Intraoperative Optimisation of Zone II Flexor Tendon Repairs Using WALANT and iTAMe

This technical note describes a reproducible technique for intraoperative assessment and optimisation of Zone II flexor tendon repairs using the Wide-Awake Local Anaesthesia No Tourniquet (WALANT) approach combined with intraoperative Total Active Movement examination (iTAMe). The aim is to provide surgeons with a systematic protocol to evaluate tendon glide, detect gapping and address pulley obstruction in real time, thereby improving repair integrity. The technique involves WALANT solution administration, tendon exposure via Bruner incision, four-strand core suture repair and iTAMe testing. Key steps include troubleshooting algorithms for gapping (suture reinforcement or re-repair) and triggering (pulley venting), complemented by intraoperative patient education (iPE) to enhance compliance. The principal conclusion is that integrating iTAMe into WALANT procedures enables immediate correction of repair flaws, reduces postoperative complications and empowers patients through direct engagement. This method offers a practical framework for surgeons adopting wide-awake tendon repair. Level of Evidence: Level V (Therapeutic).