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Wide-Awake Hand Surgery Has Its Benefits: A Study of 1,011 Patients


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Purpose Wide-awake local anesthesia with no tourniquet has dramatically changed hand surgery practice. Using lidocaine with epinephrine and no tourniquet has allowed many procedures to be moved from the main operating room to an in-office procedure room. Previous studies have shown that using local anesthesia is safe and cost effective, with high patient satisfaction. This study evaluated patient satisfaction and complications for the first 1,011 elective hand surgeries performed using wide-awake anesthesia in an in-office procedure room. Methods The first 1,011 patients who underwent elective hand surgery in an in-office procedure room were surveyed regarding their satisfaction. The patients were monitored for postoperative complications. Patient survey results and complications were logged in a database and analyzed. Results Single-digit trigger finger release was the most common procedure performed (n = 582), followed by mass excision (n = 158), multiple-digit trigger finger releases (n = 109), and carpal tunnel release (n = 41). There were 43 (4.3%) superficial skin infections, with the majority seen in single-digit trigger finger releases (n = 27). There were no deep wound infections. All infections were managed nonsurgically with oral antibiotics and local wound care. Ninety-nine percent of the patients rated the in-office procedure room experience as the same as or better than a dental visit, would recommend wide-awake anesthesia to a friend or family member, and would undergo the procedure again. Using “lean and green” hand packs saved our institution more than $65,000 and saved 18.4 tons of waste during this study period. Conclusions Surgical procedures performed with wide-awake local anesthesia with no tourniquet in an in-office procedure room can be performed safely with a low infection rate, are cost effective, and have high patient satisfaction. Clinical relevance Minor hand surgery done in an in-office procedure room is safe, is cost effective, and has high patient satisfaction.
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Original Research
Wide-Awake Hand Surgery Has Its Benets: A Study of 1,011 Patients
Kelly N. McKnight, MD,
Vanessa J.S. Smith, PA-C,
Lisa N. MacFadden, PhD,
Alex C.M. Chong, MSAE, MSME,
Robert E. Van Demark Jr., MD
Department of Graduate Medical Education, Sanford Health, Fargo, ND
School of Medicine and Health Sciences, University of North Dakota, Grand Forks, ND
Sanford Orthopedics &Sports Medicine, Sioux Falls, SD
Sanford Sports Science Institute, Sioux Falls, SD
Sanford Sports Science Institute, Fargo, ND
article info
Article history:
Received for publication November 17, 2021
Accepted in revised form May 23, 2022
Available online xxx
Key words:
Infection rate
Patient satisfaction
Purpose: Wide-awake local anesthesia with no tourniquet has dramatically changed hand surgery
practice. Using lidocaine with epinephrine and no tourniquet has allowed many procedures to be moved
from the main operating room to an in-ofce procedure room. Previous studies have shown that using
local anesthesia is safe and cost effective, with high patient satisfaction. This study evaluated patient
satisfaction and complications for the rst 1,011 elective hand surgeries performed using wide-awake
anesthesia in an in-ofce procedure room.
Methods: The rst 1,011 patients who underwent elective hand surgery in an in-ofce procedure room
were surveyed regarding their satisfaction. The patients were monitored for postoperative complications.
Patient survey results and complications were logged in a database and analyzed.
Results: Single-digit trigger nger release was the most common procedure performed (n ¼582), fol-
lowed by mass excision (n ¼158), multiple-digit trigger nger releases (n ¼109), and carpal tunnel
release (n ¼41). There were 43 (4.3%) supercial skin infections, with the majority seen in single-digit
trigger nger releases (n ¼27). There were no deep wound infections. All infections were managed
nonsurgically with oral antibiotics and local wound care. Ninety-nine percent of the patients rated the
in-ofce procedure room experience as the same as or better than a dental visit, would recommend
wide-awake anesthesia to a friend or family member, and would undergo the procedure again. Using
lean and greenhand packs saved our institution more than $65,00 0 and saved 18.4 tons of waste
during this study period.
Conclusions: Surgical procedures performed with wide-awake local anesthesia with no tourniquet in an
in-ofce procedure room can be performed safely with a low infection rate, are cost effective, and have
high patient satisfaction.
