Abstract
-
Wide-awake local anesthesia no tourniquet is named the WALANT technique.
-
WALANT has had a major positive impact on cost, convenience, ecology, patient satisfaction, access to surgical care, and outcomes in hand surgery in the last 20 years.
-
Safe and efficient application of the technique is based on two principles.
-
The first principle is the tumescent injection of a large volume low concentration 0.25–1% lidocaine, with 1:100 000–1:400 000 epinephrine.
-
The second principle of WALANT is that the proper injection should be almost painless, with the patient only feeling the first needle poke of a tiny 30G needle.
-
This wide awake patient approach reduces pain, neuropraxia, and systemic side effects of sedation with preservation of motor control, thereby aiding balanced reconstruction in hand surgery.
Introduction
Hand surgery is usually performed under three main types of anesthesia techniques: local, regional, or general anesthesia. Each technique has advantages and disadvantages (Table 1). These factors need to be outweighed by surgeons and patients to select the most ideal combination of anesthesia for specific surgical procedures in the shared decision-making model for health care that we aim for today (1, 2, 3). This paper will focus on tumescent pure local anesthesia, with only lidocaine and epinephrine, with no tourniquet and no sedation. The acronym for this technique is WALANT (wide-awake local anesthesia no tourniquet).
On current literature and experience-based estimated comparative overview of the advantages and disadvantages of the different anesthesiology types versus the WALANT technique in hand surgery in a 5-point graded scale ranging from – (absent), +− (sometimes or partially), + (present), ++ (present in a more explicit way) to +++ (present in the most prominent way).
| (Dis)advantages | Anesthesia | ||||||
|---|---|---|---|---|---|---|---|
| General | Regional | Local | |||||
| IVR | Plexus | WB | DB | LA | WALANT | ||
| Systemic effects | + | + | − | − | − | − | − |
| Time | ++ | ++ | + | + | + | + | + |
| Cost | +++ | ++ | ++ | + | + | + | + |
| Green footprint | ++ | ++ | ++ | + | + | + | + |
| Analgesia | − | + | ++ | + | + | + | ++ |
| Satisfaction | + | + | ++ | + | ++ | ++ | +++ |
| Tourniquet | + | ++ | + | + | + | + | − |
| Bleeding risk | + | + | + | + | + | + | − |
| Dynamic surgery | − | − | − | +− | + | + | + |
DB, digit block; WB, wrist block.
WALANT local anesthesia is based on two main principles. The first principle is the tumescent injection of a large volume low-concentration lidocaine, ranging from 0.25% to 1%,combined with 1:100 000 to 1:400 000 epinephrine. Tumescent refers to an adequate subcutaneous volume of local anesthesia that you can see it and feel elevating the skin, resembling a subcutaneous wave extending at least 2 cm beyond any area that will be dissected or surgically manipulated. The second principle of WALANT is that the proper injection of this tumescent local anesthesia should be nearly painless, with the patient experiencing only the initial needle prick of a small 30G (0.31 mm) needle (4).
WALANT is not a bloodless surgery, but the visibility is excellent when a window of 30 min is provided for epinephrine vasoconstriction to work well (5). Injecting the first three patients before operating on the first one is extremely efficient, allowing for performing three carpal tunnel operations per hour at a very comfortable pace with just one surgeon, one nurse, and one receptionist with field sterility conditions in a minor procedure room with no increase in the risk of surgical site infections (6, 7, 8).
Epinephrine eliminated the need for the tourniquet, which was a standard of care for decades in hand surgery (9). Tourniqueting is a painful technique that caused temporary neuropraxia within minutes due to tourniquet pressure and ischemia (10). As a result, surgery time was limited and required sedation. In addition, the surgeon could not adjust the reconstructed parts of the hand during the surgery because of the pain, neuropraxia, or motor blocks experienced by patients (11).
The latter half of the 20th century was dominated by the myth that epinephrine caused finger ischemia. Bunnell’s first American textbook on hand surgery in 1946 (12) initiated this trend. We now know that before 1950 procaine, rather than epinephrine, was the primary culprit for causing finger ischemia (13). Studies in the 21st century have produced ample evidence that epinephrine is safe to use in the finger (14, 15, 16). In addition, phentolamine reliably reverses epinephrine vasoconstriction in the finger, but this is seldom required (17, 18).
Advantages
The advantages of WALANT can be summarized in three main categories included in the abbreviation:
-
Wide awake: the patient has no sedation or general anesthesia. Local anesthesia is preferred for its elimination of systemic risks of sedation: nausea, vomiting, aspiration pneumonia, respiratory suppression, thromboembolism, cardiovascular effects, malignant hyperthermia, cerebral influences, etc. Pure local anesthesia also has economic benefits, time efficiency, and organizational surgical independence (19, 20, 21, 22). In ASA 3 or 4 patients with important comorbidities, WALANT makes hand surgery safe and possible when systemic sedation is considered too risky (23). Being awake and alert, the patient can gain insight into his condition and therapy, which will help in postoperative rehabilitation (24).
