Arm Tourniquet Research Articles

Outcomes of Wide Awake Local Anaesthesia no Tourniquet (WALANT) In Soft Tissue Surgeries Of The Hand

Introduction: Hemostasis in hand surgery can be achieved by use of an arm tourniquet but it has its own disadvantages like tourniquet-related pain, muscle and nerve injury, post-tourniquet thrombosis, and bleeding. Another method can be the use of epinephrine locally, but surgeons are concerned with digital ischemia and necrosis as seen with use of procaine in the 1970s. Recently Wide Awake Local Anesthesia No Tourniquet (WALANT) is being popular among hand surgeons in which a mixture of local anesthetic with adrenaline and sodium bicarbonate is used. Despite the absence of tourniquet related complications in WALANT technique, surgeons are reluctant to use lignocaine with epinephrine in hand surgery.
 Objectives: The objective of this study is to observe the outcomes of WALANT technique in various surgical procedures of hand.
 Methodology: This prospective study involved 103 patients undergoing soft tissue surgery of the hand at Birat Medical College Teaching Hospital. Patients meeting inclusion criteria and willing to participate in study were included. A proforma was filled by the operating surgeon and another proforma was to be filled by patient at home after discharge which was retrieved at follow-up visit. A mixture of 10 ml of 2% lignocaine with adrenaline diluted in equal volume of normal saline and 2ml of 8.4% sodium bicarbonate was used for local anesthesia.None of our patients developed digital ischemia or necrosis, one patient developed surgical site infection which recovered with oral antibiotics. The mean VAS score at the time of administration of local anesthesia was 3.8+1.2, intraoperatively it was 1.8+ 1.1 and at 2 hours postoperatively it was 2.3+1.3. VAS score at 6 hours, 12 hours and 24 hours postoperatively was 3.2+1.2, 3.4+1.4 and 3.7+1.1 respectively. Hemostasis control was excellent in 33 cases, very good in 58 cases, good in 8 cases, and poor in 4 cases.
 Conclusion: We conclude that WALANT technique is safe to use in various soft tissue surgeries of hand surgery in terms digital ischemia, necrosis or wound infection and effective in providing excellent control of hemostasis at surgical site.

Extensor Carpi Ulnaris “Turn Around” Ligamentoplasty For Distal Radioulnar Joint Instability

Extensor Carpi Ulnaris “Turn Around” Ligamentoplasty For Distal Radioulnar Joint Instability

WAFER trial: a study protocol for a feasibility randomised controlled trial comparing wide-awake local anaesthesia no tourniquet (WALANT) to general and regional anaesthesia with tourniquet for flexor tendon repair

IntroductionFlexor tendons are traditionally repaired under either general anaesthesia (GA) or regional anaesthesia (RA), allowing for the use of an arm tourniquet to minimise blood loss and establish a bloodless...

Wide Awake Local Anesthesia No Tourniquet (WALANT) technique improves the efficiency of distal nerve blocks for carpal tunnel release

BackgroundAxillary block is the standard for carpal tunnel release (CTR), providing effective anesthesia, and tolerance of tourniquet. Conversely, distal blocks are less used due to poor tolerance of tourniquet. Wide Awake Local Anesthesia No Tourniquet (WALANT), proposed for hand and wrist surgeries, avoids its use. This study assesses the benefits of the addition of WALANT to distal blocks during endoscopic CTR (eCTR). MethodsThis randomized, open-label, controlled trial prospectively enrolled 60 patients scheduled for eCTR. Patients were randomized to receive distal blocks at the wrist combined to either a high arm tourniquet (Distal block group) or a WALANT in the area of surgery (Distal + Walant group). The primary endpoint was the global pain score summing pain scores related to puncture, local anesthetic injection, pneumatic tourniquet, surgical procedure, tourniquet deflation, and residual sensitivity after surgery. ResultsMean global pain score was significantly reduced in the Distal + Walant group (0.5 ± 1.4 vs. 2.2 ± 2.4; p < 0.001). No need for an additional anesthetic procedure was required in the Distal + Walant group. Even if the quality of visualization was high in both groups, it was better in the Distal block group (5 [5–5] vs. 4 [4–5]; p < 0.001). No rescue tourniquet was necessary for the Distal + Walant group. The rate of hematoma 15 days post-surgery was significantly reduced in the Distal + Walant group (20% vs. 57%; p < 0.01). ConclusionsThe addition of WALANT to distal blocks is adapted for eCTR. This combined technique decreases perioperative pain scores, provides good surgery conditions, and reduces the risk of postoperative hematoma. Clinical trial number and registry URLThe trial was registered on ClinicalTrials.gov (NCT04494100) on July 31, 2020 https://clinicaltrials.gov/ct2/show/NCT04494100?term=CMC+ambroise+pare&cntry=FR&draw=4&rank=28.

