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Model Z, Benavent KA, Zhang D, Blazar PE, Earp BE. Factors Influencing Patient Preference for Anesthesia in Ambulatory Hand Surgery. Hand (N Y) 2024; 19:306-310. [PMID: 36154310 PMCID: PMC10953523 DOI: 10.1177/15589447221120846] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/10/2023]
Abstract
BACKGROUND The purpose of this study was to identify factors that influence preoperative patient preferences toward anesthesia in patients in a hand and upper extremity clinic. METHODS A survey was administered to consecutive patients in a hand and upper extremity orthopedic clinic at an urban tertiary academic institution. The survey addressed presenting clinical complaint, anesthesia preference for minor soft tissue hand and wrist procedures, factors influencing anesthesia preference, and patient history of anesthesia and surgical treatment. The primary outcome measure was anesthesia preference: local-only or local with sedation. RESULTS Surveys were completed by 219 patients over a 1-month period with a mean patient age of 55 years. Most patients presented with a hand/wrist complaint (56%). One hundred fifty-two patients (71%) preferred local anesthesia with sedation and 61 patients (29%) preferred local-only anesthesia. Patients who preferred local-only anesthesia reported being more likely to be influenced by surgeon preference and cost, and also were more likely to have had prior experience with local-only anesthesia. In contrast, patients who preferred local anesthesia with sedation were more likely to be concerned about pain or were nervous about surgery. Prior surgical experience did not influence preference for anesthesia. CONCLUSION Patient preferences for local-only anesthesia versus local anesthesia with sedation for ambulatory hand surgery are mixed, with most patients preferring sedation. Understanding patient preferences for anesthesia can better inform preoperative discussions and shared decision-making in anesthesia choice.
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Affiliation(s)
- Zina Model
- Brigham and Women’s Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Massachusetts General Hospital, Boston, USA
| | | | - Dafang Zhang
- Brigham and Women’s Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Philip E. Blazar
- Brigham and Women’s Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Brandon E. Earp
- Brigham and Women’s Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
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2
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Boddu SP, Lin E, Gill VS, Hinckley NB, Lai CH, Renfree KJ. Low-Income, Poor Physical Health, Poor Mental Health, and Other Social Risk Factors Are Associated With Decreased Access to Care in Patients With Carpal Tunnel Syndrome. J Prim Care Community Health 2024; 15:21501319241240348. [PMID: 38504598 PMCID: PMC10953096 DOI: 10.1177/21501319241240348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Revised: 02/24/2024] [Accepted: 03/01/2024] [Indexed: 03/21/2024] Open
Abstract
BACKGROUND Carpal Tunnel Syndrome (CTS) is associated with a significant personal and societal burden. Evaluating access to care can identify barriers, limitations, and disparities in the delivery of healthcare services in this population. The purpose of this study was to evaluate access to overall healthcare and healthcare utilization among patients with CTS. METHODS This is a retrospective cohort study conducted with the All of Us database. Patients diagnosed with CTS that completed the access to care survey were included and matched to a control group. The primary outcomes were access to care across 4 domains: (1) delayed care, (2) could not afford care, (3) skipped medications, and (4) over 1 year since seeing provider. Secondary analysis was then performed to identify patient-specific factors associated with reduced access to care. RESULTS In total, 7649 patients with CTS were included and control matched to 7649 patients without CTS. In the CTS group, 33.7% (n = 2577) had delayed care, 30.4% (n = 2323) could not afford care, 15.4% (n = 1180) skipped medications, and 1.6% (n = 123) had not seen a provider in more than 1 year. Within the CTS cohort, low-income, worse physical health, and worse mental health were associated with poor access to care. CONCLUSION Patients experience notable challenges with delayed care, affordability of care, and medication adherence regardless of having a diagnosis of CTS. Targeted interventions on modifiable risk factors such as low income, poor mental health, and poor physical health are important opportunities to improve access to care in this population.
