Abstract
Purpose
Hand surgery fellowships include trainees from orthopedic, plastic, and general surgery. These pathways present an opportunity to examine variations in graduate medical education structures, such as program size, sponsoring department, and leadership composition. Limited research exists on the characteristics of these programs. The purpose of this study is to assess the structural and leadership characteristics of the Accreditation Council of Graduate Medical Education-accredited hand surgery fellowships in the United States. We hypothesized that characteristics (ie, faculty-to-fellow ratios and case volume) vary by specialty sponsorship. Leadership, although shaped by merit-based criteria, faces challenges in achieving broader demographic diversity.
Methods
A cross-sectional analysis of 95 US hand surgery fellowship programs was conducted in 2025. Program characteristics were compared by region and specialty sponsorship.
Results
Most programs were orthopedic-sponsored (n = 74, 77.9%), followed by plastic surgery (n = 19, 20.0%) and general surgery (n = 2, 2.11%). Programs averaged 2.22 fellows (SD = 1.35), with a faculty-to-fellow ratio of 3.98 (SD = 2.01) and an annual case volume of 846 per fellow (SD = 332). Orthopedic-sponsored programs had more fellows on average, a lower faculty-to-fellow ratio, and were less open to general surgery applicants compared to plastic surgery-sponsored programs. No notable regional differences were found in these characteristics. Program directors were predominantly men (n = 81, 85.3%) and orthopedic-trained (n = 70, 73.7%).
Conclusions
Hand surgery fellowships show consistent structural features, with notable differences between orthopedic- and plastic surgery-sponsored programs in enrollment, faculty-to-fellow ratios, and openness to general surgery applicants. Women leadership underrepresentation warrants further evaluation.
Type of study/level of evidence
Cross-sectional descriptive study, level IV.
Key words: Fellowship, Graduate medical education, Hand surgery, Leadership, Surgical education
Hand surgery fellowships reflect the multidisciplinary legacy forged by the specialty’s pioneers, providing advanced training to residents who have completed an orthopedic, plastic, or general surgery residency. The field of hand surgery emerged from necessity when Major General Norman T. Kirk recognized the absence of a dedicated field to address the surge of hand injuries sustained in combat.1 Enlisting Dr Sterling Bunnell’s expertise, Kirk integrated principles from orthopedic, plastic, and general surgery, establishing the foundation for specialized care that endures today.1 As outlined by the Accreditation Council of Graduate Medical Education (ACGME), this 12-month program builds on that foundation, fostering specialized expertise. Fellows develop a diverse skill set encompassing congenital defects, acquired impairments, nerve repair, and tissue reconstruction.2 They balance clinical mastery with research and professional growth to prepare them for independent management of complex hand and wrist conditions and to serve as community resources.2 It requires care for patients across every demographic—infants to the elderly, affluent to the indigent—in contexts ranging from trauma to outpatient settings.
Given the unique and diverse competencies required, hand surgery training provides a broad lens for evaluating surgical training at the graduate medical education (GME) level. The inherent multidisciplinary nature of hand surgery fellowship programs offers distinct insights into the educational experiences shaping future surgeons. These insights are highly relevant to the GME community. The current literature lacks a comprehensive analysis of the structural and leadership characteristics of hand surgery fellowships across the United States. Although studies in other surgical subspecialties have examined case volumes and specific training outcomes,3,4 there is a limited understanding of how factors such as accreditation status, specialty sponsorship, fellow and faculty numbers, operative experiences, and program director (PD) demographics shape competency standardization in hand surgery—a critical component in ensuring equitable training outcomes.
Our main objective was to examine the current structural and leadership characteristics of hand surgery fellowship programs across the United States. We evaluated the aforementioned factors and assessed regional and specialty-specific variations in training volumes, essential markers for GME educators seeking standardization in outcomes. We hypothesized that structural characteristics of hand surgery fellowships vary by specialty sponsorship, and that leadership, although shaped by merit-based criteria, still faces challenges in achieving broader demographic diversity.
Materials and Methods
This cross-sectional quantitative study was conducted in 2025 using publicly available data from all 95 US-based hand surgery fellowship programs listed in the American Society for Surgery of the Hand (ASSH) Fellowship Directory. Additional program details were collected from official program websites. Programs were included if they were active and listed in the directory at the time of data collection.
No interventions were implemented, as this was an observational study. The methodology focused on collecting descriptive data and conducting comparative analysis. The feasibility of the study was high, given the use of publicly available data sources and open-access tools. Data collection and analysis were completed over 2 months, from February to April 2025. There were no associated costs or participant burden, and the study posed no ethical concerns.