-
Local anesthesia: the numbness is administered only in the operative field. The upper limb remains under motor control by the wide awake patient. He can help by moving reconstructed parts actively during the surgery, when certain procedures need balanced fixation or tension of joints and tendons, such as in flexor tendon repair, boutonniere fingers, or in tendon transfers (25, 26, 27, 28). Pain control persists after surgery, diminishing the need for opioids when compared to general or regional anesthesia (29, 30, 31, 32). Local anesthesia is cheaper, greener, faster, and easier to perform, increasing economic efficiency in hospitals due to quick recovery and short stay (33, 34, 35, 36, 37). Improved access to surgical care has been well documented (38). Additionally, the patient does not need to be sober, so the technique can be used in urgent, isolated conditions or unplanned settings (39, 40). Epinephrine minimizes bleeding and facilitates operating on patients without stopping anticoagulant medications (41).
-
No tourniquet: This approach reduces pain and neuropraxia. It allows for longer surgery time if needed, increased comfort of the patient, and the opportunity for the patient to actively collaborate with the surgical procedure. Patients with lymphedema or arteriovenous shunt, in whom tourniquets need to be avoided, now have a safe alternative to allow for hand surgery. There is less rush to race through an operation. This can decrease mistakes that are haste induced and facilitates surgical resident learning with less time pressure (42).
Contraindications
Overall, the complication rate of WALANT is very low (1.7%), with minor superficial infection being the most common problem (32, 43). Absolute contraindications to WALANT pure local anesthesia are very few, as they are in dentistry (44). If true allergic anaphylaxis to lidocaine and epinephrine actually exists, it is extremely rare. If patients have very limited blood flow to the fingers in situations such as Buerger’s disease, scleroderma, severe Raynaud’s, or renal failure, finger injection of epinephrine is not advised or required (34, 44). In these situations, lidocaine can be used without epinephrine. The surgeon must be able to communicate with a patient who can understand, be open to this option, and be cooperative. Shared decision-making of surgeons and patients remains the basis of successful treatment (45). Infection surgery is no longer considered a relative contraindication (46, 47, 48).
Technique
Injection of tumescent local anesthetic should be almost painless in 2024, even when injecting large areas. The reader should read papers with videos that demonstrate important techniques to minimize the pain of injection of tumescent local anesthetic (49). (1) Buffer painful acidic local with bicarbonate. (2) Start with a 30G needle. (3) Do not blast local in quickly! Slow down! (4) Stabilize the syringe with both hands to avoid wobble pain. (5) Insert the needle perpendicular to the skin. (5) Use sensory noise such as pinching the skin into the needle. (6) Inject at least 2 mL slowly in the fat just below the dermis without moving the needle. (7) Never advance sharp needle tips anywhere that is not numb. (8) Only reinsert needles in numb skin. (9) Always inject too much volume instead of not enough volume. (10) Ask the patient to count the number of times he feels pain every time you inject so you can score yourself as an injector. (11) Always inject from proximal to distal. Most naturally, a calm, comforting conversation and touching reassuring hand pressure on the forearm during infiltration are examples of distraction and psychological support to enhance patients’ experience (4).
The operative field is marked with a 1–2 cm zone beyond the intended area of dissection (Fig. 1). Beginning with a small 27G or 30G (0.3–0.4 mm) needle, tumescent local anesthesia is performed by injecting 1% lidocaine with 1:100 000 epinephrine buffered with 10:1 8.4% sodium bicarbonate. It is usually recommended to follow the 7 mg per kg dose of lidocaine and epinephrine (50 mL in adults), even though higher doses have been shown to be safe so that no monitoring is required, such as at the dentist (49, 50). If more volume is required, simply add saline. About 0.25% lidocaine with 1:400 000 gives you a comfortable 3 h to perform most operations without the need to add longer-lasting local anesthetics (48). By using enough injection volume, the soft tissue swelling will elevate the overlying skin 2 cm beyond the marked area, which you can see and palpate while injecting.
A ten-step illustration to perform the WALANT technique in hand surgery.
(1) Stop before you block.
(2) Prepare the syringe (long 30G needle, lidocaine 1% bicarbonate buffered room temperature).
(3) Mark the needle entry point proximal to the operation field (B).
(4) Introduce the needle 90° in the skin by pinch injection and inject a 0.5 mL visible bleb (A).
(5) Use both hands: one on the syringe and one to stabilize.
(6) Progress from proximal to distal.
(7) Blow before you go.
(8) Avoid large nerves by keeping 5 mm distance and awareness (ultrasound optional).
(9) Second needle prick, if needed, within the 1 cm marge of palpable tumescence.
(10) Wait 30 min before incising.
Citation: EFORT Open Reviews 9, 5; 10.1530/EOR-24-0033
To avoid large nerve damage, it is advised to keep a minimum of 5 mm distance with the sharp needle tip (51). WALANT is not large nerve block anesthesia. It takes up to 100 min for lidocaine molecules to reach the center of large nerves in non-ultrasound-guided nerve blocks (48). WALANT tumescence bathes all nerves, large and small. The small nerves are intensely numb with tumescence after 30 min, and epinephrine has had time to work in that time. It is therefore advised to inject 30 min before incising.
Indications
Over the last 20 years, the indications for the WALANT technique in hand surgery have increased. Most hand surgical procedures are feasible with the WALANT technique, but the clinical advantages are outstanding in dynamic surgery, where function is unpredictable if intraoperative active testing and fine-tuning is not possible. Therefore, tendon and double-joint finger surgery are the most important indications. Here, we will focus on the most common interventions of hand surgery under WALANT.
Minor surgical procedures
Commonly performed trigger fingers, carpal tunnels, cubital tunnels, de Quervain decompressions, and ganglion cyst excisions, are the procedures in which WALANT surgery improves cost, efficiency, and patient/surgeon convenience the most (52). Eliminating the tourniquet greatly improves the patient experience (53).
