Related Digital Media are available in the full-text ver-
sion of the article on www.PRSGlobalOpen.com.
Disclosure: Dr. Clarkson is the Chief Medical Ofcer for
a Virtual Reality Company “Wide Awake VR”. No funding
was received for this article.
From the *Michigan State University College of Human Medicine,
East Lansing, Mich.; †Department of Surgery, Michigan State
University, East Lansing, Mich.; and ‡Department of Surgery,
Division of Plastic and Reconstructive Surgery, Michigan State
University, East Lansing, Mich.
Received for publication October 20, 2021; accepted February 28,
Presented as a poster at the ASSH Annual Meeting, San Antonio,
Tex., October 1, 2020.
Copyright © 2022 The Authors. Published by Wolters Kluwer Health,
Inc. on behalf of The American Society of Plastic Surgeons. This
is an open-access article distributed under the terms of the Creative
Commons Attribution-Non Commercial-No Derivatives License 4.0
(CCBY-NC-ND), where it is permissible to download and share the
work provided it is properly cited. The work cannot be changed in
any way or used commercially without permission from the journal.
The engineering required to support sterile technique
and general anesthesia rst came together in the operat-
ing room in the early 20th century, creating the walled
garden that enabled the golden age of surgical devel-
opment to take place.1 This delivery model still dictates
the location and method of surgical and anesthesia care
while more surgeries than ever before are offered to an
aging population of increasingly frail patients. The most
routine smaller hand procedures are at the front line in
the debate over whether we might be providing overly
expensive, environmentally wasteful, and unproven lev-
els of sterile services in addition to unnecessary exposure
to anesthesia. (See gure, Supplemental Digital Content
1, which displays the main operating room triad. http://
Patient morbidity will be reduced once central ner-
vous anesthesia is truly found to be unnecessary for a
large percentage of a hand practice. For example, it is
observed that 12% of older patients undergoing a gen-
eral anesthetic develop cognitive decline in the postop-
erative period, 40% of whom do not fully recover by 6
months.2 Wide-awake, local anesthesia, no tourniquet
(WALANT) has also challenged long-held unproven
Tannur C. Oakes, MD*
Karren C. Wong, MD*
Kyle J. Schank, MD†
Pam Haan, BSN†
Stephanie M. Bray, MD, MS‡
James H. W. Clarkson, MD‡
Background: We transitioned our hand practice from the operating room (OR)
to our ofce-based procedure room (OPR) to offer wide-awake, local anesthesia,
no tourniquet (WALANT). We have established that using wide-awake virtual real-
ity improves patient comfort and anxiety during wide-awake procedures and helps
facilitate our patients’ choice of venue. We aimed to assess the effect of this transi-
tion on infection rates for procedures performed by a single surgeon in the OR
versus the OPR.
Methods: A retrospective chart review was performed on a single surgeon’s adult
patients who underwent elective and closed traumatic upper limb surgeries. A sur-
gical site infection was dened as supercial or deep, based on clinical examina-
tion conducted by the surgeon, and was treated with antibiotics within a 4-week
Results: From August 2017 to August 2019, 538 (216 OR and 322 OPR) consecu-
tive cases met inclusion criteria. There were six (2.78%) supercial infections and
zero deep space infections in the OR cohort compared with four (1.24%) super-
cial and zero deep space infections in the OPR cohort with no statistical signi-
cance. Two-thirds of cases were converted to WALANT and delivered in the ofce.
Conclusions: This narrative study concurs with the current literature that WALANT
in the ofce setting is as safe as the hospital OR-based procedures for selected elec-
tive cases. By transitioning suitable cases from the OR to the OPR, a surgeon’s over-
all infection rate should not change. (Plast Reconstr Surg Glob Open 2022;10:e4285;
doi: 10.1097/GOX.0000000000004285; Published online 13 May 2022.)
Infection Rate Comparison during Transition from
Hospital to Ofce WALANT Enabled by Virtual
PRS Global Open • 2022
medical dictums, such as the dangers of epinephrine in
the hand, which have been shown to be errors dating
back to over 90 years ago.3
WALANT has been gaining international traction
over the last decade.4 A recent survey reported that 62%
of United States hand surgeons now incorporate some
degree of WALANT in their practice.5 Two common barri-
ers to WALANT include the physician’s concern for infec-
tion under eld sterility and a patient’s concern for the
experience during awake surgery. Over the past 20 years,
several studies have supported that simplied eld sterility
alone is suitable for many hand procedures.6–10 To address
the patient experience whilst undergoing WALANT, we
have applied the developing technology of wide-awake
virtual reality.11 Procedures done in the ofce are also
signicantly less costly than those performed in the main
With the original triad in mind, we refocused our hand
surgical practice with a new triad utilizing virtual reality
(VR) to encourage patient uptake of ofce-based surgery.
