Functional Outcomes of Flexor Tendon Repair in the Fingers: A Comparison of Wide-Awake Local Anesthesia No Tourniquet Versus Traditional Anesthesia

Background: Flexor tendon lacerations in the fingers are challenging injuries that can be repaired using the wide-awake local anesthesia no tourniquet (WALANT) technique or under traditional anesthesia (TA). The purpose of our study was to compare the functional outcomes and complication rates of patients undergoing flexor tendon repair under WALANT versus TA. Methods: All patients who underwent a primary flexor tendon repair in zone I and II without tendon graft for closed avulsions or open lacerations between 2015 and 2019 were identified. Electronic medical records were reviewed to record and compare patient demographics, range of motion, functional outcomes, complications, and reoperations. Results: Sixty-five zone I (N = 21) or II (N = 44) flexor tendon repairs were included in the final analysis: 23 WALANT and 42 TA. There were no statistical differences in mean age, length of follow-up, proportion of injured digits, or zone of injury between the groups. The final Quick Disabilities of the Arm, Shoulder, and Hand score in the WALANT group was 17.2 (SD: 14.4) versus 23.3 (SD: 18.5) in the TA group. There were no statistical differences between the groups with any final range of motion (ROM) parameters, grip strength, or Visual Analog Scale pain scores at the final follow-up. The WALANT group was found to have a slightly higher reoperation rate (26.1% vs 7.1%; P = .034) than the TA group. Conclusions: This study represents one of the first clinical studies reporting outcomes of flexor tendon repairs performed under WALANT. Overall, we found no difference in rupture rates, ROM, and functional outcomes following zone I and II flexor tendon repairs when performed under WALANT versus TA.

Proximal Interphalangeal Joint Arthroplasty Using the Wide-Awake Local Anesthesia No Tourniquet Technique

Background: Proximal interphalangeal joint (PIPJ) osteoarthritis is a common condition that results in pain, stiffness, and loss of function in the affected hand. Proximal interphalangeal joint arthroplasty is an effective treatment option when conservative methods have failed. The wide-awake local anesthesia no tourniquet (WALANT) technique to perform surgery carries advantages such as lack of tourniquet discomfort, reduces the staffing and costs associated with anesthesia and sedation, and allows faster recovery. We aimed to determine whether the WALANT technique was safe and effective in the context of PIPJ arthroplasty. Methods: Patients were enrolled retrospectively from January 2015 to October 2020 by examining operating theater records and surgeon logbooks. Electronic patient records were examined to obtain patient data. Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaires and Visual Analog Scale (VAS) for pain were sent by post to patients—with a separate DASH and VAS for each digit operated on. Results: Twenty-nine PIPJ arthroplasties were carried out using WALANT technique by 3 different surgeons all using the dorsal approach. All cases were successfully carried out as day-case procedures. There was a significant correlation with increasing VAS and increasing DASH score. Proximal interphalangeal joint arthroplasty improved range of motion from 28.9 ± 5.5° to 79.4 ± 13.3° ( P < .0001). Two cases developed complications related to surgery. Conclusions: Our study is the first to report the use of WALANT to perform PIPJ arthroplasty, and shows comparable results with traditional methods. Larger, multicenter prospective trials are required to determine the efficacy of this technique and to quantify its economical benefit.

Wide Awake Local Anesthesia No Tourniquet Technique in Hand Surgery: The Patient Experience

Background: We attempted to evaluate patient satisfaction and overall experience during wide awake, local anesthesia, with no tourniquet (WALANT) hand surgery and quantify surgery-related outcomes. Methods: We conducted a retrospective analysis of patient demographics, comorbidities, and patient reported outcomes via Single Assessment Numeric Evaluation (SANE) scores collected pre- and postoperatively of patients undergoing WALANT surgery by the 2 participating senior authors. A solution of 1% lidocaine with 1:100,000 epinephrine was used by 1 surgeon, while the other used a 1:1 ratio of 1% lidocaine with 1:100,000 epinephrine and 0.5% bupivacaine for local anesthetic injection. Patients were administered a postoperative survey to assess patient experience, including anxiety and pain levels, and overall satisfaction in the perioperative period. Results: Overall, 97.7% of patients indicated that they would undergo a WALANT-style surgery if indicated in the future, 70.5% ate the day of surgery, and a total of 39.1% of patients reported driving to and from surgery. Postoperative SANE scores increased as compared with preoperative scores across all patients. The use of combination 1% lidocaine with 1:100,000 epinephrine and 0.5% bupivacaine was associated with lower intraoperative and postoperative visual analog scale pain scores. Conclusions: WALANT hand surgery was generally well tolerated with excellent surgical outcomes. Patients reported ease of preparation for surgery, faster recovery, and lack of anesthetic side effects as the main benefits of wide-awake surgery. Combination use of lidocaine and bupivacaine may be better than lidocaine alone with respect to pain control in the initial recovery period.