Clinical relevance: Minor hand surgery done in an in-ofce procedure room is safe, is cost effective, and
has high patient satisfaction.
Copyright ©2022, THE AUTHORS. Published by Elsevier Inc. on behalf of The American Society for Surgery of the Hand.
This is an open access article under the CC BY-NC-ND license (
Wide-awake local anesthesia with no tourniquet (WALANT)
procedures have allowed hand surgery to move out of the operating
room and into minor procedure rooms, revolutionizing the practice
of hand surgery.
This is benecial for both hospitals and patients.
It ofoads demand for operating rooms and decreases cost by
eliminating the need for anesthesia monitoring, an operating room,
and postanesthesia care.
It saves the patient time and money by
eliminating the need for a preoperative evaluation and time off
Additionally, there are cost savings associated with the
decreased need for surgical drapes, equipment, and hospital
There is also a decrease in the waste generated by
these procedures, as they are typically done under minor eld
sterility, which consists of sterile prep, a single drape, a minor in-
strument tray, sterile gloves and a mask (no gown or antibiotics),
and local anesthesia.
Declaration of interests: No benets in any form have been received or will be
received related directly or indirectly to the subject of this article.
Corresponding author: Robert E. Van Demark, Jr, MD, Sanford Orthopedics &
Sports Medicine, Sanford USD Medical Center, 1210 W. 18th Street, Suite G01, Sioux
Falls, SD 57104.
E-mail address: (R.E. Van Demark).
Contents lists available at ScienceDirect
Journal of Hand Surgery Global Online
journal homepage:
2589-5141/Copyright ©2022, THE AUTHORS. Published by Elsevier Inc. on behalf of The American Society for Surgery of the Hand. This is an open access article under the
CC BY-NC-ND license (
Journal of Hand Surgery Global Online xxx (2022) 1e5
Previous studies regarding WALANT have been conducted at
military hospitals, large academic institutions, or in foreign coun-
tries. Those studies have shown the technique is safe, with high
patient satisfaction. The purpose of this study in a United States
communityebased in-ofce procedure room was 2-fold: (1) to
evaluate patient satisfaction with surgery done in a procedure
room; and (2) to evaluate postoperative complications after pro-
cedures done in procedure rooms. To measure patient satisfaction
and infection rates, all patients who underwent a procedure in our
in-ofce procedure room from its inception in 2015 through 2020
were surveyed, and their charts were reviewed for infection. The
hypothesis of our study was that patients would be highly satised
and have an infection rate comparable to those of previous studies
done in in-ofce procedure rooms.
Materials and Methods
Sanford Health Institutional Review Board approval was not
obtained, as it was deemed unnecessary by our institution because
of the deidentied data already stored in the RedCap database.
Using Current Procedural Terminology codes (64721, 26055, 20670,
26951, 11760, 25000, 10120, 26121, 26115, 26111, 26160, and 26011)
and a premade database, a retrospective review was performed on
the rst 1,011 patients who underwent WALANT surgery in our in-
ofce procedure room. All patients, regardless of age or medical
comorbidities, who were seen in our practice and indicated for
minor hand or wrist surgery, were offered the option of having
their outpatient hand surgery performed in an in-ofce procedure
room. There were only 2 contraindications to wide-awake surgery
using lidocaine with epinephrine: a history of vasospastic disease
(Raynaud) or xed-vessel disease, such as calciphylaxis (calcic
uremic arteriolopathy).
We had no patients who t these criteria,
so none were excluded. No preoperative laboratory or medical
examinations were performed. Procedures were performed using
minor eld sterility, by 1 of 3 fellowship-trained orthopedic hand
surgeons (R.E.V., M.C.A., H.A.B.) between February 2015 and
December 2020. Preoperative sedation was not ordered for patients
having in-ofce procedures. If patients were too anxious or nervous
to have an in-ofce procedure, they could choose to have surgery at
the hospital under sedation.
