June 7, 2024
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June 7, 2024
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Hand Surgery 2.0: Less Painful, More Convenient

When you say “hand surgery,” for many people the first thing that comes to mind is carpal tunnel or trigger finger surgery. These are quick surgeries that generally lead to tremendous improvements in quality of life.

Historically, patients with these types of hand problems (if they did not respond to conservative treatment) had to have intravenous (IV) anesthesia for surgery.

While modern anesthetics are generally safe, there is still an element of added risk from “going under.” Anesthetics are powerful drugs, and can cause side effects such as nausea, dry mouth and constipation. They also cause drowsiness for up to 48 hours after the procedure, a major inconvenience for what might otherwise be minor surgery. Sedated patients can’t drive themselves on the day of their procedure. They also have to have an empty stomach, so they must fast on the day of surgery.

Anesthetics also can harm a fetus, so if a pregnant person had carpal tunnel syndrome, for example, they might have had to wait until after delivery to have the surgery and feel relief. Finally, in most cases, adults who undergo anesthesia usually need preoperative exams, which can be an extensive and time-consuming workup including blood tests, X-rays, and even cardiac testing.

Now, patients have a better option for hand surgery—the technique known as WALANT. Studies have shown WALANT patients are more satisfied, have less pain, and are more likely to recommend WALANT.

What is WALANT? WALANT is a streamlined and improved approach to hand surgery. It stands for “Wide-Awake, Local-Anesthesia, No Tourniquet,” although there are many variations that can be used. While the phrase “wide awake” may sound frightening in the context of surgery, the area is fully numbed for the procedure, and the process is far simpler and less painful than going to sleep for surgery. It’s comparable to a trip to the dentist, only much easier, since it’s your hand that’s being worked on, not your mouth.

How is WALANT possible? The key is a chemical called epinephrine, also known as adrenaline. It might sound familiar; the human body produces adrenaline naturally, and uses it daily. It is a hormone that does many things. Among its many effects, it causes blood vessels to temporarily contract.

When used in combination with a local anesthetic like lidocaine, it allows a surgeon to operate on a hand without having to apply a painful tourniquet on the patient’s arm to control bleeding. The lidocaine numbs the area, and the epinephrine does the job of the tourniquet. That allows patients to be awake for the procedure, whether that means relaxing, watching television, listening to music, or even talking to their surgeon.

WALANT has been used for decades in Canada, where it was developed by a surgeon named Dr. Donald Lalonde. It is very safe when performed by a hand surgeon trained in the technique—arguably safer than traditional anesthesia.

Hand surgeons in the U.S. now regularly use WALANT to allow patients with conditions like carpal tunnel syndrome, trigger finger, lacerations, tendon injuries, and De Quervain’s tenosynovitis to have their surgery in a far more convenient fashion. The only thing the patient feels is the initial stick of a tiny needle to inject the medicine. The needle used for a WALANT injection is smaller than the needle required to put in an IV.

WALANT allows patients to skip the fasting, skip the pre-op testing, skip the nausea, and experience a less-painful surgery. Patients who are pregnant don’t need to wait until their baby is born to get relief from their carpal tunnel syndrome or De Quervain’s. Best of all, WALANT isn’t more expensive, it’s actually the far cheaper alternative—always a factor worth considering in the era of high-deductible health plans.

Many patients who have WALANT surgery can drive themselves to and from their procedure, and the surgery is often able to be done safely in a more-convenient location such as an outpatient surgery center, even sometimes in the office.

WALANT can also lead to better patient outcomes. During trigger finger releases, surgeons can have the patient actively move their fingers to test the tendon release and make sure the job is done right the first time. It doesn’t hurt because the area is numb. In cases of tendon injuries, surgeons who have started using WALANT find it easier to decide when the repair is strong enough, allowing them to jump-start recovery by beginning an early motion protocol with a certified hand therapist.

While not all hand surgery can be done using WALANT (some surgeries are simply too involved, or too major, to consider having the patient awake) most can. Not every hand surgery patient is a good candidate for WALANT, but most are.

Not all hand surgeons offer the technique, however. Many hand surgeons lack experience and training in this technique, and still, even today, sedate all their patients—even for a five-minute trigger finger release procedure. While it’s far easier for the patient, WALANT demands a bit of added effort from the surgeon, which is enough to deter some surgeons from trying it.

Any patient who is considering a hand procedure should ask their doctor if WALANT is an option for them.

For the patient, WALANT is as easy as relaxing on a comfortable bed with your hand lying on a table. Best of all, if you have a question during surgery, such as what to expect afterward, or what the tendon looks like, you can simply ask your surgeon. They might even be able to show you the anatomy in some cases, a once-in-a-lifetime opportunity to appreciate the wonderful complexity of the inner workings of the human body.

Joseph A. Rosenbaum, MD, is a board-certified orthopedic surgeon with subspecialty fellowship training in hand and wrist surgery. He is the clinical director of hand surgery at Holy Name Medical Center and sees patients in Teaneck. Dr. Rosenbaum is trained in WALANT surgery, and offers this technique to all patients for whom it is appropriate.

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