Conceptual origins, current practice, and views of wide awake hand surgery

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.

Wide-Awake Carpal Tunnel Release in the United States: Trends in Volume and Reimbursement by Operative Setting

BACKGROUND

Office-based surgery can increase logistical and financial efficiency for patients and surgeons. The current study compares wide-awake, office-based carpal tunnel release to wide-awake operations performed in the operating room in terms of volume, financial burden, narcotic prescriptions, and adverse events.

METHODS

Operations performed under local-only anesthesia from 2010 to 2020 were identified in a national administrative database (PearlDiver). Patients were grouped by surgical setting and matched based on age, sex, comorbidity burden, and geographic region. Primary endpoints included total disbursement and physician reimbursement, and 30-day narcotics prescriptions, emergency department (ED) visits, and surgical site infections (SSIs).

RESULTS

Before matching, there were 303,741 operating room operations and 5463 office operations. From 2010 to 2020, the percentage of operations in the office increased from 1.2% to 3.4%. Matched cohorts included 21,835 operating room operations and 5459 office operations. Office surgery was associated with lower total disbursement and physician reimbursement for patients with commercial insurance, Medicaid, and Medicare. Linear regression modeling indicated that office-based surgery was significantly associated with lower total disbursement and physician reimbursement. Fewer office patients filled narcotic prescriptions and visited the ED, and there was no difference in SSIs.

CONCLUSIONS

Compared with operating room surgery, office surgery was associated with lower financial burden, fewer narcotics prescriptions and ED visits, and a similar incidence of SSIs. These findings, together with literature showing greater efficiency in the office, suggest that office-based operations are safe and cost-effective and should continue to grow.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Lacertus syndrome: recent advances

Lacertus syndrome consists in proximal median nerve entrapment with median nerve compression at the lacertus fibrosus, causing hand weakness and fatigue, forearm pain and occasional numbness. Recent advances emphasized the importance of clinical examination, due to limitations in electromyographic diagnosis and delayed diagnosis. The Hagert clinical triad, lacertus notch sign, lacertus antagonist test and taping help accurate diagnosis. Non-operative treatment should be tried; and surgical techniques, whether open or ultrasound-guided under WALANT (wide-awake, local anesthesia, no tourniquet) show promising outcomes. Improved awareness, accurate diagnosis and innovative treatments enhance patient care for this challenging condition.

The history of tourniquet use in limb surgery

PURPOSE

As tourniquets have been present in medicine since almost its conception, understanding and following their development through time is not only an exercise in history but also an insight into the evolution of medical devices over more than two millennia. From simple leather bands wrapped around patients' limbs to the modernised digital devices used widely in surgical theatres globally, tourniquets have undergone tectonic change both in their design and application, moving from battlefields to hospitals. Hence, the aim of this article is to outline the historical development of these devices alongside their present and modern use.

METHODS

The historical development of emergency and surgical tourniquets is chronologically outlined, with particular emphasis on the impact of warfare on their widespread adoption in trauma and emergency medicine and elective surgery. Novel surgical trends and their impact on the future of tourniquet use are evaluated.

RESULTS

The development of tourniquets across two millennia has closely reflected both the scientific understanding of human physiology and anatomy as well as technological discoveries and advancements that have reshaped their design and application. Prominent figures in the field of surgery, such as Sushruta, Fabricius Hildanus, John Louis Petit, Joseph Lister, Harvey Cushing and James McEwen, all fundamentally influenced their evolution and helped popularise and modernise them. The views on their use have been controversial and drastically changed across different eras, with data collected from modern warfare serving to embed their use in clinical practice.

CONCLUSION

The historical development of tourniquets since pre-historic times represents an excellent outline of the adaptive nature of medicine, led, firstly, by scientific rigour and discipline and, secondly, by pioneers who serve as catalysts for change and improvement. The modern inflatable cuff tourniquets that are omnipresent in theatres globally will undoubtedly remain the standard of care for the foreseeable future. Tourniquets that can dynamically monitor blood pressure and consequently adjust inflation pressures, as well as ones with inbuilt axonal excitability monitoring, will further improve their safety profile, reduce associated complication rates and represent the next step in the evolution of these devices. Notably, there might be a shift away from tourniquet use altogether, reflected by the wide use of the wide-awake local anaesthesia no-tourniquet technique that has become the new norm in hand surgery.

Wide Awake Local Anesthetic No Tourniquet in Hand and Wrist Surgery: Current Concepts, Indications, and Considerations

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.

Intraoperative Hemostasis Using WALANT Versus Tourniquet; A Focused Review on Carpal Tunnel Syndrome and Trigger Finger Release

Maintaining intraoperative haemostasis is crucial when conducting wide-awake hand surgeries, this is particularly to improve visibility which will improve patient's outcome. There are various methods that could achieve the aforementioned, some of which is wide awake local anaesthesia without tourniquet (WALANT) or Tourniquet alongside sedation. Each method has its own benefits and drawbacks. This study primarily focuses on Carpal Tunnel Syndrome and Trigger Finger release. A comprehensive literature review was conducted through PUBMED, Scopus, google scholar, and web of science. A total of 45 articles were included in the study. We aimed to assess whether the literature supports the use of a tourniquet alongside sedation, or only local anesthesia and epinephrine in wide awake hand surgeries. Moreover, we aimed to highlight the benefits and drawbacks of using a tourniquet, and determine the patient population most likely to benefit from tourniquet application.