Trauma
Most simple hand traumas, such as fractures and lacerations of major structures, are easily managed with the WALANT technique (54). Local flap surgery is also safely performed (31, 55, 56). Although regional or general anesthesia in the main operating room is still preferred for major mangling of hands or replantation, for most simple traumas, WALANT provides a much more efficient venue in minor procedure rooms for tendon repair or simple K wiring with no increase in the rate of infections (57, 58, 59).
Tendon surgery
Tendon reconstruction is ideal for WALANT surgery. In flexor tendon tendon repair, active patient motion during the surgery aids in repairing gaps to avoid rupture, and with the adequate venting of pulleys to avoid tenolysis (27, 60, 61, 62). Balancing tendons in extensor hood repair can be tuned to perfection (63). Similarly, the reconstruction of pulleys and their function can be evaluated if the patient can actively move during surgery (49). A great application is the transfer of the extensor indicis proprius to reconstruct extensor pollicis longus function after rupture in wrist fracture. The classic advice to determine optimal transfer tension during motor block anesthesia is to study IP extension in passive wrist flexion and spontaneous thumb flexion in wrist extension. However, this rough estimate can lead to over or under tensioning of the transfer and secondary surgery. Seeing the patient move during surgery makes tensioning easy (64). Similar dynamic transfers to reconstruct lost motion such as opposition of the thumb have been described (65). Tenolysis of adherent tendons with stiff joints is ideal for WALANT hand surgery. It permits intraoperative testing of active motion to identify small remaining adhesions that can affect the result. Active motion during the procedure often helps to release the tendons and regain mobility (25).
Joint reconstruction
In trapeziectomy and thumb implant arthroplasty, balancing thumb motion can be challenging (66). WALANT may help with intraoperative release of adduction contracture or the stabilization of metacarpophalangeal instability if a swan-neck deformity persists during surgery (67). Reconstruction of interphalangeal joints with WALANT can provide active testing of the implants (68).
Double joint dysfunction
Nothing is more challenging in hand surgery than the reconstruction of finger motion with the combined pathology of all the tendons, ligaments, and muscles that act across two joints. Mallet finger with secondary swan-neck deformity and boutonniere dysfunctions are classic examples. in repair of the mallet with tenodermodesis, transarticular K-wiring of the distal interphalangeal joint (DIP) or splinting and in some cases fusion of the DIP often resolve the secondary hyperextension of the proximal interphalangeal joint (PIP) (Fig. 2). However, this is impossible to evaluate if the hand is paralyzed, and the necessity to add a PIP stabilizing soft tissue procedure is unpredictable. Boutonniere deformity may be even more challenging (26). The classical four-step Curtis procedure, where every step needs to be tested dynamically to steer decision-making, is only possible in active testing by the patient as is only possible with WALANT (69).
Posttraumatic swan-neck deformity in a goal keeper (A), treated with Zancolli transfer and temporary extension-block K-wire reconstruction with intraoperative dynamic testing of fully achieved active flexion (B) and extension (C) of the finger under WALANT.
Citation: EFORT Open Reviews 9, 5; 10.1530/EOR-24-0033
Dupuytren disease
In Dupuytren’s (Fig. 3), both the surgeon and patient receive immediate feedback on the dynamic result of cord release, which may positively influence further dissection as well as rehabilitation (50). Microfasciectomy, where the microscope is used during the surgical process, is perfectly feasible under WALANT (70).
Illustrative intraoperative view of Boutonniere Dupuytren contracture deformity with fixed hyperextension of the DIP (A and B), treated by microfasciectomy and tendinous release (Fowler tenotomy) with the WALANT technique (extra material: video). Full active DIP flexion was achieved (C).
Citation: EFORT Open Reviews 9, 5; 10.1530/EOR-24-0033
General condition of the patient
Patients with severe medical comorbidities are often confronted with hand problems that require surgery. However, the general condition may render sedation for surgery inadvisable. If these patients need surgical treatment of their pathology, WALANT makes it safer and possible. Tendon reconstructions, nerve decompression, and even infections can thus be treated without endangering the patient.
Future Prospects
Every year, new reports that push boundaries are published. There are recent reports of wrist surgery, radius, and ulna fracture plating, elbow surgery, clavicle plating, and major limb amputations (71, 72, 73, 74, 75, 76, 77, 78, 79, 80). Although the cost benefits of this approach in these cases are evident, the absolute indications for these procedures are not yet completely clear and are still limited to preferences or circumstances outruling other options (66, 81, 82, 83). WALANT in children is being explored with increasing experience (84). WALANT is increasingly adopted in hand surgery, but up to 40% of hand surgeons have still not yet incorporated it into their daily practice (34, 85). The COVID-19 pandemic did move the needle forward in using WALANT for many procedures (86, 87). It would be beneficial to include the WALANT technique in the surgical training curriculum, particularly for tendon repair and reconstruction in which the benefit of WALANT is likely to be higher (88). It will remain important that decision-making by the surgeons should be shared with the patient as the center and director of his own care.
Conclusion
The WALANT technique has become a game changer in hand surgery. While greatly decreasing costs and solid waste, this technique is increasing access to surgical care as well as safety in hand surgery. It is also helping us achieve better outcomes in some procedures such as tendon reconstruction. The adoption of this technique is becoming part of the algorithm of modern hand surgery practice. Continued learning, implementation, and research will improve this success story in daily practice.
