Abstract
Background:
Flexor tendon lacerations in the fingers are challenging injuries that can be repaired using the wide-awake local anesthesia no tourniquet (WALANT) technique or under traditional anesthesia (TA). The purpose of our study was to compare the functional outcomes and complication rates of patients undergoing flexor tendon repair under WALANT versus TA.
Methods:
All patients who underwent a primary flexor tendon repair in zone I and II without tendon graft for closed avulsions or open lacerations between 2015 and 2019 were identified. Electronic medical records were reviewed to record and compare patient demographics, range of motion, functional outcomes, complications, and reoperations.
Results:
Sixty-five zone I (N = 21) or II (N = 44) flexor tendon repairs were included in the final analysis: 23 WALANT and 42 TA. There were no statistical differences in mean age, length of follow-up, proportion of injured digits, or zone of injury between the groups. The final Quick Disabilities of the Arm, Shoulder, and Hand score in the WALANT group was 17.2 (SD: 14.4) versus 23.3 (SD: 18.5) in the TA group. There were no statistical differences between the groups with any final range of motion (ROM) parameters, grip strength, or Visual Analog Scale pain scores at the final follow-up. The WALANT group was found to have a slightly higher reoperation rate (26.1% vs 7.1%; P = .034) than the TA group.
Conclusions:
This study represents one of the first clinical studies reporting outcomes of flexor tendon repairs performed under WALANT. Overall, we found no difference in rupture rates, ROM, and functional outcomes following zone I and II flexor tendon repairs when performed under WALANT versus TA.
Keywords: flexor, tendon, repair, wide-awake, anesthesia, outcomes
Introduction
Flexor tendon lacerations in the fingers (zone I and II) are challenging injuries. While flexor tendon repair is the standard treatment, postoperative stiffness is a common problem.1,2 To minimize this risk and to allow for earlier postoperative motion, surgeons have identified aspects of the surgical repair technique that are associated with increased repair strength, including the number and size of core tendinous suture strands across the repair site and the presence of epitendinous suture reinforcement.3,4 Similarly, wide-awake local anesthesia no tourniquet (WALANT) surgery has gained increasing popularity for flexor tendon repairs due to the ability to assess the repair through active motion intraoperatively and thereby minimizing bunching at the pulleys or gapping of the repair.5-7 In fact, a recent survey of the American Society for Surgery of the Hand revealed that 20% of hand surgeons have performed a flexor tendon repair with WALANT, and that 9% of surgeons performed all their flexor tendon repairs with WALANT. 8
Despite this increasing popularity, data regarding outcomes of flexor tendon injuries repaired using WALANT are limited, with most information in the literature in the form of surgical technique.7,9 The purpose of our study was to compare the functional outcomes and complication rates of patients undergoing flexor tendon repair under WALANT versus traditional anesthesia (TA; general or intravenous sedation). We hypothesized that wide-awake surgery would have similar functional outcomes and rates of complications following flexor tendon repair.
Materials and Methods
Institutional review board approval was obtained, with a waiver of informed consent per institutional protocol. All patients who underwent a primary flexor tendon repair in zone I and II without tendon graft for closed avulsions or open lacerations (Common Procedural Terminology [CPT] codes 23656 and 26370, respectively) between 2015 and 2019 were identified. All procedures were performed at our institution by 1 of the 12 fellowship-trained hand surgeons. Patients with a bony injury requiring fixation and patients with less than 3 months of postoperative follow-up were excluded from the study. A total of 31 flexor tendon repairs were excluded due to not meeting inclusion criteria, producing a final study cohort of 65 flexor tendon repairs. Electronic medical records were reviewed to record patient demographics, range of motion (ROM), functional outcomes, complications, and reoperations. Operative reports were then reviewed to stratify the included patients into 2 cohorts—those who underwent repair under TA (general or intravenous sedation, TA group), and those treated with wide-awake surgery using local anesthesia only (WALANT group). Chart reviewers were blinded to the study groups while recording outcome and complication data. The WALANT group included patients of 2 fellowship-trained hand surgeons, and the TA group included patients of 12 fellowship-trained hand surgeons.
