No Muss, No Fuss for Hand and Wrist

Popular WALANT technique provides superior pain management, an improved patient experience and quicker turnovers.

In the world of hand and wrist surgery, the Wide-Awake Local Anesthesia No Tourniquet (WALANT) technique has revolutionized both pain management and the patient experience for many procedures, including carpal tunnel and trigger finger release.

The technique utilizes epinephrine as a hemostatic agent in conjunction with lidocaine as a local anesthetic. Both are injected directly into the area of the procedure, with no tourniquet required, and most patients don’t require sedation. By minimizing bleeding as well as anesthesia requirements, WALANT not only enables hand and wrist surgeons to treat patients’ conditions safely and effectively but also gets their patients in and out of surgery centers and even their own offices in rapid time. That enhances the patient experience as well as facilities’ ability to efficiently handle more patients each day.

When the procedure is over, patients go home immediately, with no recovery period required. Postoperative pain management is usually a breeze, with patients taking ibuprofen and acetaminophen for a few days, after which they can often resume work and leisure activities in little additional time.

Hand surgeons who have performed WALANT procedures for years find them to be not only a better experience for their patients, but also for themselves in terms of their ability to provide the most individualized and effective surgical interventions to as many patients as possible.

‘They just rave about it’

Michael Cohn, MD, an orthopedic hand and upper extremity surgeon with Baptist Health Orthopedic Care, works out of three Florida locations: Boca Raton, Boynton Beach and Deerfield Beach. According to Baptist, he is the first hand surgeon in the Boca Raton area to offer minimally invasive carpal tunnel release under live ultrasound visualization using a single-use device, with the procedure performed in minutes.

Dr. Cohn has employed the WALANT technique for carpal tunnel release and numerous other hand and wrist procedures, including trigger finger surgery, removal of tumors of the hand and fingers, little nail procedures and even tendon repairs, since the tail end of his training at NYU in 2010.

I don’t have an anesthesia provider for these cases. I’m the anesthesia provider.
Michael Cohn, MD

“WALANT has been growing gradually for the last 15 years,” says Dr. Cohn. “It’s not rare to perform some of the more minor hand surgeries under WALANT. Some surgeons are pushing the envelope even further by doing some larger fractures and other things using this technique as well.”

Dr. Cohn touts WALANT’s benefits to the patient. “If you do it right, they really enjoy every aspect of it, from the time savings to not needing a medical clearance or preoperative testing,” he says. “They’re not fasted, so they don’t mind if I’m doing them in the afternoon after my bigger anesthesia cases. It’s easier, it’s safer and patients have minimal pain and a rapid recovery.

Really, they just rave about it. I’d encourage ASCs and hospitals around the nation to really look into WALANT further and see if this makes sense for them.”

Dr. Cohn’s WALANT procedures mostly range in duration from a couple minutes to a half-hour. He performs them in a hospital-based ASC and even at his office. “I actually do trigger fingers in my office with a no-incision technique I developed,” he says. “On Thursdays, for example, I always do my full day of operating room cases and then come down and do a number of trigger fingers in my office under WALANT.”

ALREADY HOME For many of Dr. Michael Cohn’s WALANT patients, the postoperative pain regimen is over-the-counter acetaminophen and ibuprofen.

In the room with Dr. Cohn during most WALANT surgeries are a circulating nurse, another nurse who monitors the patient and documents their vitals, a scrub tech and sometimes his physician assistant. As for anesthesia? “I don’t have an anesthesia provider for these cases,” he says. “I’m the anesthesia provider.”

This double-duty arrangement can work when it’s well-orchestrated. “I usually have two rooms, and we’ll stay one or two patients ahead with the blocks and just go back and forth,” says Dr. Cohn. “Sometimes my PA will do some blocks in the holding area while I’m doing a case, depending on the flow. I like the local anesthesia to take effect for a good 30 minutes with the epinephrine. I find that gives us the best hemostasis and a really complete block.”

He provides carpal tunnel release as an example of his anesthesia regimen. “For carpal tunnel, I use 1% lidocaine with epinephrine,” says Dr. Cohn. “It’s a one to 100,000 concentration of the epinephrine, and I use 10 cc’s. I give a carpal tunnel block under ultrasound guidance in the holding area after I greet the patient and sign them in, and we let that take effect for about 30 minutes before we bring them back to the OR to do the procedure. We do it without a tourniquet. They’re already numb and ready to go. The procedure itself only takes a matter of a few minutes.”

The patient experience is efficient. “With a lot of these cases, we’re not doing a full draping, we’re doing more minimal draping,” says Dr. Cohn. “We’ll even have the patient not get off their stretcher. We attach a hand table to it with very minimal draping. It’s cost-effective. It’s efficient. We’re not transferring the patient over needlessly to an OR table and back and forth.”

The efficiency, both in terms of time and cost, extends to instrumentation. “Often we won’t use an extensive instrument tray,” says Dr. Cohn. “We’ll use modified instrument trays that just have the two to five instruments I might need for the procedure we’re doing, so we save a lot of time.”

He tries to make the brief experience as enjoyable as possible for his wide-awake patients. “We play whatever music they want to make them comfortable, which they love,” he says.

