Wide-awake Local Anesthesia Research Articles

The Efficacy of WALANT Technique in the Management of Distal End Radius Fracture - A Case Series.

To improve hemostasis and visibility, a tourniquet was used throughout the majority of hand and wrist procedures, despite the fact that patient experience unnecessary and excruciating pain from the tourniquet. The more current method known as wide-awake local anesthesia without tourniquet (WALANT) enables intraoperative function evaluation while the patient is completely conscious. Individuals with displaced distal radius fractures that required surgery and isolated, non-concomitant injuries requiring spinal or general anesthesia were considered for WALANT technique. In our study, five patients underwent dorsal plate fixation and five patients underwent volar plate fixation. Patients receiving dorsal plate fixation required definite dorsal buttress to prevent radiocarpal dislocation. The WALANT technique is a simple, reliable, and effective anesthetic method for internal fixation and open reduction of distal radius fractures. Since a tourniquet is not necessary, the patient is protected from the discomfort and risks associated with one.

Flexor Pronator Slide Under Local Anesthesia without a Tourniquet for Non-Ischemic Contractures of the Forearm.

Flexor Pronator Slide Under Local Anesthesia without a Tourniquet for Non-Ischemic Contractures of the Forearm.

Patellar Fracture Fixation Using Wide-Awake Local Anesthesia No Tourniquet (WALANT): A Novel Method

Objective: Patellar fractures, which account for approximately 1% of all fractures, frequently require surgical intervention for significant displacement. Traditional anesthesia methods pose various risks and complications, especially for patients with comorbidities. This study aims to evaluate the safety and feasibility of wide-awake local anesthesia no tourniquet (WALANT) for patellar fracture fixation. Methods: A retrospective evaluation was conducted on a total of 8 patients who underwent patellar fracture fixation using the WALANT technique between 2020 and 2022. Patient demographics, clinical findings, and postoperative outcomes were collected. Peroperative pain was assessed using the Numerical Pain Rating Score (NPRS) and Visual Analogue Scale (VAS). Outcomes, including bleeding, complications, and the Lysholm Knee Score at 12 months postoperatively, were evaluated. Results: The median age at surgery for a total of 8 patients, 6 males and 2 females, was 56 years (range: 38-73). The median surgery duration was 52 minutes (range, 38-73) , and postoperative pain onset was 160 minutes (range, 130-220). Minimal intraoperative bleeding was observed in most cases. Patient satisfaction with WALANT was high, with median VAS scores of 1 (range, 0-3) at 2 hours and 3 (range, 1-5) at 24 hours post-surgery. The median hospital stay was 2 (range, 1-7) days. One patient experienced a superficial skin infection. At 12 months postoperatively, the Lysholm Knee Score indicated satisfactory functional outcomes. Conclusion: This study is the first to explore WALANT for patellar fracture fixation. WALANT provides safe, effective anesthesia, high patient satisfaction, effective pain management, and shorter hospital stays. It benefits patients with comorbidities and offers an alternative to traditional anesthesia. Further research is needed to validate these findings and support wider use.

Dellon Triple Decompression under WALANT

The Wide-Awake Local Anesthesia No Tourniquet (WALANT) Approach to Dellon Triple decompression involves the use of local anesthetic with epinephrine and no tourniquet. This study shows that WALANT is a safe and effective procedure and can be performed in an outpatient setting for the decompression of the common peroneal nerve in the knee, tibial nerve in the ankle and deep peroneal nerve in the dorsum of the foot in diabetic patients with superimposed nerve compressions to diabetic neuropathy. WALANT technique demonstrated to be a safe procedure to surgically treat diabetic patients with superimposed compressive neuropathy to diabetic neuropathy in the lower limbs and had no complications.

WALANT Scaphoid Fixation Under Field Sterility: A Case Report and Description of Technique

Wide Awake Local Anesthesia No Tourniquet (WALANT) technique has become an increasingly popular method of treating common hand pathologies. We present its application in the treatment of an acute minimally displaced scaphoid fracture. In addition, we demonstrate this can be achieved with field sterility using minimal surgical PPE and draping in a minor surgery setting, outside the main operating room theatre.

