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Wide-Awake Hand Surgery Has Its Benefits: A Study of 1,011 Patients

Open AccessPublished:June 17, 2022DOI:https://doi.org/10.1016/j.jhsg.2022.05.008

      Purpose

      Wide-awake local anesthesia with no tourniquet has dramatically changed hand surgery practice. Using lidocaine with epinephrine and no tourniquet has allowed many procedures to be moved from the main operating room to an in-office procedure room. Previous studies have shown that using local anesthesia is safe and cost effective, with high patient satisfaction. This study evaluated patient satisfaction and complications for the first 1,011 elective hand surgeries performed using wide-awake anesthesia in an in-office procedure room.

      Methods

      The first 1,011 patients who underwent elective hand surgery in an in-office procedure room were surveyed regarding their satisfaction. The patients were monitored for postoperative complications. Patient survey results and complications were logged in a database and analyzed.

      Results

      Single-digit trigger finger release was the most common procedure performed (n = 582), followed by mass excision (n = 158), multiple-digit trigger finger releases (n = 109), and carpal tunnel release (n = 41). There were 43 (4.3%) superficial skin infections, with the majority seen in single-digit trigger finger releases (n = 27). There were no deep wound infections. All infections were managed nonsurgically with oral antibiotics and local wound care. Ninety-nine percent of the patients rated the in-office procedure room experience as the same as or better than a dental visit, would recommend wide-awake anesthesia to a friend or family member, and would undergo the procedure again. Using “lean and green” hand packs saved our institution more than $65,000 and saved 18.4 tons of waste during this study period.

      Conclusions

      Surgical procedures performed with wide-awake local anesthesia with no tourniquet in an in-office procedure room can be performed safely with a low infection rate, are cost effective, and have high patient satisfaction.

      Clinical relevance

      Minor hand surgery done in an in-office procedure room is safe, is cost effective, and has high patient satisfaction.

