Wide-awake local anaesthesia no tourniquet (WALANT) vs regional or general anaesthesia for flexor tendon repair in adults: protocol for a systematic review and meta-analysis

Abstract Background Flexor tendon injuries most commonly occur following a penetrating injury to the hand or wrist. These are challenging injuries and the standard treatment is surgical repair under general or regional anaesthesia. ‘Wide-awake’ surgery is an emerging technique in hand surgery where a conscious patient is operated on under local anaesthetic. The vasoconstrictive effect of adrenaline (epinephrine) creates a ‘bloodless’ operating field and a tourniquet is not required. The potential advantages include intra-operative testing of the repair; removal of the risks of general anaesthesia; reduced costs; no aerosol generation from intubation therefore reduced risk of COVID-19 spread to healthcare professionals. The aim of this study will be to systematically evaluate the evidence to determine if wide-awake surgery is superior to general/regional anaesthetic in adults who undergo flexor tendon repair. Methods We designed and registered a study protocol for a systematic review and meta-analysis of comparative and non-comparative studies. The primary outcome will be functional active range of motion. Secondary outcomes will be complications, resource use (operative time) and patient-reported outcome measures. A comprehensive literature search will be conducted (from 1946 to present) in MEDLINE, EMBASE, CINAHL, and Cochrane Library. Grey literature will be identified through Open Grey, dissertation databases and clinical trials registers. All studies on wide-awake surgery for flexor tendon repair will be included. The comparator will be general or regional anaesthesia. No limitations will be imposed on peer review status or language of publication. Two investigators will independently screen all citations, full-text articles and abstract data. Potential conflicts will be resolved through discussion or referral to a third author when necessary. The study methodological quality (or bias) will be appraised using an appropriate tool. If feasible, we will conduct a random effects meta-analysis. Discussion This systematic review will summarise the best available evidence and definitively establish if function, complications, cost, or patient-reported outcomes are improved when flexor tendons are repaired using wide-awake technique. It will determine if this novel approach is superior to general or regional anaesthesia. This knowledge will help guide hand surgeons by continuing to improve outcomes from flexor tendon injuries. Systematic review registration PROSPERO CRD42020182196

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Wide awake surgery for flexor tendon primary repair: A literature review

Orthopedic Reviews ◽

10.4081/or.2020.8668 ◽

2020 ◽

Author(s):

Camillo Fulchignoni ◽

Mario Alessandri Bonetti ◽

Giuseppe Rovere ◽

Antonio Ziranu ◽

Giulio Maccauro ◽

...

Keyword(s):

Local Anesthesia ◽

Flexor Tendon ◽

Primary Repair ◽

Tendon Repair ◽

Tendon Injuries ◽

Awake Surgery ◽

Cochrane Library ◽

Surgical Approaches ◽

Flexor Tendon Injuries ◽

Wide Awake

Flexor tendon injuries are extremely challenging conditions to manage for hand surgeons. Over the last few years enormous progress has been made for the treatment of these lesions with new surgical approaches being performed. One of these is the wideawake local anesthesia no tourniquet (WALANT) technique, also known as Wide Awake Technique that allows tendon repair under local anesthesia, enabling the tendon to move actively during surgery. Dynamic movement of the tendon during surgery is crucial for the orthopedic surgeon in order to understand if the tendon has been correctly repaired before leaving the operatory table. An electronic literature research was carried out on Pubmed, Google Scholars and Cochrane Library using ((Flexor tendon injury) OR (flexor tendon) OR (injury muscle tendon) OR (flexor pollicis longus tendon) AND ((wide awake repair) OR (wide awake) OR (wide awake hand surgery))as search terms. Authors believe that WALANT is an enormous add-on in the management of patients with flexor tendon injuries mainly because it allows direct visualization of the repair during flexion and extension movement of the fingers and also because it avoids general anesthesia or brachial plexus being more cost effective. The aim of these review was therefore to sum up the evidences available so far on the wade awake technique as an emerging treatment for patients with flexor tendon injuries.

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Complications After Flexor Tendon Repair: A Systematic Review and Meta-Analysis

The Journal Of Hand Surgery ◽

10.1016/j.jhsa.2011.11.006 ◽

2012 ◽

Vol 37 (3) ◽

pp. 543-551.e1 ◽

Cited By ~ 92

Author(s):

Christopher J. Dy ◽

Alexia Hernandez-Soria ◽

Yan Ma ◽

Timothy R. Roberts ◽

Aaron Daluiski

Keyword(s):

Systematic Review ◽

Flexor Tendon ◽

Meta Analysis ◽

Tendon Repair ◽

Flexor Tendon Repair

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Evaluation of flexor tendon repair (zone II) with Wide Awake Anesthesia

QJM ◽

10.1093/qjmed/hcab105 ◽

2021 ◽

Vol 114 (Supplement_1) ◽

Author(s):

Ahmed Adel Zaghloul Fayed ◽

Naglaa Mohamed Abdel Aziz ◽

Ebrahim Mohamed Amin Abdel Gawad ◽

Ibrahim Hussien Kamel ◽

Ahmed Elshahat

Keyword(s):