Using the local injection technique described by Lalonde and
1% lidocaine with 1:100,000 epinephrine was injected in a
clinic room approximately 25 minutes prior to moving the patient
into our 23.2 square meters, in-ofce procedure room (Fig. 1). Pa-
tients remained in their street clothes, could eat before surgery, and
could continue taking their medications, including oral anticoag-
ulants. All procedures were performed under minor eld sterility
with minimal instrumentation (Fig 2). The extremities were prep-
ped and draped using 1 drape that had a hole for the hand. No
antibiotics were administered, and no cardiovascular monitoring
was done. The surgical team consisted of a hand surgeon, surgical
assistant, and nurse or medical assistant. Phentolamine was avail-
able if needed for digit ischemia.
Following surgery, patients were asked survey questions
regarding their experience, using a questionnaire (Fig 3) modied
from Rhee et al
and Davison et al.
If the questions were not asked
at the time of surgery, the patients were called after surgery. The
patients were called once and, if there was no reply, they were
encouraged to call the clinic to participate.
Charts were reviewed for survey responses, and clinic notes
from the patientsrst postoperative visit to their last follow-up
were reviewed for any complications, including erythema,
drainage, swelling, or other signs of infection after surgery. For
most patients, the follow-up was about 6 weeks long. If patients
had any of these signs or symptoms, they were counted as having
an infection, and management of the infection was recorded. These
were classied as either deep or supercial infections. Deep in-
fections included exor tenosynovitis, deep abscess, or wound
dehiscence. Supercial infections included erythema around the
incision or suture abscess. The primary outcome of our study was
looking at all infections, both supercial and deep.
Statistical methods
Demographic information, including age and gender, along with
the procedure type, number of procedures, survey responses, and
infections were found in the RedCap database and pulled for the
use of this study.
Over the study period, 1,011 patients (337 men; 674 women;
average age, 60.7 years; range, 15e93 years) underwent an in-ofce
hand procedure. Most of the procedures were single-digit trigger
nger releases (582 procedures), followed by mass removal (158
Figure 1. Our in-ofce procedure room.
Figure 2. The in-ofce procedure room back table set-up. The instruments include 2
mosquito forceps, 2 towel forceps, 1 needle holder, 1 Mayo scissor, 1 bandage scissor, 2
Adson forceps, 4 Ragnell retractors, 1 scalpel knife handle, and 1 freer. Senn retractors
are also available.
K.N. McKnight et al. / Journal of Hand Surgery Global Online xxx (2022) 1e52
procedures), multiple-digit trigger nger releases (109 procedures),
and carpal tunnel release (41 procedures; Table 1). One hundred
and eighteen patients returned during the study period for a
separate procedure.
There were no major complications in this group, as assessed
from their rst postoperative visit to their last recorded follow-up,
which for most patients was 6 weeks. There were no hospital ad-
missions noted. Supercial skin infections were the most common
complication. There were 43 supercial infections (4.3%) in our
study group, as assessed from the rst postoperative visit through
the last recorded follow-up. All infections were supercial, and
were managed with oral antibiotics and local wound care. No
secondary procedures for infections were done. There were no
deep infections. There were 27 infections in the single-digit trigger
nger group, 8 in the 2-digit trigger nger release group, and 3 in
the mass removal group (Table 1). No patients required phentol-
amine rescue.
The survey response rate was 91% (922 patients). Ninety-nine
percent of patients said the experience was better than or the
same as going to the dentist, they would recommend the procedure
to a friend or family member, and they would do surgery with
WALANT again (Table 2).
Around the time of the inception of this project, lean and
greenhand packs were created at our institution to decrease
surgical waste in minor eld sterility procedures (Fig 2).
The cost
of one of our lean and greenhand packs is $37.46, compared with
our traditional pack of $46.68. Only 1.80 kg of waste are created
from the lean and greenhand pack, compared with 4.09 kg of
waste created from our traditional pack.
Our institution saved an
estimated $64,542 and an estimated 16,692.2 kg in waste during
this project.