      Key words

      Wide-awake local anesthesia with no tourniquet (WALANT) procedures have allowed hand surgery to move out of the operating room and into minor procedure rooms, revolutionizing the practice of hand surgery.
      • Lalonde D.H.
      • Wong A.
      Dosage of local anesthesia in wide awake hand surgery.
      • Rhee 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.
      • Davison P.G.
      • Cobb T.
      • Lalonde D.H.
      The patient’s perspective on carpal tunnel surgery related to the type of anesthesia: a prospective cohort study.
      • Lalonde D.
      • Martin A.
      Epinephrine in local anesthesia in finger and hand surgery: the case for wide-awake anesthesia.
      • Lalonde D.H.
      Conceptual origins, current practice, and views of wide awake hand surgery.
      • Lalonde D.
      Minimally invasive anesthesia in wide awake hand surgery.
      • Lalonde D.
      • Martin A.
      Tumescent local anesthesia for hand surgery: improved results, cost effectiveness, and wide-awake patient satisfaction.
      This is beneficial for both hospitals and patients. It offloads demand for operating rooms and decreases cost by eliminating the need for anesthesia monitoring, an operating room, and postanesthesia care.
      • Lalonde D.
      Minimally invasive anesthesia in wide awake hand surgery.
      It saves the patient time and money by eliminating the need for a preoperative evaluation and time off work.
      • Greenfield P.T.
      • Spencer C.C.
      • Dawes A.
      • Wagner E.R.
      • Gottschalk M.B.
      • Daly C.A.
      The preoperative cost of carpal tunnel syndrome. J Hand Surg Am.
      Additionally, there are cost savings associated with the decreased need for surgical drapes, equipment, and hospital staffing.
      • Rhee 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.
      • Davison P.G.
      • Cobb T.
      • Lalonde D.H.
      The patient’s perspective on carpal tunnel surgery related to the type of anesthesia: a prospective cohort study.
      • Lalonde D.
      • Martin A.
      Epinephrine in local anesthesia in finger and hand surgery: the case for wide-awake anesthesia.
      • Lalonde D.H.
      Conceptual origins, current practice, and views of wide awake hand surgery.
      • Lalonde D.
      Minimally invasive anesthesia in wide awake hand surgery.
      • Lalonde D.
      • Martin A.
      Tumescent local anesthesia for hand surgery: improved results, cost effectiveness, and wide-awake patient satisfaction.
      • Greenfield P.T.
      • Spencer C.C.
      • Dawes A.
      • Wagner E.R.
      • Gottschalk M.B.
      • Daly C.A.
      The preoperative cost of carpal tunnel syndrome. J Hand Surg Am.
      • Farkash U.
      • Herman A.
      • Kalimian T.
      • Segal O.
      • Cohen A.
      • Laish-Farkash A.
      Keeping the finger on the pulse: cardiac arrhythmias in hand surgery using local anesthesia with adrenaline.
      • Tang J.B.
      Local anesthesia without tourniquet in hand and forearm surgery: my story of using and promoting it.
      • Maliha S.G.
      • Cohen O.
      • Jacoby A.
      • Sharma S.
      A cost and efficiency analysis of the WALANT technique for the management of trigger finger in a procedure room of a major city hospital.
      • Rabinowitz J.
      • Kelly T.
      • Peterson A.
      • Angermeier E.
      • Kokko K.
      In-office wide-awake hand surgery versus traditional surgery in the operating room: a comparison of clinical outcomes and healthcare costs at an academic institution.
      • Look N.
      • Lalka A.
      • Korrell H.
      • Kabrick K.
      • Wheeler A.
      • Bolson R.
      Outcomes of orthopedic hand surgeries in minor procedure rooms at a Veterans Affairs Medical Center.
      • Stephens A.R.
      • Presson A.P.
      • Jo Y.J.
      • et al.
      Evaluating the safety of the hand surgery procedure room: a single-center cohort of 1,404 surgical encounters.
      • Yu J.
      • Ji T.A.
      • Craig M.
      • McKee D.
      • Lalonde D.H.
      Evidence-based sterility: the evolving role of field sterility in skin and minor hand surgery.
      • Van Demark R.E.
      • Smith V.J.S.
      • Fiegen A.
      Lean and green hand surgery.
      • Choukairi F.
      • Ibrahim I.
      • N A Murphy R.
      • et al.
      Development of the Manchester wide-awake hand trauma service in 2020: the patient experience.
      • Steiner M.M.
      • Calandruccio J.H.
      Use of wide-awake local anesthesia no tourniquet in hand and wrist surgery.
      • White M.
      • Parikh H.R.
      • Wise K.L.
      • Vang S.
      • Ward C.M.
      • Cunningham B.P.
      Cost savings of carpal tunnel release performed in-clinic compared to an ambulatory surgery center: time-driven activity-based-costing.
      • de Boccard O.
      • Müller C.
      • Christen T.
      Economic impact of anaesthesia methods used in hand surgery: global costs and operating room’s throughput.
      • Codding J.L.
      • Bhat S.B.
      • Ilyas A.M.
      An economic analysis of MAC versus WALANT: a trigger finger release surgery case study.
      • Chatterjee A.
      • McCarthy J.E.
      • Montagne S.A.
      • Leong K.
      • Kerrigan C.L.
      A cost, profit, and efficiency analysis of performing carpal tunnel surgery in the operating room versus the clinic setting in the United States.
      • Kazmers N.H.
      • Presson A.P.
      • Xu Y.
      • Howenstein A.
      • Tyser A.R.
      Cost implications of varying the surgical technique, surgical setting, and anesthesia type for carpal tunnel release surgery.
      • LaBove G.
      • Davison S.P.
      Cost analysis of an office-based surgical suite.
      • Carr L.W.
      • Morrow B.
      • Michelotti B.
      • Hauck R.M.
      Direct cost comparison of open carpal tunnel release in different venues.
      • Nguyen C.
      • Milstein A.
      • Hernandez-Boussard T.
      • Curtin C.M.
      The effect of moving carpal tunnel releases out of hospitals on reducing United States health care charges.
      • Warrender W.J.
      • Lucasti C.J.
      • Ilyas A.M.
      Wide-awake hand surgery: principles and techniques.
      • Alter T.H.
      • Warrender W.J.
      • Liss F.E.
      • Ilyas A.M.
      A cost analysis of carpal tunnel release surgery performed wide awake versus under sedation.
      • LeBlanc M.R.
      • Lalonde D.H.
      • Thoma A.
      • et al.
      Is main operating room sterility really necessary in carpal tunnel surgery? A multicenter prospective study of minor procedure room field sterility surgery.
      There is also a decrease in the waste generated by these procedures, as they are typically done under minor field sterility, which consists of sterile prep, a single drape, a minor instrument tray, sterile gloves and a mask (no gown or antibiotics), and local anesthesia.
      • Van Demark R.E.
      • Smith V.J.S.
      • Fiegen A.
      Lean and green hand surgery.
      ,
      • LeBlanc M.R.
      • Lalonde D.H.
      • Thoma A.
      • et al.
      Is main operating room sterility really necessary in carpal tunnel surgery? A multicenter prospective study of minor procedure room field sterility surgery.
      Previous studies regarding WALANT have been conducted at military hospitals, large academic institutions, or in foreign countries. Those studies have shown the technique is safe, with high patient satisfaction. The purpose of this study in a United States’ community–based in-office procedure room was 2-fold: (1) to evaluate patient satisfaction with surgery done in a procedure room; and (2) to evaluate postoperative complications after procedures done in procedure rooms. To measure patient satisfaction and infection rates, all patients who underwent a procedure in our in-office procedure room from its inception in 2015 through 2020 were surveyed, and their charts were reviewed for infection. The hypothesis of our study was that patients would be highly satisfied and have an infection rate comparable to those of previous studies done in in-office procedure rooms.

