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Volume:4 Issue:8 Number:4 ISSN#:2563-559X
OE Original

Wide-Awake Local Anesthesia No Tourniquet (WALANT) Technique for Atraumatic Hand Surgery: A Systematic Review and Meta-analysis

Authored By: OrthoEvidence

August 23, 2021

How to Cite

OrthoEvidence. Wide-Awake Local Anesthesia No Tourniquet (WALANT) Technique for Atraumatic Hand Surgery: A Systematic Review and Meta-analysis. OE Original. 2021;4(8):4. Available from: https://myorthoevidence.com/Blog/Show/144

Highlights


  • - Nine randomized controlled trials (RCTs) were eligible and included.


  • - Preoperative preparation time, defined as the time from injection to skin incision, in the WALANT group was significantly higher than that in the anesthesia with tourniquet group for patients undergoing atraumatic hand surgery, which was due to the extra time awaiting adrenaline for optimal vasoconstriction


  • - Use of WALANT technique in atraumatic hand surgical surgery resulted in significantly less intraoperative and acute postoperative pain, compared to anesthesia with tourniquet.


  • - No statistically significant differences were found between WALANT and anesthesia with tourniquet in terms of operative time, intraoperative blood loss, injection pain, pain 7 days after surgery, and incidence of complications.


  • - All of the outcomes meta-analyzed were of low or very low quality except preoperative preparation time (moderate quality of evidence). More RCTs with high methodological quality and large sample size are warranted.






… in times [the COVID-19 pandemic] where limiting unnecessary exposure between healthcare providers and patients is paramount, WALANT presents a unique opportunity to provide continued care to patients. The intrinsic benefits, including bypassing preoperative testing requirements, minimizing the number and need for OR and postoperative anesthesia care unit personnel, and reducing medical waste through a limited field of sterility and draping make this mode of anesthesia an attractive choice.


 Kurtzman et al. (2021)







The wide-awake local anesthesia no tourniquet (WALANT) technique has become increasingly popular for various types of hand and upper extremity procedures. As the name indicates, WALANT is a technique in which patients undergo the surgery being wide awake, analgesia is delivered directly to the operative site via a local injection, and the use of tourniquet is avoided. Neutralized lidocaine and adrenaline (also known as epinephrine, which minimizes bleeding on the surgical field by imposing a vasoconstrictive effect in the subcutaneous layer) are often used for hand and upper extremity operations (Lalonde, 2010, 2014).


WALANT is believed to have a number of advantages over the use of general or regional anesthesia with tourniquet for hand and upper extremity surgeries. For example, patients feel more comfortable without the use of a tourniquet, which may cause nerve damage and pain (Evangelista et al., 2019; Kurtzman et al., 2021).


Moreover, with patients being awake, the operating surgeon may exchange information with the patient and carry out the intraoperative assessment of the strength and function of repairs and reductions (Evangelista et al., 2019; Kurtzman et al., 2021).


It was also reported that WALANT may result in substantial savings in health care resources, which could make the procedures more accessible to patients with economic disadvantage (Rhee et al., 2017).


Additionally, WALANT is also a simple and convenient procedure for both patients and clinicians in the sense, for instance, that obtaining preoperative clearance is no longer required, fasting prior to surgical procedure is no longer necessary, and intraoperative anesthesia and monitoring is not essential any more (Evangelista et al., 2019; Kurtzman et al., 2021).


Finally, the simplicity and convenience of the hand or upper extremity surgeries using WALANT are attractive and potentially beneficial during the COVID-19 pandemic by limiting the unnecessary exposure between patients and health care workers and quickly clearing surgical backlogs caused by the pandemic. The benefits of WALANT under COVID-19 have been supported by anecdotal experiences (Kurtzman et al., 2021).


In terms of the application of WALANT for atraumatic hand surgery, few systematic reviews and meta-analyses, such as Evangelista et al. (2019), exist in the literature. In the past 2 years, a number of new randomized controlled trials (RCTs) have been published (Farkash et al., 2020; Farzam et al., 2021; Ki Lee et al., 2020; Saleh et al., 2021). In this OE Original, we conduct an up-to-date systematic review and meta-analysis to review the body of RCT evidence with regard to the efficacy and safety of WALANT for atraumatic hand surgery.




Methods


We searched OrthoEvidence, Ovid MEDLINE, Ovid EMBASE, and Cochrane Controlled Register of Trials (CENTRAL) from inception to August 9, 2021 with both indexed terms and free text terms with regard to WALANT. We also searched existing systematic reviews (i.e., Evangelista et al., 2019; Olaiya et al., 2020) to identify additional eligible studies.


