Beyond Borders: How Michigan Medicine is Pioneering Rapid-Response Surgical Education

The video connection stabilizes after a brief flicker. From his office at Michigan Medicine, Paul Cederna, MD, watches intently as a surgery unfolds 5,000 miles away in a Ukrainian hospital. Despite challenging conditions—limited equipment, intermittent power—the surgeon's hands move with practiced confidence.

"Like this?" the surgeon asks through a translator, holding up the tissue graft.
"Exactly," Cederna confirms, nodding with approval. "Beautiful work."

In that moment, decades of Michigan research flow across continents, through a laptop screen, into the hands of a surgeon who will use this knowledge thousands of times. Each procedure prevents chronic pain. Each restores function. Each changes the trajectory of a life.

This is medical education reimagined. And it began with a simple question: When urgent needs meet proven solutions, how quickly can knowledge travel?

From Ann Arbor to Kyiv: A Partnership Forms

The collaboration started in 2022, as news emerged of massive casualties from the Ukraine conflict. More than 18,000 major limb amputations have been performed since the war's escalation—mostly young soldiers and civilians facing decades of life ahead.

David Brown, MD, a Michigan Medicine plastic surgeon who had previously led burn surgery missions in Ukraine, recognized an opportunity. He reached out to colleague Paul Cederna, Chief of the Section of Plastic Surgery, whose team has spent almost two decades pioneering a technique called regenerative peripheral nerve interface (RPNI) surgery.

The innovation is elegant: instead of simply severing nerves during amputation, surgeons implant nerve endings into small grafts of free muscle tissue. The nerve regenerates into the muscle, preventing painful neuroma formation, phantom limb pain, and enabling remarkably intuitive prosthetic control.

Michigan's research, supported by approximately $60 million in federal funding and published in over 200 peer-reviewed papers, demonstrates profound impact:

• Zero symptomatic neuromas in RPNI patients, compared to 13.3% with traditional techniques, one year following amputation
• 4.7-times lower risk of chronic post-amputation pain
• 4.4-times lower risk of chronic opioid dependence
• In pediatric patients, average narcotic use is just 1.7 MME/day versus 16.4 MME/day

"We thought this would be a great opportunity to ensure that these men and women losing limbs protecting their country can achieve the best outcome possible," Cederna said.

Working with Gennadiy Fuzaylov, MD, a pediatric anesthesiologist at Massachusetts General Hospital who speaks Ukrainian and Russian, they began reaching out to Ukrainian hospitals.

Building Bridges Through Education

What the team discovered was both challenging and inspiring. Ukrainian surgeons—skilled physicians working in extraordinarily difficult conditions—were performing amputations using traditional techniques. Not for lack of expertise, but lack of access to recent innovations published primarily in English-language journals and presented at international conferences.

"I asked them how they deal with amputation," Fuzaylov recalls, "and they said, 'We just cut them.' And then what? 'And then we don't see them.'"

The solution was direct: teach them.

The first virtual lecture in November 2022 exceeded all expectations. Brown had anticipated perhaps six attendees. Twenty-five to thirty surgeons from a single hospital joined the call—dedicated physicians hungry for knowledge, despite crushing workloads and dangerous conditions.

Three hospitals in Dnipro, Kyiv, and Vinnytsia participated in the initial training sessions. Virtual lectures evolved into real-time surgical consultations, with Ukrainian surgeons performing procedures while video-conferencing with the Michigan team.

"When I heard the lecture, I thought I could do it myself," Fuzaylov said. "It was so simple in terms of presentation."

By January 2023, three patients had received RPNI procedures at Ukrainian hospitals, with the American team consulting via Zoom throughout. The surgeons' enthusiasm was unmistakable.

"They are unbelievably resilient," Cederna said. "Despite everything going on, they are still somehow maintaining enough infrastructure to stay connected."

The Power of Scale

One Ukrainian surgeon reported performing 3,000 amputations in two years—a staggering volume that illustrates both the humanitarian crisis and the potential for impact.

"You can perform one operation at a time and help one person," Cederna noted. "But if you can train a group of surgeons, and they're each going to do 3,000 operations. Through these surgeons, you will be able to help far more people than you could ever help in a lifetime. It provides an exponential impact on the people who need it the most."

This multiplier effect extends beyond individual procedures. Each RPNI surgery prevents:

• Chronic pain that makes prosthetic use impossible
• Long-term opioid dependence
• Loss of mobility and independence
• Economic burden on families and healthcare systems

For young adults facing 60 or more years ahead, getting the surgery right the first time shapes decades of positive outcomes.

