Lower extremity joint reconstruction fellowships are abundant. There are isolated hip or knee fellowships, combined hip and knee, and more general arthritis programs. Some programs may include upper extremity cases; others offer exposure to trauma-related or sports-related areas. The first step in identifying a good match is to determine in which category a given fellowship belongs. An equally important step is the process of self-examination, to determine which type of fellowship is best for you based on your strengths, weaknesses, and career plans.
Joint reconstruction fellowships are very likely to have overlap among the practices of the participating attendings. It is not unusual to have attendings who concentrate primarily on hip arthritis or knee arthritis. One critical aspect, although difficult to discern, is whether the fellowship attendings work together as a team or whether the fellowship is factionalized. In this situation a fellow often feels pressured to become aligned with an attending and subsequently can be perceived as belonging to the “opposite camp.” A lack of collegiality between attendings and fellows can become very detrimental to the training process.
Because joint replacement is a central part of orthopaedic surgery, you can expect to have residents working on the service concurrently with the fellow. In some fellowships, the fellows may have to divide cases with upper level residents. In others, fellows are teamed up with junior residents so the workload is more appropriately allocated according to the level of training. The best way to ensure conflicts are minimized is to have adequate case numbers but, ideally, a good policy stated in advance will help prevent these problems. Find out what opportunities you will have with resident and medical school teaching.
Joint reconstruction fellowships can be geared toward preparing you for either academic medicine or community practice. Find out where the program's recent graduates have gone in the past few years, and make sure these outcomes are suited to your own personal goals. It is also important to find out how well the program has helped place their graduates. The output of a given fellowship can be easily determined and speaking with recent graduates is often helpful. An ideal program is so well balanced that either career path is open to you at the end of training. It would seem logical for you to seek a fellowship where the track record matches the rhetoric: a fellowship that claims it wants to train academicians but does not succeed in doing so may be suspect.
The very name “reconstruction” implies this is a surgical fellowship, and it is. Still, pay careful attention to how much time and instruction you get in the office setting including coverage of both patient and practice management issues. A successful arthroplasty surgeon must be able to communicate well with patients and referring physicians, keep track of outcomes (and constantly strive to improve them), and also work well with non-physician healthcare providers. Education in these related areas, particularly the use of an electronic record system, should not be considered optional.
Research in joint replacement, especially clinical research, centers on the reporting of patient outcomes. If you want to be productive in this area, you are better off selecting a program that has an extensive database and an active research program. Be sure you receive good instruction on proper study design, and that you will be provided with the necessary skills to help build your own patient registry when you begin practice. Having some protected time to do research is an important aspect of the fellowship. An organized and comprehensive educational and conference schedule with active participation by the attendings is also essential to any well-rounded program.
You should also assess whether the fellowship is associated predominately or exclusively with one implant manufacturer. Most importantly, you should seek a fellowship where the decision on implant usage follows a logical framework based on the pathology rather than an alliance with an implant manufacturer. This is a sign of intellectual honesty that will carry over to other to other aspects of the training experience. Ideally, there will be several or multiple industrial alliances which allow you to use different manufacturers' implants on a routine basis. The ultimate goal should be the attainment of technical skill using a variety of different implants and techniques. This diversity of experience will help you pay attention to different clinical scenarios and facilitate your role as a responsible decision maker for appropriate implant usage in your own practice.
Just as hip and knee replacements can be performed with different implants, they may also be completed with different surgical exposures and techniques. A fellowship-trained joint replacement surgeon should be comfortable with anterior and posterior approaches to the hip, as well as classical midline and alternative surgical approaches to the knee. The final word on so-called minimally invasive surgery has not yet been written, and I would not rank a program solely based on the presence or absence of these types of cases.
Probably more important than the aggregate number of cases is the diversity of the case mix. Primary joint replacement in the absence of deformity is, quite fairly, a case for a community generalist. What will differentiate you from the community practice surgeon is your ability to tackle complex revisions and cases with marked deformity. At the completion of your fellowship, you should be comfortable operating on a dysplastic hip or a valgus knee with a flexion contracture. You should be able to deal with the spectrum of options available for implant removal such as ultrasonic cement removal, performing extended trochanteric osteotomies, or transfemoral approaches during revision hip arthroplasty. You should be able to master extensile approaches for the revision knee arthroplasty and know how to deal with problems such as severe bone deficiency or ligamentous instability. You should receive training in the management of periprosthetic fractures. The only way to become proficient in these areas is to see these types of cases repeatedly during the fellowship.
Although the primary focus of a joint reconstruction fellowship is arthroplasty, you will ideally learn an overall approach toward hip and knee pathology that also includes non-arthroplasty options. In the hip, this includes femoral and periacetabular osteotomies, decompression of hip impingement, and alternative treatments for osteonecrosis of the femoral head. You may even receive some exposure to hip arthroscopy. In the knee, you should be able to perform periarticular osteotomies and, more importantly, you should know when these operations are surgically indicated.
In the end, you must close the loop and ask why you want to participate in an adult reconstructive fellowship. Are you seeking clinical experience to augment your residency training? Do you already plan to join a group that has requested you obtain additional training in this area? Do you plan to pursue an academic career in adult reconstruction? These are all extremely valid reasons and yet each reason may lead you to choose an entirely different fellowship. There are many good and excellent fellowships, and it will be hard to pick a “bad” one; yet you could easily pick one for which you are ill-suited. For these reasons, it is important you begin your fellowship search with a heavy dose of introspection. Good luck.