Wide-Awake Olecranon Fracture Fixation: Is it Possible?

The wide-awake local anesthesia no tourniquet technique has been widely performed in hand and wrist surgery with remarkable results. However, its use on the elbow has rarely been reported. Here we describe the use of wide-awake local anesthesia no tourniquet in olecranon fracture fixation in 4 cases. Tumescent anesthesia was injected from the proximal ulna to approximately 10 cm distally and into the periosteum and fracture site, approximately 25 minutes before skin incision. The fracture underwent closed reduction and was fixed using a long 6.5-mm cancellous screw with a washer through a small incision. No tourniquet was applied and none or mild sedation was administered. At the end of the operation, patients were asked to perform active elbow flexion-extension and forearm pronosupination movements under an image intensifier to test the range of motion and fracture stability. The surgical procedure was completed in all 4 cases. Two patients reported mild pain during ulnar medullary canal reaming, with pain scores of 3 and 4 on a 10-point scale, respectively. One case was resolved with additional local anesthetic injection. The other case required the administration of intravenous propofol. Both patients were able to actively move the elbow at the end of the operation. The use of wide-awake local anesthesia no tourniquet for olecranon fracture fixation has the advantage of obviating the need for an arm tourniquet, general anesthesia or heavy sedation, preoperative tests, and discontinuing routine medications (including anticoagulants). The stability of the elbow fixation was tested by active motion during surgery. This simple, safe, low-cost, and reproducible technique may be a good option for patients with contraindications or high risk of general or regional nerve block anesthesia. Therapeutic IV.

A Randomized Trial of Postoperative Handgrip Exercises for Fistula Maturation in Patients With Newly Created Wrist Radiocephalic Arteriovenous Fistulas

We aimed to substantiate the benefit of postoperative handgrip exercises (HGEs) in enhancing the maturation of an arteriovenous wrist fistula. We randomly assigned 119 patients aged 20 to 80 years who had wrist arteriovenous fistulas (AVFs) to undergo either a basic HGE program (group A), an advanced program (group B), or an advanced-plus upper arm banding program (group C). Outcomes were assessed by ultrasonographic evaluation of the diameter and flow at each follow-up. The attending nephrologist decided the clinical use of the fistula. We identified no significant differences among the HGE groups in the mean diameter and blood flow 14, 30, 60, and 90 days after the creation of the wrist AVF (P= 0.55, 0.88, 0.21, and 0.19 for the diameter; 0.94, 0.81, 0.49, and 0.56 for the flow, respectively). The intent-to-treat analysis also found no difference in the clinical use of fistulas for hemodialysis (HD) (P= 0.997). In patients with a newly created wrist AVF, advancing frequency, with or without adding intensity using an upper arm tourniquet, of postoperative HGEs did not enhance the growth of the fistula or increase the rate of clinical use over 3 months. (ClinicalTrials.gov ID: NCT03077815).

Value of Modified Duran’s Test in Clinical Diagnosis of Carpal Tunnel Syndrome

Background: Carpal tunnel syndrome (CTS) is a medical condition, the most common, most important, and best defined, and the most carefully studied of all nerve entrapment syndromes. Objective: Our study aims to evaluate clinical tests in the diagnosis of CTS with special reference to modified Duran’s test regarding specificity and sensitivity. Patients and Methods: A prospective study carried out on 300 hands in 240 patients with symptomatic CTS was taken, from August 2015 to February 2017, at Erbil Teaching hospital (Orthopedic department). History, clinical examination, and Electrophysiological by Electromyography and Nerve conduction study and 250 persons without symptoms on 300 hands were taken as a controlling group. We applied the five clinical provocative tests on each group, Phalen’s test, Tinal’s test, original Duran’s test, arm Tourniquet test, and Reversed Phalen’s test. In this research, we compared former tests by our test modification (Duran’s test), considering specificity, accuracy, and sensitivity. Results: Findings show that the modified Duran’s test was the most specific (94%), accurate (94%), and sensitive (94%) in comparison with the other provocative tests. The modified Duran test had the highest positivity rate, according to the cases in less than 1-month history of symptoms it reached: 81.8% which was higher than the result of the previous tests in comparison to the previous clinical tests. Its mean time was 11.5 s. Conclusions: Modified Duran’s test was simple, noninvasive, most sensitive, and most specific in comparison to other clinical tests. Furthermore, the reaction time of Modified Duran’s test was the shortest,

