Wide-Awake Local Anesthesia, No Tourniquet Surgery in the Philippines

The use of wide-awake local anesthesia, no tourniquet (WALANT) has been adapted by most hand surgeons in the Philippines. This is especially true for centers with a large volume of patients needing specialized care for the hand. The use of WALANT has enabled surgeons to do procedures on an outpatient basis, thus potentially creating cost-saving measures for patients and health care facilities. Aside from common outpatient procedures like carpal tunnel syndrome, trigger finger, and de Quervain tenosynovitis, open reduction internal fixation of hand fractures, acute tendon repairs, tendon transfers, and reconstructions have been performed under WALANT as outpatient procedures. The future of WALANT surgery in the Philippines is promising. Teaching WALANT to other areas of the country can counterbalance the large disproportion of hand surgeons to patients and the concentration of specialized care in urban areas. This will enable patients to receive surgical hand care without going to large urban centers. The use of wide-awake local anesthesia, no tourniquet (WALANT) has been adapted by most hand surgeons in the Philippines. This is especially true for centers with a large volume of patients needing specialized care for the hand. The use of WALANT has enabled surgeons to do procedures on an outpatient basis, thus potentially creating cost-saving measures for patients and health care facilities. Aside from common outpatient procedures like carpal tunnel syndrome, trigger finger, and de Quervain tenosynovitis, open reduction internal fixation of hand fractures, acute tendon repairs, tendon transfers, and reconstructions have been performed under WALANT as outpatient procedures. The future of WALANT surgery in the Philippines is promising. Teaching WALANT to other areas of the country can counterbalance the large disproportion of hand surgeons to patients and the concentration of specialized care in urban areas. This will enable patients to receive surgical hand care without going to large urban centers. The use of local anesthesia in hand surgery is not new, and this is usually performed with the tourniquet for procedures lasting not more than an hour. In most urban centers, these are performed in operating rooms inside hospitals as outpatient surgeries, smaller surgicenters, or surgical centers. The wide-awake local anesthesia no tourniquet (WALANT) has gained much attention in recent years because of its effectiveness, safety, cost, and patient satisfaction. 1Kurtzman J.S. Etcheson J.I. Koehler S.M. Wide-awake local anesthesia with no tourniquet: an updated review.Plast Reconstr Surg Glob Open. 2021; 9e3507Crossref Scopus (26) Google Scholar The WALANT technique uses a combination of lidocaine and epinephrine to establish hemostasis and local anesthesia without the use of a tourniquet with the patient awake. There are many published studies on the usefulness of WALANT in hand surgery procedures. 2Abdullah S. Chia Hua L. Sheau Yun L. et al.A review of 1073 cases of wide-awake-local-anaesthesia-no-tourniquet (walant) in finger and hand surgeries in an urban hospital in Malaysia.Cureus. 2021; 13e16269Google Scholar, 3Rhee P.C. Fischer M.M. Rhee L.S. McMillan H. Johnson A.E. 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: e139-e147Abstract Full Text Full Text PDF PubMed Scopus (107) Google Scholar, 4Pina M. Cusano A. LeVasseur M.R. Olivieri-Ortiz R. Ferreira J. Parrino A. Wide awake local anesthesia no tourniquet technique in hand surgery: the patient experience.Hand (N Y). 2021; 15589447211058838Crossref PubMed Scopus (1) Google Scholar, 5Pires Neto P.J. Ribak S. Sardenberg T. Wide awake hand surgery under local anesthesia no tourniquet in South America.Hand Clin. 2019; 35: 51-58Abstract Full Text Full Text PDF PubMed Scopus (12) Google Scholar, 6Alves R.S. Consoni D.A.P. Fernandes P.H.O. et al.Benefits of the WALANT technique against the COVID-19 pandemic.Acta Ortop Bras. 2021; 29: 274-276Crossref PubMed Scopus (3) Google Scholar, 7Woo S.H. Yoo M.J. Ahn H.C. Lessons learned in the authors' first years of wide-awake hand surgery at the W Hospital in Korea.Hand Clin. 2019; 35: 59-66Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar Although the technique