Medicine:WALANT

From HandWiki

WALANT (Wide Awake Local Anesthesia No Tourniquet) is a technique that uses local anesthesia and hemostatic agent (e.g., 1% lidocaine with 1:100,000 epinephrine, sometimes buffered with sodium bicarbonate) in hand surgery in unsedated patients. The absence of a tourniquet avoids tourniquet-related discomfort and complications, while the use of epinephrine provides vasoconstriction, resulting in a decreased blood loss that is suitable for most hand procedures.[1][2] It is a safe, cost-effective, efficient, and widely accessible approach with a low complication rate.[3][4] The technique allows the patient to remain fully awake and utilize active movement, which allows for intraoperative assessment of tendon function, fracture stability, or nerve decompression.[5][6] Its exclusion of general anesthesia allows it to be done in an office or outpatient setting, which eliminates the need for operating room resources, anesthesia personnel, and post-anesthesia care units.[7][8][9]

History

Canadian plastic hand surgeon Donald H. Lalonde first published this method in 2003 to decrease surgical wait times; he formally proposed the concept in 2005, which has been internationalized since.[10][11] The WALANT technique has also been increasingly popular during the COVID-19 pandemic because it shifted away from the need for general anesthesia and operating room personnel while being resource-efficient.[12]

Technique

A local anesthetic solution, most commonly lidocaine 1% with epinephrine 1:100,000 buffered with sodium bicarbonate is injected under the skin and into deeper tissues at the planned incision site.[13] Sodium bicarbonate is thought to decrease pain during injection and quicken anesthesia onset.[14][15] Bupivacaine 0.25-0.5% can be added optionally to provide extended postoperative analgesia.[16] Phentolamine can reverse the effects of epinephrine should digital ischemia present itself.[17][18]

Indications

Indications for the WALANT technique include most elective and trauma-related procedures of the hand and fingers, such as carpal tunnel release, trigger finger release, tendon repair, nerve decompression, excision of masses (e.g., ganglion cyst), and fracture fixation. It allows for intraoperative active mobilization for flexor tendon repairs and tenolysis, fracture fixation of metacarpal and phalangeal bones, trigger finger release, and tendon transfers.[19][20]

Contraindications

Contraindications are primarily related to patient factors and local tissue status. Absolute contraindications include known allergy to local anesthetic agents or epinephrine, active infection at injection site, and severe peripheral vascular disease. Relative contraindications include poorly controlled anxiety and inability to cooperate during the procedure, which can be seen in certain pediatric or cognitively impaired patients.[21][22][23][24] However, recent literature demonstrates that those with preexisting anxiety report high satisfaction with WALANT when appropriate counseling and supportive measures are provided, which can include music, virtual reality, or active conversation.[25][26][27]

Complications

A 2024 systematic review and meta-analysis demonstrates an overall complication rate of approximately 1.7% in upper limb procedures.[28] The most common complications include superficial infection (51%), recurrent disease (6.7%) , and other minor issues like hematoma.[28]

Transient digital ischemia can occur with epinephrine, but these cases are typically short-lived and reversible, leading to no long-term sequelae.[29] If persistent, phentolamine is recommended as a reversal agent.[30]

Cardiac arrhythmias are not increased in WALANT.[31] Minor arrhythmias (e.g., sinus tachycardia, asymptomatic bradyarrhythmias) may occur but do not require intervention.[31]