Wide awake local anesthesia no tourniquet (WALANT) – a revolutionary improvement in hand surgery

Abstract Objective Wide awake local anesthesia no tourniquet (WALANT) hand surgery offers the opportunity to create a bloodless field without using an arm tourniquet. Lidocaine for anesthesia mixed with epinephrine for hemostasis is frequently used without concerns in the hand and finger. This is a major improvement for the patient and the surgeon in terms of patient comfort and having the opportunity to test the hand and finger function intraoperatively. The movement away from tourniquet surgery, which often requires sedation or general anaesthesia is one of the most significant recent advances in hand surgery. Methods A subcutaneous infiltration of a mixture (1:100’000) of lidocaine (1%) and epinephrine (buffered 10:1 with 8.4% bicarbonate) is done with a 27 G canula. The mixture is infiltrated wherever surgical dissection, k-wire insertion, or manipulation of fractured bones will occur. The local anesthetic results in an extravascular Bier block. The injection is done slowly from proximal to distal to minimize injection pain. After the last injection a minimum time of 30 minutes should be waited for maximal epinephrine vasoconstriction in the finger. Results In the beginning WALANT was only used for small procedures like trigger finger or carpal tunnel release. Meanwhile also major hand surgical procedures like finger fractures, flexor tendon repairs, tendon transfers, arthroscopies, arthroplasties and open triangular fibrocartilage complex (TFCC) repair are performed in WALANT. Even procedures like trapeziectomy have been described using wide awake hand surgery, which involves numbing the joint itself. Conclusion The use of WALANT is a proven safe technique that can be used in up to 95% of hand surgical procedures. The benefits for patients and surgeons are obvious. Patients prefer the technique because there are no side effects of opiates or sedation. The anesthetic risk is minimized. Time at hospital is reduced. Patients do not have to suffer tourniquet pain. Surgeons prefer the technique because of the bloodless surgical field without tourniquet, the possibility of intraoperative testing of stability of prosthesis or fracture stabilization, strength of a tendon repair, the movement and gliding properties in the flexor tendon sheath after repair or testing the tension of tendon transfers. These are probably the reasons for the continuously growing popularity of this technique worldwide.

Fasciectomy under local anaesthetic and adrenaline for Dupuytren's contracture in a community setting in the UK with a cost analysis.

In the UK, fasciectomy for Dupuytren's contracture is generally performed under general or regional anaesthetic, with an arm tourniquet and in a hospital setting. We have changed our practice to use local anaesthetic with adrenaline, no arm tourniquet, and perform the surgery in a community setting. We present the outcome of a consecutive series of 30 patients. Prospective data were collected for 30 patients undergoing open fasciectomy on 36 digits (six having two digits affected), over a one-year period and under the care of two surgeons. In total, 10 ml to 20 ml volume of 1% lidocaine with 1:100,000 adrenaline was used. A standard postoperative rehabilitation regime was used. Preoperative health scores, goniometer measurements of metacarpophalangeal (MCP), proximal interphalangeal (PIP) contractures, and Unité Rheumatologique des Affections de la Main (URAM) scores were measured pre- and postoperatively at six and 12 weeks. The mean preoperative contractures were 35.3° (0° to 90°) at the metacarpophalangeal joint (MCPJ), 32.5° (0° to 90°) at proximal interphalangeal joint (PIPJ) (a combined deformity of 67.8°). The mean correction was 33.6° (0° to 90°) for the MCPJ and 18.2° (0° to 70°) for the PIPJ leading to a combined correction of 51.8°. There was a complete deformity correction in 21 fingers (59.5%) and partial correction in 14 digits (37.8%) with no correction in one finger. The mean residual deformities for the partial/uncorrected group were MCP 4.2° (0° to 30°), and PIP 26.1° (0° to 85°). For those achieving a full correction the mean preoperative contracture was less particularly at the PIP joint (15.45° (0° to 60°) vs 55.33° (0° to 90°)). Mean preoperative URAM scores were higher in the fully corrected group (17.4 (4 to 31) vs 14.0 (0 to 28)), but lower at three months post-surgery (0.5 (0 to 3) vs 4.40 (0 to 18)), with both groups showing improvements. Infections occurred in two patients (three digits) and both were successfully treated with oral antibiotics. No other complications were noted. The estimated cost of a fasciectomy under local anaesthetic in the community was £184.82 per patient. The estimated hospital theatre costs for a fasciectomy was £1,146.62 under general anaesthetic (GA), and £1,085.30 under an axillary block. This study suggests that a fasciectomy performed under local anaesthetic with adrenaline and without an arm tourniquet and in a community setting is safe, and results in favourable outcomes regarding the degree of correction of contracture achieved, functional scores, and short-term complications. Local anaesthetic fasciectomy in a community setting achieves a saving of £961.80 for a GA and £900.48 for an axillary block per case. Cite this article: Bone Joint J 2020;102-B(10):1354-1358.

