UCLA HAND SURGERY- MICROSURGERY FELLOWSHIP 
UNIVERSITY OF CALIFORNIA, LOS ANGELES

HOSPITAL ROTATIONS 

1.      UCLA  Medical Center

The majority of the fellowship is based at UCLA Medical Center where the fellows will be exposed to traumatic and elective hand surgery as well as attending the private offices of Drs. Benhaim, Jones and Meals.  UCLA is one of four Level 1 Trauma Centers in LA County and one of two University Hospitals (the other being USC-LA County).

2.      Olive View County Medical Center
 
One of the fellows will attend the alternate Thursday hand clinic which sees approximately 70 patients per clinic and participate in the elective hand surgery operating on the other alternate Thursday.  There is an abundant volume of straight forward hand trauma seen through the Olive View Emergency Room – primarily wrist and hand fractures and tendon and nerve injuries.  There is only one plastic surgery resident at Olive View and the fellows act as an attending hand surgeon on an alternate weekly call.  However, this is not an onerous call schedule and the fellows rarely have to go out to Olive View at night.   The patient population at Olive View is interesting in that they come from virtually every country in the world looking for their “piece of the American dream”.   Consequently, they are extremely motivated to return to work and are very grateful for their hand surgery.

3.      West Los Angeles VA Hospital     

This is not really a fellowship rotation and is primarily for the two hand surgery residents.  However the fellow may occasionally cover the Friday VA hand clinic or the Monday hand surgery operating session if the hand residents are away or if the attending, Dr. Ghiassi is away.

4.      Santa Monica-UCLA Hospital

This is a private hospital in Santa Monica that was recently taken over by UCLA and will eventually become a second campus for the UCLA Medical Center.  The fellows will occasionally be called for straight-forward hand emergencies such as hand fractures, tendon and nerve injuries, the schedule being approximately one week a month.

5.      Shriners Hospital – Los Angeles  

One fellow will accompany Dr. Jones to a monthly congenital hand clinic at Shriners Hospital on the second Tuesday of the month.  Both fellows will gain experience in microsurgical reconstruction of congenital hand anomalies, such as toe transfers, approximately once a month as well as gaining exposure to approximately 6 pollicization procedures per year with John Lawrence, M.D.

FACULTY 
 
Neil F. Jones, M.D., Fellowship Director,  Professor Department of Orthopaedic Surgery and Division of Plastic and Reconstructive Surgery

Prosper Benhaim, M.D., Assistant Professor, Department of Orthopaedic Surgery and Division of Plastic and Reconstructive Surgery

Roy Meals, M.D., Clinical Professor, Department of Orthopaedic Surgery  

Malcolm Lesavoy, M.D. , Clinical Professor, Division of Plastic and Reconstructive Surgery

Dr. Jones is currently on the Council of the American Society for Surgery of the Hand and has just finished a two year term as Secretary of the American Society for Reconstructive Microsurgery.  He has been an Associate Editor of the Journal of Hand Surgery.

Dr. Meals is currently the Deputy Editor of the Journal of Hand Surgery and has served previously on the Council of the American Society for Surgery of the Hand.

Dr. Benhaim is currently an Associate Editor of the Journal of the American Society for Surgery of the Hand.

The fellows will also occasionally interact with clinical attendings such as Alidad Ghiassi, M.D. at the West Los Angeles VA Hospital, and John Lawrence, M.D. at Shriners Hospital of Los Angeles. 

There are three dedicated hand therapists at UCLA and one dedicated hand therapist at Olive View County Medical Center.

UCLA HAND SERVICE 

This is a totally combined service between the Department of Orthopaedic Surgery and the Division of Plastic and Reconstructive Surgery.  There is no alternating trauma call between orthopaedic surgery and plastic surgery.  All bony and soft tissue injuries distal to the wrist go to the Hand Surgery Service.  Virtually all distal radius fractures now also go to the Hand Service.   Complex combined injuries of the upper extremity and nerve injuries of the upper extremity also go to the Hand Service.  The Hand Surgery Service is also frequently consulted for Grade III open fractures of the lower extremity. 

The Hand Surgery Service consists of:

─ 4 attendings
─ 2 hand surgery fellows
─ Chief Orthopaedic Resident – PGY5 or 6, 6 residents alternating every two months
─  Junior Plastic Surgery Resident – PGY6, 3 residents alternating every four months
─  Junior Orthopaedic Resident  - PGY2 or 3 alternating every month.   The junior orthopaedic resident takes care of all the minor hand trauma in the Emergency Room including finger tip injuries and initial reduction of wrist and hand fractures.   Patients with more severe hand injuries are initially seen by one of the 2 hand residents and the hand fellow is then involved in the operative treatment or in a consultant role.

FELLOWSHIP GOALS 

The UCLA hand fellowship is completely integrated between orthopaedic surgery and plastic surgery and there are very few totally integrated fellowships in the United States.  Secondly, it is very much a mentorship type fellowship with a “one-on-one” relationship between the fellow and faculty.   This is in contradistinction to fellowships where a fellow only spends one or two months with six attendings and does not get to understand the thinking and judgement of an attending.  The fellow spends three months with Dr. Jones and then three months with Dr. Meals and Dr. Benhaim and this is then repeated.  All of the attendings are very good teachers and will take the fellow through surgical procedures rather than having the fellow “hold hooks” or at the other extreme “relearn the wheel”.   The full spectrum of hand surgery is seen at UCLA, nothing is too over emphasized and there is really nothing missing.  Fellows will see the full spectrum of trauma, post-traumatic reconstruction, distal radius fractures, wrist pain, rheumatoid and congenital.  The UCLA fellowship is particularly strong in microsurgery with a good volume of peripheral nerve surgery, and free flap and toe transfer reconstructions of the upper extremity.  There is excellent exposure to extremity salvage reconstruction after malignant tumor resections and toe transfers for congenital hand reconstruction.  In addition, the fellows will be involved in free flaps for coverage of the lower extremity for lower extremity trauma and osteomyelitis and also free bone transfers for bony reconstruction.