Intraoperative Challenges in Hand Surgery

A wide array of intraoperative issues can arise during surgery involving the hand and upper extremity. An understanding of the common pitfalls within hand surgery may help practicing hand surgeons circumvent such issues. Within this manuscript, we first identify problems with the increasingly popular technique of wide-awake local anesthesia no tourniquet (WALANT). Achieving appropriate hemostasis and anesthetic can be bothersome, especially for procedures proximal to the distal palmar crease. We discuss our local anesthetic timing and concentrations to help mitigate such issues, as well as other problems that may arise in WALANT procedures. There also lies a barrier in connecting the traumatized patient to care in the outpatient/ambulatory setting. Additionally, the polytraumatized patient increases the complexity of care coordination for not just the hand surgeon, but all surgical providers involved. The order in which multidisciplinary surgical procedures are performed is influenced by both the complexity of the patient's case as well as the institution's current protocol. All academic institutions are faced with challenges in providing optimal intraoperative education to trainees. We acknowledge that there should be a balance between the attending surgeon executing key portions of the procedure and the trainee gaining the appropriate hands-on experience. This manuscript elaborates on the issues of intraoperative education provided to residents and anecdotal methods that may help overcome such challenges. Resources within hand surgery can often be limited and become particularly problematic in the operative setting. Specific examples include but are not limited to the lack of dedicated teams, inability to obtain appropriate intraoperative imaging, access to appropriate hardware, and intraoperative complications in an ambulatory surgery center setting.

Healing strength of tendon repair with or without knots between two tendon ends and histological changes in a chicken model

We studied the healing strength and histological changes of digital flexor tendons repaired using Kessler (core suture knots placed over the tendon surface) and modified Kessler (core suture knots placed between two tendon ends) in 31 long toes of chicken. Four weeks after surgery, the healing tendons were measured in a tensile testing machine, and the adhesion formation and histological changes were observed. The strength of the Kessler repairs was significantly greater than that of the modified Kessler repairs with a 35% mean difference. No significant difference was found between the adhesion scores of the tendons repaired with both techniques. In histological sections, the arrangement of collagen fibers in the modified Kessler repair group was more disordered. We conclude that the tendons repaired with the Kessler method are stronger than those with the modified Kessler technique. The knots between tendon ends are detrimental to the early healing strength of digital flexor tendons.

13 years of hand surgery without an anesthesiologist. An analysis of efficacy and safety of presurgical anesthesia as delivered by surgeons without the assistance of anesthesiologists

<b><br>Introduction:</b> The assistance of anaesthesiologist is considered an inseparable part of most surgical procedures, with the exception of a small proportion of minor procedures performed under local anaesthesia. In hand surgery, a vast majority of procedures, even those lasting several hours, can be carried out under regional (brachial plexus block) or local (infiltration) anaesthesia. These can be delivered by the surgeons themselves, allowing the surgeries to be carried out without the assistance of anesthesiologists.</br> <b><br>Aim:</b> The aim of this study was to analyze the efficacy and safety of presurgical anesthesia as delivered by surgeons without the assistance of anesthesiologists in the course of hand surgery procedures performed within the institution headed by the author of this article.</br> <b><br>Material and methods:</b> The analysis was based on the records of anesthesia protocols filled out by the surgeons who delivered the anesthesia and who operated on the patients. The variables considered included the efficacy of anesthesia and the anesthesia-related adverse effects and complications.</br> <b><br>Results:</b> Over a period of 13 years (2010-2022), a total of 24,703 surgeries were delivered; of these, 22,228 (91%) surgeries were carried out without anesthesiologists, with anesthesia being delivered by the surgeon him/herself. The efficacy of these procedures (local anasthesia and brachial plexus blocks combined) was 99%. A total of 631 (2.8%) anesthesia-related adverse reactions were recorded, most of them being transient, requiring immediate interventions and not leading to any serious sequelae. In only 17 cases (0.07%), adverse effects resulted in cancellation and rescheduling of the elective surgery.</br> <b><br>Conclusions:</b> Pre-surgical anesthesia as delivered prior to hand surgery procedures by the surgeons without the assistance of anesthesiologists is effective and safe while being associated with numerous benefits for patients, surgeons and the health care system's budget.</br>.

Intraoperative immediate strength recovery following lacertus fibrosus release in patients with proximal median nerve compression at the elbow

PURPOSE

In the literature, we find that patients with lacertus syndrome (LS), proximal median nerve compression at the elbow, present subjective improvement of thumb, and index flexion strength after lacertus fibrosus (LF) release. The aim of this study is to objectively evaluate the immediate change in intraoperative flexion strength after LF release.

METHOD

We retrospectively reviewed prospectively collected data of a cohort of 24 patients with a double crush syndrome of the median nerve with no response to conservative treatment. All patients had surgery with LF and carpal tunnel release (CTR) under wide-awake local anaesthesia and no tourniquet (WALANT) and were evaluated intraoperatively with a dynamometer immediately before and after LF release. Flexor digitorum profundus of the second finger (FDP2) and Flexor pollicis longus (FPL) were tested in peak strength to failure. The primary outcome was the percentage of change in strength before and after the release in both assessed muscles. CTR was done after evaluating the change in flexor strength.

RESULTS

A percentage of 79.2 women with an average age of 43.3 years. The average strength of FDP2 before LF release was 15.5 pounds (lbs.) (7.0 kg) (SD, 7.2 lbs (3.3 kg)) and 27.1 lbs. (12.2 kg) (SD, 7.1 lbs. (3.2 kg)) after LF release, which corresponds to a 96% (SD, 70%) change in strength (p=0.000). For FPL, the average pre-release strength was 17.7 lbs. (8.0kg) (SD, 4.8 lbs. (2.2 kg)) and 27.4 lbs. (12.4 kg) (SD, 5.2 lbs. (2.4 kg)) post-release, this corresponded to a 65% (SD, 38%) change in strength (p=0.000).

CONCLUSIONS

Peak strength to failure in FDP2 and FPL has an immediate significant recovery after LF surgical release in patients with Lacertus syndrome.

LEVEL OF EVIDENCE

IV, retrospective study.