has been quite popular in other countries, in the Philippines, this technique gained traction after Dr Don Lalonde gave a talk on WALANT during the 11th Asian Pacific Federation of Societies for Hand Surgery 2017 in Cebu, Philippines.8Estrella E.P. Orillaza Jr., N.S. Report on the 11th Asian Pacific Federation of Societies for Surgery of the Hand (APFSSH).J Hand Surg Asian Pac Vol. 2018; 23: 306-312Crossref PubMed Scopus (1) Google Scholar A session was dedicated to tendon surgeries using WALANT ranging from primary repairs to tendon transfers to tenolysis. Since then, more local surgeons in the Philippines have been using WALANT, especially for day surgeries like carpal tunnel, trigger finger, de Quervain disease, and excision of benign tumors of the hand and upper extremity. The use of WALANT surgery is prevalent among hand surgeons. A pilot study on this was recently reported by Magtoto and Alagar9Castro Magtoto I.J. Alagar D.L. Wide awake local anesthesia no tourniquet: a pilot study for carpal tunnel release in the Philippine Orthopedic Center.J Hand Surg Asian Pac Vol. 2019; 24: 389-391Crossref PubMed Scopus (3) Google Scholar on their experience at a local government hospital on carpal tunnel syndrome. Although in their report, none were bloodless nor had too much bleeding, no complications were noted, and the pain was very well controlled in their 13 patients. The hesitancy in using epinephrine in hand surgery is because of the fear of finger necrosis. In a recent review, there have been several case reports of using 1% lidocaine with 1:100,000 epinephrine associated with digital necrosis.1Kurtzman J.S. Etcheson J.I. Koehler S.M. Wide-awake local anesthesia with no tourniquet: an updated review.Plast Reconstr Surg Glob Open. 2021; 9e3507Crossref Scopus (26) Google Scholar In an extensive literature review in 2001 by Denkler,10Denkler K. A comprehensive review of epinephrine in the finger: to do or not to do.Plast Reconstr Surg. 2001; 108: 114-124Crossref PubMed Scopus (189) Google Scholar of the 48 cases of digital gangrene and necrosis after local anesthesia, only 21 cases involved the use of epinephrine, and only 4 were in which the concentration was recorded. In a multicenter prospective study of 3,100 cases of hand and finger procedures using epinephrine, Lalonde et al11Lalonde D. Bell M. Benoit P. Sparkes G. Denkler K. Chang P. A multicenter prospective study of 3,110 consecutive cases of elective epinephrine use in the fingers and hand: the Dalhousie Project clinical phase.J Hand Surg Am. 2005; 30: 1061-1067Abstract Full Text Full Text PDF PubMed Scopus (246) Google Scholar reported no incidence of phentolamine rescue or digital necrosis. As of 2022, the Association of Hand Surgeons of the Philippines (AHSP) has 43 members, mostly concentrated in urban centers and Metro Manila, the capital of the country. These hand surgeons are distributed among various private and government hospitals. Traditionally, most procedures are done on the wrist and hand, and some fingers are under general anesthesia, regional block with or without sedation. Until recently, there has been an increasing trend in the use of WALANT in various bone and soft-tissue surgeries of the hand and upper extremity. The administration of WALANT in the Philippines is usually performed by surgeons, unlike in South Korea, where it is administered by an anesthetist.7Woo S.H. Yoo M.J. Ahn H.C. Lessons learned in the authors' first years of wide-awake hand surgery at the W Hospital in Korea.Hand Clin. 2019; 35: 59-66Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar In a survey among members of the AHSP, 23 responded that they do WALANT on their cases, and 5 declared that they do not use WALANT, with 2 saying that they use it sometimes. The most common soft-tissue procedures are open carpal tunnel, trigger finger, and de Quervain’s releases, including excision of benign tumors and tumor-like lesions. For bone procedures, phalangeal and metacarpal fixations are the most common. Also, some have used WALANT on certain acute scaphoid percutaneous screw fixations. Flexor tendon repairs are usually done with the patient under general anesthesia, and the strength of the repair was gauged by the passive extension of the digits after repair. Tension was usually