(See gure, Supplemental Digital Content 2, which dis-
plays the ofce procedure room triad. http://links.lww.
During this period, we transitioned two-thirds of our
suitable cases from the main operating room (OR) to
the ofce-based procedure room (OPR). Prior studies
at our institution have already demonstrated the util-
ity of VR in reducing anxiety and pain while increasing
patient enjoyment for awake patients undergoing ofce
The objective of this study was to report our narrative
of a transition of suitable surgical cases from the main OR
to the ofce. The primary outcome measure was the com-
parative postoperative infection rates between the operat-
ing room and ofce-based procedure room.
We performed a retrospective chart review of a single
surgeon’s (senior author JHWC) elective upper limb cases
from the OR and OPR. An institutional review board
at both centers approved the review. Surgical site infec-
tions were identied via chart review by accessing both
institutions’ electronic health records. Inclusion criteria
encompassed all adults, 18 years or older, with upper limb
surgeries at either center between August 2017 to August
2019. Patients were excluded from the study if there was
failure to follow up or if the elective surgery took place
shortly after an open trauma or recent infection, to elimi-
nate the impact of contamination from the injury on this
infection rate study. We dene “full sterility” as that found
in the main OR and “eld sterility” as that which is used
in the OPR.
Based on the CDC guidelines,16 a surgical site infection
was dened as a surgical site that on clinical examination
was deemed to be infected by the senior author, within
30 days of the procedure. This was categorized as any
evidence of cellulitis, spreading erythema or presence of
purulence. Simple suture abscesses were excluded unless
there was evidence of spreading erythema. An infection
was classied as a deep infection if it were noted to be
tracking below the fascial layer.
The OR surgeries were performed following the hos-
pital’s standard sterile protocol, including upper extrem-
ity and full body drapes in an accredited operating room.
This location was able to make use of plates and screws not
available in the OPR where internal xation was restricted
to k wires. The OPR is a single room that has been set
up to perform WALANT surgeries and other minor pro-
cedures. A single medical assistant performs circulating
and rst assistant duties. Between surgeries in the OPR,
the medical assistant washes the patient’s chair, surgical
table, stools, counter, mayo stand, and VR headset. The
VR headset has a silicone elastomer face shield, which
Our OPR protocol has patients rst enter an exam
room where their vitals are taken, and the surgical site is
anesthetized with tumescent local anesthesia described
by Lalonde and Wong.17 If patients are needle phobic or
anxious, they are offered the use of VR during injection.
Patients wait for approximately 30 minutes for maximal
effect, and during that time they scrub the surgical site
with iodine or chlorhexidine themselves without main-
taining sterility. Afterward they are moved to the proce-
dure room where they remain in their street clothing.
The patient is then positioned in a sitting or supine
position and VR is offered. The limb is prepared with
alcohol chlorhexidine (Chloraprep) and draped using
sterile towels. The surgeon wears sterile gloves, gown,
cap, and mask. We use an autoclave to process towels and
Descriptive statistics were used for summarizing the
data. Pearson’s χ² and Fisher’s exact tests were conducted
on categorical variables. A logistic regression was per-
formed on variables pertaining to patient demographics.
Patient demographics included sex, age, postoperative
antibiotics, smoking status, use of immunosuppressive
drugs, use of insulin and a history of diabetes, asthma,
chronic obstructive pulmonary disease, cerebral vas-
cular accident, coronary artery disease, hypertension,
or chronic kidney disease. Patients were not matched
Question: Does a hand surgeon’s overall infection rate
change as they transition cases from the operating room
to the clinic-based procedure room, performing the sur-
geries via the WALANT technique?
Findings: There is no statistically signicant difference
between a single surgeon’s infection rates when compar-
ing all elective and closed trauma cases between the oper-
ating room and clinic-based procedure room.
Meaning: It is safe in regard to infection rates, to operate
via WALANT in a clinic-based procedure room with the
assistance of virtual reality for patient comfort.