The overall goals of this study were to evaluate the safety of and
patient satisfaction with WALANT surgery in an in-ofce procedure
room in a community-based hospital. Sanford USD Medical Center
serves a state with a population of <1,000,000 people. We are
based in the largest city in the state and frequently have patients
who drive from hours away to be seen. We were motivated to
create an in-ofce procedure room to help these patients have
Figure 3. Patient satisfaction survey, modied from Rhee et al
and Davison et al.
Table 1
Patient Demographics, Procedure Types, and Infections for In-ofce Procedures
From 2015e2020
Procedure Overall Infections
2de Quervain 1 0
2 x Dupuytren 1 0
2mass 3 0
2trigger nger 109 8
2trigger nger, mass 1 0
3trigger nger 20 1
4trigger nger 2 0
Revision amputation 3 0
Carpal tunnel 41 0
Carpal tunnel, 2 trigger nger 1 0
Carpal tunnel, 3 trigger nger 1 0
Carpal tunnel, trigger 10 0
De Quervain 18 1
De Quervain, trigger 1 0
Dupuytren 6 0
Foreign body removal 10 0
Hardware removal 5 0
Incision &drainage 8 1
Mass 158 3
Nailbed 14 1
Nailbed, foreign body removal 1 0
Nailbed, mass 1 0
Scar revision 4 0
Tendon repair 1 0
Trigger nger 582 27
Trigger nger, Dupuytren 2 0
Trigger nger, mass 7 1
Total 1,011 43
Male 337
Female 674
Average age, y 60.7
A mass was dened as any soft tissue tumor, mucous cyst, or ganglion cyst
removal. Hardware removal was Kirschner wire removal. All carpal tunnel releases
were done open.
K.N. McKnight et al. / Journal of Hand Surgery Global Online xxx (2022) 1e53
easier access to medical care and to ofoad demand for our main
operating rooms. Patients can drive themselves home, eat break-
fast, take their medications, and minimize long travel days and time
off work. It is more cost effective for the patient on a multitude of
levels. Getting our hospital management on board was challenging
but, with persistence and by showing the data, we were able to
establish an in-ofce procedure room.
In this patient cohort, we found a low infection rate and high
patient satisfaction with WALANT. The ability to do hand surgery in
procedure rooms is related to 2 factors: (1) the use of epinephrine
in the hand; and (2) the concept of minor eld sterility. Historically,
surgeons were taught that local anesthesia with epinephrine
should not be injected into ngers for fear of necrosis. This dogma
has been disproven, as multiple studies have shown the safety of
epinephrine in the hand and ngers.
Another breakthrough in hand surgery is the concept of eld
Field sterility has allowed procedures to be done outside
of a formal operating room, with a minimal amount of equipment
needed and with similar infection rates to those of procedures
performed in operating rooms. After the advent of WALANT, there
were concerns about potential increases in infection rates in pro-
cedures done outside of the traditional operating room. This
concern is unfounded. Procedures done in minor procedure rooms
using eld sterility have been shown to have similar infection rates
as compared to those performed in operating rooms.
systematic review by Jagodzinski et al
reviewed articles dealing
with hand surgery done in a variety of locations, such as procedure
rooms and minor operative suites, instead of the main hospital
operating room. In 3 studies, there were no infections, and in 2
studies with a combined 1,962 carpal tunnel releases, the infection
rate was 0.4%.
Our ndings conrm a low infection rate in our in-ofce pro-
cedure room; overall, we had an infection rate of 4.3%. It is inter-
esting that many of our infections came from the trigger nger
groups, with the single-digit trigger nger group having an infec-
tion rate of 4.6% and the 2-digit trigger nger group having an
infection rate of 7.3%. This is perhaps due to the association of
diabetes and trigger ngers, as well as the relatively small numbers
(582 and 109 hands, respectively) in these groups. We did not
exclude patients with comorbidities or recent steroid injections
and did not collect these data, so it is difcult to say denitively
whether these variables played a role or not.
