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.

Middle finger tenolysis using WALANT surgical technique in a pediatric patient: A case report.

INTRODUCTION AND IMPORTANCE: Wide Awake Local Anesthesia No Tourniquet (WALANT) is a surgical technique used in hand surgery that allows for active patient participation during surgery while avoiding the pain and discomfort associated with general anesthesia and tourniquets. Using this technique for tenolysis enables a surgeon to assess the repair intraoperatively. However, this technique is more commonly used in adults than in pediatric patients. We aimed to present a case that may contribute to the use of the WALANT technique on the pediatric population. CASE PRESENTATION: This case presents the successful use of the WALANT technique multiple times in a 7-year-old Hispanic male patient to repair recurrent tendon adhesions and joint contracture due to a prior gunshot wound that caused a comminuted, displaced fracture with intra-articular extension of the third finger. CLINICAL DISCUSSION: To the best of our knowledge, few reports and case series of WALANT hand surgery in children are available within the literature. The presented case is rare in terms of the mechanism of injury, the age of the patient, and the fact that multiple WALANT interventions were successfully performed on the same patient. CONCLUSION: Our findings showcase the potential of the WALANT technique on pediatric patients as an alternative to traditional techniques. Due to the scarcity of pediatric WALANT cases in the literature, and the benefits provided by the technique, this case report may be of clinical relevance.

Wide-Awake Olecranon Fracture Fixation: Is it Possible?

Purpose: The wide-awake local anesthesia no tourniquet technique has been widely performed in hand and wrist surgery with remarkable results. However, its use on the elbow has rarely been reported. Here we describe the use of wide-awake local anesthesia no tourniquet in olecranon fracture fixation in 4 cases. Methods: Tumescent anesthesia was injected from the proximal ulna to approximately 10 cm distally and into the periosteum and fracture site, approximately 25 minutes before skin incision. The fracture underwent closed reduction and was fixed using a long 6.5-mm cancellous screw with a washer through a small incision. No tourniquet was applied and none or mild sedation was administered. At the end of the operation, patients were asked to perform active elbow flexion-extension and forearm pronosupination movements under an image intensifier to test the range of motion and fracture stability. Results: The surgical procedure was completed in all 4 cases. Two patients reported mild pain during ulnar medullary canal reaming, with pain scores of 3 and 4 on a 10-point scale, respectively. One case was resolved with additional local anesthetic injection. The other case required the administration of intravenous propofol. Both patients were able to actively move the elbow at the end of the operation. Conclusions: The use of wide-awake local anesthesia no tourniquet for olecranon fracture fixation has the advantage of obviating the need for an arm tourniquet, general anesthesia or heavy sedation, preoperative tests, and discontinuing routine medications (including anticoagulants). The stability of the elbow fixation was tested by active motion during surgery. This simple, safe, low-cost, and reproducible technique may be a good option for patients with contraindications or high risk of general or regional nerve block anesthesia. Type of study/level of evidence: Therapeutic IV.

What Is the Infection Rate of Carpal Tunnel Syndrome and Trigger Finger Release Performed Under Wide-Awake Anesthesia?

BACKGROUND: High infection rates have been reported in hand procedures using the wide-awake local anesthesia no tourniquet (WALANT) method, causing some to question the validity of this approach. However, little evidence exists surrounding the direct use of WALANT compared with monitored anesthetic care (MAC). This study was conducted to directly compare the postoperative infection rates of carpal tunnel syndrome (CTS) and trigger finger (TF) release surgeries performed under WALANT and MAC. METHODS: A retrospective study comparing postoperative infection rates between patients undergoing CTS and TR releases was conducted. Our primary outcome measure was postoperative infection. Our secondary outcome was postoperative complications. Comparative statistics were used to compare means of infection between the groups. RESULTS: A total of 526 patients underwent CTS release (255 with WALANT and 271 with MAC), and 129 patients underwent TF release (64 with WALANT and 65 with MAC). Patients undergoing WALANT and MAC were statistically comparable in terms of sex, smoking status, diabetes, and American Society of Anesthesiologists physical status classification. In patients undergoing CTS release, there were no infections with WALANT and 6 infections (2.2%) with MAC. In patients undergoing TF release, there were no infections in either group. There were similar rates of complications in patients undergoing WALANT and MAC for CTS and TF releases. CONCLUSION: There was no increased risk of infection with WALANT compared with MAC in CTS or TR surgeries. These surgeries can be safely conducted with lidocaine and epinephrine without a concern for increased risk of infections or complications.

The Impact of Intraoperative Nursing Care on Perioperative Complications During Wide-Awake Local Anesthesia Hand Surgery.

