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Teaching Flexor Tendon Repair
Samuel Buonocore, MD1; Marc Walker, MD, MPh1; Charlie Chen, MD1; Niclas Broer, MD2; John W. Emerson, PhD3; J. Grant Thomson, MD1; Michael K. Matthew, MD3; (1)Yale University School of Medicine, (2)New York University, (3)Yale University
Yale University SOM, New Haven, CT, USA


Changes in surgical education, most notably work hour restrictions, require residents to spend less time in the operating room. Surgical simulation is used to fill this void. Although less common in hand surgery, simulation may be of great importance especially when teaching challenging procedures such as flexor tendon repair (FTR). We sought to determine if the validated measures to asses surgical skill used in the other fields of surgery, (surgical check list and global scale ratings) were applicable in measuring resident proficiency in hand surgery. We investigated the use of an instructional video to determine its roll in speeding time to proficiency. Finally we sought to determine if improvement in resident’s performance correlated with other objective measurements including; changes in work of flexion (WoF) before and after repair, and pullout strength of repairs.


8 plastic surgery residents with no prior experience performing FTR, were randomized within PGY level to the use of an instructional video or not. Each resident performed a total of five zone 2 repairs, of the profundus tendon in cadaveric hands. Regardless of group each resident received a one on one teaching session, as well as individual feedback after each repair. Both the instructional video and teaching session demonstrated a 4 strand modified Kessler repair with a locking epitendinous suture. Each participant completed the repairs, over 2 sessions. Performances were videotaped and analyzed in a blinded fashion, using a 15 point Check list, and a graded global scale, by two attending surgeons. Repairs were analyzed in a tensile testing machine, measuring WoF before, and after repair. Repair strength, was measured as the load (N) to failure. Other data points collected, were total time to complete the repairs, and quality of repair, as demonstrated by photographic appearance.


Interator reliability between the blinded graders was found to be good to excellent. Significant improvement occurred in both groups after the one on one teaching session. The instructional video group scored significantly better than the non-video group early on, followed by a leveling of performance. Pullout strength increased for both groups, but never reached the peak strength reported for this repair. Changes in WoF before and after repair did not correlate with improved performance.


Cadaveric repairs enhanced residence performance and are a useful simulation prior to operative experiences. Validated measures used in other specialties to assess surgical skill can be used in hand surgery.

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