ICMJE Conflict of Interest Statement
The authors declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of this instructional lecture.
Funding Statement
This instructional lecture did not receive any specific grant from any funding agency in the public, commercial, or not-for-profit sector.
Acknowledgement
ID thanks the senior clinical fellowship of FWO (fonds wetenschappelijk onderzoek).
References
- 1↑
Kortlever JTP, Ring D, Schuurman AH, Coert JH, Vagner GA, & Reichel LM. Patient perspectives on decision making for carpal tunnel syndrome. Journal of Hand Surgery 2019 44 940-946.e4. (https://doi.org/10.1016/j.jhsa.2019.08.005)
- 2↑
Vranceanu AM, Cooper C, & Ring D. Integrating patient values into evidence-based practice: effective communication for shared decision-making. Hand Clinics 2009 25 83–96. (https://doi.org/10.1016/j.hcl.2008.09.003)
- 3↑
Yek JLJ, Lee AKY, Tan JAD, Lin GY, Thamotharampillai T, & Abdullah HR. Defining reasonable patient standard and preference for shared decision making among patients undergoing anaesthesia in Singapore. BMC Medical Ethics 2017 18 6. (https://doi.org/10.1186/s12910-017-0172-2)
- 4↑
Joukhadar N, & Lalonde D. How to minimize the pain of local anesthetic injection for wide awake surgery. Plastic and Reconstructive Surgery 2021 9 e3730. (https://doi.org/10.1097/GOX.0000000000003730)
- 5↑
Mckee DE, Lalonde DH, Thoma A, & Dickson L. Achieving the optimal epinephrine effect in wide awake hand surgery using local anesthesia without a tourniquet. Hand 2015 10 613–615. (https://doi.org/10.1007/s11552-015-9759-6)
- 6↑
LeBlanc MR, Lalonde DH, Thoma A, Bell M, Wells N, Allen M, Chang P, McKee D, & Lalonde J. Is main operating room sterility really necessary in carpal tunnel surgery? A multicenter prospective study of minor procedure room field sterility surgery. Hand 2011 6 60–63. (https://doi.org/10.1007/s11552-010-9301-9)
- 7↑
Oakes TC, Wong KC, Schank KJ, Haan P, Bray SM, & Clarkson JHW. Infection rate comparison during transition from hospital to office WALANT enabled by virtual reality. Plastic and Reconstructive Surgery 2022 10 e4285. (https://doi.org/10.1097/GOX.0000000000004285)
- 8↑
Schank KJ, Engwall AJ, Kuhns BW, Oakes TC, Bray SM, & Clarkson JHW. Guidelines for wide-awake local anesthesia surgery with no tourniquet in the office setting using field preparation sterility. Plastic and Reconstructive Surgery 2023 151 267e–73e. (https://doi.org/10.1097/PRS.0000000000009850)
- 9↑
Odinsson A, & Finsen V. Tourniquet use and its complications in Norway. Journal of Bone and Joint Surgery 2006 88 1090–1092. (https://doi.org/10.1302/0301-620X.88B8.17668)
- 10↑
Teunkens A, Vermeulen K, Belmans A, Degreef I, van de Velde M, & Rex S. Patient satisfaction with intravenous regional anaesthesia or an axillary block for minor ambulatory hand surgery: a randomised controlled study. European Journal of Anaesthesiology 2020 37 847–856. (https://doi.org/10.1097/EJA.0000000000001259)
- 11↑
Drosos GI, Kiziridis G, Aggelopoulou C, Galiatsatos D, Anastassopoulos G, Ververidis A, & Kazakos K. The effect of the silicone ring tourniquet and standard pneumatic tourniquet on the motor nerve conduction, pain and grip strength in healthy volunteers. Archives of Bone and Joint Surgery 2016 4 16–22.