A 2-Stage Approach in Managing Diabetic Forefoot Ulcers.

Forefoot plantar ulcers in patients with diabetic neuropathy are considered to be primarily the result of increased shear forces applied over prominent plantar bony prominences. The purpose of this article is to describe a 2-stage treatment pathway utilizing an outpatient percutaneous tendon-Achilles lengthening (TAL) as the first stage procedure and subsequent proximal metatarsal osteotomy (MTO) as a second stage procedure for a persistent or recurrent ulcer. A consecutive 112 patients (146 feet), who presented to our Multidisciplinary Diabetic Foot Team clinics since February 2019 with plantar nonischemic forefoot ulcers were included in this study. Excluding the patients who died or were lost to follow-up, 96 feet were followed for a minimum 12 months (range 12-36 months). After TAL, patients were encouraged to walk in a walking cast for 6 weeks and were followed for a minimum 12 months. Patients with persistent or recurrent ulcers were investigated with magnetic resonance imaging scan, and based on intramedullary osteomyelitis and septic destruction of distal metatarsal, we describe a second-stage MTO with the 3 most common clinical presentations. Of 96 feet, none had infection or wound-related problems following TAL. Complete transection of the tendon was noted in 4 patients (4%) and heel callosity in 1 patient. In 92 feet (96%), the ulcers healed within 10 weeks (±4 weeks) after TAL but, in 12 feet (10%), the ulcer failed to heal or recurred. At a minimum 12 months after the second-stage MTO, none in this subgroup had recurrence of ulcer or a transfer lesion. TAL followed with a walking cast as an outpatient procedure was effective in healing forefoot ulcers in 96% of feet. Comparable to the widely practiced hand surgery Wide Awake Local Anesthesia No Tourniquet (WALANT) procedure, our approach involved active control of the degree of ankle dorsiflexion by the patient, and the procedure was proven to be safe and well tolerated. When the second-stage MTO was required to offload the forefoot, in our small cohort, patients had ulcer-free outcome for a minimum 12 months. Level IV, retrospective case series.

Wide-Awake Local Anesthesia No Tourniquet Surgery for Zone VII Extensor Tendon Reconstruction: Stages in Active Range of Motion From Intraoperative to Final Recovery

We investigated chronological changes in active range of motion (ROM) of the metacarpophalangeal (MCP) joint after zone VII extensor tendon reconstruction with wide-awake local anesthesia no tourniquet (WALANT) surgery. Reconstruction of the extensor tendons ruptured in zone VII of 82 fingers in 40 patients was performed using WALANT techniques. The mean patient age was 71.3 years. During surgery, we evaluated passive stretch distance and active contraction distance of the ruptured musculocutaneous unit. The sum of passive stretch distance and active contraction distance was defined as total excursion. In cases with total excursion ≥30 mm, we selected bridge tendon grafting for tendon reconstruction. In cases with total excursion <30 mm, end-to-side tendon transfer was performed. Active ROM of the MCP joint was measured before surgery; during surgery; 1, 3, and 5 months after surgery, and at the final follow-up. Extension lag of the MCP joint was 49.2° before surgery, improving to 2.9° during surgery, deteriorating to 18.7° at 1-month, and improving again to 15.6° at 3-months, 13.6° at 5-months, and 10.5° at the final follow-up. Meanwhile, the active flexion angle of the MCP was 87.9° before surgery, 87.3° during surgery, 67.6° at 1-month, 76.0° at 3-months, 79.7° at 5-months, and 81.0° at the final follow-up. Extension and flexion angles at each time point remained nearly constant regardless of whether tendon grafting or tendon transfer was used. Extensor tendon reconstruction using WALANT surgery allowed intraoperative measurement of active ROM, confirming near-complete extension and flexion after reconstruction. The changes in ROM of the MCP joint during follow-up are an approximate indication of the progression of postoperative recovery. Therapeutic Ⅳ.

