Moral injury in orthopaedic surgery: Distinguishing burnout from system-level ethical conflict

Orthopaedic surgeons experience some of the highest rates of burnout, depression, and suicidal ideation among all surgical specialties, yet existing wellness frameworks may not fully account for the specific nature of their distress. When surgeons are prevented from providing timely, indicated care by system constraints, pressured to participate in clinical decisions that conflict with their professional judgment, or repeatedly exposed to preventable disability and suffering, the resulting harm is not simply exhaustion. It is moral injury-a deeper disruption of professional identity, trust, and conscience that burnout frameworks alone do not capture. This manuscript introduces a three-domain model of moral injury in orthopaedic surgery, linking constraint-based, permission-based, and exposure-based mechanisms to measurable surgeon-level and system-level outcomes. We examine how this framework differs from burnout and moral distress, why orthopaedic surgery is uniquely vulnerable, and what individual, departmental, and institutional interventions are most applicable. A structured research agenda and GRADE-informed recommendations are provided to guide future investigation and departmental implementation.