      Materials and Methods

      Sanford Health Institutional Review Board approval was not obtained, as it was deemed unnecessary by our institution because of the deidentified data already stored in the RedCap database. Using Current Procedural Terminology codes (64721, 26055, 20670, 26951, 11760, 25000, 10120, 26121, 26115, 26111, 26160, and 26011) and a premade database, a retrospective review was performed on the first 1,011 patients who underwent WALANT surgery in our in-office procedure room. All patients, regardless of age or medical comorbidities, who were seen in our practice and indicated for minor hand or wrist surgery, were offered the option of having their outpatient hand surgery performed in an in-office procedure room. There were only 2 contraindications to wide-awake surgery using lidocaine with epinephrine: a history of vasospastic disease (Raynaud) or fixed-vessel disease, such as calciphylaxis (calcific uremic arteriolopathy).
      • Zhang J.X.
      • Gray J.
      • Lalonde D.H.
      • Carr N.
      Digital necrosis after lidocaine and epinephrine injection in the flexor tendon sheath without phentolamine rescue.
      We had no patients who fit these criteria, so none were excluded. No preoperative laboratory or medical examinations were performed. Procedures were performed using minor field sterility, by 1 of 3 fellowship-trained orthopedic hand surgeons (R.E.V., M.C.A., H.A.B.) between February 2015 and December 2020. Preoperative sedation was not ordered for patients having in-office procedures. If patients were too anxious or nervous to have an in-office procedure, they could choose to have surgery at the hospital under sedation.
      Using the local injection technique described by Lalonde and Wong,
      • Lalonde D.H.
      • Wong A.
      Dosage of local anesthesia in wide awake hand surgery.
      1% lidocaine with 1:100,000 epinephrine was injected in a clinic room approximately 25 minutes prior to moving the patient into our 23.2 square meters, in-office procedure room (Fig. 1). Patients remained in their street clothes, could eat before surgery, and could continue taking their medications, including oral anticoagulants. All procedures were performed under minor field sterility with minimal instrumentation (Fig 2). The extremities were prepped and draped using 1 drape that had a hole for the hand. No antibiotics were administered, and no cardiovascular monitoring was done. The surgical team consisted of a hand surgeon, surgical assistant, and nurse or medical assistant. Phentolamine was available if needed for digit ischemia.
      Figure thumbnail gr2
      Figure 2The in-office procedure room back table set-up. The instruments include 2 mosquito forceps, 2 towel forceps, 1 needle holder, 1 Mayo scissor, 1 bandage scissor, 2 Adson forceps, 4 Ragnell retractors, 1 scalpel knife handle, and 1 freer. Senn retractors are also available.
      Following surgery, patients were asked survey questions regarding their experience, using a questionnaire (Fig 3) modified from Rhee et al
      • Rhee 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.
      and Davison et al.
      • Davison P.G.
      • Cobb T.
      • Lalonde D.H.
      The patient’s perspective on carpal tunnel surgery related to the type of anesthesia: a prospective cohort study.
      If the questions were not asked at the time of surgery, the patients were called after surgery. The patients were called once and, if there was no reply, they were encouraged to call the clinic to participate.
      Figure thumbnail gr3
      Figure 3Patient satisfaction survey, modified from Rhee et al
      • Rhee 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.
      and Davison et al.
      • Davison P.G.
      • Cobb T.
      • Lalonde D.H.
      The patient’s perspective on carpal tunnel surgery related to the type of anesthesia: a prospective cohort study.
      Charts were reviewed for survey responses, and clinic notes from the patient’s first postoperative visit to their last follow-up were reviewed for any complications, including erythema, drainage, swelling, or other signs of infection after surgery. For most patients, the follow-up was about 6 weeks long. If patients had any of these signs or symptoms, they were counted as having an infection, and management of the infection was recorded. These were classified as either deep or superficial infections. Deep infections included flexor tenosynovitis, deep abscess, or wound dehiscence. Superficial infections included erythema around the incision or suture abscess. The primary outcome of our study was looking at all infections, both superficial and deep.

      Statistical methods

      Demographic information, including age and gender, along with the procedure type, number of procedures, survey responses, and infections were found in the RedCap database and pulled for the use of this study.