Description of WALANT technique in open bone and ligament wrist surgery

The gold-standard for bone, ligament and joint surgery in the wrist is locoregional anesthesia in most countries. Wide-Awake Local Anesthesia No Tourniquet (WALANT) is commonly used for simple soft-tissue hand surgery procedures such as carpal tunnel or trigger finger release, and can now also be safely used in procedures such as proximal row carpectomy, scapholunate ligament repair or partial wrist fusion, to name but a few. This article describes the use of WALANT for complex surgery in the wrist. WALANT surgery offers many known benefits, such as enhanced patient safety and comfort, simplified perioperative process and avoidance of anesthesia-related risks, and also allows the surgeon to perform intraoperative testing of the repaired structures. Thus, the surgeon can tailor the rehabilitation program and shorten recovery time. We describe detailed guidelines for performing WALANT procedures safely and effectively, making it a favorable option for complex surgeries in the wrist.

The history of tourniquet use in limb surgery.

As tourniquets have been present in medicine since almost its conception, understanding and following their development through time is not only an exercise in history but also an insight into the evolution of medical devices over more than two millennia. From simple leather bands wrapped around patients' limbs to the modernised digital devices used widely in surgical theatres globally, tourniquets have undergone tectonic change both in their design and application, moving from battlefields to hospitals. Hence, the aim of this article is to outline the historical development of these devices alongside their present and modern use. The historical development of emergency and surgical tourniquets is chronologically outlined, with particular emphasis on the impact of warfare on their widespread adoption in trauma and emergency medicine and elective surgery. Novel surgical trends and their impact on the future of tourniquet use are evaluated. The development of tourniquets across two millennia has closely reflected both the scientific understanding of human physiology and anatomy as well as technological discoveries and advancements that have reshaped their design and application. Prominent figures in the field of surgery, such as Sushruta, Fabricius Hildanus, John Louis Petit, Joseph Lister, Harvey Cushing and James McEwen, all fundamentally influenced their evolution and helped popularise and modernise them. The views on their use have been controversial and drastically changed across different eras, with data collected from modern warfare serving to embed their use in clinical practice. The historical development of tourniquets since pre-historic times represents an excellent outline of the adaptive nature of medicine, led, firstly, by scientific rigour and discipline and, secondly, by pioneers who serve as catalysts for change and improvement. The modern inflatable cuff tourniquets that are omnipresent in theatres globally will undoubtedly remain the standard of care for the foreseeable future. Tourniquets that can dynamically monitor blood pressure and consequently adjust inflation pressures, as well as ones with inbuilt axonal excitability monitoring, will further improve their safety profile, reduce associated complication rates and represent the next step in the evolution of these devices. Notably, there might be a shift away from tourniquet use altogether, reflected by the wide use of the wide-awake local anaesthesia no-tourniquet technique that has become the new norm in hand surgery.

Comparison of distal radius fracture plating surgery under wide-awake local anesthesia no tourniquet technique and balanced anesthesia: a retrospective cohort study

BackgroundDistal radius fractures (DRF) are frequently treated with internal fixation under general anesthesia or a brachial plexus block. Recently, the wide-awake local anesthesia with no tourniquet (WALANT) technique has been suggested as a method that results in higher patient satisfaction. This study aimed to evaluate the functional outcomes, complications, and patient-reported outcomes of DRF plating surgery under both the WALANT and balanced anesthesia (BA).MethodsNinety-three patients with DRFs who underwent open reduction and plating were included. Regarding the anesthetic technique, 38 patients received WALANT, while 55 received BA, comprised of multimodal pain control brachial plexus anesthesia with light general support. The patient's overall satisfaction in both groups and the intraoperative numerical rating scale of pain and anxiety (0–10) in the WALANT group were recorded. The peri-operative radiographic parameters were measured; the clinical outcomes, including Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) score, wrist mobility, and grip strength, were recorded in up to 1-year follow-up. Results presented with a mean difference and 95% confidence intervals and mean ± standard deviation.ResultsThe mean age of patients in the WALANT group was higher than in the BA group (63 ± 17 vs. 54 ± 17, P = 0.005), and there were fewer intra-articular DRF fractures in the WALANT group than in the BA group (AO type A/B/C: 30/3/5 vs. 26/10/19, P = 0.009). The reduction and plating quality were similar in both groups. The clinical outcomes at follow-up were comparable between the two groups, except the WALANT group had worse postoperative 3-month pronation (88% vs. 96%; − 8.0% [ − 15.7 to − 0.2%]) and 6-month pronation (92% vs. 100%; − 9.1% [ − 17.0 to − 1.2%]), and better postoperative 1-year flexion (94% vs. 82%; 12.0% [2.0–22.1%]). The overall satisfaction was comparable in the WALANT and BA groups (8.7 vs. 8.5; 0.2 [ − 0.8 to 1.2]). Patients in the WALANT group reported an injection pain scale of 1.7 ± 2.0, an intraoperative pain scale of 1.2 ± 1.9, and an intraoperative anxiety scale of 2.3 ± 2.8.ConclusionThe reduction quality, functional outcomes, and overall satisfaction were comparable between the WALANT and BA groups. With meticulous preoperative planning, the WALANT technique could be an alternative for DRF plating surgery in selected patients.Trial registration This retrospective study was approved by the Institutional Review Board of Kaohsiung Medical University Hospital (KMUHIRB-E(I)-20210201).