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Affiliation(s)
- Sayi P. Boddu
- Mayo Clinic Alix School of Medicine, Scottsdale, AZ, USA
| | | | - Vikram S. Gill
- Mayo Clinic Alix School of Medicine, Scottsdale, AZ, USA
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3
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Gouveia K, Harbour E, Gazendam A, Bhandari M. Fixation of Distal Radius Fractures Under Wide-Awake Local Anesthesia: A Systematic Review. Hand (N Y) 2024; 19:58-67. [PMID: 35880346 PMCID: PMC10786102 DOI: 10.1177/15589447221109632] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The purpose of this systematic review was to analyze the available literature on fixation of distal radius fractures (DRFs) under wide-awake local anesthesia no-tourniquet (WALANT), and to examine postoperative pain scores and functional outcomes, operative data including operative time and blood loss, and the frequency of adverse events. METHODS Embase, MEDLINE, Web of Science, and SCOPUS were searched from inception until May 2022 for relevant studies. Studies were screened in duplicate, and data on pain scores, functional outcomes, and adverse events were recorded. Due to methodological and statistical heterogeneity, the results are presented in a descriptive fashion. RESULTS Ten studies were included comprising 456 patients with closed, unilateral DRFs, of whom 226 underwent fixation under WALANT. These patients had a mean age of 52.8 ± 8.3 years, were 48% female, and had a mean follow-up time of 11.6 months (range: 6-24). Operative time for WALANT patients averaged 60.4 ± 6.5 minutes, with mean postoperative pain scores of 1.4 ± 0.6 on a 10-point scale. Studies that compared WALANT to general anesthesia found shorter hospital stays with most WALANT patients being sent home the same day, decreased postoperative pain scores, and decreased costs to the healthcare system. No adverse events were reported for WALANT patients. CONCLUSIONS A growing body of literature reports that for closed, unilateral DRF, surgical fixation under WALANT is a safe and effective option. It allows patients to have surgery sooner, with improved pain scores and good functional outcomes, with a very low incidence of adverse events.
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Affiliation(s)
- Kyle Gouveia
- Division of Orthopaedic Surgery, McMaster University, Hamilton, ON, Canada
| | - Eric Harbour
- School of Medicine, University of Limerick, Ireland
| | - Aaron Gazendam
- Division of Orthopaedic Surgery, McMaster University, Hamilton, ON, Canada
| | - Mohit Bhandari
- Division of Orthopaedic Surgery, McMaster University, Hamilton, ON, Canada
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Sawhney A, Thacoor A, Nagra R, Geoghegan L, Akhavani M. Wide Awake Local Anesthetic No Tourniquet in Hand and Wrist Surgery: Current Concepts, Indications, and Considerations. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2024; 12:e5526. [PMID: 38260757 PMCID: PMC10803042 DOI: 10.1097/gox.0000000000005526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Accepted: 11/01/2023] [Indexed: 01/24/2024]
Abstract
Background Traditionally, the use of a pneumatic arterial tourniquet was requisite for safe and effective surgery of the hand. The use of arterial tourniquets necessitates the use of regional or general anaesthesia. Wide-awake local anaesthetic no tourniquet (WALANT) has emerged as a novel technique to overcome the limitations of tourniquet use in conjunction with regional/general anaesthesia. This review aimed to examine the safety and effectiveness of WALANT and provide guidance for surgeons with limited WALANT experience. Methods A literature review of MEDLINE was performed up to March 2021 to identify all articles related to the use of WALANT in hand surgery. Any article reporting original data related to the use of WALANT was eligible for inclusion. Results A total of 101 articles were identified through database searching. Of these, 79 met full inclusion criteria and described the use of WALANT in 19 elective and trauma procedures. Current data suggest that WALANT is safe and effective for use in a range of procedures. Conclusions WALANT surgery is increasing in popularity as evidenced by the variety of surgical indications reported in the literature. There is limited comparative data on the cost-effectiveness of WALANT compared to conventional methods. Current data suggest that WALANT is safe, better tolerated by patients and associated with direct and indirect cost savings.
