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Purpose: Wide-awake local anesthesia with no tourniquet has dramatically changed hand surgery practice. Using lidocaine with epinephrine and no tourniquet has allowed many procedures to be moved from the main operating room to an in-office procedure room. Previous studies have shown that using local anesthesia is safe and cost effective, with high patient satisfaction. This study evaluated patient satisfaction and complications for the first 1,011 elective hand surgeries performed using wide-awake anesthesia in an in-office procedure room., Methods: The first 1,011 patients who underwent elective hand surgery in an in-office procedure room were surveyed regarding their satisfaction. The patients were monitored for postoperative complications. Patient survey results and complications were logged in a database and analyzed., Results: Single-digit trigger finger release was the most common procedure performed (n = 582), followed by mass excision (n = 158), multiple-digit trigger finger releases (n = 109), and carpal tunnel release (n = 41). There were 43 (4.3%) superficial skin infections, with the majority seen in single-digit trigger finger releases (n = 27). There were no deep wound infections. All infections were managed nonsurgically with oral antibiotics and local wound care. Ninety-nine percent of the patients rated the in-office procedure room experience as the same as or better than a dental visit, would recommend wide-awake anesthesia to a friend or family member, and would undergo the procedure again. Using "lean and green" hand packs saved our institution more than $65,000 and saved 18.4 tons of waste during this study period., Conclusions: Surgical procedures performed with wide-awake local anesthesia with no tourniquet in an in-office procedure room can be performed safely with a low infection rate, are cost effective, and have high patient satisfaction., Clinical Relevance: Minor hand surgery done in an in-office procedure room is safe, is cost effective, and has high patient satisfaction., (© 2022 The Authors.)

Pediatric wide-awake local anesthesia no-tourniquet technique (WALANT) hand surgery is feasible for the treatment of the spectrum of pediatric hand surgeries, which can include traumatic injuries and congenital hand differences. The key component for success is identifying the appropriate patient for this technique, with the typical patient frequently being >10 years of age. The discussion with the patient and adequate preparation for maximum efficiency become key for patient and surgeon comfort. Here we describe a practical approach for successfully performing this valuable technique for the pediatric population., (© 2022 The Authors.)

Wide awake local anesthetic no tourniquet (WALANT) is gaining popularity amongst hand surgeons. Digital adrenaline use has been shown to be safe in multiple studies and the misconception forbidding it is receding. Phentolamine has been shown to safely reverse the effects of adrenaline should the feared complication of digital ischemia occur. A survey was circulated to 40 specialist practitioners who regularly perform hand procedures at a major tertiary plastic and hand surgery unit. Knowledge and understanding of WALANT, onset and duration of adrenaline effects and reversal was assessed. Whilst the majority of respondents (80%) recognized digital adrenaline use as safe, only 65% were aware of the delay until adrenaline takes full effect. Similarly, only 25% of respondents were aware of the duration of effect of adrenaline. Half of respondents were aware that phentolamine is the established reversal agent for adrenaline with only 20% knowing the correct dose. Given the lack of clinician knowledge surrounding adrenaline and its reversal, we feel that to safely undertake WALANT surgery at our Unit a WALANT protocol must be implemented. Drawing on the successes in the airline industry, a variety of safety frameworks have been established to deliver targeted education for prevention and eventual management of predictable risks. We plan to develop a checklist style protocol targeting the knowledge gaps raised in the survey. This will educate and equip all practitioners working with adrenaline with the knowledge to safely manage complications should they occur. LEVEL OF EVIDENCE: Level 5 (UK Oxford Centre for Evidence based Medicine (CEBM) Levels of Evidence)., (Crown Copyright © 2022. Published by Elsevier Masson SAS. All rights reserved.)

Purpose: In this retrospective study, we evaluated the results of central slip reconstruction with a modified Snow's technique under wide-awake local anesthesia no tourniquet., Methods: Between 2016 and 2019, 13 patients with boutonniere deformity were operated. All of the patients had boutonniere deformity with a passively correctable proximal interphalangeal joint. In 7 patients, temporary proximal interphalangeal joint transfixation with a K-wire to secure the repair was preferred. For the rest of the patients, postoperative follow-up was done with an orthosis. All patients were referred to a hand therapist for postoperative rehabilitation., Results: The mean interval between the injury time and the surgery was 55.7 days. After the surgery, the average proximal interphalangeal joint flexion was 104.8° and the loss of proximal interphalangeal joint extension was 6.15°. The average distal interphalangeal flexion was 65.3°. Seven cases had excellent results, 4 patients had good results, and 2 patients had fair results., Conclusions: Our study demonstrated that with a modified Snow technique, encouraging results can be achieved for neglected central slip injuries in which primary repair is impossible. Surgery under wide-awake local anesthesia no tourniquet enables the surgeon to check the stability of the repair, and early active motion with relative motion flexion orthoses can be started with confidence., Type of Study/level of Evidence: Therapeutic IV., (© 2022 The Authors.)

