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Avoiding Flexor Tendon Repair Rupture with Intraoperative Total Active Movement Examination



Wide-awake flexor tendon repair in tourniquet-free unsedated patients permits intraoperative Total Active Movement examination (iTAMe) of the freshly repaired flexor tendon. This technique has permitted the intraoperative observation of tendon repair gapping induced by active movement when the core suture is tied too loosely. The gap can be repaired intraoperatively to decrease postoperative tendon repair rupture rates. The authors record their rupture rate in the first 15 years of experience with iTAMe. This was a retrospective chart review of 102 consecutive patients with wide-awake flexor tendon repair (no tourniquet, no sedation, and pure locally injected lidocaine with epinephrine anesthesia) in which iTAMe was performed by two hand surgeons in two Canadian cities between 1998 and 2008. Intraoperative gapping and postoperative rupture were analyzed. The authors observed intraoperative bunching and gap formation with active movement in flexor tendon repair testing (iTAMe) in seven patients. In all seven cases, they redid the repair and repeated iTAMe to confirm gapping was eliminated before closing the skin, and those seven patients did not rupture postoperatively. In 68 patients with known outcomes, four of 122 tendons ruptured (tendon rupture rate, 3.3 percent) in three of 68 patients (patient rupture rate, 4.4 percent). All three patients who ruptured had accidental jerk forced rupture. All those patients who did what we asked them did not rupture. Tendons can gap with active movement if the core suture is tied too loosely. Gapping can be recognized intraoperatively with iTAMe and repaired to decrease postoperative rupture.
Avoiding Flexor Tendon Repair Rupture
with Intraoperative Total Active
Movement Examination
Amanda Higgins, B.Sc.O.T.
Donald H. Lalonde, M.D.
Michael Bell, M.D.
Daniel McKee, B.Sc.
Jan F. Lalonde, R.N.,
Saint John, New Brunswick, and
Ottawa, Ontario, Canada
Background: Wide-awake flexor tendon repair in tourniquet-free unsedated
patients permits intraoperative Total Active Movement examination (iTAMe) of
the freshly repaired flexor tendon. This technique has permitted the intraop-
erative observation of tendon repair gapping induced by active movement when
the core suture is tied too loosely. The gap can be repaired intraoperatively to
decrease postoperative tendon repair rupture rates. The authors record their
rupture rate in the first 15 years of experience with iTAMe.
Methods: This was a retrospective chart review of 102 consecutive patients with
wide-awake flexor tendon repair (no tourniquet, no sedation, and pure locally
injected lidocaine with epinephrine anesthesia) in which iTAMe was performed
by two hand surgeons in two Canadian cities between 1998 and 2008. Intraop-
erative gapping and postoperative rupture were analyzed.
Results: The authors observed intraoperative bunching and gap formation with
active movement in flexor tendon repair testing (iTAMe) in seven patients. In
all seven cases, they redid the repair and repeated iTAMe to confirm gapping
was eliminated before closing the skin, and those seven patients did not rupture
postoperatively. In 68 patients with known outcomes, four of 122 tendons
ruptured (tendon rupture rate, 3.3 percent) in three of 68 patients (patient
rupture rate, 4.4 percent). All three patients who ruptured had accidental jerk
forced rupture. All those patients who did what we asked them did not rupture.
Conclusions: Tendons can gap with active movement if the core suture is tied
too loosely. Gapping can be recognized intraoperatively with iTAMe and re-
paired to decrease postoperative rupture. (Plast. Reconstr. Surg. 126: 941,
We perform the vast majority of our flexor
tendon repairs under pure local anes-
thesia in nonsedated patients with no
tourniquet using only lidocaine and epinephrine
for anesthesia and hemostasis. This wide-awake
approach1,2 allows our comfortable, nonsedated,
cooperative, tourniquet-free patients to test the
freshly repaired tendon with full active flexion and
extension before we close the skin in every case.
The term that describes this maneuver is intraoper-
ative Total Active Movement examination (iTAMe).
We have a combined 15 years of experience
with iTAMe. With this iTAMe, we have seen the
suture bunch in the tendon and create a gap in
the repair in seven patients, where the core su-
tures were initially tied too loosely. On those
occasions, we have repaired the gap intraoper-
atively and the patients did not rupture postop-
eratively. We feel that the same suture bunching
would have occurred postoperatively and would
have led to rupture if we had not recognized it
and repaired it intraoperatively.
We have had the impression that eliminating
the active movement/tendon bunching source of
From Saint John Regional Hospital, Dalhousie University,
and Ottawa University.
Received for publication January 10, 2010; accepted Febru-
ary 23, 2010.
Presented at the 2010 Annual Meeting of the American
Association for Hand Surgery, in Boca Raton, Florida, Jan-
uary 6 through 11, 2010.