Supraclavicular nerve sparing versus sacrifice during open reduction internal fixation of acute midshaft clavicle fracture

BackgroundThe branches of the supraclavicular nerve are often sacrificed during open reduction and internal fixation (ORIF) for clavicle fracture. No consensus exists on whether the supraclavicular nerve should be routinely identified and protected during ORIF.MethodsWe developed a simple method to make nerve sparing easier; Wide-Awake Local Anesthesia No Tourniquet (WALANT) solution is locally injected prior to the surgical incision being made. This retrospective study enrolled 340 patients and divided them into supraclavicular-nerve-sparing (n = 45) and supraclavicular-nerve-sacrifice (n = 295) groups. Surgical outcomes—including operative time, estimated blood loss, postoperative pain, union rate, time to union, functional score, paresthesia, complications, implant removal rate, and complication rate—were recorded.ResultsIncisional or anterior chest wall numbness and intraoperative blood loss were significantly less (p < 0.001) in the nerve-sparing group. The operative time was similar in the two groups. No significant differences were discovered in QuickDASH score, postoperative pain score, union rate, time to union, implant removal rate, complication rate, or revision rate.ConclusionsOur study demonstrated that the outcomes of supraclavicular nerve sparing during ORIF with WALANT can reduce postoperative incisional and anterior chest wall numbness and intraoperative blood loss without increasing the operative time or complication rate.

Demystifying Giant Cell Tumours of Tendon Sheath (GCTTS): A Case Series of 18 Cases with Review of Literature.

The giant cell tumour of the tendon sheath (GCTTS) is the second most frequent soft tissue tumour affecting the hand. No consensus exists on the etiology, prognostic factors, or recurrence rate of GCTTS. This article presents a series of 18 cases supplemented by a literature review that examines the epidemiology, presentation, gross and microscopic characteristics, and recurrence rate of GCTTS. A total of 18 patients with a histo-pathological diagnosis of a GCTTS of the hand or finger were reviewed. The location for the tumour was limited to the wrist and hand. All cases were operated under Wide Awake Local anaesthesia (WALANT), and using a magnifying loupe. A total of 18 patients presented at our institution with a diagnosis of GCTTS from 2016 to 2018. Of the 18 patients, 11 were female and 7 were male. The mean age of included patients was 43.6years (31-59years). The most common site for the lesion was the middle finger (4/18), followed by the index finger, wrist, and thumb (3/18 each). The little and ring finger were least commonly affected with one case each. The mean size of the tumour was 2.4cm (0.5-5cm). None of the patients reported recurrence of the lesion on an average follow-up of 18.8months. GCTTS is a benign, slowly growing lesion of the hand that typically does not cause any symptoms and is treated with surgical resection. Meticulous excision of the GCTTS using magnification loupes to ensure appropriate wide excision of the tumour is the treatment of choice to prevent a recurrence. In addition, a radiographic and histopathological examination must be performed on the tumour to rule out other diagnoses. Finally, the function of the hand should be reconstructed to minimize the loss of any functional unit.

