WALANT surgery of the hand: state of the art.

Wide-awake local anesthesia no tourniquet is named the WALANT technique. WALANT has had a major positive impact on cost, convenience, ecology, patient satisfaction, access to surgical care, and outcomes in hand surgery in the last 20 years. Safe and efficient application of the technique is based on two principles. The first principle is the tumescent injection of a large volume low concentration 0.25-1% lidocaine, with 1:100 000-1:400 000 epinephrine. The second principle of WALANT is that the proper injection should be almost painless, with the patient only feeling the first needle poke of a tiny 30G needle. This wide awake patient approach reduces pain, neuropraxia, and systemic side effects of sedation with preservation of motor control, thereby aiding balanced reconstruction in hand surgery.

New Frontiers in Wide-Awake Surgery.

LEARNING OBJECTIVES: After studying this article, the participant should be able to: 1. Explain the most important benefits of wide-awake surgery to patients. 2. Tumesce large parts of the body with minimal pain local anesthesia injection technique to eliminate the need for sedation for many operations. 3. Apply tourniquet-free surgery to upper and lower limb operations to avoid the sedation required to tolerate tourniquet pain. 4. Move many procedures out of the main operating room to minor procedure rooms with no increase in infection rates to decrease unnecessary cost and solid waste in surgery. SUMMARY: Three disruptive innovations are changing the landscape of surgery: (1) minimally painful injection of large-volume, low-concentration tumescent local anesthesia eliminates the need for sedation for many procedures over the entire body; (2) epinephrine vasoconstriction in tumescent local anesthesia is a good alternative to the tourniquet and proximal nerve blocks in extremity surgery (sedation for tourniquet pain is no longer required for many procedures); and (3) evidence-based sterility and the elimination of sedation enable many larger procedures to move out of the main operating room into minor procedure rooms with no increase in infection rates. This continuing medical education article explores some of the new frontiers in which these changes affect surgery all over the body.

Self-induced Hot Water Finger Burn Trying to Get Feeling Back after Ropivacaine Block.

This case report is about a patient with self-induced hot water burns several hours after an infraclavicular block with ropivacaine for a scaphoid fracture operation. This patient was honest about what happened. However, some patients are too embarrassed to admit what they did to themselves. The injury may be misdiagnosed by the emergency department physician or by the surgeon because the history is incomplete. The resulting burn, which can lead to fingertip loss when severe, can be erroneously misdiagnosed as an ischemic injury after lidocaine with epinephrine local anesthesia. Most hand surgeons have seen ischemic finger injuries the morning after failed finger replantation. Acutely ischemic fingers from arterial insufficiency do not have parallel hot water burn lines, reactive hyperemia at the base of the burn, or burn blisters at the fingertips. The purpose of this article and its video is to help physicians and nurses recognize the three signs of self-induced hot water finger burns after local anesthesia: (1) a parallel hot water line in the fingers at the proximal burn level; (2) reactive hyperemia just proximal to the burn line; (3) burn blisters in the submerged fingertips. When seeing postoperative patients with these signs, the examining clinician may tactfully ask: "Did you try to get the feeling back in your fingers by warming them?" It is hoped that the patient may then reveal that he tried warming the finger in water, and that may lead to the truth that the water was indeed too hot.

Tips, Tricks, and Pearls for a Superior Patient and Surgeon Experience for Wide-awake Dupuytren Surgery.

Fasciectomy for Dupuytren disease is a common procedure traditionally performed with a tourniquet under general or regional anesthesia. Since the year 2001, the wide-awake local anesthesia no tourniquet (WALANT) approach has been applied successfully to Dupuytren surgery, with current excellent surgeon and patient satisfaction. However, using WALANT for Dupuytren surgery may be intimidating for hand surgeons who want to begin using this method. The purpose of this article is to offer a series of tips and tricks the authors have learned after having performed hundreds of WALANT fasciectomies, to make this technique easier for surgeons and a more pleasurable experience for patients.

Adoption of the Wide-Awake Local Anesthesia No Tourniquet Technique in Hand Surgery.

¼ Wide-awake local anesthesia no tourniquet (WALANT) technique featuring tumescent infiltration of lidocaine with epinephrine at the operative site has broad application in hand surgery including both soft-tissue and bone procedures.¼ The advantages of wide-awake anesthesia include high patient satisfaction, preserved intraoperative finger and wrist motion, cost-effectiveness, improved operating room efficiency, fewer opioids during recovery, and improved access to hand surgery, which may be performed in an office-based setting without the need for anesthesia personnel.¼ In properly selected patients, use of lidocaine with epinephrine in the hand and fingers is safe. Rare postprocedure digital ischemia may be effectively treated with phentolamine rescue.¼ Barriers to adopting wide-awake anesthesia may be overcome by educating resistant stakeholders, including hospital administrators, nurse leaders, and anesthesia colleagues, about the advantages of the WALANT method.¼ The risk of postoperative complications after hand procedures may be mitigated by using the wide-awake technique instead of regional anesthesia with sedation or general anesthesia.

