Tendon Repair and What is WALANT?
WALANT your Tendon
Understanding Tendon Repair — and How the “Wide-Awake” Technique (WALANT) Is Changing the Game
Introduction
As an orthopedic surgeon at Mountain Orthopedics, serving the greater Salt Lake metro and north Utah region, I'm frequently asked by patients: “How is a tendon repaired — and how does that wide-awake technique I heard about work?” This blog post aims to walk through tendon repair in accessible language, explain why it's a critical procedure, and then focus on how the technique known as Wide Awake Local Anesthesia No Tourniquet (WALANT) has become an exciting innovation in hand-surgery care.
Why Tendon Repair Matters
Tendons are the cables that transmit muscle force to bones — in the hand and wrist, these tendons allow us to grip, pinch, extend, and fine-tune our movements. When a tendon is lacerated, torn, or damaged, the result can be a serious loss of function (and significant disability) unless it is repaired appropriately.
In the hand, the stakes are high: even small deficits in range of motion (ROM), gliding of the tendon, or scarring can markedly impact daily activities and quality of life.
Key goals in tendon repair:
Restore continuity of the tendon so that muscle contraction will translate into motion.
Preserve gliding under the pulleys (in the case of flexor tendons) so that the tendon does not become tethered or “stick”.
Provide sufficient repair strength so that early motion can be allowed (to minimize adhesions) yet avoid rupture.
Optimize the healing environment — minimal bleeding, good visualization, no undue tension, and early controlled rehabilitation.
Traditional Approach vs. Modern Innovations
Traditionally, flexor (and sometimes extensor) tendon repairs have been done under regional block or general anesthesia, often with a pneumatic tourniquet to provide a bloodless field. The patient is asleep or sedated, the surgeon repairs the tendon, the patient is immobilized (sometimes in a protective splint), and then rehab begins. While this works well, limitations include: tourniquet pain (or intolerance), inability to test active motion intra-operatively, and the cost/complexity of sedation or block.
That’s where WALANT comes in.
What is WALANT?
WALANT stands for Wide Awake Local Anesthesia No Tourniquet. In practice this means:
Local anesthesia (usually lidocaine with epinephrine, sometimes buffered with bicarbonate) is injected into the surgical field. (surgicoll.scholasticahq.com)
No pneumatic tourniquet is inflated (or if used, minimally) — the epinephrine effect provides hemostasis and a relatively bloodless field. (PMC)
The patient is awake and can cooperate during the surgery (for example, making active flexion/extension of the finger).
The surgeon can immediately test the repair: does it glide? Does it gap under tension? Are the pulleys functioning well? If not, adjustments can be made on the spot. (PMC)
Why WALANT Makes a Difference in Tendon Repair
Here are the specific benefits of WALANT in the setting of tendon repair:
Intra-operative testing of repair integrity & gliding
Because the patient is awake and able to flex/extend the finger during the procedure, the surgeon can observe tendon movement, gliding under pulleys, and detect any gapping of the repair or triggering of the tendon before leaving the OR. For example, in one study:“WALANT provides … an opportunity to assess the strength of tendon repair, gapping or triggering and managing them intra-operatively.” (PMC)
That means fewer surprises post-op, and possibly lower re-rupture or tenolysis rates.Avoiding tourniquet discomfort and sedation risks
Tourniquets can cause pain, nerve compression, and discomfort. By avoiding them, patients often have improved intra- and postoperative comfort. (surgicoll.scholasticahq.com)
Also, because sedation and general anesthesia carry risks (especially in older or medically complex patients), the wide-awake technique can be more efficient and safer for many.Cost and efficiency benefits
WALANT frees the procedure from the full operating‐room suite, reduces anesthetic staff, decreases turnover time, and can streamline care. (jhsgo.org)
For patients and payers alike, that can translate to value.Enhanced patient engagement and education
The awake patient is able to see what’s happening, ask questions, and get immediate feedback. Some surgeons use this moment to prime the patient for rehabilitation, show them how movement must occur, and reinforce the importance of therapy.
What the Evidence Shows
Although WALANT is relatively newer in the tendon-repair sphere than in simpler hand cases (carpal tunnel, trigger finger), the emerging evidence is promising.
