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Introduction: Wide-awake local anesthesia and no tourniquet (WALANT) represents a revolutionary technique for hand surgeons who dismiss tourniquets and sedation. In this study, we present our experience with the WALANT technique in primary flexor tendon injuries of the hand. Patient and methods: This prospective research was carried out on 30 patients undergoing hand primary, flexor tendon repair surgery. Flexor tendon injury zones 2, 3, 4, and 5 were included. WALANT was prepared and injected. The tendons were surgically managed by a cruciate single cross-stitched locked 4-strand technique. The pain was assessed using a visual analog scale (VAS) score. The range of motion (ROM) of affected fingers was assessed according to the Strickland evaluation system. Results: There was a highly significant relationship between the patient's compliance with physiotherapy and obtained ROM of the affected finger with a P value

Background: The Dorsal Internal Brace reconstruction is designed to treat scapholunate ligament (SLL) instability. Wide awake surgery without a tourniquet allows the movement of the bones and thus the instability of the carpal bones to be actively visualized during surgery. Hypothesis: The aim of this prospective study is to analyze the feasibility of the Wide Awake Procedure (Walant) for this surgical technique, to assess the stability of the SLL in active motion and then to allow for an early rehabilitation protocol. Material: From January 2021 to December 2022, 6 adult patients with scapholunate instability stage 3 or 4 according to the Garcia Elias classification were included. Operating under Walant allowed the surgeon to confirm the dynamic instability in active movement per operation and at the end of the procedure to confirm the solidity of the suture without bone impingement. A splint was applied for 3 weeks and then the patients were asked to start rehabilitation. Results: Osteoporosis in a 60-year-old woman led to failure of the anchor implant. Reconstruction was successful in the other 5 patients. The QuickDASH score decreased from 34 to 9/100. Clinical and radiological examination (X-ray and ultrasound) before surgery and at 6 weeks, 3 months and 6 months postoperatively showed a continued good result. Discussion: This preliminary observational report is the first to investigate the feasibility of Walant for SLL repair. We conclude that this technique of anesthesia should be suggested to surgeons to evaluate SLL instability and its treatment. Level of evidence: IV.

Background: The flexor pollicis longus tendon rupture following distal radius fractures is a known complication and reconstruction with interposition tendon graft achieved a good outcome. Therefore, this study aims to analyze the outcome of FPL tendon reconstruction using the wide-awake local anesthesia no tourniquet (WALANT) technique. Methods: Seven patients with attritional FPL rupture were retrospectively analyzed between 2014 and 2021. All these patients had FPL reconstruction using palmaris longus interposition graft under WALANT. The patient demographics, Soong volar plate prominence classification, volar plate type, and functional outcome assessment were reviewed. Results: The FPL tendon rupture occurred at a mean of 1.1 years (range, 6 months −3 years) following volar plate fixation. The patients had T-buttress (n ​= ​6) and volar locking plates (n ​= ​1). The mean follow-up of our study was 16.5 months (range 12–19 months). The total interphalangeal joint movement, grip strength, pinch strength, and Kapandji score were significantly less than the uninjured hand (p ​

Purpose: The purpose of the study was to determine if perioperative prescription anticoagulant (AC) or antiplatelet (AP) medication use increases the rate of revision surgeries or complications following wide-awake hand surgery performed under local anesthesia., Methods: All patients who underwent outpatient wide-awake hand surgery under local anesthesia without a tourniquet by two fellowship-trained orthopedic hand surgeons at a single academic practice over a 3-year period were included. Prescription history was reviewed to determine if any prescriptions were filled for an AC/AP drug within 90 days of surgery. All cases requiring revision were identified. Office notes were reviewed to determine postoperative complications and/or postoperative antibiotics prescribed for infection concerns. The number of revisions, complications, and postoperative antibiotic prescriptions were compared between patients who did, and did not, use perioperative AC/AP drugs., Results: A total of 2,162 wide-awake local anesthesia surgeries were included, and there were 128 cases (5.9%) with perioperative AC/AP use. Of the 2,162 cases, 19 cases required revision surgery (18 without AC/AP use and one with AC/AP use). Postoperative wound complications occurred in 42 patients (38 without AC/AP use and four with AC/AP use). Of the wound complications, four were related to postoperative bleeding, one case of incisional bleeding, and three cases of incisional hematomas (three without AC/AP use and one with AC/AP use). None of these patients required additional intervention; their incisional bleeding or hematoma was resolved by their subsequent office visit. Sixty-five patients received postoperative antibiotics for infection concerns (59 without AC/AP use and six with AC/AP use)., Conclusions: Prescription