Flexor Tendon ◽

Tendon Repair ◽

Tendon Injuries ◽

Flexor Tendon Repair ◽

Active Motion ◽

Rehabilitation Protocol ◽

Flexor Tendon Injuries ◽

Zone Ii ◽

Active Rehabilitation ◽

Wide Awake

Abstract Background Recent advances in hand surgery has been the movement away from tourniquet surgery, which often requires sedation or GA and the patient will be awake and cooperative. Wide awake approach depends on the safety of adrenaline which is now well established. This review will evaluate the role of the wide awake approach in reducing rupture and tenolysis rate after flexor tendon repair zone 2. Objective To evaluate the functional outcome of flexor tendon repair zone II (most challengeable) under wide awake anesthesia. Patients and Methods After approval of local ethical committee of faculty of medicine Ain Shams University, this Prospective study has been conducted targeting patients with acute zone II flexor tendon injuries admitted at El Sahel Teaching Hospital within the period from September 2019 till January 2020, and their follow up for minimum three months at outpatient clinic. A Written informed consent explaining the whole procedure under study in this research has been obtained from all patients and absolute confidentiality as regard the patients’ names and addresses was given special care and attention. Final outcome evaluated by Original Strickland evaluation system. Results Using the wide awake technique provides an optimal opportunity to test repair strength through Intra-operative Total Active Movement (ITAM) making the surgeon much more comfortable to initiate early active motion. Besides, rising trend toward using early active rehabilitation protocol in case of strong repair using four or more strands repairs is recently supported in literature. This study adopted early active rehabilitation protocol with slight differences among them Conclusion This preliminary study assessing the outcomes of primary tendon repair in flexor tendon injuries in zone II using the wide-awake technique demonstrates encouraging results, being satisfactory for both surgeons and patients that makes this new approach a competitive to the other approaches of flexor tendon repair implemented under conventional methods of anesthesia.

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Complications After Flexor Tendon Repair: A Systematic Review and Meta-Analysis

Yearbook of Hand and Upper Limb Surgery ◽

10.1016/j.yhls.2012.04.070 ◽

2012 ◽

Vol 2012 ◽

pp. 56-57

Author(s):

S.S. Shin

Keyword(s):

Systematic Review ◽

Flexor Tendon ◽

Meta Analysis ◽

Tendon Repair ◽

Flexor Tendon Repair

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Wide-awake Flexor Tendon Repair and Early Tendon Mobilization in Zones 1 and 2

Hand Clinics ◽

10.1016/j.hcl.2013.02.009 ◽

2013 ◽

Vol 29 (2) ◽

pp. 207-213 ◽

Cited By ~ 65

Author(s):

Donald H. Lalonde ◽

Alison L. Martin

Keyword(s):

Flexor Tendon ◽

Tendon Repair ◽

Flexor Tendon Repair ◽

Wide Awake

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A Systematic Review of 2-Strand Versus Multistrand Core Suture Techniques and Functional Outcome After Digital Flexor Tendon Repair

The Journal Of Hand Surgery ◽

10.1016/j.jhsa.2013.12.037 ◽

2014 ◽

Vol 39 (4) ◽

pp. 686-695.e2 ◽

Cited By ~ 19

Author(s):

Joseph T. Hardwicke ◽

Jessica J. Tan ◽

Mark A. Foster ◽

O. Garth Titley

Keyword(s):

Systematic Review ◽

Functional Outcome ◽

Flexor Tendon ◽

Tendon Repair ◽

Suture Techniques ◽

Flexor Tendon Repair

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Is there a correlation between patient-reported outcome assessed by the Disabilities of the Arm, Shoulder and Hand Questionnaire and total active motion after flexor tendon repair?

Hand Therapy ◽

10.1258/ht.2012.012005 ◽

2012 ◽

Vol 17 (2) ◽

pp. 37-41 ◽

Cited By ~ 1

Author(s):

Paola Errera Magnani ◽

Aline Miranda Ferreira ◽

Eula Katucha da Silva Rodrigues ◽

Rafael Inácio Barbosa ◽

Nilton Mazzer ◽

...

Keyword(s):

Flexor Tendon ◽

Tendon Repair ◽

Patient Reported Outcome ◽

Flexor Tendon Repair ◽

Active Motion ◽

Patient Reported ◽

Total Active Motion

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Flexor Tendon Repair in Zone 2 Followed by Controlled Active Mobilisation

Journal of Hand Surgery (European Volume) ◽

10.1016/0266-7681_89_90153-8 ◽

1989 ◽

Vol 14 (4) ◽

pp. 392-395

Author(s):

K. W. CULLEN ◽

PAMELA TOLHURST ◽

D. LANG ◽

R. E. PAGE

Keyword(s):

Flexor Tendon ◽

Tendon Repair ◽

Tendon Injuries ◽

Adult Patients ◽

Flexor Tendon Repair ◽

Flexor Tendon Injuries

Over a two-year-period, 34 adult patients who had suffered zone two flexor tendon injuries to 38 fingers (70 tendons) were managed post-operatively by a regime of early active mobilisation. The results of this technique, assessed by the Strickland criteria after a mean follow-up period of 10.2 months, compared favourably with other more cumbersome methods.

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