References

  1. ↑ Ahmad, Amir Adham; Lalonde, Donald H. (April 2025). "State-of-the-art review: The advantage and use of Wide Awake Local Anaesthesia No Tourniquet (WALANT) for nerve decompression surgery" (in en). International Orthopaedics 49 (4): 959–963. doi:10.1007/s00264-025-06432-4. ISSN 0341-2695. https://link.springer.com/10.1007/s00264-025-06432-4. 
  2. ↑ Lalonde, D.; Martin, A. (2013-08-01). "Epinephrine in Local Anesthesia in Finger and Hand Surgery: The Case for Wide-awake Anesthesia" (in en). Journal of the American Academy of Orthopaedic Surgeons 21 (8): 443–447. doi:10.5435/JAAOS-21-08-443. ISSN 1067-151X. PMID 23908250. http://www.jaaos.org/cgi/doi/10.5435/JAAOS-21-08-443. 
  3. ↑ Connors, Katherine M.; Guerra, Sara M.; Koehler, Steven M. (November 2022). "Current Evidence Involving WALANT Surgery" (in en). Journal of Hand Surgery Global Online 4 (6): 452–455. doi:10.1016/j.jhsg.2022.01.009. PMID 36420465. 
  4. ↑ Billig, Jessica I.; Nasser, Jacob S.; Chen, Jung-Sheng; Lu, Yu-Ting; Chung, Kevin C.; Kuo, Chang-Fu; Sears, Erika D. (2020-10-13). "Comparison of Safety and Insurance Payments for Minor Hand Procedures Across Operative Settings" (in en). JAMA Network Open 3 (10): e2015951. doi:10.1001/jamanetworkopen.2020.15951. ISSN 2574-3805. PMID 33048128. 
  5. ↑ Ahmad, Amir Adham; Lalonde, Donald H. (April 2025). "State-of-the-art review: The advantage and use of Wide Awake Local Anaesthesia No Tourniquet (WALANT) for nerve decompression surgery" (in en). International Orthopaedics 49 (4): 959–963. doi:10.1007/s00264-025-06432-4. ISSN 0341-2695. https://link.springer.com/10.1007/s00264-025-06432-4. 
  6. ↑ Hyatt, Brad T.; Rhee, Peter Charles (March 2019). "Wide-Awake Surgical Management of Hand Fractures: Technical Pearls and Advanced Rehabilitation" (in en). Plastic & Reconstructive Surgery 143 (3): 800–810. doi:10.1097/PRS.0000000000005379. ISSN 0032-1052. https://journals.lww.com/00006534-201903000-00027. 
  7. ↑ Shadid, Omar; Novo, Jennifer; Saini, Raj; Marcaccini, Gianluca; Sacks, Brett K.; Rozen, Warren M.; Seth, Ishith; Cuomo, Roberto (2025-08-30). "Hand Surgery Anaesthesia Innovations: Balancing Efficiency, Cost, and Comfort with WALANT, Ultrasound, and Emerging Adjuncts—A Narrative Review" (in en). Journal of Clinical Medicine 14 (17): 6146. doi:10.3390/jcm14176146. ISSN 2077-0383. PMID 40943906. 
  8. ↑ Alter, Todd H.; Warrender, William J.; Liss, Frederic E.; Ilyas, Asif M. (December 2018). "A Cost Analysis of Carpal Tunnel Release Surgery Performed Wide Awake versus under Sedation" (in en). Plastic & Reconstructive Surgery 142 (6): 1532–1538. doi:10.1097/PRS.0000000000004983. ISSN 0032-1052. PMID 30188472. https://journals.lww.com/00006534-201812000-00027. 
  9. ↑ Stocker-Downing, T. Hunter; McAllister, Rebecca; Chan, Sean; Mullikin, Ian; Krul, Kevin (2025-09-11). "Wide-Awake Local Anesthesia with No Tourniquet (WALANT) Carpal Tunnel Release in the Clinic: A Clinical Practice Update" (in en). Journal of Clinical Medicine 14 (18): 6407. doi:10.3390/jcm14186407. ISSN 2077-0383. PMID 41010612. 
  10. ↑ Lalonde, D.; Martin, A. (2013-08-01). "Epinephrine in Local Anesthesia in Finger and Hand Surgery: The Case for Wide-awake Anesthesia" (in en). Journal of the American Academy of Orthopaedic Surgeons 21 (8): 443–447. doi:10.5435/JAAOS-21-08-443. ISSN 1067-151X. PMID 23908250. http://www.jaaos.org/cgi/doi/10.5435/JAAOS-21-08-443. 
  11. ↑ Ahmad, Amir Adham; Lalonde, Donald H. (April 2025). "State-of-the-art review: The advantage and use of Wide Awake Local Anaesthesia No Tourniquet (WALANT) for nerve decompression surgery" (in en). International Orthopaedics 49 (4): 959–963. doi:10.1007/s00264-025-06432-4. ISSN 0341-2695. https://link.springer.com/10.1007/s00264-025-06432-4. 