      Results

      Over the study period, 1,011 patients (337 men; 674 women; average age, 60.7 years; range, 15–93 years) underwent an in-office hand procedure. Most of the procedures were single-digit trigger finger releases (582 procedures), followed by mass removal (158 procedures), multiple-digit trigger finger releases (109 procedures), and carpal tunnel release (41 procedures; Table 1). One hundred and eighteen patients returned during the study period for a separate procedure.
      Table 1Patient Demographics, Procedure Types, and Infections for In-office Procedures From 2015–2020
      A mass was defined as any soft tissue tumor, mucous cyst, or ganglion cyst removal. Hardware removal was Kirschner wire removal. All carpal tunnel releases were done open.
      ProcedureOverallInfections
      2 × de Quervain10
      2 x Dupuytren10
      2 × mass30
      2 × trigger finger1098
      2 × trigger finger, mass10
      3 × trigger finger201
      4 × trigger finger20
      Revision amputation30
      Carpal tunnel410
      Carpal tunnel, 2 × trigger finger10
      Carpal tunnel, 3 × trigger finger10
      Carpal tunnel, trigger100
      De Quervain181
      De Quervain, trigger10
      Dupuytren60
      Foreign body removal100
      Hardware removal50
      Incision & drainage81
      Mass1583
      Nailbed141
      Nailbed, foreign body removal10
      Nailbed, mass10
      Scar revision40
      Tendon repair10
      Trigger finger58227
      Trigger finger, Dupuytren20
      Trigger finger, mass71
      Total1,01143
      Male337
      Female674
      Average age, y60.7
      A mass was defined as any soft tissue tumor, mucous cyst, or ganglion cyst removal. Hardware removal was Kirschner wire removal. All carpal tunnel releases were done open.
      There were no major complications in this group, as assessed from their first postoperative visit to their last recorded follow-up, which for most patients was 6 weeks. There were no hospital admissions noted. Superficial skin infections were the most common complication. There were 43 superficial infections (4.3%) in our study group, as assessed from the first postoperative visit through the last recorded follow-up. All infections were superficial, and were managed with oral antibiotics and local wound care. No secondary procedures for infections were done. There were no deep infections. There were 27 infections in the single-digit trigger finger group, 8 in the 2-digit trigger finger release group, and 3 in the mass removal group (Table 1). No patients required phentolamine rescue.
      The survey response rate was 91% (922 patients). Ninety-nine percent of patients said the experience was better than or the same as going to the dentist, they would recommend the procedure to a friend or family member, and they would do surgery with WALANT again (Table 2).
      Table 2Survey Responses
      Procedure Year201520162017201820192020Final
      Response %92%99%99%99%89%74%91%
      Survey responses:
      Better than the dentistn43106162185114133743
      %62%90%82%85%75%80%81%
      Same as the dentistn231135313931170
      %33%9%18%14%25%19%18%
      Worse than the dentistn3112029
      %4%1%1%1%0%1%1%
      Would recommend to friend/family membern68118198216151166917
      %99%100%100%99%99%100%99%
      Would not recommend to friend/family membern1002205
      %1%0%0%1%1%0%1%
      Would do another procedure under WALANTn68118198217152166919
      %99%100%100%100%99%100%100%
      Would not do another procedure under WALANTn1001103
      %1%0%0%0%1%0%0%
      Around the time of the inception of this project, “lean and green” hand packs were created at our institution to decrease surgical waste in minor field sterility procedures (Fig 2).
      • Van Demark R.E.
      • Smith V.J.S.
      • Fiegen A.
      Lean and green hand surgery.
      The cost of one of our “lean and green” hand packs is $37.46, compared with our traditional pack of $46.68. Only 1.80 kg of waste are created from the “lean and green” hand pack, compared with 4.09 kg of waste created from our traditional pack.
      • Van Demark R.E.
      • Smith V.J.S.
      • Fiegen A.
      Lean and green hand surgery.
      Our institution saved an estimated $64,542 and an estimated 16,692.2 kg in waste during this project.

