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Optimization of Carpal Tunnel Syndrome Using WALANT Method

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Abstract

As surgical management of carpal tunnel release (CTR) becomes ever more common, extensive research has emerged to optimize the contextualization of this procedure. In particular, CTR under the wide-awake, local-anesthesia, no-tourniquet (WALANT) technique has emerged as a cost-effective, safe, and straightforward option for the millions who undergo this procedure worldwide. CTR under WALANT is associated with considerable cost savings and workflow efficiencies; it can be safely and effectively executed in an outpatient clinic under field sterility with less use of resources and production of waste, and it has consistently demonstrated standard or better post-operative pain control and satisfaction among patients. In this review of the literature, we describe the current findings on CTR using the WALANT technique.
Citation: Segal, K.R.; Debasitis, A.;
Koehler, S.M. Optimization of Carpal
Tunnel Syndrome Using WALANT
Method. J. Clin. Med. 2022,11, 3854.
https://doi.org/10.3390/jcm11133854
Academic Editor: Jorma Ryhänen
Received: 16 May 2022
Accepted: 30 June 2022
Published: 3 July 2022
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Journal of
Clinical Medicine
Review
Optimization of Carpal Tunnel Syndrome Using
WALANT Method
Kathryn R. Segal , Alexandria Debasitis and Steven M. Koehler *
Department of Orthopaedic Surgery, Albert Einstein College of Medicine, Montefiore Medical Center,
Bronx, NY 10461, USA; kathryn.segal@einsteinmed.edu (K.R.S.); alexandria.debasitis@einsteinmed.edu (A.D.)
*Correspondence: stkoehler@montefiore.org
Abstract:
As surgical management of carpal tunnel release (CTR) becomes ever more common,
extensive research has emerged to optimize the contextualization of this procedure. In particular, CTR
under the wide-awake, local-anesthesia, no-tourniquet (WALANT) technique has emerged as a cost-
effective, safe, and straightforward option for the millions who undergo this procedure worldwide.
CTR under WALANT is associated with considerable cost savings and workflow efficiencies; it can
be safely and effectively executed in an outpatient clinic under field sterility with less use of resources
and production of waste, and it has consistently demonstrated standard or better post-operative
pain control and satisfaction among patients. In this review of the literature, we describe the current
findings on CTR using the WALANT technique.
Keywords:
carpal tunnel syndrome; carpal tunnel release; wide-awake anesthesia; local anesthesia;
WALANT
1. Introduction
As the most common peripheral-nerve entrapment disorder worldwide, millions of
individuals are affected by carpal tunnel syndrome (CTS) each year [
1
4
]. CTS has a wide
variety of risk factors, including demographic (female sex), occupational (repetitive tasks
and postures), and medical (obesity, pregnancy, renal failure, hypothyroidism, congenital
heart failure, and distal radius fractures) [
5
]. Interestingly, Kasielska-Trojan et al. have even
suggested a role for pre- and post-natal sex steroids in the development of CTS, which
could explain the notably higher prevalence of CTS in the female population [6].
Meanwhile, surgical management through carpal tunnel release (CTR) has continued
to increase in popularity and prevalence [
7
,
8
]. With this trend, there has been extensive
research to contextualize the settings and conditions that optimize CTR. Wide-awake,
local-anesthesia, no-tourniquet (WALANT) surgery has emerged as a feasible, safe and
cost-effective option for a wide array of surgical procedures involving the hand, including
CTR. In a 2020 survey of American hand surgeons, nearly 80% reported having performed
WALANT surgeries during their career and over 60% were currently using WALANT in
their practices [
9
]. Since that time, its popularity and utility has continued to grow, most
notably during the recent COVID-19 pandemic where its feasibility in outpatient settings
and its better infectious-safety profile resulting from the avoidance of aerosol-generating
anesthesia were preferred [10,11].
In this review of the literature, we describe the current findings relating to the use
of WALANT for CTR, particularly as it pertains to cost and efficiency, operative set-up
and resource optimization, complications and safety, patient satisfaction and perspectives,
pain control, and return to functioning. We also discuss contraindications to the use of
WALANT.
J. Clin. Med. 2022,11, 3854. https://doi.org/10.3390/jcm11133854 https://www.mdpi.com/journal/jcm
J. Clin. Med. 2022,11, 3854 2 of 10
2. Efficiencies and Cost Savings
Efficiencies and cost savings have long been established with WALANT procedures, in-
cluding CTR. Studies that have looked at these issues have particularly focused on: savings
associated with clinic-based surgery; peri-operative metrics such as total procedural time;
direct costs between CTR under WALANT and other types of anesthesia; and its scalability
and applicability in low-resource settings. Additionally, considerable cost savings have
been achieved from optimizing the room set-up and instruments used, which we discuss
in greater detail in the next section.
2.1. Clinic-Based Procedures
It is becoming more common for CTR to be performed in outpatient clinics [
12
]. As
such, considerable cost savings have been derived from integrating CTR into this less costly
setting. Leblanc et al. originally estimated that the cost of CTR performed in an ambulatory
setting was close to one-fourth of the cost of CTR performed in an operating room [
13
].