Dr. Cohn lauds the real-time intraoperative patient feedback that WALANT enables. “For tendon procedures, for example, we can see how the repair has done under live visualization with the patient moving,” says Dr. Cohn. “We can make sure things are tracking well, that the tendon is not pulling apart or gapping. It’s really great.”

If you’re efficient as a surgeon, and you have two rooms, you can do two to three per hour without rushing.
Joseph Rosenbaum, MD

In terms of patient selection, WALANT is applicable to many if not most patients who agree to it, says Dr. Cohn. “I operate these days almost on all comers in this manner that fit the indications for the procedure I’m offering,” he says. “If they’re highly anxious and they know it, if they’re uncomfortable or highly scared, I can just tell and don’t even offer the local anesthesia. Or they’ll tell me, ‘You know what? I don’t know if I can handle that.’”

Some patients who agree to the WALANT technique experience sudden anxiety about it on the day of surgery, or the days before. In these cases, Dr. Cohn prescribes an oral anxiolytic like diazepam either preoperatively or at the surgery center. “They’ll take the Valium 30 to 45 minutes before we wheel them back, and usually they’ll be very relaxed or even sleepy,” he says. “But they’re safe and breathing on their own, and I can perform the procedure without worry of them having an anxiety attack or a hypertensive episode.”

Postoperatively, pain management is a relative breeze. “I tell most patients they’re going to get by just fine with Tylenol and a nonsteroidal such as ibuprofen,” says Dr. Cohn. “I don’t even write a prescription for it. We just tell them to take them over-the-counter together as needed for pain. Typically, just to cover all bases, I’ll preemptively write a very small prescription, maybe five tablets, of a stronger narcotic painkiller just so they have it. Maybe one out of 10 or 15 people end up taking one, two or three of those the first 24 hours. You never can predict exactly how somebody is going to respond, but I’d say, by and large, at least 90% of my patients for your typical carpal tunnel release are not taking anything more than Tylenol and ibuprofen for the first 24 hours. For my ultrasound-guided carpal tunnel releases, I would say at most they’ll take Tylenol and ibuprofen for two days. The pain is usually under very good control.”

The beauty of this is that patients return to normal function rapidly. “They’re getting back to their activities shortly thereafter, including most forms of work, and usually within a week they’re getting back to exercise if that’s something they enjoy doing,” says Dr. Cohn. “I’ve even had some people get back to golf and tennis within about seven days with ultrasound carpal tunnel release.”

Dr. Cohn says once a hand surgeon is comfortable with WALANT, they’ll likely want to employ the technique for more and more procedures. “You can do it in almost all comers now,” he says. “I even do some elbow surgeries this way — cubital tunnel, for example. I think WALANT is a great thing for patients and patient care, and something that should be looked at further.”

‘They don’t even get an IV’

Joseph Rosenbaum, MD, clinical director of hand surgery at Holy Name Medical Center in Teaneck, N.J., uses WALANT for a wide range of procedures including carpal tunnel release surgery and trigger finger release surgery. He says some hand surgeons are exploring the use of WALANT for more complex procedures such as finger and wrist fracture fixation.

“WALANT has been catching on recently among hand surgeons,” says Dr. Rosenbaum. “Traditionally, we had to have patients sedated for hand surgery.” The use of epinephrine was long considered too dangerous for use in the fingers, he says, but surgeons have proven it safe over the past couple decades. Dr. Rosenbaum has employed the WALANT technique for about seven years.

“With epinephrine, you don’t need to use a painful tourniquet to control bleeding,” he says. “That’s really the game changer. Patients are numb, so they don’t feel the surgery you’re doing.”

He says WALANT has seen various levels of adoption, with some surgeons using it only for procedures like trigger fingers and carpal tunnels, and others employing it in a more widespread manner, such as for tendon repair.

“With the patient awake, you can test the tendon motion,” he says. “They can move their finger on their own power, rather than the surgeon just pulling it. You can see how the repaired tendon will glide, which is a big advantage. When you repair a tendon, sometimes the repair is bulky and doesn’t fit in through the tunnel system. You can best discover that if the patient is actively moving their finger because it is natural motion. It shows both you and the patient what they’ll experience after the surgery is done. If you can’t get a smooth glide in the OR with active motion, you know you need to do a bit of a release or make a little more room. It gives you real-time feedback that you can’t get if the patient is asleep.”

QUICK HANDIWORK The range of hand procedures that Dr. Michael Cohn (second from left) and his team perform on wide-awake patients can last from a couple minutes to a half-hour.

Dr. Rosenbaum administers 1% or 2% lidocaine with a one to 100,000 concentration of epinephrine at least 25 minutes before the incision. As for sedation? “Not at all, zero,” he says. “They don’t even get an IV.” When he performs the surgery, he is joined by a circulating nurse and, occasionally, a second nurse.

Like Dr. Cohn, he focuses on efficiency in his double role as surgeon and anesthesia provider. “I usually will inject one or two patients ahead of the current case,” he says. “The patients go into a waiting area. If I have three or more scheduled, I’ll try to stay one case ahead, so by the time one case is done, the next patient’s injection is ready to go.”