Surgeons are familiar with surgical technique articles that provide step-by-step details of various surgical procedures relevant to clinical practice. This article is a communications technique article that provides step-by-step things that a surgeon can say to a wide-awake patient during the surgery to improve outcomes in clinical practice. The absence of anamnestic sedation enables memorable patient education from their surgeon to decrease the risk of postoperative complications., (© 2022 The Authors.)

A 48-year-old man with drug addiction presented with gangrene of the right hand following an inadvertent intra-arterial administration of crushed dihydrocodeine tartrate (DF 118) tablets (GlaxoSmithKline S.A.) dissolved in water; the solution was injected into his right antecubital fossa. After 3 weeks of pain, paresthesia, and cyanosis, his right hand became gangrenous. We performed a right forearm amputation by use of the wide-awake local anesthesia no tourniquet technique. After surgery, his wound healed well, and he was successfully fitted with a hand prosthesis., (© 2022 The Authors.)

Although rare, the thumb can trigger because of de Quervain disease. An 18-year-old woman presented with painful triggering during thumb movements. Physical examination revealed locking upon thumb extension and painful snapping upon thumb flexion, with tenderness over the first extensor compartment. During the ultrasonography examination, the extensor pollicis brevis tendon snapped with a jerky movement. According to intraoperative active movement under wide-awake local anesthesia no tourniquet, only the extensor pollicis brevis tendon subcompartment was released, and the snapping was resolved. The patient was symptom-free at the second postoperative week control. Triggering because of de Quervain tenosynovitis is a rare condition, and surgical release is required in most cases. Dynamic ultrasonography is an effective tool for precise preoperative assessment of pathology and assists surgical planning. Surgery under wide-awake local anesthesia no tourniquet is advised, which helps intraoperative assessment of pathology and ensures accurate treatment., (© 2022 The Authors.)

Background: The use of minor field sterility in hand/upper extremity cases has been shown to improve workflow efficiency while maintaining patient safety. As this finding has been limited to specific procedures, we investigated the safety of performing a wide array of hand/upper extremity procedures outside the main operating room using minimal field sterility with Wide-Awake Local Anaesthesia No Tourniquet (WALANT) anaesthesia by evaluating superficial and deep infection rates across a diverse series of cases., Methods: This study was a case series conducted between October 2017 and June 2020. Of all, 217 patients underwent hand/upper extremity procedures performed in a minor procedure room via WALANT technique with field sterility. Primary outcome measures include superficial and deep surgical site infections within 14 days post-surgery., Results: Of all, 217 patients were included in this study; 265 consecutive hand/upper extremity operations were performed by a single surgeon, with notable case diversity. The majority of patients (n = 215, 99.1%) did not report or present with signs of infection before or after their operation. We report 0% 14-day and 0.37% 30-day surgical site infection rates for such hand/upper extremity procedures performed in a minor procedure room with field sterility., Conclusion: Hand/upper extremity procedures performed via WALANT technique with field sterility in a minor procedure room are associated with low surgical site infection rates. These rates are comparable to surgical site infection rates for similar surgeries performed in main operating rooms with standard sterilization procedures. Thus, the implementation of this technique may allow for improved workflow efficiency and reduced waste, all while maintaining patient safety., Competing Interests: Declaration of Conflicting Interests: The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article. Steven M. Koehler is a committee member of the American Society for Surgery of the Hand (ASSH), a paid consultant and speaker for Integra LifeSciences, Inc, a paid consultant for Tissium, Inc., a stockholder and member of the medical advisory board for Reactiv, Inc., a member of the advisory board for Androes, LLC, and a speaker for TriMed, Inc., (© 2021 The Author(s).)

Wide Awake Local Anesthesia No Tourniquet (WALANT) is an anesthetic method which uses a local injection of anesthetic and epinephrine, avoiding use of a tourniquet. During the COVID-19 pandemic, human and logistic resources had to be reorganized, and WALANT ensured resilience in our department to maintain access to surgical care. The objective of the present study was to compare hand function recovery 3 months after surgery for unstable metacarpal or phalangeal fracture under regional anesthesia versus WALANT. From November 2020 to May 2021, 36 patients presenting a metacarpal or phalangeal fracture requiring surgical treatment were included in a single-center study in a university hospital center. Nineteen patients underwent surgery under locoregional anesthesia with tourniquet, and 17 under WALANT. The main endpoint was functional recovery at 3 months on QuickDASH score. Need for complementary anesthesia, surgery duration, analgesic consumption, reintervention rate, and patient satisfaction were also assessed. There was no significant difference between groups in functional recovery at 3 months or on the secondary endpoints. In the COVID-19 context, WALANT proved to be a safe and effective method in hand fracture surgery, ensuring access to surgical care. It should be included in surgical training to optimize day-to-day surgical care and face future crises., (Copyright © 2021 SFCM. Published by Elsevier Masson SAS. All rights reserved.)