Similarly, Kazmers et al. found that a decrease in costs of an order greater than six-fold was
associated with the performance of open CTR, under WALANT, in the clinic instead of in
the traditional operating room. White et al. demonstrated average savings of nearly USD
400 at their institution when CTR was performed in the clinic instead of in an ambulatory
surgery center (USD 151.92 versus USD 557.07, respectively) [
14
,
15
]. In addition to finding
considerable cost savings with clinic-based CTR, Chatterjee et al. calculated an opportunity
cost of USD 2700 when CTR was performed in an operating room instead of a clinic [
16
].
Moreover, Rogers et al. demonstrated through econometric modeling that office-based CTR
not only achieves cost savings for the individuals involved, but results in significant cost
reductions for the larger health care system and society as a whole [17].
2.2. Time Savings and Workflow Efficiencies
Several studies have also measured the time saved when CTR is performed under
WALANT. When compared with IV anesthesia and sedation, Okamura et al. found that
patients spent more time in the operating room, averaging an additional 13.5 min, when IV
anesthesia was used. Alter et al. and Via et al. found significant time savings for WALANT
patients, measured as the time spent in the post-anesthesia care unit (PACU) (average
savings of 77 and 22 min, respectively, for the two procedures) [
18
20
]. Patients were able
to leave the PACU more promptly following surgery under WALANT. Kamal et al. created
a clinical pathway specific to CTR under WALANT that involved particular interventions
such as: the administration of local anesthesia in a pre-operative holding room; a CTR-
specific surgical tray; and prompt attention in the PACU. Following implementation of this
pathway, the authors demonstrated a 31% reduction in total costs and 34% reduction in
total time spent by patients at the facility, with no changes in quality of outcomes or patient
experience [
21
]. Other studies have also demonstrated greater operative throughput and
workflow efficiencies with the incorporation of WALANT [15,22].
In addition, WALANT has reduced the need for historically-based pre-operative
assessments such as standard blood work, electrocardiograms, and chest radiographs. This
allows patients to undergo CTR more promptly and seamlessly [23].
2.3. Estimates of Cost Savings
Several studies have estimated the direct cost savings associated with the use of
CTR under WALANT. One single-center, single-surgeon study found that the total costs
of CTR under WALANT amounted to USD 89.12 compared with USD 1409.28 for intra-
venous (IV) anesthesia [
19
]. When introducing hand surgery procedures under WALANT,
34% of which were CTR, a military medical center reported it saved USD 393,100 over a
21-month period [24]. One study found absolute cost savings of USD 390 from anesthesia
services alone when performing CTR under WALANT, but the total costs were similar
when controlled for the location of the clinical setting [
20
]. This finding suggests that
J. Clin. Med. 2022,11, 3854 3 of 10
the majority of cost savings achieved with WALANT are derived from setting-specific
circumstances.
2.4. Scalability and Utilization in Low-Resource Settings
Barriers to surgical care and accessibility in low-resource regions have long been
studied by the academic community [
25
]. The World Health Organization’s Global Health
Estimate suggested there was an unmet need for over 40 million musculoskeletal-related
surgeries in calendar year 2010 [
26
]. In this context, use of WALANT with its considerable
cost savings and lower utilization of resources provides an opportunity for drastic improve-
ments in scalability and application in under-served regions. Though not studied for CTR
specifically, Behar et al. and Holoyda et al. have described the successful integration of
WALANT into a variety of hand procedures in clinics and in a teaching hospital in Kumasi,
Ghana [27,28].
3. Operative Set-Up and Resource Optimization
As discussed, it has become increasingly popular for CTR, particularly under WALANT,
to take place in the outpatient clinic. With this trend, it is important to consider how the
procedure room differs from the traditional operating room. First, the use of field sterility in-
stead of main-operating-room sterility has allowed for considerable cost and waste reductions,
without impacting upon the likelihood of surgical site infections (Figure 1) [
29
31
]. Instead
of needing the full standard set-up for main-operating-room sterility (which includes head
covers, neck-to-knee sterile surgeon gowns, shoe covers, laminar airflow, and full-patient-body
sterile draping), CTR can safely be performed in a clinic’s procedure room with nothing more
than a mask, sterile gloves, and single drape. Importantly, where CTR is performed in such
settings, the absence of costly, specialized ventilation systems such as laminar air filtration
or high-efficiency particulate air filters has not been linked to worse outcomes. Currently,
more than 90% of CTRs by Canadian surgeons are performed under this minimalistic sterility
set-up [32].
J. Clin. Med. 2022, 11, x FOR PEER REVIEW 3 of 10
majority of cost savings achieved with WALANT are derived from setting-specific cir-
cumstances.
2.4. Scalability and Utilization in Low-Resource Settings
Barriers to surgical care and accessibility in low-resource regions have long been
studied by the academic community [25]. The World Health Organization’s Global Health
Estimate suggested there was an unmet need for over 40 million musculoskeletal-related
surgeries in calendar year 2010 [26]. In this context, use of WALANT with its considerable
cost savings and lower utilization of resources provides an opportunity for drastic im-
provements in scalability and application in under-served regions. Though not studied
for CTR specifically, Behar et al. and Holoyda et al. have described the successful integra-
tion of WALANT into a variety of hand procedures in clinics and in a teaching hospital in
Kumasi, Ghana [27,28].