The primary outcomes of interest included regional and specialty-based differences in program characteristics. These outcomes included geographic region, fellowship director demographics, required training background of applicants, sponsoring specialty (ie, plastic surgery, orthopedic surgery, or general surgery), operative case volume per fellow, the number of fellows and faculty, ACGME accreditation status, presence of a level 1 trauma center, and pediatric hospital exposure during training. Regional classifications are presented in Table S1, available online on the Journal’s website at https://www.jhsgo.org. Operative case volume per fellow was calculated based on program-reported estimates from the ASSH directory. When a range was provided, the midpoint was used. All variables reported by the ASSH directory can be found in Table S2, available online on the Journal’s website at https://www.jhsgo.org.
Program characteristics were summarized across regional distribution, with differences between groups assessed using Fisher exact test for categorical variables and the Kruskal-Wallis rank sum test for continuous variables. A direct comparison of plastic surgery programs to orthopedic surgery programs was performed using Fisher exact test, Wilcoxon rank sum test, and Pearson chi-squared test to detect group differences. All analyses were performed using R version 4.4.0. Statistical significance was defined as a P value of <.05. The total sample included 95 fellowship programs, representing the complete population of programs listed in the ASSH directory at the time of data collection. Because this was a population-level study with no sampling, power calculations were not performed. No adjustments were made for multiple comparisons.
This study was grounded in a descriptive epidemiologic framework, which supports the systematic characterization of hand surgery fellowship training programs in the United States. The goal was to provide a comprehensive overview of the program structure and variation to inform applicants, educators, and policymakers. This study did not involve human subjects, human specimens, or identifiable private information; therefore, it was exempt from review by the Institutional Review Board.
Results
All 95 fellowship programs were accredited by the ACGME. Data were accessed in March 2025. Descriptive statistics by region are presented in Table 1. Orthopedic departments sponsored the majority of programs (n = 74, 77.9%), whereas the remaining programs were sponsored by plastic surgery divisions/departments (n = 19, 20.0%) or general surgery departments (n = 2, 2.11%). Orthopedic-trained surgeons were eligible to apply for a fellowship position in 92 (98.9%) programs, whereas 85 (91.4%) programs accepted plastic surgery-trained physicians. Only 50.5% (n = 47) of programs were open to applicants from general surgery. The mean number of fellows per program was 2.22 (SD = 1.35), with an average faculty-to-fellow ratio of 3.98 (SD = 2.01) and an annual case volume of 846 cases per fellow (SD = 332; 18 programs unreported). Additionally, n = 84, 90.3% of programs were affiliated with level 1 trauma centers, and n = 85, 92.4% were affiliated with children’s hospitals.
Table 1.
Hand Fellowships by Region
| Characteristic | Overall, N = 95∗ | Northeast, N = 29∗ | Southeast, N = 25∗ | Midwest, N = 19∗ | West, N = 15∗ | Southwest, N = 7∗ | P value† |
|---|---|---|---|---|---|---|---|
| ACGME accredited | 95 (100%) | 29 (100%) | 25 (100%) | 19 (100%) | 15 (100%) | 7 (100%) | |
| Sponsoring specialty | .82 | ||||||
| Orthopedic surgery | 74 (77.9%) | 25 (86.2%) | 18 (72%) | 13 (68.4%) | 12 (80.0%) | 6 (85.7%) | |
| Hand surgery | 19 (20%) | 4 (13.8%) | 6 (24.0%) | 5 (26.3%) | 3 (20%) | 1 (14.3%) | |