WALANT (Wide Awake Local Anesthesia No Tourniquet) presents a theoretical risk of digital ischemia due to the presence of epinephrine, associated to the local anesthetic. For this reason, in France, the market authorization prohibits the use of epinephrine in digital extremities. The main objective of the present study was to assess the risk of ischemic complications reported in literature, and then to analyze the medicolegal implications in France. A systematic literature review was performed by three independent readers, using the PubMed and Embase databases. Also, declarations of claims and legal proceedings between 2007 and 2020 in France were examined in the official national Légifrance and Doctrine databases. Eight of the 424 articles retrieved were selected. Only 3 cases of digital necrosis following local anesthesia with adrenalized lidocaine were reported. Adrenalized xylocaine may be considered in case of peripheral microcirculation disorder. From a medicolegal point of view, no complaints or medicolegal implications were associated with WALANT in France. It seems that the market authorization for adrenalized local anesthesia could be extended to use in the digital extremities. However, the lack of medical and legal data calls for caution. We therefore recommend the use of an institutional protocol specifying the cases of overdose and the patient's pathway, and training for practitioners wishing to use this technique., (Copyright © 2022 SFCM. Published by Elsevier Masson SAS. All rights reserved.)

Purpose: We investigated the frequency of wide-awake local anesthesia no tourniquet (WALANT) use for hand surgery in the a 10- to 18-year-old age group and patients' experiences., Methods: Patients aged 10-18 years who had hand surgery in June 2016 to March 2020 were identified. The frequency of patients who agreed to have surgery under WALANT was calculated (%). Patients who received WALANT over the previous year were interviewed for their surgical experiences., Results: A total of 69 patients were identified, and 46 of them received WALANT. The mean age was 14.5 ± 2 years, and 22 of them were boys. Sixteen patients were called for a surgical experience assessment via questionnaire. They reported pain less than 1/10 during anesthesia injection and surgery. Ten patients (62%) found their operation easy, and 14 (87.5%) would prefer WALANT again., Conclusions: This study showed that most patients in the 10-18 years age group accepted WALANT, and their surgical experiences were positive. For its advantages, WALANT should be considered in hand surgery for compliant patients in this age group., Type of Study/level of Evidence: Therapeutic III., (© 2022 The Authors.)

Purpose: Wide-Awake Local Anesthesia No Tourniquet (WALANT) is a novel anesthesia technique in distal radius and ankle fracture fixation. However, to date, there are limited studies in diaphyseal plating of forearm fractures under WALANT. This research is to study the feasibility of the use of WALANT technique in plating of diaphyseal fractures of the forearm as well as peri-operative outcomes., Methods: Sixty-one adult patients who underwent diaphyseal plating of the forearm under WALANT between the period of January 2019 and January 2021. It consists of 31 radius fractures, 15 ulna fractures and 15 ipsilateral radius and ulna fractures. Outcomes evaluated were duration of stay, peri-operative numerical pain rating scale, peri-operative blood pressure and heart rate, visual analogue scale for anxiety, blood loss, surgery duration, adverse effect, patient's satisfaction and any complications at 6 months follow up., Results: Fifty-four patients (88.5%) were male and 7 patients (11.5%) were female with a mean age of 31.7 years (SD = 13.564). Thirty-eight out of 61 patients were totally pain free throughout the surgery. Ten (13%) patients reported pain during muscle dissection, 14 (18%) patients reported pain during bone manipulation and 12 (16%) patients reported pain during bone drilling. There was no significant difference in pain score between radius and ulna bones ( P > .05). There was a significant change in blood pressure after LA infiltration ( P < .01). The mean estimated blood loss was 27.39 ml (SD = 11.44) and the mean duration of post-surgery hospital stay was 1 day (SD = 1.026). Fifty-six patients (92%) recommended diaphyseal plating of the forearm under WALANT. None of the patients required conversion to general anesthesia and had any adverse events or infection during 6 months follow up., Conclusions: Diaphyseal plating of the forearm under WALANT is a feasible alternative anesthesia technique and is well tolerated by patients., Type of Study/level of Evidence: Therapeutic III., (© 2022 The Authors.)

Wide-awake local anesthesia no-tourniquet (WALANT) surgery is an attractive option for hand surgeons, particularly during resource-scarce periods, as it eliminates dependence on main operating rooms or hospital-based procedures. The limited prepping or draping used for WALANT field sterility is as effective, if not more effective, than standard sterile prepping or draping. Patient anxiety surrounding WALANT surgery is similar to or less than that of general or local anesthesia with or without tourniquet. Patients use the same or lower amounts of postoperative narcotics after WALANT as compared to after the other anesthetic methods. Wide-awake local anesthesia no-tourniquet surgery saves significant costs for the same surgeries when performed under general or local anesthesia with or without tourniquet. There are very few complications associated with the WALANT method of anesthesia; rare case reports include vasovagal syncope and cardiac arrhythmia due to inadvertent intravascular injection of epinephrine., (© 2022 The Authors.)

