الفهرس 
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Abstract
Flexor tendon laceration in the hand is a common injury with unique characteristics owing to the anatomy of flexor tendons contained within a flexor sheath, requiring good surgical technique as well as strict rehabilitation protocol for regaining function. Zone II is originally described as “no man’s land”, by Bunnel historically back to the 14th century (area outside London used for executions) because it was previously believed that primary repair should not be done in this zone and preferred secondary repair of it later on by excision of both flexor tendons and undertaking a tendon graft for FDP only.
Wide awake local anesthesia no tourniquet (WALANT) is an emerging technique in hand surgery and is gaining popularity with flexor tendon repair. We hypothesized that results of zone II flexor tendon repair done under WALNAT would be superior to those done under general anesthesia (GA).
A randomized controlled trial was conducted to compare results of repair of zone II flexor tendon lacerations under WALANT versus repair done under GA. Following sample size calculation, 86 digits were included and randomized into one of the 2 groups. All surgeries were done by a single fellowship trained hand surgeon utilizing the same 6 stranded core suture technique and running epitenon stitch. All patients followed the same Saint John early active rehabilitation protocol. The primary outcome was functional recovery calculated using the Strickland and Glovac criteria. Secondary outcomes included rupture of the repair, complications, and DASH score. All of outcomes were reported on the 6 months visit for all patients. Results were collected on a redcap database created specifically for the project.
Of the 86 digits, 3 were lost to follow up. Analysis was done on 43 digits for the WALANT group and 40 for the GA group that reached the 6 months endpoint. Demographic characteristics including age and sex were comparable in both groups. Rupture of the repair occurred in 2 digits in the WALANT group and in 2 in the GA group. According to Strickland and Glovac Criteria, 49% of the digits in the Walant group had an excellent or good outcome, compared to 56% in the GA group. This difference was not statistically significant with a P-value of 0.59. Average DASH score for the WALANT group was 12.9 and that for the GA group was 8.4. This difference was statistically significant with a P-value of 0.012, nonetheless, this difference may not be translated to be of clinical value. In light of these results, we failed to reject the null hypothesis.
Although WALANT technique of anesthesia has many benefits including cost saving and convenience to a selected population of patients in comparison to general anesthesia, this study suggests that WALANT may not be superior in regards function, rates of rupture and patient reported outcomes.
• We feel compelled to conclude that surgeons can be confident in choosing either technique as long as rigorous patient selection, sound surgical technique and proper hand therapy have been sought.
References:
Flexor tendon laceration in the hand is a common injury with unique characteristics owing to the anatomy of flexor tendons contained within a flexor sheath, requiring good surgical technique as well as strict rehabilitation protocol for regaining function. Zone II is originally described as “no man’s land”, by Bunnel historically back to the 14th century (area outside London used for executions) because it was previously believed that primary repair should not be done in this zone and preferred secondary repair of it later on by excision of both flexor tendons and undertaking a tendon graft for FDP only.
Wide awake local anesthesia no tourniquet (WALANT) is an emerging technique in hand surgery and is gaining popularity with flexor tendon repair. We hypothesized that results of zone II flexor tendon repair done under WALNAT would be superior to those done under general anesthesia (GA).
A randomized controlled trial was conducted to compare results of repair of zone II flexor tendon lacerations under WALANT versus repair done under GA. Following sample size calculation, 86 digits were included and randomized into one of the 2 groups. All surgeries were done by a single fellowship trained hand surgeon utilizing the same 6 stranded core suture technique and running epitenon stitch. All patients followed the same Saint John early active rehabilitation protocol. The primary outcome was functional recovery calculated using the Strickland and Glovac criteria. Secondary outcomes included rupture of the repair, complications, and DASH score. All of outcomes were reported on the 6 months visit for all patients. Results were collected on a redcap database created specifically for the project.
Of the 86 digits, 3 were lost to follow up. Analysis was done on 43 digits for the WALANT group and 40 for the GA group that reached the 6 months endpoint. Demographic characteristics including age and sex were comparable in both groups. Rupture of the repair occurred in 2 digits in the WALANT group and in 2 in the GA group. According to Strickland and Glovac Criteria, 49% of the digits in the Walant group had an excellent or good outcome, compared to 56% in the GA group. This difference was not statistically significant with a P-value of 0.59. Average DASH score for the WALANT group was 12.9 and that for the GA group was 8.4. This difference was statistically significant with a P-value of 0.012, nonetheless, this difference may not be translated to be of clinical value. In light of these results, we failed to reject the null hypothesis.
Although WALANT technique of anesthesia has many benefits including cost saving and convenience to a selected population of patients in comparison to general anesthesia, this study suggests that WALANT may not be superior in regards function, rates of rupture and patient reported outcomes.
• We feel compelled to conclude that surgeons can be confident in choosing either technique as long as rigorous patient selection, sound surgical technique and proper hand therapy have been sought.