Chapter 32 Flexor Tendon Repair of the Finger
ADVANTAGES OF WALANT VERSUS SEDATION AND TOURNIQUET IN FLEXOR TENDON REPAIR OF THE FINGER
Intraoperative Testing of a Repair
Intraoperative testing of a repair with WALANT (such as asking the patient to actively extend and flex the operated finger fully) can reveal gapping of a weak repair and decrease rupture rates.
If you see the repair gapping after you ask the patient to make a full fist and completely straighten the fingers, you can repair the gap with more sutures, retest the repair to confirm that it is reliable with intraoperative flexion testing, and then close the skin. This is like testing blood flow through a microvascular anastomosis to avoid failure.
You are less likely to have to perform a secondary surgery for rupture repair if you test the repair intraoperatively by having the patient take the fingers through a full range of flexion and extension before skin closure.1,2
Clip 32-2 contains other useful tips on avoiding rupture during and after surgery.
WALANT Can Decrease Tenolysis Rates
You are less likely to have to come back for tenolysis if you see the patient take the fingers through a full range of motion before you close the skin. You know the repair will fit through the pulleys. You only need to vent (divide) the parts of the pulleys that are required to obtain a full range of intraoperative active movement of the finger, including all of A4 or one half to two thirds of the distal A2 pulley. (See Clip 32-12 of A4 pulley venting with no bowstringing in the Tips and Tricks section of this chapter.)
Seeing the patient make a full fist and completely straighten out the fingers without gapping at surgery gives the surgeon full confidence to allow up to half a fist of true active movement 3 to 5 days later.
We have abandoned the use of Kleinert rubber bands as well as “place-and-hold” active extension and passive flexion in favor of true active movement in our postoperative regimen. We feel that up to half a fist of true active finger flexion and full finger phalangeal joint extension has improved the results of our repair. We allow full wrist extension, up to half a fist of active flexion (45 degrees of active metacarpophalangeal [MP] extension, and up to 45 degrees of active proximal interphalangeal [PIP] and distal interphalangeal [DIP] flexion). Half a fist of flexion translates to 1 cm of active flexor digitorum profundus (FDP) tendon glide. (See Clip 32-16 on 1 cm of tendon glide with half a fist in the Tips and Tricks section of this chapter.)
Intraoperative Patient Education
The ability to educate the patient intraoperatively during a WALANT flexor tendon repair decreases rupture and tenolysis rates because the patient sees it all and remembers the consequences of moving versus using the hand after surgery.
WALANT allows you and the hand therapist (see Chapter 15) to assess patients and educate them for up to 60 uninterrupted minutes during the surgery. We think this has been very important in improving our results.
You are able to talk to unsedated patients, who usually become very interested in learning about the procedure during the operation. Patients have the greatest stake in the result, and this propels them to be more effective members of the rehabilitation team. When patients leave the operating room, they know exactly what they need to do to get a good result. What is more important, they know what they must not do. They know they can move the fingers, but that they cannot use the fingers or they will lose the good result.
The therapist can also participate with the surgeon in intraoperative patient evaluation and education if invited into the operating room, as we do at our hospital (see Chapter 15).
For a clip on a surgeon and therapist explaining the Saint John postoperative flexor tendon repair protocol to a patient during surgery, see Clip 15-3 in Chapter 15.
Patients get to see that the repaired tendon works as they watch themselves moving the fingers through a full range of motion before the skin is closed. They know that their finger will function well once they get past the postoperative discomfort and stiffness if they put the effort into therapy.
You and the hand therapist can get to know patients during the surgery and decide whether you can trust them with early protected movement.
WALANT Allows You to Determine Whether Superficialis Repair Is Appropriate
In a wide awake procedure you are able to have the patient move the hand through a full range of active movement.
Based on this, you can repair the superficialis and see how this affects the full range of active movement during the surgery. If superficialis repair downgrades the movement, you can resect one of the slips or take down the whole superficialis repair to get the best possible active movement before you end the operation.
For the full-length video of the repair of the 6-year-old patient shown in Clip 32-6, see Chapter 9, Clip 9-1. Also see Chapter 9, Clip 9-2, of a flexor tendon repair in a 10-year-old patient.
Other Advantages of WALANT Versus Sedation and Tourniquet
A major advantage of eliminating sedation and the tourniquet for flexor tendon repair is that you do not need to perform the procedure in the main operating room. Some of us (authors) do all tendon repairs in minor procedure rooms in the clinic outside the main operating room Monday to Friday, 8 AM to 4 PM (see Chapter 16). Others of us still prefer to perform flexor tendon repair in the main operating room.
We no longer need to perform such procedures at night. We know that we do better tendon repairs at 2 PM when we are fresh and awake than at 2 AM, when we are tired and sleepy.
We no longer have to admit patients because of their medical comorbidities, which are only a problem when we sedate them.
We perform the surgery with field sterility or add gowns and drapes for augmented field sterility (see Chapter 10).
Working outside the main operating room also allows our hand therapists to be there to teach patients during the surgery and see the repair (see Chapter 15).
You can suture the tendon inside the flexor sheath through sheathotomies to get a 1 cm bite without having to cut long segments of sheath when patients are wide awake (see the Tips and Tricks section). You can do this because you then test active flexion to prove that you have not caught your needle and suture inside the sheath.
All of the general advantages listed in Chapter 2 apply to both the surgeon and the patient.
WHERE TO INJECT THE LOCAL ANESTHETIC FOR FLEXOR TENDON REPAIR OF THE FINGER
See Chapter 1, Atlas, for more illustrations of the anatomy of diffusion of tumescent local anesthetic in the forearm, wrist, and hand.