Pain and outcomes of carpal tunnel release under local anaesthetic with or without a tourniquet: a randomized controlled trial

The Effect of Upper Extremity Tourniquet Time on Postoperative Pain and Opiate Consumption

BACKGROUND

There is widespread use of pneumatic tourniquet for both upper and lower extremity orthopedic surgeries. Tourniquet use improves visualization, decreases blood loss, and as a result, decreases operative time. Exceeding a certain amount of tourniquet time can cause lasting neuromuscular damage. Orthopedic procedures cause significant pain, and the perioperative narcotic prescriptions after orthopedic surgery have been identified as one of the major contributors to the opioid epidemic. Our aim was to determine whether increasing tourniquet time had a negative impact on immediate postoperative opiate usage in the upper extremity, and to determine other factors associated with increased immediate postoperative opiate usage.

METHODS

A retrospective medical record review was performed on patients who underwent volar pleading for fracture fixation between January 2014 and December 2019 at a single institution. Postoperative pain, morphine equivalent dose (MED) usage, and demographic variables were collected. Multivariable analysis was performed, with P < .05 considered significant.

RESULTS

Immediate postoperative MED consumed was not correlated with operative time, tourniquet time, preoperative substance usage, or sex. However, postoperative MED consumed was correlated with preoperative narcotic use, high body mass index (BMI), and fracture surgery complexity.

CONCLUSIONS

Tourniquet usage under current guidelines does not appear to have an effect on postoperative pain and narcotic usage. Preoperative narcotic usage, BMI, and surgery complexity are significant factors for postoperative opiate consumption.

WALANT Technique versus Sedation for Endoscopic Carpal Tunnel Release

BACKGROUND

This study sought to investigate complication rates/perioperative metrics after endoscopic carpal tunnel release (eCTR) via wide-awake, local anesthesia, no tourniquet (WALANT) versus sedation or local anesthesia with a tourniquet.

METHODS

Patients aged 18 years or older who underwent an eCTR between April 28, 2018, and December 31, 2019, by 1 of 2 fellowship-trained surgeons at our single institution were retrospectively reviewed. Patients were divided into 3 groups: monitored anesthesia care with tourniquet (MT), local anesthesia with tourniquet (LT), and WALANT.

RESULTS

Inclusion criteria were met by 156 cases; 53 (34%) were performed under MT, 25 (16%) under LT, and 78 (50%) under WALANT. The MT group (46.1 ± 9.7) was statistically younger compared with LT (56.3 ± 14.1, P = .007) and WALANT groups (53.5 ± 15.8, P = .008), F(2, 153) = 6.465, P = .002. Wide-awake, local anesthesia, no tourniquet had decreased procedural times (10 minutes, SD: 2) compared with MT (11 minutes, SD: 2) and LT (11 minutes, SD: 2), F(2, 153) = 5.732, P = .004). Trends favored WALANT over MT and LT for average operating room time (20 minutes, SD: 3 vs 32 minutes, SD: 6 vs 23 minutes, SD: 3, respectively, F(2, 153) = 101.1, P < .001), postanesthesia care unit time (12 minutes, SD: 7 vs 1:12 minutes, SD: 26 vs 20 minutes, SD: 22, respectively, F(2, 153) =171.1, P < .001), and door-to-door time (1:37 minutes, SD: 21 vs 2:51 minutes, SD: 40 vs 1:46 minutes, SD: 33, respectively, F(2, 153) = 109.3, P < .001). There were no differences in complication rates.

CONCLUSIONS

Our data suggest favorable trends for patients undergoing eCTR via WALANT versus MT versus LT.

Wide-awake surgery in orthopaedics: "Scoping review"

INTRODUCTION

The anaesthetic modality "wide-awake" or "WALANT" (wide awake local anaesthesia not tourniquet) is based on the combination of a local anaesthetic with a vasoconstrictor to reduce bleeding during surgery and to avoid the use of a pneumatic tourniquet. The combination of 1% lidocaine together with 1:100,000 epinephrine is the most commonly used formula. The objective of this work is to carry out a review of the literature about this anaesthetic modality in the field of orthopaedic surgery and traumatology.