Recently, Stephens et al
evaluated the safety of WALANT
anesthesia in a procedure room. A group of 1,401 patients with
1,796 procedures were reviewed to look at the safety of a hand
surgery procedure room.No patients were excluded based on
American Society of Anesthesiologistsscores or comorbidities. No
patients were admitted to the hospital, and no procedures were
stopped owing to patient intolerance or surgeon inability to com-
plete the procedure. Minor complications included exion con-
tractures, infection, persistent symptoms, recurrence, numbness, or
stiffness. There were 7 infections (0.6%) noted, and only 2 patients
required operative debridement.
In a recent review article of eld sterility, Yu et al
advocated for
eld sterility for all skin and hand procedures. They found no evi-
dence to support the use of main operating room sterility guide-
lines (head covers, gowns, full patient draping, and laminar airow)
for minor procedures. They argued that the waste and the costs
generated by main operating rooms are not justied for minor skin
and hand procedures. When supercial infections occur, they can
be easily treated, with minimal patient morbidity.
The ability to
minimize surgical waste with minor hand procedures has also been
documented by other authors.
Patients have been pleased with WALANT surgery done in pro-
cedure rooms. High patient satisfaction rates have been reported
both in the United States and abroad.
Our study
found similar results, with 99% of patients rating their experience
as better than or the same as going to the dentist. Ninety-nine
percent of our patients would recommend wide-awake hand sur-
gery to a friend or family member and would also do surgery while
wide awake again if needed. One hundred and eighteen patients
returned for another procedure in the procedure room during the
study period. Although the survey used is not a validated outcome
measure, patient satisfaction was high, and there was an overall
positive perception of WALANT hand surgery.
Moving minor hand surgery cases from the main operating
rooms to procedure rooms results in dramatic cost savings. Pro-
cedure rooms are less expensive and more efcient.
The sav-
ings begin before the patient steps foot in the procedure room, with
no need for preoperative laboratory testing and medical evalua-
tions. In a study of preoperative carpal tunnel patients, Greeneld
et al
found a per-patient average cost of $858.74 was spent on
preoperative work-ups and nonsurgical management of patients
who underwent carpal tunnel release.
Chatterjee et al
compared the costs and prot margins for
carpal tunnel surgeries done in a clinic procedure room versus the
hospital operating room. They found the prot margin for an ofce-
based open carpal tunnel release was $1,186. In contrast, an open
carpal tunnel release done in the main operating room had a net
loss of $650 per case. When factoring in the lost opportunity cost,
the actual real loss for a main operating room open carpal tunnel
release was $3,349 per case.
Table 2
Survey Responses
Procedure Year 2015 2016 2017 2018 2019 2020 Final
Response % 92% 99% 99% 99% 89% 74% 91%
Survey responses:
Better than the dentist n 43 106 162 185 114 133 743
% 62% 90% 82% 85% 75% 80% 81%
Same as the dentist n 23 11 35 31 39 31 170
% 33% 9% 18% 14% 25% 19% 18%
Worse than the dentist n 3 1 1 2 0 2 9
Would recommend to friend/family member n 68 118 198 216 151 166 917
% 99% 100% 100% 99% 99% 100% 99%
Would not recommend to friend/family member n 1 0 0 2 2 0 5
Would do another procedure under WALANT n 68 118 198 217 152 166 919
% 99% 100% 100% 100% 99% 100% 100%
Would not do another procedure under WALANT n 1 0 0 1 1 0 3
K.N. McKnight et al. / Journal of Hand Surgery Global Online xxx (2022) 1e54
There are some limitations to our study. This study is a retro-
spective chart review, so there is a risk for self-selection bias. At our
institution, all patients seen in our practice are given the option of
having their procedure done in ofce, regardless of medical
comorbidities. The patients were free to choose the location for
their procedure, in either the in-ofce procedure room or the
hospital operating room. There was no control group, and no pa-
tient outcome measurements were collected. Potential for recall
bias exists in the 110 patients who were called for survey responses
after their surgeries, instead of being asked at the conclusion of
their surgery.
Since information about infections was gathered from patient
chart data that were imported into RedCap, it is possible that the
patient medical records do not accurately reect their infections or
that they received treatment for infections elsewhere. Any patient
who received an antibiotic for a postoperative wound problem was
counted as having an infection. All patients were treated with oral
antibiotics and local wound care.