AC/AP medication use in the perioperative period for wide-awake hand surgery performed under local anesthesia was not associated with an increased risk for revision surgery or postoperative wound complications. This study demonstrates the safety of continuing patients' prescribed AC/AP medications during wide-awake hand surgery., Type of Study/level of Evidence: Prognosis IV., Competing Interests: Conflicts of Interest No benefits in any form have been received or will be received related directly to this article., (Copyright © 2024 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Purpose: To define self-reported WALANT use among American Society for Surgery of the Hand (ASSH) members. We aimed to define surgeon and practice demographics relative to WALANT use and identify potential barriers for WALANT implementation. Methods: An anonymous multiple-choice survey was electronically distributed to all active ASSH members. Incomplete surveys were included in the final analysis. Surgeons were asked to provide reasons for not performing WALANT, which were categorized based on general themes. We compared practice and surgeon demographic information relative to WALANT use. Results: Of 3,826 ASSH members, 869 responded (23%). A total of 79% of respondents had performed at least one WALANT procedure; 62% currently incorporated WALANT into their practice. Hospital-owned outpatient surgery centers were the most common location for WALANT procedures (31%). Canadian surgeons were more likely to use WALANT, compared with US and international surgeons. Surgeons with fewer years in practice and higher-volume surgeons were more likely to use WALANT. There was no statistically significant association between either practice or income structure and WALANT use. For carpal tunnel release (CTR), 13% did not offer patients WALANT, whereas 43% offered WALANT to all patients. Moreover, 51% of surgeons reported that anesthesia staff was required to be present for WALANT cases at their institution. In determining reasons for not using WALANT, 16% reported that they preferred a tourniquet for visualization. Only 2% had concerns regarding epinephrine use in the hand. Conclusions: The results of this survey illustrate current WALANT use among ASSH members and defines the demographics of those employing WALANT. Lack of familiarity with WALANT and an acceptance of the use of epinephrine in the hand has increased from prior ASSH surveys. Lack of familiarity with the technique, concerns regarding operating room efficiency, and patient preferences remain considerable barriers to more widespread adoption of WALANT procedures. Type of study/level of evidence: Economic and Decision Analysis V.

Purpose: Environmental sustainability is an important issue in health care because of large amounts of greenhouse gases attributable to hospitals. The operating room has been highlighted as one of the highest contributors, prompting several initiatives by organizations focused on the care of hand and upper extremity conditions. This study aimed to quantify and compare the carbon footprint of a common hand surgery in two different surgical settings, the procedure room (PR) and operating room. We hypothesized that open carpal tunnel release (oCTR) will generate a greater environmental impact in the operating room than in the PR., Methods: This was a retrospective review of oCTRs performed at a tertiary care medical center. Current procedural technology codes isolated a single cohort of patients who underwent bilateral oCTR, one side performed in the PR and the contralateral side in the operating room. Current published emission conversions were used to calculate carbon footprint at our institution based on energy expenditure necessary for the creation and disposal of waste and sterilization of surgical equipment. Surgery time was combined with heating, ventilation and air conditioning/lighting energy consumption to estimate facility emissions., Results: Fourteen patients had bilateral oCTR surgery performed in both settings. Open CTR performed in the operating room generated 3.7 kg more solid waste than when performed in the PR. In total, emissions from oCTR performed in the operating room generated 32.4 kg CO 2 , whereas oCTR in the PR emitted 13.0 kg CO 2 per surgery., Conclusions: Performing a common hand procedure (oCTR) is more environmentally sustainable in the PR than in the operating room, with a 60% reduction in carbon footprint., Clinical Relevance: Greater effort should be made to perform surgery in the PR instead of the operating room in appropriately indicated patients. Surgical sets should be evaluated for the necessity of included equipment and unnecessary waste., Competing Interests: Conflicts of Interest No benefits in any form have been received or will be received related directly to this article., (Copyright © 2024 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

A feature of the flexor pollicis longus tendon injury is the frequency of palmar retraction so that a wrist approach is needed for retrieval of the proximal stump. We are reporting on our first outpatient zone T2 flexor pollicis longus tendon repair under WALANT with ultrasound guidance. In the event of zone T2 flexor pollicis rupture, ultrasound location of tendon extremities is used to plan surgical WALANT strategy and to guide the injection of lidocaine with epinephrine whilst limiting the injected volume to what is strictly necessary.