Tips to Successful Flexor Tendon Repair and Reconstruction with WALANT.

WALANT has generated many changes that have improved flexor tendon repair and reconstruction in the last 10 years. Seeing awake unsedated educable patients move repaired reconstructed tendons during the surgery has changed how we do surgery and therapy in many ways for the better. This article offers many tips on how to get better results in using these new techniques with the help of WALANT.

Effective Things Surgeons Can Tell Patients During Wide-Awake Local Anesthesia No Tourniquet Surgery to Decrease Complications and Improve Outcomes.

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.

K-wire Fixation of Closed Hand Fractures Outside the Main Operating Room Does Not Increase Infections.

Closed reduction and internal fixation (CRIF) of closed hand fractures in the main operating room (OR) is much more expensive than outside of the OR. However, there is a reluctance to fix fractures out of the OR due to the perceived increase in infections. Our goal was to prospectively analyze the infection rates of performing CRIF of closed metacarpal and phalangeal fractures in these two settings. Methods: A multicenter prospective analysis of patients undergoing CRIF of metacarpal or phalangeal fractures inside or outside the OR was performed. Demographic data, injury characteristics, surgery information and postoperative infectious complications were recorded, including cellulitis, frank pus, and osteomyelitis. Results: The study involved 1042 patients with a total of 2265 Kirschner-wires (K-wires). Infection rates were not statistically higher in the 719 patients who had CRIF outside of the OR (cellulitis 2.5%, frank pus 1.4%) compared with the 323 patients with CRIF in the OR group (cellulitis 3.4%, frank pus 2.5%). The OR group had a longer time to operation and a longer procedure time, but a shorter time with the K-wires in place. Conclusion: K-wire fixation of closed hand fractures outside of the OR under field sterility is safe because it does not increase infectious complications compared to CRIF in the main OR under full sterility.

Reconstructive Surgery in a Patient with High Radial Nerve Palsy Using the WALANT Technique.

Tendon transfers can be tied too tight or too loose. Both impede good function after surgery. Performing tendon transfers without sedation and pain during the surgery and then watching the patient move the transfer have helped us adjust the tension more accurately. This method can be applied to complex transfers such as radial nerve palsy triple tendon transfers. We describe the technique and results of a triple tendon transfer using wide-awake local anesthesia no tourniquet in a patient with a high radial nerve palsy. This was a complex case of reconstruction after five operations at the level of the humerus. This left him with a pseudoarthrosis of the humerus and a complete radial nerve palsy. We performed tendon transfers of pronator teres to extensor carpi radialis brevis, flexor carpi ulnaris to extensor digitorum communis, and palmaris longus to extensor pollicis longus tendons. Eighteen months after the triple tendon transfer surgery for the radial nerve palsy, the patient has good extension of the fingers, wrist, and thumb. He can open and close the hand properly. He has excellent function and mobility allowing him to perform most activities in a manner that is practically normal. Wide-awake local anesthesia no tourniquet can be used safely and successfully in complex cases requiring triple radial nerve tendon transfers of pronator teres to extensor carpi radialis brevis, flexor carpi ulnaris to extensor digitorum communis, and palmaris longus to extensor pollicis longus tendons.

Ten Questions About Wide Awake Local Anaesthesia No Tourniquet (WALANT) Surgery.

The aim of this review article is to provide many important tips and tricks for surgeons to start Wide Awake Local Anaesthesia No Tourniquet (WALANT) hand surgery in their practice. The massive cost reduction of this disruptive new approach will enable them to increase access to hand surgery for their patients who cannot afford unnecessary sedation or unnecessary sterility of the expensive main operating room environment. Evidence-based sterility will permit surgeons to move a lot of their surgery out of the main operating room to minor procedure rooms without a significant increase in infection rates. Important pointers on how to inject minimally painful local anaesthesia will have patients thinking the surgeon injector is a bit of a magician. WALANT enables surgeons to improve the outcomes of many hand surgery procedures. Level of Evidence: Level V (Therapeutic).

Time to Stop Routinely Prescribing Opiates after Carpal Tunnel Release.