METHODS

PubMed and Embase databases were consulted with clearly defined operators. Two independent searches were conducted by two investigators, which were combined. Experimental, observational comparative studies, descriptive studies with n> 5 cases and cost studies were included. The individual results of the included studies are described.

RESULTS

A total of 8794 entries were collected of which a total of 36 studies were included in the review. A large number of these studies have been published since 2010 and refer almost entirely to hand surgery, with multiple indications applied. There is heterogeneity regarding the type of study design and variables studied, among others. In addition, there is a disparity when defining the methodology of the WALANT technique between the different studies.

CONCLUSIONS

This is the first comprehensive and reproducible review of the current state of the WALANT modality. There is great heterogeneity in terms of the study populations, the different comparators, variables studied between the different studies and a lack of precise details regarding the WALANT technique.

LEVEL OF EVIDENCE

III, Therapeutic study.

Tourniquet Does Not Affect Long-term Outcomes in Minor Hand Surgery: A Randomized Controlled Trial

Surgeons often prefer to use a tourniquet during minor procedures, such as carpal tunnel release (CTR) or trigger finger release (TFR). Besides the possible discomfort for the patient, the effect of tourniquet use on long-term results and complications is unknown. Our primary aim was to compare the patient-reported outcomes 1 year after CTR or TFR under local anesthesia with or without tourniquet. Secondary outcomes included satisfaction, sonographically estimated scar tissue thickness after CTR‚ and postoperative complications.

Optimization of Carpal Tunnel Syndrome Using WALANT Method

As surgical management of carpal tunnel release (CTR) becomes ever more common, extensive research has emerged to optimize the contextualization of this procedure. In particular, CTR under the wide-awake, local-anesthesia, no-tourniquet (WALANT) technique has emerged as a cost-effective, safe, and straightforward option for the millions who undergo this procedure worldwide. CTR under WALANT is associated with considerable cost savings and workflow efficiencies; it can be safely and effectively executed in an outpatient clinic under field sterility with less use of resources and production of waste, and it has consistently demonstrated standard or better post-operative pain control and satisfaction among patients. In this review of the literature, we describe the current findings on CTR using the WALANT technique.

The what, why and when of wide awake local anaesthesia no tourniquet surgery

Wide awake local anaesthesia no tourniquet, also known as WALANT, is the practice of performing surgery under local anaesthetic in the absence of a tourniquet. This technique uses the vasoconstrictive effects of adrenaline and the local anaesthetic effects of lignocaine to establish a Bier block with haemostatic control. Permitting active patient participation intraoperatively, wide awake local anaesthesia no tourniquet surgery improves patient compliance with rehabilitation and yields higher patient satisfaction. With reduced cost and equipment requirements, this method improves accessibility for patients and productivity for healthcare institutions. This is of particular benefit within the current COVID-19 climate, as wide awake local anaesthesia no tourniquet technique provides a means of overcoming restrictions to theatre access and anaesthetic support. This review delves into the current uses of wide awake local anaesthesia no tourniquet surgery, outlining the initial conception of the practice by Canadian surgeons. The advantages and disadvantages are considered, and potential future applications of this technique are discussed.

Operative outcomes for wide awake local anesthesia versus regional and general anesthesia for flexor tendon repair

Operative repair of flexor tendons after traumatic injury may be performed under general anesthesia (GA), regional blocks, or a wide-awake local anesthesia no tourniquet (WALANT) technique. To our knowledge there are currently no large-scale reports evaluating outcomes of flexor tendon repair in patients where wide-awake anesthesia was utilized in comparison to regional anesthesia (RA) and general anesthesia. We performed a retrospective analysis of patients who underwent treatment for flexor tendon injuries at a tertiary referral center for hand surgery over a two-year period. A total of 151 patients were included (53 WALANT, 57 RA, and 41 GA) and a total of 251 tendons were repaired (63 WALANT, 104 RA and 84 GA). No statistically significant difference was observed in rates of tendon rupture, adhesions, infection, or hand function. Flexor tendon repair under WALANT is found to be safe and presents comparable operative and functional outcomes to more traditional anesthetic techniques. Additional advantages, including the ability to test the repair intraoperatively, patient education, and the potential for boosting theatre efficiency. Further studies, preferably utilizing a randomized trial methodology, may further elucidate the benefits and risks of WALANT versus regional and general anesthesia.