- 13↑
Thomson CJ, Lalonde DH, Denkler KA, & Feicht AJ. A critical look at the evidence for and against elective epinephrine use in the finger. Plastic and Reconstructive Surgery 2007 119 260–266. (https://doi.org/10.1097/01.prs.0000237039.71227.11)
- 14↑
Lalonde D, & Martin A. Epinephrine in local anesthesia in finger and hand surgery: the case for wide-awake anesthesia. Journal of the American Academy of Orthopaedic Surgeons 2013 21 443–447. (https://doi.org/10.5435/JAAOS-21-08-443)
- 15↑
Tang JB, Gong KT, Xing SG, Yi L, & Xu JH. Wide-Awake Hand Surgery in Two Centers in China: experience in Nantong and Tianjin with 12,000 patients. Hand Clinics 2019 35 7–12. (https://doi.org/10.1016/j.hcl.2018.08.011)
- 16↑
Lalonde D, Bell M, Benoit P, Sparkes G, Denkler K, & Chang P. A multicenter prospective study of 3,110 consecutive cases of elective epinephrine use in the fingers and hand: the Dalhousie Project clinical phase. Journal of Hand Surgery 2005 30 1061–1067. (https://doi.org/10.1016/j.jhsa.2005.05.006)
- 17↑
Nodwell T, & Lalonde D. How long does it take phentolamine to reverse adrenaline-induced vasoconstriction in the finger and hand? A prospective, randomized, blinded study: the Dalhousie project experimental phase. Canadian Journal of Plastic Surgery 2003 11 187–190. (https://doi.org/10.1177/229255030301100408)
- 18↑
Lalonde DH. Ten questions about wide awake local anaesthesia no tourniquet (WALANT) surgery. Journal of Hand Surgery Asian-Pacific Volume 2022 27 219–225. (https://doi.org/10.1142/S2424835522300031)
- 19↑
Kazmers NH, Stephens AR, Presson AP, Yu Z, & Tyser AR. Cost implications of varying the surgical setting and anesthesia type for trigger finger release surgery. Plastic and Reconstructive Surgery 2019 7 e2231. (https://doi.org/10.1097/GOX.0000000000002231)
- 20↑
Kamnerdnakta S, Huetteman HE, & Chung KC. Utilization and associated spending for anesthesiologist administered services in minor hand surgery. Plastic and Reconstructive Surgery 2018 141 960–969. (https://doi.org/10.1097/PRS.0000000000004230)
- 21↑
Burn MB, Shapiro LM, Eppler SL, Behal R, & Kamal RN. Clinical care redesign to improve value for trigger finger release: a before-and-after quality improvement study. Hand 2021 16 624–631. (https://doi.org/10.1177/1558944719884661)
- 22↑
Teunkens A, Vanhaecht K, Vermeulen K, Fieuws S, Van de Velde M, Rex S, & Bruyneel L. Measuring satisfaction and anesthesia related outcomes in a surgical day care centre: a three-year single-centre observational study. Journal of Clinical Anesthesia 2017 43 15–23. (https://doi.org/10.1016/j.jclinane.2017.09.007)
- 23↑
Bilgetekin YG, Kuzucu Y, Öztürk A, Yüksel S, Atilla HA, & Ersan Ö. The use of the wide-awake local anesthesia no tourniquet technique in foot and ankle injuries. Foot and Ankle Surgery 2021 27 535–538. (https://doi.org/10.1016/j.fas.2020.07.002)
- 24↑
Lalonde DH. Effective things surgeons can tell patients during wide-awake local anesthesia no tourniquet surgery to decrease complications and improve outcomes. Journal of Hand Surgery Global Online 2022 4 464–466. (https://doi.org/10.1016/j.jhsg.2022.04.009)
- 25↑
Zukawa M, Osada R, Hirokawa T, Suzuki K, Makino H, & Kawaguchi Y. Usefulness of wide-awake local anesthesia no tourniquet surgery to decide on tendon transfer versus grafting in chronic flexor tendon rupture. Journal of Hand Surgery Global Online 2022 4 408–413. (https://doi.org/10.1016/j.jhsg.2022.04.001)
- 26↑
Bas CE, Ayhan E, Kunu O, & Kuru CA. Successful boutonniere reconstruction with wide-awake local anesthesia no tourniquet. Journal of Hand Surgery Global Online 2022 4 421–425. (https://doi.org/10.1016/j.jhsg.2022.05.001)
- 27↑
Lalonde DH, & Sepehripour S. Tips to successful flexor tendon repair and reconstruction with WALANT. Hand Clinics 2023 39 165–170. (https://doi.org/10.1016/j.hcl.2022.08.017)
- 28↑
Ayhan E, Tuna Z, & Oksuz C. Getting better results in flexor tendon surgery and therapy. Plastic and Reconstructive Surgery 2021 9. (https://doi.org/10.1097/GOX.0000000000003432)
- 29↑
Dar QA, Avoricani A, Rompala A, Levy KH, Shah NV, Choueka D, White CM, & Koehler SM. WALANT hand surgery does not require postoperative opioid pain management. Plastic and Reconstructive Surgery 2021 148 121–130. (https://doi.org/10.1097/PRS.0000000000008053)
- 30↑
Kang SW, Park HM, Park JK, Jeong HS, Cha JK, Go BS, & Min KT. Open cubital and carpal tunnel release using wide-awake technique: reduction of postoperative pain. Journal of Pain Research 2019 12 2725–2731. (https://doi.org/10.2147/JPR.S210366)
- 31↑