Competing Interests: Declaration of Competing Interest None.

Isolated fractures of shaft of ulna are common. Plate fixation with anatomic reduction is thought to produce the best functional results in closed or open fractures. Surgery can be done under general and various types of regional anaesthesia. We report a case of fracture shaft of ulna treated by plating under a combination of WALANT (wide awake, local anaesthesia, no tourniquet) using tumescent anaesthesia and periosteal nerve block as a day care procedure.

Purpose: We investigated chronological changes in active range of motion (ROM) of the metacarpophalangeal (MCP) joint after zone VII extensor tendon reconstruction with wide-awake local anesthesia no tourniquet (WALANT) surgery., Methods: Reconstruction of the extensor tendons ruptured in zone VII of 82 fingers in 40 patients was performed using WALANT techniques. The mean patient age was 71.3 years. During surgery, we evaluated passive stretch distance and active contraction distance of the ruptured musculocutaneous unit. The sum of passive stretch distance and active contraction distance was defined as total excursion. In cases with total excursion ≥30 mm, we selected bridge tendon grafting for tendon reconstruction. In cases with total excursion <30 mm, end-to-side tendon transfer was performed. Active ROM of the MCP joint was measured before surgery; during surgery; 1, 3, and 5 months after surgery, and at the final follow-up., Results: Extension lag of the MCP joint was 49.2° before surgery, improving to 2.9° during surgery, deteriorating to 18.7° at 1-month, and improving again to 15.6° at 3-months, 13.6° at 5-months, and 10.5° at the final follow-up. Meanwhile, the active flexion angle of the MCP was 87.9° before surgery, 87.3° during surgery, 67.6° at 1-month, 76.0° at 3-months, 79.7° at 5-months, and 81.0° at the final follow-up. Extension and flexion angles at each time point remained nearly constant regardless of whether tendon grafting or tendon transfer was used., Conclusions: Extensor tendon reconstruction using WALANT surgery allowed intraoperative measurement of active ROM, confirming near-complete extension and flexion after reconstruction. The changes in ROM of the MCP joint during follow-up are an approximate indication of the progression of postoperative recovery., Type of Study/level of Evidence: Therapeutic Ⅳ., (Copyright © 2023 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Purpose: Recent studies examining the implementation of clinic-based procedure rooms (PRs) for wide-awake hand surgery have reported cost reduction, decreased burden on hospital systems, and improved patient satisfaction. This study evaluates other resource savings, primarily time spent by patients in the hospital., Methods: Thirty-two patients were enrolled in a PR or the operating room group for prospective evaluation. Time spent in the hospital on the day of surgery, several preprocedure appointments, complications, and cost comparisons were evaluated between the two groups. Patient-reported outcomes were also evaluated with postoperative surveys assessing anxiety, pain, and satisfaction., Results: Significant time savings were noted between the groups. The median time spent in the hospital on the day of surgery for the patients in the operating room group was 256 minutes versus 90 minutes for the PR group, a time savings of approximately 3 hours. Eight additional preoperative clinic visits for operating room patients were generated compared with no additional preoperative visits for PR patients. Cost savings for surgeries performed in the clinic-based procedure amounted to $232,411. No postoperative complications were observed in the clinic setting., Conclusions: Continued utilization of the clinical PR for select hand surgery procedures will reduce the cost and time burdens for procedures while maintaining satisfaction and safety., Clinical Relevance: A clinic-based PR for performing minor hand surgeries saves the patient time and ostensibly allows the operating room to be used for more complex surgeries that are not easily amenable to a wide-awake in-clinic procedure., (Copyright © 2023 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Purpose: The purpose of this study was to examine the true monetary implications, at the health system level, of moving simple hand procedures, performed with wide-awake local anesthesia no tourniquet surgery, from the ambulatory surgery center (ASC) to office setting., Methods: We analyzed the costs, revenues, case times, and patient demographics for 2 cohorts of patients who underwent hand and non-hand surgical procedures over a 2-year period. We calculated the mean margin per minute for the top 5 procedures in non-hand orthopedic surgery subgroups, complex plastics hand, and non-hand plastic surgery. We then calculated the following: (1) hours operating room or ASC time gained by moving hand procedures to the office, (2) additional subgroup patients theoretically treated by using the ASC hours gained, and (3) net margin (in dollars) because of additional procedures., Results: Six board-certified hand surgeons performed 623 simple ASC and 808 in-office procedures, consisting of 795 carpal tunnel releases, 84 first dorsal compartment releases, and 446 trigger finger releases. The net margin per minute for simple ASC and in-office hand procedures was $25.01/min and $5.63/min, respectively. In the office setting, hand surgery freed up 821 hours of ASC time, which could be theoretically used to treat over 300 additional patients awaiting outpatient orthopedic hand or plastic surgery. Depending on the subspecialty and type of substituted cases, the theoretical net margin varied from -$150,413 to $3.9 million., Conclusions: Transitioning simple hand operations out of ASCs realized a mean cost savings of 82% per case ($1,137 vs $206) and effectively opened 821 additional hours of operating room time over a 2-year period., Clinical Relevance: Transitioning simple hand operations out of the operating room setting and into the office setting reduces the cost of hand surgical care, improves operating room access for alternate procedures or patients, and validates the sustainability of safe and effective wide-awake local anesthesia no tourniquet surgery from a hospital system's financial standpoint., (Copyright © 2023. Published by Elsevier Inc.)