Operative repair of flexor tendons after traumatic injury may be performed under general anesthesia (GA), regional blocks, or a wide-awake local anesthesia no tourniquet (WALANT) technique. To our knowledge there are currently no large-scale reports evaluating outcomes of flexor tendon repair in patients where wide-awake anesthesia was utilized in comparison to regional anesthesia (RA) and general anesthesia. We performed a retrospective analysis of patients who underwent treatment for flexor tendon injuries at a tertiary referral center for hand surgery over a two-year period. A total of 151 patients were included (53 WALANT, 57 RA, and 41 GA) and a total of 251 tendons were repaired (63 WALANT, 104 RA and 84 GA). No statistically significant difference was observed in rates of tendon rupture, adhesions, infection, or hand function. Flexor tendon repair under WALANT is found to be safe and presents comparable operative and functional outcomes to more traditional anesthetic techniques. Additional advantages, including the ability to test the repair intraoperatively, patient education, and the potential for boosting theatre efficiency. Further studies, preferably utilizing a randomized trial methodology, may further elucidate the benefits and risks of WALANT versus regional and general anesthesia., (Copyright © 2021 SFCM. Published by Elsevier Masson SAS. All rights reserved.)

Wide-Awake Local Anesthesia No Tourniquet (WALANT) may be a satisfactory anesthesia alternative for the management of upper limb peripheral nerve palsy sequelae. The main advantages are the possibility of active patient cooperation through intraoperative active mobilization, comfort and cost reduction. The legislation about WALANT in France remains unclear; the modalities of lidocaine epinephrine injection should be redefined. For palliative upper limb surgery, WALANT allows the surgeon to adjust the tension on the tendon transfer intraoperatively. Level 1 studies are needed to evaluate the effectiveness of WALANT relative to standard anesthesia techniques (regional/general anesthesia)., (Copyright © 2021 SFCM. Published by Elsevier Masson SAS. All rights reserved.)

The emergence of the COVID-19 pandemic imposed fundamental changes in the field of surgery. Reorganization was made in order to adequately treat the patients during the pandemic. WALANT (Wide Awake Local Anesthesia No Tourniquet) approach was found to be a very convenient method in facilitating continuity in hand surgery with limited staff. A retrospective comparative study was performed between period of April 2020 till September 2021 at our clinic to evaluate advantages of WALANT approach. This study included 136 patients, from which 72 (53%) were operated with WALANT, compared to the control group of 64 (47%) patients without WALANT. Average hospital stay for the WALANT group was 2.2 days vs. 4.7 days for the control group. Average operating room personnel were 3.8 for WALANT and 6.2 for the control non-WALANT group. Intraoperative and postoperative VAS (visual analogue scale) score was evaluated. Due to its diversity, low cost and low complication rate, we recommend WALANT approach in acute and elective hand surgery.

Backround: The aim of this study was to determine, if Wide Awake Local Anesthesia No Tourniquet (WALANT) can be used as an alternative method of providing anesthesia in management of deep infections of the hand. Since the advent of WALANT in 2003, infections of the hand have been regarded as a contraindication to its use. Occasional shortage of anesthesiologic manpower, especially during busy call hours and the current COVID-19 pandemic can lead to delay of treatment where urgent surgery is needed, to prevent progress of an infection, that can result in severe morbidity., Methods: In the period from 2015 to 2020, 16 patients with various infections of the hand underwent 17 operations using WALANT in a Hand Trauma and Replantation Center (HTRC) in Germany. Retrospective cohort analysis of their operation reports, with emphasis on location of infection, time and duration of the operation, intraoperative incidents and complications were carried out. We also evaluated the need for revision surgery or necessity to convert to general anesthesia and factors causing delay till the time of surgery., Results: No case of inadequate analgesia, the need to convert to general anesthesia, ischemic events or cardiovascular complications with the use of the WALANT solution containing adrenaline and lidocaine in the treatment of deep tissue infections.The highest priority of limb preservation was ensured as no patient progressed to amputation of a digit or the hand. There was a statistically significant difference (p ≤ 0.01) in delay from the time of admission until surgery of up to 9h24 m (SD±3h34 m) during the week and 4h10 m (SD±2h28 m) during the weekend., Conclusion: The status of infection as an absolute contraindication to the use of WALANT should be revised. Especially when human resources are limited, WALANT is an adequate technique to enable quick anesthesia for urgent treatment to prevent progression of hand infections., Competing Interests: None., (© 2021 The Authors.)