Copyright ©2010 by the American Society of Plastic Surgeons
DOI: 10.1097/PRS.0b013e3181e60489
Disclosures: Dr. Lalonde is a consultant for ASSI
instruments, which has no bearing on the contents
of this article. None of the other authors has any
financial disclosures to report. 941
tendon repair gapping has decreased our flexor
tendon repair rupture rate. We therefore decided
to document the incidence of rupture in our first
combined 15 years of experience of consecutive
iTAMe wide-awake flexor tendon repairs.
A retrospective chart review was performed of
every consecutive wide-awake flexor tendon repair
(no tourniquet, no sedation, and pure locally in-
jected lidocaine with epinephrine anesthesia) in
which iTAMe was performed by two hand sur-
geons in two Canadian cities (Saint John and Ot-
tawa) between 1998 and 2008. A total of 102 pa-
tients were studied (28 patients with 45 tendons
from Saint John and 74 patients with 128 tendons
from Ottawa), comprising a total of 173 flexor
tendon repairs.
There were 25 flexor pollicis longus repairs:
seven in zone 1, eight in zone 2, five in zone 3,
three in zone 4, and two in undocumented zones.
There were 148 flexor digitorum profundus and
flexor digitorum superficialis repairs: 61 in zone 1,
57 in zone 2, 19 in zone 3, five in zone 4, and six
in undocumented zones. All of these were com-
plete repairs except for two of the tendons, which
were partial repairs with 75 percent and 30 per-
cent lacerations. There were 22 women and 87
men involved in this study.
Only flexor tendon injuries that were repaired
using local anesthesia and epinephrine in which
iTAMe was performed were included in the study.
Patients with digital nerve repair were included.
The repairs consisted of mostly two-strand with
some four-strand Kessler repairs with monofila-
ment or braided nonabsorbable suture. Epitenon
sutures were used under pulleys.
Postoperative Follow-Up
Surgeon and therapist charts were reviewed
for 102 patients to determine length and adequacy
of patient follow-up. Records were checked to see
whether patients were followed by either surgeon
or therapist for 12 weeks after surgery. Patients
who could not be physically examined during the
entire 12-week therapy program were followed
up by telephone interview. Patients were asked
whether they were able to bend the injured finger
or thumb at both the middle and end joints,
whether their end joint of the finger or thumb felt
floppy or straight when the middle joint was bent,
and whether they felt their finger was moving since
having the surgery. If the answers did not clearly
confirm an intact tendon repair, the patient was
reported as one of the unknown rupture patients.
If patients were not physically examined up to 12
weeks, and if they could not be satisfactorily fol-
lowed by telephone, they were considered to have
an unknown rupture rate because of insufficient
Ottawa Patients
Of the 74 patients seen in Ottawa, 128 flexor
tendons were repaired, with three repair ruptures
recorded in two patients. One long finger flexor
digitorum profundus (2001) ruptured 8 days after
repair when the patient caught his baby falling in
a baby seat getting out of the car. Re-repair was
performed under local anesthesia with lidocaine
and epinephrine and did not rupture with fol-
low-up past 30 months after the second repair. The
other patient (2005) had both small finger ten-
dons rupture 2.2 months after repair in an acci-
dent at work in which the operated finger was
reinjured when it was wedged between two heavy
metal falling objects.
Forty-seven of the remaining 72 patients did
not complete the entire 3-month flexor tendon
program follow-up. These patients were therefore
contacted by telephone to determine whether
their repair had ruptured unbeknownst to the
surgeon or therapist. We were able to satisfactorily
contact 19 of these 43 patients who were all ver-
bally able to report that their injured fingers were
able to bend. This left 24 patients (43 tendons)
with insufficient follow-up that could not be re-
ported as rupture free. This brings the known
flexor tendon repair number to 85, with a rupture
rate of 3.5 percent of the tendons.
Saint John Patients
Of the 28 patients seen in Saint John, 45 flexor
tendons were repaired, with one repair rupture
recorded. The only tendon rupture was the flexor
digitorum profundus of a small finger (2004) rup-
tured 10 days after repair as the patient punched
someone while in jail.
There were 16 patients who did not complete
the entire 3-month flexor tendon program follow-
up. We were able to establish nonrupture in 11 of
these 16 patients (19 tendons) by telephone. We
were able to get two of these 11 patients to come
back for a recheck by either the surgeon or the
hand therapist, and it was determined that the
tendons were not ruptured. This left five patients
(eight tendons) that cannot be reported as being
rupture free. This brings the known flexor tendon
Plastic and Reconstructive Surgery September 2010
repair number to 37, with a tendon rupture rate
of 2.7 percent.
Combined Data
Of all 173 wide-awake flexor tendon repairs in
102 patients in which iTAMe was performed, 122 of
these tendons in 68 patients have a known outcome.
In the 68 patients with known outcomes, four of 122
flexor tendons repaired ruptured (tendon rupture
rate, 3.3 percent) in three of 68 patients (patient
rupture rate, 4.4 percent). All three patients had
well-documented rupture events that were acciden-
tally induced with violent jerk movement. There
were no ruptures in patients who followed pre-
scribed controlled postoperative therapy and use of
the fingers. The last recorded rupture occurred in
2005 from charts reviewed from 1998 to 2008. The
last 3 years had no ruptures.
