new program applications once annually, will evaluate the submission. Most applications must identify residency slots or secure external funding. If approved, programs must establish infrastructure, hire support staff and coordinate with the Designated Institutional Official (DIO). Some institutions use consultants to assist with application preparation and revisions before final submission. Some sponsoring institutions will hire a consulting firm or outside resources to assist with the program application, edits and revision with the experts, the final step is to submit the application to the ACGME and await a response detailing the next steps.

2. Site Visit Preparation

Once your application is reviewed by the ACGME, you will be notified of your site visit date. This visit involves interviews with leadership, program director, faculty, support staff and rotation site chiefs. making it essential to thoroughly prepare in advance.  Reviewing the ACGME’s guide on site visit preparation and your detailed application is a critical first step.  To help faculty understand what to expect, consider organizing a mock site visit. With the assistance of the DIO or an experienced colleague who has navigated the process, this exercise can identify areas for improvement and ensure readiness prior to the official visit. The site visit typically spans several days, during which the ACGME representative will verify the program’s compliance with all required policies and standards, commitment of the institution and resources and faculty engagement and involvement. Proper preparation can help ensure a smooth and successful visit.

Figure 6: Orthopaedic surgery minimums that reflect Common Core Competence (3C). Adapted from ACGME. Minimum case requirements for orthopaedic surgery residency as defined by the ACGME. Procedures listed under “Minimums That Reflect Common Core Competence (3C)” also count toward their respective anatomic area totals. CPT codes identify qualifying procedures.“Total by Anatomic Area” reflects cumulative requirements for each anatomical region. “New Minimums” indicate recently designated procedural thresholds. Asterisked items (*) are tracked but do not count toward total case minimums; for pediatric procedures, only operative cases with the “Pediatrics” flag in the case log qualify.

Marketing and Recruitment

Develop Your Marketing Strategy

If the program receives approval, the next step is to get the name of the program out to the public. It is important to think about how you plan to notify prospective students about the new residency program and consider registering for services needed to establish a connection between prospective applicants and the program, such as ERAS, NRMP and FREIDA as well as more orthopaedic specific sites such as Orthogate and MSOS. Clerkship directors and other notable faculty within medical schools can be contacted so they can learn more about the program and potentially recommend applicants.  Developing a strong online presence is another great way to build name recognition. Utilizing social media and finding someone who can manage those accounts will further work to adequately market the program [40,41]. Other activities that can be conducted by faculty include networking at conferences and other professional events and meetings or visiting career days held by medical schools.

Engage Everyone in Active Recruitment 

Recruitment requires the collective effort of all program members to ensure success. Although orthopaedic surgery positions are highly sought after, a well-crafted marketing strategy, engaging the entire team to implement these plans can optimize quality of applicants and recruitment [40,41]. Once the program’s recognition has been established, the process of selecting applicants can begin. Given the inherent uncertainties of a new program without a precedent or legacy, it is essential to impress candidates with the quality of education, case volumes and surgical experience and new innovative teaching and training techniques and curriculum [42]. Emphasizing the unique benefits of joining a new program, particularly one with opportunities for growth, input, innovation and leadership opportunities can help attract strong candidates. When interviewing, aim to review 15-20 applicants per position and consider inviting a broad pool. After interviews, rank all candidates you would seriously consider, prioritizing those whose strengths align with your program’s mission and goals.

Timeline

This report includes a timeline designed for those interested in establishing orthopaedic programs, outlining the estimated duration of each step in the process (Table 4). We estimate the total time required to establish a program to be between 3- 5 years, though this timeline may vary depending on institutional requirements, regulatory environments and other factors.

Table 4: Timeline to create an orthopaedic surgery residency program. Timelines are approximate and may vary based on institutional resources, regulatory requirements and program complexity. ACGME = Accreditation Council for Graduate Medical Education.