Application of Field Sterility to Safely Reduce Cost and Waste in Cleft Surgery

BACKGROUND

Healthcare spending in the United States remains a major concern, requiring reforms to control spending and curtail costs. Medical supply is one of the largest expenses for hospitals and strategies should be utilized to reduce nonbeneficial service delivery, which increases cost without concomitant increase in value. Introduction of field sterility is one of the potential strategies that has been applied in several surgical disciplines to improve cost-efficiency by reducing overuse of resources and decreasing enormous medical waste. Of course, this must be applied without a diminution in safety.

METHODS

The PubMed, Medline, and Cochrane databases from 1980 to 2022 were used to review literature. Key words included "cleft surgery and field sterility," "sterile gloves and oral surgery," "oral surgery and field sterility," "sterile techniques and cleft palate surgery," "sterile versus nonsterile gloves," "sterile and non-sterile gloves and minor surgery," "skin laceration repair and sterile techniques," "sterile gloves and wound suture," "surgical site infection and field sterility," "operating room versus clinical setting," "operating rooms economics and hand surgery," and "main operating room versus ambulatory."

RESULTS

The literature search yielded 827 articles. Following evaluation of titles, abstracts, and manuscript contents, 23 articles were ultimately included, of which 10 discussed field sterility and cost-efficiency for cutaneous procedures, 9 hand surgery, and 4 oral surgery. There was no study evaluating field sterility application in cleft surgery. In the reviewed studies, no statistical significance was observed in surgical site infection (SSI) with substantial cost savings and medical waste reduction when hand procedures were performed in ambulatory settings with field sterility compared to the main operating room (OR). Furthermore, no difference was observed for SSI in wound closure, excision of skin lesions, or Mohs micrographic surgery when nonsterile gloves were used.

CONCLUSION

The incidence of infection following most cleft-related procedures remains low. As such, the application of field sterility may be ideal for this setting. The cost and waste associated with standard operating protocols are not warranted for many cleft procedures.

Wide-awake local anesthesia and no tourniquet (WALANT) in upper limb fractures

Wide-awake local anesthesia and no tourniquet (WALANT), first used for hand surgery, has been sparingly described for use in fracture fixation of the upper limb. We present our experience using this technique. 26 patients with upper limb fractures (3 distal radius, 6 radial shaft, 11 ulnar shaft, and 6 olecranon fractures) were operated on using WALANT by three orthopedic surgeons. We used 35-40ml of 2% Lignocaine with 1:80000 Adrenaline(7mg/kg) diluted with normal saline. Numeric Pain Rating (NPR) scoring was done during injection and per-operatively, and the Likert scale was used for the surgeon's satisfaction. The average NPR score was reported as 0.65 (1-3) during injection and 0.15 (0-2) preoperatively. All three surgeons reported excellent satisfaction in all the cases operated on. No complication occurred due to anesthesia. WALANT is a much simpler option and can be safely used in place of general anesthesia or regional blocks for fixation of fractures of the upper limb, with added advantages of no need for a tourniquet and better intraoperative assessment of fracture fixation.

A Study of Hand Flap Viability when Using a Wide Awake Local Anesthesia No Tourniquet (WALANT) Technique

Objectives  Flap surgery using a wide awake local anesthesia no tourniquet (WALANT) technique has historically been avoided because of technical challenges and concerns regarding the vasoconstriction caused by the necessary injection of epinephrine alongside the local anesthetic. The objective of our work was to evaluate the viability of the hand flaps performed using a WALANT technique compared with those performed under regional with a tourniquet. Materials and Methods  Seventy-four patients were enrolled in a prospective comparative single-center study and subsequently divided into two groups: 36 patients in the locoregional anesthesia group and 38 patients in the WALANT group. Flap viability was evaluated on day 2 and day 10 using predetermined criteria. Results  We did not find any significant difference in outcomes assessed for flap viability between the two groups postoperatively. Conclusion  There was no evidence to suggest that vascularization of the flaps was compromised by the injection of epinephrine. The WALANT technique may, therefore, potentially be able to be safely deployed within this population.

Regional Anesthesia in Upper-Limb Surgery

BACKGROUND

Local and regional anesthesia is associated with numerous clinical and institutional advantages relative to general anesthesia. As anesthesiologists and surgeons increasingly integrate local and regional anesthesia into their clinical practice, an understanding of the principles, evolution, and trends underpinning modern anesthetic techniques continues to be relevant.

METHODS

A review of the literature in databases Medline, PubMed, and EMBASE identified recent developments, ongoing trends, and historical milestones in upper-limb regional anesthesia.

RESULTS

Advances in regional anesthetic techniques in the last century have led to reduced postoperative pain, improved safety, and improved outcomes in upper-limb surgery. The development of ultrasound-guided techniques, as well as pharmacological advances in local anesthetic drugs and adjuncts, has further advanced the role of regional anesthesia. Wide-awake local anesthesia with no tourniquet has allowed certain procedures to be performed on select patients in outpatient and low-resource settings.

CONCLUSIONS

This review provides an overview of local and regional anesthesia in the upper-limb from its historical origins to its contemporary applications in upper-limb surgery, particularly during the COVID-19 pandemic.

Flexor Tendon Repair Techniques: M-Tang Repair

The authors present the methods and outcomes from six institutes where M-Tang repairs with early active flexion exercise are used for zone 2 digital flexor tendon repair. The authors had close to zero repair ruptures, and few digits needed tenolysis. The excellent to good results are generally between 80% and 90%. In the pandemic period, less stringent therapy supervision might have allowed some patients to move too aggressively, with repair ruptures not seen before the pandemic in one institute. In Nantong, Yixing, and Saint John, the rupture incidence is zero to 1%. In Florence and Heidelberg, the rupture incidence was 3%.

Distal radius fracture fixation using WALANT versus general and regional anesthesia: A systematic review and meta-analysis

BACKGROUND

WALANT (wide-awake local anaesthetic no tourniquet) has become a popular technique in upper limb surgery including distal radius fracture fixation. The purpose of this systematic review and meta-analysis is to assess the effectiveness of the WALANT technique in distal radius fracture fixation, and to compare it to both general and regional anaesthesia.

