8. Learning Curve of Wrist Level Tendon Repairs using a Novel Tendon Stapler Device vs. Traditional Suture Methods

Abstract

Background: Tendon repairs in spaghetti wrists, wrist level replantation, or vascularized composite hand allotransplantations are time-consuming. Experience and skill greatly influence overall time in the operating room. A novel tendon stapler device (TSD) has the potential to mitigate these discrepancies among surgeons of varying levels of experience by enhancing the speed and consistency of primary tendon repairs. Methods: Participants of varying levels of surgical experience (novice, intermediate, expert) performed tendon repairs via suture method or TSD. Comparisons were performed on wrist level flexors and extensors from human cadaver arms. Suture repairs were performed using 3.0 braided polyester modified Kessler with horizontal mattress for a 4-strand repair. On matched, contralateral donor arms, TSD repairs were completed with a single simple 5.0 polypropylene stitch to approximate the tendon ends prior to device deployment. All repairs were timed by a non-participating data recorder. Learning curves were compared across repair types and surgeons with scatterplots fitted with Loess curves. Statistical analyses utilized one-way ANOVA, Tukey pairwise comparisons, two-sided independent samples t-test, and Fisher’s exact test. Results: A total of 228 tendon repairs from 12 donor arms were analyzed. Mean suture repair times were 3.25, 4.08, and 4.46 minutes for expert, intermediate, and novice, respectively with the expert being faster than the other two groups (p≤0.001). Mean TSD repair times were 1.32, 1.31, 1.28 minutes for expert, intermediate, and novice respectively, with no difference between groups. TSD repairs were significantly faster than suture repair (p<0.01). Suture repairs decreased to stable or “learned” level around repair #30, and then demonstrated small increases at the end of the session, suggesting user fatigue. TSD repairs showed faster, less variable time that stabilized around repair #23, consistent with a more efficient learning curve. Educational time required for both novice and intermediate groups to achieve competency was higher for the suture technique (106 and 54 minutes) than for the TSD (60 and 38 minutes). Conclusion: The TSD demonstrates tremendous potential for complex multi-tendon traumas by drastically reducing the learning curve, operative and warm ischemia times, overall cost, and surgeon variability based on experience and repair strength.