White Papers

NEW – WALANT – Orthopaedic Practice

Marc Trzeciak, DO
Program Director, Valley Orthopedic Surgery Residency

Wide-Awake Local Anesthesia No Tourniquet (WALANT) has been shown to be a safe and effective care model that has led to improved outcomes, patient satisfaction, and cost-savings. An increasing number of hand surgeons have been incorporating WALANT procedures into their practices. However, recent studies have shown office-based surgery (OBS) is still very rare accounting for only 2-3% of all carpal tunnel releases.^1,2 Another benefit of performing WALANT procedures is that they preclude the risks associated with anesthesia and patients on complex pharmaceutical regimens don’t need to discontinue their medications.³ In regards to cost, procedures performed in a procedure room rather than the operating room have demonstrated a cost savings of 80-85%.^4,5 The purpose of this study was to find the preferences of hand surgeons who perform WALANT procedures. An email survey was sent to practicing hand surgeons were listed in the California Orthopaedic Association database. A total of 49 surgeons responded to the request to complete our survey.

A majority of surgeons who perform WALANT procedures perform them in an ambulatory surgery center (53.1%); with 16.3% (n=8) performing WALANT procedures in an office based setting (OBS). 42.2% of the surgeons who reported performing WALANT procedures at different types of surgery centers reported that their patients do receive an IV, with 56.8% reporting that they do not order an IV for their patients. Out of all survey participants 44.9% (n=22) reported routinely giving their patients perioperative antibiotics for soft tissue elective surgeries. This noteworthy, given the evidence that perioperative antibiotics for clean soft tissue procedures are not indicated.⁶ However, this is a lower percentage of surgeons reporting giving perioperative antibiotics compared to a 2015 study in which 51% of hand surgeons reported regularly using perioperative antibiotics.² The antibiotics given were Ancef (n=13), Keflex (n=8), and Cipro (n=1). For surgeons who reported not prescribing their patients antibiotics, their main reason for not doing so was that the literature reports they are not necessary.

Peters B, Giuffre JL. Canadian Trends in Carpal Tunnel Surgery. J Hand Surg Am. 2018;43(11):1035 e1031-1035 e1038.
Munns JJ, Awan HM. Trends in carpal tunnel surgery: an online survey of members of the American Society for Surgery of the Hand. J Hand Surg Am. 2015;40(4):767-771 e762.
Tan E, Bamberger HB, Saucedo J. Incorporating Office-Based Surgery Into Your Practice With WALANT. J Hand Surg Am. 2020.
Rhee PC, Fischer MM, Rhee LS, McMillan H, Johnson AE. 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. J Hand Surg Am. 2017;42(3):e139-e147.
Chatterjee A, McCarthy JE, Montagne SA, Leong K, Kerrigan CL. A cost, profit, and efficiency analysis of performing carpal tunnel surgery in the operating room versus the clinic setting in the United States. Ann Plast Surg. 2011;66(3):245-248.
Tosti R, Fowler J, Dwyer J, Maltenfort M, Thoder JJ, Ilyas AM. Is antibiotic prophylaxis necessary in elective soft tissue hand surgery? Orthopedics. 2012;35(6):e829-833.