We found that in-ofce hand procedures performed under
WALANT and minor eld sterility are safe, with high patient satis-
faction. Our study was conducted at a single, community-based
hospital in the United States. In addition, minor hand surgery
done in a procedure room has been shown to be efcient, to be cost
effective, and to decrease surgical waste.
The authors thank Dr Don Lalonde for his advice and counsel.
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Objective: Evaluate the experience of private and public health services with the WALANT procedure in the COVID-19 pandemic. Methods: This is a retrospective, multicenter longitudinal study gathering cases of hand surgery subjected to the WALANT technique in the Hospitals Dr. Radamés Nardini and IFOR during the COVID-19 pandemic (August 2020). As a parameter, the verbal numerical rating scale for twenty patients referring to the preoperative, intraoperative and postoperative periods was applied. Results: The patients did not feel any pain during surgery, which showed the efficiency of the anesthetic technique in its purpose. Conclusion: The results indicate the WALANT technique as beneficial when facing the COVID-19 pandemic, as the main differential of the technique is that it is applied by a well-trained orthopedic hand surgeon. Level of Evidence IV, Case Series.
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Epinephrine supplements in local anesthetics are regularly used for surgery in areas with terminal vessels. According to the pharmaceutical guidelines, the use of epinephrine as an additive to local anesthetics is contraindicated for these areas. This review provides an overview of the current scientific data as well as new clinical developments in various fields. It also reviews the current legal situation. A literature research was carried out to survey the current status of relevant data. Written inquiries to several German institutions (Institute for Quality and Efficiency in Health Care, National Association of Statutory Health Insurance Physicians, Center for Clinical Studies Tübingen, Federal Institute for Drugs and Medical Devices) were made to determine the legal situation. No evidence was found in the literature for a causal relationship between the use of epinephrine as a vasoconstrictor and necrosis of the finger or penis. Studies and reviews show that the use of local anesthetics with epinephrine on the fingers or penis is a safe procedure with many clinical and economic advantages. In routine clinical practice, the WALANT method (Wide Awake Local Anesthesia No Tourniquet) as well as the increasing incidence of skin tumors in acral areas has led to a tendency towards increasing use. However, its use is still legally contraindicated, and the pharmaceutical companies show no interest in supporting a drug study. Further clinical trials – regardless of the strength of the evidence – would not change the current legal contraindication.
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Purpose There is a high demand for minor hand surgeries within the veteran population. The objective of this study was to compare clinical outcomes and resource use at a Veterans Affairs Medical Center (VAMC) of hand surgeries performed in minor procedure rooms (MPR) and operating rooms using local anesthesia with or without monitored anesthesia care. Methods We retrospectively evaluated all patients undergoing carpal tunnel release, de Quervain's release, foreign body removal, soft tissue mass excision, or A1 pulley release at a VAMC over a 5-year period. Data collected included demographic information, mental health comorbidities, presence of preoperative and postoperative pain, complications after surgery, time to surgery, number of personnel in surgery, turnover time between cases, and time spent in the postanesthesia care unit. Statistical analysis included Fisher exact or chi-square analysis to compare MPR versus operating room groups and Student t test or Mann-Whitney test to compare continuous variables. Results In this cohort of 331 cases, 123 and 208 patients underwent surgery in MPRs and operating rooms, respectively. Preoperative and postoperative pain were similar between the MPR and operating room groups. Complications were slightly lower in the MPR group versus the operating room group (0% MPR vs 2.9% operating room). Median time from surgical consult to surgery was 6 days less for MPR patients (15 vs 21). The MPR cases also used fewer personnel during surgery, averaging 4.76 versus 4.99 people. The MPR patients spent 9 minutes less in the postanesthesia care unit (median, 36 vs 45 minutes) and turnover time between cases was nearly 8 minutes faster in MPRs than in operating rooms (median, 20 vs 28 minutes). Conclusions Minor procedure rooms at a VAMC allow more veteran patients to be scheduled for minor hand surgeries within a shorter time frame, utilize less staff and postoperative monitoring, and maintain excellent outcomes with limited complications. Clinical relevance Minor hand surgeries in MPRs have outcomes equivalent to those of operating rooms with improved time savings and resource use.