This study aimed to evaluate the effectiveness of the WALANT technique in managing spaghetti wrist lacerations. Thirteen consecutive patients with spaghetti wrist laceration were operated on under WALANT technique and followed prospectively. All patients were operated on by the same hand surgeon in a university hospital setting. At the final follow-up, arterial patency, tendon repair, nerve regeneration, handgrip strength and overall patient satisfaction were assessed. All patients were male, with a mean age of 23.8 ± 7.7 years (range, 18-42). The mean waiting time from admission to operation was 33.6 ± 5.1 min (range, 26-42). The operation lasted a mean 119.6 ± 33.8 min (range, 75-185). Mean time from admission to discharge was 269.3 ± 35.0 min (range, 225-341). Mean VAS for intraoperative pain was 1.0 ± 0.9 points (range, 0-3). Patients were followed up for at least 6 months: mean 9.8 ± 1.6 months (range, 7-12). Ten of the 12 repaired arteries were patent and 2 were occluded at the final follow-up. Six of the 17 repaired nerves were evaluated as excellent, 9 as good and 2 as fair on 2-point discrimination test. Total active range of motion was perfect in 6 patients, good in 6, and fair in 1. Grip strength was averaged 86.8% (range, 76.9-93.5%) of the contralateral value. All patients were either very satisfied (n: 9) or satisfied (n: 4). The WALANT technique can be used for spaghetti wrist lacerations involving the tendons, arteries and nerves, with favorable outcome. Major arterial anastomosis can be performed without any surgical limitation., (Copyright © 2021 SFCM. Published by Elsevier Masson SAS. All rights reserved.)

We report on the surgical technique for mini-open derotation osteotomy using retrograde osteosynthesis by headless compression screw under WALANT anesthesia (video attached). Preoperative CT showed the feasibility of this technique, with a 2.2 mm headless compression screw. The mechanical stability of the resulting constructs combined with intraoperative active motion testing under WALANT authorized immediate rehabilitation without immobilization, thus preventing stiffness. Joint range of motion recovered by day 4 and bone consolidation was achieved at 30 days., (Copyright © 2021 SFCM. Published by Elsevier Masson SAS. All rights reserved.)

We describe an innovative mini-open technique for reinsertion of the flexor digitorum profundus tendon under Wide Awake Local Anesthesia No Tourniquet (WALANT) with ultrasound assistance. Ultrasound-aided detection at the surgeon's practice is used to plan the surgical tendon repair procedure so that tendon reinsertion can be performed with the smallest incision possible. Passage of the tendon through the digital sheath was accomplished with the help of a compressive tendon guide to avoid a surgical approach. Reinsertion of the tendon under WALANT monitoring enables intraoperative validation of repair tension and physiological restitution of tendon glide within the digital sheath. Postoperative ultrasonographic examination at the surgeon's practice is an occasion to further patient education begun intraoperatively under WALANT., (Copyright © 2021 SFCM. Published by Elsevier Masson SAS. All rights reserved.)

Percutaneous staged lateral band tenotomy can restore the balance between finger flexion and extension in the management of swan neck deformity due to intrinsic muscle retraction. Using WALANT confirmed the effectiveness of this technique because it provides an instantaneous intraoperative assessment of the deformity's correction., (Copyright © 2021 SFCM. Published by Elsevier Masson SAS. All rights reserved.)

We hypothesized that WALANT would provide similar perioperative analgesic comfort compared to local anesthesia with peripheral nerve blocks (LAPNV). We analyzed whether the patient's active participation during surgery would improve its early functional results. We did a retrospective, single study in an outpatient surgery unit, comparing two types of surgery: trapeziometacarpal arthroplasty (TMCA) under LAPNV and TMCA under WALANT. Fifteen patients were included per group. Pain levels were determined during anesthesia induction, intraoperatively, postoperatively, at rest and during activity at the last follow-up visit. The overall satisfaction with the surgery and time to resume daily activities and work were documented. The statistical analysis was performed on SAS software with an ANOVA. The significance threshold was set at 0.05. The groups were comparable on age, sex, dominant side, and operated side. No patients were lost to follow-up. The mean follow-up was 4 months (2.3-11). The QuickDASH score was 4.93 for TMCA under WALANT vs. 13.47 for TMCA under LAPNV (p = 0.01). There was no loosening, dislocation, or major complication. Our study showed that TMCA performed with WALANT yields similar results to the same procedure with LAPNV for perioperative pain relief without additional complications. Functional scores seem to be slightly improved with WALANT compared to LAPNV, but these results should be confirmed with longer follow up., (Copyright © 2021 SFCM. Published by Elsevier Masson SAS. All rights reserved.)

Postoperative dressing protocols after clean surgery without implant vary widely. The purpose of this study was to elucidate whether early postoperative dressing removal is a valid option, as compared to untouched dressing or twice-weekly dressing change approach. A prospective randomized study was conducted on patients who underwent carpal tunnel release (CTR) or trigger finger release (TFR) between January and November 2020. Patients were randomly distributed into 3 groups: surgical dressing untouched until first follow up (SDU); surgical dressing changed twice a week in a health maintenance organization (HMO); and surgical dressing removed at first postoperative day (SDR). Data collected included patient characteristics, pre-and post-operative functional (QuickDASH) and autonomy (Instrumental Activities of Daily Living performance (IADL)) scores, Vancouver scar scale (VSS) and potential complications. Eighty-four patients were included: 28 (33.3%), 29 (34.5%) and 27 (32.1%) in the SDU, HMO and SDR groups, respectively. Deterioration in mean IADL score at 2-week follow-up was statistically significant in the HMO group (mean delta 3.35, p = 0.008). Quick DASH score improved significantly between preoperative and 2-week follow-up values only in the SDU group (mean delta 9.12, p = 0.012). Other parameters, including wound complications, did not differ significantly between groups. Early removal of postoperative dressing and immediate wound exposure was a safe option after CTR and TFR. An untouched bulky dressing correlated with early functional improvement. Finally, iterative dressing change in HMO showed no benefit and led to significant deterioration in early postoperative autonomy. IRB APPROVAL: 0548-18-TLV. LEVEL OF EVIDENCE: I., (Copyright © 2021. Published by Elsevier Masson SAS.)