We included only RCTs with full texts published in English. Eligible studies should compare outcomes between WALANT [defined as local anesthesia plus adrenaline without tourniquet as described by Lalonde, (2010 and 2014)] vs anesthesia with tourniquet for adult patients with atraumatic hand diseases undergoing elective hand surgery.


We adopted the Cochrane risk-of-bias tool and the GRADE approach to determine the risk of bias (RoB) and the quality of evidence for included RCTs, respectively. Two reviewers independently worked on the study screening and selection processes.



Results


1. Characteristics of included studies


In total, 446 records were retrieved, among which 10 RCTs were eligible and included (Braithwaite et al., 1993; Farkash et al., 2020; Farzam et al., 2021; Gunasagaran et al., 2017; Iqbal et al., 2018; Ki Lee et al., 2020; Nitz et al., 1989; Ralte et al., 2010; Ruxasagulwong et al., 2015; Saleh et al., 2021).


The characteristics of the included RCTs are presented in Table 1. Two RCTs were published around 30 years ago (Braithwaite et al., 1993; Nitz et al., 1989), and the rest 8 RCTs were published in or after 2010 with 6 of them being published in and after 2017 (Farkash et al., 2020; Farzam et al., 2021; Gunasagaran et al., 2017; Iqbal et al., 2018; Ki Lee et al., 2020; Saleh et al., 2021). This suggests the increasing attention to the application of WALANT for atraumatic surgery among researchers and clinicians.


The patient conditions for receiving hand surgery included carpal tunnel syndrome, trigger finger, biopsy, ganglion, and de Quervain’s disease. In the WALANT group, 8 out of the 10 included RCTs used lidocaine for local anesthesia (Farkash et al., 2020; Farzam et al., 2021; Gunasagaran et al., 2017; Iqbal et al., 2018; Ki Lee et al., 2020; Ralte et al., 2010; Ruxasagulwong et al., 2015; Saleh et al., 2021), and 9 studies involved adrenaline (Braithwaite et al., 1993; Farkash et al., 2020; Farzam et al., 2021; Gunasagaran et al., 2017; Iqbal et al., 2018; Ki Lee et al., 2020; Ralte et al., 2010; Ruxasagulwong et al., 2015; Saleh et al., 2021).




Table 1. Characteristics of included RCTs

Study ID

Country

Sample Size

Condition

Age (years)

Intervention

Control

Braithwaite et al. (1993)

United Kingdom

23 (46 hands)

Bilateral carpal tunnel release

Not reported

Bupivacaine with adrenaline, no tourniquet

Bupivacaine with tourniquet

Farkash et al. (2020)

Israel

102

Carpal tunnel release, trigger finger, or biopsy

Mean: 59.7 (SD: 13.6)

Lidocaine and adrenaline, no tourniquet

Lidocaine with tourniquet

Farzam et al. (2021)

Iran

85

Minor hand surgeries, such as carpal tunnel release, trigger finger, ganglion

Intervention: 46.9 (14.2); Control: 49.9 (14.3)

Adrenaline-contained lidocaine without tourniquet)

Lidocaine with tourniquet

Gunasagaran et al. (2017)

Malaysia

40

Minor hand surgeries, such as carpal tunnel release, trigger finger, ganglion

63 (11.7)

Lidocaine, adrenaline, and sodium bicarbonate, no tourniquet

Lidocaine with tourniquet

Iqbal et al. (2018)

United Kingdom

73

Carpal tunnel release

Intervention: 64.2 (13.5); Control: 61.5 (12.5)

Lidocaine, adrenaline, no tourniquet

Levobupivacaine with tourniquet

Ki Lee et al. (2020)

South Korea

188

Carpal tunnel release, trigger finger, or de Quervain’s disease

Intervention: 52.66 (11.26); Control: 53.33 (6.9)

Lidocaine, adrenaline, sodium bicarbonate, no tourniquet

Lidocaine with tourniquet

Nitz et al. (1989)

United States

60

Carpal tunnel release

Not reported

Mepivacaine hydrochloride or bupivacaine hydrochloride, no tourniquet

Lidocaine with tourniquet

Ralte et al. (2010)

United Kingdom

50

Carpal tunnel release

Not reported

Lidocaine, marcaine, adrenaline, no tourniquet

Lidocaine, marcaine, with tourniquet

Ruxasagulwong et al. (2015)

Thailand

60

Carpal tunnel release, trigger finger, or de Quervain’s disease

Intervention: 55.33 (9.98); Control: 55.53 (11.49)