Plate osteosynthesis of single metacarpal fracture: WALANT technique is a cost-effective approach to reduce postoperative pain and discomfort in contrast to general anesthesia and wrist block

Background The WALANT (wide-awake local anesthesia with no tourniquet) technique was based on local infiltration of lidocaine and epinephrine. This technique has rapidly gained popularity in recent years and can perform most hand operations. This study aimed to investigate the time spent on anesthesia and operation and perform an economic analysis among general anesthesia, wrist block with a tourniquet, and the WALANT technique for the internal fixation of metacarpal fractures. Methods We retrospectively reviewed all the single metacarpal fractures managed with the same procedure, open reduction, and internal fixation with the plate between January 2015 and December 2019. They were divided into three groups according to the method of anesthesia: (1) general anesthesia (GA group), (2) wrist block with a tourniquet (WB group), and (3) WALANT technique (WALANT group). We collected and analyzed patient demographic data, perioperative or postoperative complications, number of hospital days, and postoperative functional recovery assessment. Results A total of 63 patients met the inclusion criteria, including 24 in the GA group, 28 in the wrist block group using a tourniquet, and 11 in the WALANT group. There were no complications during the operation and follow-up in each group. The GA group had an average of 32.8 min of anesthesia time, significantly longer than the other two groups. However, there is no significant difference regarding surgical time among the presenting three groups. The discomfort of vomiting and nausea after surgery occurred in 20 patients in the GA group (38.1%). Nevertheless, there was no postoperative vomiting and nausea present in both the WB and WALANT groups. Most patients achieved full recovery of pre-injury interphalangeal and metacarpophalangeal motion at the final assessment of functional recovery. Conclusions The patients undergoing metacarpal fixation surgery under WALANT or WB had significantly less anesthesia time and postoperative vomiting and nausea. Moreover, there was no difference in surgical time and intraoperative complications. The time-related reduction improved the utilization of the operation room for additional cases. The reduction of the preoperative examination, anesthesia fee, postoperative recovery room observation, and hospitalization can effectively reduce medical costs. Furthermore, the WALANT group is more acceptable because of no tourniquet, which commonly causes discomfort.

Lower total blood loss in total knee arthroplasty with a low-pressure tourniquet than without

Tourniquet-use has been described in litera- ture as a surgical factor leading to increased post-operative hidden blood loss in total knee arthroplasty (TKA). The hypothesis for this retro- spective study was that low-pressure tourniquet TKA would offer the benefits of tourniquet surgery without the potential negative effects on late blood loss after the procedure. Therefore, this study evaluated total (TBL) and hidden blood loss (HBL) in TKA with or without a tourniquet. We retrospectively compared two groups : one group (n= 54) undergoing TKA without a tourniquet and one group with a low-pressure tourniquet (n= 110). The outcomes compared were hemoglobin levels 2 weeks before surgery and at days 2 and 4 after surgery to calculate total and hidden blood loss, transfusion rate, and functional outcome. A higher total blood loss was observed in the no tourniquet group with a mean loss of 1073 mL against 890 mL in the tourniquet group (p-value = 0,003). Hidden blood loss values between both groups were statistically not significant : in the no-tourniquet group, Hb drop between D2 and D4 was 0.5 g/dL against 0.4 g/ dL in the low-pressure tourniquet group. The tourniquet-less group did not present with better functional scores. This study showed that low- pressure tourniquet use reduces TBL without increasing HBL in TKA.