Wide-Awake Local Anesthesia No Tourniquet for Rhizarthrosis Surgery: Technique and Experience for 16 Consecutive Cases.

Since it was described, wide-awake local anaesthesia no tourniquet (WALANT) has gainedpopularity. Our department has started using WALANT for hand surgery with increasing complexity.We present our results with WALANT rhizarthrosis surgery, including prosthetic replacement, trapeziectomy with suture button suspensionplasty and revision surgery. Aretrospective review of all rhizarthrosis procedures underWALANT was performed from April 2021 to July 2022. We included patients who fulfilled inclusioncriteria and had adequate imaging and clinical follow-up. A satisfaction survey was performed by telephone. Surgical time, complications, conversion to conventional anesthesia, pain, anxiety and global satisfaction were recorded. Tumescent anesthesia is performed 20-25 minutes before surgery, and isperformed in four or five strategic locationsthat allow adequate anesthesia and vasoconstriction for the procedure to be comfortably carried out. We observed a series of 16 sequential surgeries involving 14 patients. All were female with a mean age of 65 years. Fourteen cases were performed due to primary rhizarthrosis, eight trapeziectomies with suture button suspensionplasty, six prosthetic replacements, and two revision surgeries.One patient needed to be converted to conventional anaesthesia due to anxiety during the procedure. Mean procedure time was 73 minutes.There were no WALANT-related complications.Mean patient-reported satisfaction with the anesthetic technique was a 9 (on a scale from 1 to 10) and 100% of patients would choose to undergo surgery with WALANT anesthesia for a future procedure.We find it useful to actively engage the patients during surgery to keep them comfortable and also help the surgeons assess stability and functional results.After wound closure, the hand is shown to the patient and he performs various tasks.There is somewhat of a learning curve for rhizarthrosis surgery under WALANT; patient comfort can be achieved through an adequate anesthetic technique and reassurance before and during surgery. We recommend that the first few cases be done in the presence of an anesthesiologist and a fasting patient in case there is a need to convert to conventional anesthesia. Wide awake rhizarthrosis surgery,even revision surgery, is safe and pain-free. Patient-reported satisfaction is also high. The authorsfind that including patient participation in their own surgery might be promising for post-op rehabilitation. There are limitations in this study such as the absence of a control conventional anesthesia group, the satisfaction questionnaire was not done immediately post-operatively, as such, a memory bias cannot be excluded, and it is not yet validated for the Portuguese population.

Wide-awake local anesthesia and no tourniquet (WALANT) in upper limb fractures.

Wide-awake local anesthesia and no tourniquet (WALANT), first used for hand surgery, has been sparingly described for use in fracture fixation of the upper limb. We present our experience using this technique. 26 patients with upper limb fractures (3 distal radius, 6 radial shaft, 11 ulnar shaft, and 6 olecranon fractures) were operated on using WALANT by three orthopedic surgeons. We used 35-40ml of 2% Lignocaine with 1:80000 Adrenaline(7mg/kg) diluted with normal saline. Numeric Pain Rating (NPR) scoring was done during injection and per-operatively, and the Likert scale was used for the surgeon's satisfaction. The average NPR score was reported as 0.65 (1-3) during injection and 0.15 (0-2) preoperatively. All three surgeons reported excellent satisfaction in all the cases operated on. No complication occurred due to anesthesia. WALANT is a much simpler option and can be safely used in place of general anesthesia or regional blocks for fixation of fractures of the upper limb, with added advantages of no need for a tourniquet and better intraoperative assessment of fracture fixation.