Adrenaline-contained lidocaine, with tourniquet but no pressure applied

Lidocaine, with tourniquet

Saleh et al. (2021)

Canada

67

Carpal tunnel release, trigger finger

Intervention: 60.3 (14.3); Control: 55.1 (14.8)

Xylocaine, marcaine, adrenaline, no tourniquet

Xylocaine, marcaine, with tourniquet




In terms of RoB assessment (Figure 1), none of the RCTs blinded participants except one (Ruxasagulwong et al, 2015), in which both groups had tourniquet but were blinded to the amount of tourniquet pressure. The majority of the included RCTs did not provide adequate information on random sequence generation, allocation concealment, blinding of outcome assessment, and selective reporting. Moreover, none of the RCTs except one (Iqbal et al., 2018) provided detailed information on criteria for surgeon’s participation or expertise (other bias).









2. Evidence synthesis results


2.1 Outcomes related to surgical procedure


2.1.1 Preoperative preparation time


Three RCTs reported preoperative preparation time (Gunasagaran et al., 2017; Ki Lee et al., 2020; Saleh et al., 2021). Gunasagaran et al. (2017) and Saleh et al. (2021) defined the preparation time as the time from injection to skin incision. Ki Lee et al. (2020) defined the preparation time as the time from injection to skin incision in the WALANT group and the time from arm elevation to skin incision in the control group (i.e., anesthesia with tourniquet).


As shown in Figure 2, preoperative preparation in the WALANT group was significantly more time-consuming [mean difference (MD): 14.36 minutes; 95% confidence interval (CI): 5.85 to 22.88] than that in the control group.










2.1.2 Operative time


Eight RCTs reported operative time (Braithwaite et al., 1993; Farzam et al., 2021; Gunasagaran et al., 2017; Iqbal et al., 2018; Ki Lee et al., 2020; Nitz et al., 1989; Ralte et al., 2010; Saleh et al., 2021). Three studies explicitly defined the operative time as the time from skin incision/inflation of tourniquet to the completion of the last suture/dressing (Braithwaite et al., 1993; Gunasagaran et al., 2017; Ki Lee et al., 2020).


There was no significant difference in operative time between the WALANT group and the anesthesia with tourniquet group (MD: 0.61 minutes; 95% CI: -0.17 to 1.38; Figure 2). We also conducted sensitivity analysis excluding 2 RCTs (i.e., Braithwaite et al., 1993; Nitz et al., 1989) that were done around 30 years ago. The difference remained insignificant (MD: 0.33 minutes; 95% CI: -0.59 to 1.25).


2.1.3 Blood loss


Two RCTs reported blood loss during the procedure (Gunasagaran et al., 2017; Ruxasagulwong et al., 2015). We found no significant difference in blood loss between two groups (MD: -0.16 mL; 95% CI: -2.75 to 2.44; Figure 2).


2.2 Pain


Several RCTs reported visual analog (VAS) scale pain (range: 0 to 10, a higher score indicates worse pain).


2.2.1 Injection pain


Three RCTs reported VAS pain during the anesthesia injection (Ki Lee et al., 2020; Ralte et al., 2010; Ruxasagulwong et al., 2015). No statistically significant difference in VAS injection pain between the WALANT and control groups (MD: -1.31; 95% CI: -3.58 to 0.96; Figure 3).


2.2.2 Pain during surgery


Three RCTs reported VAS pain during surgery (Gunasagaran et al., 2017; Iqbal et al., 2018; Ralte et al., 2010). Patients in the WALANT group felt significantly less pain than those who received anesthesia with tourniquet (MD: -2.39; 95% CI: -3.21 to -1.56; Figure 3).


2.2.3 Postoperative pain


Two RCTs reported VAS pain 0-6 hours after surgery (Braithwaite et al., 1993; Ki Lee et al., 2020). The pooled estimate showed significant pain reduction in the WALANT group (MD: -2.19; 95% CI: -2.32 to -2.06), compared to the control group (Figure 3).


Ki Lee et al. (2020) also reported VAS pain 7 days after surgery, which showed no significant difference between two groups (Figure 3).








2.3 Complications





Seven RCTs reported complications (Braithwaite et al., 1993; Farkash et al., 2020; Farzam et al., 2021; Gunasagaran et al., 2017; Nitz et al., 1989; Ruxasagulwong et al., 2015; Saleh et al., 2021). No significant differences were found in incidence of complications between the WALANT group and the anesthesia with tourniquet group [Relative risk (RR): 0.63; 95% CI: 0.05 to 8.06; Figure 4]. The sensitivity analysis, excluding two RCTs done 30 years ago, also showed no statistical significance (RR: 1.99; 95% CI: 0.33 to 11.93). 




