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WALANT Technique In Upper Extremity Surgery

By Bernard F. Hearon, MD

Since 2010, one of the distinguishing features of my practice has been the adoption of wide awake local anesthesia and no tourniquet (WALANT) technique for most hand and wrist surgeries and even for some forearm and elbow procedures. In the central plains where I practice, many contemporaries continue to use regional or general anesthesia for hand cases rather than embracing this new approach to anesthesia.

Similar to many hand surgeons across the country, I initially started using the WALANT technique for simple elective procedures such as trigger digit release, first dorsal compartment release, carpal tunnel release, ganglion cystectomy and small tumor excisions. After gaining confidence with the method, I included trauma cases such as extensor or flexor tendon repair, small joint collateral ligament repair, percutaneous or open finger fracture fixation and hardware removal even at the wrist and forearm level. Then I used the technique for digital nerve repair, partial wrist denervation and for more complex procedures such as tendon transfers, partial fasciectomy for Dupuytren’s contracture and trapeziectomy with suspension-interposition arthroplasty for basal thumb arthrosis. In highly selected patients, I have used WALANT for wrist arthroscopy, olecranon bursectomy with spur excision and for open common extenor origin release with partial lateral epicondylectomy.

The essential features of the WALANT technique as popularized by Lalonde are summarized in his must-read textbook.1 The preferred anesthetic is lidocaine with epinephrine (1:100,000), which is injected subcutaneously through a fine needle with slow infiltration, allowing the lidocaine to precede the tip of the advancing needle. The anesthesia is administered only where it is needed for the planned procedure. At least 25 minutes should be allowed for the anesthetic to set up prior to starting the operation. The local anesthesia is supplemented during the deeper dissection as required. For example, in basal thumb arthroplasty, injecting the trapeziometacarpal joint after the superficial dissection has been completed is key to keeping the patient comfortable during the trapeziectomy and thereafter.

As epinephrine in the anesthetic obviates the need for a pneumatic tourniquet, intraoperative tourniquet pain and post-ischemic hyperemia after tourniquet deflation are avoided. Since the surgeon must maintain meticulous hemostasis during a procedure done without a tourniquet, the incidence of post-surgical bleeding complications is markedly reduced. Typically, the surgical field following a WALANT procedure is dry even, for instance, after partial palmar fasciectomy for Dupuytren’s disease.

Improved efficiency and cost reduction are other advantages of the WALANT technique. Since the anesthetic is administered in the preoperative holding area, the patient’s time in the operating room is minimized thereby conserving this valuable resource. Procedure charges are less than they would be with regional or general anesthesia as there is no anesthesia fee when the surgeon or mid-level surgical staff member administers the local anesthesia. Since no intravenous access is required for sedation, these hand procedures, commonly done in ambulatory surgery centers, may also be done in an office setting further minimizing operative cost.

In my experience, patient satisfaction with the WALANT technique has been high, even among those who expressed reservations about the technique during the preoperative informed consent process. Wide awake, cooperative patients may perform gentle active digital range of motion intraoperatively when directed to do so by the surgeon. In this way, the absence of triggering after A1 pulley release, restoration of digital motion without tendon gapping following tendon repair, or improved digital motion after Dupuytren’s contracture release may be demonstrated at the time of surgery to the satisfaction of both patient and surgeon.

With proper supervision, mid-level practitioners, medical students and residents may be trained to perform these injections and become expert at them. However, strict adherence to proper injection technique is mandatory in order to avoid the rare complication of prolonged digital ischemia.2 Phentolamine should be available to reverse persistent digital ischemia if it is necessary to do so.

Despite the considerable efforts of Lalonde and others to educate the medical community, some medical schools still erroneously propagate the old teaching that fingers are off-limits to lidocaine with epinephrine. We must continue to educate our colleagues in medical schools and in clinical practice that this is a misconception that dates back to Bunnell’s first hand surgery textbook. In my opinion, the WALANT technique has improved patient satisfaction and surgical outcomes and has been one of the most significant advances in hand surgery during my professional career.

 

References:

  1. Lalonde DH. Wide Awake Hand Surgery.  Boca Raton, FL: CRC Press, Taylor & Francis Group, 2016.
  2. Zhang JX, Gray J, Lalonde DH, Carr N. Digital necrosis after lidocaine and epinephrine injection in the flexor tendon sheath without phentolamine rescue. J Hand Surg Am. 2017; 42(2):e119-e123.

 

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