19.6 million Americans live in a county with no orthopedic surgeon

In April, the American College of Surgeons published a county map of the surgical workforce and a number that traveled: 15.1 million Americans live in one of 1,180 counties with no general surgeon.¹ I wanted the same map for my own specialty, and I wanted it to answer the questions a surgeon asks next. How far is the nearest colleague? Which hospitals have no orthopedic surgeon in the county at all? How much of the workforce is within a decade of retiring? The map at techysurgeon.com/tools/ortho-workforce answers those for every county, and this brief reports what it shows.

The count

The Centers for Medicare & Medicaid Services publishes every clinician enrolled to bill Medicare, with each practice address, in the Doctors and Clinicians National Downloadable File.² The August 18, 2026 release lists 58,743 practice-location rows for 23,440 clinicians whose primary specialty is orthopedic surgery. I assigned each ZIP code to the county that contains the Census internal point of its ZIP Code Tabulation Area (the county holding the largest share of the area when the point falls outside every county polygon), dropped 6,654 rows where the enrolled organization is a physical-therapy or rehabilitation company (a billing reassignment for therapy, one company in Cranberry Township, Pennsylvania lists 627 orthopedic surgeons at one address), and dropped 1,222 rows whose ZIP is outside the 50 states or a post-office box with no tabulation area. That leaves 22,963 surgeons. Residents and fellows do not enroll as billing clinicians, so the count excludes trainees, as the ACS count did.

A surgeon who lists addresses in two counties is counted in both, and for rates each surgeon is split evenly across their addresses so the weighted total equals 22,963. Divided by the Census Bureau's 2024 population estimates, the national supply is 6.8 orthopedic surgeons per 100,000 residents.³ The ACS reported 59.2 surgeons per 100,000 across its 12 specialties from a different file (the NPI registry), so the two figures are not the same measurement and I do not compare them directly.

Counties with no orthopedic surgeon

1,270 of the 3,143 counties, 40 percent, have no orthopedic surgeon at any listed address. 19.6 million people live in them, 5.8 percent of the country. A further 373 counties have exactly one, covering 9.7 million people.

The gap is rural in count and suburban in population. 966 of the empty counties are nonmetropolitan under the USDA's 2023 rural-urban codes, and 11.4 million of the 46.3 million people in nonmetro America live in one.⁴ The other 304 empty counties are inside metropolitan areas and hold 8.2 million people, and they include the largest counties on the list. Comal County, TX, between San Antonio and Austin, has 201,628 residents and no orthopedic surgeon address; the nearest county with one is Hays County, 22 miles away by county center. Suburban counties like these are served by surgeons across the county line, so for a patient the gap is a drive, and for a hospital in that county it is a call schedule with nobody local on it.

By state, Texas has the most people in counties with no orthopedic surgeon, 2.1 million across 141 of its 254 counties, followed by Virginia and Tennessee. Tennessee's nonmetro counties have 2.1 surgeons per 100,000 against 7.2 in its metro counties, the widest urban-rural spread of any large state, and Florida's nonmetro rate is 2.1. Nationally the metro rate is 7.0 and the nonmetro rate 5.4.

Distance to the nearest surgeon

The ACS map stops at presence. To get at access I measured the great-circle distance from each empty county's Census internal point to the nearest county that has an orthopedic surgeon.⁵ It is a floor on travel distance, not a drive time, and it flatters the West, where a county center can sit 60 miles from its own hospital. Even so: 3.7 million Americans in 419 counties live 30 or more miles from any county with an orthopedic surgeon, and 409,540 people in 60 counties live 60 or more miles away. In the lower 48 the farthest is Nye County, NV, 55,990 people and 131 miles from White Pine County; Val Verde County, TX, on the border at Del Rio, has 47,999 residents 90 miles from Uvalde County. For a hip fracture, that distance is a transfer, a delay to surgery, and the mortality that follows delay.

Hospitals with no orthopedic surgeon in the county

728 of the 4,623 hospitals CMS lists, 16 percent, sit in a county with no orthopedic surgeon address, and 539 of them are critical access hospitals, 39 percent of all 1,378 critical access hospitals in the country.⁶ These are the emergency departments that receive the fall, the farm injury and the motorcycle crash first, and they stabilize and transfer nearly all of it. Texas has 77 such hospitals, Kansas 63, and in Kansas 59 of them are critical access. The ACS found 475 hospitals in counties without a full-time surgeon of any kind; the orthopedic number is larger because orthopedic coverage is thinner than general surgical coverage in the same towns.

Supply by state

State supply runs from 5.2 per 100,000 in Texas to 13.1 in Wyoming, a 2.5-fold spread. The sparse mountain and plains states rank highest because their populations are small and their surgeons cluster in a few towns that also serve the empty counties around them, so a high state rate and a long drive coexist. The four largest states, California, Texas, Florida and New York, employ 31 percent of the workforce and all four sit below the national rate.

Age and gender of the workforce

The CMS file records each clinician's medical-school graduation year. The median orthopedic surgeon finished medical school 22 years ago, and 31.7% of the workforce is 30 or more years out, which at a typical age puts them past 55. In Delaware, Arkansas and Maryland the share is above 38 percent; in South Dakota and Utah it is near 20. The retirement exposure concentrates where supply is already thin: in 199 counties with 5.9 million residents every orthopedic surgeon on the list is 30 or more years out, and in 146 of the 373 single-surgeon counties, home to 3.9 million people, that one surgeon is. Those counties join the no-surgeon list within the decade unless someone is recruited to replace them.

Women are 8.8% of orthopedic surgeons enrolled in Medicare, the lowest share of any surgical specialty in the ACS series. Minnesota (16.6%), Oregon and Massachusetts lead; Alaska, North Dakota and Arkansas are under 4 percent.

Hand surgery and sports medicine

Medicare enrolls hand surgeons under their own specialty, which mixes orthopedic and plastic hand surgeons: 1,788 are mapped, about 0.5 per 100,000. Sports medicine is a secondary specialty that 1,427 orthopedic surgeons list. Both are layers on the map, and both are even more urban than the parent specialty.

Limits of the data

A practice address is not a privilege list, a call schedule, or a case volume; a surgeon with two addresses may operate at one. The file covers clinicians enrolled to bill Medicare, which is nearly every practicing orthopedic surgeon but under-counts pediatric and military practice. Distances are between county centers. Connecticut is shown by its eight former counties with 2021 population estimates because the county boundaries and the ZIP relationship file still use them. A ZIP's internal point can sit across a county line from the practice itself, so a border-town group may land in the neighboring county. And this is a snapshot of one file on one date; the ACS used the NPI registry from April 2025, so the two maps will disagree at the margins, and where they do, the disagreement is a good place to look.

The workforce question for orthopedics is not how many of us there are. It is whether there is one within reach when a 78-year-old breaks her hip on a Sunday in a county that has a hospital and no one to fix it.