BACKGROUND: North American surgeons continue to routinely order narcotic medication for postoperative pain relief after carpal tunnel surgery. For some patients, this instigates persistent use. This double-blind, multicenter trial investigated whether over-the-counter medications were inferior to opioid pain control after carpal tunnel release. METHODS: Patients undergoing carpal tunnel release in five centers in Canada and the United States (n = 347) were randomly assigned to postoperative pain control with (opioid) hydrocodone/acetaminophen 5/325 mg versus over-the-counter ibuprofen/acetaminophen 600/325 mg. The two primary outcome measures were the Numeric Pain Rating Scale (0 to 10) and the six-item Patient-Reported Outcome Measurement Information System Pain Interference T-score. Secondary outcome measures were total medication used and overall satisfaction with pain medication management. RESULTS: The authors found no significant differences between opioid and over-the-counter patients in the Numeric Pain Rating Scale scores, Pain Interference T-scores, number of doses of medication, or patient satisfaction. The highest Numeric Pain Rating Scale group difference was the night of surgery, when opiate patients had 0.9/10 more pain than over-the-counter patients. The highest group difference in Pain Interference T-scores (2.1) was on the day of surgery, when the opiate patients had more pain interference than the over-the-counter group. Patient nationality or sex did not generate significant pain score differences. CONCLUSIONS: Pain management is not inferior for patients managed with over-the-counter acetaminophen/ibuprofen versus opioids. This study provides high-quality evidence that U.S. and Canadian surgeons should stop the routine prescription of narcotics after carpal tunnel surgery for patients who are not taking pain medicines daily before surgery. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.

How to Create an Exceptional Hand Surgery Patient Experience with WALANT.

This article provides practical tips that surgeons can use to improve their patient experience with wide awake local anesthesia no tourniquet hand surgery. The difference between patient satisfaction and patient experience is explained. Delivering a superior patient experience leads to better outcomes for patients, less postoperative complications, and a better quality of life and practice for the surgeon. Practical tips are presented, broken down into the preoperative, operative, and postoperative phases. Surgeons who commit to improving their patient experience will enjoy superior outcomes, patient loyalty, more fulfillment, and a rejuvenated sense of purpose.

Incidence of the "Adrenaline Rush" and Vasovagal Response with Local Anesthetic Injection.

BACKGROUND: Many patients feel an "adrenaline rush" or a vasovagal reaction when injected with lidocaine and epinephrine during wide awake surgery. The incidence of these reactions is not well documented in the literature. METHODS: In total, 387 patients were prospectively injected with lidocaine and epinephrine for minor procedures without sedation between July 1, 2019 and November 1, 2020. A concentration of epinephrine with 1:100,000 in 2% lidocaine was injected, with most patients getting less than 20 mL of volume. RESULTS: Eight (2.2%) of the patients had adrenaline rush symptoms, which included nervousness, anxiety, tremors, shaky feelings, flushing, diaphoresis, light-headedness, tingling, and "heart racing." Seven patients (1.8%) experienced vasovagal responses, which included nausea, a feeling of being unwell, faint, or lightheaded, or had circumoral pallor. CONCLUSIONS: Patients run a low risk of feeling an adrenaline rush or vasovagal reaction when injected with lidocaine and epinephrine. Routinely advising patients that the adrenaline rush can happen, and that this is not an allergic reaction can be helpful to allay fear of the unknown and to prevent false allergy beliefs. Injecting patients lying down may decrease the incidence of vasovagal reactions by increasing cerebral blood flow with the advantage of gravity.

An Assessment Tool for Hand Surgical Education Needs and Capacity in Resource-Limited Settings.

BACKGROUND: Hand surgeons have the potential to substantially decrease the surgical disability burden in the developing world through educator trips. The Lancet Commission supports contextually driven educator trips grounded in the needs of local hosts, yet few organizations perform a comprehensive assessment of learning interests or the hosting institutions' surgical capacity before the trips. METHODS: The authors adapted the Personnel, Infrastructure, Procedures, Equipment, and Supplies questionnaire, which was modified from the World Health Organization's validated Tool for Situational Analysis to Assess Emergency and Essential Surgical Care. The authors revised each aspect of the questionnaire to reflect items pertinent to upper extremity surgery and hand trauma care. They added sections to gauge self-identified learning needs, local disease burden, operative resources, and current practices. The tool was distributed by means of Qualtrics; descriptive statistics were used to summarize data. The authors analyzed the data for all participants and performed two subgroup analyses to examine variation by regions and countries. RESULTS: The authors received 338 responses from 27 countries. There was wide variability in local surgical disease burden, learning interests, and skill level of upper extremity procedures. Although learners were most interested in learning tendon transfers and microsurgical techniques, the majority did not have adequate infrastructure at their institution to sustain capacity for microvascular procedures. CONCLUSIONS: Needs assessments can gauge how best to provide education during short-term visiting educator trips and optimize its impact in resource-limited settings. Understanding the needs, learning interests, and availability of resources of local learners is imperative to creating a sustainable global surgical workforce.