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Affiliation(s)
- Akshat Sawhney
- From the Department of Plastic, Reconstructive and Burns Surgery, Stoke-Mandeville Hospital, Aylesbury, United Kingdom
| | - Amitabh Thacoor
- Department of Plastic and Reconstructive Surgery, St Georges Hospital, London, United Kingdom
| | - Raveenjot Nagra
- University College London, Division of Surgery and Interventional Science, London, United Kingdom
| | - Luke Geoghegan
- Section of Vascular Surgery, Department of Surgery and Cancer, Imperial College London, London, United Kingdom
| | - Mo Akhavani
- Department of Plastic and Reconstructive Surgery, Royal Free Hospital, London, United Kingdom
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5
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Faraz A, Bahl A, Khan S, Ahmad M, Khan MN, Mannan S, Jayadeep J, Kumar K. Carpal Tunnel Decompression Under Wide Awake Local Anaesthesia No Tourniquet Technique (WALANT): A Cost Effective and Outcome Analysis. Cureus 2023; 15:e42125. [PMID: 37602033 PMCID: PMC10437000 DOI: 10.7759/cureus.42125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/19/2023] [Indexed: 08/22/2023] Open
Abstract
Introduction Wide-awake local anaesthesia with no tourniquet (WALANT) technique is cost-effective, resource-friendly, and safe. This can be used as an alternative to hand surgery procedures in outpatient units. It can be performed in clinics or operating rooms. Methods We retrospectively evaluated the outcomes of WALANT for carpal tunnel decompression (CTD) over two years. Measured results include wound infections, relief of symptoms, paraesthesia, haematoma, Visual Analogue Scale (VAS), hospital anxiety and depression scale score (HADS) and cost-effectiveness. Results Eighteen patients underwent CTD under the WALANT technique over two years. VAS score was recorded at 3.1 ± 1.2 during the procedure and 1.67 ± 0.933 at two weeks follow-up. Persistent paraesthesia was found in only one patient at follow-up. Minimal bleeding was recorded during the procedure. No wound infections, revision surgery or post-operative haematoma formation were found. Hospital Anxiety and Depression Scale (HADS) was reported as 4.77 ± 2.1 after surgery. WALANT was also cost-effective, with an overall amount of £20. Conclusion Performing carpal tunnel decompression under WALANT in one stop upper limb clinic is a safe and cost-effective technique with no significant patient-related complications.
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Affiliation(s)
- Ahmad Faraz
- Trauma and Orthopaedics, North Cumbria Integrated Care, Carlisle, GBR
| | - Anisha Bahl
- Trauma and Orthopaedics, University of Central Lancashire, Carlisle, GBR
| | - Shoaib Khan
- Trauma and Orthopaedics, Whiston Hospital, Liverpool, GBR
| | - Mahmood Ahmad
- Trauma and Orthopaedics, Redcliffe Hospital, Oxford, GBR
| | - Mohammad N Khan
- Trauma and Orthopaedics, Royal Victoria Hospital, Belfast, GBR
| | - Syed Mannan
- Trauma and Orthopaedics, Cumberland Infirmary, Carlisle, GBR
| | | | - Krishna Kumar
- Trauma and Orthopaedics, Cumberland Infirmary, Carlisle, GBR
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Morris MT, Rolf E, Tarkunde YR, Dy CJ, Wall LB. Patient Concerns About Wide-Awake Local Anesthesia No Tourniquet (WALANT) Hand Surgery. J Hand Surg Am 2022; 47:1226.e1-1226.e13. [PMID: 34774346 DOI: 10.1016/j.jhsa.2021.08.026] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2020] [Revised: 08/13/2021] [Accepted: 08/19/2021] [Indexed: 02/02/2023]
Abstract
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.
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Affiliation(s)
- Marie T Morris
- Department of Orthopaedic Surgery, Washington University School of Medicine, St. Louis, MO
| | - Elizabeth Rolf
- Department of Surgery, Division of Public Health Sciences, Washington University School of Medicine, St. Louis, MO
| | - Yash R Tarkunde
- Department of Orthopaedic Surgery, Washington University School of Medicine, St. Louis, MO
| | - Christopher J Dy
- Department of Orthopaedic Surgery, Washington University School of Medicine, St. Louis, MO; Department of Surgery, Division of Public Health Sciences, Washington University School of Medicine, St. Louis, MO
| | - Lindley B Wall
- Department of Orthopaedic Surgery, Washington University School of Medicine, St. Louis, MO.
