Mounisamy et al. present a thorough narrative review of institutional development and support in orthopedic education, emphasizing mentorship, technological incorporation, and institutional backing as key areas to improve trainee growth. The authors further outline important program barriers such as time, workload, and resources, offering pragmatic solutions such as simulation laboratories, incorporation of virtual reality (VR), and mentorship. The authors call for standardized and well-supported solutions to support the ongoing needs and evolutions in orthopedic training.

The article’s aims are clear and succinct, with the authors searching across multiple databases and presenting a synthesis rather than a meta-analysis. We commend the authors for explicitly acknowledging the heterogeneity of the included designs, outcomes, and follow-ups that may influence any drawn conclusions. However, we respectfully raise two areas of consideration that may affect the interpretation and utility of the piece.

First, outcomes and evaluation frameworks would benefit from being standardized with established tools. Interventions could be mapped to validated tools, such as the Kirkpatrick model, to assess measurable results, whereas competency could be mapped to the Accreditation Council for Graduate Medical Education milestones ^[1,2]. Standardizing these into measurable frameworks would help translate these concepts into granular data for greater reader interpretability. In addition, the inclusion tables listing performance metrics (scores, milestone gains, and scholarly output) could seek to further operationalize intervention success. Second, technological advancements should be considered alongside the context of resource constraints. While simulations and VR technology are promising, programs in resource-constrained settings may seek more feasible alternatives, and this must be considered for generalizability ^[3]. Therefore, the inclusion of a tiered resource-dependent recommendation system would greatly improve the equity of adoption. Overall, the authors provide a valuable presentation to improve orthopedic training. With added specificity around the methods, contextual information, and resource scarcity, it will further bolster the points raised by the authors to improve training across environments.