Open Carpal Tunnel Release Under WALANT – Suitable for All Ages?

Purpose

Wide-awake local anesthesia with no tourniquet (WALANT) as a walk-in procedure has become a standard technique in open carpal tunnel release (OCTR) and continues to replace the long-established intravenous regional anesthesia with a tourniquet (IVRA/”bier-block”) in our clinic. The aim of this study was to compare patient satisfaction with either WALANT or IVRA/”bier-block” and define subgroups that are particularly suited for either of the two procedures. We hypothesized that older patients would prefer IVRA because of a shorter period of postoperative surveillance.

Methods

In this retrospective study we evaluated patient satisfaction with either WALANT or IVRA using an adjusted questionnaire on a standard Swiss grading system (from 1 = insufficient/very strong pain to 6 = excellent/no pain). Secondary outcomes included postoperative pain or satisfaction with the tourniquet and quality of postoperative care.

Results

For the 176 patients (WALANT, n = 109; IVRA, n = 67) included in the study, there was high patient satisfaction with both procedures (WALANT, 5.5/6; IVRA, 5.5/6). Patients aged 80 years and older had significantly less postoperative pain after WALANT (WALANT, 5.8/6 vs IVRA, 4.9/6).

Conclusions

Patients aged 80 years and older had significantly less postoperative pain after WALANT than that after IVRA. Here, sarcopenia may have contributed to the prolonged discomfort after tourniquet application. Immediate postoperative discharge after WALANT did not negatively affect older patients.

Clinical relevance

For OCTR, WALANT as a walk-in procedure is a safe and comfortable alternative to IVRA, which is commonly planned with short postoperative surveillance. Both anesthesia techniques are suitable for all ages and sexes but based on this study we recommend WALANT as a tourniquet-free operation in older patients.

Comparing Minor Hand Procedures Performed with or without the Use of a Tourniquet: A Randomized Controlled Trial

Background

Carpal tunnel syndrome and trigger finger are two of the most common conditions treated by the hand surgeon. During these procedures, a tourniquet is often used to minimize bleeding and improve visualization of the operative field. However, it may be associated with pain and discomfort. To date, there are few prospective studies investigating the safety and patient-centered outcomes of tourniquet-free minor hand procedures.

Methods

This is a randomized controlled trial comparing patients undergoing open carpal tunnel or trigger finger release with or without the use of a tourniquet. Perioperative subjective patient experience was investigated for both techniques. This was measured based on a numerical rating scale for pain, anxiety, and overall satisfaction. In addition, this was an equivalence trial in terms of operative time, bleeding scores, and perioperative complication rates.

Results

A total of 67 patients were recruited. Both groups were similar with respect to distribution of age, sex, handedness, anti-platelet use, and tobacco use. Median scores for operative time, anxiety, and overall satisfaction were comparable between the 2 groups. With regard to patient discomfort, median scores were significantly higher in the tourniquet group when compared with the no tourniquet group (3.58 versus 1.68, respectively, P = 0.02). Bleeding scores for the tourniquet group were significantly lower than for the no tourniquet group (1.14 versus 1.90, respectively, P = 0.001).

Conclusions

The application of wide awake local anesthesia no tourniquet (WALANT) in minor hand surgery procedures has been shown to decrease tourniquet-associated discomfort, improving perioperative patient experience. Additionally, it demonstrated the noninferiority of the tourniquet-free technique with respect to operative time and the rate of perioperative complications.

Application of WALANT technique for repairing finger skin defect with a random skin flap

BACKGROUND

Wide-awake local anesthesia no tourniquet (WALANT) technique has emerged among hand surgeons with other indications. Surgeries involving pedicled flap and revascularization are no longer used as contraindications. The present study aimed to evaluate the feasibility and merits of the WALANT technique in random skin flap surgery.