The Use of Wide-Awake Local Anesthesia No Tourniquet (WALANT) Technique for Distal Fibula Hardware Removal

Ankle fracture is one of the most common fractures that are mainly treated with open reduction and internal fixation. Wide-awake local anesthesia no tourniquet (WALANT) technique has been widely used for hand and wrist surgeries, this method has been scarcely utilized in ankle surgery. To the best of our knowledge, only one study has evaluated the safety and efficacy of the WALANT technique in distal fibula hardware removal surgeries. This study aimed to investigate the result of using the WALANT technique in distal fibula hardware removal surgery. From April 2020 until March 2021 randomized clinical trial was performed on 60 patients between the ages of 18 and 60 years in our educational orthopedic center. In group A, an anesthesiologist administered spinal anesthesia and in group B the WALANT technique was used for anesthesia. The results of the current study showed that the visual analog scale in group B a day after the surgery was significantly lower, in comparison to group A. The outcome of our study demonstrated lesser blood loss in patients operated under the WALANT. This finding could be related to the vasoconstrictive properties of epinephrine used in the WALANT solution. Our findings suggest that the WALANT technique application in the proper setting and appropriate patient selection could lead to reduced postoperative pain, minimal bleeding, and shorter admission time. Other advantages include the simplicity and safety of the technique, it is being time and cost-effective. Level of Evidence: Diagnostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Patient Experiences With Hand Surgery in the Office Versus Ambulatory Surgery Center.

Background In hand surgery, physicians are working to improve patient satisfaction by offering several minor procedures in the physician's office via the Wide-Awake Local Anesthesia No Tourniquet (WALANT) method.This study investigates the degree of patient satisfaction, out-of-pocket costs, peri- and postoperative pain, convenience, and comfort experienced with in-office hand procedures compared to ambulatory surgery center (ASC) procedures. Methods A 10-question survey consisting of a 10-point Likert scale of agreement and numerical questions was administered to patients treated with minor hand operations in the office and ASC settings in Florida, USA. The surgical procedures included are bony reconstruction, percutaneous pinning, open reduction internal fixation, closed fracture reduction, mass removal, endoscopic carpal tunnel release, Dupuytren's release/tendon repair, and trigger finger release. Procedures and patient demographics were assessed via chart review. Independent samples t-test was used to determine statistical associations with significance defined as p < 0.05. Results Patients reported a strong level of agreement in response to questions 1-3 and 6-8, indicating a high degree of convenience, comfort, and overall satisfaction with both in-office and ASC procedures. Positive metrics gauged in questions 1-3 and 6-8 averaged 9.64 ± 0.14 in the office setting and 9.62 ± 0.16 in the ASC setting.Questions 4 and 5 averaged 2.74 ± 0.29 in the office setting and 2.84 ± 4.12 in the ASC setting, indicating mild disagreement that the surgery or recovery period was painful. In-office patients reported taking 0.91 ± 2.80 days off work and ASC patients reported taking 12.43 ± 22.51 days off work following surgery (p = 0.0039). Respondents reported an out-of-pocket cost averaging $348 ± $943 in the office setting and $574 ± $1262 in the ASC setting, depending on insurance coverage (p = 0.3019). Conclusions Though costs and time off of work differed between the two groups due to the different procedures in either setting, patient satisfaction metrics were comparable. While patient satisfaction depends on the operating physician, these results demonstrate that patients treated in-office and in an ASC have similar levels of approval with their hand surgery care.

Case Series: Wide-Awake Local Anaesthesia Without Tourniquet (WALANT) for Camitz Transfer.

Background: Wide-Awake Local Anaesthesia Without Tourniquet (WALANT), with the benefit of simplicity and a low complication rate, is a well-recognised procedure in orthopaedic surgery. To date, there is no report using WALANT technique with the Camitz transfer procedure. The aim of this study is to determine the early outcomes of using WALANT for Camitz transfer and compare these with outcomes of similar procedures in literature. Methods: Between January 2012 and January 2018, all patients with severe carpal tunnel syndrome (CTS) with thenar muscle atrophy who underwent the Camitz transfer procedure as day surgery under the WALANT technique at the Thammasat University Hospital were included. With the WALANT technique, the 10 mL of prepared anaesthesia was injected into the area around the palmaris longus tendon from 5-cm proximal to the distal wrist crease to the distal palmar crease, while an additional 10 mL was injected from the radial side of the metacarpophalangeal joint of the thumb to the distal wrist crease before the operation. Upon completion of the operation, the patients' hand was placed in a thumb spica splint. Patient demographic data, visual analogue scale (VAS) during injection and during procedure, operative time, blood lost and complications were recorded. Results: Thirty-six patients (8 males and 28 females) were included. The average age of the patients was 65.9 (37-87) years old. The average VAS score during the anaesthetic injection was 6.22 (5-8). The average VAS pain score during the operation was 0.52 (0-3). The average operative time was 27.06 (17-47) minutes. The mean intraoperative blood loss was 3 (2.4-6.8) mL. All patients underwent the procedure without any complications. Conclusions: The WALANT technique is safe and can be used as alternative anaesthesia for the Camitz transfer. Level of Evidence: Level IV (Therapeutic).