The death of the myth of epinephrine danger
in the finger in the past decade3,4 has permitted us
to perform flexor tendon repairs on wide-awake
comfortable patients with no tourniquet, as if they
were at the dentist. During surgery, these nonse-
dated cooperative patients are able to totally ac-
tively flex and extend their fingers while the sur-
geon examines the tendon repair site so that
adjustments can be made before the skin is closed
(iTAMe). The authors report their first 15 years of
experience of tendon rupture after wide-awake
flexor tendon repair and iTAMe. Only three pa-
tients ruptured. All three patients had well-docu-
mented rupture events that were accidentally in-
duced postoperatively with violent jerk movement.
All those patients who did what we asked them
after surgery did not rupture, and the authors did
not have any ruptures in the last 3 years of the
Until now, the causes of tendon rupture have
usually been listed as poor surgical technique, in-
fection, inadequate suture material, overly aggres-
sive therapy, patient noncompliance, and tendon
“softening” that peaks in the 2 weeks after
surgery.5The authors of this article would like to
add to the literature another cause of tendon rup-
ture: tendon bunching in the suture resulting
from the forces of active flexion on a tendon re-
paired with the core sutures being too loose. In
this report, the authors document the observation
of flexor tendon repair gap occur with iTAMe.
(Click the link to view
the film from the Video Plus article on wide-awake
flexor tendon repair1and go to the 18-minute
24-second mark of the film to see tendon bunch-
ing causing a gap in a flexor tendon repair.) When
core sutures are not tied tightly enough, the ten-
don bunches in the suture and gaps with active
movement. The authors have seen it intraopera-
tively in seven patients. One of those seven cases
can be seen in the film linked above. In all seven
cases, they redid the repair and repeated the
iTAMe to confirm that gapping was eliminated
before closing the skin, and those seven patients
did not rupture postoperatively. The authors be-
lieve that if they had performed the operation
under general or block anesthesia where iTAMe is
not possible, the tendon bunching may well have
occurred when the patients had started their ac-
tive movement in the postoperative period, and
this may have led to postoperative rupture.
Both of the tendons illustrated in Figures 1
and 2 have been repaired with core sutures that
are too loose and would likely gap and rupture
with suture bunching in the postoperative period.
The tendon in Figure 1 has the skin closed and
leaves the core sutures too loose, whereas the ten-
don in Figure 2 had iTAMe, which permitted rec-
ognition of the gapping that can be repaired be-
fore the skin is closed (Table 1).
The most dreaded complication of flexor ten-
don repair is rupture. The outcome of this terrible
complication is seldom satisfactory. It is therefore
important to do anything we can to avoid or de-
crease the rate of this complication. Most of the
world literature on flexor tendon repair rupture is
focused on animal models,6with little human lit-
erature except for the reporting of rupture rates.
Tang7reported that tendon repair ruptures occur
Fig. 1. This tendon has just been repaired with a core suture
that is too loose. It looks okay but it is not. There is no gap seen
at this time because it has not been tested with iTAMe. This is
how many repairs are accepted and the skin closed under gen-
eral or block anesthesia, as they are not tested for active move-
ment intraoperatively. This repair may well rupture in the
postoperative period when the tendon bunches in the suture
when active movement begins.
Volume 126, Number 3 Flexor Tendon Repair
in 4 to 10 percent of repaired fingers and 3 to 17
percent in flexor pollicis longus of thumbs. Peck
et al.8reported rupture rates of 4 to 17 percent.
Boyer et al.9commented that a 9 percent rupture
rate is considered a high repair-site failure and
should be taken into consideration when using a
certain postoperative program. Harris et al.10 re-
ported a low rupture rate of 4 percent in 526
fingers. Until now, all articles in the literature
dealing with flexor tendon repair rupture have
one thing in common: all tendon repairs occurred
under general or proximal block (Bier or axillary)
anesthesia. None of those patients tested the repair
during the operation (iTAMe) to reveal and correct
suture bunching to prevent postoperative rupture.
Two of the clear weaknesses of our study are
its retrospective design and the fact that some of
the follow-up data were obtained by telephone for
part of the postoperative period. Postoperative fol-
low-up is a challenge in all flexor tendon repair
studies, as many of the patients who put them-
selves in a situation where tendons get lacerated
are not always reliable. We only included tele-
phone follow-up where we felt confident that a
lack of rupture could be determined on the call.
The ideal way to study whether or not wide-
awake flexor tendon repair and iTAMe reduce
tendon rupture rates would be to test these pa-
tients and compare them prospectively in a ran-
domized level 1 study to a group of patients who
are asleep or sedated with blocks and in whom the
repairs cannot be actively tested during surgery.
The authors encourage those who still use general
or block anesthesia to perform such a study.
Primary repair of flexor tendons using pure
local anesthesia with the wide-awake approach al-
lows the surgeon to do much more than test for
and repair tendon gapping during surgery: it al-
lows him or her to enter into three new important
arenas of patient care.