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., (Copyright © 2022. Published by Elsevier Inc.)

As demands for faster return to function, improvement in surgical scarring, and minimal disruption to personal schedule have increased, so also have the demands increased for minimally invasive procedures under the wide awake, local anesthetic, no tourniquet method. However, owing to the subcutaneous yet constrained position of the ulnar nerve at the elbow, wide-awake endoscopic cubital tunnel release has remained a technical challenge. We describe a 2-stage local anesthetic injection method that safely introduces local anesthetic within the cubital tunnel and simultaneously achieves comfort, sufficient visualization, and the ability to decompress multiple compression sites through a minimal incision., (Copyright © 2022 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Office-based surgery (OBS) with wide-awake local anesthesia no tourniquet (WALANT) surgery is a safe and cost-effective care model that is convenient for patient and provider alike. Currently, the practice is growing, but in the majority of North America the ambulatory-care center is still the most common setting for hand surgery. This article discusses the practical issues of implementing OBS with WALANT including clinical setup and workflows for OBS, negotiating payor contracts, and managing liability., (Copyright © 2020 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Purpose: To evaluate the cost-effectiveness of corticosteroid injection(s) versus open surgical release for the treatment of trigger finger., Methods: Using a US health care payer perspective, we created a decision tree model to estimate the costs and outcomes associated with 4 treatment strategies for trigger finger: offering up to 3 steroid injections before to surgery or immediate open surgical release. Costs were obtained from a large administrative claims database. We calculated expected quality-adjusted life-years for each treatment strategy, which were compared using incremental cost-effectiveness ratios. Separate analyses were performed for commercially insured and Medicare Advantage patients. We performed a probabilistic sensitivity analysis using 10,000 second-order Monte Carlo simulations that simultaneously sampled from the uncertainty distributions of all model inputs., Results: Offering 3 steroid injections before surgery was the optimal strategy for both commercially insured and Medicare Advantage patients. The probabilistic sensitivity analysis showed that this strategy was cost-effective 67% and 59% of the time for commercially insured and Medicare Advantage patients, respectively. Our results were sensitive to the probability of injection site fat necrosis, success rate of steroid injections, time to symptom relief after a steroid injection, and cost of treatment. Immediate surgical release became cost-effective when the cost of surgery was below $902 or $853 for commercially insured and Medicare Advantage patients, respectively., Conclusions: Multiple treatment strategies exist for treating trigger finger, and our cost-effectiveness analysis helps define the relative value of different approaches. From a health care payer perspective, offering 3 steroid injections before surgery is a cost-effective strategy., Type of Study/level of Evidence: Economic and Decision Analyses II., (Copyright © 2020 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Purpose: Wide-awake local anesthesia no tourniquet (WALANT) is an increasingly popular surgical technique. However, owing to surgeon preference, patient factors, or hospital guidelines, it may not be feasible to inject patients with solutions containing epinephrine the recommended 25 minutes prior to incision. The purpose of this study was to assess pain and patient experience after short hand surgeries done under local anesthesia using a tourniquet rather than epinephrine for hemostasis., Methods: Ninety-six consecutive patients undergoing short hand procedures using only local anesthesia and a tourniquet (LA-T) were assessed before and after surgery. A high arm pneumatic tourniquet was used in 73 patients and a forearm pneumatic tourniquet was used in 23. All patients received a local, unbuffered plain lidocaine injection. No patients received sedation. Pain related to local anesthesia, pneumatic tourniquet, and the procedure was assessed using a visual analog scale (VAS). Patient experience was assessed using a study-specific questionnaire based on previous WALANT studies. Tourniquet times were recorded., Results: Mean pain related to anesthetic injection was rated 3.9 out of 10. Mean tourniquet related pain was 2.9 out of 10 for high arm pneumatic tourniquets and 2.3 out of 10 for forearm pneumatic tourniquets. Patients rated their experience with LA-T favorably and 95 of 96 patients (99%) reported that they would choose LA-T again for an equivalent procedure. Mean