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The Impact of Residency and Fellowship Training on the Practice of Microsurgery by Members of the American Society for Surgery of the Hand
River M. Elliott, MD, Abtin Foroohar, MD, L. Scott Levin, MD, FACS.
University of Pennsylvania Health System, Philadelphia, PA, USA.

BACKGROUND: Several economic, educational, and lifestyle factors have converged to create an environment that discourages the routine practice of microsurgery by hand surgeons. The purpose of this study was to perform a detailed assessment of the microsurgical training background of current members of the American Society for Surgery of the Hand (ASSH) and then determine the impact that prior training had on current microsurgical practice.
METHODS: A 174-item, anonymous Web-based survey was sent to all active members of the ASSH. Eleven items addressed general microsurgical practice, two items concerned training background, and 156 addressed the surgeon’s training, comfort, and current practice of specific microsurgical procedures. The remaining items concerned practice setting, training background, and general comments. Data were analyzed using frequency tables, cross-tabulations, and chi-square tests.
RESULTS: Responses were received from 377 of the 2019 ASSH members surveyed (18.7% response rate). Residency training was primarily in orthopaedics (n=249, 66.9%), plastic surgery (n=56, 15.1%), or general surgery (n=55, 14.8%). The majority of respondents participated in orthopaedic hand fellowships (n=242, 65.1%), followed by combined (n=65, 17.5%), and plastic surgery (n=15, 4%) fellowships. Practice settings included private practice with or without academic affiliation (n=247, 67.2%), academic medical centers (n=106, 28.7%), or regional medical centers (n=15, 4.1%). Microsurgical procedures involving nerves were performed by the majority of surgeons (n=337, 96.6%). In this category, there were no statistically significant differences between hand surgeons who had completed residency in plastic surgery versus orthopaedic surgery, and no differences between those who had completed orthopaedic versus combined fellowships. General microvascular procedures were performed by fewer surgeons (n=208, 56.1%), while replantations were performed by exactly 50% of respondents (n=179). One hundred thirteen respondents (30.6%) performed free tissue transfer. When compared to hand surgeons with orthopaedic residency backgrounds, hand surgeons who completed plastic surgery residencies were more likely to perform general microvascular procedures (78.6% vs. 47.8%, p=3.02x10-5), replantations (70.6% vs. 44.8%, p=0.00231), and free tissue transfer (77.4% vs. 20.7%, p=7.41x10-16). Hand surgeons trained at combined fellowship programs were more likely to perform replantations (58.1% vs. 43.9%, p=0.0475) and free tissue transfer (40.6% vs. 23.6%, p=0.00686) when compared to those who trained at orthopaedic fellowship programs. There was no significant difference between groups with respect to general microvascular procedures. Small numbers of respondents trained in plastic surgery hand fellowships prevented statistical analysis of this group.
CONCLUSIONS: Educational and training backgrounds have a substantial impact on microsurgical practice by hand surgeons. Although nearly all surgeons perform microsurgical procedures involving nerves, significant differences were seen in other areas. Complex microsurgical procedures are more frequently performed by surgeons trained in plastic surgery residencies and combined fellowship programs. Specifically, hand surgeons trained in plastic surgery residency programs are more likely to perform replantations, free tissue transfer, and general microvascular surgery, while those trained at combined fellowship programs are more likely to perform replantations and free tissue transfer.


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