First, it enables the surgeon to make intraop-
erative adjustment such as dividing pulleys and
trimming or adding sutures to the repair so that
the freshly repaired tendons glide through the
sheath and pulleys for a full range of intraopera-
tive active movement. Common sense would sug-
gest that if a patient cannot achieve a full range of
movement during surgery, he or she is not likely
to achieve it after surgery and may end up requir-
ing tenolysis. The authors have also had the im-
pression that their tenolysis rate has decreased
since the introduction of iTAMe, but this was not
studied in this report.
Second, the surgeon is much more comfort-
able initiating a true active movement protocol
postoperatively if he or she has seen the patient
move the finger through full flexion and exten-
sion with no gapping during surgery. It becomes
obvious to the operating surgeon that if the ten-
don repair does not gap with a full range of finger
active movement during surgery, it is not likely to
gap and rupture with active movement after sur-
gery. In the beginning of the study period, both
authors were using a combination of active exten-
sion, passive flexion, and place-and-hold postop-
erative motion regimens. However, both authors
moved to active flexion protocols during the study
period with increasing confidence that ruptures
were not occurring because iTAMe showed an
intact nongapping tendon repair with full active
flexion and extension during the operation. One
of the senior authors has just retired (M.B.), and
the other (D.H.L.) now uses an active flexion pro-
tocol starting at day 3 after the repair with pro-
tective splints and instructions to the patient that
“You can move it but you cannot use it.”
Third and finally, the surgeon gets more than a
full hour of uninterrupted time to talk to the non-
Table 1. Case Breakdown
John Total
No. of patients with tendon repairs 74 28 102
No. of patients with adequate
follow-up examination 35 14 49
No. of patients with
telephone follow-up 19 9 28
No. of patients with no
ability to follow up 24 5 25
No. of patients with ruptures 2 1 3
Fig. 2. This tendon has also just been repaired with a core suture
with iTAMe of the freshly repaired flexor tendon during wide-
awake flexor tendon repair. Tendon bunching in the suture has
occurred and a gap has revealed itself. The gap can be corrected
before the skin is closed and repeated iTAMe will verify that the
suture is now snug enough to withstand the forces of active flex-
ion.Itisbettertodiscoverthatacoresutureistooloose during the
operation when it can be redone than after the operation when
a postoperative rupture occurs.
Plastic and Reconstructive Surgery September 2010
sedated patient during the operation and find out
what type of person he or she is dealing with before
deciding on the postoperative movement regimen.
The patient can be educated intraoperatively on ten-
don rupture, scarring, and postoperative require-
ments for optimal results. This is greatly enhanced
if the therapist can also be present at the surgery to
educate the patient, as occurs in our center. The
patient has an opportunity to see what the tendon
appears like, buy into the process, and understand
why he or she needs to follow a controlled post-
operative rehabilitation program to the letter to
achieve a successful outcome.
Donald H. Lalonde, M.D.
Hilyard Place, Suite C204
600 Main Street
Saint John, New Brunswick E2K 1J5, Canada
1. Lalonde DH. Wide-awake flexor tendon repair. Plast Reconstr
Surg. 2009;123:623–625.
2. Lalonde DH. Wide-awake approach to flexor tendon repair
in hand & wrist surgery. In: Chung K, ed. Operative Techniques:
Hand and Wrist Surgery. Vol. II. Philadelphia: Saunders/
Elsevier; 2007:533.
3. Thomson CJ, Lalonde DH, Denkler KA, et al. A critical look
at the evidence for and against elective epinephrine use in
the finger. Plast Reconstr Surg. 2007;119:260–266.
4. Lalonde DH, Bell M, Benoit P, Sparkes G, Denkler K, Chang
P. A multicentre prospective study of 3110 consecutive cases
of elective epinephrine use in the fingers and hand: The
Dalhousie Project clinical phase. J Hand Surg (Am.) 2005;30:
5. Lilly SI, Messer TM. Complications after treatment of flexor
tendon injuries. J Am Acad Orthop Surg. 2006;14:387–396.
6. Zhao C, Moran SL, Cha SS, Kai-Nan-An A, Amadio PC. An
analysis of factors associated with failure of tendon repair in
the canine model. J Hand Surg (Am.) 2007;32:518–525.
7. Tang JB. Clinical outcomes associated with flexor tendon
repair. Hand Clin. 2005;21:199–210.
8. Peck FH, Kennedy SM, Watson JS, Lees VC. An evaluation of
the influence of practitioner-led hand clinics on rupture
rates following primary tendon repair in the hand. Br J Plast
Surg. 2004;57:45–49.
9. Boyer MI, Goldfarb CA, Gelberman RH. Recent progress in
flexor tendon healing: The modulation of tendon healing
with rehabilitation variables. J Hand Ther. 2005;18:80–85.