Purpose: Wide-awake local anesthesia no-tourniquet (WALANT) hand surgery has gained popularity because of its cost savings, safety, favorable outcomes, and high patient satisfaction. However, the wide-awake nature of the technique causes many patients to experience anxiety during the procedure. Nonorthopedic studies have reported the anxiolytic effects of intraprocedural music in a variety of wide-awake medical procedures. This prospective randomized controlled trial investigated the effects of wearing noise-canceling headphones and listening to music on patient anxiety during WALANT hand surgery., Methods: Institutional review board approval was obtained. Patients were randomized to one of the following groups: (1) a headphones group that wore noise-canceling headphones and listened to music (genre of their choice) during the surgery, or (2) a control group that neither wore noise-canceling headphones nor listened to music during surgery. Patient anxiety was assessed on a 10-point visual analog scale before, during, and after surgery. All patients completed an overall experience questionnaire after surgery., Results: Fifty patients were enrolled, with 25 in each group. Both the groups were similar in terms of patient characteristics, diagnosed anxiety, and preoperative level of anxiety. The headphones group was found to have significantly less intraoperative anxiety (1.02 vs 2.32, respectively; P  = .017) and a significantly greater net decrease in anxiety from the preoperative to intraoperative level (-1.78 vs -0.56, respectively; P  = .033) than the control group. In the headphones group, 92% (23/25) of patients stated that they would recommend wearing noise-canceling headphones and listening to music to other WALANT hand surgery patients. All (50/50) patients in both groups reported that they would choose to undergo WALANT hand surgery again if needed for the same problem., Conclusions: The use of noise-canceling headphones with music during WALANT hand surgery significantly decreases intraoperative patient anxiety. This intervention represents an effective, safe, and inexpensive nonpharmacologic measure to improve patient anxiety and overall experience with WALANT hand surgery., Type of Study/level of Evidence: Therapeutic I., (© 2021 The Authors.)

The Wide-Awake Local Anesthesia No Tourniquet (WALANT) method is a recent anesthesia option for surgery of the upper limbs based on the injection of an anesthetic solution containing adrenaline at the surgical site, hence circumventing tourniquet use. In a prospective study, we compared the functional outcomes using this anesthesia technique with those of the regional anesthesia (RA) technique for the surgical care of distal radius fractures (DRF). From November 2019 to June 2020, a non-randomized, single-center study was conducted with a cohort of 41 patients suffering from a DRF and who received volar plate fixation at a university hospital center. Twenty-one patients had WALANT surgery and 20 had RA with installation of a tourniquet. Over a period of 7 months, the clinical and radiological outcomes as well as the QuickDASH functional score were evaluated. Recovery of wrist function return to work, and analgesic withdrawal for the WALANT group occurred earlier than for the RA group. No noticeable differences were found regarding surgery duration or radiographic results. Using WALANT, functional wrist recovery occurs earlier than with RA. In our study, earlier analgesic stoppage, a quicker return to work and resumption of activity were observed with WALANT. As such, it should become part of the therapeutic arsenal for surgical treatment of DRF., (Copyright © 2021 SFCM. Published by Elsevier Masson SAS. All rights reserved.)

The field of hand surgery continues to evolve in new and exciting directions. Advances in diagnosis and management for common complaints and complex injuries allow higher-level care, while still being cognizant of the cost of health care delivery. Indications and protocols for past paradigm shifts, such as volar locked plating for distal radial fractures, continue to be honed, and the outcomes seen for modern flexor tendon repairs are impressive. Open questions remain, but promising results for scaphoid nonunion surgery and peripheral nerve reconstruction with processed allograft will continue to shed light on these unsolved problems., Competing Interests: Disclosures The author has no relevant financial disclosures., (Copyright © 2021 Elsevier Inc. All rights reserved.)