Idiopathic Carpal Spasm (Trousseau’s Sign) After Intraoperative Arm Tourniquet Inflation in an Intubated Patient

We present a case of a 38-year-old male who sustained a laceration from a knife to the volar aspect of his left index and middle fingers. He had clinical injury to his flexor digitorum profundus tendons to both digits. He underwent operative exploration and repair of the tendons under general anaesthetic. An arm tourniquet was inflated to allow for haemostasis in the operative field. A few minutes after inflation, the patient’s hand went into carpal spasm. The tourniquet was deflated and the spasm resolved. Intraoperative serum calcium and carbon dioxide levels were normal. The operation proceeded with the tourniquet deflated. Postoperatively serum calcium and magnesium levels were within normal limits, as was serum vitamin D and parathyroid hormone levels. It has been reported that carpal spasm can occur with tourniquet use in the anxious patient due to hyperventilation and resultant metabolic alkalosis. This however is the first reported case of carpal spasm in the setting of tourniquet use and normal serum electrolytes and respiratory parameters in an intubated patient.

The feasibility of using forearm intravenous regional anaesthesia instead of the standard upper arm technique in wrist and hand surgery

Aim of the study: to compare between the efficacy of using forearm intravenous regional anesthesia (IVRA) and upper arm IVRA and investigate the effects of nitroglycerine (NTG) compared to fentanyl when added to lidocaine in IVRA in wrist and hand surgery. Patients and Methods: 100 patients divided into 4 equal groups. Patients had upper arm tourniquet and received lidocaine (3 mg/kg) mixed with fentanyl (1 μg/kg) in Group I and NTG (400 μg) in Group III. Patients had forearm tourniquet and received half dose of the aforementioned drugs in Group II and Group IV. Results: there was a rapid sensory and motor block onset and reduction in postoperative diclofenac requirement in group III and group IV compared to group I and group II. Conclusion: Both forearm and upper arm tourniquets showed comperable results. Nitroglycerin was associated with rapid onset of sensory and motor block, and reduction in postoperative diclofenac requirement.

A randomized controlled trial of trigger finger release under digital anesthesia with (WALANT) and without adrenaline.

Trigger finger release utilizing wide-awake local anesthesia no tourniquet (WALANT) usage in extremity surgery is not widely used in our setting due to the possibility of necrosis. Usage of a tourniquet is generally acceptable for providing surgical field hemostasis. We evaluate hemostasis score, surgical field visibility, onset and duration of anesthesia, pain score, and the duration of surgery and potential side effects of WALANT. Eighty-six patients scheduled for trigger finger release between July 2016 and December 2017 were randomized into a control group (1% lignocaine and 8.4% sodium bicarbonate with arm tourniquet; given 10 min prior to procedure) and an intervention group (1% lignocaine, 1:100,000 of adrenaline and 8.4% sodium bicarbonate; given 30 min prior to procedure), with a total of 4 ml of solution injected around the A1 pulley. The onset of anesthesia and pain score upon injection of the first 1 ml were recorded. After the procedure, the surgeon rated for the hemostasis score (1-10: 1 as no bleeding and 10 being profuse bleeding). Duration of surgery and return of sensation were recorded. Hemostasis score was grouped into visibility score as 1-3: good, 4-6: moderate, and 7-10: poor. The intervention group (with adrenaline) had a 74% of good surgical field visibility compared to 44% from the controlled group (without adrenaline; p < 0.05). Duration of anesthesia was longer in the intervention group (with adrenaline), with a 2.77-h difference. WALANT provides excellent surgical field visibility and is safe and on par with conventional methods but without the usage of a tourniquet and its associated discomfort.