3. Operative Set-Up and Resource Optimization
As discussed, it has become increasingly popular for CTR, particularly under
WALANT, to take place in the outpatient clinic. With this trend, it is important to consider
how the procedure room differs from the traditional operating room. First, the use of field
sterility instead of main-operating-room sterility has allowed for considerable cost and
waste reductions, without impacting upon the likelihood of surgical site infections (Figure
1) [2931]. Instead of needing the full standard set-up for main-operating-room sterility
(which includes head covers, neck-to-knee sterile surgeon gowns, shoe covers, laminar
airflow, and full-patient-body sterile draping), CTR can safely be performed in a clinic’s
procedure room with nothing more than a mask, sterile gloves, and single drape. Im-
portantly, where CTR is performed in such settings, the absence of costly, specialized ven-
tilation systems such as laminar air filtration or high-efficiency particulate air filters has
not been linked to worse outcomes. Currently, more than 90% of CTRs by Canadian sur-
geons are performed under this minimalistic sterility set-up [32].
(a) (b)
Figure 1. (a) Intraoperative set-up. Main surgical attending (right) is accompanied by a resident
surgeon (left) during CTR under WALANT using field sterility. (b) Collection of all disposable ma-
terials from one CTR procedure.
Figure 1.
(
a
) Intraoperative set-up. Main surgical attending (
right
) is accompanied by a resident
surgeon (
left
) during CTR under WALANT using field sterility. (
b
) Collection of all disposable
materials from one CTR procedure.
J. Clin. Med. 2022,11, 3854 4 of 10
Moreover, with a less complex room set-up, fewer personnel and surgical instruments
are needed for successful execution of CTR. Avoricani et al. showed that hand surgeries
under WALANT can safely be undertaken with a single circulating nurse instead of the
two that are typically required by most institutions. Leblanc et al. showed that a consid-
erable proportion of Canadian surgeons performed CTR without an anesthesia specialist
present [
13
,
33
]. Kamal et al., in their clinical pathway for CTR under WALANT, describe
creating an instrument pack specific to the CTR procedure to optimize workflow and
reduce waste [
21
]. Maliha et al. found that the use of a surgery-specific instrument tray for
trigger-finger release resulted in a 70% decrease in costs when compared with the standard
instrument tray used in a traditional operating room [
34
]. This has been equally studied
with regard to its applicability to WALANT. While not studied specifically for CTR, it
is reasonable to assume that CTR-specific instrument trays also result in significant cost
reductions and workflow efficiencies. The layout and contents of CTR-specific surgical
tables and instrument trays are shown in Figure 2.
J. Clin. Med. 2022, 11, x FOR PEER REVIEW 4 of 10
Moreover, with a less complex room set-up, fewer personnel and surgical instru-
ments are needed for successful execution of CTR. Avoricani et al. showed that hand sur-
geries under WALANT can safely be undertaken with a single circulating nurse instead
of the two that are typically required by most institutions. Leblanc et al. showed that a
considerable proportion of Canadian surgeons performed CTR without an anesthesia spe-
cialist present [13,33]. Kamal et al., in their clinical pathway for CTR under WALANT,
describe creating an instrument pack specific to the CTR procedure to optimize workflow
and reduce waste [21]. Maliha et al. found that the use of a surgery-specific instrument
tray for trigger-finger release resulted in a 70% decrease in costs when compared with the
standard instrument tray used in a traditional operating room [34]. This has been equally
studied with regard to its applicability to WALANT. While not studied specifically for
CTR, it is reasonable to assume that CTR-specific instrument trays also result in significant
cost reductions and workflow efficiencies. The layout and contents of CTR-specific surgi-
cal tables and instrument trays are shown in Figure 2.
(a) (b)
Figure 2. (a) Close-up of the surgical table in a clinic-based procedure room, holding a single-use
tray of sterile instruments, sutures, wound dressing, gauze, Coban wrap, and a water basin. (b)
Close-up of sterile instruments included in the single-use instrument tray.
4. Complications and Safety
With the striking changes made to CTR by the use of WALANT, it is important to
consider ways in which this could negatively affect outcomes. While complications are
possible with any surgical procedure, some practitioners have feared that certain compli-
cations are more likely to occur as a result of the nature of WALANT procedures. These
complications can be grouped as follows: infection-related complications; bleeding-re-
lated complications; and complications stemming from the use of local anesthesia (most
commonly, a combination of lidocaine and epinephrine).
4.1. Infections
As discussed, procedures under WALANT are often performed with less extensive
sterility set-ups. Thus, it is possible that WALANT could be associated with more surgical
site infections. However, no studies to date have demonstrated higher infection rates
when WALANT has been used, regardless of operative location, type of sterility used, or
composition of personnel present for the procedure [29,30,33,35–39].
4.2. Bleeding
Another potential complication associated with WALANT is increased risk of intra-
operative bleeding from the absence of a tourniquet. The use of epinephrine helps limit
Figure 2.
(
a
) Close-up of the surgical table in a clinic-based procedure room, holding a single-use tray
of sterile instruments, sutures, wound dressing, gauze, Coban wrap, and a water basin. (
b
) Close-up
of sterile instruments included in the single-use instrument tray.
4. Complications and Safety
With the striking changes made to CTR by the use of WALANT, it is important
to consider ways in which this could negatively affect outcomes. While complications
are possible with any surgical procedure, some practitioners have feared that certain
complications are more likely to occur as a result of the nature of WALANT procedures.