      Discussion

      The overall goals of this study were to evaluate the safety of and patient satisfaction with WALANT surgery in an in-office procedure room in a community-based hospital. Sanford USD Medical Center serves a state with a population of <1,000,000 people. We are based in the largest city in the state and frequently have patients who drive from hours away to be seen. We were motivated to create an in-office procedure room to help these patients have easier access to medical care and to offload demand for our main operating rooms. Patients can drive themselves home, eat breakfast, take their medications, and minimize long travel days and time off work. It is more cost effective for the patient on a multitude of levels. Getting our hospital management on board was challenging but, with persistence and by showing the data, we were able to establish an in-office procedure room.
      In this patient cohort, we found a low infection rate and high patient satisfaction with WALANT. The ability to do hand surgery in procedure rooms is related to 2 factors: (1) the use of epinephrine in the hand; and (2) the concept of minor field sterility. Historically, surgeons were taught that local anesthesia with epinephrine should not be injected into fingers for fear of necrosis. This dogma has been disproven, as multiple studies have shown the safety of epinephrine in the hand and fingers.
      • Bruce A.M.
      • Spencer J.M.
      Surgical myths in dermatology.
      • Denkler K.
      A comprehensive review of epinephrine in the finger: to do or not to do.
      • Fitzcharles-Bowe C.
      • Denkler K.
      • Lalonde D.
      Finger injection with high-dose (1 : 1,000) epinephrine: does it cause finger necrosis and should it be treated?.
      • Schnabl S.M.
      • Ghoreschi F.C.
      • Scheu A.
      • Kofler L.
      • Häfner H.M.
      • Breuninger H.
      Use of local anesthetics with an epinephrine additive on fingers and penis – dogma and reality.
      • Thomson C.J.
      • Lalonde D.H.
      • Denkler K.A.
      • Feicht A.J.
      A critical look at the evidence for and against elective epinephrine use in the finger.
      • Lalonde D.H.
      Latest advances in wide awake hand surgery.
      Another breakthrough in hand surgery is the concept of field sterility.
      • LeBlanc M.R.
      • Lalonde D.H.
      • Thoma A.
      • et al.
      Is main operating room sterility really necessary in carpal tunnel surgery? A multicenter prospective study of minor procedure room field sterility surgery.
      Field sterility has allowed procedures to be done outside of a formal operating room, with a minimal amount of equipment needed and with similar infection rates to those of procedures performed in operating rooms. After the advent of WALANT, there were concerns about potential increases in infection rates in procedures done outside of the traditional operating room. This concern is unfounded. Procedures done in minor procedure rooms using field sterility have been shown to have similar infection rates as compared to those performed in operating rooms.
      • Rhee 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.
      ,
      • Tang J.B.
      Local anesthesia without tourniquet in hand and forearm surgery: my story of using and promoting it.
      • LeBlanc M.R.
      • Lalonde D.H.
      • Thoma A.
      • et al.
      Is main operating room sterility really necessary in carpal tunnel surgery? A multicenter prospective study of minor procedure room field sterility surgery.
      • Lalonde D.H.
      Latest advances in wide awake hand surgery.
      • Hanssen A.D.
      • Amadio P.C.
      • DeSilva S.P.
      • Ilstrup D.M.
      Deep postoperative wound infection after carpal tunnel release.
      • Ariyan S.
      • Watson H.K.
      The palmar approach for the visualization and release of the carpal tunnel. An analysis of 429 cases.
      • Halvorson A.J.
      • Sechriest V.F.
      • Gravely A.
      • DeVries A.S.
      Risk of surgical site infection after carpal tunnel release performed in an operating room versus a clinic-based procedure room within a Veterans Affairs Medical Center.
      A systematic review by Jagodzinski et al
      • Jagodzinski N.A.
      • Ibish S.
      • Furniss D.
      Surgical site infection after hand surgery outside the operating theatre: a systematic review.
      reviewed articles dealing with hand surgery done in a variety of locations, such as procedure rooms and minor operative suites, instead of the main hospital operating room. In 3 studies, there were no infections, and in 2 studies with a combined 1,962 carpal tunnel releases, the infection rate was 0.4%.
      • Jagodzinski N.A.
      • Ibish S.
      • Furniss D.
      Surgical site infection after hand surgery outside the operating theatre: a systematic review.
      Our findings confirm a low infection rate in our in-office procedure room; overall, we had an infection rate of 4.3%. It is interesting that many of our infections came from the trigger finger groups, with the single-digit trigger finger group having an infection rate of 4.6% and the 2-digit trigger finger group having an infection rate of 7.3%. This is perhaps due to the association of diabetes and trigger fingers, as well as the relatively small numbers (582 and 109 hands, respectively) in these groups. We did not exclude patients with comorbidities or recent steroid injections and did not collect these data, so it is difficult to say definitively whether these variables played a role or not.
      Recently, Stephens et al
      • Stephens A.R.
      • Presson A.P.
      • Jo Y.J.
      • et al.
      Evaluating the safety of the hand surgery procedure room: a single-center cohort of 1,404 surgical encounters.
      evaluated the safety of WALANT anesthesia in a procedure room. A group of 1,401 patients with 1,796 procedures were reviewed to look at the safety of a hand surgery procedure room. No patients were excluded based on American Society of Anesthesiologists’ scores or comorbidities. No patients were admitted to the hospital, and no procedures were stopped owing to patient intolerance or surgeon inability to complete the procedure. Minor complications included flexion contractures, infection, persistent symptoms, recurrence, numbness, or stiffness. There were 7 infections (0.6%) noted, and only 2 patients required operative debridement.