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Abukhudair A, Mortada H, Alhindi N, Alarbedi L, Alshehri A, Alharbi A, Kattan AE, Mortada H, Alharbi A, Kattan AE. "Anesthesia for Endoscopic Carpal Tunnel Syndrome Release: A Comprehensive Systematic Review and Meta-Analysis of Local Versus Regional Versus General Anesthesia". JPRAS Open 2022; 35:89-101. [PMID: 36785700 PMCID: PMC9918389 DOI: 10.1016/j.jpra.2022.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Accepted: 11/17/2022] [Indexed: 11/24/2022] Open
Abstract
Background Worldwide, carpal tunnel syndrome (CTS) is the most common peripheral neuropathy due to compression. A minimally invasive endoscopic carpal tunnel release (ECTR) procedure is available to treat this condition. This study aims to identify and compare the different types of anesthesia in ECTR, particularly in terms of functional outcomes, patient satisfaction, and operative time. Methods PRISMA guideline was used to design and conduct this systematic review. MEDLINE, Cochrane, and EMBASE databases were searched systematically from inception to May 2022. For the search, MeSH terms such as ECTR, general anesthesia, local anesthesia (LA), and regional anesthesia were used. Results As a result of reviewing the literature, 198 publications were reviewed. After implanting our criteria, 12 studies were included. We included 14589 patients who underwent ECTR. LA has a higher satisfaction rate and a shorter operative time than general anesthesia. LA had a mean operative time of 20.1 min, compared to 45 min and 51 min for regional anesthesia and general anesthesia. The number of patients with postoperative ECTR surgical complications was 2.7% (95%CI). After ECTR with LA, 95% of patients are back to their daily routine within six months. Conclusion All the reported methods were effective, with LA being the most commonly used. Furthermore, it showed a shorter operative time and a higher satisfaction rate than other types of anesthesia. Due to the heterogeneity of the data, we recommend future randomized controlled trials to highlight the differences in anesthesia types used in ETCR. Level of evidence III, risk/prognostic study.
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Affiliation(s)
- Abdulrahman Abukhudair
- Faculty of Medicine, King Abdulaziz University, Rabigh, Saudi Arabia,Corresponding author: Abdulrahman Abukhudair, Faculty of Medicine, King Abdulaziz University, Rabigh, Saudi Arabia. PO Box 25753, Saudi Arabia, Mobile: 00966 55 336 9664
| | - Hatan Mortada
- Division of Plastic Surgery, Department of Surgery, King Saud University Medical City, King Saud University and Department of Plastic Surgery & Burn Unit, King Saud Medical City, Riyadh, Saudi Arabia
| | - Nawaf Alhindi
- Faculty of Medicine, King Abdulaziz University, Rabigh, Saudi Arabia
| | - Layal Alarbedi
- Faculty of Medicine, King Abdulaziz University, Rabigh, Saudi Arabia
| | | | - Abdullah Alharbi
- Orthopedic Surgery Department, King Abdulaziz Hospital, Makkah, Saudi Arabia
| | - Abdullah E. Kattan
- Division of Plastic Surgery, Department of Surgery, College of Medicine, King Saud University, Riyadh, Saudi Arabia
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8
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Meunier V, Mares O, Gricourt Y, Simon N, Kouyoumdjian P, Cuvillon P. Patient satisfaction after distal upper limb surgery under WALANT versus axillary block: A propensity-matched comparative cohort study. HAND SURGERY & REHABILITATION 2022; 41:576-581. [PMID: 35809895 DOI: 10.1016/j.hansur.2022.06.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Revised: 06/20/2022] [Accepted: 06/28/2022] [Indexed: 06/15/2023]
Abstract
Distal upper limb surgery is performed under WALANT (Wide Awake Local Anesthesia No Tourniquet) in many outpatient centers because the benefits are numerous: simple, low-cost technique, with fast turnover and short length of stay. In view of a paucity of data concerning patient satisfaction, this non-randomized cohort study was designed to compare EVAN-LR anesthesia satisfaction questionnaire results (information, pain, expectation, attention, discomfort: 0-100 points) between patients receiving WALANT or axillary nerve block (AxB). After IRB approval, patients (>18 years, stable ASA 1-3) scheduled for outpatient distal upper limb surgery were prospectively enrolled in the two groups. At discharge, patients in both groups received standard information on postoperative recovery and care, with a multimodal analgesic regime (acetaminophen and ketoprofen for 5 days). The primary endpoint was EVAN-LR score before discharge. Secondary endpoints were pain relief and side-effects over a 7-day period. Results were recorded as median and 25-75% interquartile range. Propensity-score-matched analysis was performed. Over the study period, from October 2019 to November 2020, 183 patients were included; 48 WALANT patients were propensity-score matched to 48 AxB patients. Pre-procedural APAIS anxiety score was lower in the WALANT than the AxB group: 9 (IQR, 6-12) vs 12 (IQR, 8-14) (p = 0.01). EVAN-LR scores were similar between the WALANT (78 [72-82]) and the AxB group (73 [67-80]). Incidences of paresthesia and of pain (NRS pain score, opioid rescue) were similar. WALANT patients had shorter length of stay: 135 (110-175) min vs 170 (110-250) min (p = 0.01). The present study demonstrated that WALANT was associated with a high level of patient satisfaction. For clinical relevance and quality of care, WALANT should be proposed in first line for distal limb surgery.