METHODS

From May 2018 to March 2019, 12 patients with finger skin defects repaired with random skin flaps were reviewed. Abdominal skin flaps or thoracic skin flaps were used to cover the wound. Both the fingers and the donor sites were anesthetized by the WALANT technique. A 40-mL conventional volume consisted of a mixture of epinephrine and lidocaine. A volume of 5 mL was injected at the distal palmar for nerve block, the other 5 mL was injected around the wound for hemostasis, and the remaining was injected at the donor site of flaps for both analgesia and hemostasis. Baseline data with respect to sex, age, side, type of finger, donor sites, flap size, dosage of anesthetics, usage of finger tourniquet, intraoperative and postoperative pain, hemostasis effect, operation time, Disabilities of the Arm, Shoulder, and Hand Questionnaire (QuickDASH) score, and hospitalization expense, were collected.

RESULTS

All patients tolerated the procedure, and none of them needed sedation. Single finger skin defect in 8 patients and double finger skin defect occurred in 4 patients; 5 patients were repaired by abdominal skin flaps, and 7 patients were repaired by thoracic skin flaps. The good surgical field visibility was 91.7%. All flaps survived adequately, without necrosis, pulling fingers out, and other complications. The average visual analog scale (VAS) score of the maximal pain was 1.1 in fingers vs. 2.1 in donor sites during the operation. On postoperative day one, the average VAS score of the maximal pain in fingers and donor sites was 1.3 and 1.1, respectively. The average hospitalization expense before reimbursement of the whole treatment was 11% less expensive compared to the traditional method. The average QuickDASH score was 9.1.

CONCLUSIONS

Under wide-awake anesthesia, patients have the ability to control their injured upper extremities consciously, avoiding the complications due to pulling flap pedicles. With the merits of safety, painlessness, less bleeding, and effectivity, the WALANT technique in random skin flaps is feasible and a reliable alternative to deal with finger skin defect.

Patients' Perspective on Carpal Tunnel Release with WALANT or Intravenous Regional Anesthesia

BACKGROUND

The authors conducted a prospective study to compare patients' intraoperative experience of open carpal tunnel release under "wide awake, local anesthesia, no tourniquet" (WALANT) on the one hand and intravenous regional anesthesia on the other. The authors hypothesized that WALANT would offer a better intraoperative experience than intravenous regional anesthesia.

METHODS

Twenty-four patients with bilateral carpal tunnel syndrome had one hand operated on using WALANT and the contralateral hand with the intravenous regional anesthesia method. At the postoperative second hour, patients completed a questionnaire to quantify their pain levels on a numerical rating scale and compare the operation with dental procedures. They were also asked about their expectations and feelings about reoperation with the anesthesia methods. The results were compared for the two anesthesia methods.

RESULTS

There were no significant differences between numerical rating scale pain values during anesthetic administration or for surgical site pain on the WALANT and intravenous regional anesthesia sides. Patients reported moderate tourniquet pain for intravenous regional anesthesia sides. For WALANT sides, a significantly higher number of patients reported carpal tunnel release to be an easier procedure than dental procedures (91.6 percent WALANT and 37.5 percent intravenous regional anesthesia). For WALANT sides, a significantly higher number of patients reported carpal tunnel release to be an easier procedure than they expected (91.6 percent WALANT and 50 percent intravenous regional anesthesia). For the reoperation, 83.3 percent of patients preferred WALANT, 8.3 percent preferred intravenous regional anesthesia, and 8.3 percent reported no preference.

CONCLUSIONS

WALANT offered a better intraoperative experience. Tourniquet pain, preoperative preparation basics, and the extended anesthesia duration are likely the major drawbacks of the intravenous regional anesthesia method.

Use of Wide-Awake Local Anaesthetic No Tourniquet (WALANT) in upper limb and hand surgery: A systematic review protocol

Introduction

Wide Awake Local Anaesthetic No Tourniquet (WALANT) technique has been developed to eliminate tourniquet pain during upper limb and hand surgery whilst also improving utilisation of operating theatre time and inpatient stay, however inconclusive data still limits the techniques uptake. Here presents a protocol for a systematic review to collate findings to produce conclusive data on efficacy of WALANT.