METHODS

Pubmed, Embase, and Scopus databases were searched on 26/06/21 according to the PRISMA guidelines with the following search terms: radius, WALANT, "local anesthetic", wide-awake surgery. All studies comparing WALANT with other forms of anaesthesia for distal radius fracture fixation were included.

RESULTS

110 articles were identified, six studies (410 patients) were included, 164 of these patients were in the WALANT group. Two patients (1.2%) in the WALANT group and seven (6.5%) in the regional anaesthesia group required conversion to general anaesthesia. There was no statistically significant difference in post-operative complications, intra-operative VAS pain scores, operative times, functional or radiological outcomes. A statistically significant 8.6 mls increase in pooled mean blood loss in the WALANT group was noted (p = 0.02) although the clinical significance of this is doubtful.

CONCLUSION

The WALANT technique for distal radius fracture fixation is non-inferior to regional and general anaesthesia. It is a safe and effective technique that surgeons may consider utilising, especially for patients not suitable for general anaesthetic or in centres in which there is a lack of access to specialist anaesthetic equipment and care.

Comparison of the effectiveness of local anesthesia for the digital block between single-volar subcutaneous and double-dorsal finger injections: a systematic review and meta-analysis of randomized control trials

Local anesthesia is an effective method to perform digital nerve blocks. In this study, we compare the effectiveness of single-volar subcutaneous and double-dorsal injection through a systematic review and meta-analysis of randomized controlled trials (RCTs). A systematic search of PubMed, Embase, and the Cochrane Library from inception to 7 April 2021 was performed. RCTs with the effects of single-volar subcutaneous and double-dorsal injection were eligible. Meta-analysis was performed using random effect models with pooled standardized mean differences (SMDs) and 95% confidence intervals (CI). RoB 2.0 and GRADE of Recommendation Assessment, Development, and Evaluation criteria were applied for evaluating the bias. A total of 2484 studies were initially identified, with 11 eligible RCTs finally included in the meta-analysis (1363 patients). The pooled data of nine studies showed single-volar injection had a statistically significantly lower pain score (pooled SMD: 0.20, 95% CI, 0.01 to 0.39, p = 0.041, I2 = 58%, N = 1187) and higher patient preference but invalid anesthesia at the dorsal proximal digit. No significant differences were observed in the onset of anesthesia, adjacent digit invalid numbness, distal phalanx invalid anesthesia, additional injection rate, and adverse effects. In conclusion, this meta-analysis of RCTs showed that the single-volar injection was associated with a lower pain sensation during injection and higher patient satisfaction with a reduced anesthetic effect over the proximal dorsal phalanx. Further high-quality RCTs with a higher number of cases are needed to validate our results.

Guidelines for Wide-Awake Local Anesthesia Surgery with No Tourniquet in the Office Setting Using Field Preparation Sterility

SUMMARY

Wide-awake local anesthesia surgery with no tourniquet, or WALANT, has become popular in surgery, especially among hand surgeons. With the increasing number of surgeons performing office-based procedures, this article provides guidelines that may be used in the office setting to help transition more traditional hospital operating room-based procedures to the office setting. This article outlines the benefits of performing office-based wide-awake local anesthesia surgery with no tourniquet and provides a step-by-step guide to performing procedures that can be easily incorporated into any hand surgeon's practice successfully and safely.

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.

Via clínica para cirugía mediante técnica WALANT fuera del estándar de cirugía mayor ambulatoria

Objetivo Desarrollar y valorar al año una vía clínica para procedimientos de cirugía de mano utilizando anestesia local sin torniquete y con el paciente despierto, denominada técnica WALANT (wide awake, local anesthesia, no tourniquet, en inglés).

Materiales y Métodos Se planificó y ejecutó una vía clínica para pacientes de cirugía de mano no compleja, y se realizó una comparativa de costes entre dotación completa del quirófano y cirugía local con la técnica WALANT.

Como indicadores de la calidad, se calculó la tasa de suspensiones quirúrgicas y el número de pacientes intervenidos. Se comparó el tiempo medio de estancia hospitalaria entre los pacientes intervenidos de forma ordinaria y en el quirófano WALANT. Se valoró la reducción en la lista de espera quirúrgica en síndrome del túnel del carpo y dedo en gatillo.

Resultados Los gastos directos fueron un 48,9% menores en el procedimiento WALANT. Se valoraron 254 pacientes en 2020 y 339 en 2021. La tasa de suspensión fue del 5,1% (0,4% por motivos médicos). El tiempo de estancia en el hospital fue significativamente menor para los pacientes del grupo WALANT (z = -8,743; p = 0,000). La disminución en la lista quirúrgica fue de 113 días.

Conclusiones La cirugía mediante la técnica WALANT adecuada a esta vía clínica permite la intervención de pacientes con menos recursos, lo que disminuye los gastos directos y alivia las unidades de Cirugía Ambulatoria.

Patient satisfaction after distal upper limb surgery under WALANT versus axillary block: A propensity-matched comparative cohort study

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 (&gt;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.

Wide-awake surgery in orthopaedics: "Scoping review"

INTRODUCTION

The anaesthetic modality "wide-awake" or "WALANT" (wide awake local anaesthesia not tourniquet) is based on the combination of a local anaesthetic with a vasoconstrictor to reduce bleeding during surgery and to avoid the use of a pneumatic tourniquet. The combination of 1% lidocaine together with 1:100,000 epinephrine is the most commonly used formula. The objective of this work is to carry out a review of the literature about this anaesthetic modality in the field of orthopaedic surgery and traumatology.

