The value of local dexmedetomidine as an adjuvant to ultrasound-guided wide awake local anesthesia no tourniquet (WALANT) in flexor tendon repair surgeries: a randomized controlled trial.

BACKGROUND: The Wide-Awake Local Anesthesia No Tourniquet (WALANT) technique allows intraoperative motor assessment of tendon repair integrity of the hand compared with general anesthesia or brachial plexus block. No studies have tested the effect of adding dexmedetomidine to lidocaine on the analgesic properties of the WALANT technique, which is the aim of our study. METHODS: A total of 128 patients aged more than 18 years were scheduled for surgical flexor tendon injury repair using WALANT technique. Patients were divided into two equal groups. Ultrasound-guided subcutaneous injection of lidocaine 1% with dexmedetomidine (1 µg/kg), Group D, or without dexmedetomidine, Group C, was performed at four points: proximal to the wrist joint, the distal forearm, palm region, and proximal phalanges. The primary outcome was total morphine consumption throughout the first postoperative day. Secondary outcomes included number of patients requiring rescue analgesia, time to first analgesic request, and pain score. RESULTS: Total morphine consumption was significantly (P < 0.001) lower in group D (2.66 ± 0.998) than in group C (3.66 ± 1.144) mg. Number of patients requiring rescue analgesia was significantly (P < 0.001) lower in group D (54.7% (35)) than group C (100.0% (64)). The time for first request for analgesia was significantly (P < 0.001) longer in group D (11.31 ± 6.944) than in group C (5.91 ± 4.839) h. Pain score was significantly higher in group C than D at three (P < 0.001), and six (P = 0.001) hours (P = 0.001) postoperatively. CONCLUSION: Dexmedetomidine significantly improves the analgesic quality of WALANT when added to lidocaine with less opioid consumption. TRIAL REGISTRATION: (ID: PACTR202203906027106; Date: 31/07/2023).

The Effect of Anticoagulant and Antiplatelet Medications on Wide-Awake Hand Surgery: An Analysis of 2,162 Cases.

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.

Carbon Footprint of Open Carpal Tunnel Release Surgery Performed in the Procedure Room Versus Operating Room Setting.

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 CO2, whereas oCTR in the PR emitted 13.0 kg CO2 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.

What Is a Surgical Site Infection After Carpal Tunnel Release?

PURPOSE: Considerable variation exists in the literature on published rates of surgical site infection (SSI) after carpal tunnel release, ranging over 20-fold, from 0.28% to 6.4%. The reason for this variability is unknown. METHODS: A retrospective review was conducted on 748 open carpal tunnel releases performed under wide-awake local anesthetic no tourniquet in an in-office procedure room. The following three different definitions of infection were used for analysis: definition A: prescription of an oral antibiotic; Definition B: SSI definition by the Centers for Disease Control and Prevention; Definition C: infection that required reoperation. RESULTS: Infection rate by definition A was 8.9% (67/748), by definition B was 2.3% (17/748), and by definition C was 0.4% (3/748), resulting in a 22-fold range. CONCLUSIONS: The infection rate after carpal tunnel release is heavily influenced by the definition of SSI. The definition of SSI needs to be considered when making comparisons, either in research or quality assurance/quality improvement applications. CLINICAL RELEVANCE: When analyzing SSI rates, the exact definition of infection must be ascertained to accurately compare an individual's practice or institutional data to the literature.

Complications and side effects of Wide-Awake Local Anaesthesia No Tourniquet (WALANT) in upper limb surgery: a systematic review and meta-analysis.

PURPOSE: Wide-Awake Local Anaesthesia No Tourniquet (WALANT), a groundbreaking anaesthetic technique resurging in practice, warrants a comprehensive safety analysis for informed adoption. Our study aimed to identify complications/side effects of WALANT upper limb procedures through a systematic review and meta-analysis. METHODS: This PROSPERO-registered study was performed with strict adherence to PRISMA guidelines. Embase, OVIDMedline, Cochrane, Web of Science, and Scopus databases were searched until February 2023. Inclusion criteria involved English articles, reporting complications/side effects in primary WALANT upper limb surgeries. Outcomes included all complications and side effects, data on the anaesthetic mixture, publication year/location, study type, and procedures performed. The meta-analysis employed the Freeman-Tukey Double Arcsine Transformation, computed I2 statistics, and utilized common or random effects models for pooled analysis. RESULTS: 2002 studies were identified; 79 studies met the inclusion criteria representing 15,595 WALANT patients. A total of 301 patients had complications, and the meta-analysis using a random effects model provided a complication rate of 1.7% (95% CI: 0.93-2.7%). The most reported complications were superficial infection (41%, n = 123/300), other/specified (12%, n = 37/300), and recurrent disease (6.7%, n = 20/300). A decade-by-decade analysis revealed no statistically significant difference in complication rates spanning the last three decades (p = 0.42). Adding sodium bicarbonate to the anaesthetic solution significantly reduced postoperative complications (p = 0.025). CONCLUSION: WALANT has a low overall complication rate of 1.7%, with no significant temporal variation and a significant reduction in complications when sodium bicarbonate is added to the anaesthetic solution. Our findings support the safety of WALANT in upper limb procedures. REGISTRATION: PROSPERO: CRD42023404018.