A prospective study of 30 patients undergoing primary flexor tendon repair under WALANT found that intra-operative testing allowed immediate correction of gapping or triggering, and there were no postoperative ruptures in the cohort. (PMC)
A randomized controlled trial comparing zone II flexor tendon repair under WALANT vs general anesthesia found no statistically significant difference in rupture rate or functional outcome (excellent/good results) between the groups — suggesting that WALANT can be at least non-inferior. (PubMed)
Reviews of WALANT techniques emphasize that although high-quality RCTs remain limited in tendon repair specifically, the technique is safe, reproducible, and increasingly supported in hand-surgery literature. (surgicoll.scholasticahq.com)
How I Approach Tendon Repair with WALANT at Mountain Orthopedics
Given the advantages and my commitment to patient-centered, high-value surgical care, here’s how I typically incorporate WALANT for tendon repair (especially flexor tendon lacerations) in our practice:
Patient selection
Ideal for patients who are medically stable and agreeable to being awake during surgery (we explain this in the preoperative consult).
Tendon injury amenable to primary repair (e.g., flexor or extensor tendon laceration, no massive segmental loss, no concomitant major fracture/vascular injury in many cases).
The patient must be willing to actively participate in rehabilitation (which is critical to success).
For more complex injuries (e.g., multi‐digit zone II injuries with segmental loss, or patients who prefer sedation) we may consider standard regional/general anesthesia.
Preoperative preparation
I explain to the patient what WALANT means, what they’ll feel (little/no pain) and what to expect (they will see the hand, they may move the finger intra-op).
We plan the local anesthetic injection time appropriately: lidocaine 1% with epinephrine (1:100 000) plus buffering (sodium bicarbonate) is standard — and we allow at least 25-30 minutes after injection for optimal vasoconstriction. (surgicoll.scholasticahq.com)
Check for any contraindications (allergy to anesthesia, severe vascular compromise, patient anxiety that would make awake surgery impractical).
Intraoperative technique
After adequate anesthesia, I make the exposure, debride tendon ends, repair using a robust core suture (for example a 4- or 6-strand repair) plus epitendon suture as appropriate.
While still in the OR, I ask the patient to gently flex/extend the finger to assess tendon gliding, check for any gapping, triggering or pulley-related problems. If I see any catching or gapping, I revise the repair or vent the pulley system accordingly.
I finish with skin closure, apply a dorsal slab or splint (often in the balanced wrist/MP/IPP progression consistent with our early active motion protocol) and discuss the rehabilitation plan.
Postoperative care & rehabilitation
Early active motion is usually initiated (under hand‐therapist supervision) according to the protocol we prefer (which I tailor for each patient). The ability to test the repair intra-operatively gives me more confidence to allow controlled motion earlier.
I provide the patient with clear handouts (QR‐coded, linking to our educational video) on their therapy exercises, splinting schedule, and what to avoid (e.g., forceful gripping until cleared).
Follow-up visits at week 1, week 3, week 6, and so on to monitor ROM, tendon glide, signs of adhesions or rupture.
Discussing Realistic Expectations — What WALANT Doesn’t Guarantee
It’s critical to set realistic expectations for patients. WALANT is a tool — a powerful one — but it doesn’t replace meticulous surgical technique, robust rehabilitation, or patient compliance. Some things to keep in mind:
Outcome is still influenced by the zone of the tendon injury (zone II is historically challenging), patient age, mechanism of injury, delay to repair, associated injuries (nerve, vessel), and therapy compliance.
Although intra-operative testing reduces the risk of gapping/triggering/rupture, it does not eliminate — but it may reduce — the risk of adhesions, rupture, or tenolysis.
While some studies show outcomes at least equivalent to standard anesthesia, the data are still maturing — we must avoid over-promising.
The technique requires surgeon and staff comfort with awake surgery protocols (including patient coaching, intraoperative communication, and anesthesia injection technique) and hand therapy availability.
Why This Matters for the Northern Utah Patient Population
In our region (Salt Lake and the northern Utah corridor) we have unique factors that make WALANT especially compelling:
Patients often want to return to work or active lifestyle quickly — earlier motion and potentially faster recovery align with that.
Some patients have comorbidities (diabetes, cardiovascular issues) where minimizing sedation or general anesthesia risk is beneficial.
Access to hand therapy in the outpatient setting is strong, so the rehabilitation piece is practical.