10. Harris SB, Harris D, Foster AJ, Elliot D. The aetiology of acute
rupture of flexor tendon repairs in zones 1 and 2 of the
fingers during early mobilization. J Hand Surg (Br.) 1999;24:
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Volume 126, Number 3 Flexor Tendon Repair
... WALANT has been used in hand surgeries (3,4) as well as procedures involving foot and ankle (1,2). This anaesthetic technique has fewer risks and side effects compared to conventional sedation or general anaesthesia technique. ...
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Lower limb surgery is usually performed under general or regional anaesthesia in normal operating room setting. However, when the surgery need to be performed in situations where there are limited resources and equipment, especially during a pandemic outbreak, in battlefields or area of disaster occurrence, the wide-awake local anaesthesia no tourniquet (WALANT) surgery can be utilised. This study aims to assess the efficacy of performing lower limb surgery using WALANT technique. A randomised cross-sectional study was designed to assess the effectiveness of WALANT in lower limb surgery, particularly in terms of duration of anaesthesia, Hamilton Anxiety Rating Scale (HAM-A), pain visual analogue scale (VAS), duration of surgery, amount of estimated blood loss (EBL) and total length of stay (LOS). A total of 91 patients requiring lower limb surgery were recruited, with only 83 patients completed the VAS pain assessment for all time points of the study. Mean age of patients was 52.1 ± 14.9 years. Mean VAS score were 1.19 ± 1.53 and 1.46 ± 1.86, preoperatively and intraoperatively. Mean VAS score were 0.55 ± 1.52, 0.60 ± 1.41, and 1.06 ± 1.69 at 2, 4, and 6 h post-surgery, respectively. Majority (79; 86.8%) of patient has preoperative anxiety score that was <17. Mean surgery duration was 65.28 ± 39.02 min, mean EBL was 91.34 ± 78.94 cc, whereas mean LOS was 3.35 ± 1.16 days. EBL was a weak predictor of postoperative pain. In conclusion, WALANT technique for lower limb surgery is effective and safe.
... The widely accepted maximal dose of lidocaine that is believed to be safe for upper extremity surgery is 7 mg/kg (25). The addition of epinephrine prolongs the duration of action of lidocaine from 30-60 min to 120-360 min (26). The acidity of the solution (pH: 4.2) is likely to cause pain to the patient during injection; therefore, buffering the WALANT solution (1% Frontiers in Surgery | ...
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Background Distal radius fractures are treated using open reduction and internal fixation and using general anesthesia (GA) or regional blocks. A new technique, wide-awake local anesthesia with no tourniquet (WALANT), allows this operation to be conducted in nonsedated patients without the use of tourniquets.Objective We analyzed whether WALANT yields better outcomes than GA in the treatment of patients with distal radius fractures.Evidence ReviewWe searched the PubMed, Cochrane Library, Embase, and Scopus databases for cases of distal radius fractures treated using WALANT or GA. The outcomes of interest were duration of preparation for surgery, duration of surgery, blood loss, and length of postoperative hospitalization; visual analog scale (VAS), Mayo wrist score, and Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) questionnaire score on postoperative day 1; range of motion (ROM); time until bone union; and complication rate.FindingsWe systematically reviewed 4 studies with a total of 263 patients (128 with WALANT and 135 with GA). In comparison with GA, WALANT required less time for preparation for surgery, shorter postoperative hospitalization, and lower postoperative day 1 VAS scores; however, blood loss was greater. Functional outcomes (ROM, QuickDASH score, and Mayo wrist score), complication rates, and times until union did not differ considerably between the two methods.Conclusion The included studies demonstrated that durations of preparation for surgery and postoperative hospitalization were shorter and pain on postoperative day 1 was less severe with WALANT than with GA. Although blood loss in surgery was greater with WALANT, this technique is a novel and promising alternative to GA.
Background: Tendon injuries of the upper extremity remain a common surgical condition requiring prompt intervention. We review our initial experience with the PONTiS flexor tendon repair system (PFRS) - a knotless, multifilament stainless steel crimp system. Methods: Consecutive patients undergoing repair by our plastic and orthopedic surgeons with the PFRS were reviewed from 2015-2017. Multivariate risk and Kaplan-Meier survival analyses were performed to assess risk factors associated with complications. Results: Eighty-one patients with mean follow up of 75 days (range 0 - 33 months) were identified. The most common demographics of our patients were right-handed (82.9%), male (71.4%), laborer (35.7%), sustaining laceration injuries (77.1%) at zone 2 (27.2%). There was an average of 3.7 tendon injuries per patient. Associated injuries included fractures (21.4%), arterial injuries (24.3%), and nerve injuries (61.4%). Thirteen (16.0%) patients developed complications: adhesions/contracture (4), rupture (2), flap ischemia (2), arterial thrombosis (1), wound dehiscence (1), tendon lag (1), and erosion of the PFRS through soft-tissue grafts (2). Multivariate analysis identified poor soft-tissue coverage (OR 9.990; p=0.043) and zone 2 involvement (OR 7.936; p=0.016) as risk factors, while epitendinous repairs (OR 0.096; p=0.010) were protective against complications. Conclusions: The PFRS system is rapid and simple to deploy and advantageous especially in multiple traumatic tendon injuries. Compared to traditional suture repair, it has a comparable overall complication profile but superior rupture and tenolysis rates. We advise use with caution in cases with poor soft tissue coverage to minimize risks of extrusion and strongly recommend the use of epitendinous sutures concurrently to limit complications.
