Anesthesia and Awake Hand Surgery 

Wide-Awake Local Anesthesia No Tourniquet (WALANT) is a technique that uses local anesthetic for hand surgery in place of general anesthesia and a tourniquet [1]. WALANT surgeries typically use lidocaine, which provides analgesia, with epinephrine, which constricts the blood vessels and minimizes bleeding. These injections are given around thirty minutes before surgery. With WALANT, the patient stays awake during surgery and can give the surgeon feedback or perform certain movements intraoperatively, like flexion or extension, which can improve the accuracy of repairs. WALANT surgeries are flexible and can be performed in a surgery center or even a surgery office. Patients can safely drive themselves both to and from the procedure.  

Most hand surgeries can be done via WALANT, but it is usually indicated for patients who may not be able to undergo surgery with full sedation without greater risk. This could be due to conditions like sleep apnea, heart failure, or contraindications to using a tourniquet like patients with AV fistulas. Another important benefit of WALANT is that it makes hand surgical care more accessible in places that may not have resources such as an operating room or anesthesiologists [2]. In the case of more advanced procedures, which may require more instruments and personnel, WALANT can also be easily used in an operating room.  

The three main benefits of WALANT are patient safety, better access to surgery, and improvements in surgeons’ diagnoses and assessments intraoperatively [1]. For example, patient participation can help for repairing tendons as it requires an accurate assessment of tension through certain movements. Another advantage includes decreased adhesion formation in the hand or wrist, effectively minimizing stiffness of the tendons and soft tissue post-operatively. Thus, mobility is often improved after WALANT hand surgery. Further, many studies have shown WALANT to be both cheaper and more efficient by allowing surgery to be done in the ambulatory setting broadly rather than strictly in an operating room [3].   

The most common complication of WALANT is a vasovagal response which can result in fainting [7]. Other complications include anxiety and concerns about being awake during surgery. One study found that all participants would consider WALANT but with reservations involving mostly hearing the surgery or feeling pain [4]. In order to dissipate concerns or fears surrounding WALANT, surgeons should counsel patients on their local anesthesia prior to surgery, include options for distractions during surgery such as music or video with headphones, and confirm a patient’s numbness prior to making any incisions. Overall, patient satisfaction has been found to be very high with WALANT and studies have shown 94% of people would choose to undergo WALANT again for future surgeries [3]. Postoperatively, patients have reported decreased pain compared to surgery with sedation and a tourniquet, and some studies have reported accelerated healing with WALANT [6]. Tourniquets cause significant pain and can only be used for a limited amount of time before the recovery process becomes very complicated. Other potential tourniquet injuries include brachial plexus injuries and damage to upper extremity muscles or vascular structures [5]. In conclusion, WALANT is a great alternative to general anesthesia with tourniquet use for hand surgery and can be incorporated in many different healthcare settings.  

References 

1. Fish, Michael, and H Brent Bamberger. Wide-Awake Local Anesthesia No Tourniquet (WALANT) Hand Surgery. StatPearls Publishing, Jan. 2022, www.ncbi.nlm.nih.gov/books/NBK570646/. 

2. Pires Neto, Pedro José, et al. “Wide Awake Hand Surgery under Local Anesthesia No Tourniquet in South America.” Hand Clinics, vol. 35, no. 1, Feb. 2019, pp. 51–58, 10.1016/j.hcl.2018.08.005. 

3. Tan, Emily, et al. “Incorporating Office-Based Surgery into Your Practice with WALANT.” The Journal of Hand Surgery, vol. 45, no. 10, Oct. 2020, pp. 977–981, 10.1016/j.jhsa.2020.07.003. 

4. Morris, Marie T., et al. “Patient Concerns about Wide-Awake Local Anesthesia No Tourniquet (WALANT) Hand Surgery.” The Journal of Hand Surgery, Nov. 2021, 10.1016/j.jhsa.2021.08.026. 

5. Hutchinson, Douglas T., and Michael A. McClinton. “Upper Extremity Tourniquet Tolerance.” The Journal of Hand Surgery, vol. 18, no. 2, Mar. 1993, pp. 206–210, 10.1016/0363-5023(93)90347-6. 

6. Tahir, Muhammad, et al. “Fixation of Distal Radius Fractures Using Wide-Awake Local Anaesthesia with No Tourniquet (WALANT) Technique.” Bone & Joint Research, vol. 9, no. 7, 1 July 2020, pp. 429–439, www.ncbi.nlm.nih.gov/pmc/articles/PMC7468561/, 10.1302/2046-3758.97.BJR-2019-0315.R1. 

7. Lalonde, Donald H., and Alison Wong. “Dosage of Local Anesthesia in Wide Awake Hand Surgery.” The Journal of Hand Surgery, vol. 38, no. 10, Oct. 2013, pp. 2025–2028, 10.1016/j.jhsa.2013.07.017.