Our patient base appreciates transparency, involvement in their surgical journey, and value-based care — all of which WALANT supports.
How to Decide If WALANT Is Right for You (as a Patient)
Here are questions I invite patients to ask during our consultation:
Will I be awake during the procedure? What will I feel/see?
How much anesthesia will be injected, and how long does it take to become effective?
Will there be a tourniquet? If not, how do you achieve a blood-less field?
Can I move my finger during the procedure so the surgeon can test the repair?
What is the early rehabilitation plan? How soon will therapy start?
Are there specific risks unique to being awake during surgery (anxiety, intra-operative movement)?
How does the outcome compare (in your experience) with standard anesthesia?
Does being awake change the cost, postoperative pain, or recovery timeline?
Conclusion
Tendon repair remains a technically demanding but highly rewarding procedure — especially in the hand and wrist, where restored motion translates to meaningful improvements in quality of life. The WALANT technique — Wide Awake Local Anesthesia No Tourniquet — adds a modern layer to tendon-repair care: enabling intra-operative testing, improving patient comfort, streamlining logistics, and aligning with early motion rehabilitation strategies.
At Mountain Orthopedics, we’re committed to delivering evidence-based, patient-centered care. If you have sustained a tendon injury or are referred for repair of a hand tendon, we’d be happy to evaluate whether the wide-awake approach is appropriate in your case and walk through the details with you and your therapy team.
If you’d like, I can create a downloadable PDF patient-handout (with QR code to a short video explanation) on WALANT tendon repair — would that be helpful for your website or office hand-outs?
The Hidden Strength in Your Hands: Why Hand Health Matters (and What to Do Before It’s Too Late)
Your hands are more than tools. They are your connection to the world. They type, lift, cook, create, and comfort. Too often, we take them for granted until pain, tingling, or stiffness remind us how vital they are.
Today let’s look at:
Why hand health is often overlooked
The early warning signs you should not ignore
Smart strategies to protect and restore function
Modern treatment options that can help you recover faster
1. Why Most People Ignore Their Hands Until It’s Too Late
Most people never think of their hands as high-risk. But statistics tell another story.
Conditions such as carpal tunnel syndrome, trigger finger, wrist tendonitis, thumb arthritis, and Dupuytren’s contracture are extremely common.
Early symptoms are mild, often just tingling or stiffness, and are blamed on overuse or fatigue.
Waiting too long allows nerve compression, joint wear, or tendon damage to progress, which makes recovery slower and more difficult.
Your hands deserve attention before they become a problem.
2. Recognize the Early Warning Signs
Your body gives you clues if you are willing to listen.
Symptom What It May Indicate What to Do Immediately Tingling or numbness in the thumb, index, or middle fingers Early carpal tunnel syndrome Try a night wrist brace, reduce repetitive motions, and schedule an evaluation A finger that catches or will not straighten fully Trigger finger or tendon inflammation Rest the hand, avoid tight gripping, and perform gentle stretches Pain or stiffness at the base of the thumb Thumb arthritis Use a thumb support and modify activities Wrist pain with lifting or bending Tendonitis or overuse injury Ice, rest, and use gentle compression Gradual curling of the fingers toward the palm Early Dupuytren’s contracture Begin hand therapy and discuss options with a specialist
If symptoms last more than a few days or continue to worsen, seek medical care. Early evaluation makes a real difference.
3. Simple Habits That Protect Your Hands
You do not need surgery to maintain healthy hands. A few daily habits can make a major impact.
Prioritize ergonomics
Keep your wrists straight at your desk. Avoid constant bending or twisting. Use ergonomic keyboards and mouse supports.Take micro-breaks
Every 30 to 45 minutes, pause for half a minute. Shake out your hands, stretch your fingers, and rotate your wrists.Stretch and strengthen
Try gentle tendon glides, thumb opposition movements, grip strengthening with therapy putty, and light wrist stretches.Know your limits
Avoid gripping tools for long periods or using vibrating equipment without breaks. Listen to early signs of fatigue.Act early
Ice, compression, elevation, and rest can slow or stop early inflammation when symptoms begin.
These small steps can prevent many common hand disorders and keep you performing at your best.
4. When Non-Surgical Care Isn’t Enough
Sometimes conservative care is not enough to relieve pain or restore function. That is when advanced treatment options come in.
