The Christine M. Kleinert Institute Hand Surgery Fellowship
by Christina L. Kaufman Ph.D.

How often do you have a nationally and internationally recognized program that many even within the local community don’t know about? Such is the Hand Surgery Fellowship at the Christine M. Kleinert Institute for Hand and Microsurgery (CMKI) in Louisville, Ky. Currently directed by Dr. B. Thomas Harter, each year between 18 and 24 fully trained surgeons come from all over the United States as well as the world to spend one year immersing themselves in hand surgery.

Since its inception in 1960, CMKI’s hand surgery fellowship program has trained nearly 1,300 surgeons from 59 different countries. The philosophy is to promote an educational environment that brings together surgeons from general, orthopedic and plastic surgery, as well as microsurgery specialties. CMKI has the only hand surgery fellowship program in the country that accepts foreign as well as American surgeons. This mixture allows the ACGME hand fellows to work with some of the world’s best and brightest surgeons who constantly provide innovative perspectives and techniques.

Previous CMKI fellows have moved on to running departments, their own fellowship programs and have been elected presidents of national hand surgery societies—not only in this country, but in countries all over the world.

A Typical Day
The educational “recipe” was first developed by Dr. Harold E. Kleinert and Dr. Joseph E. Kutz over a hand-shake. These two pioneers in hand surgery adhere to life-long principles of service to the patient with an emphasis on education. That translated today to a team of 12 attending surgeons actively mentor and promote the 20 to 24 fellows who are in training at any given time, and continuously seek ways to improve the program.

Morning conference, a didactic lecture series, is held five days a week at 6:30 a.m. and covers all aspects of hand surgery. On any given weekday morning you can find fellows with Dr. Tsu-Min Tsai, Dr. Kutz , Dr. Huey Tien as well as Dr. Harter listening to talks from Kleinert Kutz surgeons from a lecture series carefully planned by Dr. Tuna Ozyurekoglu. The fellows also regularly present cutting-edge papers from the literature on hand surgery as well as interesting hand surgery case presentations. Discussions of the best way to approach a clinical challenge with a dozen talented surgeons in the mix can become lively.

Many past fellows (after they no longer have to be there at 6:30 a.m. every morning) comment that morning conference is one of the jewels of the fellowship.

The discussions and sharing of techniques move from the conference room each morning to the clinic and the O.R. Young surgeons who have trained in orthopedic, plastic and general surgery from some of the premiere institutions in our country discuss their experience with procedures such as digital replants (sewing severed fingers back on the patient) with other young surgeons from countries such as Korea and China who may have performed this operation hundreds of times.

Immersion in hand surgery would not be complete without exposure to research as well. It is a delight to see surgeons who have performed a procedure the same tried and true way for decades leap at the chance to try a new technique if it will be better for the patient. Kleinert Kutz Hand Care Center (KKHCC) and CMKI surgeons are responsible for many world firsts such as the first repair of digital arteries, the first bilateral hand and forearm replant, the first successful technique for primary flexor tendon repair, the first successful, and world’s longest surviving hand transplant. In fact, the VCA program, which is a collaborative effort between CMKI, the Kleinert Kutz Hand Care Center, the University of Louisville and partner Jewish Hospital and St. Mary’s Healthcare, has the largest hand transplant program in the country.

Research has changed over the last ten years in that studies are more often collaborative. Cutting edge surgical procedures are being combined with new treatments and new drugs that require collaborative efforts. CMKI fellows and staff surgeons relentlessly pursue new research projects with more than 30 clinical studies underway, such as novel collaborations with the Cardiovascular Innovation Institute using adipose derived stem cells to treat osteoarthritis, speed healing and promote nerve regeneration.

The model of a hand surgery fellowship developed at CMKI is unique in the field. Like most training programs outside of medicine, the fellowship does not exclude the fully trained and practicing orthopedic and plastic surgeons who want to come to learn hand surgery from all over the world. These fellows are embraced and they enrich the education of our American fellows and continue to enhance the ongoing education of our surgeons and researchers.

Time Restrictions
We continue to work with some of the best and brightest surgeons in this country as well as all over the world. However education in hand surgery has changed in the last ten years, and not entirely to the good. We have noted a striking difference in the rules which govern American fellows, especially with respect to duty hours. With some exceptions, surgeons from overseas are not restricted in the number of hours they can train. Although well intentioned, the system we have set up is that young doctors cannot fully immerse themselves, and are often mandated to leave the O.R. and an interesting case in order to avoid duty hour violations. This system would make sense if surgeons also had these limitations once they start their own practice. But in fact there are no duty hours when you are a practicing surgeon.

We ask young surgeons to learn their limitations once they are on their own. Not while they are under the mentorship of a fully trained hand surgeon. American residency and fellowship training programs are increasingly restricted in the amount of time young surgeons can train, usually with no increase in the number of residents or fellows assigned to a department. Time will tell regarding these policies, but early indications are not positive.

Nonetheless, the future is bright. As long as we have a group of surgeons dedicated to education and research, and continue to have the privilege of working and training with some the finest young surgeons in the world, great things are to come.

To quote Dr. Kleinert, “As teachers we believe we are successful only if our students ultimately become far better than their teachers.”
Infobox: Kleinert Kutz Hand Care Center and Christine M. Kleinert Institute for Hand and Microsurgery surgeons are responsible for many world firsts such as:
• The first repair of digital arteries;
• The first bilateral hand and forearm replant;
• The first successful technique for primary flexor tendon repair;
• The first successful, and world’s longest surviving hand transplant.

Christina L. Kaufman Ph.D. is executive director of the Christine M. Kleinert Institute for Hand and Microsurgery Inc in Louisville, Ky.