Overcoming the Learning Curve: A Novel Approach to Teaching Zone II

Flexor Tendon RepairsA. Sina Bari, M.D.; Colin YL Woon, M.D.; Brian C

Pridgen, B.S.; James Chang, M.D.

Stanford Division of Plastic & Reconstructive Surgery

Nothing to Disclose

Introduction

• Increasing liability, time & cost sensitivities of OR

• Models & Simulators have been used successfully in other high risk industries

• Zone II Flexor Tendon Repair is a complex, evolved technique

Objectives

1. Standardize Technique for Zone II Flexor Tendon Repair

2. Create and Validate a Teaching Model for Zone II Flexor Tendon Repairs

• PGY 1-6 Plastic Surgery Residents (n=14)

• Randomized, matched L & R segments of Human Cadaveric FDP & FPL Tendons

• Pre- & Post-Test Questionnaire

• Pre- & Post-Tutorial Zone II Flexor Tendon Repair

• Follow up retesting at 6 months

Methods I

Methods II

• Anatomy• Clinical Presentation• Repair

– Suture & Needle Type– Repair Technique– Placement of Knots– # of Strands– Locking vs. Grasping– Suture Caliber– Purchase– Epitendinous Suture

• Rehabilitation

Methods III

Methods IV

Results

Pre-tutorial Post-tutorial 6 months0

10

20

30

40

50

60

* *

*

*

Average Repair Strength Pre-Tutorial, Post-Tu-torial, and at 6 months

2mm GapUltimate Strength

Forc

e (N

)

Results

PGY 1-3 PGY 4-6 PGY 1-3 PGY 4-60

10

20

30

40

50

60

70

*

*

**

Repair Strength by Level of Training

2mm Gap

Ultimate Strength

Pre-Tutorial Post-Tutorial

Forc

e (N

)

Results

Pre-tutorial Post-tutorial

2mm Gap Strength

(N)

Ultimate Strength

(N)

Mode of Failure 2mm Gap Strength

(N)

Ultimate Strength

(N)

Mode of Failure

Pull-through

Rupture Pull-throug

h

Rupture

Total (n=14) 18.9 ± 3.5 28.6 ± 3.9 8 6 44.0 ± 5.1 55.9 ± 5.6 3 11

Upperclass (n=7)

23.7 ± 6.0 34.1 ± 6.4 5 2 46.8 ± 4.9 58.4 ± 4.8 2 5

Lowerclass (n=7)

14.1 ± 3.0 23.0 ± 3.9 3 4 41.2 ± 5.5 53.4 ± 6.5 1 6

Pre-tutorial Post-tutorial

2mm Gap Strength

(N)

Ultimate Strength

(N)

Mode of Failure 2mm Gap Strength

(N)

Ultimate Strength

(N)

Mode of Failure

Pull-through

Rupture Pull-throug

h

Rupture

Total (n=14) 18.9 ± 3.5 28.6 ± 3.9 8 6 44.0 ± 5.1 55.9 ± 5.6 3 11

Upperclass (n=7)

23.7 ± 6.0 34.1 ± 6.4 5 2 46.8 ± 4.9 58.4 ± 4.8 2 5

Lowerclass (n=7)

14.1 ± 3.0 23.0 ± 3.9 3 4 41.2 ± 5.5 53.4 ± 6.5 1 6

Pre-tutorial Post-tutorial

2mm Gap Strength

(N)

Ultimate Strength

(N)

Mode of Failure 2mm Gap Strength

(N)

Ultimate Strength

(N)

Mode of Failure

Pull-through

Rupture Pull-throug

h

Rupture

Total (n=14) 18.9 ± 3.5 28.6 ± 3.9 8 6 44.0 ± 5.1 55.9 ± 5.6 3 11

Upperclass (n=7)

23.7 ± 6.0 34.1 ± 6.4 5 2 46.8 ± 4.9 58.4 ± 4.8 2 5

Lowerclass (n=7)

14.1 ± 3.0 23.0 ± 3.9 3 4 41.2 ± 5.5 53.4 ± 6.5 1 6

Results

Pre-Tutorial Post-Tutorial0

1

2

3

4

5

6

7

8

*

Average Tendon Purchase Pre- and Post-Tutorial

Purc

hase

(mm

)

Results

Pre-Tutorial Post-Tutorial0

1

2

3

4

5

6

7

8

9

10

11

Average Resident Confidence Pre- and Post-Tu-torial

Confi

denc

e (5

pt S

cale

)

Discussion• We present a new model for teaching flexor

tendon repair1. Incorporates a practical model & didactic

curriculum2. Standardizes Zone II Flexor Tendon Repair based

on the best evidence3. Is outside the time- and error- sensitive confines

of the OR• Our data suggest value to all levels of resident

training and persistance over time