These complications can be grouped as follows: infection-related complications; bleeding-
related complications; and complications stemming from the use of local anesthesia (most
commonly, a combination of lidocaine and epinephrine).
4.1. Infections
As discussed, procedures under WALANT are often performed with less extensive
sterility set-ups. Thus, it is possible that WALANT could be associated with more surgical
site infections. However, no studies to date have demonstrated higher infection rates
when WALANT has been used, regardless of operative location, type of sterility used, or
composition of personnel present for the procedure [29,30,33,3539].
4.2. Bleeding
Another potential complication associated with WALANT is increased risk of intra-
operative bleeding from the absence of a tourniquet. The use of epinephrine helps limit
J. Clin. Med. 2022,11, 3854 5 of 10
intra-operative bleeding, though some studies still show an increase in blood loss with
CTR under WALANT. It is important, however, to consider the clinical significance and
interpretation of the reported increases in such intra-operative bleeding. Sasor et al. found
that, on average, only one more milliliter (mL) of blood was lost when CTR was performed
under WALANT than when a tourniquet was used (3.28 mL vs. 4.19 mL). Farzam et al.
demonstrated that Bier block anesthesia was more likely to be categorized as “bloodless or
little blood”, whereas all WALANT surgeries were deemed “bloody field, but performable”.
Saleh et al. found higher bleeding scores among surgeries performed under WALANT, but
noted that the bleeding was always controlled by “simply dabbing the incision site” [
40
42
].
In a meta-analysis of the literature examining the use of a tourniquet, Olaiya et al. concluded
that tourniquet use provided no clinically significant benefit but instead, as we will discuss,
led to increased post-operative pain [
43
]. Additionally, Croutzet and Guinand found that
patients were able to safely continue use of anticoagulation or anti-platelet medications when
undergoing hand surgery under WALANT without being at increased risk of intra-operative
bleeding [44].
4.3. Use of Local Anesthesia
Several concerns regarding the use of local anesthesia still exist as barriers to adoption
of WALANT for CTR, despite the literature finding that these risks are exceedingly rare.
Local-anesthetic systemic toxicity (LAST) is a risk of using local anesthesia which is consid-
ered serious and potentially fatal. However, this has not been reported in the literature for
CTR under WALANT and there are several strategies that are in common use to prevent
this such as the co-administration of epinephrine [45].
The use of epinephrine in the local anesthetic used for WALANT comes with its own set
of risks. These can range from minor effects, such as symptoms of an “adrenaline rush” or
transient vasovagal symptoms, to more serious catecholamine-induced arrhythmias [
39
,
46
].
Farkash et al. monitored heart rhythms during hand procedures under WALANT and
did not find any arrhythmogenic properties associated with the local anesthesia used.
They concluded that heart monitoring is not needed during these procedures in patients
who have no history of arrhythmias [
47
]. Another potential risk of using epinephrine
during WALANT is digital ischemia. While case reports have shown instances of digital
ischemia following use of epinephrine in hand surgeries, including CTR, the literature
demonstrates the rarity of such cases in the general population [
48
50
]. Importantly, 20 mL
of 1% lidocaine with 1:100,000 epinephrine and 8.4% bicarbonate are often all that is needed
for CTR with WALANT (10 mL between the ulnar and median nerves and 10 mL in the
subcutaneous tissue under the incision). This falls below the generally accepted maximal
dose of lidocaine with epinephrine (seven mg/kg, equating to 50 mL in a 70-kg adult) [
51
].
Additionally, easy access to phentolamine allows for quick and efficacious reversal of any
epinephrine-induced ischemia [52].
5. Pain Control
Pain control in the WALANT technique has been another point of interest. Several
studies have found that WALANT is associated with lower or equal levels of pain when
compared with tourniquet-utilizing techniques, monitored anesthesia care (MAC), or
nerve-block techniques.
5.1. Intra-Operative and Post-Operative Pain Scores
In multiple studies, WALANT was found to be superior to comparison groups in
levels of both intra- and post-operative pain (as measured using a visual analogue scale),
and of analgesic need. Some studies even went as far as attributing most of the patient’s
discomfort to the use of a tourniquet [
18
,
41
,
42
,
53
,
54
]. Lech et al. focused on patients aged
80 or older and again found significantly less pain post-operatively in the WALANT group
than in patients who underwent IV regional anesthesia with a tourniquet [55].
J. Clin. Med. 2022,11, 3854 6 of 10
However, the results have not been entirely consistent across studies. While
Far-Riera et al. found that the WALANT group had significantly lower levels of post-
operative pain, with less analgesic need than comparison groups, they reported similar
intra-operative pain across the anesthesia types [
56
]. Additionally, several studies found
no differences in intra- or post-operative pain between WALANT groups, IV regional
anesthesia groups, or MAC groups [
20
,
57
,
58
]. Beyond these studies of neutral conclusion,
there emerges the possibility that WALANT provides at least an opportunity of decreasing
both intra- and post-operative pain experienced by patients, and in many cases leads to
decreased observable and reported pain.
5.2. Opioid Use
When WALANT was first introduced, there were concerns that patients would need
more analgesia post-operatively since lighter anesthesia was used during the procedure.