Oakes et al. • Infection Rates: OR vs WALANT in Clinic
From August 2017 to August 2019, we identied 538
consecutive elective cases that met the inclusion crite-
ria, with 216 cases in the OR and 322 cases in the OPR
(Fig.1). Of all patients receiving surgery over that period,
two-thirds of them have converted to WALANT. The aver-
age age of the patients in the OPR cohort was greater, with
a mean of 54.8 years old, versus the mean of 46.2 years old
in the OR cohort. Along with increased age, Table1 shows
that the OPR cohort had a statistically signicant increase
in the prevalence of comorbid coronary artery disease,
diabetes, hypertension, and chronic kidney disease.
In total, there were six supercial infections and zero
deep space infections in the OR cohort compared with
four supercial and zero deep space infections in the OPR
cohort. The overall infection rate was 1.86%, and infec-
tion rates of 2.78% and 1.24% were observed in the OR
and OPR, respectively. The difference did not reach statis-
tical signicance with Fisher exact test (P = 0.211, Table2),
although it was noted that a higher rate of infection was
observed in the main OR.
Figure2 shows the breakdown of surgeries performed
over the study period. There were 597 procedures per-
formed on the 538 patients, with 81 of the patients having
multiple procedures at the same time. A subanalysis of sur-
geries involving open carpal tunnel releases (CTRs) was
done to further analyze infection rates. A total of 46 CTRs
were performed in the OR compared with 178 CTR cases
performed in the OPR. There were three incidences of
infection in the OR cases (6.7% infection rate) compared
with one identied infection in the OPR cases (0.56%
infection rate), which was noted to be statistically signi-
cant (P = 0.028). However, it should be noted that all three
of the patients in the OR underwent multiple procedures
and most OPR CTRs were done as standalone procedures.
The infection rate of 1.24% seen in our patients
undergoing WALANT hand surgery falls in the reported
observed range reported by others who operate in the
OPR.7,10 Additionally, our overall average infection rate
of 1.86% falls in the reported infection rate range of
1%–11% seen after CTR in the literature.18 When CTR
cases were analyzed, they demonstrated even lower infec-
tion rates in the ofce, with an incidence of only 0.56%.
This agrees with the multiple other studies that have
shown no increase in infection rates when compared with
the traditional OR9,19 despite the OPR population being
older with more comorbidities.
Our patients undergoing surgeries in the OPR were
poorer surgical candidates with an increased prevalence
of diabetes (24% in OPR versus 11% in OR), hyperten-
sion (44% in OPR versus 30% in OR) and chronic kidney
disease (5% in OPR versus 1% in OR). These risk factors
have been shown to increase the incidence of surgical
site infections following CTR.20 Our OPR patients were
also older, which increases the risk of anesthesia-related
This is a narrative study comparing the transition
period when cases were moving into the ofce from the
main OR; therefore, we recognize that the two groups
are not similar, which is a weakness to the study. Once the
efciencies and safety became apparent with ofce-based
WALANT, more cases and procedures were offered in the
clinic in accordance with the surgeon’s comfort level. The
more complex cases were less likely to transition to the
ofce environment, which is seen in Figure2. Reasons to
retain more complex cases in the main OR were varied,
including the need for sophisticated or expensive equip-
ment and implants in addition to the location that the
patient was encountered such as the emergency room of
the hospital with urgent need for surgery. This compari-
son demonstrates the current real world constraints of
implementing WALANT in an ofce-based setting.
Although the implication of this study might encour-
age surgeons to migrate all their hand surgery to the ofce
environment, our study does not include permanent
indwelling implants in the ofce setting. In this study,
open reduction and internal xation were performed in
the OPR using buried K wires. The main OR was the set-
ting when an open approach was need using plates and
Fig. 1. Breakdown of patients meeting inclusion criteria.
Table 1. Demographics of the Study Population
Women 103 204 307 0.0003
Men 113 118 231
Nonsmoker 170 252 422 0.297
Current smoker 46 54 100
Asthma 41 50 91 0.42
COPD 12 11 23 0.35
Previous CVA 4 10 14 0.476
CAD 2 21 23 0.005
Diabetes 24 78 102 0.001
HTN 64 145 209 0.001
CKD 2 15 17 0.046
Average age 46.2 54.8 51 <0.0001
Bolded Pvalues indicated signicance. COPD, chronic obstructive pulmonary
disease; CVA, cerebrovascular accident; CAD, coronary artery disease; HTN,
hypertension; CKD, chronic kidney disease.
