Tendon Repair and What is WALANT?

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:

1. 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.

2. 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.

3. 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.

4. 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:

1. Will I be awake during the procedure? What will I feel/see?

2. How much anesthesia will be injected, and how long does it take to become effective?

3. Will there be a tourniquet? If not, how do you achieve a blood-less field?

4. Can I move my finger during the procedure so the surgeon can test the repair?

5. What is the early rehabilitation plan? How soon will therapy start?

6. Are there specific risks unique to being awake during surgery (anxiety, intra-operative movement)?

7. How does the outcome compare (in your experience) with standard anesthesia?

8. 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?