Lin YC, Chen WC, Chen CY, & Kuo SM. Plate osteosynthesis of single metacarpal fracture: WALANT technique is a cost-effective approach to reduce postoperative pain and discomfort in contrast to general anesthesia and wrist block. BMC Surgery 2021 21 358. (https://doi.org/10.1186/s12893-021-01362-5)
- 32↑
Lalchandani GR, Halvorson RT, Rahgozar P, & Immerman I. Wide-awake local anesthesia for minor hand surgery associated with lower opioid prescriptions, morbidity, and costs: a nationwide database study. Journal of Hand Surgery Global Online 2020 2 7–12. (https://doi.org/10.1016/j.jhsg.2019.09.011)
- 33↑
Tevlin R, Panton JA, & Fox PM. Greening hand surgery: targeted measures to reduce waste in ambulatory trigger finger and carpal tunnel decompression. Hand 2023 15589447231220412. (https://doi.org/10.1177/15589447231220412)
- 34↑
Hearon BF, Isaacs-Pullins SR, & Lalonde DH. Adoption of the wide-awake local anesthesia no tourniquet technique in hand surgery. JBJS Reviews 2023 11. (https://doi.org/10.2106/JBJS.RVW.23.00068)
- 35↑
Starr BW, Davenport RO, Granzow D, Johnson SP, & Lien JR. Optimizing the use of operating rooms by transitioning common hand surgeries into the office setting. Journal of Hand Surgery 2023 48 217–225. (https://doi.org/10.1016/j.jhsa.2022.11.010)
- 36↑
Lalonde DH. Latest advances in wide awake hand surgery. Hand Clinics 2019 35 1–6. (https://doi.org/10.1016/j.hcl.2018.08.002)
- 37↑
Bravo D, Townsend CB, Tulipan J, & Ilyas AM. Economic and environmental impacts of the wide-awake, local anesthesia, no tourniquet (WALANT) technique in hand surgery: a review of the literature. Journal of Hand Surgery Global Online 2022 4 456–463. (https://doi.org/10.1016/j.jhsg.2022.05.009)
- 38↑
Holoyda KA, Farhat B, Lalonde DH, Owusu-Danso O, Agbenorku P, Hoyte-Williams PE, & Rockwell WB. Creating an outpatient, local anesthetic hand operating room in a resource-constrained Ghanaian hospital builds surgical capacity and financial stability. Annals of Plastic Surgery 2020 84 385–389. (https://doi.org/10.1097/SAP.0000000000002196)
- 39↑
Claudic Y, Letissier H, Perruisseau-Carrier A, Hu W, Le Nen D, & Andro C. WALANT for hand wound exploration in isolated conditions: feasibility study. Orthopaedics and Traumatology, Surgery and Research 2023 109 103551. (https://doi.org/10.1016/j.otsr.2023.103551)
- 40↑
Koch O. How to start WALANT practice in South Africa: ‘service with a smile if you are willing to wait awhile.’ Journal of Hand Surgery Global Online 2022 4 467–470. (https://doi.org/10.1016/j.jhsg.2022.05.010)
- 41↑
Folberg CR, Alves JAO, Pereira FMS, & Rabuske WBS. Wide-awake olecranon fracture fixation: is it possible? Journal of Hand Surgery Global Online 2023 5 201–205. (https://doi.org/10.1016/j.jhsg.2022.12.006)
- 42↑
Tang JB, Xing SG, Ayhan E, Hediger S, & Huang S. Impact of wide-awake local anesthesia no tourniquet on departmental settings, cost, patient and surgeon satisfaction, and beyond. Hand Clinics 2019 35 29–34. (https://doi.org/10.1016/j.hcl.2018.08.012)
- 43↑
Lawand J, Hantouly A, Bouri F, Muneer M, Farooq A, & Hagert E. Complications and side effects of wide-awake local anaesthesia no tourniquet (WALANT) in upper limb surgery: a systematic review and meta-analysis. International Orthopaedics 2024. (https://doi.org/10.1007/s00264-024-06104-9)
- 44↑
Zargaran D, Zargaran A, Nikkhah D, & Mosahebi A. WALANT Protocol: stop before you block. Journal of Plastic, Reconstructive and Aesthetic Surgery 2021 74 2776–2820. (https://doi.org/10.1016/j.bjps.2021.05.025)
- 45↑
Model Z, Benavent KA, Zhang D, Blazar PE, & Earp BE. Factors influencing patient preference for anesthesia in ambulatory hand surgery. Hand 2022 15589447221120846. (https://doi.org/10.1177/15589447221120846)
- 46↑
Onochie A, Enechukwu M, Bucher F, Dastagir K, Jokuszies A, Vogt PM, & Könneker S. NC-ND license. Annals of Medicine and Surgery 2021 71 102993. (https://doi.org/10.1016/j.amsu.2021.102993)
- 47↑
Hobday D, Welman T, O’Neill N, & Pahal GS. A protocol for wide awake local anaesthetic no tourniquet (WALANT) hand surgery in the context of the coronavirus disease 2019 (COVID-19) pandemic. Surgeon 2020 18 e67–e71. (https://doi.org/10.1016/j.surge.2020.06.015)
- 48↑
Janes L, Sepehripour S, & Lalonde D. Clinically important pharmacologic considerations for wide awake local no tourniquet (WALANT) hand surgery. Plastic and Reconstructive Surgery 2023. (https://doi.org/10.1097/PRS.0000000000010706)
- 49↑
Lalonde DH Wide Awake Hand Surgery and Therapy Tips, 2 nd ed. Lalonde DH, Ed., pp. 1–425. New Brunswick, Canada: Thieme Medical Publishers, Inc. 2022.