PRS Global Open • 2022
screws. In the face of limited evidence for the benets of
enhanced sterility, we still advocate that where the conse-
quence of deep space infection around an implant would
be devastating, it is still common sense to make use of
main OR sterility until more data are present.
The use of VR has been well documented during
anxiety provoking or painful procedures other than hand
surgery. This includes burn dressing changes, dental pro-
cedures, and inpatient invasive procedures.23–27 We have
previously demonstrated that wide-awake virtual reality
reduces anxiety, pain, and increases fun for patients.15
The same study demonstrated the safety of VR use during
Many of our patients who were at rst hesitant to be
alert during the procedure were put at ease when offered
the ability to focus their attention elsewhere using VR.
In answer to their request “just put me out doc,” we were
able to offer to “put them somewhere else” while alert and
cooperative during the procedure. Increasing appeal with
wide-awake virtual reality allowed the practice to better
recruit patients to undergo WALANT. We are currently
looking for ways to trial this hypothesis.
The practice of medicine is replete with ritualistic behav-
iors, which serve other motives in addition to any practical
effects.28 Indeed cleansing rituals have been depicted as
an example of a “Macbeth effect,” serving both moral and
practical purposes.29 As physicians we need to be cognizant
of the possibility that behind our behaviors may lie the
bones of a more ancient cultural meme that serves to drive
these behaviors beyond their practical application. For
example, these memes may even predispose us to accept
unnecessary regulatory or industrial complexity. To enable
this insight, it is helpful to look at the original facts that lie
behind them. For hand surgery, we may examine the ori-
gins of sterile technique. William Arbuthnot Lane (1856–
1943), amongst many things, is acknowledged as Harold
Gillies’ greatest political sponsor in the First World War.
He was also the rst surgeon to introduce the plating of
orthopedic fractures. He rened and further engineered
the 19th-century work of Lister and Semmelweis with his
“no touch technique” and by introducing dry steam ster-
ilization at Guy’s Hospital in London, England, around
1904, after reading of the technology from the Berlin sur-
geon, Ernst von Bergmann. This involved no more sterile
engineering than a “pig” steam sterilizer between the oper-
ating rooms, dry sterile towel, sterile instruments, gowns,
and gloves. This is closer to our OPR “eld sterility” model
than the elaborate sterility precautions encountered in a
Table 2. Infection Breakdown in Each Operative Environment
Total Cases Supercial Infection Deep Infection Total Infections Infection Percent P
Operating Room 216 6 0 6 2.78 0.211Procedure Room 322 4 0 4 1.24
All Cases 538 10 0 10 1.86
Fig. 2. Breakdown of all procedures and the location they were performed. There were 597 total pro-
cedures in the 538 cases. Each trigger nger was counted as a separate procedure, and many nerve
releases were also performed with other procedures.
Oakes et al. • Infection Rates: OR vs WALANT in Clinic
modern 21st-century operating room, and yet it permitted
him to commence the rst plating of closed orthopedic
fractures with close to zero reported infections.1 Although
to cut down on a closed fracture was surgical heresy at that
time, 120 years of history have proven him right. These
are the original facts and yet, over the same period, sterile
protocol has become increasingly complex and regulated,
increasing the costs associated with hospital and surgery
center services despite little evidence that more sterility is
Following the current trend toward ofce-based sur-
gery, hand surgeons and health care systems who primarily
operate in the OR can feel comfortable when considering
transitioning suitable cases out of the operating room.
The evidence from this narrative study suggests that a sur-
geon should not see their overall infection rate increase
when they begin transitioning their practice to the ofce-
based procedure room for smaller cases.
The ofce-based WALANT literature is rapidly increas-
ing, demonstrating that the technique is a comparable
surgical option when compared with the traditional ways
of performing hand surgery, such as using a tourniquet,
intravenous regional anesthesia, and general anesthesia.
Have we “ritualized” sterile technique beyond its practical
effects? In Lane’s own words: “If everyone believes a thing,
it is probably untrue.”30,31
Tannur C. Oakes, MD
Michigan State University College of Human Medicine
Sparrow Professional Building, Ste. 305
1200 East Michigan Avenue
Lansing, MI 48912
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