Surgeons are familiar with surgical technique articles that provide step-by-step details of various surgical procedures relevant to clinical practice. This article is a communications technique article that provides step-by-step things that a surgeon can say to a wide-awake patient during the surgery to improve outcomes in clinical practice. The absence of anamnestic sedation enables memorable patient education from their surgeon to decrease the risk of postoperative complications.
Local anesthesia is an effective method to perform digital nerve blocks. In this study, we compare the effectiveness of single-volar subcutaneous and double-dorsal injection through a systematic review and meta-analysis of randomized controlled trials (RCTs). A systematic search of PubMed, Embase, and the Cochrane Library from inception to 7 April 2021 was performed. RCTs with the effects of single-volar subcutaneous and double-dorsal injection were eligible. Meta-analysis was performed using random effect models with pooled standardized mean differences (SMDs) and 95% confidence intervals (CI). RoB 2.0 and GRADE of Recommendation Assessment, Development, and Evaluation criteria were applied for evaluating the bias. A total of 2484 studies were initially identified, with 11 eligible RCTs finally included in the meta-analysis (1363 patients). The pooled data of nine studies showed single-volar injection had a statistically significantly lower pain score (pooled SMD: 0.20, 95% CI, 0.01 to 0.39, p = 0.041, I2 = 58%, N = 1187) and higher patient preference but invalid anesthesia at the dorsal proximal digit. No significant differences were observed in the onset of anesthesia, adjacent digit invalid numbness, distal phalanx invalid anesthesia, additional injection rate, and adverse effects. In conclusion, this meta-analysis of RCTs showed that the single-volar injection was associated with a lower pain sensation during injection and higher patient satisfaction with a reduced anesthetic effect over the proximal dorsal phalanx. Further high-quality RCTs with a higher number of cases are needed to validate our results.
Purpose: The purpose of this study was to present the outcomes of wide-awake flexor tendon repairs in zones 1 and 2 in a major hand trauma referral center. Methods: Zone 1 and zone 2 wide-awake flexor tendon repairs performed between August 2018 and March 2020 were analyzed retrospectively. Outcomes were assessed by the original Strickland-Glogovac criteria for fingers and Buck-Gramcko scoring system for thumbs. Further descriptive analysis of the groups according to potential negative factors, such as injury mechanism, concomitant neurovascular injury, and the extent of injury in zone 2, were performed. Results: A total of 94 tendons were repaired in 67 digits (58 fingers, 9 thumbs) of the 61 patients included in the study. Satisfactory results were achieved in 89.6% of the fingers and 77.8% of the thumbs. Intraoperative gapping was corrected after active digital extension-flexion test in 1 patient. Rupture was seen in 1 patient for a rate of 1.5%. The tenolysis indication rate was 5.1% for fingers and 11.1% for thumbs. Conclusions: In our series, functional outcome scores, tenolysis, and rupture rates remained similar with findings in the literature. The outcome of a flexor tendon repair is influenced by many factors that cannot be controlled intraoperatively. To assess the effect of performing the repair in a wide-awake setting on the outcome, clinical trials with large patient groups are needed. Level of evidence: Therapeutic IV.
Background and aim WALANT procedures are becoming more popular, and are particularly useful in the COVID-19 pandemic. Procedures can be performed without needing access to general theatres and anaesthetic support, minimising the number of patient-healthcare interactions and avoiding aerosolisation. Our unit has taken this approach and aim to present a case series that demonstrates the efficacy and safety of WALANT. Methods A prospective analysis of WALANT cases in a single plastic surgery centre during March-August 2020 was performed. All procedures using a WALANT approach were included, that would have otherwise required general anaesthetic or regional block. Data was collected on a number of variables, including patient satisfaction. Results: 37 procedures were included in analysis. The majority of the injuries consisted of hand trauma. There were no cases of post-operative complications, although one required completion in main theatres due to technicality. No patients required additional anaesthetic during the procedure and all reported pain score as 0/10. Overall patient satisfaction was 10/10 for 26 patients, 9/10 for 10 patients and 7/10 for one patient. Conclusions Results show the use of WALANT can facilitate an effective plastic surgery trauma service during COVID-19. Most of the procedures were performed in the outpatient department setting, without the need for main operating theatres or anaesthetic support. All procedures were performed within 24 hours of initial presentation and were able to be discharged on the same day. In addition, patient satisfaction remained high and post-operative complications were minimal. We propose that the use of WALANT should continue and increase beyond the current pandemic.