Full-text available
Background: Flexor 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. Methods: We 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. Discussion: 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. This knowledge will help guide hand surgeons by continuing to improve outcomes from flexor tendon injuries. Systematic review registration: PROSPERO CRD42020182196
Purpose Carpal tunnel syndrome is a common condition, with well-defined diagnostic and treatment guidelines. Despite these guidelines, continued variation in care exists, with providers variably using diagnostic tests and nonsurgical treatment modalities prior to surgery. The purpose of this study was to evaluate the variation and cost associated with the diagnosis and nonsurgical treatment of patients prior to undergoing carpal tunnel release. Methods We queried the Truven MarketScan database to identify patients who underwent carpal tunnel release from 2010 to 2017. Patients were identified using common current procedural terminology codes and included if they were enrolled in the database for a minimum of 12 months prior to surgery to allow all preoperative data to be captured. All associated current procedural terminology codes during the 1-year preoperative period were refined to codes related to median neuropathy and categorized as office visits, diagnostic imaging (x-ray, ultrasound, and magnetic resonance imaging), electrodiagnostic testing, injections, occupational or physical therapy, durable medical equipment, and preoperative laboratory tests. Results In total, 378,381 patients were included in the study. A per-patient average cost of $858.74 was spent on preoperative workup and nonsurgical treatment. Electrodiagnostic testing represented 44.6% of the cost, and office visits represented 31.9%. Regarding nonsurgical treatment, 16.1% of the patients received an injection during the 1-year preoperative period, 26.8% received a medical brace, and 6.6% used physical therapy. When analyzed based on age group, the per-patient average cost for patients aged 70 years or older was significantly less than those younger than 70 years ($723.92 vs $878.76). Conclusions Despite robust clinical practice guidelines and high volumes, significant variation in presurgical care exists. These data are useful to begin to critically analyze the causes of variation in the diagnosis and treatment of carpal tunnel syndrome and move toward a more effective, efficient, and informed treatment strategy. Type of study/level of evidence Economic/decision analysis II.
Purpose Performing hand surgeries in the procedure room (PR) setting instead of the operating room effectively reduces surgical costs. Understanding the safety or complication rates associated with the PR is important in determining the value of its use. Our purpose was to describe the incidence of medical and surgical complications among patients undergoing minor hand surgeries in the PR. Methods We retrospectively reviewed all adult patients who underwent an operation in the PR setting between December 2013 and May 2019 at a single tertiary academic medical center by 1 of 5 fellowship-trained orthopedic hand surgeons. Baseline patient characteristics were described. Complication rates were obtained via chart review. Results For 1,404 PR surgical encounters, 1,796 procedures were performed. Mean patient age was 59 ± 15 years, 809 were female (57.6%), and average follow-up was 104 days. The most common surgeries were carpal tunnel release (39.9%), trigger finger release (35.9%), and finger mass or cyst excision (9.6%). Most surgeries were performed using a nonpneumatic wrist tourniquet (58%), whereas 42% used no tourniquet. No patient experienced a major medical complication. No procedure was aborted owing to intolerance. No patient required admission. No intraoperative surgical or medical complications occurred. Observed complications included delayed capillary refill requiring phentolamine administration after a trigger thumb release performed using epinephrine without a tourniquet (n = 1; 0.1%), complex regional pain syndrome (n = 3; 0.2%), infection requiring surgical debridement (n = 2; 0.2%), and recurrent symptoms requiring reoperation (n = 8; 0.7%). Conclusions In this cohort of patients in whom surgery was performed in a PR, there were no major intraoperative surgical or medical complications. There was a low rate of postoperative infection, development of complex regional pain syndrome, and a low need for revision surgery. These observations do not support the concern for safety as a barrier to performing minor hand surgery in the PR setting. Type of study/level of evidence Therapeutic IV.