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Affiliation(s)
- V Meunier
- Department of Anesthesiology and Pain Management, Centre Hospitalo-Universitaire (CHU) Carémeau, Place du Professeur Debré, Nîmes, and Montpellier University 1, Montpellier, France
| | - O Mares
- Department of Traumatology and Orthopedic Surgery, Centre Hospitalo-Universitaire (CHU) Carémeau, Place du Professeur Debré, Nîmes, and Montpellier University 1, Montpellier, France
| | - Y Gricourt
- Department of Anesthesiology and Pain Management, Centre Hospitalo-Universitaire (CHU) Carémeau, Place du Professeur Debré, Nîmes, and Montpellier University 1, Montpellier, France
| | - N Simon
- Department of Anesthesiology and Pain Management, Centre Hospitalo-Universitaire (CHU) Carémeau, Place du Professeur Debré, Nîmes, and Montpellier University 1, Montpellier, France
| | - P Kouyoumdjian
- Department of Traumatology and Orthopedic Surgery, Centre Hospitalo-Universitaire (CHU) Carémeau, Place du Professeur Debré, Nîmes, and Montpellier University 1, Montpellier, France
| | - P Cuvillon
- Department of Anesthesiology and Pain Management, Centre Hospitalo-Universitaire (CHU) Carémeau, Place du Professeur Debré, Nîmes, and Montpellier University 1, Montpellier, France.
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Lech L, Loucas R, Leitsch S, Vater A, Mayer JM, Giunta R, Holzbach T. Is there a need for postoperative monitoring after open carpal tunnel release under WALANT? HAND SURGERY & REHABILITATION 2022; 41:638-643. [PMID: 35850181 DOI: 10.1016/j.hansur.2022.07.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Revised: 06/27/2022] [Accepted: 07/08/2022] [Indexed: 06/15/2023]
Abstract
Open carpal tunnel release (OCTR) under wide-awake local anesthesia with no tourniquet (WALANT) is a common outpatient procedure in hand surgery worldwide. In our clinic, WALANT has replaced intravenous regional anesthesia with a tourniquet (IVRA, or 'Bier block') as standard practice in OCTR. We therefore wondered what the optimal postoperative setting after OCTR under WALANT is. In this study, we compared patient satisfaction in two postoperative settings: immediate discharge (ID) after the operation, or short postoperative monitoring (PM) period in the outpatient clinic. Our hypothesis was that older patients would prefer a brief postoperative surveillance. We retrospectively analyzed patient satisfaction with the two settings using an adjusted questionnaire based on the standard Swiss grading system. We also assessed postoperative pain, satisfaction with the perioperative preparations and the reasons for unscheduled postoperative consultations, as secondary outcomes. One hundred and nine patients (ID, n = 63; PM, n = 46) were included in this single-center retrospective observational study. Patients were highly satisfied with both postoperative settings (Mean: ID 5.1/6; PM 5.5/6; p = 0.07). Even patients aged ≥80 years reported extremely high satisfaction with both settings (ID 5.6/6; PM 6.0/6; p = 0.08). Fifteen patients (ID, n = 11 [17.5%]; PM, n = 4 [8.7%], p = 0.72) unexpectedly consulted a doctor after surgery. OCTR under WALANT as an outpatient procedure with immediate discharge was associated with high patient satisfaction. However, detailed postoperative monitoring could contribute to the patient's well-being and education on how to cope with the postoperative course, and help with any questions.
