For orthopedic residents interested in hip and knee replacement, the adult reconstruction fellowship process can feel like one more competitive hurdle at the end of a long training pathway. But the fellowship landscape is changing quickly, and applicants today may have more leverage than they realize.
In Episode 47 of The Joint Replacement Podcast, I spoke with William “Bill” Hamilton, MD of the Anderson Orthopaedic Clinic about how residents should approach adult reconstruction fellowship applications, interviews, rank lists, and ultimately the decision of where to spend that critical final year of training.
Hamilton brings a unique perspective as both an experienced arthroplasty surgeon and educator. He also recently coauthored an analysis of adult reconstruction fellowship match trends from 2021 through 2026, giving us actual data to pair with the conventional wisdom surrounding the fellowship application process.
Adult Reconstruction Fellowship Is Becoming an Applicant-Friendly Market
One of the biggest changes is simply the number of available positions.
From 2021 to 2026, the number of adult reconstruction fellowship positions increased 17%, reaching 236 positions across 114 programs in 2026. During that same period, applicant volume remained relatively stable, averaging 267 applicants per year.
That imbalance has led to a growing number of unfilled positions. Only one fellowship position went unfilled in 2021. By 2025, 38 positions, or 16.1%, went unfilled.
Hamilton described the practical implication very clearly during our conversation: there are now more fellowship positions than there are U.S. applicants in adult reconstruction. As a result, competition is increasingly occurring not only among applicants, but among programs trying to attract the best residents.
That competition may ultimately be good for trainees. Programs have an incentive to provide better educational experiences, stronger mentorship, support for meetings and job searches, and an environment where fellows are treated as trainees rather than simply additional labor.
When Should Residents Start Preparing?
Hamilton recommends that residents begin thinking seriously about fellowship well before applications open.
The application process generally begins early in PGY-4, but residents should ideally decide on their subspecialty during PGY-3. That gives them time to develop relationships with mentors, secure meaningful letters of recommendation, and participate in research before applications are submitted.
For residents who think adult reconstruction may be their path, finding an arthroplasty mentor during PGY-2 or PGY-3 can be particularly helpful.
The goal is not simply to accumulate items on a CV. Hamilton emphasized that a meaningful research contribution can be more valuable than a large number of superficial publications.
Has the Publication Arms Race Gone Too Far?
One of the more interesting parts of our conversation involved the growing number of publications appearing on resident applications.
Hamilton routinely sees fellowship applicants with 15, 20, or even 30 publications. But he questioned whether publication count alone is a useful measure of an applicant’s quality.
He noted that fellowship directors understand that research opportunities differ significantly among residency programs. A few meaningful projects from a program with fewer research resources may tell a different story than a long publication list from an institution built to produce large amounts of academic work.
Later in the conversation, he made the point even more directly: he would rather see an applicant take one meaningful project from beginning to completion than simply appear as a minor author on numerous papers.
For residents, that is an important message. Research matters, particularly at academically oriented fellowships, but quality, engagement, and genuine interest in the field still matter more than simply chasing a number.
Personal Recommendations Still Matter
Another practical piece of advice was the importance of mentorship and advocacy.
Hamilton said that one of the most meaningful things he receives during application season is a personal call from an attending whom he knows or trusts recommending a particular resident.
A generic letter saying someone is in the “top 3%” of every resident a faculty member has ever trained may not distinguish an applicant nearly as much as a trusted colleague calling and saying, in essence, “You need to meet this person.”
His advice to applicants is to leverage mentors appropriately. If there are one or two programs that truly matter to you, asking an attending to personally advocate for you may help secure an interview.
How Should Applicants Use Fellowship Signals?
Preference signaling introduces another strategic element.
Orthopedic fellowship applicants now have a limited number of signals they can use to identify programs in which they have particular interest.
Hamilton compared the strategy to building a college application list. An applicant might use some signals on highly sought-after programs, others on programs where they believe they are competitive, and some on less prominent programs they would still be genuinely happy to attend.
As signaling becomes more established, Hamilton expects those signals to become increasingly valuable. Some highly competitive programs may eventually focus interviews primarily on applicants who have signaled them.
That makes indiscriminately using all of your signals on the same group of programs potentially risky.
How Many Fellowship Interviews Do You Really Need?
This may have been the most useful finding for current applicants.
The conventional approach has often been to interview broadly, sometimes at 15, 20, or more programs. The contemporary match data suggest that may no longer be necessary.
By 2026, 95% of applicants matched within their top seven ranked programs. Only about 2% of applicants in recent years matched beyond their tenth-ranked program.
At the same time, applicants are interviewing less. The average number of completed interviews declined from 15.4 in 2021 to 12.8 in 2026.
Hamilton’s interpretation is that roughly seven to ten interviews may be sufficient for many applicants, with perhaps 10 to 12 providing an additional margin of comfort.
His message was memorable: the days of feeling obligated to take 15 or 20 interviews may be over.
That matters because every additional interview carries a cost in travel, money, time away from residency, and opportunities taken away from other applicants.
Don’t Choose a Fellowship Based on Case Volume Alone
Applicants understandably ask about operative volume, but Hamilton cautioned against equating more cases with better training.