A Comparison between the Use of Patient-worn Virtual Reality in Wound Care and Hand Surgery: How Does Virtual Reality Work?

Twenty-five wound care patients were randomly assigned to either a VR group or non-virtual reality (NVR) group, singly blinded. Pre-debridement, peri-debridement, and immediately postdebridement anxiety, fun, and pain scores were collected using a Likert scale (0 = least; 10 = most) from each group of patients. These measurements were compared among the VR versus NVR group in the setting of routine wound debridement procedures. The results are compared with our previously published data on patients who underwent wide awake local anesthesia no tourniquet (WALANT) hand surgery. The WALANT surgery patients using VR experienced significant reduction in anxiety and increase in fun compared with the NVR group. In the wound debridement group with VR, there was improved fun, but no statistically significant reduction in pain or anxiety when compared with the NVR group. The mean score for anxiety was higher for awake hand surgery than for wound debridement cases (3.3 versus 1.7, P = 0.004). VR seems to be more effective in higher anxiety settings, could VR work via a neurological mechanism akin to the Melzack and Wall gate control theory of pain? VR may act primarily on the anxiety axis, providing negative feedback via cortical pathways to the amygdala.

Evaluation of intraoperative bleeding in shoulder arthroscopy with preoperative injection of epinephrine saline: a retrospective comparative study.

Several studies report the positive effects of epinephrine saline irrigation in shoulder arthroscopy3,4,15,18,22,23. Cardiovascular adverse effects have been described1,2,5,6,7,9,19. The Wide Awake Local Anesthesia No Tourniquet (WALANT) limits bleeding13,16,24,25. The aim of this study is to evaluate the effects of epinephrine saline infiltrations of the shoulder on arthroscopic visual comfort. We carried out a retrospective comparative study composed of 2 groups. We included all patients admitted to the department for a rotator cuff surgery. Our exclusion criteria were any other surgical indication and patient refusal. The protocol consisted in making 3 preoperative shoulder infiltrations of 20 ml of epinephrine saline at 0.005 mg/mL. Injections were performed in all patients in group 1 and no specific treatment was performed in group 2 (control group). Data collection was performed the same way in both groups. The main judgment criterion was the evaluation of the surgeon's overall visual comfort using the Visual Analogue Scale (VAS) at the end of the procedure. We also evaluated the intraoperative discomfort related to bleeding every 15 minutes by an objective scale (the Visual Numeric Rating Scale VNRS), as well as the cumulative bleeding time, operating time, the quantity of irrigation fluid used, the blood pressure at the times of the bleeding, the mean blood pressure during the surgery and the presence of thromboembolic and cardiovascular adverse events. We included 30 patients in group 1 and 30 patients in the control group. The mean VAS value at the end of the intervention is significantly higher in group 1 than in the control group: VAS = 10 in group 1 versus VAS = 5 in group 2 (p<0.0001) (higher is better). We also observed a significant decrease in VNRS between the two groups: VNRS = 0.25 in group 1 versus VNRS = 1,00 in group 2 (p<0.0001) (lower is better). Bleeding time was significantly lower in patients in group 1 (1min 39s) compared to patients in group 2 (9min 57s) (p<0.0001). No significant difference was demonstrated concerning the operating times, the quantity of irrigation fluid used and the blood pressure data of the two groups. No adverse effects were observed. The infiltration of low doses of adrenaline as performed in WALANT procedures seems effective in improving visualization in arthroscopy by reducing the bleeding. It can be a simple, efficient, and cost-effective technique with no iatrogenic risk to improve the surgeon's comfort in arthroscopic procedures.

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...