Conclusion

Orthopaedic surgery remains one of the most competitive specialties and the increasing demand for orthopaedic services highlights the urgent need for additional residency programs. This paper provides a step-by-step guide to assist aspiring program directors and institutions in taking the first steps toward establishing their own program. Key considerations include becoming well-versed in ACGME and ABOS guidelines, develop a detailed understanding of your programs application and seek advice from well-seasoned experts in the field. The process of creating a residency program is a significant undertaking that will shape the careers of future orthopaedic surgeons and contribute to meeting the growing needs of patients. By following a structured approach and focusing on the principles outlined in this guide, establishing new residency training positions and orthopaedic surgery programs  can make a lasting impact on the profession and the communities they serve.

Conflict of Interest

The authors declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.

Funding Statement

This research did not receive any specific grant from funding agencies in the public, commercial or non-profit sectors.

Acknowledgement

The authors have no acknowledgments to declare.

Data Availability Statement

The data supporting the findings of this study are available from the corresponding author upon reasonable request.

Ethical Statement

The project did not meet the definition of human subject research under the purview of the IRB according to federal regulations and therefore was exempt.

Informed Consent Statement

Informed consent was not required for this study due to the use of anonymized data with no identifiable personal information.

Authors’ Contributions

All authors contributed equally to this paper.