| General surgery | 2 (2.1%) | 0 (0%) | 1 (4%) | 1 (5.3%) | 0 (0%) | 0 (0%) | |
| No. of fellows | 2.2 (1.4) | 2.4 (1.6) | 2.2 (1.5) | 2.2 (1.2) | 1.87 (0.8) | 2.3 (0.8) | .86 |
| No. of full-time faculty | 7.5 (3.1) | 7.8 (3.3) | 7.0 (2.6) | 8.2 (3.0) | 7.0 (3.4) | 7.3 (2.9) | .66 |
| Unknown | 3 | 1 | 2 | 0 | 0 | 0 | |
| Faculty-to-fellow ratio | 4.0 (2.0) | 4.2 (2.7) | 3.8 (1.7) | 4.1 (1.3) | 4.1 (2.0) | 3.6 (1.2) | .75 |
| Unknown | 3 | 1 | 2 | 0 | 0 | 0 | |
| Annual case volume per fellow | 846 (332) | 901 (451) | 776 (199) | 854 (311) | 803 (197) | 861 (321) | .94 |
| Unknown | 18 | 3 | 8 | 3 | 4 | 0 | |
| Level 1 trauma center Affiliation | 84 (90.3%) | 26 (89.7%) | 21 (91.3%) | 18 (94.7%) | 14 (93.3%) | 5 (71.4%) | .54 |
| Unknown | 2 | 0 | 2 | 0 | 0 | 0 | |
| Children's hospital Affiliation | 85 (92.4%) | 27 (96.4%) | 21 (91.3%) | 18 (94.8%) | 13 (86.7%) | 6 (85.7%) | .62 |
| Unknown | 3 | 1 | 2 | 0 | 0 | 0 | |
| Fellowship director gender | .83 | ||||||
| Women | 14 (14.7%) | 6 (20.7%) | 3 (12.0%) | 3 (15.8%) | 2 (13.3%) | 0 (0%) | |
| Men | 81 (85.3%) | 23 (79.3%) | 22 (88%) | 16 (84.2%) | 13 (86.7%) | 7 (100%) | |
| Director specialty | .70 | ||||||
| Orthopedic surgery | 70 (73.7%) | 24 (82.8%) | 18 (72%) | 13 (68.4%) | 10 (66.7%) | 5 (71.4%) | |
| Hand surgery | 25 (26.3%) | 5 (17.2%) | 7 (28%) | 6 (31.6%) | 5 (33.3%) | 2 (28.6%) | |
| Open to general surgery Residents | 47 (50.5%) | 17 (58.6%) | 12 (52.2%) | 7 (36.8%) | 6 (40%) | 5 (71.4%) | .42 |
| Unknown | 2 | 0 | 2 | 0 | 0 | 0 | |
| Open to orthopedic surgery Residents | 92 (98.9%) | 29 (100%) | 23 (100%) | 19 (100%) | 14 (93.3%) | 7 (100%) | .24 |
| Unknown | 2 | 0 | 2 | 0 | 0 | 0 | |
| Open to plastic surgery Residents | 85 (91.4%) | 28 (96.6%) | 21 (91.3%) | 16 (84.2%) | 13 (86.7%) | 7 (100%) | .55 |
| Unknown | 2 | 0 | 2 | 0 | 0 | 0 |
n (%); Mean (SD).
Fisher exact test; Kruskal-Wallis rank sum test.
Program directors were predominantly men (n = 81, 85.3%) versus women (n = 14, 14.7%), P < .001, with specialty backgrounds in orthopedics (n = 70, 73.7%) or plastic surgery (n = 25, 26.3%). Women PDs led 9 (12.2%) orthopedic-sponsored and 4 (21.1%) plastic surgery-sponsored programs, with no significant difference in representation between the two specialties (P = .46). The northeast had the highest number of fellowship programs (n = 29, 30.5%), followed by the southeast (n = 25, 26.3%), midwest (n = 19; 20.0%), west (n = 15; 15.8%), and southwest (n = 7, 7.4%). When analyzing regional trends among fellowship programs, no differences achieved statistical significance (P = .24−.92). A visual comparison of these findings is presented in Figure 1, Figure 2, Figure 3. Annual cases per fellow spanned 776 (SD = 199, southeast) to 901 (SD = 451, northeast). The faculty-to-fellow ratio varied from 3.25 (SD = 1.23, southwest) to 4.16 (SD = 2.72, northeast). Women directors ranged from 0% in the southwest to 20.7% (n = 6) in the northeast.
Figure 1.
Regional distribution of program characteristics. Bar graph illustrating the proportion of key program variables within each geographic region, highlighting regional differences in hand surgery fellowship structures.
Figure 2.
Specialty representation in leadership and sponsorship by region. Bar graph illustrating the distribution of specialty sponsorship and program director roles across geographic regions, comparing the influence of orthopedic surgery, plastic surgery, and general surgery programs.
Figure 3.
Comparison of fellowship and faculty metrics across regions. Bar graph comparing the average number of fellows, average number of faculty members, faculty-to-fellow ratios, and average case volume per fellow among different US regions.