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Affiliation(s)
- L Lech
- Department of Hand and Plastic Surgery, Thurgau Hospital Group, Pfaffenholzstraße 4, 8500 Frauenfeld, Switzerland; Department of General, Visceral, Transplantation, Vascular and Paediatric Surgery, University Hospital Würzburg, Oberdürrbacherstraße 6, 97080 Würzburg, Germany.
| | - R Loucas
- Department of Hand and Plastic Surgery, Thurgau Hospital Group, Pfaffenholzstraße 4, 8500 Frauenfeld, Switzerland.
| | - S Leitsch
- Department of Hand and Plastic Surgery, Thurgau Hospital Group, Pfaffenholzstraße 4, 8500 Frauenfeld, Switzerland.
| | - A Vater
- Department of Trauma, Hand, Plastic and Reconstructive Surgery, University Hospital Würzburg, Oberdürrbacherstraße 6, 97080 Würzburg, Germany.
| | - J M Mayer
- Department of Plastic and Hand Surgery, Inselspital, University Hospital Bern, Freiburgstrasse, 3010 Bern, Switzerland.
| | - R Giunta
- Divison of Hand-, Plastic and Aesthetic Surgery, University Hospital LMU Munich: Marchioninistraße 15, 81377 Munich, Germany.
| | - T Holzbach
- Department of Hand and Plastic Surgery, Thurgau Hospital Group, Pfaffenholzstraße 4, 8500 Frauenfeld, Switzerland.
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10
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Segal KR, Debasitis A, Koehler SM. Optimization of Carpal Tunnel Syndrome Using WALANT Method. J Clin Med 2022; 11:jcm11133854. [PMID: 35807138 PMCID: PMC9267271 DOI: 10.3390/jcm11133854] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 06/28/2022] [Accepted: 06/30/2022] [Indexed: 12/28/2022] Open
Abstract
As surgical management of carpal tunnel release (CTR) becomes ever more common, extensive research has emerged to optimize the contextualization of this procedure. In particular, CTR under the wide-awake, local-anesthesia, no-tourniquet (WALANT) technique has emerged as a cost-effective, safe, and straightforward option for the millions who undergo this procedure worldwide. CTR under WALANT is associated with considerable cost savings and workflow efficiencies; it can be safely and effectively executed in an outpatient clinic under field sterility with less use of resources and production of waste, and it has consistently demonstrated standard or better post-operative pain control and satisfaction among patients. In this review of the literature, we describe the current findings on CTR using the WALANT technique.
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11
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Lech L, Leitsch S, Krug C, Bonaccio M, Haas E, Holzbach T. Open Carpal Tunnel Release Under WALANT – Suitable for All Ages? JOURNAL OF HAND SURGERY GLOBAL ONLINE 2021; 3:129-132. [PMID: 35415544 PMCID: PMC8991431 DOI: 10.1016/j.jhsg.2021.02.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Accepted: 02/10/2021] [Indexed: 12/02/2022] Open
Abstract
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.
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12
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Spindler N, Langer S, Heister S. [Implementation of the wide awake local anesthesia no tourniquet (WALANT) type of anesthesia in hand surgery]. DER ORTHOPADE 2021; 50:415-424. [PMID: 33847790 DOI: 10.1007/s00132-021-04098-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 03/05/2021] [Indexed: 12/14/2022]
Abstract
Wide awake local anesthesia no tourniquet (WALANT) refers to an anesthesia technique with low bleeding and complication rates, which enables interventions on the hand in an awake patient without the use of a tourniquet. Bleeding control is achieved through addition of vasoconstrictors to the infiltration solution. Since the motor function of the extremity is not affected, it offers the additional possibility of intraoperative active function testing. The WALANT procedure constitutes an established, effective, easily learnt and resource-sparing technique. The spectrum of surgical possibilities with WALANT is wide and covers nearly all elective and many emergency procedures. Due to multiple advantages in contrast to other regional and general anesthesia procedures, WALANT features an increasing spectrum of surgical applications and practitioners. It is therefore of interest for hand surgeons working both in hospitals and private practices.