The type of anesthetic, method of repair, and postoperative rehabilitation protocol were at the discretion of the treating surgeon. Zone II repairs were performed with a combination of a core suture (3-0 or 4-0 braided, nonabsorbable) and an epitendinous suture (5-0 or 6-0 monofilament, nonabsorbable). Zone I repairs were performed with a pull-out suture over an acrylic button, bone tunnels, or a suture anchor. Early active motion postoperative rehabilitation protocols were used in 30 patients (46.2%), while the rest were enrolled in early passive ROM protocols.
The outcome measures assessed at the final clinical follow-up included the Quick Disabilities of the Arm, Shoulder, and Hand (qDASH) scores, Visual Analog Scale (VAS) Pain scores, grip strength (Jamar dynamometer, position 2), and active joint ROM measurements including distance to the distal palmar crease (DPC). Complications such as infection, tendon rupture, stiffness requiring reoperation, and complex regional pain syndrome were tabulated. Any infection requiring irrigation and debridement was considered a deep infection, whereas infections that resolved with oral antibiotics without requiring surgical intervention were considered superficial infections.
All data were recorded and analyzed using the Statistical Package for the Social Sciences (SPSS Inc, Version 26.0). Descriptive statistics were used to report patient demographics and outcomes within each treatment cohort. Categorical outcome variables were compared between the 2 groups using the Fisher exact or Pearson χ2 test with 2-sided significance reported. Numerical outcomes were first assessed for normality using the Shapiro-Wilk test and then compared between the 2 groups using either the Student t test or Mann-Whitney U test as indicated. Statistical significance was maintained for all testing at P < .05.
Results
Sixty-five zone I (N = 21) or II (N = 44) flexor tendon repairs were included in the final analysis. This consisted of 40 men and 25 women at an average age of 43.7 years (SD: 17.1, range: 14-82) and a mean follow-up of 6.9 months (SD: 5.7, range: 3-27) (Table 1). Twenty-three of these patients were in the WALANT group, and 42 were in the TA group. The WALANT group had a significantly greater proportion of men than the TA group (78.3% vs 52.4%; P = .040). There were no other statistical differences in mean age, length of follow-up, proportion of injured digits, or zone of injury between the 2 groups (Table 1).
Table 1.
Demographics.
| Demographics | All | WALANT | TA | P value |
|---|---|---|---|---|
| N | 65 | 23 | 42 | |
| Sex (SD) | .04 | |||
| Male | 40 (61.5) | 18 (78.3) | 22 (52.4) | |
| Female | 25 (38.5) | 5 (21.7) | 20 (47.6) | |
| Age (SD) | 43.7 (17.1) | 41.3 (14.1) | 45.0 (18.6) | .41 |
| Length of F/U in months | 6.9 (5.7) | 9.1 (8.2) | 5.7 (3.2) | .07 |
| Digit (%) | .36 | |||
| 1 | 12 (18.5) | 2 (8.7) | 10 (23.8) | |
| 2 | 16 (24.6) | 8 (34.8) | 8 (19.0) | |
| 3 | 11 (16.9) | 5 (21.7) | 6 (14.3) | |
| 4 | 11 (16.9) | 4 (17.4) | 7 (16.7) | |
| 5 | 15 (23.1) | 4 (17.4) | 11 (26.2) | |
| Zone of injury (%) | .43 | |||
| 1 | 21 (32.3) | 6 (26.1) | 15 (35.7) | |
| 2 | 44 (67.7) | 17 (73.9) | 27 (64.3) | |
| Received prophylactic antibiotics (%) | 34 (52.3) | 9 (39.1) | 25 (59.5) | .12 |
Note. WALANT = wide-awake local anesthesia no tourniquet; TA = traditional anesthesia; F/U = follow-up.