- 50↑
Barone N, Lalonde DH, & Brutus JP. Tips, tricks, and pearls for a superior patient and surgeon experience for wide-awake Dupuytren surgery. Plastic and Reconstructive Surgery 2024 12 e5570. (https://doi.org/10.1097/GOX.0000000000005570)
- 51↑
Moreira SB, Chagas DC, & Yamashita CT. Ultrasound-guided WALANT technique in carpal tunnel decompression surgery. Revista Brasileira de Ortopedia 2023 58 538–542. (https://doi.org/10.1055/s-0041-1735172)
- 52↑
Lovely LM, Chishti YZ, Woodland JL, & Lalonde DH. How much volume of local anesthesia and how long should you wait after injection for an effective wrist median nerve block? Hand 2018 13 281–284. (https://doi.org/10.1177/1558944717709072)
- 53↑
Faraz A, Bahl A, Khan S, Ahmad M, Khan MN, Mannan S, Jayadeep J, & Kumar K. Carpal tunnel decompression under wide awake local anaesthesia no tourniquet technique (WALANT): a cost effective and outcome analysis. Cureus 2023 15 e42125. (https://doi.org/10.7759/cureus.42125)
- 54↑
Knopp BW, Kushner J, Eng E, Goguen J, & Esmaeili E. Patient experiences with hand surgery in the office versus ambulatory surgery center. Cureus 2023 15 e43763. (https://doi.org/10.7759/cureus.43763)
- 55↑
Prénaud C, Merlini L, Hurst SA, Gregory T, & Dacheux C. A study of hand flap viability when using a wide awake local anesthesia no tourniquet (WALANT) technique. Journal of Hand and Microsurgery 2023 15 270–274. (https://doi.org/10.1055/s-0042-1742456)
- 56↑
Lalonde DH, & Tang JB. How the wide awake tourniquet-free approach is changing hand surgery in most countries of the world. Hand Clinics 2019 35 xiii–xiv. (https://doi.org/10.1016/j.hcl.2018.10.001)
- 57↑
Wheelock M, Petropolis C, & Lalonde DH. The Canadian Model for instituting wide-awake hand surgery in our hospitals. Hand Clinics 2019 35 21–27. (https://doi.org/10.1016/j.hcl.2018.08.001)
- 58↑
Gillis JA, Lalonde J, Alagar D, Azzi A, & Lalonde DH. K-wire fixation of closed hand fractures outside the main operating room does not increase infections. Plastic and Reconstructive Surgery 2022 10 e4679. (https://doi.org/10.1097/GOX.0000000000004679)
- 59↑
Connors KM, Kurtzman JS, & Koehler SM. Successful use of WALANT in local and regional soft tissue flaps: a case series. Plastic and Reconstructive Surgery 2023 11 e4756. (https://doi.org/10.1097/GOX.0000000000004756)
- 60↑
Nolan GS, Kiely AL, Madura T, & Karantana A. Wide-awake local anaesthesia no tourniquet (WALANT) vs regional or general anaesthesia for flexor tendon repair in adults: protocol for a systematic review and meta-analysis. Systems Research 2020 9 264. (https://doi.org/10.1186/s13643-020-01532-1)
- 61↑
Moriya K, Yoshizu T, Tsubokawa N, Narisawa H, Hara K, & Maki Y. Clinical results of releasing the entire A2 pulley after flexor tendon repair in zone 2C. Journal of Hand Surgery 2016 41 822–828. (https://doi.org/10.1177/1753193416646521)
- 62↑
Yu J, Ji TA, Craig M, McKee D, & Lalonde DH. Evidence-based sterility: the evolving role of field sterility in skin and minor hand surgery. Plastic and Reconstructive Surgery 2019 7 e2481. (https://doi.org/10.1097/GOX.0000000000002481)
- 63↑
Matharu GS, Gatt IT, Delaney R, Loosemore M, & Hayton MJ. Extensor hood injuries in elite boxers: injury characteristics, surgical technique and outcomes. Journal of Hand Surgery 2022 47 1162–1167. (https://doi.org/10.1177/17531934221123139)
- 64↑
Hong JJ, Kang HJ, Whang JI, Sung SY, Kim SH, Shin SC, Kim SN, & Kim JS. Comparison of the wide-awake approach and conventional approach in extensor indicis proprius-to-extensor pollicis longus tendon transfer for chronic extensor pollicis longus rupture. Plastic and Reconstructive Surgery 2020 145 723–733. (https://doi.org/10.1097/PRS.0000000000006611)
- 65↑
Niempoog S, & Jaroenporn W. Case Series: wide-awake local anaesthesia without tourniquet (WALANT) for Camitz transfer. Journal of Hand Surgery 2023 28 441–445. (https://doi.org/10.1142/S2424835523500492)
- 66↑
Müller CT, Christen T, Heidekruger PI, Lamouille J, Raffoul W, McKee D, Lalonde DH, & Durand S. Wide-awake anesthesia no tourniquet trapeziometacarpal joint prosthesis implantation. Plastic and Reconstructive Surgery 2018 6 e1714. (https://doi.org/10.1097/GOX.0000000000001714)
- 67↑
Tang JB, Lalonde D, Harhaus L, Sadek AF, Moriya K, & Pan ZJ. Flexor tendon repair: recent changes and current methods. Journal of Hand Surgery 2022 47 31–39. (https://doi.org/10.1177/17531934211053757)
- 68↑
Sharma S, Ong J, & Putti A. Proximal interphalangeal joint arthroplasty using the wide-awake local anesthesia no tourniquet technique. Hand 2023 18 612–615. (https://doi.org/10.1177/15589447211063545)
- 69↑
Curtis RM, Reid RL, & Provost JM. A staged technique for the repair of the traumatic boutonniere deformity. Journal of Hand Surgery 1983 8 167–171. (https://doi.org/10.1016/s0363-5023(8380009-4)