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Affiliation(s)
- Nick Spindler
- Bereich für Plastische, Ästhetische und Spezielle Handchirurgie, Klinik für Orthopädie, Unfallchirurgie und Plastische Chirurgie, Universitätsklinikum Leipzig, Liebigstr. 20, Haus 4, 04103, Leipzig, Deutschland.
| | - Stefan Langer
- Bereich für Plastische, Ästhetische und Spezielle Handchirurgie, Klinik für Orthopädie, Unfallchirurgie und Plastische Chirurgie, Universitätsklinikum Leipzig, Liebigstr. 20, Haus 4, 04103, Leipzig, Deutschland
| | - Simon Heister
- Bereich für Plastische, Ästhetische und Spezielle Handchirurgie, Klinik für Orthopädie, Unfallchirurgie und Plastische Chirurgie, Universitätsklinikum Leipzig, Liebigstr. 20, Haus 4, 04103, Leipzig, Deutschland
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Xu J, Yin L, Cao S, Zhan H, Zhang J, Zhou Q, Gong K. Application of WALANT technique for repairing finger skin defect with a random skin flap. J Orthop Surg Res 2021; 16:164. [PMID: 33653373 PMCID: PMC7923484 DOI: 10.1186/s13018-021-02319-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Accepted: 02/22/2021] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Wide-awake local anesthesia no tourniquet (WALANT) technique has emerged among hand surgeons with other indications. Surgeries involving pedicled flap and revascularization are no longer used as contraindications. The present study aimed to evaluate the feasibility and merits of the WALANT technique in random skin flap surgery. METHODS From May 2018 to March 2019, 12 patients with finger skin defects repaired with random skin flaps were reviewed. Abdominal skin flaps or thoracic skin flaps were used to cover the wound. Both the fingers and the donor sites were anesthetized by the WALANT technique. A 40-mL conventional volume consisted of a mixture of epinephrine and lidocaine. A volume of 5 mL was injected at the distal palmar for nerve block, the other 5 mL was injected around the wound for hemostasis, and the remaining was injected at the donor site of flaps for both analgesia and hemostasis. Baseline data with respect to sex, age, side, type of finger, donor sites, flap size, dosage of anesthetics, usage of finger tourniquet, intraoperative and postoperative pain, hemostasis effect, operation time, Disabilities of the Arm, Shoulder, and Hand Questionnaire (QuickDASH) score, and hospitalization expense, were collected. RESULTS All patients tolerated the procedure, and none of them needed sedation. Single finger skin defect in 8 patients and double finger skin defect occurred in 4 patients; 5 patients were repaired by abdominal skin flaps, and 7 patients were repaired by thoracic skin flaps. The good surgical field visibility was 91.7%. All flaps survived adequately, without necrosis, pulling fingers out, and other complications. The average visual analog scale (VAS) score of the maximal pain was 1.1 in fingers vs. 2.1 in donor sites during the operation. On postoperative day one, the average VAS score of the maximal pain in fingers and donor sites was 1.3 and 1.1, respectively. The average hospitalization expense before reimbursement of the whole treatment was 11% less expensive compared to the traditional method. The average QuickDASH score was 9.1. CONCLUSIONS Under wide-awake anesthesia, patients have the ability to control their injured upper extremities consciously, avoiding the complications due to pulling flap pedicles. With the merits of safety, painlessness, less bleeding, and effectivity, the WALANT technique in random skin flaps is feasible and a reliable alternative to deal with finger skin defect.
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Affiliation(s)
- Jianhua Xu
- Department of Hand Microsurgery, Tianjin Hospital, NO. 406, South Jiefang Road, Hexi District, Tianjin, 300211, People's Republic of China
| | - Lu Yin
- Department of Hand Microsurgery, Tianjin Hospital, NO. 406, South Jiefang Road, Hexi District, Tianjin, 300211, People's Republic of China
| | - Shuming Cao
- Department of Hand Microsurgery, Tianjin Hospital, NO. 406, South Jiefang Road, Hexi District, Tianjin, 300211, People's Republic of China
| | - Haihua Zhan
- Department of Hand Microsurgery, Tianjin Hospital, NO. 406, South Jiefang Road, Hexi District, Tianjin, 300211, People's Republic of China
| | - Jianbing Zhang
- Department of Hand Microsurgery, Tianjin Hospital, NO. 406, South Jiefang Road, Hexi District, Tianjin, 300211, People's Republic of China
| | - Qiang Zhou
- Department of Hand Microsurgery, Tianjin Hospital, NO. 406, South Jiefang Road, Hexi District, Tianjin, 300211, People's Republic of China
| | - Ketong Gong
- Department of Hand Microsurgery, Tianjin Hospital, NO. 406, South Jiefang Road, Hexi District, Tianjin, 300211, People's Republic of China.