METHODS

PubMed and Embase databases were consulted with clearly defined operators. Two independent searches were conducted by two investigators, which were combined. Experimental, observational comparative studies, descriptive studies with n> 5 cases and cost studies were included. The individual results of the included studies are described.

RESULTS

A total of 8794 entries were collected of which a total of 36 studies were included in the review. A large number of these studies have been published since 2010 and refer almost entirely to hand surgery, with multiple indications applied. There is heterogeneity regarding the type of study design and variables studied, among others. In addition, there is a disparity when defining the methodology of the WALANT technique between the different studies.

CONCLUSIONS

This is the first comprehensive and reproducible review of the current state of the WALANT modality. There is great heterogeneity in terms of the study populations, the different comparators, variables studied between the different studies and a lack of precise details regarding the WALANT technique.

LEVEL OF EVIDENCE

III, Therapeutic study.

Virtual Reality Improves Patient Experience and Anxiety During In-office Carpal Tunnel Release

BACKGROUND

This study examined how wide- awake local anesthesia no tourniquet (WALANT) surgery in the office versus the standard operating room (OR) impacts patient experience, and the effect wide awake virtual reality (WAVR) has in conjunction with WALANT on patient experience.

METHODS

This is a patient-reported outcome study of patients undergoing carpal tunnel release by a single surgeon between August 2017 and March 2021. Patients were classified by location; traditional OR versus WALANT in-office. In-office patients were further classified by whether they chose to use WAVR or not. Patients rated overall experience, enjoyability, and anxiety using a Likert scale (1-7).

RESULTS

The online survey had a 44.8% response rate. OR patients were twice as likely to report a neutral or negative experience (23% versus 11%, P = 0.03), significantly lower enjoyment scores (44% versus 20%, P = 0.0007)' and higher anxiety (42% versus 26%, P = 0.04) compared with office-based WALANT patients. With the addition of WAVR, office patients reported higher enjoyment than those who did not use WAVR (85% versus 73%, P = 0.05). Patients reporting an anxiety disorder were more likely to choose WAVR when compared with patients without anxiety disorder (73.8% versus 56.4%). When they chose WAVR, they had greater anxiolysis (79% versus 47%, P = 0.01)' and increased enjoyment (90% versus 59%, P = 0.005).

CONCLUSIONS

This study demonstrates improved patient experience in the office setting, further amplified by WAVR. Preexisting anxiety disorder is a positive predictive variable toward the patients' choice to use WAVR.

Wide awake local anesthesia no tourniquet (WALANT) versus axillary brachial plexus block for carpal tunnel release in a French public university hospital: Care pathways and operating room costs

INTRODUCTION

The wide awake local anesthesia no tourniquet (WALANT) is a local anesthetic technique that theoretically cuts costs and shortens surgical waiting times, but this has yet to be demonstrated in France. The main objective of this study was to assess and compare the comprehensive care pathways and costs of performing carpal tunnel release (CTR) procedures in the ambulatory surgery unit using WALANT and axillary brachial plexus block (ABPB).

METHODS

A total of 72 CTRs in 66 patients were reviewed after a minimum follow-up of 6 months. The anesthesia was performed by an anesthesiologist after a preoperative consultation. The surgical waiting time, operating room occupancy time, total time taken off work (TOW) and the return to work rate were recorded. The estimated total direct cost per patient (TDCPP) was the sum of the specialist consultation fees, the French diagnosis-related group (DRG) rates and the minimum daily cost of TOW (€27.30/day).

RESULTS

Only the total operating room occupancy time differed significantly: 27minutes for the WALANT versus 37minutes for the ABPB (p=0.004). There were no complications or reoperations in either group. The total cost for the cohort was estimated at €190,970. The mean estimated TDCPP was €2,870 for the entire cohort, €2,543 for the ABPB and €2,713 for the WALANT (p=0.791). Twenty-seven of the 45 patients returned to work after a mean TOW of 3.1 months. Fourteen CTRs were preceded by a mean preoperative TOW of 27 days, which resulted in a cost of €24,948 (13% of the total cost). There were no significant differences in TOW or revision rate between WALANT and ABPB.

CONCLUSION

Although WALANT significantly reduced operating room occupancy times in our public hospital, the societal costs were the same regardless of the anesthesia technique. Reducing surgical waiting times in France could result in a theoretical saving of nearly €14 million annually.

LEVEL OF EVIDENCE

IV.

Flexor digitorum profundus tendon injuries in Zone 2 repaired with a modified Mantero technique

From January 2010 to January 2017, 81 complete flexor digitorum profundus tendon disruptions in Zones 2B and 2C were treated using the modified Mantero technique. The patients were re-examined at a mean of 62 months (range 30-96) after operation. We analysed outcomes against ages, gender, pulley integrity, associated injuries and follow-up times. The median total range of motion of both interphalangeal joints, distal interphalangeal joint alone and Quick DASH scores were significantly better for the group with pulley vented versus no pulley vented. According to the Strickland and Glogovac criteria, 76 (91%) had excellent or good, five fair and none had poor results. There were no complications except for one deep and one superficial infection at the site of the injury. There were no tendon ruptures and only three patients (3.7%) required secondary tenolysis. The modified Mantero repair is recommended as an alternative in the repair of tendon disruptions in Zone 2B and 2C. The good results and absence of ruptures suggest that the tendon healing and strength of repair are adequate for immediate postoperative motion.Level of evidence: IV.

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.

