A Review of 1073 Cases of Wide-Awake-Local-Anaesthesia-No-Tourniquet (WALANT) in Finger and Hand Surgeries in an Urban Hospital in Malaysia

Abstract

BackgroundThe Wide-Awake-Local-Anaesthesia-No-Tourniquet (WALANT) technique achieves an almost bloodless field for clear visualization during surgeries. WALANT utilizes lidocaine and epinephrine for anesthesia and hemostasis, respectively, without the usage of sedation and tourniquet. This avoids the potential side effects of tourniquet-related pain and sedation-related complications. However, acceptance is still low due to concerns regarding the safety of epinephrine injection in the finger. There is a persistent belief that epinephrine can cause digital ischemia. PurposeTo evaluate retrospectively possible complications of hand surgeries performed using the WALANT technique. MethodsAll finger and hand procedures performed under the WALANT technique from June 2016 to May 2021 in an urban tertiary hospital were studied retrospectively. ResultsThere were a total of 1073 cases, of which 694 were females and 379 were males. The mean age was 55 years. Finger surgeries (e.g., trigger finger release, excision of finger lesions, removal of implants) consisted of 707 cases; and the rest (366 cases) were hand surgeries (e.g., carpal tunnel release, excision of hand lesions, removal of implants). In all cases reviewed, there were no instances of circulatory compromise. There were also no circumstances where usage of reversal with phentolamine is recorded. ConclusionWe believe that performing finger and hand surgeries using the WALANT technique is safe and beneficial. The usage of WALANT in hand surgeries avoids tourniquet pain. However, WALANT should be used with caution in those with vascular insufficiency or disease.

Wide-Awake Tenolysis of a Pectoralis Major to Biceps Transfer After Near Total Arm Avulsion Amputation

“…The original reluctance for the use of adrenaline in digital anaesthesia was, of course, due to a perceived risk of gangrene. The sheer number of cases for which adrenaline has been used safely now demonstrates otherwise [ 12 , 13 ]. But administering adrenaline in an area with a prior repaired vascular injury is certainly intimidating.…”

Flexor tendon laceration of the hand from opening a glass ampoule

“…In a retrospective review of 1073 cases of WALANT surgery in hand and finger surgeries, there were no reported instances of circulatory or ischaemic problems. 21 In a retrospective review of 4287 wide awake procedures with local anaesthesia and epinephrine, Ilyas et al 22 reported that there were no instances of tissue necrosis, vascular compromise or phentolamine reversal. This large series on the use of 1:100 000 epinephrine with local anaesthesia showed that it is safe for hand surgery procedures.…”

Current Evidence Involving WALANT Surgery

“… 36 Finally, a handful of studies reported digital ischemia; however, there was no finger loss in the setting of phentolamine reversal. 37 , 38 …”