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Aultman H, Roth CA, Curran J, Angeles J, Mass D, Wolf JM, Mica MC. Prospective Evaluation of Surgical and Anesthetic Technique of Carpal Tunnel Release in an Orthopedic Practice. J Hand Surg Am 2021; 46:69.e1-69.e7. [PMID: 33012615 DOI: 10.1016/j.jhsa.2020.07.023] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Revised: 06/02/2020] [Accepted: 07/30/2020] [Indexed: 02/02/2023]
Abstract
PURPOSE The goal of this study was to determine whether the type of anesthesia (monitored anesthesia care [MAC] vs wide-awake local anesthesia no tourniquet technique [WALANT]) or the surgical technique (mini-open vs endoscopic) would affect patient satisfaction with postoperative pain control, postoperative pain, or opioid use after carpal tunnel release (CTR). The hypothesis was that endoscopic and open CTR surgery would have the same patient satisfaction with postoperative pain control, postoperative pain, and opioid use, but WALANT surgery would have higher patient satisfaction with postoperative pain control, postoperative pain, and opioid use than MAC. METHODS This prospective study examined all patients undergoing carpal tunnel surgery by 4 hand surgeons at our institution. Two surgeons perform primarily 1-incision endoscopic CTR and the other 2 perform mini-open CTR. Two surgeons perform all procedures under WALANT; the other 2 employ MAC with a local anesthetic. Postsurgical questionnaires were completed at the 2-week postoperative visit. Patients reported remaining pills, average pain, highest pain, lowest pain, and overall satisfaction with postoperative pain control. RESULTS A total of 93 patients underwent CTR by the 4 participating hand surgeons. Of these, 43 underwent open CTR and 50 underwent endoscopic CTR. Sixty-two were performed under MAC and 31 with WALANT. With regard to anesthesia type, overall there was 5.5 mean morphine equivalents (MME) less prescribed and an average of 3.6 MME more remaining on the first postoperative visit with WALANT compared with MAC. Patient satisfaction with postoperative pain control was an average score of 7.9 for MAC and 7.4 for WALANT. With regard to surgical technique, overall, there was 15.2 MME less prescribed and an average of 1.03 MME more remaining on the first postoperative visit with endoscopic CTR compared with open CTR. Patient satisfaction with postoperative pain control between endoscopic and open release demonstrated an average score of 7.1 and 8.0, respectively. CONCLUSIONS This study demonstrates minimal differences in opioid pain medication use, patient satisfaction with postoperative pain control, and pain scores in a comparison of surgical technique as well as anesthesia type. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV.
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Affiliation(s)
- Hannah Aultman
- Department of Orthopaedic Surgery and Rehabilitation Medicine, University of Chicago, Chicago, IL
| | - Cameron A Roth
- Department of Orthopaedic Surgery and Rehabilitation Medicine, University of Chicago, Chicago, IL.
| | - John Curran
- Department of Orthopaedic Surgery and Rehabilitation Medicine, University of Chicago Pritzker School of Medicine, Chicago, IL
| | - Jovito Angeles
- Department of Orthopaedic Surgery and Rehabilitation Medicine, University of Chicago, Chicago, IL
| | - Daniel Mass
- Department of Orthopaedic Surgery and Rehabilitation Medicine, University of Chicago, Chicago, IL
| | - Jennifer Moriatis Wolf
- Department of Orthopaedic Surgery and Rehabilitation Medicine, University of Chicago, Chicago, IL
| | - Megan Conti Mica
- Department of Orthopaedic Surgery and Rehabilitation Medicine, University of Chicago, Chicago, IL
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