WALANT Technique in Percutaneous Scaphoid Osteosynthesis

Scaphoid fractures account for 50 to 70% of all carpal bone fractures. Percutaneous scaphoid osteosynthesis can use the dorsal or volar approach, both with good results, and is most commonly performed under general anesthesia or regional nerve block. The wide-awake local anesthesia no tourniquet (WALANT) technique is already considered a safe and cost-effective technique in hand surgery around the world. Local anesthesia with epinephrine causes vasoconstriction, which obviates the need for tourniquet and, consequently, the need to use patient sedation. Thus, the possibility of testing fixation stability under physiological forces is another great advantage of using local anesthesia. In the technique described in the present paper, active wrist and hand motion can be tested immediately after scaphoid fixation. Wide-awake local anesthesia no tourniquet has been increasingly used in soft-tissue hand surgery and in the fixation of metacarpal and phalangeal fractures. However, to date, there is no published literature addressing the use of this technique in percutaneous scaphoid osteosynthesis. The purpose of the present technical note is to describe the use of WALANT for both the dorsal and volar approaches in percutaneous scaphoid osteosynthesis.

A randomized controlled trial of three different local anesthetic methods for minor hand surgery

Purpose: Hemostasis and local anesthetic injection are essential for minor hand surgeries under local anesthesia (LA). Wide awake local anesthesia no tourniquet (WALANT) became popular for achieving hemostasis without a tourniquet. However, a recent study reported that injection is more painful than tourniquet use in minor hand surgery. Therefore, this study aimed to compare three LA methods that differ according to injection and hemostasis, namely, the combination of a tourniquet and buffered lidocaine solution (CTB), WALANT, and conventional LA. Methods: This randomized prospective single-center study included 169 patients who underwent minor hand surgery between 2017 and 2020. We randomly allocated the patients to each group and recorded the pain and anxiety score during the surgery, as well as satisfaction after the surgery. Results: Pure lidocaine injection was significantly more painful than buffered lidocaine and WALANT solution injection (p < 0.001). Local anesthesia injection was significantly more painful than tourniquet use in all groups (p < 0.001). The intraoperative anxiety score was significantly lower in the CTB group than in the conventional LA and WALANT groups (p < 0.001). The satisfaction score was significantly higher in the CTB and WALANT groups than in the conventional LA group (p < 0.001). Conclusion: CTB for minor hand surgery under LA is associated with less injection pain and patient anxiety. The tourniquet is tolerable without much pain and waiting time. Thus, CTB in minor hand surgery is a good alternative to WALANT and conventional LA.

Downstream Impact for Plastic Surgeons in the United States from the “No Surprises Act”

The No Surprises Act, signed into the US federal law in 2020, establishes a floor for reimbursement determined by insurance payors for out-of-network charges rendered by providers in emergency services. Physicians are not permitted to balance bill patients for the difference. An arbitration process is outlined for mediation between provider and payor if needed.

Outcomes After Flexor Tendon Injuries in the Pediatric Population: A 10-Year Retrospective Review

Background: Pediatric outcomes after flexor tendon repairs are variable, and evidence in the literature remains scarce. Methods: Repair of pediatric flexor tendon injuries was reviewed over a 10-year period (2005-2015). Data collection consisted of patient demographics, injury characteristics, anesthetic choice, repair technique, rehabilitation protocol, American Society for Surgery of the Hand Total Active Motion (TAM) scores, and complications. Results: There were 109 patients included in our study, with a total of 162 digits injured and 235 flexor tendon injuries. The mean age was 12 ± 4.6 years. The small finger (48 of 162; 30%) and the flexor digitorum profundus tendon (126 of 235) were the most commonly injured. The mechanism of injury was mainly from a knife (46 of 109; 42.2%) in zone II (82 of 159; 52%). Injuries were mostly repaired under general anesthetic (61 of 104; 56%). The Kessler technique was the predominant repair mechanism (111 of 225 repairs; 49%). Most patients (103 of 109; 95%) had excellent or good TAM scores with 5 postoperative ruptures reported. The most common complication was stiffness (17 of 121 complications; 14%), with most patients having no complications ( 74 of 109 patients; 68%). Patients were commonly immobilized (mean 8.4 ± 10.3 weeks) with a splint (93 of 109; 85%). There were 85 patients who followed a postoperative rehabilitation protocol for 12 ± 18 weeks. Patient demographics, time of repair, injury characteristics, anesthetic choice, and rehabilitation protocol were not significantly correlated with TAM scores or complication rates. Conclusions: Pediatric tendon injuries have good outcomes with no predictive factors identified. Surgical repairs performed under local anesthetic have similar outcomes without increased rates of complications, but remain underused in the pediatric population.

Current Evidence Involving WALANT Surgery

Wide-awake local anesthesia no-tourniquet (WALANT) surgery is an attractive option for hand surgeons, particularly during resource-scarce periods, as it eliminates dependence on main operating rooms or hospital-based procedures. The limited prepping or draping used for WALANT field sterility is as effective, if not more effective, than standard sterile prepping or draping. Patient anxiety surrounding WALANT surgery is similar to or less than that of general or local anesthesia with or without tourniquet. Patients use the same or lower amounts of postoperative narcotics after WALANT as compared to after the other anesthetic methods. Wide-awake local anesthesia no-tourniquet surgery saves significant costs for the same surgeries when performed under general or local anesthesia with or without tourniquet. There are very few complications associated with the WALANT method of anesthesia; rare case reports include vasovagal syncope and cardiac arrhythmia due to inadvertent intravascular injection of epinephrine.

Less Fluctuation in Hemodynamics of the Wide-Awake Local Anesthesia No Tourniquet Technique Than General Anesthesia in Distal Radius Plating Surgery: A Prospective Case-Control Study

This prospective case-control study aimed to compare the intraoperative hemodynamic changes between the wide-awake local anesthesia no tourniquet (WALANT) technique and general anesthesia (GA) in patients undergoing distal radius plating surgery. Forty adults with distal radius fractures underwent plating surgery via the WALANT technique (20 patients) or GA (20 patients). Mean arterial pressure (MAP) and heart rate were recorded. Intraoperative pain intensity was measured using the visual analog scale (VAS) for pain in the WALANT group. The measures of hemodynamics and VAS were recorded at seven-time points perioperatively. The VAS score decreased significantly compared with the preoperative status in the WALANT group for most of the intraoperative period except during injections of local anesthetics and fracture reduction. The intraoperative MAP in the WALANT group showed no significant change during the perioperative period. In addition, the WALANT group showed fewer perioperative MAP fluctuations than the GA group (p < 0.05). The reduction and plating quality were similar between the two groups. WALANT provided a feasible technique with less fluctuation in hemodynamic status. With gentle manipulation of the fracture reduction, distal radius plating surgery using the WALANT technique is a well-tolerated surgical procedure and shows similar reduction and plating quality to GA.