Orthopedic surgery-sponsored programs differed significantly from their plastic surgery counterparts. Compared to plastic surgery-sponsored programs, orthopedic-sponsored programs had a higher mean number of fellows (2.30 vs 1.63; P = .02). Additionally, orthopedic-sponsored programs had a lower faculty-to-fellow ratio (3.65 vs 5.39; P = .001). Furthermore, orthopedic-sponsored programs were less willing to accept general surgery applicants (n = 31, 43.1% vs n = 14, 73.7%; P = .02). However, the average number of full-time faculty members and case volume did not differ significantly (P = .66 and .59, respectively). Figure 4 illustrates the differences in fellows, faculty, and yearly case volume between plastic surgery and orthopedic surgery-sponsored fellowships. The PD specialty differed significantly as the majority of orthopedic-sponsored programs (n = 69, 93.2%) and plastic surgery-sponsored programs (n = 18, 94.7%) were led by surgeons of the same specialty (P < .001). No other significant differences were found. Complete specialty sponsorship comparisons are presented in Table 2.
Figure 4.
Fellowship and faculty metrics by specialty sponsorship. Bar graph comparing the average number of fellows, average number of faculty members, faculty-to-fellow ratios, and average case volume per fellow among orthopedic surgery-, plastic surgery-, and general surgery-sponsored fellowship programs.
Table 2.
Hand Fellowships by ACGME Accreditation
| Characteristic | Orthopedic Surgery, N = 74∗ | Hand Surgery, N = 19∗ | General Surgery, N = 2∗ | P value† |
|---|---|---|---|---|
| ACGME accredited | 74 (100%) | 19 (100%) | 2 (100%) | |
| Region | .77 | |||
| Midwest | 13 (17.6%) | 5 (26.3%) | 1 (50%) | |
| Northeast | 25 (33.8%) | 4 (21.1%) | 0 (0%) | |
| Southeast | 18 (24.3%) | 6 (31.6%) | 1 (50%) | |
| Southwest | 6 (8.1%) | 1 (5.3%) | 0 (0%) | |
| West | 12 (16.2%) | 3 (15.8%) | 0 (0%) | |
| No. of fellows | 2.3 (1.3) | 1.63 (0.8) | 5 (4.2) | .022 |
| No. of full-time faculty | 7.5 (3.2) | 7.7 (2.8) | 7.5 (0.7) | .66 |
| Unknown | 3 | 0 | 0 | |
| Faculty-to-fellow ratio | 3.7 (1.6) | 5.4 (2.7) | 2.3 (1.8) | .001 |
| Unknown | 3 | 0 | 0 | |
| Cases per fellow per year | 861 (362) | 755 (130) | 1,025 (318) | .45 |
| Unknown | 13 | 5 | 0 | |
| Affiliation with level 1 trauma center | 65 (90.3%) | 17 (89.5%) | 2 (100%) | >.99 |
| Unknown | 2 | 0 | 0 | |
| Affiliation with children's hospital | 66 (93%) | 18 (94.7%) | 1 (50%) | >.99 |
| Unknown | 3 | 0 | 0 | |
| Fellowship director gender | .46 | |||
| Women | 9 (12.2%) | 4 (21.1%) | 1 (50%) | |
| Men | 65 (87.8%) | 15 (79%) | 1 (50%) | |
| Director specialty | <.001 | |||
| Orthopedic surgery | 69 (93.3%) | 1 (5.3%) | 0 (0%) | |
| Plastic surgery | 5 (6.8%) | 18 (94.8%) | 2 (100%) | |
| Open to general surgery residents | 31 (43.1%) | 14 (73.7%) | 2 (100%) | .018 |
| Unknown | 2 | 0 | 0 | |
| Open to hand surgery residents | 72 (100%) | 18 (94.7%) | 2 (100%) | .21 |
| Unknown | 2 | 0 | 0 | |
| Open to plastic surgery residents | 64 (88.9%) | 19 (100%) | 2 (100%) | .20 |
| Unknown | 2 | 0 | 0 |
n (%); Mean (SD).
Fisher exact test; Wilcoxon rank sum test; Pearson’s chi-squared test; P-values are only comparing plastic surgery to orthopedic surgery; general surgery is excluded.
