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Repair of Zone II flexor tendon injuries is a complex technique that has benefited from many advances in recent years. These advances present new challenges, however, for teaching within the operating room. We hypothesize that a focused tutorial incorporating a practical, hands-on model and standardizing the repair technique may improve the strength of repairs performed by surgical trainees.
Methods
Plastic Surgery residents (n=14) were asked to perform their preferred Zone II flexor tendon repair using a table-top model before and after a focused tutorial. The tutorial reviewed primary literature and presented a standardized approach. Repairs were photographed and tested for load strength using a tensiometer. Blinded pre- and post-tutorial questionnaires and repairs were analyzed to determine effectiveness of this teaching approach.
Results
Post-tutorial repairs required higher loads to generate a 2mm gap (18.9N+/-3.5 to 44.0N+/-3.6 ; p<0.001) and ultimate breakage (28.6N+/-3.9 vs. 55.9N+/-4.0; p<0.001). Tendon purchase and confidence increased significantly. Subgroup analysis by level of training revealed significant improvement for both junior and senior residents.
Discussion
We created a practical educational tool to teach Zone II flexor tendon repair outside of the time- and error-sensitive confines of the operating theatre. Our approach utilizes an inexpensive hands-on tabletop model, review of the primary literature, and standardization of the technique. Analysis of resident's pre-tutorial repairs revealed common misconceptions in technique, strand count, and purchase size. This may be due in part to the multitude of suggested repair techniques, difficulty in comparing data across multiple studies, and the steep learning curve involved in learning complex flexor tendon repairs. By standardizing the repair technique, based on a thorough review of the best evidence, we believe to have overcome some of these barriers.