Dr. Rosenbaum says surgery centers and physician offices are perfect venues in which to perform WALANT procedures, but use of the office setting depends on the payor landscape. “In certain states, in-office surgery is not reimbursed,” he says. “WALANT procedures can certainly be done safely in an office, and I have done it in the past at previous practices with minimal staff. You honestly don’t need anybody with you. I do the injection, I monitor that myself, and afterward the patient can simply get up and leave.”

I’d encourage ASCs and hospitals around the nation to really look into WALANT further and see if this makes sense for them.
Michael Cohn, MD

In an ASC with an efficient setup, WALANT patients can be in and out of the facility very quickly. “Say the patient shows up at 8 a.m. for their 8:30 a.m. surgery,” says Dr. Rosenbaum. “You do the injection at 8:05 and then do the procedure at 8:30. They’re out of the OR at 8:45 or 8:50, and then they can go home. That’s under an hour. With extra time for checking in, paperwork, et cetera, 90 minutes is a safe estimate. If you’re efficient as a surgeon, and you have two rooms, you can do two to three per hour without rushing. We’re talking about cases where you used to be able to do one an hour, maybe two if you were efficient.”

In terms of patient selection, Dr. Rosenbaum says contraindications that can disqualify patients from WALANT include vascular disease, Raynaud’s Phenomenon, heavy smoking and advanced diabetes. “I usually would avoid doing WALANT in these patients, or I might modify the procedure to use less epinephrine because they can get vasospasm or ischemia to their digits,” he says. “These complications, though, are very rare. If I’m doing three or four trigger fingers at once, which is pretty rare to begin with, I would probably limit or entirely avoid using epinephrine. It’s a lot of epinephrine to deliver to the area, and there’s risk of ischemia and vascular insult.”

Dr. Rosenbaum screens patients about potential anxiety issues by “reading the room” long before the day of surgery. “When I meet a patient and we’re discussing something that might be surgical, I’ll typically gauge to see if the patient would be amenable to this,” he says.

He provides patients with an FAQ sheet that answers questions like, “Why would I want to stay awake for surgery?” “What are the benefits?” “What’s different about it?”

It’s not just about patient comfort with WALANT, however. There are also surgeon factors. “Some surgeons just don’t want their patients awake and talking to them during surgery, and are just not going to be adopters of this technique,” says Dr. Rosenbaum.

For cleanliness and sterility, Dr. Rosenbaum usually drapes patients, although in office settings he has performed WALANT procedures under field sterility with just towels. He says some patients really like to watch the procedure as it happens, which can benefit his work. “It’s helpful for patients to watch when they have a trigger finger that has been bothering them for a while, for example,” he says. “They can watch the finger go all the way into a tight fist and open smoothly with no clicking. The smile you see on that patient’s face is so rewarding. They haven’t been able to smoothly open and close their fist in months or sometimes even years, and then they’re seeing on the table that instant gratification of, ‘Wow, my surgery just started five minutes ago, and here I am making a full fist.’”

He says WALANT patients tend to be more involved in their recoveries. “If you show a patient, ‘Yes, you can safely make a fist, you can safely open it, it’s okay, you’re not going to hurt anything,’ during the surgery, then after the surgery they feel very confident they can rehabilitate,” says Dr. Rosenbaum. “And they rehabilitate very quickly.”

For almost all WALANT procedures, Dr. Rosenbaum employs an opioid-free pain management regimen.

“It’s Tylenol and Motrin,” he says. “Patients typically report to me that they’re taking those medications for maybe a day after the surgery. It’s funny, patients just take less pain medication when they’ve been awake for their surgery. I don’t know if it correlates to if those patients are also the more confident, less anxious patients, but research shows they do better.”

Dr. Rosenbaum says rehabilitation depends on the procedure. “For trigger finger release surgery, I put the patients in a small dressing,” he says. “They can use the hand for light activity. They leave the dressing on for a couple days, then they put a Band-aid on the area and can get it wet after that. I ask them to withhold from very strenuous or heavy activities for about three or four weeks. Carpal tunnel is very similar in that regard.”

A tendon repair, however, is much more complicated, and Dr. Rosenbaum’s patients usually see a hand therapist in conjunction, making the recovery process a lot more modular and guarded. “But they still can actively move their fingers again within three to five days,” he says. “They don’t have the range of a full fist, but they can start doing that.”

Dr. Rosenbaum says WALANT enables his patients to feel more like participants in their surgeries. “They seem much more invested than the patient who almost wants to be disassociated from their surgery, where it’s more like a ‘Doctor, you fix me’ thing,” he says. “When they’re awake for their surgery, their attitude is that it’s almost like a team sport. I can give them coaching, and they can ask me questions during the surgery, and I’m happy to answer them.”

That patient participation, however, must extend beyond the procedure to experience the full benefits of a successful outcome, according to Dr. Rosenbaum. “The surgery is only one facet of the recovery. I do the surgery, but if they do no rehab, they don’t do well,” he says. “It’s really up to them. They need to be invested in their care, and I think WALANT is a huge advantage in that regard.” OSM