evaluated with the tenodesis effect and observation of the finger cascade. Since WALANT has been adapted, intraoperative, real-time assessment of the tendon repair is immediately known, catching the repair site at the pulleys. Because of this, venting of the pulleys can be done immediately if needed. The traditional way of creating a window in the wrist and pulling the repaired tendon to check if it will catch on the pulley is no longer warranted. Active finger flexion can be done to check any catching and gap formation of the repair. This way, the surgeon will be more confident in the repair as the patient undergoes hand rehabilitation posttendon repair. Patient 1 is the case of a 26-year-old woman with a laceration in zone II of the flexor digitorum profundus of the right little finger (dominant hand) while opening a can. We use 1:100,000 epinephrine with 1% lidocaine. In flexor tendon injuries zone II, we injected 10 cc: 5 cc at the A1 pulley area, 2 cc each at the proximal and middle phalanx, and 1 cc at the pulp if needed. In this case, a total of only 8 cc was needed because the finger was small and we did not inject any more at the pulp area. We used a 4-0 nylon suture, and the tendon repair technique that was used was a 4-core cruciate repair with a 6-0 nylon epitendinous continuous suture for the flexor digitorum profundus and a modified Kessler for the FDS. We only repaired the ulnar slip of the FDS as we judged that repairing both will have problems in tendon gliding after surgery because of the bulkiness of the 2 repaired FDS tendons. Intraoperative observation of the repair was possible during active flexion (Fig. 1A, B). After surgery, the hand is immobilized at 20º of wrist flexion, 60º–70º metacarpophalangeal joint flexion, and neutral interphalangeal joints. We do not have a tenodesis orthosis, so we start early range of motion within 1 week with active midrange motion after days 3–4. A partial fist was achieved with approximately 45º of active flexion of the metacarpophalangeal and interphalangeal joints with active extension within the confines of the orthosis. Passive flexion of the digits was continued for the pulp to reach the palm. Some surgeons use the Modified Duran exercise program. Orthosis removal was performed at 6 weeks, with night orthosis fabrication for an additional 1 week. Then buddy taping was performed to the adjacent digit. Slight flexion contracture of the proximal interphalangeal joint was observed at the 6-month follow-up, but otherwise, there was a good range of motion for the right little finger (Fig. 1C, D). Injuries to the extensor tendons are usually because of trauma and closed ruptures from rheumatoid arthritis. One of the concerns in extensor tendon repair or reconstruction is doing the proper tensioning. On the days when the patient is sedated or under general anesthesia, the only way to determine proper tensioning after zone VI extensor tendon repair or transfer is by doing the tenodesis test and observing the cascade of the fingers as the wrist is flexed and extended. With the WALANT technique, the strength and tension of the repair during the actual movement of the digits are tested intraoperatively. Patient 2 is a right-handed 35-year-old female surgeon who consulted 1 month after sustaining a laceration on extensor zone V of the right ring finger. The extension lag of the ring finger was bothering her (Fig. 2). A total of 20 cc lidocaine-epinephrine at 1:100,000 was injected along the planned incision. The intraoperative repair with a range of motion with a recent follow-up after 3 years (Video 1, available on the Journal’s website at www.jhsgo.org) showed a better ring finger extension. In treating fractures of the hand, especially metacarpal and phalangeal fractures, the stability of the fixation is important to facilitate early rehabilitation and avoid joint stiffness. Patient 3 is a 16-year-old man with a 2-week history of a fracture of the fifth metacarpal shaft of the left hand with scissoring on physical examination (Fig. 3A, B). A total of 30 cc of lidocaine-epinephrine was administered at a 1:100,000 ratio before surgery along the planned incision until tumescence was achieved. After 30 minutes, the incision was made. An additional 10 cc intraoperatively was