  12. ↑ Shaw, Abigail V.; Holmes, David; Jansen, Victoria; Fowler, Christy; Wormald, Justin C.R.; Wade, Ryckie G.; Taha, Rowa; Reay, Emma et al. (September 2023). "RSTN COVID Hand: Hand trauma in the United Kingdom and Europe during the COVID-19 pandemic" (in en). Journal of Plastic, Reconstructive & Aesthetic Surgery 84: 258–265. doi:10.1016/j.bjps.2023.04.077. https://linkinghub.elsevier.com/retrieve/pii/S1748681523002346. 
  13. ↑ Stocker-Downing, T. Hunter; McAllister, Rebecca; Chan, Sean; Mullikin, Ian; Krul, Kevin (2025-09-11). "Wide-Awake Local Anesthesia with No Tourniquet (WALANT) Carpal Tunnel Release in the Clinic: A Clinical Practice Update" (in en). Journal of Clinical Medicine 14 (18): 6407. doi:10.3390/jcm14186407. ISSN 2077-0383. PMID 41010612. 
  14. ↑ Lee, Hyuk Jin; Cho, Young Jae; Gong, Hyun Sik; Rhee, Seung Hwan; Park, Hyun Soo; Baek, Goo Hyun (May 2013). "The Effect of Buffered Lidocaine in Local Anesthesia: A Prospective, Randomized, Double-Blind Study" (in en). The Journal of Hand Surgery 38 (5): 971–975. doi:10.1016/j.jhsa.2013.02.016. PMID 23566722. https://linkinghub.elsevier.com/retrieve/pii/S0363502313002426. 
  15. ↑ Ki Lee, Sang; Gul Kim, Sung; Sik Choy, Won (December 2020). "A randomized controlled trial of minor hand surgeries comparing wide awake local anesthesia no tourniquet and local anesthesia with tourniquet" (in en). Orthopaedics & Traumatology: Surgery & Research 106 (8): 1645–1651. doi:10.1016/j.otsr.2020.03.013. PMID 32631713. https://linkinghub.elsevier.com/retrieve/pii/S1877056820301328. 
  16. ↑ Janes, Lindsay; Sepehripour, Sarvnaz; Lalonde, Donald (August 2024). "Clinically Important Pharmacologic Considerations for Wide-Awake Local Anesthesia No Tourniquet Hand Surgery" (in en). Plastic & Reconstructive Surgery 154 (2): 391e–402e. doi:10.1097/PRS.0000000000010706. ISSN 0032-1052. PMID 37220403. https://journals.lww.com/10.1097/PRS.0000000000010706. 
  17. ↑ Zargaran, David; Zargaran, Alexander; Nikkhah, Dariush; Mosahebi, Afshin (October 2021). "WALANT Protocol: Stop before you block" (in en). Journal of Plastic, Reconstructive & Aesthetic Surgery 74 (10): 2776–2820. doi:10.1016/j.bjps.2021.05.025. PMC 8180086. https://linkinghub.elsevier.com/retrieve/pii/S1748681521002783. 
  18. ↑ Zhu, Andy F.; Hood, Brandon R.; Morris, Mark S.; Ozer, Kagan (June 2017). "Delayed-Onset Digital Ischemia After Local Anesthetic With Epinephrine Injection Requiring Phentolamine Reversal" (in en). The Journal of Hand Surgery 42 (6): 479.e1–479.e4. doi:10.1016/j.jhsa.2017.01.006. https://linkinghub.elsevier.com/retrieve/pii/S036350231630990X. 
  19. ↑ Steiner, Murphy M.; Calandruccio, James H. (January 2018). "Use of Wide-awake Local Anesthesia No Tourniquet in Hand and Wrist Surgery" (in en). Orthopedic Clinics of North America 49 (1): 63–68. doi:10.1016/j.ocl.2017.08.008. PMID 29145985. https://linkinghub.elsevier.com/retrieve/pii/S0030589817301499. 
  20. ↑ Ahmad, Amir Adham; Lalonde, Donald H. (April 2025). "State-of-the-art review: The advantage and use of Wide Awake Local Anaesthesia No Tourniquet (WALANT) for nerve decompression surgery" (in en). International Orthopaedics 49 (4): 959–963. doi:10.1007/s00264-025-06432-4. ISSN 0341-2695. https://link.springer.com/10.1007/s00264-025-06432-4. 
  21. ↑ Ahmad, Amir Adham; Lalonde, Donald H. (April 2025). "State-of-the-art review: The advantage and use of Wide Awake Local Anaesthesia No Tourniquet (WALANT) for nerve decompression surgery" (in en). International Orthopaedics 49 (4): 959–963. doi:10.1007/s00264-025-06432-4. ISSN 0341-2695. https://link.springer.com/10.1007/s00264-025-06432-4. 