Methods

This systematic review will be registered a priori. All study designs defined by the Oxford Centre for Evidence-Based Medicine will be included in the search. "WALANT" in "upper limb" and "hand" surgery will be investigated as per the devised search strategy. 18 electronic databases will be searched, including PubMed, Medline and Embase in addition to a Grey literature search. Two independent teams of 3 researchers will screen all relevant titles, abstracts and subsequent full texts for suitability. Data will be extrapolated and entered into a preformatted database for analysis.

Ethics and dissemination

This systematic review will be published in a peer-reviewed journal and presented at both national and international conferences within the field of plastic and orthopaedic surgery. This review aims to inform surgical practice and policy.

Endoscopic Carpal Tunnel Release Using Wide-Awake Anesthesia

Purpose

We report on patient and surgeon experience after single-port endoscopic carpal tunnel release (CTR) using wide-awake local anesthesia no tourniquet (WALANT) technique.

Methods

From July to November 2018, patients undergoing endoscopic CTR with WALANT were prospectively included. Follow-up was 3 months. Patient ratings before, during, and after the operation were collected. We recorded the surgeon’s experience during surgery compared with the endoscopic CTR under local anesthesia with exsanguination and tourniquet. Complications were defined as nerve injury, infection, or the need for revision surgery.

Results

The cohort consisted of 20 patients (24 wrists). All patients except one reported a complete or substantial decrease of symptoms. The 2 surgeons involved judged the procedure to be technically more demanding owing to impaired visualization (33%) caused by increased bleeding and edema in the operative field. There was one conversion from endoscopic to open surgery.

Conclusions

We recommend starting single-port endoscopic CTR using WALANT with a noninflated tourniquet in place for use when necessary.

Type of study/level of evidence

Therapeutic IV.

Wide-Awake Local Anesthesia for Minor Hand Surgery Associated With Lower Opioid Prescriptions, Morbidity, and Costs: A Nationwide Database Study

Purpose

We sought to investigate the perioperative opioid prescription patterns, complication rates, and costs associated with wide-awake local anesthesia (WALA) techniques using a nationwide insurance claims-based database.

Methods

We used the PearlDiver Humana administrative claims database to identify opioid-naive adult patients who underwent a carpal tunnel release, trigger finger release, or de Quervain release between 2007 and 2015. Patients were divided into WALA and standard anesthesia groups by the presence or absence of anesthesia Current Procedural Terminology codes. We evaluated for differences in perioperative opioid prescribing patterns, rates of opioid refills, and insurance reimbursement. The incidence of surgical complications and medical complications within 30 days of surgery were determined by International Classification of Diseases, Ninth Revision codes. Adjusted odds ratios were calculated with multivariable logistic regression models to identify factors associated with filling or refilling opioid prescriptions and complication rates.

Results

There were 6,285 patients in the WALA group and 28,657 in the standard anesthesia group. The WALA patients were prescribed significantly lower quantities of opioids than were standard anesthesia patients across all 3 procedures. After controlling for type of surgery, gender, and comorbidities in a multivariate model, WALA patients were less likely to fill an initial opioid prescription during the perioperative period but were equally likely to obtain a refill. The WALA patients had lower odds of developing both surgical and medical complications compared with standard anesthesia patients. Moreover, WALA was associated with significantly lower costs for all procedures.

Conclusions

Wide-awake local anesthesia technique is an increasingly common and viable option for minor hand surgery. It is a cost-effective and safe technique for simple hand surgical procedures and can be a strategy to minimize postoperative opioid use.

Type of study/level of evidence

Prognostic II.

Vascularized flap transfer to fingers with volar digital veins as recipient vessels

Traditionally free vascularized flap transfers to the fingers connect to the proper digital artery and dorsal veins. We report our experience using the volar digital veins as recipient veins for free vascularized flap transfers in 14 fingers of 12 patients. One or two veins (three flaps with two veins, 11 flaps with one vein) of the flap were anastomosed to volar digital veins in the recipient site. The arteries of these flaps were connected to the proper digital arteries. All the transferred flaps survived. No vessel crisis occurred. Our patients demonstrated that volar veins can be the recipient veins for free flap transfers in the fingers without increased risk of venous crisis and flap loss. Level of evidence: IV.