Patient and Surgeon Reported Experiences of Locoregional Anesthesia in Hand Surgery

Introduction  Locoregional anesthesia techniques have been increasingly adopted for use in hand surgery in recent years. However, locoregional anesthesia techniques may place patients under significant psychological stress, and there has been limited evaluation of acceptance and satisfaction rates of these techniques. Materials and Methods  An observational study was conducted in a single tertiary institution. Data were collected from patients undergoing upper limb surgery procedures with locoregional anesthesia. After completion of surgery, a questionnaire adapted from Evaluation du Vecu de l'Anesthesie LocoRegionale (EVAN-LR), with scores from 1 to 5 on the Likert scale, was conducted on the same day to evaluate patient satisfaction. Responses were also obtained from the operating surgeon to assess satisfaction. Results  A total of 101 patients were evaluated as part of the study. All EVAN-LR domains received a mean score >4.5. Responses from surgeons also showed good acceptance of locoregional anesthesia techniques with almost all giving scores ≥4 on the Likert scale. Conclusion  The results of this study showed good satisfaction and acceptance of locoregional anesthesia among patients for upper limb procedures. This provides reassurance regarding the quality of care with locoregional anesthesia techniques. It remains important to be aware of potential sources of discomfort such as tourniquet pain to minimize discomfort and maximize patient satisfaction.

Severe hand contracture treated by external fixation after proximal row carpectomy and awake tenolysis after general anesthesia: A case report

Wide-awake local anesthesia has many advantages. We describe a new method to use wide-awake local anesthesia with more flexibility. A 32-year-old man with a severe right-hand contracture after an iatrogenic tourniquet accident during an anterolateral thigh flap for a partial hand amputation underwent contracture release using external fixation after proximal row carpectomy and subsequent tenolysis. We performed most of the tenolysis procedure under general anesthesia and the final stage with an intraoperative assessment of active finger movement and dissection under local anesthesia. He regained his grip strength 2.5 years post-injury. General anesthesia is useful to treat a surgical site with extensive hard scars, whereas local anesthesia is useful for adjusting tension in an awake patient. The indication for wide-awake surgery is yet to be established; our method of combining general and local anesthesia in the tenolysis procedure illustrates the possibilities in expanding this method.

Flexor tendon repair: recent changes and current methods

The current clinical methods of flexor tendon repair are remarkably different from those used 20 years ago. This article starts with a review of the current methods, followed by presentation of past experience and current status of six eminent hand surgery units from four continents/regions. Many units are using, or are moving toward using, the recent strong (multi-strand) core suture method together with a simpler peripheral suture. Venting of the critical pulleys over less than 2 cm length is safe and favours functional recovery. These repair and recent motion protocols lead to remarkably more reliable repairs, with over 80% good or excellent outcomes achieved rather consistently after Zone 2 repair along with infrequent need of tenolysis. Despite slight variations in repair methods, they all consider general principles and should be followed. Outcomes of Zone 2 repairs are not dissimilar to those in other zones with very low to zero incidence of rupture.

The impact of WALANT anesthesia and office-based settings on patient satisfaction after carpal tunnel release: A patient reported outcome study

HYPOTHESIS

Wide awake local anesthesia with no tourniquet (WALANT) and office-based procedures are used in hand surgery. There are limited literature data on patient satisfaction when comparing methods of anesthesia and location of surgery.

METHODS

We conducted a retrospective single-surgeon study with patient reported satisfaction in three groups. We compared patient impressions of anesthesia type; WALANT vs locoregional anesthesia plus sedation. We also compared satisfaction in three surgery settings; office surgery vs hospital ambulatory minor procedure room vs main operating room. Group 1 office surgery patients had ultrasound guided surgery with WALANT. Group 2 main operating room surgery patients also had ultrasound guided surgery with WALANT. Group 3 main operating room patients had endoscopic surgery with sedation and a tourniquet. Each group had 30 patients with a minimum follow up of 2 months. We measured overall satisfaction, satisfaction with the organization of care, satisfaction with the administration of anesthesia, and satisfaction with the quality of anesthesia. We also collected secondary data on the resolution of the neuropathic symptoms.

RESULTS

Procedures performed in an office-based setting showed higher rates of patient satisfaction when compared to the ambulatory day surgery setting. WALANT anesthesia also showed significantly higher rates of patient satisfaction on a numerical analog scale when compared to sedation based on, irrespective of the surgical setting. All patients had resolution of their neuropathic symptoms regardless of the technique performed.

CONCLUSION

We found that carpal tunnel releases performed in an office-based setting produces superior patient satisfaction. WALANT anesthesia also provides improved patient satisfaction when compared to sedation and monitoring techniques, irrespective of the surgical setting and location. Carpal tunnel release with WALANT in an office-based setting is better for patient comfort and satisfaction, with no evidence of lesser clinical outcomes at a short term follow-up.

LEVEL OF EVIDENCE

III.