To evaluate the cost-effectiveness of corticosteroid injection(s) versus open surgical release for the treatment of trigger finger. 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. 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. 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. Economic and Decision Analyses II. [ABSTRACT FROM AUTHOR]

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. 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. 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. 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. Therapeutic IV. [ABSTRACT FROM AUTHOR]

Purpose: Wide-awake local anesthesia with no tourniquet (WALANT) as a walk-in procedure has become a standard technique in open carpal tunnel release (OCTR) and continues to replace the long-established intravenous regional anesthesia with a tourniquet (IVRA/"bier-block") in our clinic. The aim of this study was to compare patient satisfaction with either WALANT or IVRA/"bier-block" and define subgroups that are particularly suited for either of the two procedures. We hypothesized that older patients would prefer IVRA because of a shorter period of postoperative surveillance., Methods: In this retrospective study we evaluated patient satisfaction with either WALANT or IVRA using an adjusted questionnaire on a standard Swiss grading system (from 1 = insufficient/very strong pain to 6 = excellent/no pain). Secondary outcomes included postoperative pain or satisfaction with the tourniquet and quality of postoperative care., Results: For the 176 patients (WALANT, n = 109; IVRA, n = 67) included in the study, there was high patient satisfaction with both procedures (WALANT, 5.5/6; IVRA, 5.5/6). Patients aged 80 years and older had significantly less postoperative pain after WALANT (WALANT, 5.8/6 vs IVRA, 4.9/6)., Conclusions: Patients aged 80 years and older had significantly less postoperative pain after WALANT than that after IVRA. Here, sarcopenia may have contributed to the prolonged discomfort after tourniquet application. Immediate postoperative discharge after WALANT did not negatively affect older patients., Clinical Relevance: For OCTR, WALANT as a walk-in procedure is a safe and comfortable alternative to IVRA, which is commonly planned with short postoperative surveillance. Both anesthesia techniques are suitable for all ages and sexes but based on this study we recommend WALANT as a tourniquet-free operation in older patients., (© 2021 The Authors.)

We conducted a descriptive study of 50 consecutive cases of total trapeziometacarpal joint arthroplasty by one surgeon using wide awake local anaesthetic no tourniquet to assess the usefulness and reliability of the anaesthesia, any adverse effects and patient acceptance. No difference was found when comparing the duration of surgery with 50 cases of total trapeziometacarpal joint arthroplasty inserted in a bloodless field under general or regional anaesthesia by the same surgeon. Wide awake local anaesthetic no tourniquet was found to be useful in providing adequate anaesthesia and haemostasis, and to be reliable and safe with no adverse effects. Patient satisfaction was high with 100% willing to repeat. Overall, wide awake local anaesthetic no tourniquet was a satisfactory method of anaesthesia for trapeziometacarpal joint arthroplasty with the potential for significant benefits to both patient and surgeon compared with traditional general anaesthesia and regional block. Level of evidence: II.

The injection of collagenase followed by cord manipulation is one of the most popular treatments for Dupuytren's contracture. This is traditionally performed under local anesthesia or regional nerve block potentially with sedation. Neither the treatment with collagenase, nor the wide-awake anesthesia are novel techniques for hand surgeons. Nevertheless, we report the first experience of cord manipulation using the wide-awake approach. In this prospective study, we compared the pain perception of patients who underwent wide-awake anesthesia versus traditional local anesthesia. We recorded the pain sensation on a visual analog scale (VAS) (0 to 10) during anesthetic injection, during cord manipulation and before discharge. Wide-awake anesthesia significantly reduced pain levels during anesthetic injection (p=0.003) and cord manipulation (p=0.0009). Pain levels did not differ significantly right before discharge in the two groups (p=0.54). Wide-awake anesthesia can be successfully applied to cord manipulation after collagenase injection in Dupuytren's contracture. This way, it is possible to improve the patient's subjective perspective of the procedure., (Copyright © 2020 SFCM. Published by Elsevier Masson SAS. All rights reserved.)

Competing Interests: No conflicts of interest to declare

We have all heard the old aphorism, "Necessity is the mother of invention." While the provenance of the proverb is uncertain, its truth is not in doubt. This is true for the development of hand surgery in Malaysia. As part of the management for leprosy, patients with high ulnar nerve palsies were managed by the pioneers of hand surgery in Malaysia. They did tendon transfers to improve the quality of life of these patients. Since then, hand surgery in Malaysia have grown leaps and bounds. From a small humble beginning in the suburb of Sungai Buloh to organizing the 10th Congress of Asian Pacific Federation of Societies for Surgery of the Hand, hand surgery in Malaysia will only get better with time., Competing Interests: Conflict of Interest None declared., (Society of Indian Hand & Microsurgeons. This article is published by Thieme.)

Background: There is still some debate regarding the most proper anesthetic technique in minor hand surgeries. We hypothesized that both the WALANT and forearm tourniquet Bier block methods provide effective anesthesia in minor hand surgeries without significant difference., Methods: A total of 85 patients consented to participate in this study and were randomized into WALANT and single tourniquet forearm Bier block groups. In WALANT group, patients received adrenaline-contained lidocaine without tourniquet while lidocaine was administered accordingly after applying a forearm tourniquet in Bier group. Due to difference in intervention methods, the study was non-blinded. Need for additional analgesia during surgery, visual analogue scale (VAS) for pain intensity during operation and an hour later, amount of bleeding and active hand movements were evaluated and recorded., Results: The need for analgesia and severity of pain (VAS) during surgery and one hour later were significantly less in WALANT group, whereas the amount of bleeding was less in Bier block group. The ability to move hand and fingers during the operation was the same in both groups., Conclusion: Both WALANT and single cuff forearm tourniquet Bier block are effective methods in minor hand surgeries, however, forearm Bier block provides less analgesia and pain control with a drier field than WALANT method.