The final qDASH score in the WALANT group was 17.2 (SD: 14.4) versus 23.3 (SD: 18.5) in the TA group (P = .255) (Table 2). Grip strength percent was compared by dividing the grip strength of the injured side by the grip strength of the noninjured side and was similar between the groups (P = .269). There were no statistical differences between the groups with any final ROM parameters, including the distance to DPC (P > .05). There was no difference in the final VAS pain scores between both groups (P = .41).
Table 2.
Range of Motion and Functional Outcomes.
| Outcomes | WALANT | TA | P value |
|---|---|---|---|
| Grip % (injured/normal) (SD) | 69.7 (23.4) | 79.6 (29.5) | .27 |
| qDASH (SD) | 17.2 (14.4) | 23.3 (18.5) | .26 |
| Distance to DPC, cm (SD) | 2.3 (1.8) | 1.9 (1.7) | .51 |
| VAS pain (SD) | 0.8 (1.3) | 1.2 (1.5) | .41 |
| ROM digit 1(SD) | |||
| TAM | 76.4 (33.8) | 76.4 (34.3) | 1.00 |
| IP extension | 0 (0) | −2.8 (8.0) | .64 |
| IP flexion | 30 (35.4) | 31.5 (14.6) | .96 |
| MP extension | 0 (0) | 0.4 (5.7) | .93 |
| MP flexion | 46.5 (16.3) | 47.3 (18.3) | .96 |
| ROM digits 2-5 (SD) | |||
| TAM | 193.9 (74.9) | 167.7 (88.3) | .27 |
| DIP extension | 1.4 (8.3) | 2.3 (7.7) | .68 |
| DIP flexion | 41.6 (21.5) | 30.7 (16.7) | .06 |
| PIP extension | 1.7 (10.9) | 7.1 (12.5) | .13 |
| PIP flexion | 84.7 (21.9) | 82.4 (21.0) | .72 |
| MP extension | 1.3 (4.3) | −0.2 (5.6) | .35 |
| MP flexion | 85.9 (10.4) | 83.6 (7.6) | .41 |
Note. WALANT = wide-awake local anesthesia no tourniquet; TA = traditional anesthesia; qDASH = Quick Disabilities of the Arm, Shoulder, and Hand; DPC = distal palmar crease; VAS = Visual Analog Scale; ROM = range of motion; TAM = total active motion; IP = interphalangeal; MP = metacarpophalangeal; DIP = distal interphalangeal; PIP = proximal interphalangeal.
A subanalysis was performed of only zone II flexor tendon injuries in fingers 2 to 5. The WALANT group had significantly lesser final qDASH scores compared with the TA group (12.4 vs 28.1, P = .02). Otherwise, there were no statistical differences in grip strength, VAS pain, distance to DPC, or in any ROM parameters comparing WALANT with TA (P > .05) (Table 3).
Table 3.
Subanalysis of Range of Motion and Functional Outcomes of Zone II Injuries in Digits 2 to 5.
| Outcomes | WALANT | TA | P value |
|---|---|---|---|
| Grip % (injured/normal) | 72.2 (20.2) | 86.7 (37.6) | .28 |
| qDASH | 12.4 (10.0) | 28.1 (21.5) | .02 |
| Distance to DPC, cm | 2.0 (1.7) | 2.1 (1.6) | .92 |
| VAS pain | 0.6 (1.3) | 0.9 (1.6) | .63 |
| ROM | |||
| TAM | 187.3 (83.0) | 181.1 (79.5) | .82 |
| DIP extension | 1.5 (6.4) | 2.4 (8.1) | .74 |
| DIP flexion | 44.1 (22.1) | 32.4 (18.6) | .11 |
| PIP extension | 1.3 (12.2) | 6.8 (12.7) | .22 |
| PIP flexion | 82.2 (23.0) | 79.9 (22.6) | .77 |
| MP extension | 1.4 (5.0) | 1.5 (3.9) | .96 |
| MP flexion | 86.5 (9.3) | 82.4 (7.7) | .20 |
Note. WALANT = wide-awake local anesthesia no tourniquet; TA = traditional anesthesia; qDASH = Quick Disabilities of the Arm, Shoulder, and Hand; DPC = distal palmar crease; VAS = Visual Analog Scale; ROM = range of motion; TAM = total active motion; DIP = distal interphalangeal; PIP = proximal interphalangeal; MP = metacarpophalangeal.
