Clin Orthop Surg.  2015 Sep;7(3):275-281. 10.4055/cios.2015.7.3.275.

Wide-Awake Primary Flexor Tendon Repair, Tenolysis, and Tendon Transfer

  • 1Department of Hand Surgery, The Hand Surgery Research Center, Affiliated Hospital of Nantong University, Nantong, China.


Tendon surgery is unique because it should ensure tendon gliding after surgery. Tendon surgery now can be performed under local anesthesia without tourniquet, by injecting epinephrine mixed with lidocaine, to achieve vasoconstriction in the area of surgery. This method allows the tendon to move actively during surgery to test tendon function intraoperatively and to ensure the tendon is properly repaired before leaving the operating table. I applied this method to primary flexor tendon repair in zone 1 or 2, tenolysis, and tendon transfer, and found this approach makes tendon surgery easier and more reliable. This article describes the method that I have used for tendon surgery.


Tendon; Surgical repair; Anesthesia; Rehabilitation

MeSH Terms

Anesthetics, Local/administration & dosage/therapeutic use
Epinephrine/administration & dosage/therapeutic use
Range of Motion, Articular
Suture Techniques
*Tendon Injuries/rehabilitation/surgery
Tendon Transfer/*methods
Vasoconstrictor Agents/administration & dosage/therapeutic use
Anesthetics, Local
Vasoconstrictor Agents


  • Fig. 1 The pre-mixed anesthetic solution used for injection and the injection needle (25 or 27 gauge).

  • Fig. 2 Wide-awake local anesthesia for a case with a complete zone 2 flexor tendon cut in the middle finger. (A) The first injection (10-15 mL) was performed in the most proximal part of the likely dissection to block the nerves distally. (B) Fifteen minutes after the first injection, the second injection (2 mL) was performed subcutaneously at the palmar digital crease between both digital nerves. (C) The third injection (2 mL) was performed immediately after the second injection under the skin at the digital crease of the proximal interphalangeal joint between both digital nerves. (D) The final injection (1 mL) was performed immediately after the third injection under the skin at the digital crease of the distal interphalangeal joint between both digital nerves.

  • Fig. 3 Thirty minutes after the local anesthesia injection, the epinephrine takes effect. The skin of the operative field has turned pale. The wound was exposed through a Bruner incision, and the distal half of the A2 pulley was incised through the volar midline. The proximal end of ruptured tendon was found in a small incision in the distal palm and advanced under the preserved A1 and the proximal part of the A2 pulleys. This flexor digitorum profundus tendon shown was repaired with a 6-strand M-Tang technique.

  • Fig. 4 Either a M-shaped 6-strand repair with 4-0 looped suture (A) or a 6-strand asymmetric Kessler repair using 4-0 suture (B) is used. A simple running peripheral suture is added later.

  • Fig. 5 Sufficient core suture purchase (> 7 mm) and slight tension over the repaired segment are two important elements in surgical repair, making the sutured tendon segment slightly tensioned by creating about 10% shortening in the sutured segment. (A, B) The length of core suture purchase and the direction of slight tension (arrows) in the two repair methods.

  • Fig. 6 After flexor digitorum profundus tendon repair, the patient actively extended and flexed the finger to perform the extension-flexion test. The photo shows active extension of the repaired digit without gapping at the repair site.

  • Fig. 7 Postoperative motion: full passive digital flexion (A) is done first, followed by partial active motion (B) in the first 3 weeks.

  • Fig. 8 Follow-up at six months after surgery. (A) Full range of active extension of the left middle finger was achieved without extension deficits of the finger joints. (B) Full range of active flexion.

Cited by  1 articles

Wide-Awake Hand surgery
Young Woo Kim
Arch Hand Microsurg. 2021;26(1):1-11.    doi: 10.12790/ahm.20.0073.


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