administered: 2 cc over bone, 4 cc at the dorsal, and 4 cc at the volar area during exposure of the fracture. Intraoperative stability with the correction of malrotation was confirmed after plate fixation and immediate movement was commenced with good fracture healing at 1 year (Fig. 3C, D). Patient 4 sustained a fracture of the second metacarpal that was fixed with interfragment screws. A total of 20 cc tumescent anesthesia at 1:100,000, lidocaine-epinephrine was injected at the incision site. The incision was done after 30 minutes. Video 2 (available on the Journal’s website at www.jhsgo.org) shows the intraoperative assessment of fixation stability with a good outcome at 3 months. Tendon transfers for hand function continue to challenge hand surgeons, especially in setting appropriate tension for the transfer. One of the most common transfers performed in hand surgery is the extensor indicis propius (EIP) transfer for thumb extension.12Lalonde D.H. Wide-awake extensor indicis proprius to extensor pollicis longus tendon transfer.J Hand Surg Am. 2014; 39: 2297-2299Abstract Full Text Full Text PDF PubMed Scopus (27) Google Scholar,13Bezuhly M. Sparkes G.L. Higgins A. Neumeister M.W. Lalonde D.H. Immediate thumb extension following extensor indicis proprius-to-extensor pollicis longus tendon transfer using the wide-awake approach.Plast Reconstr Surg. 2007; 119: 1507-1512Crossref PubMed Scopus (73) Google Scholar Previous tendon transfers are usually performed with the patient under general anesthesia and tension is usually set “slightly tighter” because this was thought to be better than a loose transfer. Tenodesis testing is usually the conventional way to assess appropriate tensioning in tendon transfer in an asleep patient. Patient 5 is a 36-year-old seaman who sustained a 3-month-old laceration on the dorsum of his hand (thumb zone IV) with an inability to extend his right thumb. We did an EIP to extensor pollicis longus (EPL) transfer. A total of 25 cc of 1% lidocaine with 1:100,000 epinephrine was injected to provide tumescence at the surgical site. The tendon ends of the EPL and harvested EIP were identified (Fig. 4A, B). Side-to-side mattress temporary sutures were done before testing the wrist and thumb in a neutral position. We usually place a rolled towel in the first web space to keep the thumb and wrist in a neutral position. We did intraoperative testing of thumb extension with the patient while the patient was looking at his hand (Video 3, available on the Journal’s website at www.jhsgo.org). The patient was asked to touch the tip of the little finger with the thumb and to make a ‘thumbs up’ sign. Once with good tension, we did a Pulvertaft weave for the EIP to EPL transfer with the wrist in neutral. We found that it is easier for the patient to move his repaired tendon when he saw his hand move. This was also true for all primary tendon repairs. He performed immediate motion within 1 week within the protective orthosis with the wrist in neutral. At 3 weeks after surgery, the orthosis was maintained in between exercises, and simultaneous index finger and thumb extension was encouraged without the orthosis. At this stage, gradual flexion of the thumb was also started. The orthosis was then removed totally 6 weeks after surgery. His follow-up at 3 months showed good thumb extension (Fig. 4C, D). The diagnosis of extensor carpi ulnaris (ECU) subluxation can be challenging. Once confirmed, a trial of orthosis fabrication with the wrist in pronation, radial deviation, and extension with the elbow flexed will usually work in most cases. However, ECU instability not responsive to nonsurgical treatment may need surgery to reconstruct the ECU subsheath. Patient 6 is a 25-year-old man diagnosed with an ECU instability and magnetic resonance image showed a “perched” ECU (red circle) that did not reduce on pronation and supination (Fig. 5) and was dislocating clinically (Video 4, available on the Journal’s website at www.jhsgo.org). He underwent surgical reconstruction of the ECU subsheath after a trial of nonsurgical treatment for 5 weeks. We used the WALANT technique to reconstruct the subsheath. We injected 40 cc of 1:100,000 1% lidocaine and epinephrine and waited for 30 minutes before the surgical incision. The injection was