Chapter 38 Tenolysis
ADVANTAGES OF WALANT VERSUS SEDATION AND TOURNIQUET IN TENOLYSIS
There is no rush when performing tenolysis, because there is no tourniquet.
Your patients can help you, because they are comfortable and cooperative; they can rupture their own adhesions by actively flexing their muscles after you release some of the adhesions.
Patients can show you where their tendon is stuck with active movement; sometimes the tendon stuck in a place that may surprise you.
In Clip 38-1, Dr. Jason Wong performs tenolysis after a finger amputation. The patient, pain-free and cooperative, helps the surgeon rupture the last of the adhesions.
You will know that you finished the surgery when you see a full range of active finger movement while the patient is on the operating table. This is like testing and ensuring good patency and blood flow through a microvascular anastomosis before you close the skin.
At the end of the surgery, you can show your patients exercises they can perform. They can do their first exercises on the table in a totally pain-free manner instead of after surgery, when they will be sore. They will remember the exercises and the range of motion they can achieve because they are sedation free.
You and the patient will both know how much active movement the finger achieved at the end of the operation. This avoids unrealistic expectations for you and the patient.
In Clip 38-2, Dr. Michael Sauerbier performs tenolysis with the wide awake approach. Thus the patient can remember the movement he was able to experience on the operating table.
Patients 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 effort into their therapy.
You are able to talk to unsedated patients for the 90 or so minutes that local anesthesia and the tenolysis take to accomplish. You can educate and warn them about what to do and not do after surgery. We know that the tendon is weaker and has less blood supply after tenolysis. Therefore, to avoid rupture we warn patients to avoid jerktype movements and heavy lifting for 2 to 3 weeks until the tendon gets stronger.
You can get to know your patients better during the surgery and find out what will motivate them. The patient in Clip 38-3 wanted to succeed in an Olympic sport. Seeing her finger move at surgery motivated her to maintain the movement after surgery.
The hand therapist can also participate in intraoperative patient evaluation and education if the surgeon allows the therapist into the operating room, as we do (see Chapter 15).
All of the general advantages listed in Chapter 2 apply to both the surgeon and the patient.