Abstract
BackgroundFlexor tendon injuries most commonly occur following a penetrating injury to the hand or wrist. These are challenging injuries and the standard treatment is surgical repair under general or regional anaesthesia.‘Wide-awake’ surgery is an emerging technique in hand surgery where a conscious patient is operated on under local anaesthetic. The vasoconstrictive effect of adrenaline (epinephrine) creates a ‘bloodless’ operating field and a tourniquet is not required. The potential advantages include intra-operative testing of the repair; removal of the risks of general anaesthesia; reduced costs; no aerosol generation from intubation therefore reduced risk of COVID-19 spread to healthcare professionals. The aim of this study will be to systematically evaluate the evidence to determine if wide-awake surgery is superior to general/regional anaesthetic in adults who undergo flexor tendon repair.MethodsWe designed and registered a study protocol for a systematic review and meta-analysis of comparative and non-comparative studies. The primary outcome will be functional active range of motion. Secondary outcomes will be complications, resource use (operative time) and patient-reported outcome measures. A comprehensive literature search will be conducted (from 1946 to present) in MEDLINE, EMBASE, CINAHL, and Cochrane Library. Grey literature will be identified through Open Grey, dissertation databases and clinical trials registers. All studies on wide-awake surgery for flexor tendon repair will be included. The comparator will be general or regional anaesthesia. No limitations will be imposed on peer review status or language of publication. Two investigators will independently screen all citations, full-text articles and abstract data. Potential conflicts will be resolved through discussion or referral to a third author when necessary. The study methodological quality (or bias) will be appraised using an appropriate tool. If feasible, we will conduct a random effects meta-analysis.DiscussionThis systematic review will summarise the best available evidence and definitively establish if function, complications, cost, or patient-reported outcomes are improved when flexor tendons are repaired using wide-awake technique. It will determine if this novel approach is superior to general or regional anaesthesia. This knowledge will help guide hand surgeons by continuing to improve outcomes from flexor tendon injuries.Systematic review registrationPROSPERO CRD42020182196
Highlights
This systematic review will summarise the best available evidence and definitively establish if function, complications, cost, or patient-reported outcomes are improved when flexor tendons are repaired using wide-awake technique
It will determine if this novel approach is superior to general or regional anaesthesia
Flexor tendon injuries result in the inability to bend the fingers or thumb and occur following an injury to flexor digitorum profundus (FDP), flexor digitorum superficialis (FDS) or flexor policies longus (FPL) tendons
Summary
This protocol has been registered with PROSPERO international prospective register of systematic reviews (registration number CRD42020182196) and has been reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocols (PRISMAP) 2015 statement [11]. All comparative studies which report outcomes from patients undergoing primary flexor tendon repair via WALANT and GA or regional anaesthesia will be included. If only non-comparative studies are identified in the systematic review, a crude incidence estimate of ‘good’ or ‘excellent’ ROM, and each complication (number of events/sample size) will be calculated by metaanalysis of proportion and presented along with 95% confidence intervals The results of these will be presented in forest plots. If two or more non-comparative studies are identified with a lack of clinical heterogeneity (e.g. in terms of method of tendon repair and rehab protocol) and we will perform a meta-analysis of proportions with a random-effects model [25] This approach is appropriate given it is likely that the true value varies from study to study and these follow a normal distribution. Publication bias will be assessed by inspecting a funnel plot for asymmetry and with Egger’s test [27] where appropriate, with the results considered to indicate potential small study effects when p values are < 0.10, if more than 10 studies are included
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