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Foot and Ankle Fellowships

Hurwitz, Shepard

Section Editor(s): Bernstein, Joseph MD, Guest Editor

Clinical Orthopaedics and Related Research: August 2006 - Volume 449 - Issue - p 223-226
doi: 10.1097/01.blo.0000224065.78039.a2
SECTION I: SYMPOSIUM III: Orthopaedic Fellowships

From the Department of Orthopaedic Surgery, University of Virginia Health Systems, Charlottesville, VA.

Correspondence to: Shepard Hurwitz, MD, Department of Orthopaedic Surgery, University of Virginia Health Systems, Box 800159, Charlottesville, VA 22908. Phone: 434-243-0245; Fax: 434-243-0242; E-mail:

Foot and ankle fellowships offer surgeons the educational experience to catapult them to positions of leadership in the specialty of foot and ankle injuries and disease. Few residency programs offer more than brief rotations in foot and ankle, and thus a fellowship is an opportunity to learn foot and ankle pathology in greater depth and breadth. Year-long training or even 6-month fellowships also allow the trainee to see patients (particularly problem patients) in followup. A well-designed fellowship will carve out time for dedicated reading and study of the anatomy, physiology, and biomechanics of foot and ankle problems.

Most foot and ankle fellowships are organized as an apprenticeship. The teaching process centers on practical hands-on action, with guidance from a content or domain expert. Clinical research, if required by the program or desired by the fellow, is usually in the form of reporting a case or series of patients. Very few foot and ankle specialists themselves are expert clinical investigators who generate level I or II treatment evidence. Even fewer practicing foot and ankle surgeons are expert laboratory scientists who design experiments using mechanical or biological approaches. Research, to my thinking, is an optional-not central-part of the current foot and ankle fellowship curriculum. When scrutinizing fellowships regarding research opportunities and requirements, the key task is to determine whether the research experience includes acquiring the skills one needs to be an independent researcher after fellowship. If all the research output of a given institution is from its clinical database, once you are bereft of that resource (ie, when you're out on your own), you may not have anything to write about. On the other hand, if you are taught distinct skills in the biomechanics laboratory, the wet bench, or in classes on clinical epidemiology you will be poised to perform your own meaningful research after training.

At a minimum, a fellowship-trained foot and ankle surgeon must be expert at osteotomy, bone graft harvest, small joint fusion, tendon transfer and excisional biopsy of soft tissue. To the extent you have not mastered these in residency, you may need to favor fellowships that offer a greater opportunity for picking up the surgical skills. As a perhaps obvious yardstick, assess the surgical caseload (per fellow) at the institution, the distribution of cases, and the extent of participation by the fellow.

Regarding the case mix, look closely at what conditions are being treated and whether there is any diversity in the fellowship for addressing the pathology. You may get a far better “bunion education” doing 50 cases utilizing four different methods, as opposed to 500 procedures all done the same way. The case mix should reflect what the fellow anticipates in terms of community practice, referrals from family physicians, and emergency departments, but should also prepare the fellow to handle revision surgery and problem case referrals from fellow orthopaedic surgeons.

Some fellowships will offer exposure to pediatrics; at others, these cases are managed by the pediatric orthopaedic service. At the very least there should be exposure to adults who have the sequelae of childhood deformity (and childhood surgery). If you do not plan to handle complex pediatric cases, you may get by without much in this realm. On the other hand, if your first love is complex pediatric cases, you may in fact be better served by choosing to attend a dedicated pediatrics fellowship.

Management of hindfoot trauma is an area of shared practice with orthopaedic traumatologists. An ideal fellowship would be one where an expert traumatologist shares the responsibility for foot cases with a foot and ankle trained specialist, allowing the fellow to learn from both. I counsel applicants to consider the issue of trauma, even if not intended as a topic of career emphasis. I believe all of us should contribute something to the care of the injured, and if you want to be spared general trauma call, be prepared to offer something else. If a surgeon can offer expertise in foot and ankle trauma, he or she can still contribute-and avoid generating resentment of col leagues-without necessarily participating in all types of general trauma cases.

Consider your future career plans regarding subspecialty focus. Some future foot surgeons may wish to specialize in advanced techniques in microsurgery, others may wish to be expert arthroscopists, and still others may want to become authorities on advanced external fixation for correction of deformity. It is difficult to find one fellowship that can teach all the cutting edge techniques in addition to the fundamentals. You may simply have to pick one area and choose accordingly.

All foot surgeons should be expert in evaluating foot and ankle problems, masters of surgical anatomy, accurate interpreters of diagnostic tests-especially MRI and electrodiagnostics-and possess good communication skills. (The latter may be particularly relevant to foot and ankle specialists, as their practice may overlap with that of podiatrists, who seemed to be superbly skilled at communication and marketing.) You may wish to assess a fellowship by determining how successful its former trainees seem to be in those core areas.

You must consider the prestige of the fellowship. Most of the high prestige fellowships have a depth of faculty and wealth of clinical material-factors with inherent worth. A “name brand” fellowship may offer additional attractive features. The issue of prestige is particularly germane in foot and ankle, as some foot and ankle fellowships are esteemed precisely because of their illustrious faculty. Training with a famous surgeon will be most meaningful to your colleagues: they will recognize the name and your place in the masoretic tradition. On the other hand, a certificate from an Ivy League institution (or the like) that does not necessarily have an excellent fellowship in foot and ankle may confer greater prestige only in the lay community.

Geographic location is an important consideration when choosing a fellowship in all fields, as many fellows tend to practice somewhere near their training institution. This consideration is particularly relevant in foot and ankle. That's because a medium-sized city can support only a few tertiary care foot and ankle specialists. Thus, you should know that it will probably very difficult to remain in relatively crowded areas such as Boston or Baltimore-home to top notch training programs. You may be better off, in fact, training in cities with perhaps a little bit less to offer educationally but more to offer regarding practice opportunities. Some areas that genuinely need a foot and ankle specialist may be resistant to “carpetbaggers” who did not train nearby. Therefore, you should consider your geographic post-fellowship plans when picking a fellowship.





© 2006 Lippincott Williams & Wilkins, Inc.