- 70↑
Degreef I, Voorde KV, & Nuffel MV. Microfasciectomy in Dupuytren’s disease: microsurgery in the evolution toward safer and more efficient fasciectomy and hand surgery. EFORT Open Reviews 2023 8 291–297. (https://doi.org/10.1530/EOR-23-0033)
- 71↑
Castelo F, Santos C, Costa B, Sousa R, Ricardo R, Batista P, & Ribeiro D. Wide-awake local anesthesia no tourniquet for rhizarthrosis surgery: technique and experience for 16 consecutive cases. Cureus 2023 15 e45705. (https://doi.org/10.7759/cureus.45705)
- 72↑
Liu B, Ng CY, Arshad MS, Edwards DS, & Hayton MJ. Wide-awake wrist and small joints arthroscopy of the hand. Hand Clinics 2019 35 85–92. (https://doi.org/10.1016/j.hcl.2018.08.010)
- 73↑
Brutus JP, Chang MC, Ahmad AA, & Apard T. Description of WALANT technique in open bone and ligament wrist surgery. Hand Surgery and Rehabilitation 2024 43 101610. (https://doi.org/10.1016/j.hansur.2023.10.004)
- 74↑
Admani A, Sherman I, Jani P, Mwamuye A, Sepehripour S, & Lalonde D. Below-knee amputation with minimally painful injection of tumescent local anesthesia. Plastic and Reconstructive Surgery 2023 11 e5164. (https://doi.org/10.1097/GOX.0000000000005164)
- 75↑
Abdullah S, Ahmad AA, Abdul Latiff A, Kumar N, & Gill PS. Technique of wide-awake local anesthesia no tourniquet injection for a transradial forearm amputation in an ischemic hand. Journal of Hand Surgery Global Online 2022 4 432–436. (https://doi.org/10.1016/j.jhsg.2022.04.002)
- 76↑
Ahmad AA, Ubaidah Mustapa Kamal MA, Ruslan SR, Abdullah S, & Ahmad AR. Plating of clavicle fracture using the wide-awake technique. Journal of Shoulder and Elbow Surgery 2020 29 2319–2325. (https://doi.org/10.1016/j.jse.2020.03.003)
- 77↑
Ribak S, Folberg CR, & André de Oliveira Alves J. The Brazilian perspective of WALANT in fracture fixation from the hand to the elbow. Journal of Hand Surgery Global Online 2022 4 471–476. (https://doi.org/10.1016/j.jhsg.2022.08.006)
- 78↑
Ahmad AA, Sabari SS, Ruslan SR, Abdullah S, & Ahmad AR. Wide-awake anesthesia for olecranon fracture fixation. Hand 2021 16 402–406. (https://doi.org/10.1177/1558944719861706)
- 79↑
How HM, Khoo BLJ, Ayeop MAS, Ahmad AR, Bahaudin N, & Ahmad AA. Application of WALANT in diaphyseal plating of forearm fractures: an observational study. Journal of Hand Surgery Global Online 2022 4 399–407. (https://doi.org/10.1016/j.jhsg.2022.02.004)
- 80↑
Gouveia K, Harbour E, Gazendam A, & Bhandari M. Fixation of distal radius fractures under wide-awake local anesthesia: a systematic review. Hand 2024 19 58–67. (https://doi.org/10.1177/15589447221109632)
- 81↑
Chen CT, Chou SH, Huang HT, Fu YC, Jupiter JB, & Liu WC. Comparison of distal radius fracture plating surgery under wide-awake local anesthesia no tourniquet technique and balanced anesthesia: a retrospective cohort study. Journal of Orthopaedic Surgery and Research 2023 18 746. (https://doi.org/10.1186/s13018-023-04243-0)
- 82↑
Folberg CR, Alves JAde O, Pereira FMS, & Pedrozo VB. WALANT na osteossíntese percutânea do escafoide. Revista Brasileira de Ortopedia 2022 57 1070–1073. (https://doi.org/10.1055/s-0041-1726070)
- 83↑
Shou Wai AT, Abdullah S, Ahmad AA, Yong LC, Jabar FA, & Ahmad AR. Prospective evaluation of pain and anxiety levels between wide-awake local anesthesia no tourniquet and General Anesthesia With tourniquet in excision of wrist ganglions. Journal of Hand Surgery Global Online 2022 4 414–420. (https://doi.org/10.1016/j.jhsg.2022.07.002)
- 84↑
Kapadia K, Shah S, & Galvez MG. Pediatric wide-awake local anesthesia no-tourniquet hand surgery: a practical approach. Journal of Hand Surgery Global Online 2022 4 426–431. (https://doi.org/10.1016/j.jhsg.2022.05.002)
- 85↑
Grandizio LC, Graham J, & Klena JC. Current trends in WALANT surgery: a survey of American Society for Surgery of the Hand members. Journal of Hand Surgery Global Online 2020 2 186–190. (https://doi.org/10.1016/j.jhsg.2020.04.011)
- 86↑
Shaw AV, Holmes DGW, Jansen V, Fowler CL, Wormald JCR, Wade RG, Reay EK, Gardiner MD & #RSTNCOVID Hand Collaborative. Adapting to the COVID-19 pandemic: a survey of UK and European hand surgery units. Journal of Plastic, Reconstructive and Aesthetic Surgery 2022 75 1682–1688. (https://doi.org/10.1016/j.bjps.2021.11.052)
- 87↑
Ruterana P, Abitbol A, Castel LC, & Gregory T. WALANT technique versus locoregional anesthesia in the surgical management of metacarpal and phalangeal fractures: lessons from the Covid-19 crisis. Hand Surgery and Rehabilitation 2022 41 220–225. (https://doi.org/10.1016/j.hansur.2021.12.002)
- 88↑
Thakkar M, & Bednarz B. Should WALANT surgery be included in the training curriculum? Journal of Plastic, Reconstructive and Aesthetic Surgery 2020 73 1575–1592. (https://doi.org/10.1016/j.bjps.2020.05.072)
