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Compare and Contrast of Modified Duran vs. St. John’s/ Lelond (Early Action Motion -

WALANT procedure) for Flexor Tendon Repairs

Flexor tendon repairs are performed with varying surgical procedures that all have

different approaches for wrist positioning in the dorsal blocking splint (DBS), splint duration, the

initiation of active flexion exercises, surgical techniques, and the incorporation of synergistic

exercises. The two techniques/ protocols that will be discussed in this review are the Modified

Duran and WALANT flexor tendon repairs. Modified Duran is a 4 strand repair of the flexor

tendon(s) done under typical surgical procedures where the patient is fully sedated while in

operation. The WALANT procedure is a 4-6 strand repair performed while the patient is fully

awake and full flexion and extension is observed during the operation to ensure no signs of

bowstringing.

Postoperatively, both procedures require a DBS. However, the position of the wrist and

length of wear time vary with each one. With Modified Duran, the guidelines for the DBS are 20

degrees of wrist flexion with the MCP’s flexed and IP’s in full extension. While with WALANT,

the wrist is in up to 45 degrees of extension with the hand in a comfortable position with the

MCP’s in 30 degrees flexion and IP’s in full extension. Thus, while the MCP and IP positions are

similar with each, wrist positioning is very different and should be carefully noted by the

therapist.

Regarding the wear time of the DBS with each surgical repair, Duran requires the original

DBS to be worn until 4.5 weeks post-op at which point it is replaced with a wrist strap and

rubber band traction is applied and removed at 5.5 weeks or a DBS shortened to wrist level. By

week 6, if no progress has been made, a dynamic/static progressive splint may be implemented.
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With WALANT, the original DBS is discharged at 2-4 weeks post-op and replaced with a short

DBS to include only the MCP’s, PIP’s and DIP’s which is then discharged at 6 weeks where a

relative motion orthosis can be made for use of daytime activity if the therapist and patient deem

it helpful.

Active flexion protocol varies with each procedure. Regarding Duran, gentle active

flexion is initiated at 3 weeks post-op. Prior to active flexion initiation, immediately post-op,

only passive protected extension is to be performed. WALANT requires active flexion 3-5 days

to 2 weeks post-op where the surgeon and therapist reinforce to the patient, ”You can move it,

but you can't use it!” Passive ROM is used as a warm up before active flexion and 10 reps is to

be performed every waking hour.

In regards to synergistic movements of the wrist with finger flexion exercises, Duran

initiates active composite wrist and digital extension at 4.5 weeks to reduce any extrinsic flexor

tightness. WALANT synergistic exercises are performed at 4 weeks post-op in the shortened

DBS with wrist extension up to 45 degrees with digital active flexion followed by wrist flexion

and digital extension.

In conclusion, while both surgical protocols aim to get patients to the same place of

recovery after a flexor tendon repair, they vary drastically with their approach to do so. Wrist

positioning in the DBS, splint duration, the initiation of active flexion exercises, surgical

techniques, and the incorporation of synergistic exercises are just a few of the varying

differences. It is important for therapists to note the similarities and differences between the two

protocols and recognize the individualized recovery process of their patient in order to

successfully help them reach their full potential of healing and recovery following a flexor

tendon repair.
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References

De Herder, E. (2020). Evidence-based hand and upper extremity protocols (2nd ed.). Elizabeth

De Herder.

Masker, K., & Gift, H. (2021). Test prep for the CHT exam (4th ed.). American Society of Hand

Therapists.

Skirven, T. M., Osterman, A. L., Fedorczyk, J. M., Amadio, P. C., Feldscher, S.B., Shin, E, K.

(2021). Rehabilitation of the Hand and Upper Extremity (7th ed., Vol. 1). Elsevier.