Background We attempted to evaluate patient satisfaction and overall experience during wide awake, local anesthesia, with no tourniquet (WALANT) hand surgery and quantify surgery-related outcomes. Methods We conducted a retrospective analysis of patient demographics, comorbidities, and patient reported outcomes via Single Assessment Numeric Evaluation (SANE) scores collected pre- and postoperatively of patients undergoing WALANT surgery by the 2 participating senior authors. A solution of 1% lidocaine with 1:100,000 epinephrine was used by 1 surgeon, while the other used a 1:1 ratio of 1% lidocaine with 1:100,000 epinephrine and 0.5% bupivacaine for local anesthetic injection. Patients were administered a postoperative survey to assess patient experience, including anxiety and pain levels, and overall satisfaction in the perioperative period. Results Overall, 97.7% of patients indicated that they would undergo a WALANT-style surgery if indicated in the future, 70.5% ate the day of surgery, and a total of 39.1% of patients reported driving to and from surgery. Postoperative SANE scores increased as compared with preoperative scores across all patients. The use of combination 1% lidocaine with 1:100,000 epinephrine and 0.5% bupivacaine was associated with lower intraoperative and postoperative visual analog scale pain scores. Conclusions WALANT hand surgery was generally well tolerated with excellent surgical outcomes. Patients reported ease of preparation for surgery, faster recovery, and lack of anesthetic side effects as the main benefits of wide-awake surgery. Combination use of lidocaine and bupivacaine may be better than lidocaine alone with respect to pain control in the initial recovery period.
Operative repair of flexor tendons after traumatic injury may be performed under general anesthesia (GA), regional blocks, or a wide-awake local anesthesia no tourniquet (WALANT) technique. To our knowledge there are currently no large-scale reports evaluating outcomes of flexor tendon repair in patients where wide-awake anesthesia was utilized in comparison to regional anesthesia (RA) and general anesthesia. We performed a retrospective analysis of patients who underwent treatment for flexor tendon injuries at a tertiary referral center for hand surgery over a two-year period. A total of 151 patients were included (53 WALANT, 57 RA, and 41 GA) and a total of 251 tendons were repaired (63 WALANT, 104 RA and 84 GA). No statistically significant difference was observed in rates of tendon rupture, adhesions, infection, or hand function. Flexor tendon repair under WALANT is found to be safe and presents comparable operative and functional outcomes to more traditional anesthetic techniques. Additional advantages, including the ability to test the repair intraoperatively, patient education, and the potential for boosting theatre efficiency. Further studies, preferably utilizing a randomized trial methodology, may further elucidate the benefits and risks of WALANT versus regional and general anesthesia.
The canine model is commonly used for flexor tendon repair research. The purpose of this study was to analyze the factors, including laceration mode (partial and complete), suture techniques, therapy methods, and weight-bearing status, associated with tendon repair rupture or gap formation in the canine model in vivo. We reviewed the factors associated with repair failure among 624 flexor tendon repairs in zone II from 242 dogs reported previously from our institution, including both partial and complete lacerations. We found that weight-bearing due to failure of postoperative immobilization was the most important factor influencing tendon repair rupture or gap formation. As has been noted clinically, in our canine model failure and gapping of a flexor tendon repair was primarily the result of uncontrolled loading. Rehabilitation strategies that reduce the risk of catastrophic loading of the repair are critical to reducing the experimental failure rate when using dogs for flexor tendon research. Similar strategies may also reduce such failures in humans.
Five hundred and eight patients with 840 acute complete flexor tendon injuries in 605 fingers in zones 1 and 2 underwent surgery and postoperative mobilization in a controlled or early active motion (active flexion-active extension) regimen over a period of 7.5 years. Sixty-eight patients with 79 finger flexor divisions who did not complete the rehabilitation programme were excluded. Of the 440 patients with 728 complete tendon divisions in 526 fingers included in the study, 23 patients ruptured 28 tendon repair(s) in 23 fingers, an overall rupture rate of 4%. One hundred and twenty-nine fingers with zone 1 injuries had a rupture rate of 5%. Three hundred and ninety-seven fingers with zone 2 injuries had a rupture rate of 4%. This study analyses the 23 patients with flexor tendon rupture(s) to identify causative factors. In approximately half of these patients, tendon rupture followed acts of stupidity. The implications of this are discussed. There was no significant relationship between tendon rupture and the age or sex of the patients, smoking or delay between injury and tendon repair and there was no particular prevalence of zone 2C level injuries among the fingers in which tendon rupture occurred.
Practitioner-led hand clinics were introduced in our unit in the year 2000 as a response to the high and increasing number of postoperative hand trauma patients coming to consultant clinics. The aim of this study was to evaluate the influence of these clinics on rupture rates following primary tendon repair in the hand. The study specifically examined:zone II flexor tendon repairsflexor pollicis longus (FPL) tendon repairsextensor pollicis longus (EPL) tendon repairs. Prospective data collection were undertaken for these particular operations over a 17-month study period. Prior to the introduction of the practitioner-led hand clinics previous audits had demonstrated rupture rates of 30% zone II flexor tendon repairs, 16% for FPL repairs and 5% for EPL repairs. Rupture rates after the introduction of practitioner-led hand clinics fell in all of the study categories-to 17% for zone II flexor tendon repairs, 4% for FPL repairs and 0% for EPL repairs. It is suggested that improved continuity of care by experienced hand therapists may have contributed to the observed improvements in outcome.