Evaluating patient satisfaction with WALANT for hand surgery: a comprehensive questionnaire-based study.

INTRODUCTION: There has been an increase in the popularity of the wide-awake local anesthesia no-tourniquet (WALANT) procedure for various upper limb surgeries. The present study aims to conduct a comprehensive analysis of the satisfaction levels of 106 patients, considering factors such as age, gender, comorbidities, and the specific procedures they underwent. METHOD: The present study was a retrospective cohort study conducted to analyze the overall satisfaction of a cohort of 106 patients who underwent various surgical procedures of the hand between 2018 and 2023. The satisfaction was assessed with a questionnaire comprising 13 questions/statements adjusted to a standard Swiss grading system (from 1 = I strongly agree to 6 = I strongly disagree). RESULTS: Overall satisfaction with WALANT was high, with most patients expressing positive experiences. Patients with hypertension reported similar satisfaction levels compared to those without, while diabetic patients experienced significantly higher anxiety levels during the procedure (p > 0.05). CONCLUSION: WALANT exhibits versatility as an anesthesia choice, demonstrating efficacy in both routine and complex hand surgeries. Our survey-based study reveals a high satisfaction level across diverse procedures. When assessing the correlation between WALANT satisfaction and patient comorbidities, hypertension displayed no significant impact, while diabetic patients reported heightened anxiety. Importantly, patient satisfaction remained consistently high even within the subgroup with comorbidities. Our results underscore WALANT's reliability in upper limb surgery, showcasing its usefulness and positive outcomes across a broad range of patients and surgical procedures.

Utilization of a Clinic-Based Hand Surgery Procedure Room in the US Military Health System: A Performance Improvement Analysis of Resource Savings and Patient Satisfaction.

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.

Wide-Awake Local Anesthesia No Tourniquet Surgery for Zone VII Extensor Tendon Reconstruction: Stages in Active Range of Motion From Intraoperative to Final Recovery.

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.

Optimizing the Use of Operating Rooms by Transitioning Common Hand Surgeries Into the Office Setting.

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.

Cinnamon Roll Technique with WALANT for Nipple Reduction.

BACKGROUND: Nipple hypertrophy is a common esthetic problem in Asian women. Many patients are uncomfortable and seek plastic surgeons for correction. Although several reduction methods have been published, the new nipple size is not always decided by patients under conventional anesthesia. We describe a novel cinnamon roll technique with wide-awake local anesthesia no tourniquet (WALANT) to decrease pain, provide a bloodless field and allow on-table discussion of the ideal nipple size during surgery. METHODS: Between November 2015 and October 2022, fifteen patients with 30 nipples were enrolled. The patient's characteristic data, nipple height and width, and VAS while infiltration were recorded. Aesthetic results were evaluated by rating a satisfactory score from 0 to 10 at follow-up. Sensory recovery was also evaluated for 1, 3, 6, and 12 months sequentially after the surgery. RESULTS: Before surgery, the mean diameter and height of the nipples were 13.2 ± 1.8 mm and 12 ± 2.2 mm, respectively. Immediately after surgery, the mean diameter and height of the nipples were 8.8 ± 1.2 mm and 8.7 ± 1.2 mm, respectively. The mean VAS while infiltration was 1.3 ± 0.5 and the mean satisfactory score at the latest clinic follow-up was 9.3 ± 0.6. No complications such as nipple necrosis, infection, numbness or hypertrophic scar occurred. The mean clinical follow-up period was 3.4 months. CONCLUSIONS: Cinnamon roll technique with WALANT is a simple, safe and reliable method with short learning curve and high satisfaction. Our technique offers a chance for patients to control subjective pleasing size of their own nipples. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine Ratings, please refer to Table of Contents or online Instructions to Authors www.springer.com/00266.

Wide Awake Local Anesthesia No Tourniquet Endoscopic Cubital Tunnel Release.

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.

Patient Concerns About Wide-Awake Local Anesthesia No Tourniquet (WALANT) Hand Surgery.

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.