Purpose: The wide-awake local anesthesia technique in hand surgery is widely used, but there are currently no guidelines or protocols for the number of operating room personnel required to optimize patient safety intraoperatively. This study aimed to evaluate perioperative complication rates of wide-awake local anesthesia hand surgeries performed at surgery centers that used different numbers of operating room nurses. Methods: We conducted a retrospective review of patients who underwent wide-awake local anesthesia hand surgery at 4 surgical centers over a 30-month consecutive period. Two surgical centers used 3 operating room nurses, and 2 centers used 2 operating room nurses. The complications reported included intraoperative case abortion because of critical change in patient vitals, intraoperative medication delivery, intraoperative intravenous placement for medication delivery, intraoperative conversion to sedation, intraoperative medical complications, and postoperative transfer to the emergency department or a hospital. Results: A total of 1,771 wide-awake local anesthesia surgical procedures were identified, with 925 performed at a facility that used 2 operating room nurses and 846 performed at a facility that used 3 operating room nurses. There were no perioperative complications in either group during the study period. Conclusions: There was no difference in perioperative complications between the surgery centers that used 3 versus 2 intraoperative nurses during wide-awake local anesthesia hand surgery. This study supports that limiting the nursing personnel for wide-awake local anesthesia hand surgeries could be an efficient way to cut procedural costs without compromising patient safety. Type of study/level of evidence: Therapeutic IV.

Economic and Environmental Impacts of the Wide-Awake, Local Anesthesia, No Tourniquet (WALANT) Technique in Hand Surgery: A Review of the Literature.

The United States spends more on health care than any other country in the world based on the percentage of gross domestic product. This fact is coupled with health care facilities contributing nearly one-tenth of all greenhouse gas emissions in the United States, and with the health care industry's waste contributions to landfills being second only to those of the food industry. In some instances, operating rooms produce the majority of total landfill waste from hospitals; therefore, patients undergoing surgical procedures can have both financial and environmental impacts. Recently, the wide-awake, local anesthesia, no tourniquet technique in hand surgery has grown in popularity. This technique has reportedly allowed surgeons to decrease operating room costs, time, and waste, but without compromising patient safety or outcomes. This comprehensive literature review summarizes the current literature related to the economic and environmental impacts of the wide-awake, local anesthesia, no tourniquet technique in hand surgery.

Outcomes of Orthopedic Hand Surgeries in Minor Procedure Rooms at a Veterans Affairs Medical Center.

Purpose: There is a high demand for minor hand surgeries within the veteran population. The objective of this study was to compare clinical outcomes and resource use at a Veterans Affairs Medical Center (VAMC) of hand surgeries performed in minor procedure rooms (MPR) and operating rooms using local anesthesia with or without monitored anesthesia care. Methods: We retrospectively evaluated all patients undergoing carpal tunnel release, de Quervain's release, foreign body removal, soft tissue mass excision, or A1 pulley release at a VAMC over a 5-year period. Data collected included demographic information, mental health comorbidities, presence of preoperative and postoperative pain, complications after surgery, time to surgery, number of personnel in surgery, turnover time between cases, and time spent in the postanesthesia care unit. Statistical analysis included Fisher exact or chi-square analysis to compare MPR versus operating room groups and Student t test or Mann-Whitney test to compare continuous variables. Results: In this cohort of 331 cases, 123 and 208 patients underwent surgery in MPRs and operating rooms, respectively. Preoperative and postoperative pain were similar between the MPR and operating room groups. Complications were slightly lower in the MPR group versus the operating room group (0% MPR vs 2.9% operating room). Median time from surgical consult to surgery was 6 days less for MPR patients (15 vs 21). The MPR cases also used fewer personnel during surgery, averaging 4.76 versus 4.99 people. The MPR patients spent 9 minutes less in the postanesthesia care unit (median, 36 vs 45 minutes) and turnover time between cases was nearly 8 minutes faster in MPRs than in operating rooms (median, 20 vs 28 minutes). Conclusions: Minor procedure rooms at a VAMC allow more veteran patients to be scheduled for minor hand surgeries within a shorter time frame, utilize less staff and postoperative monitoring, and maintain excellent outcomes with limited complications. Clinical relevance: Minor hand surgeries in MPRs have outcomes equivalent to those of operating rooms with improved time savings and resource use.

Noise-Canceling Headphones and Music Decrease Intraoperative Patient Anxiety During Wide-Awake Hand Surgery: A Randomized Controlled Trial.

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.

Current Trends in WALANT Surgery: A Survey of American Society for Surgery of the Hand Members.

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

Wide Awake Hand Surgery Under Local Anesthesia No Tourniquet in South America.

The authors report the introduction and development of wide awake hand surgery under local anesthesia no tourniquet (WALANT) in South America, specifically in Brazil, where thousands of cases have already been performed with this technique. This was largely stimulated by Dr Lalonde's first visit to Brazil in 2012. The authors began with smaller procedures such as trigger fingers and carpal tunnels, which were easily implemented. There has been an increase in the number of more complex procedures, such as flexor tenolysis or tendon transfers, in which patient cooperation can help improve results.