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The Combination of Fractional Tendon Lengthening and the Wide Awake, Local Anesthesia, No Tourniquet Technique for Secondary Tendon Reconstruction.

ABSTRACT: Rupture is a major concern after primary flexor tendon repair. The predominant treatment for rupture of the primary repair is immediate surgical exploration and repeat repair. However, repeat repair is challenging, including achieving ideal tension in the flexor mechanism. Further, immediate repeat repair is associated with poor outcomes, particularly in the small finger. As such, there is a need to improve both the technique and outcomes of repeat repair of primary flexor tendon rupture. We present a case of primary flexor tendon repair rupture treated with a novel combination of fractional tendon lengthening and the wide awake, local anesthesia, no tourniquet technique. A combination of these techniques has multiple benefits. An intraoperative, dynamic assessment of the digits enables immediate optimization of the repair. Further, these techniques allow for better intraoperative patient education and communication, increasing the likelihood of adherence to postoperative therapy and better overall outcomes.

SUBMITTER: Chan PYW

PROVIDER: S-EPMC10039231 | biostudies-literature | 2023 Mar

REPOSITORIES: biostudies-literature

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The Combination of Fractional Tendon Lengthening and the Wide Awake, Local Anesthesia, No Tourniquet Technique for Secondary Tendon Reconstruction.

Chan Peter Y W PYW Green Anna A Fried Alta A Chao John A JA Moore Caroline C Shah Ajul A

Journal of hand surgery global online 20221028 2

Rupture is a major concern after primary flexor tendon repair. The predominant treatment for rupture of the primary repair is immediate surgical exploration and repeat repair. However, repeat repair is challenging, including achieving ideal tension in the flexor mechanism. Further, immediate repeat repair is associated with poor outcomes, particularly in the small finger. As such, there is a need to improve both the technique and outcomes of repeat repair of primary flexor tendon rupture. We pre ...[more]

PMID: 36974295

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Project description:PurposeWe investigated the clinical outcomes of flexor tendon reconstruction for chronic rupture of the flexor tendon based on an evaluation of the voluntary active contraction distance (ACD) of the ruptured musculotendinous unit and changes in intraoperative total active motion (TAM) that could only be observed during wide-awake local anesthesia no tourniquet (WALANT) surgery.MethodsReconstructions of 19 tendons of the flexor pollicis longus (FPL) and 18 tendons of the flexor digitorum profundus (FDP) were performed during WALANT surgery to evaluate the ACD of the ruptured musculotendinous unit and TAM observed during the surgery. Tendon grafting or tendon transfer was selected during the surgery based on ACD. TAM, pinch strength, and grip power were evaluated before the surgery, during the surgery, and at final follow-up, and they were surveyed based on Quick Disabilities of the Arm, Shoulder, and Hand (q-DASH) scores. The final outcomes of tendon grafting and tendon transfer were compared.ResultsIn FPL tendon reconstruction, tendon grafting was performed in 10 patients with a total PDD and ACD value greater than 30 mm, and tendon transfer was performed in 9 patients with the value less than 30 mm. In FDP tendon reconstruction, tendon grafting was performed in 8 patients and tendon repair in 2 patients with a total PDD and ACD value greater than 40 mm, and tendon transfer was performed in 8 patients with the value less than 40 mm. The TAM value, q-DASH score, pinch power, and grip strength were improved in all patients. In both the tendon reconstructions, intraoperative TAM was significantly increased compared with preoperative TAM but significantly decreased at final follow-up. No significant differences were identified in final follow-up TAM and the q-DASH scores between tendon transfer and tendon grafting.ConclusionsThe great advantage of WALANT surgery is that surgeons can evaluate the ruptured musculotendinous unit and measure TAM during the surgery.Type of study/level of evidenceTherapeutic I.

Project description:BackgroundDistal radius fractures (DRF) are frequently treated with internal fixation under general anesthesia or a brachial plexus block. Recently, the wide-awake local anesthesia with no tourniquet (WALANT) technique has been suggested as a method that results in higher patient satisfaction. This study aimed to evaluate the functional outcomes, complications, and patient-reported outcomes of DRF plating surgery under both the WALANT and balanced anesthesia (BA).MethodsNinety-three patients with DRFs who underwent open reduction and plating were included. Regarding the anesthetic technique, 38 patients received WALANT, while 55 received BA, comprised of multimodal pain control brachial plexus anesthesia with light general support. The patient's overall satisfaction in both groups and the intraoperative numerical rating scale of pain and anxiety (0-10) in the WALANT group were recorded. The peri-operative radiographic parameters were measured; the clinical outcomes, including Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) score, wrist mobility, and grip strength, were recorded in up to 1-year follow-up. Results presented with a mean difference and 95% confidence intervals and mean ± standard deviation.ResultsThe mean age of patients in the WALANT group was higher than in the BA group (63 ± 17 vs. 54 ± 17, P = 0.005), and there were fewer intra-articular DRF fractures in the WALANT group than in the BA group (AO type A/B/C: 30/3/5 vs. 26/10/19, P = 0.009). The reduction and plating quality were similar in both groups. The clinical outcomes at follow-up were comparable between the two groups, except the WALANT group had worse postoperative 3-month pronation (88% vs. 96%; - 8.0% [ - 15.7 to - 0.2%]) and 6-month pronation (92% vs. 100%; - 9.1% [ - 17.0 to - 1.2%]), and better postoperative 1-year flexion (94% vs. 82%; 12.0% [2.0-22.1%]). The overall satisfaction was comparable in the WALANT and BA groups (8.7 vs. 8.5; 0.2 [ - 0.8 to 1.2]). Patients in the WALANT group reported an injection pain scale of 1.7 ± 2.0, an intraoperative pain scale of 1.2 ± 1.9, and an intraoperative anxiety scale of 2.3 ± 2.8.ConclusionThe reduction quality, functional outcomes, and overall satisfaction were comparable between the WALANT and BA groups. With meticulous preoperative planning, the WALANT technique could be an alternative for DRF plating surgery in selected patients. Trial registration This retrospective study was approved by the Institutional Review Board of Kaohsiung Medical University Hospital (KMUHIRB-E(I)-20210201).

Dataset Information

The Combination of Fractional Tendon Lengthening and the Wide Awake, Local Anesthesia, No Tourniquet Technique for Secondary Tendon Reconstruction.

Publications

The Combination of Fractional Tendon Lengthening and the Wide Awake, Local Anesthesia, No Tourniquet Technique for Secondary Tendon Reconstruction.

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