Thirteen complications (20%) and 9 reoperations (13.8%) were observed in the overall study cohort (Table 4). Three ruptures were observed: 2 in the WALANT group and 1 in the TA group. Both ruptures in the WALANT group underwent rerepair. The rupture in the TA group had an intact flexor digitorum superficialis and did not undergo rerepair. Five infections (21.7%) were observed in the WALANT group, compared with zero in the TA group (P = .002). Three of these infections were superficial and resolved with oral antibiotics, while 2 required surgical debridement. Rates of tendon adhesions requiring tenolysis were similar between the WALANT and TA groups (4.3% vs 7.1%; P = .654). The WALANT group was found to have a higher reoperation rate (26.1% vs 7.1%; P = .034) than the TA group.
Table 4.
Complications and Reoperations.
| Complications/Reoperations | WALANT | TA | P value |
|---|---|---|---|
| Complications (%) | 8 (34.8) | 5 (11.9) | .03 |
| Superficial infection | 3 | 0 | |
| Deep infection | 2 | 0 | |
| Adhesions requiring tenolysis | 1 | 3 | |
| Rupture | 2 | 1 | |
| Other | 0 | 1 (CRPS) | |
| Reoperation (%) | 6 (26.1) | 3 (7.1) | .03 |
| Lysis of adhesions | 1 | 3 | |
| I&D | 2 | 0 | |
| Rerepair | 2 | 0 | |
| Other | 1 (nail plate removal 2/2 paronychia) | 0 |
Note. WALANT = wide-awake local anesthesia no tourniquet; TA = traditional anesthesia; CRPS = complex regional pain syndrome; I&D = irrigation and debridement.
Discussion
This study sought to investigate the outcomes and complication rates of zone I and II flexor tendon repairs performed under WALANT versus under TA. We observed no difference in rupture rates, final ROM outcomes, VAS pain scores, and functional outcome scores for flexor tendon repair performed under WALANT versus under TA.
Advocates of the WALANT technique for flexor tendon repair believe being able to observe the repair under active motion intraoperatively can allow for correction of tendon gapping or bunching. Some surgeons believe this benefit of the technique has resulted in lower rupture rates.5-7,10 However, we are aware of only 1 study in the literature that has reported the rupture rates of flexor tendon repairs performed under WALANT. Higgins et al 10 retrospective reviewed 102 consecutive WALANT flexor tendon repair patients over 10 years in 2 Canadian cities. The authors reported a rupture rate of 3.3% (4/122 flexor tendon repairs). In 7 of the 102 patients, they observed gapping and/or bunching of the repair during intraoperative active motion, which was corrected intraoperatively, and none of those 7 patients went on to rupture postoperatively. No data regarding ROM, functional outcomes, or complications were provided. In addition, the majority of the patients were evaluated at latest follow-up by telephone interview as they had not completed a 3-month therapy course. Sadek 11 reported on flexor tendon repair outcomes in 53 patients with flexor tendon laceration injuries in zone IIB, 30 of which were performed with WALANT. They reported that the WALANT patients had significantly greater final grip strength (P = .014) and had a significantly shorter duration of surgery (P = .013) compared with those with other methods of anesthesia. Two repairs in this study ruptured postoperatively; however, it is not explicitly stated if these ruptures were in WALANT patients or TA patients. Furthermore, ROM and functional outcomes were not compared between WALANT and other methods of anesthesia in this study.