  22. ↑ Zargaran, David; Zargaran, Alexander; Nikkhah, Dariush; Mosahebi, Afshin (October 2021). "WALANT Protocol: Stop before you block" (in en). Journal of Plastic, Reconstructive & Aesthetic Surgery 74 (10): 2776–2820. doi:10.1016/j.bjps.2021.05.025. PMC 8180086. https://linkinghub.elsevier.com/retrieve/pii/S1748681521002783. 
  23. ↑ Lalonde, D.; Martin, A. (2013-08-01). "Epinephrine in Local Anesthesia in Finger and Hand Surgery: The Case for Wide-awake Anesthesia" (in en). Journal of the American Academy of Orthopaedic Surgeons 21 (8): 443–447. doi:10.5435/JAAOS-21-08-443. ISSN 1067-151X. PMID 23908250. http://www.jaaos.org/cgi/doi/10.5435/JAAOS-21-08-443. 
  24. ↑ Camara-Cabrera, Jaume; Berenguer, Alexandre; Sanchez-Flo, Ricard; Marcano-Fernandez, Francesc (May 2023). "Wide-awake surgery in orthopaedics: "Scoping review"" (in en). Orthopaedics & Traumatology: Surgery & Research 109 (3). doi:10.1016/j.otsr.2022.103427. PMID 36191901. https://linkinghub.elsevier.com/retrieve/pii/S1877056822002754. 
  25. ↑ Stocker-Downing, T. Hunter; McAllister, Rebecca; Chan, Sean; Mullikin, Ian; Krul, Kevin (2025-09-11). "Wide-Awake Local Anesthesia with No Tourniquet (WALANT) Carpal Tunnel Release in the Clinic: A Clinical Practice Update" (in en). Journal of Clinical Medicine 14 (18): 6407. doi:10.3390/jcm14186407. ISSN 2077-0383. PMID 41010612. 
  26. ↑ Morris, Marie T.; Rolf, Elizabeth; Tarkunde, Yash R.; Dy, Christopher J.; Wall, Lindley B. (December 2022). "Patient Concerns About Wide-Awake Local Anesthesia No Tourniquet (WALANT) Hand Surgery" (in en). The Journal of Hand Surgery 47 (12): 1226.e1–1226.e13. doi:10.1016/j.jhsa.2021.08.026. PMID 34774346. https://linkinghub.elsevier.com/retrieve/pii/S0363502321006031. 
  27. ↑ Hoxhallari, Ediana; Behr, Ian J.; Bradshaw, Jonathan S.; Morkos, Michael S.; Haan, Pam S.; Schaefer, Maureen C.; Clarkson, James H. W. (August 2019). "Virtual Reality Improves the Patient Experience during Wide-Awake Local Anesthesia No Tourniquet Hand Surgery: A Single-Blind, Randomized, Prospective Study" (in en). Plastic & Reconstructive Surgery 144 (2): 408–414. doi:10.1097/PRS.0000000000005831. ISSN 0032-1052. https://journals.lww.com/00006534-201908000-00027. 
  28. ↑ 28.0 28.1 Lawand, Jad; Hantouly, Ashraf; Bouri, Fadi; Muneer, Mohammad; Farooq, Abdulaziz; Hagert, Elisabet (May 2024). "Complications and side effects of Wide-Awake Local Anaesthesia No Tourniquet (WALANT) in upper limb surgery: a systematic review and meta-analysis" (in en). International Orthopaedics 48 (5): 1257–1269. doi:10.1007/s00264-024-06104-9. ISSN 0341-2695. PMID 38367058. 
  29. ↑ Moog, P.; Dozan, M.; Betzl, J.; Sukhova, I.; Kükrek, H.; Megerle, K. (March 2021). "WALANT–Epinephrine injection may lead to short term, reversible episodes of critical oxygen saturation in the fingertips" (in en). Archives of Orthopaedic and Trauma Surgery 141 (3): 527–533. doi:10.1007/s00402-020-03744-5. ISSN 0936-8051. PMID 33484301. 
  30. ↑ Zargaran, David; Zargaran, Alexander; Nikkhah, Dariush; Mosahebi, Afshin (October 2021). "WALANT Protocol: Stop before you block" (in en). Journal of Plastic, Reconstructive & Aesthetic Surgery 74 (10): 2776–2820. doi:10.1016/j.bjps.2021.05.025. PMC 8180086. https://linkinghub.elsevier.com/retrieve/pii/S1748681521002783. 
  31. ↑ 31.0 31.1 Farkash, Uri; Herman, Amir; Kalimian, Tal; Segal, Ohad; Cohen, Amir; Laish-Farkash, Avishag (July 2020). "Keeping the Finger on the Pulse: Cardiac Arrhythmias in Hand Surgery Using Local Anesthesia with Adrenaline" (in en). Plastic & Reconstructive Surgery 146 (1): 54e–60e. doi:10.1097/PRS.0000000000006902. ISSN 0032-1052. PMID 32590653. https://journals.lww.com/10.1097/PRS.0000000000006902. 



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