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How We Teach Tendon Repairs Outside the Operating Room

Ingraham, John M. M.D.; Weber, Robert A. III; Weber, Robert A. M.D.

Plastic & Reconstructive Surgery: June 2010 - Volume 125 - Issue 6 - pp 266e-267e
doi: 10.1097/PRS.0b013e3181d5172d

Scott & White Memorial Hospital; Texas A&M Health Science Center College of Medicine(Ingraham)

Temple High School(Weber, III)

Scott & White Memorial Hospital; Texas A&M Health Science Center College of Medicine; Temple, Texas(Weber)

Correspondence to Dr. Ingraham Division of Plastic Surgery; Scott & White Memorial Hospital; 2401 South 31st Street; Temple, Texas 76508

Portions of this article have previously been published in Hand (DOI no. 10.1007/s11552-009-9184-9).


At our institution, we have been successful in teaching residents how to repair a tendon using a simple, efficient, and inexpensive simulation. Developing the fine motor skills needed to repair a tendon by means of surgical simulation while removed from the stress of the operating room is ideal and should enhance the trainee's ability to focus on and combine those other aspects of being a well-rounded surgeon when in the operating room.

The simulated tendon is a white, round, flexible, synthetic bait worm 10 mm in diameter and 6 cm long (Gary Yamamoto Custom Baits, Page, Ariz.). This is pinned to a foam board taped securely to the underlying table, and the model is transected at its midpoint (Fig. 1). Residents are first taught how to perform a four-strand cruciate flexor tendon repair1 by watching a 5-minute instructional video created by the authors in which the repair is drawn in a stepwise fashion and then demonstrated on the model. The residents are then free to practice and improve on repairs with the simulator. A diagram is made available for reference during the repairs. We have found that surgical residents from all levels benefit from this approach and that 10 repairs is a reasonable initial goal. Should assessment of resident progress be desired, the repairs can be timed and also graded using a global rating scale (Fig. 2) that is similar to a previously validated grading system.2 Standard surgical instruments and 4-0 monofilament suture are used.

The importance of simulation in today's surgical residencies is well recognized.2–4 To our knowledge, we are the first to report a surgical simulator designed to teach flexor tendon repairs.5 A rubber bait worm serves as a good tendon simulator in its general appearance and feel. It is inexpensive and simple to set up. The model tendon readily shows damage from heavy handling; this is advantageous in assessing for unnecessary or improper use of forceps, for example. Our goal was to provide a safer, more productive, and more efficient interface between the surgical resident and their first flexor tendon repair on a real patient. Indeed, residents who trained with the simulated tendon have subsequently reported good confidence and less anxiety in performing their first true operative repair.

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The authors have no conflicts of interest to disclose.

John M. Ingraham, M.D.

Scott & White Memorial Hospital

Texas A&M Health Science Center College of Medicine

Robert A. Weber, III

Temple High School

Robert A. Weber, M.D.

Scott & White Memorial Hospital

Texas A&M Health Science Center College of Medicine

Temple, Texas

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1. McLarney E, Hoffman H, Wolfe SW. Biomechanical analysis of the cruciate four-strand flexor tendon repair. J Hand Surg (Am.) 1999;24:295–301.
2. Wanzel KR, Matsumoto ED, Hamstra SJ, Anastakis DJ. Teaching technical skills: Training on a simple, inexpensive, and portable model. Plast Reconstr Surg. 2002;109:258–264.
3. Leach DC. Simulation and rehearsal. In: Philibert I, ed. ACGME Bull. 2005;December:1–10.
4. Grober ED, Hamstra SJ, Wanzel KR, et al. Laboratory based training in urological microsurgery with bench model simulators: A randomized controlled trial evaluating the durability of technical skill. J Urol. 2004;172:378–381.
5. Ingraham JM, Weber RA III, Weber RA. Utilizing a simulated tendon to teach tendon repair technique. Hand (NY.) 2009;4:150–155.
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