      In a recent review article of field sterility, Yu et al
      • Yu J.
      • Ji T.A.
      • Craig M.
      • McKee D.
      • Lalonde D.H.
      Evidence-based sterility: the evolving role of field sterility in skin and minor hand surgery.
      advocated for field sterility for all skin and hand procedures. They found no evidence to support the use of main operating room sterility guidelines (head covers, gowns, full patient draping, and laminar airflow) for minor procedures. They argued that the waste and the costs generated by main operating rooms are not justified for minor skin and hand procedures. When superficial infections occur, they can be easily treated, with minimal patient morbidity.
      • Yu J.
      • Ji T.A.
      • Craig M.
      • McKee D.
      • Lalonde D.H.
      Evidence-based sterility: the evolving role of field sterility in skin and minor hand surgery.
      The ability to minimize surgical waste with minor hand procedures has also been documented by other authors.
      • Lalonde D.
      Minimally invasive anesthesia in wide awake hand surgery.
      ,
      • Nguyen C.
      • Milstein A.
      • Hernandez-Boussard T.
      • Curtin C.M.
      The effect of moving carpal tunnel releases out of hospitals on reducing United States health care charges.
      ,
      • LeBlanc M.R.
      • Lalonde D.H.
      • Thoma A.
      • et al.
      Is main operating room sterility really necessary in carpal tunnel surgery? A multicenter prospective study of minor procedure room field sterility surgery.
      ,
      • Albert M.G.
      • Rothkopf D.M.
      Operating room waste reduction in plastic and hand surgery.
      ,
      • Thiel C.L.
      • Fiorin Carvalho R.
      • Hess L.
      • et al.
      Minimal custom pack design and wide-awake hand surgery: reducing waste and spending in the orthopedic operating room.
      Patients have been pleased with WALANT surgery done in procedure rooms. High patient satisfaction rates have been reported both in the United States and abroad.
      • Rhee 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.
      ,
      • Davison P.G.
      • Cobb T.
      • Lalonde D.H.
      The patient’s perspective on carpal tunnel surgery related to the type of anesthesia: a prospective cohort study.
      ,
      • Lalonde D.
      Minimally invasive anesthesia in wide awake hand surgery.
      ,
      • Lalonde D.
      • Martin A.
      Tumescent local anesthesia for hand surgery: improved results, cost effectiveness, and wide-awake patient satisfaction.
      ,
      • Tang J.B.
      Local anesthesia without tourniquet in hand and forearm surgery: my story of using and promoting it.
      ,
      • Rabinowitz J.
      • Kelly T.
      • Peterson A.
      • Angermeier E.
      • Kokko K.
      In-office wide-awake hand surgery versus traditional surgery in the operating room: a comparison of clinical outcomes and healthcare costs at an academic institution.
      ,
      • Stephens A.R.
      • Presson A.P.
      • Jo Y.J.
      • et al.
      Evaluating the safety of the hand surgery procedure room: a single-center cohort of 1,404 surgical encounters.
      ,
      • Carr L.W.
      • Morrow B.
      • Michelotti B.
      • Hauck R.M.
      Direct cost comparison of open carpal tunnel release in different venues.
      ,
      • Alves R.S.
      • Consoni D.A.P.
      • Fernandes P.H.O.
      • et al.
      Benefits of the WALANT technique against the COVID-19 pandemic.
      • Nolan G.S.
      • Kiely A.L.
      • Madura T.
      • Karantana A.
      Wide-awake local anaesthesia no tourniquet (WALANT) vs regional or general anaesthesia for flexor tendon repair in adults: protocol for a systematic review and meta-analysis.
      • Teo I.
      • Lam W.
      • Muthayya P.
      • Steele K.
      • Alexander S.
      • Miller G.
      Patients’ perspective of wide-awake hand surgery — 100 consecutive cases.
      • Evangelista T.M.P.
      • Pua J.H.C.
      • Evangelista-Huber M.T.P.
      Wide-awake local anesthesia no tourniquet (WALANT) versus local or intravenous regional anesthesia with tourniquet in atraumatic hand cases in orthopedics: a systematic review and meta-analysis.
      Our study found similar results, with 99% of patients rating their experience as better than or the same as going to the dentist. Ninety-nine percent of our patients would recommend wide-awake hand surgery to a friend or family member and would also do surgery while wide awake again if needed. One hundred and eighteen patients returned for another procedure in the procedure room during the study period. Although the survey used is not a validated outcome measure, patient satisfaction was high, and there was an overall positive perception of WALANT hand surgery.
      Moving minor hand surgery cases from the main operating rooms to procedure rooms results in dramatic cost savings. Procedure rooms are less expensive and more efficient.
      • Rhee 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.
      • Davison P.G.
      • Cobb T.
      • Lalonde D.H.
      The patient’s perspective on carpal tunnel surgery related to the type of anesthesia: a prospective cohort study.
      • Lalonde D.
      • Martin A.
      Epinephrine in local anesthesia in finger and hand surgery: the case for wide-awake anesthesia.
      • Lalonde D.H.
      Conceptual origins, current practice, and views of wide awake hand surgery.
      • Lalonde D.
      Minimally invasive anesthesia in wide awake hand surgery.
      • Lalonde D.
      • Martin A.
      Tumescent local anesthesia for hand surgery: improved results, cost effectiveness, and wide-awake patient satisfaction.
      • Greenfield P.T.
      • Spencer C.C.
      • Dawes A.
      • Wagner E.R.
      • Gottschalk M.B.
      • Daly C.A.
      The preoperative cost of carpal tunnel syndrome. J Hand Surg Am.
      • Farkash U.
      • Herman A.
      • Kalimian T.
      • Segal O.
      • Cohen A.
      • Laish-Farkash A.
      Keeping the finger on the pulse: cardiac arrhythmias in hand surgery using local anesthesia with adrenaline.
      • Tang J.B.
      Local anesthesia without tourniquet in hand and forearm surgery: my story of using and promoting it.
      • Maliha S.G.
      • Cohen O.
      • Jacoby A.
      • Sharma S.
      A cost and efficiency analysis of the WALANT technique for the management of trigger finger in a procedure room of a major city hospital.