INDEPENDENT RESPONSIBILITY

One of the advantages of the UCLA fellowship is that there are excellent opportunities for the fellow to act as an attending hand surgeon and teach orthopaedic residents and plastic surgery residents hand surgery techniques during both emergency and elective hand surgery.  However this is coupled with a “safety-net” in that the fellows can still feel comfortable by getting telephone advice from the attendings or if necessary asking the attending to come in and help.  Fellows are given an academic appointment as a Clinical Instructor at UCLA and therefore once a month can act as the attending of record for admission and surgical treatment of hand trauma patients.

As described previously, the hand fellows also act as the attendings for hand trauma patients at Olive View County Medical Center on a one in two weekly schedule and take the plastic surgery resident through the surgical cases.

EDUCATIONAL PROGRAM 


1.      Weekly Hand Conference on Tuesday afternoons.  Either a resident or fellow will give a 30 – 45 minute didactic talk on a specific topic, and this is followed by a lively discussion generated by the attendings.  At the second Tuesday of the month hand conference, the two fellows show all the interesting cases from the previous month and this also acts as an audit of cases preformed by the fellows in their attending role.  This is probably the most informative conference and the fellows are obligated to take 35 mm slides or digital photographs of all cases and relevant x-rays.  This photographic documentation allows teaching at all levels from the medical student level through the orthopaedic and plastic surgery residents up to the fellow and attending level.

2.      Monthly Journal Club 

3.      Orthopaedic Surgery Core Curriculum.  Wednesday mornings 6:45 AM to 8:15 AM   - two lectures per week for eight weeks are given on basic hand surgery topics to the orthopaedic surgery residents and usually each fellow will give two of these lectures.

4.      Hand dissections – each fellow and each resident on the service in July will demonstrate hand and upper extremity anatomy to all the orthopaedic surgery and plastic surgery residents during one or two Saturday morning sessions. 

5.      One week basic microsurgical lab course for an incoming orthopaedic-trained fellow.  We usually arrange for such a fellow to spend one week in the microsurgery lab during the first month of the fellowship in August to hone their microsurgical skills.  However, we would also prefer any incoming orthopaedic-trained fellow to have completed a one week basic microsurgery course at their home institution prior to the fellowship and similarly for any plastic surgery-trained fellow to have competed a basic AO internal fixation course prior to beginning the fellowship. 

6.      Local courses and lectures – the hand fellows are encouraged to attend lectures by visiting hand surgeons at other institutions such as Orthopaedic Hospital and USC.   Dr. Jones has organized the Regional Review Course of the American Society for Surgery of the Hand which have been held at UCLA every two or three years and the fellows would obviously be able to attend.


RESEARCH 
 

1. Microsurgery Lab in plastic surgery

2. Bio-mechanics Lab staffed by two full time Ph.D. biomechanical engineers

3  Fresh cadaver dissections in the anatomy department

4. Tissue engineering of cartilage and bone - Dr. Benhaim spearheads our research program and directs a basic science lab with a major emphasis on.  Each fellow is expected to complete two research projects, one of which is usually presented at the annual UCLA Orthopaedic Residents Day, but ultimately should be presented at a national meeting and published if possible.  Fellows have usually become involved in clinical projects but there are multiple opportunities for projects in basic science.  Previous fellows, Gordon Singer, M.D. completed a biomechanical study of flexor tendon repairs and Ranjan Gupta, M.D. studied nerve compression.  The Sumner Koch prize for the best research paper at the annual meeting of the American Society for Surgery of the Hand has been won by a UCLA fellow or resident four times out of the last eight years.  Three of our previous fellows, Ranjan Gupta, M.D., Prosper Benhaim, M.D. and James Chang, M.D. have all received major research funding after completion of the UCLA fellowship, including a NIH grant to Dr. Gupta.

SALARY, VACATION and MEETINGS  

The fellows are paid at the relevant PGY 6, 7, 8 or 9 level which is approximately $50,000. per year.  Travel and accommodation expenses are paid for one meeting per year, which is usually the American Society for Surgery of the Hand meeting in the fall and fellows receive one month of vacation. 

SUMMARY:
 

1.      The UCLA Hand Surgery-Microsurgery fellowship enjoys a solid national reputation which should continue to increase with our basic research commitment to tissue engineering and transplantation which will probably be the future of hand surgery.

2.      The fellowship is a truly integrated combined program between the Department of Orthopaedic Surgery and the Division of Plastic and Reconstructive Surgery.  It allows an orthopaedic-trained fellow to be brought up to a very high level of expertise in the management of flap coverage and nerve and tendon repairs and reconstruction, and conversely a plastic surgery-trained fellow to be brought up to a very high level in the treatment of distal radius fractures and internal fixation of hand fractures.

3.      The fellowship is a very intense mentorship type program with “one-on-one” teaching in the operating room and private offices, but at the same time allowing progressive responsibility for independent operating.

4.      Finally, the UCLA fellowship has been fortunate to match its top two or top one and three choices for several years and the UCLA fellows rank very favorably with graduates of the other top fellowship programs.  Indeed, we would expect a few of our recent fellowship graduates to eventually become leaders in academic hand surgery over the next few years.

NFJ:kes
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