Wide-Awake Approach for Flexor Digitorum Superficialis Tendon Transfer Followed by Early Active Mobilization

Background The standard clinical practice to treat closed ruptures of the flexor digitorum profundus (FDP) tendons includes free tendon grafting; however, it is not suitable when the muscle amplitude of the ruptured FDP is not sufficient. We report outcomes of six patients who underwent flexor digitorum superficialis (FDS) tendon transfer of the ring finger using the wide-awake approach to repair the closed rupture of the FDP tendon of the little finger in zone 3 or 4. Methods The patients were identified by reviewing our institutional billing records from January 2012 to October 2019 for the International Classification of Disease 10 code M66.3 that describes the diagnosis as "spontaneous rupture of flexor tendons." Results The patients comprised two men and four women with an average age of 72.2 years (standard deviation [SD], 8.4 years). All patients were hospitalized after surgery to undergo early active mobilization. The average total active motion at the final evaluation was 201.8° (range: 85-248°). According to Strickland's criteria, outcomes were excellent for two, good for three, and poor for one patient. No patients complained about the ring finger. Conclusion These results suggest that FDS tendon transfer is recommended when the muscle amplitude of the ruptured FDP is insufficient. We believe that the wide-awake approach and early active mobilization may contribute to satisfactory outcomes.

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.

BENEFITS OF THE WALANT TECHNIQUE AGAINST THE COVID-19 PANDEMIC

Objective:

Evaluate the experience of private and public health services with the WALANT procedure in the COVID-19 pandemic.

Methods:

This is a retrospective, multicenter longitudinal study gathering cases of hand surgery subjected to the WALANT technique in the Hospitals Dr. Radamés Nardini and IFOR during the COVID-19 pandemic (August 2020). As a parameter, the verbal numerical rating scale for twenty patients referring to the preoperative, intraoperative and postoperative periods was applied.

Results:

The patients did not feel any pain during surgery, which showed the efficiency of the anesthetic technique in its purpose.

Conclusion:

The results indicate the WALANT technique as beneficial when facing the COVID-19 pandemic, as the main differential of the technique is that it is applied by a well-trained orthopedic hand surgeon.Level of Evidence IV, Case Series.

Clinical Care Redesign to Improve Value for Trigger Finger Release: A Before-and-After Quality Improvement Study

Background: Trigger finger release (TFR) is a commonly performed procedure. However, there is great variation in the setting, care pathway, anesthetic, and cost. We compared the institutional cost for isolated TFR before and after redesigning our clinical care pathway. Methods: Total direct cost to the health system (excluding the surgeon and anesthesiology costs) and time spent by the patient at the surgery center were collected for 1 hand surgeon's procedures at an ambulatory surgery center over a 3-year period. We implemented a redesigned pathway that altered phases of care and anesthetic use by transitioning from intravenous (IV) sedation to wide awake local anesthesia with no tourniquet. Cost data were reported as percentage change in the median and compared both pre- to post-implementation and with 2 control surgeons using the traditional pathway within the same center. Power analysis was based on prior work on a carpal tunnel pathway. Significance was defined by a P-value < .05. Results: Ten TFRs (90% local with IV sedation) and 44 TFRs (89% local alone) were performed pre- and post-implementation, respectively. From pre- to post-implementation, the study surgeon's total direct cost decreased by 18%, while the control surgeons decreased by 2%. Median time spent at the surgery center decreased by 41 minutes post-implementation with significantly shorter setup time in the operating room (OR), total time in the OR, and time spent in recovery prior to discharge. Conclusions: Redesigning the care pathway for TFR led to a decrease in institutional cost and patient time spent at the surgery center.

Use of local anesthetics with an epinephrine additive on fingers and penis - dogma and reality

Epinephrine supplements in local anesthetics are regularly used for surgery in areas with terminal vessels. According to the pharmaceutical guidelines, the use of epinephrine as an additive to local anesthetics is contraindicated for these areas. This review provides an overview of the current scientific data as well as new clinical developments in various fields. It also reviews the current legal situation. A literature research was carried out to survey the current status of relevant data. Written inquiries to several German institutions (Institute for Quality and Efficiency in Health Care, National Association of Statutory Health Insurance Physicians, Center for Clinical Studies Tübingen, Federal Institute for Drugs and Medical Devices) were made to determine the legal situation. No evidence was found in the literature for a causal relationship between the use of epinephrine as a vasoconstrictor and necrosis of the finger or penis. Studies and reviews show that the use of local anesthetics with epinephrine on the fingers or penis is a safe procedure with many clinical and economic advantages. In routine clinical practice, the WALANT method (Wide Awake Local Anesthesia No Tourniquet) as well as the increasing incidence of skin tumors in acral areas has led to a tendency towards increasing use. However, its use is still legally contraindicated, and the pharmaceutical companies show no interest in supporting a drug study. Further clinical trials - regardless of the strength of the evidence - would not change the current legal contraindication.

How to Minimize the Pain of Local Anesthetic Injection for Wide Awake Surgery

After reading this article, the participant should be able to (1) almost painlessly inject tumescent local anesthesia to anesthetize small or large parts of the body, (2) improve surgical safety by eliminating the need for unnecessary sedation in patients with multiple medical comorbidities, and (3) convert many limb and face operations to wide awake surgery. We recommend the following 13 tips to minimize the pain of local anesthesia injection: (1) buffer local anesthetic with sodium bicarbonate; (2) use smaller 27- or 30-gauge needles; (3) immobilize the syringe with two hands and have your thumb ready on the plunger before inserting the needle; (4) use more than one type of sensory noise when inserting needles into the skin; (5) try to insert the needle at 90 degrees; (6) do not inject in the dermis, but in the fat just below it; (7) inject at least 2 ml slowly just under the dermis before moving the needle at all and inject all local anesthetic slowly when you start to advance the needle; (8) never advance sharp needle tips anywhere that is not yet numb; (9) always inject from proximal to distal relative to nerves; (10) use blunt-tipped cannulas when tumescing large areas; (11) only reinsert needles into skin that is already numb when injecting large areas; (12) always ask patients to tell you every time they feel pain during the whole injection process so that you can score yourself and improve with each injection; (13) always inject too much volume instead of not enough volume to eliminate surgery pain and the need for "top ups."