      • Rabinowitz J.
      • Kelly T.
      • Peterson A.
      • Angermeier E.
      • Kokko K.
      In-office wide-awake hand surgery versus traditional surgery in the operating room: a comparison of clinical outcomes and healthcare costs at an academic institution.
      • Look N.
      • Lalka A.
      • Korrell H.
      • Kabrick K.
      • Wheeler A.
      • Bolson R.
      Outcomes of orthopedic hand surgeries in minor procedure rooms at a Veterans Affairs Medical Center.
      • Stephens A.R.
      • Presson A.P.
      • Jo Y.J.
      • et al.
      Evaluating the safety of the hand surgery procedure room: a single-center cohort of 1,404 surgical encounters.
      • Yu J.
      • Ji T.A.
      • Craig M.
      • McKee D.
      • Lalonde D.H.
      Evidence-based sterility: the evolving role of field sterility in skin and minor hand surgery.
      • Van Demark R.E.
      • Smith V.J.S.
      • Fiegen A.
      Lean and green hand surgery.
      • Choukairi F.
      • Ibrahim I.
      • N A Murphy R.
      • et al.
      Development of the Manchester wide-awake hand trauma service in 2020: the patient experience.
      • Steiner M.M.
      • Calandruccio J.H.
      Use of wide-awake local anesthesia no tourniquet in hand and wrist surgery.
      • White M.
      • Parikh H.R.
      • Wise K.L.
      • Vang S.
      • Ward C.M.
      • Cunningham B.P.
      Cost savings of carpal tunnel release performed in-clinic compared to an ambulatory surgery center: time-driven activity-based-costing.
      • de Boccard O.
      • Müller C.
      • Christen T.
      Economic impact of anaesthesia methods used in hand surgery: global costs and operating room’s throughput.
      • Codding J.L.
      • Bhat S.B.
      • Ilyas A.M.
      An economic analysis of MAC versus WALANT: a trigger finger release surgery case study.
      • Chatterjee A.
      • McCarthy J.E.
      • Montagne S.A.
      • Leong K.
      • Kerrigan C.L.
      A cost, profit, and efficiency analysis of performing carpal tunnel surgery in the operating room versus the clinic setting in the United States.
      • Kazmers N.H.
      • Presson A.P.
      • Xu Y.
      • Howenstein A.
      • Tyser A.R.
      Cost implications of varying the surgical technique, surgical setting, and anesthesia type for carpal tunnel release surgery.
      • LaBove G.
      • Davison S.P.
      Cost analysis of an office-based surgical suite.
      • Carr L.W.
      • Morrow B.
      • Michelotti B.
      • Hauck R.M.
      Direct cost comparison of open carpal tunnel release in different venues.
      • Nguyen C.
      • Milstein A.
      • Hernandez-Boussard T.
      • Curtin C.M.
      The effect of moving carpal tunnel releases out of hospitals on reducing United States health care charges.
      • Warrender W.J.
      • Lucasti C.J.
      • Ilyas A.M.
      Wide-awake hand surgery: principles and techniques.
      • Alter T.H.
      • Warrender W.J.
      • Liss F.E.
      • Ilyas A.M.
      A cost analysis of carpal tunnel release surgery performed wide awake versus under sedation.
      • LeBlanc M.R.
      • Lalonde D.H.
      • Thoma A.
      • et al.
      Is main operating room sterility really necessary in carpal tunnel surgery? A multicenter prospective study of minor procedure room field sterility surgery.
      The savings begin before the patient steps foot in the procedure room, with no need for preoperative laboratory testing and medical evaluations. In a study of preoperative carpal tunnel patients, Greenfield et al
      • Greenfield P.T.
      • Spencer C.C.
      • Dawes A.
      • Wagner E.R.
      • Gottschalk M.B.
      • Daly C.A.
      The preoperative cost of carpal tunnel syndrome. J Hand Surg Am.
      found a per-patient average cost of $858.74 was spent on preoperative work-ups and nonsurgical management of patients who underwent carpal tunnel release.
      Chatterjee et al
      • Chatterjee A.
      • McCarthy J.E.
      • Montagne S.A.
      • Leong K.
      • Kerrigan C.L.
      A cost, profit, and efficiency analysis of performing carpal tunnel surgery in the operating room versus the clinic setting in the United States.
      compared the costs and profit margins for carpal tunnel surgeries done in a clinic procedure room versus the hospital operating room. They found the profit margin for an office-based open carpal tunnel release was $1,186. In contrast, an open carpal tunnel release done in the main operating room had a net loss of $650 per case. When factoring in the lost opportunity cost, the actual real loss for a main operating room open carpal tunnel release was $3,349 per case.
      • Chatterjee A.
      • McCarthy J.E.
      • Montagne S.A.
      • Leong K.
      • Kerrigan C.L.
      A cost, profit, and efficiency analysis of performing carpal tunnel surgery in the operating room versus the clinic setting in the United States.
      There are some limitations to our study. This study is a retrospective chart review, so there is a risk for self-selection bias. At our institution, all patients seen in our practice are given the option of having their procedure done in office, regardless of medical comorbidities. The patients were free to choose the location for their procedure, in either the in-office procedure room or the hospital operating room. There was no control group, and no patient outcome measurements were collected. Potential for recall bias exists in the 110 patients who were called for survey responses after their surgeries, instead of being asked at the conclusion of their surgery.
      Since information about infections was gathered from patient chart data that were imported into RedCap, it is possible that the patient medical records do not accurately reflect their infections or that they received treatment for infections elsewhere. Any patient who received an antibiotic for a postoperative wound problem was counted as having an infection. All patients were treated with oral antibiotics and local wound care.
      We found that in-office hand procedures performed under WALANT and minor field sterility are safe, with high patient satisfaction. Our study was conducted at a single, community-based hospital in the United States. In addition, minor hand surgery done in a procedure room has been shown to be efficient, to be cost effective, and to decrease surgical waste.

