Recent Developments in WALANT Flexor Tendon Repair and Rehabilitation

MOST PATIENTS WILL CONSENT TO WIDE-AWAKE LOCAL ANESTHESIA NO TOURNIQUET FLEXOR TENDON REPAIR WHEN IT HAS BEEN WELL EXPLAINED TO THEM This article and its videos help the surgeon explain to the patient how they can get a better result with wide-awake local anesthesia no tourniquet (WALANT) repair because of intraoperative testing of the repair, intraoperative education, and improved ability to keep their hands up and quiet if they are sober at the end of surgery.1 Most patients are afraid of the unknown and the possible pain of local anesthesia. Calm, positive explanations and the desire for the best outcome usually allay these fears. For those unwilling, traditional sedation and tourniquet surgery are still available. MOST IMPORTANT POINTS IN WALANT FINGER FLEXOR TENDON REPAIR AND REHABILITATION Minimal pain tumescent local anesthesia. Short incisions and limited dissection. Vent any pulley the length of the repair excursion distance so the repair glides freely from unvented pulley to unvented pulley. A 6-strand very solid bulky repair (10%–30%) with 1-cm bites. Treat tendon ends with respect for good healing. Epitenon sutures as required to approximate epitenon cells for gap-free healing. Test repair with WALANT intraoperative full-fist active flexion and extension. WALANT intraoperative patient education. Up to half a fist of true active movement at 3–5 days postoperatively. MINIMAL PAIN TUMESCENT LOCAL ANESTHESIA INJECTION The only pain the patient should feel is the sting of the first 30G needle insertion into the palm, then no more pain at all during the rest of the injection process or during the surgery. (See Video 1 [online], which displays minimal pain tumescent local anesthesia for WALANT flexor tendon repair.) {"href":"Single Video Player","role":"media-player-id","content-type":"play-in-place","position":"float","orientation":"portrait","label":"Video 1","caption":"displays minimal pain tumescent local anesthesia for WALANT flexor tendon repair.","object-id":[{"pub-id-type":"doi","id":""},{"pub-id-type":"other","content-type":"media-stream-id","id":"1_itkesek1"},{"pub-id-type":"other","content-type":"media-source","id":"Kaltura"}]} SHORT INCISIONS Shorter incisions make fewer adhesions to decrease the risk of tenolysis. Make a separate short incision in the palm if needed to get the proximal tendon end. Push the flexor digitorum profundus in the palm distally with 2 forceps so the flexor digitorum profundus stays inside the flexor digitorum superficialis decussation. Keep the skin bridge intact between the palm and the short finger incisions. VENT THE REPAIR EXCURSION DISTANCE Vent enough of any pulley (including A2 or A4) so that a slightly bulky, very strong repair glides freely from one unvented pulley to another with full-fist active flexion and full extension testing in the awake patient. Do not vent more than this to avoid clinically significant bowstringing.2,3 (See Video 2 [online], which displays the most important details in WALANT finger flexor tendon repair and rehabilitation.) {"href":"Single Video Player","role":"media-player-id","content-type":"play-in-place","position":"float","orientation":"portrait","label":"Video 2","caption":"displays the most important details in WALANT finger flexor tendon repair and rehabilitation.","object-id":[{"pub-id-type":"doi","id":""},{"pub-id-type":"other","content-type":"media-stream-id","id":"1_o695lsf9"},{"pub-id-type":"other","content-type":"media-source","id":"Kaltura"}]} VERY SOLID BULKY REPAIR THAT WITHSTANDS GAPPING DURING REPEATED TESTING The repair should be at least 4 strands with 1-cm bites. We prefer the 6-strand M-Tang repair with a looped suture, but most repair configurations work well if they are solid enough that they do not gap with repeated full-fist flexion and extension testing by the awake patient. We no longer use grandma kiss repairs that have tendon stumps barely touching so they can fit under unvented pulleys. Now that we properly vent pulleys, a 10%–30% bulky, very solid repair that will resist gap and rupture can easily glide from unvented pulley to unvented pulley (see Video 2 [online]). Patients do need to look at their hands to test the repair so they can know where their numb fingers are in space. If you see a gap form during testing, repair it as described in Video 2. TREAT TENDON ENDS WITH RESPECT Grab the cut tendon ends as little as possible because you should not damage the cells needed in healing. Epitenon sutures are not needed for strength with a solid repair proven with WALANT active testing.4 Noncrushing epitenon sutures are placed where needed to bridge gaps, so the epitenon cells are all touching with no gaps to promote primary epitenon healing. (See Video 3 [online], which displays the surgical repair.) {"href":"Single Video Player","role":"media-player-id","content-type":"play-in-place","position":"float","orientation":"portrait","label":"Video 3","caption":"displays the surgical repair.","object-id":[{"pub-id-type":"doi","id":""},{"pub-id-type":"other","content-type":"media-stream-id","id":"1_fmzj6suq"},{"pub-id-type":"other","content-type":"media-source","id":"Kaltura"}]} WALANT INTRAOPERATIVE PATIENT EDUCATION This is one of the most important strategies to decrease the risk of rupture and tenolysis. The patient is most likely to heed the surgeon’s advice given during the surgery. (See Video 4 [online], which displays intraoperative patient education by the surgeon to decrease rupture and tenolysis risk.) {"href":"Single Video Player","role":"media-player-id","content-type":"play-in-place","position":"float","orientation":"portrait","label":"Video 4","caption":"displays intraoperative patient education by the surgeon to decrease rupture and tenolysis risk.","object-id":[{"pub-id-type":"doi","id":""},{"pub-id-type":"other","content-type":"media-stream-id","id":"1_rv4skfh4"},{"pub-id-type":"other","content-type":"media-source","id":"Kaltura"}]} THE FIRST 3–5 DAYS AFTER SURGERY Splint in a position of comfort until collagen formation starts at 3 days. Tell the patient during surgery, and again at the end of the surgery, that they must keep their hands quietly elevated for 3–5 days. This prevents internal bleeding to avoid peritendinous hematoma, which turns to scar and adhesions. This time of immobilization and elevation also lets swelling and the work of flexion decrease. It helps patients get off all pain medication so they can follow pain guided moving when they start up to half a fist of true active movement.5 START EARLY PROTECTED TRUE ACTIVE MOVEMENT AT 3–5 DAYS AFTER SURGERY Try to be there the first day the patient moves at 3–5 days postoperatively to make sure you see the patient actively flex the distal interphalangeal (DIP) joint (see first therapy session for last 3 min of Video 2 [online]). This ensures that the repair breaks through the fibrin clot and does not get stuck in the scar. On that first day, remove the surgical dressing and rinse the wound in clean tap water. Wrap the finger with Coban to keep swelling down and cover the wounds all day except for showering. Then, show them how to loosen the joints with several rounds of passive movement. Then, force the patient to actively flex the DIP at least 5–10 degrees, enough to break up the fibrin clot. Show patients how to passively hold the metacarpal phalangeal joint in extension (minus 30 degrees) while asking the patient to force their profundus to glide with active flexion. We know it will not rupture with up to half a fist of flexion, because 3 days ago we saw a full active fist with no gapping. Encourage active proximal interphalangeal and DIP extension to avoid flexion contracture. Place them in a Manchester short splint to remind them that they can move it, but they cannot use it. Out-of-splint exercise is permitted in reliable patients.4 DISCLOSURES Dr. Lalonde receives royalties from Thieme Medical Publishers and is a consultant for ASSI, Corp. The other author has no financial interest to declare in relation to the content of this article.

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