PURPOSE : Recently, local anaesthesia has become popular among hand surgeons. We hypothesized that using the ‘’wide awake local anaesthesia, no tourniquet’’ (WALANT) approach would result in lower global costs and in an increase of the operating room's efficiency. METHODS : All cases of carpal tunnel and trigger finger releases performed over 2016 and 2017 were divided into four groups, following which anaesthesia method was used. Total operating room occupation time, surgical time and the ‘’all but surgery’’ time were analysed. A common minimal bill per anaesthesia was generated. RESULTS : WALANT or local anaesthesia & tourniquet increase the operating room's throughput by having shorter operation room occupation times than other methods (17.5-33%). Costs of the two procedures are reduced by 21-31% when using local anaesthesia methods. CONCLUSION : Preferring those techniques for carpal tunnel and trigger finger releases has a notable beneficial impact on the costs and on the operating room's efficiency. This effect is more evident on short surgical procedures. LOE : Level of evidence III, economic analysis.
Background: The wide-awake local anesthesia no tourniquet (WALANT) technique in hand surgery is gaining popularity. The authors aimed to prospectively analyze the frequency and type of arrhythmias in patients undergoing hand surgery under local anesthesia and to examine whether the addition of adrenaline affects their incidence. Methods: Adult patients undergoing hand surgery under local anesthesia were randomized into two groups: group 1, local anesthesia with lidocaine and tourniquet; and group 2, local anesthesia with lidocaine and adrenaline (WALANT). Patients with a history of arrhythmias were excluded. Patients were connected to Holter electrocardiographic monitoring before surgery and up until discharge. The records were blindly compared between the groups regarding types of arrhythmias, and frequency and timing relative to injection and tourniquet inflation. Results: One hundred two patients were included between August of 2018 and August of 2019 (age, 59.7 ± 13.6 years; 71 percent women; 51 in each group). No major arrhythmia (ventricular tachycardia, ventricular fibrillation, atrial fibrillation) or arrhythmia-related symptoms were recorded for either group. Minor arrhythmias (including atrial premature beats, ventricular premature beats, and atrial tachycardia) were recorded in 68 patients (66.6 percent), with no statistical difference between the groups. There were three patients with minor arrhythmias during inflation of the tourniquet. Patients in the adrenaline group had 2 percent sinus tachycardia during injection and 4 percent asymptomatic bradyarrhythmias. These findings do not require any further treatment. Conclusions: The authors' results show that hand operations using WALANT technique in patients with no history of arrhythmia are safe and are not arrhythmogenic; therefore, there is no need for routine perioperative continuous electrocardiographic monitoring. Clinical question/level of evidence: Therapeutic, II.
Purpose: The purpose of our study was to investigate carpal tunnel release (CTR) performed in the clinic versus the ambulatory surgery center (ASC) to evaluate for potential cost savings. Methods: Patients who underwent either CTR in clinic under a local anesthetic or CTR in the ASC with sedation and local anesthetic were prospectively enrolled in a registry between 2014 and 2016. All patients completed a Visual Analog Scale (VAS) pain scale for procedural and postprocedure pain. Time-Driven Activity-Based Costing (TDABC) was utilized to quantify cost of both CTR in clinic and CTR in the ASC. Statistical analysis involved parametric comparative tests between patient cohorts for both the TDABC-cost and patient pain. Results: A total of 59 participants completed the postprocedure CTR survey during the study period, 23 (38.9%) in the ASC group and 36 (61.1%) in the clinic group. Overall time for the procedure from patient arrival to discharge was significantly longer for the ASC cases, averaging 215.7 minutes (range: 201-230) compared to 78.6 minutes (range: 59-98) in the clinic group ( P < .01). Both procedural and postoperative VAS pain scores were comparable between clinic and ASC cohorts, procedural pain: 1.8 vs 1.9 ( P = .91) and postoperative pain: 4.8 vs 4.9 ( P = .88). TDABC analysis estimated ASC CTR procedures to cost an average of $557.07 ($522.06-$592.08) and clinic procedures to cost an average of $151.92 ($142.59-$161.25) ( P < .05). Conclusions: CTR in the clinic setting results in significant cost savings compared to CTR in the ASC with no difference in pain scores during the procedure or postoperative period. Level of Evidence: Therapeutic Level II.