However, this has not been the finding in studies that have explored this topic. Aultman
et al. and Miller et al. found minimal differences in opioid use between the WALANT
and MAC cohorts [
59
,
60
]. Chapman et al. similarly saw no difference in post-operative
consumption of opioids between WALANT and general anesthesia patients, concluding
that age and gender were more predictive of opioid consumption than anesthesia type [
61
].
Kang et al. did, however, observe that there was less need for supplemental opioid
injections in the wide-awake group than in the general anesthesia group (12% versus 35%,
respectively), showing that there is a strong possibility that WALANT could be beneficial
in reducing the need for opioids [
62
]. Additionally, Dar et al. demonstrated that WALANT
patients who were not prescribed opioids following surgery experienced lower pain scores
at 14 days post-operation than patients who underwent similar procedures under MAC [
63
].
This finding suggests that the need for opioid prescriptions post-operatively might be
reduced after utilizing the WALANT technique. Further studies would be beneficial in
elucidating the possibility that WALANT might decrease opioid use. These initial findings
are promising and confirm that the WALANT technique is not associated with increased
post-operative analgesia need or use.
6. Return to Functioning
The changes to the standard post-operative course of CTR necessary for the use of
WALANT signify that it is possible that patients could have different timelines for returning
to function. Thus far, no studies have suggested that returning to function following CTR
under WALANT is any worse or takes longer. Thompson Orfeld et al. demonstrated that,
following a unilaterally modelled WALANT procedure, patients’ driving skills were not
negatively impacted. This suggests it could be safe to drive home following a procedure
under WALANT, which is not the case with other types of anesthesia [
64
]. Kang et al. and
Iqbal et al. found patients who underwent CTR with WALANT reported similar post-
operative functional outcomes as compared with comparison groups who received general
anesthesia or wide-awake anesthesia with a tourniquet [
62
,
65
]. Interestingly, Karamanis
et al. showed that functional outcomes after CTR with WALANT did not differ regardless
of the type of local anesthetic used [36].
7. Patient Satisfaction and Perspective
While patient satisfaction with CTR tends to be high, some studies have suggested
that patient satisfaction is even higher with CTR performed under WALANT. We credit
this to many of the reasons we have previously described. Both Ki Lee et al. and Far-
Riera et al. found higher levels of patient-reported satisfaction with CTR under WALANT
compared with either local anesthesia with a tourniquet or general anesthesia with a
tourniquet [
53
,
56
]. Moscato et al. showed that a greater level of satisfaction with WALANT
than with other types of anesthesia was consistent across procedural settings [
66
]. Ayhan
took patient perspective a step further and asked patients in both treatment groups to
use standard dental procedures for their comparison. Patients in the WALANT cohort
J. Clin. Med. 2022,11, 3854 7 of 10
were likely to consider CTR dental procedures easier than patients from the IV regional
anesthesia group [
57
]. A handful of studies also showed equivalent relative levels of patient
satisfaction between WALANT and comparison groups [
20
,
42
,
58
,
59
]. Importantly, however,
no studies showed decreased levels of patient satisfaction associated with CTR performed
under WALANT.
In addition, it is important to consider patients’ perspectives and possible anxieties
related to undergoing surgery with the WALANT technique. As Morris et al. showed,
WALANT offers a solution for patients who are fearful of general anesthesia and its side
effects. With regard to WALANT specifically, patients were most concerned with hearing
or seeing the procedure as it was being performed and the possibility of feeling pain intra-
operatively [
67
]. Furthermore, Lee et al. found that anxiety was higher among WALANT
patients when compared with patients who were given local anesthesia with a tourniquet,
although there was no change in overall satisfaction [
68
]. When compared with general
anesthesia, however, Davison et al. reported that the WALANT cohort had significantly
less pre-operative anxiety [23].
8. Contraindications to WALANT
While discussing the extensive literature evaluating the use of WALANT for CTR,
it is important to clarify circumstances when the WALANT technique is contraindicated.
First, it is essential that patients are comfortable with the idea of remaining awake during
surgery. As discussed, there are multiple concerns and anxieties that may interfere with
the safe execution of CTR under WALANT [67]. It is critical for surgeons to appropriately
manage expectations in patients prior to WALANT procedures, as patients with certain
comorbidities or low thresholds of anxiety may be better suited to alternative anesthesia
methods. Additionally, patients with evidence of peripheral ischemic disease or certain
vasculopathies such as scleroderma, Raynaud’s disease, Buerger’s disease, or a vasculitis
could be at increased risk of adverse events from use of local anesthesia. For this reason, it
is common for institutions not to offer WALANT to patients with any of the aforementioned
conditions [
11
]. Other conditions that would exclude a patient from WALANT include
allergies or hypersensitivities to any component of the local anesthesia that the surgeon
plans to use, most often lidocaine and epinephrine [
69
]. While alternatives to lidocaine
have been explored in fields such as dentistry, they have not yet been studied in WALANT.
For these scenarios, traditional anesthesia would thus be indicated.
9. Conclusions
As demonstrated in this review of the literature, the WALANT technique for CTR
is cost-effective, safe, and patient-centered. Furthermore, its utility and prevalence will
continue to grow as health-care systems continue to evolve and greater emphasis is placed
on value-based, accessible care.
Author Contributions:
Conceptualization, S.M.K.; methodology, K.R.S. and A.D.; writing—original
draft preparation, K.R.S. and A.D.; writing—review and editing, K.R.S. and S.M.K.; supervision,
S.M.K. All authors have read and agreed to the published version of the manuscript.