WALANT as an Optimal Approach in Hand Surgery during Pandemics.

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.

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.

BACKGROUND: The WALANT (wide-awake local anesthesia with no tourniquet) technique was based on local infiltration of lidocaine and epinephrine. This technique has rapidly gained popularity in recent years and can perform most hand operations. This study aimed to investigate the time spent on anesthesia and operation and perform an economic analysis among general anesthesia, wrist block with a tourniquet, and the WALANT technique for the internal fixation of metacarpal fractures. METHODS: We retrospectively reviewed all the single metacarpal fractures managed with the same procedure, open reduction, and internal fixation with the plate between January 2015 and December 2019. They were divided into three groups according to the method of anesthesia: (1) general anesthesia (GA group), (2) wrist block with a tourniquet (WB group), and (3) WALANT technique (WALANT group). We collected and analyzed patient demographic data, perioperative or postoperative complications, number of hospital days, and postoperative functional recovery assessment. RESULTS: A total of 63 patients met the inclusion criteria, including 24 in the GA group, 28 in the wrist block group using a tourniquet, and 11 in the WALANT group. There were no complications during the operation and follow-up in each group. The GA group had an average of 32.8 min of anesthesia time, significantly longer than the other two groups. However, there is no significant difference regarding surgical time among the presenting three groups. The discomfort of vomiting and nausea after surgery occurred in 20 patients in the GA group (38.1%). Nevertheless, there was no postoperative vomiting and nausea present in both the WB and WALANT groups. Most patients achieved full recovery of pre-injury interphalangeal and metacarpophalangeal motion at the final assessment of functional recovery. CONCLUSIONS: The patients undergoing metacarpal fixation surgery under WALANT or WB had significantly less anesthesia time and postoperative vomiting and nausea. Moreover, there was no difference in surgical time and intraoperative complications. The time-related reduction improved the utilization of the operation room for additional cases. The reduction of the preoperative examination, anesthesia fee, postoperative recovery room observation, and hospitalization can effectively reduce medical costs. Furthermore, the WALANT group is more acceptable because of no tourniquet, which commonly causes discomfort.

Comparison of Complication Risk Following Trigger Digit Release Performed in the Office Versus the Operating Room: A Population-Based Assessment.

PURPOSE: Trigger digit release (TDR) performed in an office-based procedure room (PR) setting minimizes surgical costs compared with that performed in an operating room (OR); yet, it remains unclear whether the rates of major complications differ by setting. We hypothesized that surgical setting does not have an impact on the rate of major complications after TDR. METHODS: Adult patients who underwent isolated TDR from 2006 to 2015 were identified from the MarketScan commercial database (IBM) using the provider current procedural terminology code 26055 with a concordant diagnosis on the same claim line (International Classification of Diseases, ninth revision, clinical modification 727.03). The PR cohort was defined by presence of a place-of-service code for an in-office procedure without OR or ambulatory center revenue codes, or anesthesiologist claims, on the day of the surgery. The OR cohort was defined by presence of an OR revenue code. We identified major medical complications, surgical site complications, as well as iatrogenic neurovascular and tendon complications within 90 days of the surgery using International Classification of Diseases, ninth revision, clinical modification diagnosis and/or current procedural terminology codes. Multivariable logistic regression was used to compare the risk of complications between the PR and OR groups while controlling for Elixhauser comorbidities, smoking, and demographics. RESULTS: For 7,640 PR and 29,962 OR cases, the pooled rate of major medical complications was 0.99% (76/7,640) and 1.47% (440/29,962), respectively. The PR setting was associated with a significantly lower risk of major medical complications in the multivariable analysis (adjusted odds ratio 0.76; 95% confidence interval 0.60-0.98). The pooled rate of surgical site complications was 0.67% (51/7,640) and 0.88% (265/29,962) for the PR and OR cases, respectively, with no difference between the surgical settings in the multivariable analysis (adjusted odds ratio 0.81; 95% confidence interval 0.60-1.10). Iatrogenic complications were infrequently observed (PR 5/7,640 [0.07%]; OR 26/29,962 [0.09%]). CONCLUSIONS: Compared with performing TDR in the OR using a spectrum of commonly used anesthesia types, performing TDR in the PR using local-only anesthesia was associated with a comparably low risk of major medical complications, surgical complications, and iatrogenic complications. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic II.

WALANT-Epinephrine injection may lead to short term, reversible episodes of critical oxygen saturation in the fingertips.