done over the planned incision at the ulnar border of the wrist along the ECU. Intraoperative movement showed “snapping” ECU on wrist flexion-extension. We used 2 anchor sutures to stabilize the attenuated ECU subsheath to keep the ECU within the groove. The intraoperative stability of the ECU after reconstruction was evaluated when there was no tendon subluxation on active movements of the wrist (Video 4). The patient’s elbow was immobilized in a cast with the elbow in 90º flexion, forearm pronated 90º, and the wrist at a slight radial deviation with neutral flexion-extension for 6 weeks. Four months postsurgery showed no recurrence of subluxation with ECU stability. The concept of WALANT has made more hand surgeons confident in assessing the strength of repair of a tendon or stability of bone fixation. This has to more outpatient surgeries and an in the of patients. Patient from using a tourniquet in common procedures can be In some while for the in the outpatient can be administered in This is especially true in government or large centers where patient volume is and of patients or can facilitate patient Tendon repairs and bone fixations of the hand can be done under local anesthesia, and the patient can be after the procedures, as tendon transfers, can be performed under local anesthesia, and patients can be after the This will the of general anesthesia for the patient. This effect has to be on a in the Philippine health care Hospital may need to be and modified to savings when using to surgical care to many areas in the Philippines. A recent study showed of mostly on the where most hospitals are and the Orillaza N.S. Philippine Orthopedic of and 2021; 2 Scholar The is to the in need of for surgical procedures are in the urban Although are concentrated in centers, specialized care may be made by surgical a of The of a of the Philippines Scholar However, the to their procedures. will need and from the government and private surgical may to in centers as as they can their procedures and As for who for health patients are to will be in of the set by the Philippine or Although is in effect in government centers, it is not and the common surgical procedures. At the is in place that of that may the cost, like or or day and of of the Philippines, Philippine on and Scholar this, procedures performed as under anesthesia are to day surgery with to the available from the The increasing use of WALANT has enabled many procedures with to no from patients and the of hospital in the hospital for surgical procedures, the of and the of the were outpatient surgical procedures with WALANT have gained among hand surgeons. tendon repairs and transfers, for can be done using WALANT and as outpatient procedures. in the traditional use of WALANT were by some hand surgeons. Some surgeons the from 30 minutes to minutes as as tumescence was especially in open carpal tunnel use intraoperative to the fracture site during bone fixation procedures. The WALANT technique in hand and upper surgery to among hand surgeons, with approximately of the members using the WALANT technique with some it to bone fixations and tendon among the in using WALANT, especially for procedures like open carpal tunnel releases, trigger finger releases, and first is the fear of digital the during the surgery, and hesitancy of some patients to be awake during surgery tendon repairs or bone The local hand (AHSP) has been the use of WALANT in hand surgery to these has on its safety, cost, and if not than traditional anesthesia for the procedures. The on WALANT surgery was not only to hand surgeons. In the Philippines, most general hand surgeons and with other do procedures on the hand, like carpal tunnel, trigger finger releases, and de Quervain Some surgeons are forearm fractures under We that more hand surgeons in the Philippines will use the WALANT technique in the In with of hand surgeons and some general surgeons in the Philippines using WALANT for hand surgeries, WALANT surgery patient and to the The future of WALANT surgery in the Philippines is and will to the of hand surgery all the not in urban centers. The like to and Alagar for on WALANT surgery for fractures of the hand. with Video with Video with Video with Video 4

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