Funding: This research received no external funding.
Institutional Review Board Statement: Not applicable.
Informed Consent Statement: Not applicable.
Conflicts of Interest: The authors declare no conflict of interest.
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... Segal et al.'s [11] review describes the current practice of carpal tunnel release (CTR) using the wide-awake, local-anesthesia, no-tourniquet (WALANT) technique. This is associated with substantial cost savings and a faster workflow. ...
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This current Special Issue of JCM will highlight some of the latest studies on carpal tunnel syndrome (CTS) [...]
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Purpose: Hemostasis and local anesthetic injection are essential for minor hand surgeries under local anesthesia (LA). Wide awake local anesthesia no tourniquet (WALANT) became popular for achieving hemostasis without a tourniquet. However, a recent study reported that injection is more painful than tourniquet use in minor hand surgery. Therefore, this study aimed to compare three LA methods that differ according to injection and hemostasis, namely, the combination of a tourniquet and buffered lidocaine solution (CTB), WALANT, and conventional LA. Methods: This randomized prospective single-center study included 169 patients who underwent minor hand surgery between 2017 and 2020. We randomly allocated the patients to each group and recorded the pain and anxiety score during the surgery, as well as satisfaction after the surgery. Results: Pure lidocaine injection was significantly more painful than buffered lidocaine and WALANT solution injection ( p < 0.001). Local anesthesia injection was significantly more painful than tourniquet use in all groups ( p < 0.001). The intraoperative anxiety score was significantly lower in the CTB group than in the conventional LA and WALANT groups ( p < 0.001). The satisfaction score was significantly higher in the CTB and WALANT groups than in the conventional LA group ( p < 0.001). Conclusion: CTB for minor hand surgery under LA is associated with less injection pain and patient anxiety. The tourniquet is tolerable without much pain and waiting time. Thus, CTB in minor hand surgery is a good alternative to WALANT and conventional LA.
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Background: There are several anesthetic techniques for surgical treatment of carpal tunnel syndrome (CTS). Results from this surgery using the "wide awake local anesthesia no tourniquet" (WALANT) technique have been described. However, there is no conclusive evidence regarding the effectiveness of the WALANT technique, compared with the usual techniques. Objective: To evaluate the effectiveness of the WALANT technique, compared with intravenous regional anesthesia (IVRA; Bier's block), for surgical treatment of CTS. Design and setting: Randomized clinical trial, conducted at Hospital Alvorada Moema and the Discipline of Hand Surgery, Universidade Federal de São Paulo (UNIFESP), São Paulo (SP), Brazil. Methods: Seventy-eight patients were included. The primary outcome was measurement of perioperative pain through a visual analogue scale (VAS). The secondary outcomes were the Boston Questionnaire score, Hospital Anxiety and Depression Scale (HADS) score, need for use of analgesics, operating room times, remission of paresthesia, failures and complications. Results: The WALANT technique (n = 40) proved to be superior to IVRA (n = 38), especially for controlling intraoperative pain (0.11 versus 3.7 cm; P < 0.001) and postoperative pain (0.6 versus 3.9 cm; P < 0.001). Patients spent more time in the operating room in the IVRA group (59.5 versus 46 minutes; P < 0.01) and needed to use more analgesics (10.8 versus 5.7 dipyrone tablets; P = 0.02). Five IVRA procedures failed (5 versus 0; P = 0.06). Conclusions: The WALANT technique is more effective than IVRA for CTS surgery.
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Background: Performing open carpal tunnel release (oCTR) in an office-based procedure room setting (PR) decreases surgical costs when compared with the operating room (OR). However, it is unclear if the risk of major medical, wound, and iatrogenic complications differ between settings. Our purpose was to compare the risk of major medical complications associated with oCTR between PR and OR settings. Methods: Utilizing the MarketScan Database, we identified adults undergoing isolated oCTR between 2006 and 2015 performed in PR and OR settings. ICD-9-CM and/or CPT codes were used to identify major medical complications, surgical site complications, and iatrogenic complications within 90 days of oCTR. Multivariable logistic regression was used to compare complication risk between groups. Results: Of the 2134 PR and 76,216 OR cases, the risk of major medical complications was 0.89% (19/2134) and 1.20% (914/76,216), respectively, with no difference observed in the multivariable analysis (adjusted odds ratio [OR] 0.84; 95% CI 0.53-1.33; P=0.45). Risk of surgical site complications was 0.56% (12/2134) and 0.81% (616/76,216) for the PR and OR, respectively, with no difference in the multivariable analysis (OR 0.68; 95% C.I. 0.38-1.22; P=0.19). Iatrogenic complications were rarely observed (PR 1/2134 [0.05%], OR 71/76,216 [0.09%]), which precluded multivariable modeling. Conclusion: These results support a similar safety profile for both the PR and OR surgical settings following oCTR with similar pooled major medical complications, pooled wound/surgical site complications, and iatrogenic complications.