We observed a significantly higher rate of infection in the WALANT group compared with the TA group. Current recommendations by the American Academy of Orthopaedic Surgeons and the American Association of Plastic Surgeons do not recommend antibiotic prophylaxis in clean hand surgery such as carpal tunnel release.12,13 A recent commercial insurance claims database review of 516 986 patients revealed no difference in postoperative infection rates between patients who did or did not receive prophylactic antibiotics before clean soft tissue hand surgery. 14 However, flexor tendon lacerations are open injuries, and likely carry higher infection risks than clean hand surgeries such as carpal tunnel releases which may not benefit from prophylactic antibiotics. The cleanliness of the flexor tendon laceration, the lacerating object, the quality of the irrigation, the length of time to treatment/surgery, and the use of perioperative antibiotics likely confound the rates of postoperative infections in flexor tendon laceration patients, including in our cohort. And while it is unlikely that the anesthesia method (WALANT vs TA groups) had a direct effect on the observed postoperative infection rates in our study, other investigators have suggested that the use of epinephrine in WALANT soft tissue surgery may result in an increased incidence of infection.15,16
Adhesion formation and loss of mobility from repaired tendon bunching passing through pulleys remain common complications following flexor tendon repair.1,2 Proponents of performing these repairs under WALANT believe that these complications can be avoided by observing active tendon excursion intraoperatively, showing that the repair does not bunch and trigger on pulleys.6,17 If triggering of the repair is observed, pulleys can be vented allowing for unrestricted ROM, and some believe this may lower tenolysis rates.6,17-20 We observed a lower rate of tenolysis in the WALANT group compared with the TA group; however, this difference was not statistically significant.
While our study did not reveal significant outcome or complication differences between groups, the WALANT technique has many benefits that have contributed to its increased popularity among hand surgeons. Preoperative testing and medical clearance are not required for patients undergoing WALANT surgery, saving patients money and time and increasing convenience by avoiding these extra office visits. 21 Patients do not require anesthesia, which eliminates both patient costs for anesthesia services and the potential for adverse events from anesthesia medications.21,22 Wide-awake local anesthesia no tourniquet can be performed in outpatient surgery centers and even in the clinic setting, resulting in decreased room turnover time and doubling the number of cases a surgeon can perform during a given time period.23,24 Postoperatively, WALANT surgery patients spend less time in the postanesthesia care unit, and do not require an escort on the day of surgery as they are able to drive themselves home because they received no anesthesia. 25
This study has several limitations owing to a large degree to its retrospective design. First, surgeries in the TA group were performed by a large number of surgeons, with heterogenous repair techniques and therapy protocols. As such, any observed differences between groups could be a function of different repair techniques and postoperative protocols. Second, postoperative complications in our cohort could be underreported in clinic notes, and/or patients could have experienced complications that were treated at other institutions without our knowledge. Third, due to our relatively small numbers, we grouped zone I and II injuries together. While these are similar injuries, they may behave differently. Fourth, the repairs included thumbs and fingers, which may represent different injury patterns and display different outcomes. Fifth, 1 patient in the TA group elected against rerepair after rupture, which skews the reoperation rate reported. Sixth, our study could be underpowered to observe significant differences in rupture rates between both groups due to the rarity of both flexor tendon injuries and subsequent rupture postoperatively.
Although the WALANT group was relatively small, this is 1 of the first studies reporting outcomes of flexor tendon repairs performed with WALANT. Our investigation attempts to answer an extremely relevant clinical question that can better guide patient discussion using evidenced data. The results further elucidate the comparative benefits of WALANT versus TA and can now serve to more accurately establish preoperative expectations for surgeons and patients.
Overall, this study found no difference in rupture rates, ROM, and functional outcomes following zone I and II flexor tendon repairs when performed under WALANT versus TA. Clinical studies are lacking reporting outcomes of flexor tendon repairs performed under local anesthesia, and this study represents 1 of the first studies reporting these outcomes. More studies and outcome data are required to further characterize potential differences in outcomes of flexor tendon repairs with local versus TA.
Footnotes
Ethical Approval: This study was approved by our institutional review board.
Statement of Human and Animal Rights: No human or animal subject was subjected to bodily or psychological harm in this study.
Statement of Informed Consent: No identifiable patient information was used in this article.
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding: The author(s) received no financial support for the research, authorship, and/or publication of this article.
ORCID iDs: Clay B. Townsend 
https://orcid.org/0000-0002-7280-6025
Samir C. Sodha https://orcid.org/0000-0001-8484-0733
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