Summary and Interpretation


In this OE Original, we conduct a systematic review and meta-analysis to examine RCT evidence regarding the efficacy and safety of WALANT in patients undergoing atraumatic hand surgery. We quantitatively synthesized outcomes including preoperative preparation time (minutes), operative time (minutes), blood loss during surgery (mL), injection pain, pain during surgery, acute postoperative pain (0-6 hours after surgery), pain 7 days after surgery as well as incidence of complications. The summary of the meta-analysis results is shown in Table 2.


Overall, we found that application of WALANT in atraumatic hand surgical procedures was neither superior nor inferior to using anesthesia with tourniquet in terms of operative time, blood loss during surgery, injection pain, pain 7 days after surgery, and incidence of complications. No statistically significant differences were found in these outcomes between the WALANT and anesthesia with tourniquet groups. However, using WALANT seems superior to the use of anesthesia with tourniquet in intraoperative and acute postoperative pain reduction (pain during surgery: MD: -2.39, 95% CI: -3.21 to -1.56; pain 0-6 hours after surgery: MD: -2.19, 95% CI: -2.32 to -2.06) (Table 2).


The preoperative preparation time (defined as the time from anesthesia injection to skin incision) in the WALANT group was significantly higher than that in the anesthesia with tourniquet group (MD: 16.97 minutes, 95% CI: 8.49 to 25.45). This was due to the time to wait after the injection of adrenaline for optimal vasoconstriction for haemostasis during surgery. It is recommended that surgeons wait around 30 minutes after adrenaline injection (McKee et al., 2015). This might be considered as a disadvantage of WALANT. However, Gunasagaran et al. (2017) argued that the waiting time can be “fully utilized” and proposed that “patients can be given WALANT earlier and were made to wait 30 min, while the operating theatre is prepared and consultation given.


All of the outcomes we synthesized were of low or very low quality except preoperative preparation time being of moderate quality (Table 2). Major concerns included serious risk of bias as well as imprecision due to the CIs crossing the no-effect line and/or the number of participants not reaching the optimal information size.


We were not able to conduct a subgroup analysis based on the type of hand surgery because most of the included RCTs reported outcomes in a mixed population receiving different atraumatic hand surgical procedures. Among 4 RCTs (i.e., Braithwaite et al., 1993; Iqbal et al., 2018; Nitz et al., 1989; Ralte et al., 2010) which were conducted in only patients receiving carpal tunnel release, we were only able to pool operative time due to data availability, which showed no significant difference between the WALANT group and the control group (data not shown).



Table 2: Summary of meta-analysis and quality of evidence

Outcomes

Point Estimate Favors

Statistical Significance

Quality of Evidence

Preoperative preparation time (minutes)

Anesthesia with tourniquet

Yes

14.36 (5.85 to 22.88)

Moderate

Operative time (minutes)

Anesthesia with tourniquet

No

Very Low

Blood loss (mL)

WALANT

No

Very Low

Injection pain

WALANT

No

Very Low

Pain during surgery

WALANT

Yes

-2.39 (-3.21 to -1.56)

Low

Pain (0-6 hours after surgery)

WALANT

Yes

-2.19 (-2.32 to -2.06)

Low

Pain (7 days after surgery)

Anesthesia with tourniquet

No

Very Low

Complications

WALANT

No

Low






Bottom Line


Application of WALANT technique in atraumatic hand surgical procedures seems superior to using anesthesia with tourniquet in terms of significantly less intraoperative and acute postoperative pain. WALANT was neither superior nor inferior to anesthesia with tourniquet in terms of operative time, intraoperative blood loss, injection pain, pain 7 days after surgery, and incidence of complications. Application of WALANT technique required significantly longer time from anesthesia injection to skin incision than the tourniquet group due to the extra time awaiting adrenaline for optimal vasoconstriction. All of the outcomes meta-analyzed were of low or very low quality except preoperative preparation time (moderate quality of evidence). More RCTs with high methodological quality and large sample size are warranted.