Massive Thrombophlebitis as a Complication after Carpal Tunnel Release: Comorbid Factors?

Seven days before the patient had an endoscopic carpal tunnel release under locoregional anesthesia. We performed a single-portal technique as described by Agee. The patient was positioned in dorsal decubitus with this right arm on a side table. The arm tourniquet was inflated to a pressure 100mmHg above systolic blood pressure. The tourniquet was inflated after draping and was released after suture. The vertical incision was located radiocarpal along the ulnar border of the musculus palmaris longus. A proximal based flap of the superficial fascia is created and elevated. A blunt probe was used to gently probe the undersurface of the ligament. Sequentially larger dilators are passed into the carpal tunnel. The arthroscope with the blade is passed in and the dissection of the ligamentum transversum carpi is made. The incision is closed with resorbable sutures after which a compressive bandage is applied.

Massive Thrombophlebitis as a Complication after Carpal Tunnel Release: Comorbid Factors?

Seven days before the patient had an endoscopic carpal tunnel release under locoregional anesthesia. We performed a single-portal technique as described by Agee. The patient was positioned in dorsal decubitus with this right arm on a side table. The arm tourniquet was inflated to a pressure 100mmHg above systolic blood pressure. The tourniquet was inflated after draping and was released after suture. The vertical incision was located radiocarpal along the ulnar border of the musculus palmaris longus. A proximal based flap of the superficial fascia is created and elevated. A blunt probe was used to gently probe the undersurface of the ligament. Sequentially larger dilators are passed into the carpal tunnel. The arthroscope with the blade is passed in and the dissection of the ligamentum transversum carpi is made. The incision is closed with resorbable sutures after which a compressive bandage is applied.

The analgesic efficacy of intravenous regional anesthesia with a forearm versus conventional upper arm tourniquet: a systematic review

BackgroundThe main objective of this review is to perform a systematic review and meta-analysis of the existing evidence related to the analgesic efficacy with the use of conventional, upper arm intravenous regional anesthesia (IVRA) as compared to a modified, forearm IVRA in adult patients undergoing procedures on the distal upper extremity.MethodsMEDLINE, EMBASE and CENTRAL (Cochrane) databases were searched for randomized controlled trials published in English, French, Dutch, German or Spanish language. Primary outcomes of interest including description of quality level of anesthesia and onset of sensory block were assessed for this review. Dosage of the local anesthetic, local anesthetic toxicity and need for sedation due to tourniquet pain were considered as secondary outcomes.ResultsOur literature search yielded 3 papers for qualitative synthesis. Four other articles were added into a parallel analysis of 7 reports that provided data on the incidence of complications and success rate after forearm IVRA. Forearm IVRA was found to be as efficient as upper arm IVRA (RR = 0.98 [0.93, 1.05], P = 0.78), but comes with the advantage of a lower need for sedation due to less tourniquet pain.ConclusionOur results demonstrate that forearm IVRA is as effective in providing a surgical block as compared to a conventional upper arm IVRA, even with a reduced, non-toxic dosage of local anesthetic. No severe complications were associated with the use of a forearm IVRA. Other benefits of the modified technique include a faster onset of sensory block, better tourniquet tolerance and a dryer surgical field.Registration of the systematic reviewA review protocol was published in the PROSPERO register in November 2015 with registration number CRD42015029536.

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

I.