A fellowship advertising more than 1,000 cases may sound impressive. But if the fellow is simply moving rapidly through operating rooms without time to think about exposure, alignment, balancing, surgical decision-making, or complications, the educational value may not match the case count.
Hamilton’s advice was to focus on the quality of the operative experience rather than just quantity.
The same logic applies to revision surgery.
He suggested that thoughtfully participating in 25 complex hip revisions, including planning the case and performing meaningful portions of the operation, may be more educational than watching an extremely high-volume surgeon perform 100 revisions.
Fellowship should be about building judgment, not simply logging numbers.
Fellows Still Need Clinic
This is something many residents may not want to hear.
Everyone wants operating room experience. Few trainees are applying to an adult reconstruction fellowship because they want more clinic.
But Hamilton believes a fellowship without meaningful clinic exposure has a significant weakness.
The technical components of hip and knee replacement are only part of independent practice. Surgeons also have to decide who should undergo surgery, explain realistic expectations, manage complications, discuss partial versus total knee replacement, counsel patients about technology, and determine when a revision is actually appropriate.
Those skills are developed by watching experienced surgeons interact with patients.
We are training physicians, not simply technicians.
Should Fellows Learn Robotics or Manual Surgery?
Hamilton’s comments about robotics will undoubtedly generate discussion.
Although he uses robotic technology in his own practice, he believes fellowship training should prioritize developing excellent fundamental surgical technique.
His argument is that robotics can be learned relatively quickly, while developing exposure, saw technique, soft-tissue handling, and the judgment required to become a technically gifted surgeon takes much longer.
For residents evaluating programs, the broader lesson may be more important than the robotics debate itself: choose a fellowship that teaches principles rather than simply one system.
Technology will change during a surgeon’s career. Fundamental surgical judgment has to remain.
Should You Stay at Your Residency Program for Fellowship?
Hamilton strongly favors going somewhere different when possible.
After five years of residency, trainees have already absorbed much of their institution’s culture, philosophies, and surgical techniques. Spending fellowship somewhere else exposes them to another way of approaching the same problems.
That could mean different hip approaches, different alignment philosophies, new technologies, alternative revision strategies, or simply watching different surgeons communicate with patients.
A fellowship lasts only one year, but the different perspective may influence an entire career.
Talk to the Current Fellows
One of the most valuable resources on an interview day may not be the program director.
It is the current fellows.
Hamilton believes applicants should pay close attention to whether the current fellows actually seem happy. If a program limits applicants’ access to its fellows, he considers that a potential warning sign.
Residents should ask fellows what faculty members are really like in the operating room, how much autonomy they receive, whether promised case exposure actually materializes, what call is like, how much they travel between hospitals or surgery centers, and whether the program supports them outside the operating room.
The answers often reveal far more about fellowship culture than any brochure.
What Are Fellowship Directors Ultimately Looking For?
After the publications, recommendation letters, signals, and interviews, the decision may become surprisingly simple.
Hamilton described the questions faculty are really asking:
Is this someone I want to spend a year with?
Will this person take good care of my patients?
Will they show up prepared?
Will they think through a complex revision and make sure the necessary equipment is available?
Are they hardworking, detail-oriented, trustworthy, and pleasant to work with?
Those characteristics are difficult to quantify on a CV, but they become apparent during an interview.
For residents preparing for the adult reconstruction fellowship match, that may be the most reassuring message of all.
You do not need to manufacture the perfect application.
Find good mentors. Do meaningful work. Understand what you want from fellowship. Use your signals thoughtfully. Interview at programs you would genuinely consider. Talk to the fellows. And when you arrive at the interview, demonstrate the kind of surgeon and colleague you hope to become.
The fellowship landscape may be changing, but those fundamentals probably will not.
Listen to Episode 47 of The Joint Replacement Podcast with Bill Hamilton, MD on YouTube and Spotify.
References
- Ledford CK, Parks NL, Hamilton AC, Taunton MJ, Hamilton WG. Trends in Adult Reconstruction Fellowship Applications and Match Outcomes: A Report from the AAHKS Fellowship Committee. Analysis of 2021–2026 San Francisco Match data.
- Lum ZC, Sarpong NO, Hartzler MA, Ihehweazu UN, O’Connor MI, Adelani MA. Demographics of the American Association of Hip and Knee Surgeons and fellowship match data. J Arthroplasty. 2025;40(5):1097-1100.
- Krueger CA, Chisari E, Israel H, Cannada LK. Residency program reputation influences the American Association of Hip and Knee Surgeons match results. J Arthroplasty. 2020;35(9):2676-2681.
- Guthrie ST, Dagher T, Essey-Stapleton J, et al. Preference signaling in the orthopaedic surgery match: applicant and program perspectives. JBJS Open Access. 2024;9:e23.00146.
- Choy KB, Ganz M, Cannada LK, White PB, Steinmann S, Cohn RM, Mont MA, Bitterman AD. Orthopaedic adult reconstruction fellowship match rates: how do degree and sex affect match success? J Arthroplasty. 2025;40(7):1885-1890.