A Model Goes Global

The success in Ukraine has opened doors worldwide. Cederna and colleagues have brought RPNI education to:

• Indonesia, teaching large groups of surgeons managing high volumes of traumatic amputations
• Japan, where senior surgeons have limited connection to international medical communities, conducts educational sessions and live surgical demonstrations in Tokyo
• Czech Republic, leading comprehensive reconstruction courses in Brno
• East Africa, including Uganda, Nigeria, Kenya, and Tanzania, where motorcycle accidents create substantial amputation volumes
• Vienna and Taiwan, hosting international surgeons for intensive courses combining lectures, cadaver dissections, and live surgical demonstrations
• India, teaching large groups of surgeons, with massive clinical volume, helps people to achieve their maximal functional outcome

Each location reveals the same pattern: surgical expertise exists in pockets of excellence, but surgeons who most need knowledge often have least access to it—separated by language barriers, journal paywalls, conference costs, or simply geographic distance.

"We spend a lot of time writing papers and giving talks at meetings, but it isn't accessible to many surgeons who need it," Cederna explained. "So we decided to reach out."

A Vision for the Future

The improvised approach is working, but it's revealing even greater possibilities. Cederna envisions two-week intensive training programs near conflict zones, bringing together 100 surgeons at a time for hands-on education: cadaver dissections, live surgery observations, small-group mentoring, and train-the-trainer models that create sustainable knowledge transfer.

The approach could be applied far beyond conflict zones—to natural disasters, disease outbreaks, or long-standing disparities in surgical access.

"We as academic institutions are good at innovating, discovering, performing research, advancing knowledge," Cederna reflected. "But we could transfer these skills through high-intensity educational interventions to areas that need them urgently. We're good at programmatic development and education to ensure that clinical care is optimized for years to come. That is what we need to do in places like Ukraine."

What Success Looks Like

The Ukrainian partnership demonstrates what becomes possible when universities commit to rapid knowledge deployment:

• Immediate impact: Surgeons applying new techniques within weeks of initial training
• Sustained relationships: Ongoing consultations that refine skills and troubleshoot challenges
• Cascading knowledge: Trained surgeons teaching colleagues, multiplying expertise organically
• Measurable outcomes: Patients experiencing less pain, better prosthetic tolerance, reduced opioid use
• Mutual learning: Ukrainian colleagues demonstrating resilience and innovation that inspires Michigan's approach to care

"I don't need a story written about me," Cederna emphasized. "I care about the mission. Our partners there and what they're doing—that's what's important."

Learning From Ukraine

The partnership has proven transformative in both directions. Cederna emphasizes that the exchange of knowledge flows both ways. "There is no question in my mind that I have learned as much from my colleagues in Ukraine as they have learned from me," Cederna said. Working under conditions most surgeons will never face—limited resources, intermittent power, ongoing conflict—Ukrainian physicians demonstrate what Cederna calls 'a singular focus on excellence in all of their pursuits.' "It is remarkable how resilient they are and how capable they are at providing the highest level of care possible for their patients at all times with limited resources," he observed. "They are always providing the most kind and compassionate care under incredibly challenging situations."

That resilience has influenced how Cederna and his colleagues think about their own work. When Ukrainian surgeons demonstrate that sophisticated reconstructive techniques can be performed despite severe resource constraints, it challenges assumptions about what's essential versus what's convenient in surgical practice.

"They show that anything is possible. They show this every single day," Cederna said. "I am so impressed with them."

The mutual respect and learning that characterizes this partnership reflects a shift in how academic medical centers approach global collaboration—moving beyond one-directional knowledge transfer toward genuine exchange where insights flow in both directions.

Building Institutional Capacity

This work currently relies on extraordinary faculty initiative—surgeons dedicating time beyond regular responsibilities, leveraging personal connections, working within existing constraints.

It's producing remarkable results. But it also reveals opportunities for greater institutional support: dedicated funding for rapid-response education, logistical infrastructure for international programs, recognition of this work in faculty advancement, and frameworks for cross-disciplinary collaboration.

The University of Michigan has an opportunity to lead in developing this model—not replacing traditional strengths in research and teaching, but adding new capability for responding to urgent global needs.

As Cederna looks ahead, he sees expanding networks of trained surgeons, refined educational approaches, and growing evidence that knowledge can travel as quickly as need demands.

"I wish I had more time in the week," he said, "because there are so many people in need. Many will have an amputation and never walk again because they hurt so badly. Anything we can do to change that matters."

The Road Ahead

The American team hopes to expand beyond virtual education with in-person programs in Poland—safely distanced from active conflict but accessible to Ukrainian surgeons. Meanwhile, the virtual consultations continue, one Zoom call at a time.

In operating rooms from Kyiv to Kyoto, from Dnipro to Dar es Salaam, surgeons are learning techniques developed at Michigan Medicine. Knowledge is flowing. Lives are changing.

And a new model of academic medicine is taking shape—one where universities respond as urgently as they innovate, where knowledge reaches those who need it most, and where impact is measured not just in publications, but in prevented pain and restored function.

The work continues.

About the Research

Regenerative peripheral nerve interface (RPNI) surgery was pioneered at the University of Michigan with support from approximately $60 million in research funding from the Department of Defense, DARPA, NIH, and other federal agencies. The technique has been validated through extensive basic science research, animal studies, and clinical trials demonstrating significant reductions in post-amputation pain and improved prosthetic outcomes.