tourniquet time was 9.6 minutes and only 1 patient had a tourniquet inflated for more than 20 minutes. Tourniquet times less than 10 minutes were associated with less pain than tourniquet times greater than 10 minutes (P < .05); however, both groups reported the tourniquet to be on average less painful than the local anesthetic injection., Conclusion: Short wide-awake procedures using a tourniquet are feasible and well accepted. Local anesthetic injection was reported to be more painful than pneumatic tourniquet use. Tourniquets for short wide-awake procedures can be used in settings in which preprocedure epinephrine injections are logistically difficult or based on surgeon preference., Type of Study/level of Evidence: Therapeutic IV., (Copyright © 2020 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Introduction: Ankle fractures frequently occur and must be treated with open reduction for long-term stability. The existing anaesthesia methods include general anaesthesia, spinal and epidural anaesthesia, peripheral nerve block and local anaesthesia with IV sedation. However, each method has its inherent risks and potential costs, and the use of a tourniquet is inevitable. Therefore, the wide-awake local anaesthesia no tourniquet (WALANT) technique provides an alternative method for equivalent haemostasis and pain control without the use of a tourniquet., Patients and Methods: We prospectively enrolled 13 consecutive patients (9 males and 4 females) who presented ankle fractures and required ORIF from January 2017 to December 2017. The fracture types of the 13 patients included lateral malleolar fracture (three patients), bimalleolar fracture (two patients), bimalleolar equivalent fracture (three patients), medial malleolar fracture (two patients) and trimalleolar fracture (three patients; articular surface involvement <25%). We used a solution of 1% lidocaine mixed with 1:40,000 epinephrine for WALANT., Results: All patients underwent surgery if they exhibited an initial numerical pain rating scale (NPRS) score of 0 without using a tourniquet. Only two patients required an additional 5 ml of local anaesthesia due to NPRS score elevation during the surgery; no dose exceeded the safe limit of 7 mg/kg. No local complications occurred, and no shifts to other anaesthesia methods were required due to the failure of WALANT., Conclusions: WALANT simplified surgical preparations and provided a safe and reliable method for ankle fracture management. Because the use of a tourniquet was not required, reduced postsurgical pain was observed. Moreover, the use of local anaesthesia resulted in more satisfied patients and facilitated easier recovery., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Purpose: Carpal tunnel surgery is one of the most common procedures completed on the upper limb in the United States. There is currently no evidence-based high-value clinical care pathway to inform the management of carpal tunnel syndrome (CTS). We created an evidence-based care pathway and implemented a quality improvement initiative to evaluate its effect on patient time, quality, and cost in a tertiary care ambulatory surgery center., Methods: We developed a high-value clinical care pathway for CTS and implemented the intraoperative phase of the pathway. This included (1) implementing an evidence-based protocol for wide-awake local anesthesia, (2) removing non-value-added processes of care, and (3) implementing educational sessions with surgery staff regarding the initiative. We prospectively collected data on patient time, visual analog scale pain scores (quality), and percent change in total direct costs of the intraoperative phase of care (cost)., Results: A total of 50 patients were included in this implementation study: 30 prior to implementation of the intervention and 20 after. There was a significant decrease in average patient wheels in to surgery time, postanesthesia care unit to discharge time, and total patient time (lead time). There was no difference in preoperative or postoperative pain before and after the intervention. There was a 31% reduction in total direct costs., Conclusions: Implementing the intraoperative phase of this clinical care pathway with wide-awake surgery can reduce patient lead time, maintain quality, and reduce total direct costs in an ambulatory surgery center., Clinical Relevance: Quality improvement interventions, such as the implementation of an evidence-based clinical care pathway for the treatment for CTS, may improve value to health systems., (Copyright © 2019 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Fractures of the distal radius are one of the most common types of injuries encountered in hand surgery. Plate osteosynthesis is recommended for unstable fractures. Because distal radius fracture fixation is usually performed under general or regional anesthesia with the use of a tourniquet, this exposes patients, especially elderly people