Review of the outcomes of clinical flexor tendon repairs reported over the past 15 years showed advances in the outcomes with excellent or good functional return in more than three fourths of primary tendon repairs following a variety of postoperative passive/active mobilization treatments. Strickland and Glogovac criteria are the most commonly adopted methods to assess function. Repair ruptures (4%-10% for zone II finger flexors and 3%-17% for the FPL tendon), adhesion formations, and stiffness of finger joints remain frustrating problems in flexor tendon repairs and rehabilitation. Four approaches are suggested to improve outcomes of the repairs and to solve these difficult problems,which include stronger surgical repairs, appropriate pulleys or sheath management, optimization of rehabilitation regimens, and modern biologic approaches.
Until recently, attempts to optimize the postoperative regimen following intrasynovial flexor tendon repair had been essentially empirical, in that both the time and graduation of the exercise regimen have lacked clear conceptual guidelines. The magnitude of load applied in previous studies had not been clearly controlled, and similarly, the effects of increased repair site excursion and gap formation had not been evaluated in clinically relevant models. Recent experimental in vivo data on the application of force and excursion as independent variables by the authors and other investigators have helped to clarify the respective roles of these two variables. The goal of surgical treatment of intrasynovial flexor tendon lacerations is the achievement of a primary tendon repair of tensile strength sufficient to allow early controlled motion after surgery. The implementation of an appropriate postoperative rehabilitation protocol will, based on the experimental data discussed in this article, decrease the formation of intrasynovial adhesions, facilitate the restoration of the gliding surface, and stimulate the accrual of strength at the repair site.
To examine prospectively the incidence of digital infarction and phentolamine rescue in a large series of patients in whom local anesthesia with adrenaline was injected electively into the hand and fingers. There continues to be a commonly held belief that epinephrine injection is contraindicated in the finger despite a lack of valid evidence to support this concept in the literature. From 2002 to 2004 there were 9 hand surgeons in 6 cities who prospectively recorded each consecutive case of elective hand and finger epinephrine injection. They recorded each instance of skin or tissue loss and the number of times phentolamine reversal of adrenaline vasoconstriction was required. There were 3,110 consecutive cases of elective injection of low-dose epinephrine (1:100,000 or less) in the hand and fingers and none produced any instance of digital tissue loss. Phentolamine was not required to reverse the vasoconstriction in any patients. The true incidence of finger infarction in elective low-dose epinephrine injection into the hand and finger is likely to be remote, particularly with the possible rescue with phentolamine.
The goals of flexor tendon repair are to promote intrinsic tendon healing and minimize extrinsic scarring in order to optimize tendon gliding and range of motion. Despite advances in the materials and methods used in surgical repair and postoperative rehabilitation, complications following flexor tendon injuries continue to occur, even in patients treated by experienced surgeons and therapists. The most common complication is adhesion formation, which limits active range of motion. Other complications include joint contracture, tendon rupture, triggering, and pulley failure with tendon bowstringing. Less common problems include quadriga, swan-neck deformity, and lumbrical plus deformity. Meticulous surgical technique and early postoperative tendon mobilization in a well-supervised therapy program can minimize the frequency and severity of these complications. Prompt recognition of problems and treatment with hand therapy, splinting, and/or surgery may help minimize recovery time and improve function. In the future, the use of novel biologic modulators of healing may nearly eliminate complications associated with flexor tendon injuries.
Medical texts continue to perpetuate the belief that epinephrine should not be injected in fingers. Little attention has been paid to analyze the evidence that created this belief to see whether it is valid. The significance is that elective epinephrine finger injection has been shown to remove the need for a tourniquet, and therefore delete sedation and general anesthesia for much of hand surgery. All of the evidence for the antiadrenaline dogma comes from 21 mostly pre-1950 case reports of finger ischemia associated with procaine and cocaine injection with epinephrine. The authors performed an in-depth analysis of those 21 cases to determine their validity as evidence. They also examined in detail all of the other evidence in the literature surrounding issues of safety with procaine, lidocaine, and epinephrine injection in the finger. The adrenaline digital infarction cases that created the dogma are invalid evidence because they were also injected with either procaine or cocaine, which were both known to cause digital infarction on their own at that time, and none of the 21 adrenaline infarction cases had an attempt at phentolamine rescue. The evidence that created the dogma that adrenaline should not be injected into the fingers is clearly not valid. However, there is considerable valid evidence in the literature that supports the tenet that properly used adrenaline in the fingers is safe, and that it removes the need for a tourniquet and therefore removes the need for sedation and general anesthesia for many hand operations.
Wide-awake approach to flexor tendon repair in hand & wrist surgery
  • D H Lalonde
Lalonde DH. Wide-awake approach to flexor tendon repair in hand & wrist surgery. In: Chung K, ed. Operative Techniques: Hand and Wrist Surgery. Vol. II. Philadelphia: Saunders/ Elsevier; 2007:533.