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Abstract Background: Wide-Awake-Local-Anaesthesia-No-Tourniquet (WALANT) technique achieves an almost bloodless field for clear visualisation during surgeries. WALANT utilizes lidocaine and epinephrine for anaesthesia and haemostasis respectively without usage of sedation and tourniquet. This avoids the potential side effects of tourniquet-related pain and sedation-related complications. However, acceptance is still low due to concerns regarding the safety of epinephrine injection in the finger. There is a persistent belief that epinephrine can cause digital ischaemia. Purpose: To evaluate retrospectively possible complications of hand surgeries performed using the WALANT technique. Methods: All finger and hand procedures were performed under the WALANT technique from June 2016 to May 2021 in an urban tertiary hospital were studied retrospectively. Results: There were a total of 1073 cases of which 694 were females and 379 were males. The mean age was 55 years old. Finger surgeries (e.g., trigger finger release, excision of finger lesions, removal of implant) consisted of 707 cases; and the rest (366 cases) were hand surgeries (e.g., carpal tunnel release, excision of hand lesions, removal of implants). In all cases reviewed, there were no instances of circulatory compromise. There were also no circumstances where usage of reversal with phentolamine is recorded. Conclusion: We believe that performing finger and hand surgeries using WALANT technique is safe and beneficial. Usage of WALANT in hand surgeries avoids tourniquet pain. However, WALANT should be used with caution in those with vascular insufficiency or disease.
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Background:. Many patients feel an “adrenaline rush” or a vasovagal reaction when injected with lidocaine and epinephrine during wide awake surgery. The incidence of these reactions is not well documented in the literature. Methods:. In total, 387 patients were prospectively injected with lidocaine and epinephrine for minor procedures without sedation between July 1, 2019 and November 1, 2020. A concentration of epinephrine with 1:100,000 in 2% lidocaine was injected, with most patients getting less than 20 mL of volume. Results:. Eight (2.2%) of the patients had adrenaline rush symptoms, which included nervousness, anxiety, tremors, shaky feelings, flushing, diaphoresis, light-headedness, tingling, and “heart racing.” Seven patients (1.8%) experienced vasovagal responses, which included nausea, a feeling of being unwell, faint, or lightheaded, or had circumoral pallor. Conclusions:. Patients run a low risk of feeling an adrenaline rush or vasovagal reaction when injected with lidocaine and epinephrine. Routinely advising patients that the adrenaline rush can happen, and that this is not an allergic reaction can be helpful to allay fear of the unknown and to prevent false allergy beliefs. Injecting patients lying down may decrease the incidence of vasovagal reactions by increasing cerebral blood flow with the advantage of gravity.
Article
Purpose Wide-Awake Local Anesthetic No Tourniquet (WALANT) hand surgery avoids many medical risks associated with traditional anesthesia options. However, patients may be hesitant to choose the WALANT approach because of concerns about being awake during surgery. The purpose of this study was to characterize patients’ thoughts and concerns about being awake during hand surgery and determine factors that may affect their decision about anesthesia options. Methods Qualitative interviews were conducted with 15 patients with a diagnosis of carpal tunnel syndrome, trigger finger, or De Quervain’s tenosynovitis who were receiving nonoperative care. Interviews were conducted using a semi-structured interview guide. Inductive thematic analysis was used to identify themes, concerns, and potential intervention targets. Results Eight participants reported that patients have a general bias against being “knocked out,” 7 of whom described concerns of uncertainty about emerging from anesthesia. All participants would consider WALANT, with some reservations. Recurrent themes included ensuring they would not feel, see, or hear the surgery and a preference toward distractions, such as music or engaging conversation. Of 15 participants, 13 would not want to see the surgery. For patients who found WALANT appealing, they valued the decreased time investment compared to sedation and the avoidance of side effects or exacerbation of comorbidities. A recurring theme of trust between surgeon and patient arose when deciding about anesthesia type. Conclusions Most patients are open to WALANT, but have concerns of hearing the surgery or feeling pain. Potential interventions to address these concerns, beyond establishing a trusting physician-patient relationship, include music or video with headphones and confirming skin numbness prior to surgery. Clinical relevance This study provides insights into patients’ thought processes regarding WALANT hand surgery and give the surgeon talking points when counseling patients on their anesthesia type for hand surgery.