One of the most effective modern techniques is Ultrasound-Guided Carpal Tunnel Release (US-CTR) for carpal tunnel syndrome.
This approach uses real-time ultrasound imaging to see the anatomy clearly and protect surrounding structures.
It is done through a tiny 4 to 5 millimeter incision under local anesthesia, with no need for general anesthesia.
There are no stitches, minimal tissue disruption, and most patients return to light activity within days.
Compared with traditional open surgery, it can result in less pain, faster recovery, and fewer complications.
It is an excellent option for patients who have not improved with bracing, therapy, or injections.
Other minimally invasive procedures are available for tendon problems, trigger finger, thumb arthritis, and Dupuytren’s disease.
The key is identifying the right treatment before long-term damage develops.
5. Why Choose a Hand Specialist Who Focuses Exclusively on the Upper Extremity
In my practice:
I am double-board certified in orthopedic surgery and hand surgery.
I specialize in minimally invasive and ultrasound-assisted techniques that reduce trauma and speed recovery.
Each patient receives a customized treatment plan based on their goals, lifestyle, and diagnosis.
Education is a core value in my care. I make sure every patient understands why a procedure or therapy is recommended.
Your hands deserve the same precision and expertise you bring to everything you do.
6. Turning Pain Into an Opportunity
Pain, numbness, or stiffness are not simply inconveniences. They are your body’s way of asking for attention.
When you respond early, you can preserve function, avoid long recovery times, and return quickly to the activities that matter most.
Do not wait until daily tasks like opening a jar or typing become painful. Take the next step now to protect your grip, dexterity, and comfort.
Ready to take the next step?
If you are experiencing persistent hand symptoms or want to explore minimally invasive options such as ultrasound-guided procedures, schedule a consultation today.
Your hands deserve care that matches your lifestyle and your goals.
What Is Ultrasound-Guided Carpal Tunnel Release (US-CTR)?
It all begins with an idea.
Ultrasound-Guided Carpal Tunnel Release: A Modern Approach to Relief
Carpal Tunnel Syndrome (CTS) is the most common nerve compression disorders. It causes numbness, tingling, and weakness in the hand. For patients suffering from persistent or severe symptoms, surgery is the best long-term solution. Today, a cutting-edge technique called Ultrasound-Guided Carpal Tunnel Release (US-CTR) offers a minimally invasive alternative to traditional open surgery.
What Is US-CTR?
Ultrasound-Guided Carpal Tunnel Release is a procedure that uses real-time ultrasound imaging to guide a small surgical instrument to release the transverse carpal ligament — the structure compressing the median nerve.
Unlike traditional open surgery, which requires a larger incision and often more tissue dissection, US-CTR is performed through a very small incision (typically 4–5mm) under local anesthesia, without the need for sedation.
Key Advantages of US-CTR
✅ Minimally invasive: Small incision means less disruption to surrounding tissue.
✅ No stitches required
✅ Faster recovery: Most patients return to light activity within days.
✅ Lower pain levels: Less postoperative discomfort and reduced need for pain meds.
✅ Local anesthesia only: Avoids risks associated with general anesthesia.
Who Is a Good Candidate?
Patients with clinical and diagnostic confirmation of CTS (including nerve conduction studies) who have not responded to conservative treatments such as bracing or corticosteroid injections may be candidates. I evaluate patients individually to determine whether US-CTR is appropriate.
How Is the Procedure Performed?
The hand is numbed using local anesthetic.
Using ultrasound guidance, I identify he median nerve, the transverse carpal ligament, and other important structures.
A small incision is made at the base of the wrist.
A specially designed device (NewClip Kemis Knife) is inserted and used to safely release the ligament.
A small bandage is applied — no sutures necessary.
What Is Recovery Like?
Most patients return to daily activities within 1–3 days.
Full grip strength typically returns over a few weeks.
Postoperative pain is generally mild and manageable with over-the-counter medication.
Why Choose Dr. Chris English for US-CTR?
I am double board-certified orthopedic hand surgeon serving the Salt Lake City metro and northern Utah region. I specialize in minimally invasive techniques that offer faster recovery, less pain, and excellent long-term outcomes for patients with hand and upper extremity conditions.
Ready to find relief from carpal tunnel symptoms?
Book a consultation with Dr. English today to see if you’re a candidate for US-CTR.