Fellowship will never hurt, but the quality of most residencies today is pretty high. A lot of the confidence to doing surgery is somewhat innate (as well as based on case preparation IMO). You will realize that once you get into the OR.
There are many alumni of my program who routinely do Ilizarovs, triples, and other complex recon without flinching. A few are residency directors, others are main residency attendings who bring a good amount of RRA, and some work in ortho groups. They feel comfortable doing those cases, they like them, and the patients need the recon. There are also other alumni who were those same guys' co-residents yet do basically just forefoot surgery... and co-scrub any of their RRA with a partner or completely refer the more complex cases within or outside their group. Is there a training difference between those doing RRA and those not? Not at all... case volume/diversity, med rotations, etc are almost identical (remember, they were co-residents). A lot just comes down to personal comfort level, interests, goals, and confidence.
You will see that some surgeons - regardless of training - decide that they just don't want the complex follow up and burdens of the RRA cases. While the anatomy is bigger and the surgery is therefore arguably easier, nobody will argue that the RRA complications aren't more frequent and more devastating (in terms of function/pain, not necessarily malpractice rate/settlement) than the forefoot complications typically are. The RRA cases are usually longer with bigger incisions and more procedures... therefore more prone to infection and post-op pain. The more proximal joints and neurovasc structures are more essential than distal ones and therefore more disabling when malfunctional. The hindfoot cases often require longer periods of nonweightbearing and protected weightbearing, and therefore more cast complications, DVTs, etc.
You will especially find that a lot of the peds cases have high medicolegal risk, trauma cases are often a financial loss for DPMs since most hospitals don't pay DPMs to take call (yet the trauma cases are still a medicolegal risk), and much of the RRA is just not time:income efficient compared with office time or more basic surgical work. That is not being said to dissuade you by any means, but you will realize that RRA (esp trauma) really holds a LOT more allure to most students/residents than it typically does to attendings. Again, when you are training and when you are an attending, you will decide what's important, comfortable, and interesting to you personally.
I always maintain that being good at F&A surgery is basically a 4 part equation: interest + prep work, training, confidence, and natural talent (motor coordination + 3D anatomic/biomech thinking). A fair amount of the guys you see on the ACFAS podium did a 1yr residency. A lot of the biggest ortho F&A author/educator names never did a fellowship (often since F&A ortho fellowships were in infancy or not around yet); they just did gen ortho took special interest and pride in F&A cases. In the end, a lot just depends on the individual.
Fellowships can be useful to see more cases or different types than you might have seen in residency, but we are fortunately to the point where the vast majority of PM&S residencies can give you what you need if you apply yourself. As was mentioned, everyone's goals are different, and you just want to do what makes sense to you personally in terms of residency, fellowship, practice focus, etc choices.