Embrochage à foyer fermé antérograde pour les fractures des métacarpiens – étude prospective sur 150 cas

The aim of the study was to asses the results of antegrade percutaneous intramedullary K-wire fixation, for unstable displaced metacarpal fractures in a large number of cases in order to support the usage of this mini invasive technique in the largest variety of fractures as possible. One hundred and fifty patients with 165 metacarpal fractures were evaluated. Average follow-up 10 weeks. TAM of the digit, rotational deformity, Q-DASH score and PRWHE score were recorded. The radiographic outcome was assessed by evaluating the dorsal angulation and shortening of the metacarpal. Regional anesthesia, fluoroscopic guidance and upper arm tourniquet were always used. Once the metacarpal fracture was reduced, a hole at the proximal epiphiseal dorsal corner was performed percutaneously with a pointed tip K-wire (2 mm of diameter) with an incidence of about 40°. Then, a blunt tip K-wire, was inserted through the hole in the metacarpal bone in the anterograde direction along the whole intramedullary canal until the internal cortical bone of the metacarpal head, in order to obtain a stable fixation. Number and diameter of the K-wire depend on the fracture morphotype and on the size of medullary canal. They were selected to fit in the intramedullary space well to supply maximum fracture stability, verified with dynamic test. The wires were bent approximately of 90° to be perpendicular to the dorsal skin and then cut to about 2 cm outside of it to prevent tendon impingement, which is possible with subcutaneous wire cutting. A soft dressing was applied for all the patients, encouraged to begin full motion exercises. At 5 weeks the wires were removed. Few precautions distinguish our technique over others described in the literature, but they are crucial in our opinion. Percutaneous antegrade approach without joint transfixation and tendon exposition joined to an immediate finger motion is able to avoid stiffness and tendon adhesions. The thickness of K-wires is always the largest possible to ensure rotational and length stability. Do not cut the wire under the skin, prevents tendon irritations and this leads to a very low incidence of complications such as infection, algodystrophy and need for second operations. This technique represents a valid solution for the treatment of many kind of displaced and unstable fractures of the metacarpals, being of fast running, of low cost and offering excellent results both in terms clinical and radiographic.

Questioning the use of tourniquets in carpal tunnel surgery and determining ideal level

Our aim was to determine if tourniquet use was a requirement in CTS release surgery, by evaluating patients in which tourniquets were used at different levels and patients in which tourniquets were not used during surgery. A total of 48 patients were included in the study. Eighteen patients had bilateral carpal tunnel syndrome. In these patients, the surgery of one side was performed with a forearm tourniquet, while the other side was performed with the conventional upper arm tourniquet. Thirty patients underwent carpal tunnel release surgery without a tourniquet. The duration of surgery, heart rate, blood pressure, pain status (visual analogue scale) of all patients, and the blood loss of patients who underwent surgery without a tourniquet were recorded. When the tourniquet and no-tourniquet groups were compared, there were no significant differences in terms of pain and physiological response. However, patient satisfaction was higher in the no-tourniquet group while operation times were longer. We believe that the local anesthetic + epinephrine without tourniquet method is advantageous compared to the other methods.

The Use of Arm Tourniquet in Unilateral Carpal Tunnel Release: Does It Actually Have Advantage on Surgical Time &amp; Clinical Outcome ?

The Use of Arm Tourniquet in Unilateral Carpal Tunnel Release: Does It Actually Have Advantage on Surgical Time &amp; Clinical Outcome ?

Timed wake-up anaesthesia in hand: A modification to wide awake surgery of hand.

Introduction:Wide awake surgery of the hand (WASH) is a well-accepted technique in hand surgery which allows the surgeon to identify and rectify on the table of some of the inadvertent shortcomings in the surgical procedures to optimise the final outcome. The advantage, however, precludes the use of tourniquet. We describe a modified method which preserves all the advantages of WASH and allows the surgeon to use tourniquet.Patients and Methods:Thirty-one cases of hand surgeries were carried out using the modified technique where a wrist block was supplemented with the ultra-short acting intravenous propofol which allowed the surgeon to use the upper arm tourniquet. The propofol infusion was stopped, and the tourniquet was released after the important surgical step. Within an average of 10 min of stoppage of the infusion, all the patients were awake for active intraoperative painless movements to aid the surgeon to identify, rectify and fine tune the procedure to optimise the results.Results:Five of the 31 patients needed correction based on the intraoperative movements. All the 31 patients were pain free at the surgical site during surgery. All the 31 patients were cooperative enough to perform full range of pain-free intraoperative movements. No patient experienced significant tourniquet pain during the procedure. Patient's and surgeon's satisfaction at the end of the procedure has been quite satisfactory.Conclusion:Timed wake-up anaesthesia, an improvement over the original WASH, has been suggested where the surgeon can add without subtracting the benefits of the procedure in the form of usage of the tourniquet providing the clear tissue plane and haemostasis during the surgery. However, an additional cost is incurred for the use of anaesthesia and equipment should be kept in mind.