Discussion
Our findings demonstrate that hand surgery fellowships across 95 programs exhibit universal accreditation, operative volume, and exposure, with no regional differences observed. Significant differences emerged based on specialty sponsorship. Plastic surgery-sponsored programs had fewer fellows and a higher faculty-to-fellow ratio. This study also demonstrates that orthopedics currently dominates the hand fellowship landscape, with most programs and leaders coming from orthopedics. This is reflected in current ASSH membership data and pass rates for the Surgery of the Hand examination, as 72.1% of hand surgeons in the United States are trained in orthopedics.5
Our findings suggest plastic surgery-sponsored programs are more open to general surgery applicants. This is attributable to their familiarity with general surgery trainees, as all plastic surgeons were once required to complete general surgery training first. In 1995, the integrated model was introduced, allowing trainees to fulfill both general and plastic surgery requirements within a single residency program and in a shorter time span. There is still an independent pathway, in which plastic surgeons can complete a general surgery residency prior to completing a 3-year plastic surgery residency. No such pathway exists from general surgery to orthopedics. Recent data show that general surgery graduates continue to make up a small fraction of those matching into hand fellowships; in 2023, they accounted for just 3.7% of filled positions.6 Other notable study findings include differences in fellow cohort size and faculty-to-fellow ratios, suggesting that the sponsoring specialty may influence the program environment and available resources. However, no significant differences were observed in operative case volume between programs sponsored by orthopedics, plastic surgery, or general surgery.
Additionally, our findings highlight a persistent issue: the underrepresentation of women among PDs. Program directors were predominantly men. The gender disparity in leadership mirrors prior findings in hand surgery, in which a 2022 analysis reported only 11.6% of women PDs in hand surgery.7 Similar trends are seen in the broader hand surgery workforce, in which only 14.3% of hand surgeons are women.8 When looking at residency level trends, 18.3%9 and 11%10 of PDs are women in plastic surgery and orthopedics, respectively. Broader comparisons across surgical fellowships show similarly low rates of women leadership, with hand surgery ranking 10th out of 14 subspecialties analyzed.11 Although leadership positions should be based on competence and merit, historical factors—including limited access to opportunities, lack of representation, and reduced awareness of specialty pathways—may have contributed to current disparities.12 It is important to recognize that although there are highly qualified women and individuals from underrepresented backgrounds who are deserving of leadership roles, they may have faced additional barriers to advancement.
Our study, constrained by the available database, did not assess other metrics such as race or ethnicity for PDs, as self-reported data were not publicly available in the ASSH directory or program websites. Although gender representation in the hand surgery fellowship applicants has improved, diversity from traditionally underrepresented groups remains limited.13,14 In hand surgery, in which complex problem-solving and innovation are essential, diverse leadership broadens perspectives, strengthens decision-making, and improves the ability to address the needs of a varied patient population.15
Our findings must be interpreted within several limitations. Although our sample of 95 programs is robust, case volume data from 18 programs (19%) were unreported, potentially masking variations in operative exposure. A limitation of our study is that fellowships were classified solely by specialty sponsorship, as the ASSH directory did not specify programs with integrated or combined faculty. Another limitation is that non-ACGME-accredited hand fellowships in the United States are not listed in the ASSH directory and were thus excluded. Additionally, case volume data were obtained from program-reported estimates in the ASSH directory, which may differ from fellow-reported ACGME case logs, which provide more detailed breakdowns of bony, soft tissue, and peripheral nerve experiences. Furthermore, the cross-sectional design limits insights into longitudinal trends, such as shifts in PD diversity over time. The absence of trainee-level data also restricts the correlation of program structure with educational outcomes like satisfaction, competency, or career paths. Although publicly available data provide valuable insights, they do not capture the nuances of the learning environment or the experiences of underrepresented groups. Future studies with qualitative or longitudinal methods could reveal disparities or strengths beyond quantitative analysis. Despite these constraints, this study offers an updated perspective on the hand surgery fellowship landscape and highlights the importance of efforts to ensure that leadership opportunities are accessible to all qualified candidates. Hand surgery’s relatively standardized educational foundation is a strength; however, ongoing investment in equitable pipelines, focused on talent development, mentorship, and opportunity expansion, will be key to cultivating diverse and highly competent future hand surgeons.
Future research should examine how leadership diversity and program structure influence trainee outcomes and evaluate the long-term impact of pipeline interventions on increasing representation in hand surgery leadership. Studies should also explore the career trajectories of hand surgery fellows, including transitions to academic or private practice and advancement to leadership roles, stratified by trainee background (orthopedic, plastic, or general surgery) and PD affiliations, to better understand the factors shaping long-term professional outcomes. Accordingly, these findings should serve as an impetus to develop initiatives that expand awareness, mentorship, and access to leadership opportunities, while maintaining the focus on competence and excellence, to broaden the pipeline of future hand surgeons.16, 17, 18
Conflicts of Interest
Dr. Rozental is a consultant for Stryker and Teladoc Health, Inc. No benefits in any form have been received or will be received by the other authors related directly to this article.
Acknowledgments
We thank Julia B. Nascimben, BS, for her assistance with data collection for this study.
Supplementary Data
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