A physiological assessment of patient pain during surgery with wide-awake local anesthesia

Purpose

Patients receiving surgery with wide-awake local anesthesia typically report little or no intraoperative pain. However, self-report assessments of pain are susceptible to bias. In the present study, patient self-report ratings were supplemented with objective physiological measures of electrodermal activity.

Methods

Fifteen patients receiving forefoot surgery using wide-awake local anesthesia were recruited. Pain ratings and skin conductance responses were acquired during the initial anesthetic injection (into unanesthetized tissue), during a follow-up anesthetic injection (into anesthetized tissue), and during five intraoperative procedures.

Results

The highest ratings of self-reported pain coincided with the initial anesthetic injection, and pain ratings were similarly low at all remaining measurement points. Fourteen patients reported no pain beyond the initial injection, whereas one patient reported minimal pain during two intraoperative procedures. Skin conductance data were consistent with pain ratings such that responses to the initial injection were significantly larger than responses at any subsequent measurement point.

Conclusion

These results provide further evidence that patients experience little or no pain during surgery with wide-awake local anesthesia.

Minimising Tourniquet Time and Post-operative Pain During Carpal Tunnel Decompression

Background

Pain and discomfort at the tourniquet and wound site are recognised complications of carpal tunnel surgery. Studies have shown that longer tourniquet times lead to increased pain, local and systematic complications. We hypothesise that minimising the intraoperative tourniquet time will reduce post-operative pain and complications.

Objective

Our aim is to present the results of our novel operative technique for carpal tunnel decompression which minimises tourniquet time.

Method

The study represented a prospective case series in which 55 consecutive and unselected patients with positive nerve conduction study results were operated on by a single surgeon at a single hospital site over a period of 12 months. The patients filled in a questionnaire based on a visual analogue score (VAS) (1-10) for pain at (1) first presentation at the clinic, (2) recovery in theatre post-operatively and (3) on discharge from care at 12 weeks post-operatively. Questions included the perception of pain at the tourniquet site and at the wound site.

Results 

A total of 55 (female 39 and male 16) patients participated in the study. The average tourniquet time was 5 minutes 50 seconds. 98% of patients had a VAS of 1 at both the wound and tourniquet site post-operatively. One patent had a score of 3 at the tourniquet site. Eleven patients had undergone contralateral carpal tunnel decompression surgery. Of the remaining 43 patients, all said they would have the other side operated on in the same way.

Conclusion 

We have demonstrated a safe and efficient technique to reduce post-operative pain by minimising tourniquet inflation time. Our patient cohort experienced no significant complications and minimal pain post-operatively.

Wide-Awake Hand Surgery in Two Centers in China: Experience in Nantong and Tianjin with 12,000 patients

This article summarizes the application of local anesthesia no tourniquet in 2 hand surgery centers in China, Nantong and Tianjin, where more than 12,000 patients were operated on with the new approach. This approach achieves excellent anesthetic and vasoconstrictive effects. In Nantong, surgeons performed fracture fixation, soft tissue tumor excision, and flap transfer in the hand with this approach. In Tianjin, surgeons applied it to cases of hand trauma emergency surgery. The authors' experience shows that this approach to hand surgery is safe, economical, and patient friendly, with no increase in infection rate.

Impact of Wide-Awake Local Anesthesia No Tourniquet on Departmental Settings, Cost, Patient and Surgeon Satisfaction, and Beyond

This article reviews the impact of wide-awake hand surgery without tourniquet on departmental settings and savings on patients' medical cost, and efficiency of fellowship training and practice of junior hand surgeons in 3 units in 3 countries. The medical cost of the commonly performed procedures is decreased remarkably with this approach in the 3 units. Hand surgery fellowship training and practice of junior surgeons are benefited from this approach in 2 units in Turkey and Switzerland. Overall, this approach improves the surgeons' and patients' quality of life and its application is expanding to almost all procedures of hand surgery.