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Training improves accuracy of in-office ultrasound identification of partial zone II flexor tendon lacerations
Ian Zweifel, BS
1, Riley Onoszko, BS
1, Margaret Szymanski, BS
1, Jordan E Nus, BS
2, Khusbo Desai, MD
1, Ryan Kozlowski, MD
1; Erin L Weber, MD, PhD
1(1)Indiana University, Indianapolis, IN, (2)Indiana University School of Medicine, Indianapolis, IN
Introduction: Our previous study of hand surgeons' ability to identify partial zone II flexor tendon (FDP) lacerations by console ultrasound demonstrated that untrained hand surgeons were no more accurate than chance. In this study, we introduced three interventions: a handheld ultrasound, application of tension to the proximal tendon to induce gapping at the laceration, and ultrasound training. We hypothesized that these additional interventions would increase the surgeons' accuracy in identifying partial FDP lacerations.
Materials and Methods: Eleven partial (20%, 40%, 60%, 80%) and two complete FDP lacerations were created in zone II over the proximal phalanx of the index through small fingers of four cadaver hands amputated at the mid-forearm level. Identical dissections were performed on three additional digits, leaving the FDP intact. Seven hand surgeons used a Lumify handheld ultrasound with linear array transducer to identify the percentage of partial FDP laceration for 8 digits. Tension was then applied to the proximal tendon and the surgeons repeated the assessment of each digit. The surgeons then underwent training consisting of a 15-minute presentation covering basic ultrasound technique and examples of ultrasound images of lacerated zone II FDP tendons from published articles. They then repeated the assessment of the 8 digits.
Results: The surgeons correctly identified the percentage of laceration with an accuracy of 21.4% using console ultrasound, 12.5% using Lumify, 19.6% using Lumify + tension, and 37.5% using Lumify + tension + training, compared to 16.7% by chance. The surgeons correctly identified the need for surgery (lacerations greater than 50%) with an accuracy of 51.8% using console ultrasound, 46.4% using Lumify, 50 % using Lumify + tension, and 55.4% using Lumify + tension + training, compared to 50% by chance. Using a Student's t-test, statistical significance was discovered in all percent lacerated comparison groups that included training.
Conclusion: A trend towards improvement was noted with each added intervention. However, only the addition of ultrasound training demonstrated significantly improved performance. While training did improve accuracy, surgeon identification of FDP partial lacerations was still only minimally better than chance. With intensive training, one may become adept at accurately identifying partial flexor tendon lacerations but, if not extensively trained, operative exploration or referral to radiology for ultrasound analysis is recommended.
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