INTRODUCTION: Although the WALANT technique's long-term safeness has been demonstrated in many studies, there are only few data investigating its short-term effects on tissue perfusion and oxygen levels. It was hypothesized that, temporarily, critical levels of tissue perfusion may occur. METHODS: Seventeen patients, who were scheduled for different procedures in WALANT technique, were injected with 5-7 ml of 1% Articain containing 1:200,000 epinephrine at the finger base. Capillary-venous oxygen saturation, hemoglobin volume in the capillaries, and relative blood flow in the fingertips were recorded once per second by white light spectrometry and laser Doppler flowmetry before, during and after injection for an average of 32 min. RESULTS: Clinically, no persistent tissue malperfusion was observed, and there were no postoperative complications. Capillary-venous oxygen saturation was reduced by ≥ 30% in seven patients. Critical levels of oxygen saturation were detected in four patients during 13 intervals, each lasting for 132.5 s on average. Oxygen saturation returned to noncritical values in all patients by the end of the observation period. Blood flow in the fingertips was reduced by more than 30% in nine patients, but no critical levels were observed, as with the hemoglobin. Three patients demonstrated a reactive increase in blood flow of more than 30% after injection. CONCLUSIONS: Injection of tumescent local anesthesia containing epinephrine into finger base may temporarily cause a substantial reduction in blood flow and lead to critical levels of oxygen saturation in the fingertips. However, this was fully reversible within minutes and does not cause long-term complications.

The use of the wide-awake local anesthesia no tourniquet technique in foot and ankle injuries.

PURPOSE: Although the wide-awake anesthesia no tourniquet (WALANT) technique has demonstrated high efficacy, safety, patient satisfaction, and cost-effectiveness in hand surgery, there are limited data on its use in foot and ankle surgery. This study aimed to evaluate the efficacy of the WALANT technique in selected foot and ankle injuries in terms of intra- and post-operative characteristics. MATERIAL AND METHODS: Patients with foot and ankle injuries who underwent surgery with the WALANT technique were evaluated in this retrospective study. A total of 31 patients (22 male/9 female) with a mean age of 40 ± 16 years were evaluated for the type of injury, underlying comorbidities, American Society of Anesthesiologists Classification (ASA) score, intraoperative visual analog pain (VAS) and anxiety (VAS-A) scores, duration of operation, complications, need for intensive care and duration of hospitalization. RESULTS: There were 15 patients with medial malleolus fracture, 5 with lateral malleolus fracture, 5 with Achilles tendon ruptures, 2 with proximal phalangeal fracture, and 1 with Lisfranc injury, medial malleolus + syndesmotic injury, deltoid ligament + syndesmotic injury and fifth metatarsal fracture. ASA I-II score was determined in 27 patients and ASA III score in 4. The mean operation time was 36.6 ± 7 min, and the mean length of hospital stay was 8.3 ± 6.1 h. The median VAS pain score was 1 (range, 0-4), the median VAS-A score was 1 (range, 0-3) and no patient needed further anesthetics during the operation. No patient needed intensive care unit stay and no complications were observed in any patient. CONCLUSION: The WALANT technique was seen to provide satisfactory anxiety and pain scores, acceptable complications, and a short length of hospital stay in patients with foot and ankle injuries. Simple foot and ankle injuries can be managed successfully with this technique through adequate hemostasis without a tourniquet. LEVEL OF EVIDENCE: Level III.

Incorporating Office-Based Surgery Into Your Practice With WALANT.

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.

A protocol for wide awake local anaesthetic no tourniquet (WALANT) hand surgery in the context of the coronavirus disease 2019 (COVID-19) pandemic.

There are new and unique challenges to emergency surgery service provision posed by the Coronavirus disease 2019 global pandemic. It is in the best interests of patients for care providers to streamline services where possible to maximise the number of cases that can be performed by limited surgical and anaesthetic teams, as well as minimising patient interactions and admission times to reduce potential spread of the virus. There is evidence that wide awake local anaesthetic no tourniquet (WALANT) hand and upper limb surgery can meet this need in a number of ways, including reduced pre-operative work up, the lack of a need for an anaesthetist or ventilator, shorter inpatient stays and improved cost efficiencies. Though updated national guidelines exist that advocate increased use of WALANT surgery in response to the pandemic there are not yet clear protocols to facilitate this. We outline a protocol being developed at one UK Major Trauma Centre tailored to the expansion of WALANT hand and upper limb emergency surgery with particular emphasis on facilitating timely surgical care while minimising healthcare encounters pre and post-operatively. This will serve to reduce potential transmission of the virus and create cost efficiencies to free funding for COVID-19 related care. Our protocol is easily replicable and may be of benefit to other centres dealing with emergency upper limb surgery in the new climate of COVID-19.

A Cost-Effectiveness Analysis of Corticosteroid Injections and Open Surgical Release for Trigger Finger.

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.