Introduction: Epinephrine and sodium bicarbonate (NaHCO 3 ) used in wide-awake local anesthesia no tourniquet (WALANT) affect many areas such as hemostasis, injection pain, anesthetic effect and others. However, few clinical trials have focused on injection pain and the duration of anesthetic effect, and no prospective studies have reported the benefits of WALANT post operation. This study compared WALANT with conventional local anesthesia with tourniquet in minor hand surgeries, and aimed to answer following questions: (1) Does WALANT have enough benefits for injection pain and duration of anesthetic effect?; (2) How does WALANT affect postoperative management (such as postoperative pain and use of analgesics)?; (3) How satisfied are the patients with the surgery?, Hypothesis: We hypothesized that WALANT had advantages in injection pain, duration of anesthetic effect, and postoperative management compared to conventional local anesthesia., Materials and Methods: The present study is designed as a randomized prospective one center study. This study included 185 patients who received surgical treatment for the diagnosis of carpal tunnel syndrome, trigger finger, or de Quervain's disease between 2017 and 2019. We randomly allocated the patients to either the WALANT group or the conventional group. We inquired and recorded patients' injection pain, duration of anesthetic effect, postoperative pain, the use of analgesics, and satisfaction with the surgery., Results: The injection pain was significantly lower in the WALANT group in all procedures (p<0.001). The duration of anesthetic effect was significantly longer in the WALANT group in all procedures (p<0.001). As for the postoperative management of all procedures, the pain score was significantly lower in the WALANT group until the first day after surgery, with the biggest difference at 6hours after surgery. The use of analgesics was significantly lower in the WALANT group until the second day after surgery. Satisfaction with surgery was significantly higher in the WALANT group in all procedures: A1 pulley release (p=0.026), 1st extensor retinaculum (p=0.045), and carpal tunnel release (p=0.003)., Discussion: Our study showed better results in WALANT than in the conventional method, with no tourniquet pain, lower injection pains, longer anesthetic duration, and less postoperative pain. It provided patients with great satisfaction. In addition, WALANT has the potential benefits of no time limit due to tourniquet pain and long anesthetic effect. Therefore, WALANT is comfortable and cost effective, and could be a good alternative to conventional local lidocaine anesthesia., Level of Evidence: II., (Copyright © 2020 Elsevier Masson SAS. All rights reserved.)

Purpose: Carpal tunnel syndrome is a common disease treated operatively. During the operation, the patient may be wide-awake or sedated. The current literature has only compared separate cohorts. We sought to compare patient experience with both local-only anesthesia and sedation. Methods: Staged bilateral carpal tunnel release utilizing open or endoscopic technique was scheduled and followed through to completion of per-protocol analysis in 31 patients. Patients chose initial hand laterality and were randomized regarding initial anesthesia method: local-only or sedation. Data collection via questionnaires began at consent and continued to 6 weeks postoperatively from second procedure. Primary outcome measures included patient satisfaction and patient anesthesia preference. Results: At final follow-up, 6 weeks postoperatively, high satisfaction (30 of 31 patients per method) was reported with both types of anesthesia. Among these patients, 17 (54%) preferred local-only anesthesia, 10 (34%) preferred sedation, 2 had no preference, and 2 opted out of response. Although anesthesia fees were approximately $390 lower with local-only anesthesia, total costs for carpal tunnel release were not significantly different with respect to the anesthesia cohorts. Total time in surgical facility was approximately 26 minutes quicker with local-only anesthesia, largely due to shorter time in the post-anesthesia care unit. Scaled comparison of worst postoperative pain following the 2 procedures revealed no difference between local-only anesthesia and sedation. Conclusions: Patients reported equal satisfaction scores with carpal tunnel release whether performed under local-only anesthesia or with sedation. In addition, local-only anesthesia was indicated as the preference of patients in 59% of cases.

Background: Fixation of clavicle fractures has now become a more popular option as it provides better outcome compared with conservative management. Wide-awake local anesthesia no tourniquet (WALANT) has been effectively used in plating of distal radius and olecranon fractures. This paper expands the usage of WALANT into the shoulder girdle, namely plating of the clavicle that has not been described. The operation is typically performed under general anesthesia., Methods: We report a case series of 16 patients who successfully underwent fixation of the clavicle under the wide-awake technique. The clavicle fractures were grouped under the AO Fracture Classification. The WALANT solution comprised 1% lidocaine, 1:100,000 epinephrine, and 10:1 sodium bicarbonate. A total of 40 mL was injected in each patient with 10 mL subcutaneously along the clavicle followed by 30 mL subperiosteally at multiple intervals and directions., Results: The Numerical Pain Rating Score was 0 during WALANT injection and during surgery except for 2 patients with Numerical Pain Rating Scores of 1 and 2, respectively, during reduction., Conclusion: We conclude that clavicle plating under WALANT is a good alternative option of anesthesia., (Copyright © 2020 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)