Article
Hypothesis: Wide awake local anesthesia with no tourniquet (WALANT) and office-based procedures are used in hand surgery. There are limited literature data on patient satisfaction when comparing methods of anesthesia and location of surgery. Methods: We conducted a retrospective single-surgeon study with patient reported satisfaction in three groups. We compared patient impressions of anesthesia type; WALANT vs loco regional anesthesia plus sedation. We also compared satisfaction in three surgery settings; office surgery vs hospital ambulatory minor procedure room vs. main operating room. Group 1 office surgery patients had ultrasound guided surgery with WALANT. Group 2 main operating room surgery patients also had ultrasound guided surgery with WALANT. Group 3 main operating room patients had endoscopic surgery with sedation and a tourniquet. Each group had 30 patients with a minimum follow up of 2 months. We measured overall satisfaction, satisfaction with the organization of care, satisfaction with the administration of anesthesia, and satisfaction with the quality of anesthesia. We also collected secondary data on the resolution of the neuropathic symptoms. Results: Procedures performed in an office-based setting showed higher rates of patient satisfaction when compared to the ambulatory day surgery setting. WALANT anesthesia also showed significantly higher rates of patient satisfaction on a numerical analog scale when compared to sedation based on, irrespective of the surgical setting. All patients had resolution of their neuropathic symptoms regardless of the technique performed. Conclusion: We found that carpal tunnel releases performed in an office-based setting produces superior patient satisfaction. WALANT anesthesia also provides improved patient satisfaction when compared to sedation and monitoring techniques, irrespective of the surgical setting and location. Carpal tunnel release with WALANT in an office-based setting is better for patient comfort and satisfaction, with no evidence of lesser clinical outcomes at a short term follow up. Level of evidence: III
Article
This study evaluates current guidelines for patients receiving local anesthesia, set forth by the Association of Perioperative Nurses (AORN), within the context of hand surgery. The study reviewed 217 patients and 265 operations performed under wide-awake local anesthesia no tourniquet (WALANT) technique in an outpatient procedure room with minor field sterility. Only the surgeon, one resident, and one circulating nurse were present. All surgical complications were documented, including any infection at postoperative follow-ups. One female patient developed a deep surgical site infection (SSI) following repair of her flexor digitorum superficialis and flexor digitorum profundus, which resolved after irrigation/debridement. We report 0% intraprocedural complication, 0% superficial SSI, and 0.37% deep SSI (n = 1) incidence across this cohort. Most institutions require two nurses present for local anesthesia, but our low complication and infection incidence suggest a single circulating nurse present during WALANT hand surgeries may improve nurse staffing, drive greater turnover efficiency, and reduce costs. (Journal of Surgical Orthopaedic Advances 30(3):156-160, 2021).
Article
Background: It is unclear which carpal tunnel release (CTR) strategy (i.e., which combination of surgical technique and setting) is most cost-effective. A cost-effectiveness analysis was performed to compare (1) open CTR in the procedure room (OCTR/PR), (2) OCTR in the operating room (OCTR/OR), and (3) endoscopic CTR in the operating room (ECTR/OR). Methods: A decision analytic model was used to compare costs and health utilities between treatment strategies. Utility and probability parameters were identified from the literature. Medical costs were estimated with Medicare ambulatory surgical payment data. Indirect costs were related to days out of work due to surgical recovery and complications. The effectiveness outcome was quality-adjusted life years (QALYs). Probabilistic sensitivity analyses and one-way sensitivity analyses were performed. Cost-effectiveness was assessed from the societal and health-care system perspectives with use of a willingness-to-pay threshold of $100,000/QALY. Results: In the base-case analysis, OCTR/PR was more cost-effective than OCTR/OR and ECTR/OR from the societal perspective. The mean total costs and QALYs per patient were $29,738 ± $4,098 and 0.88 ± 0.08 for OCTR/PR, $30,002 ± $4,098 and 0.88 ± 0.08 for OCTR/OR, and $41,311 ± $4,833 and 0.87 ± 0.08 for ECTR/OR. OCTR/PR was also the most cost-effective strategy from the health-care system perspective. These findings were robust in the probabilistic sensitivity analyses: OCTR/PR was the dominant strategy (greater QALYs at a lower cost) in 55% and 61% of iterations from societal and health-care system perspectives, respectively. One-way sensitivity analysis demonstrated that OCTR/PR and OCTR/OR remained more cost-effective than ECTR/OR from a societal perspective under the following conditions: $0 surgical cost of ECTR, 0% revision rate following ECTR, equalization of the return-to-work rate between OCTR and ECTR, or 0 days out of work following ECTR. OCTR/OR became more cost-effective than OCTR/PR with the median nerve injury rate tripling and doubling from societal and health-care system perspectives, respectively, or if surgical direct costs in the PR exceeded those in the OR. Conclusions: Compared with OCTR/OR and ECTR/OR, OCTR/PR minimizes costs to the health-care system and society while providing favorable outcomes. Level of evidence: Economic and Decision Analysis Level III. See Instructions for Authors for a complete description of levels of evidence.
Article
Background: Currently, opioids are the standard of care for postoperative pain management. Avoiding unnecessary opioid exposure in patients is of current interest because of widespread abuse. Methods: This is a prospective cohort study in which wide-awake, local anesthesia, no-tourniquet (WALANT) technique was used for 94 hand/upper extremity surgical patients and compared to patient cohorts undergoing similar procedures under monitored anesthesia care. Patients were not prescribed opioids postoperatively but were instead directed to use over-the-counter pain relievers. Pain scores on a visual analogue scale were collected from patients preoperatively, and on postoperative days 1 and 14. WALANT visual analogue scale scores were compared to those of the two patient cohorts who either did or did not receive postoperative opioids after undergoing similar procedures under monitored anesthesia care. Electronic medical records and New York State's prescription monitoring program, Internet System for Tracking Over-Prescribing, were used to assess prescription opioid-seeking. Information on sex, age, comorbidity burden, previous opioid exposure, and insurance coverage was also collected. Results: Decreased pain was reported by WALANT patients 14 days postoperatively compared to preoperatively and 1 day postoperatively, with a total group mean pain score of 0.37. This is lower than mean scores of monitored anesthesia care patients with and without postoperative opioids. Only two WALANT patients (2.1 percent) sought opioid prescriptions from outside providers. There was little evidence suggesting factors including sex, age, comorbidity burden, previous opioid exposure, or insurance status alter these results. Conclusion: WALANT may be a beneficial technique hand surgeons may adopt to mitigate use of postoperative opioids and reduce risk of abuse in patients. Clinical question/level of evidence: Therapeutic, II.