with extensive comorbidities, to adverse effects commonly associated with these forms of anesthesia. As such, many of these patients are unable to undergo surgery in a timely manner until they are deemed medically fit for surgery or anesthesia, and some may still be treated nonsurgically. Injecting local anesthetic of lidocaine and epinephrine into the surgical field and without using a tourniquet is known to be advantageous for various surgical procedures of the hand. However, this approach, also known as wide-awake local anesthesia no tourniquet (WALANT), has not been used in the fixation of fractures beyond the wrist. Using the WALANT approach as an alternative anesthetic for plating of distal radius fractures may enable patients who are normally denied surgery owing to their age or medical comorbidities to undergo plate fixation for the fractures. This article outlines the WALANT approach used for a single case of fixation of distal end radius fracture with a detailed description of the technique of administering local anesthesia., (Copyright © 2018 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Purpose: Carpal tunnel release (CTR) is a common surgical procedure, representing a financial burden to the health care system. The purpose of this study was to test whether the choice of CTR technique (open carpal tunnel release [OCTR] vs endoscopic carpal tunnel release [ECTR]), surgical setting (operating room vs procedure room [PR]), and anesthetic type (local, monitored anesthesia care [MAC], Bier block, general) affected costs or payments., Methods: Consecutive adult patients undergoing isolated unilateral CTR between July 2014, and October 2017, at a single academic medical center were identified. Patients undergoing ECTR converted to OCTR, revision surgery, or additional procedures were excluded. Using our institution's information technology value tools, we calculated total direct costs (TDCs), total combined payment (TCP), hospital payment, surgeon payment, and anesthesia payment for each surgical encounter. Cost data were normalized using each participant's surgical encounter cost divided by the average cost in the data set and compared across 8 groups (defined by surgery type, operation location, and anesthesia type)., Results: Of 479 included patients, the mean age was 55.3 ± 16.1 years, and 68% were female. Payer mix included commercial (45%), Medicare (37%), Medicaid (13%), workers' compensation (2%), self-pay (1%), and other (3%) insurance types. The TDC and TCP both differed significantly between each CTR group, and OCTR in the PR under local anesthesia was the lowest. The OCTR/local/operating room, OCTR/MAC/operating room, and ECTR/operating room, were associated with 6.3-fold, 11.0-fold, and 12.4-16.6-fold greater TDC than OCTR/local/PR, respectively., Conclusions: Performing OCTR under local anesthetic in the PR setting significantly minimizes direct surgical encounter costs relative to other surgical methods (ECTR), anesthetic methods (Bier block, MAC, general), and surgical settings (operating room)., Clinical Relevance: This study identifies modifiable factors that may lead to cost reductions for CTR surgery., (Copyright © 2018 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Purpose: Wide-awake, local anesthesia, no tourniquet (WALANT) hand surgery was developed to improve access to hand surgery care while optimizing medical resources. Hand surgery in the clinic setting may result in substantial cost savings for the United States Military Health Care System (MHS) and provide a safe alternative to performing similar procedures in the operating room., Methods: A prospective cohort study was performed on the first 100 consecutive clinic-based WALANT hand surgery procedures performed at a military medical center from January 2014 to September 2015 by a single hand surgeon. Cost savings analysis was performed by using the Medical Expense and Performance Reporting System, the standard cost accounting system for the MHS, to compare procedures performed in the clinic versus the operating room during the study period. A study specific questionnaire was obtained for 66 procedures to evaluate the patient's experience., Results: For carpal tunnel release (n = 34) and A1 pulley release (n = 33), there were 85% and 70% cost savings by having the procedures performed in clinic under WALANT compared with the main operating room, respectively. During the study period, carpal tunnel release, A1 pulley release, and de Quervain release performed in the clinic instead of the operating room amounted to $393,100 in cost savings for the MHS. There were no adverse events during the WALANT procedure., Conclusions: A clinic-based WALANT hand surgery program at a military medical center results in considerable cost savings for the MHS., Type of Study/level of Evidence: Economic/Decision Analysis IV., (Copyright © 2017 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)