References

1. Rynecki N, Para A, Gantz O. An analysis of trends in National Residency Matching Program match data for orthopedic surgery. Orthopedics. 2020;43(6):e616-22.
2. Stateline RB. To address doctor shortages, some states focus on residencies. KFF Health News. 2015.
3. Association of American Medical Colleges. Medical school enrollments grow, but residency slots have not kept pace. 2025.
4. Lubowitz JH, Brand JC, Rossi MJ. The 2022 orthopaedic surgery residency match leaves many qualified candidates unmatched. Arthroscopy. 2022;38(6):1755-7.
5. Trikha R, Keswani A, Ishmael CR, Greig D, Kelley BV, Bernthal NM. Current trends in orthopaedic surgery residency applications and match rates. J Bone Joint Surg Am. 2020;102(6):e24.
6. Kheir MM, Tan TL, Rondon AJ, Chen AF. The fate of unmatched orthopaedic applicants: risk factors and outcomes. JBJS Open Access. 2020;5(2):e20.00043.
7. Rullán PJ, Deren ME, Zhou G. The arthroplasty surgeon growth indicator: A tool for monitoring supply and demand trends in the orthopaedic surgeon workforce from 2020 to 2050. J Bone Joint Surg Am. 2023;105(13):1038-45.
8. Padegimas EM, Maltenfort M, Lazarus MD, Ramsey ML, Williams GR, Namdari S. Future patient demand for shoulder arthroplasty by younger patients: National projections. Clin Orthop Relat Res. 2015;473(6):1860-7.
9. Kurtz S, Ong K, Lau E, Mowat F, Halpern M. Projections of primary and revision hip and knee arthroplasty in the United States from 2005 to 2030. J Bone Joint Surg Am. 2007;89(4):780-5.
10. American Academy of Orthopaedic Surgeons. Orthopaedic surgeons will need to double total joint arthroplasty caseload to meet demand by 2050. 2023.
11. Van Heest AE, Dougherty PJ. Orthopaedic education: Operative assessment and the ACGME milestones: Time for change. Clin Orthop Relat Res. 2015;473(3):775-8.
12. Accreditation Council for Graduate Medical Education International. Orthopaedic surgery milestones 2.0. 2020.
13. Padmore J, Hauer KE, Ekpenyong A, Edgar L, Holmboe E, Andolsek K. Assessment in graduate medical education. 2014.
14. Accreditation Council for Graduate Medical Education. Program requirements for graduate medical education in orthopaedic surgery. 2023.
15. Kohring JM, Bishop MO, Presson AP. Operative experience during orthopaedic residency compared with early practice in the United States. J Bone Joint Surg Am. 2018;100(7):605-16.
16. Trends in medical training and leadership at academic orthopedic programs. Cureus. 2022.
17. Ronback L, Huff T, Reis M, Templeton K. Access to orthopaedic care in rural America. J Am Acad Orthop Surg. 2025;33(10):518-26.
18. Roberts D, Fox M. The need for specialist training exposure in residency programs. Curr Rev Musculoskelet Med. 2014;7(2):151-4.
19. Kashner TM, Greenberg PB, Henley SS, Bowman MA, Sanders KM. Assessing physician resident contributions to outpatient clinical workload. Med Care. 2022;60(9):709.
20. Deeds SA, Corning KA, Wipf JE, Takahashi TA. Expanding primary care experiences with novel rotations for residents at a VA medical center. J Grad Med Educ. 2019;11(6):691-7.
21. Accreditation Council for Graduate Medical Education. Fees. 2025.
22. Barajaz M, Turner T. Starting a new residency program: A step-by-step guide for institutions, hospitals and program directors. Med Educ Online. 2016;21:32271.
23. Pauwels J, Weidner A. The cost of family medicine residency training: impacts of federal and state funding. Fam Med. 2018;50(2):123-7.
24. Centers for Medicare and Medicaid Services. Direct graduate medical education. 2025.
25. Medicare payments for graduate medical education: what every medical student, resident and advisor needs to know. 2015.
26. Association of American Medical Colleges. Survey of resident and fellow stipends and benefits. 2025.
27. Eden J, Berwick D, Wilensky G. GME financing. In: Graduate medical education that meets the nation’s health needs. Washington (DC): National Academies Press; 2014.
28. Ngatuvai M, Yeager M, Newsome K. Analysis of surgical residents’ salaries and associated funding during eight residency training cycles. J Surg Res. 2023;281:70-81.
29. Berns JS, Goldstein JL, Hartmann DM, Simons K, Opas L. The expanding role of designated institutional officials in graduate medical education. Acad Med. 2025;100(2):131-6.
30. Compensation report: Orthopedist salaries. 2023.
31. Accreditation Council for Graduate Medical Education. National case log data reports: Orthopaedic surgery. 2023.
32. Federico V, Higgins J, Nolte M, Kogan M. Promoting wellness in orthopaedic surgery residency. JAAOS Glob Res Rev. 2022;6(3).
33. Philibert I, Taradejna C. A brief history of duty hours and resident education. 2011.
34. Wilson A, Dow E, Hanami D, Vasa M, Billimek J. Encouraging mental health care in family medicine residents. PRiMER. 2022;6.
35. Lightsey HM, Maier SP, Bono CM, Kang JD, Harris MB. In-hospital 24-hour exercise spaces for resident and staff wellness. HSS J. 2023;19(2):140-5.
36. Althausen PL, Lybrand KE. The role of business education in the orthopedic curriculum. Orthop Clin North Am. 2018;49(4):445-3.
37. van Vendeloo SN, Prins DJ, Verheyen CCPM. The learning environment and resident burnout: A national study. Perspect Med Educ. 2018;7(2):120-5.
38. Casey VF, Schenk JL. Building a culture of wellness in an orthopaedic group. J Pediatr Orthop. 2020;40:S38.
39. Accreditation Council for Graduate Medical Education International. Advanced specialty continued accreditation application for orthopaedic surgery. 2020.
40. Yong TM, Pappas MA, Ray GS, McManus TG, Coe MP. Social media use among orthopaedic surgery residency programs. JBJS Open Access. 2021;6(3):e21.00017.
41. Bhayani RK, Fick L, Dillman D, Jardine DA, Oxentenko AS, O’Glasser A. Twelve tips for utilizing residency program social media accounts for recruitment. MedEdPublish. 2020;9:178.
42. Barajaz M, Denniston S, Kumar S, Wolfe A. Candidate attitudes toward a new residency program. MedEdPublish. 2018;7:245.