Reference


Braithwaite, B. D., et al. (1993). Haemostasis During Carpal Tunnel Release Under Local Anaesthesia: A Controlled Comparison of a Tourniquet and Adrenaline Infiltration. Journal of Hand Surgery, 18(2), 184-186. doi:10.1016/0266-7681(93)90103-M

Evangelista, T. M. P., et al. (2019). Wide-Awake Local Anesthesia No Tourniquet (WALANT) versus Local or Intravenous Regional Anesthesia with Tourniquet in Atraumatic Hand Cases in Orthopedics: A Systematic Review and Meta-Analysis. The journal of hand surgery Asian-Pacific volume, 24(4), 469-476. doi:https://dx.doi.org/10.1142/S2424835519500619

Farkash, U., et al. (2020). Keeping the Finger on the Pulse: Cardiac Arrhythmias in Hand Surgery Using Local Anesthesia with Adrenaline. Plastic and reconstructive surgery, 146(1), 54e-60e. doi:http://dx.doi.org/10.1097/PRS.0000000000006902

Farzam, R., et al. (2021). Comparison of anesthesia results between wide awake local anesthesia no tourniquet (WALANT) and forearm tourniquet bier block in hand surgeries: A randomized clinical trial. Archives of Bone and Joint Surgery, 9(1), 116-121. doi:http://dx.doi.org/10.22038/ABJS.2020.49526.2487

Gunasagaran, J., et al. (2017). Perceived comfort during minor hand surgeries with wide awake local anaesthesia no tourniquet (WALANT) versus local anaesthesia (LA)/tourniquet. Journal of orthopaedic surgery (Hong Kong), 25(3), 2309499017739499. doi:10.1177/2309499017739499

Iqbal, H. J., et al. (2018). Pain and outcomes of carpal tunnel release under local anaesthetic with or without a tourniquet: a randomized controlled trial. Journal of hand surgery, European volume, 43(8), 808-812. doi:10.1177/1753193418778999

Ki Lee, S., et al. (2020). A randomized controlled trial of minor hand surgeries comparing wide awake local anesthesia no tourniquet and local anesthesia with tourniquet. Orthopaedics & traumatology, surgery & research : OTSR, 106(8), 1645-1651. doi:10.1016/j.otsr.2020.03.013

Kurtzman, J. S., et al. (2021). Wide-awake Local Anesthesia with No Tourniquet: An Updated Review. Plastic and reconstructive surgery. Global open, 9a(3), e3507. doi:https://dx.doi.org/10.1097/GOX.0000000000003507

Lalonde, D. H. (2010). "Hole-in-one" local anesthesia for wide-awake carpal tunnel surgery. Plast Reconstr Surg, 126(5), 1642-1644. doi:10.1097/PRS.0b013e3181f1c0ef

Lalonde, D. H. (2014). Minimally invasive anesthesia in wide awake hand surgery. Hand Clin, 30(1), 1-6. doi:10.1016/j.hcl.2013.08.015

McKee, D. E., et al. (2015). Achieving the optimal epinephrine effect in wide awake hand surgery using local anesthesia without a tourniquet. Hand (N Y), 10(4), 613-615. doi:10.1007/s11552-015-9759-6

Nitz, A. J., et al. (1989). Upper extremity tourniquet effects in carpal tunnel release. The Journal of Hand Surgery, 14(3), 499-504. doi:https://doi.org/10.1016/S0363-5023(89)80011-5

Olaiya, O. R., et al. (2020). Carpal Tunnel Release without a Tourniquet: A Systematic Review and Meta-Analysis. Plastic and reconstructive surgery, 145(3), 737-744. doi:http://dx.doi.org/10.1097/PRS.0000000000006549

Ralte, P., et al. (2010). Haemostasis in Open Carpal Tunnel Release: Tourniquet vs Local Anaesthetic and Adrenaline. The open orthopaedics journal, 4, 234-236. doi:10.2174/1874325001004010234

Rhee, P. C., et al. (2017). Cost Savings and Patient Experiences of a Clinic-Based, Wide-Awake Hand Surgery Program at a Military Medical Center: A Critical Analysis of the First 100 Procedures. The Journal of Hand Surgery, 42(3), e139-e147. doi:https://doi.org/10.1016/j.jhsa.2016.11.019

Ruxasagulwong, S., et al. (2015). Wide awake technique versus local anesthesia with tourniquet application for minor orthopedic hand surgery: a prospective clinical trial. Chotmaihet thangphaet [Journal of the Medical Association of Thailand], 98(1), 106-110.

Saleh, E., et al. (2021). Comparing Minor Hand Procedures Performed with or without the Use of a Tourniquet: A Randomized Controlled Trial. Plastic and reconstructive surgery. Global open, 9(4), e3513. doi:https://dx.doi.org/10.1097/GOX.0000000000003513

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