      Acknowledgments

      The authors thank Dr Don Lalonde for his advice and counsel.

      References

        • Lalonde D.H.
        • Wong A.
        Dosage of local anesthesia in wide awake hand surgery.
        J Hand Surg Am. 2013; 38: 2025-2028
        • Rhee 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-e147
        • Davison P.G.
        • Cobb T.
        • Lalonde D.H.
        The patient’s perspective on carpal tunnel surgery related to the type of anesthesia: a prospective cohort study.
        Hand (N Y). 2013; 8: 47-53
        • Lalonde D.
        • Martin A.
        Epinephrine in local anesthesia in finger and hand surgery: the case for wide-awake anesthesia.
        J Am Acad Orthop Surg. 2013; 21: 443-447
        • Lalonde D.H.
        Conceptual origins, current practice, and views of wide awake hand surgery.
        J Hand Surg Eur Vol. 2017; 42: 886-895
        • Lalonde D.
        Minimally invasive anesthesia in wide awake hand surgery.
        Hand Clin. 2014; 30: 1-6
        • Lalonde D.
        • Martin A.
        Tumescent local anesthesia for hand surgery: improved results, cost effectiveness, and wide-awake patient satisfaction.
        Arch Plast Surg. 2014; 41: 312-316
        • Greenfield P.T.
        • Spencer C.C.
        • Dawes A.
        • Wagner E.R.
        • Gottschalk M.B.
        • Daly C.A.
        The preoperative cost of carpal tunnel syndrome. J Hand Surg Am.
        (Published online September 8, 2021)
        https://doi.org/10.1016/j.jhsa.2021.07.027
        • Farkash U.
        • Herman A.
        • Kalimian T.
        • Segal O.
        • Cohen A.
        • Laish-Farkash A.
        Keeping the finger on the pulse: cardiac arrhythmias in hand surgery using local anesthesia with adrenaline.
        Plast Reconstr Surg. 2020; 146: 54e-60e
        • Tang J.B.
        Local anesthesia without tourniquet in hand and forearm surgery: my story of using and promoting it.
        Hand Clin. 2019; 35: xv-xx
        • Maliha S.G.
        • Cohen O.
        • Jacoby A.
        • Sharma S.
        A cost and efficiency analysis of the WALANT technique for the management of trigger finger in a procedure room of a major city hospital.
        Plast Reconstr Surg Glob Open. 2019; 7e2509
        • Rabinowitz J.
        • Kelly T.
        • Peterson A.
        • Angermeier E.
        • Kokko K.
        In-office wide-awake hand surgery versus traditional surgery in the operating room: a comparison of clinical outcomes and healthcare costs at an academic institution.
        Curr Orthop Pract. 2019; 30: 429-434
        • Look N.
        • Lalka A.
        • Korrell H.
        • Kabrick K.
        • Wheeler A.
        • Bolson R.
        Outcomes of orthopedic hand surgeries in minor procedure rooms at a Veterans Affairs Medical Center.
        J Hand Surg Glob Online. 2021; 3: 7-11
        • Stephens A.R.
        • Presson A.P.
        • Jo Y.J.
        • et al.
        Evaluating the safety of the hand surgery procedure room: a single-center cohort of 1,404 surgical encounters.
        J Hand Surg Am. 2021; 46: 623.e1-623.e9
        • Yu J.
        • Ji T.A.
        • Craig M.
        • McKee D.
        • Lalonde D.H.
        Evidence-based sterility: the evolving role of field sterility in skin and minor hand surgery.
        Plast Reconstr Surg Glob Open. 2019; 7e2481
        • Van Demark R.E.
        • Smith V.J.S.
        • Fiegen A.
        Lean and green hand surgery.
        J Hand Surg Am. 2018; 43: 179-181
        • Choukairi F.
        • Ibrahim I.
        • N A Murphy R.
        • et al.
        Development of the Manchester wide-awake hand trauma service in 2020: the patient experience.
        J Hand Surg Eur Vol. 2021; 46: 569-573
        • Steiner M.M.
        • Calandruccio J.H.
        Use of wide-awake local anesthesia no tourniquet in hand and wrist surgery.
        Orthop Clin North Am. 2018; 49: 63-68
        • White M.
        • Parikh H.R.
        • Wise K.L.
        • Vang S.
        • Ward C.M.
        • Cunningham B.P.
        Cost savings of carpal tunnel release performed in-clinic compared to an ambulatory surgery center: time-driven activity-based-costing.
        Hand (N Y). 2021; 16: 746-752
        • de Boccard O.
        • Müller C.
        • Christen T.
        Economic impact of anaesthesia methods used in hand surgery: global costs and operating room’s throughput.
        J Plast Reconstr Aesthet Surg. 2021; 74: 2149-2155
        • Codding J.L.
        • Bhat S.B.
        • Ilyas A.M.
        An economic analysis of MAC versus WALANT: a trigger finger release surgery case study.
        Hand (N Y). 2017; 12: 348-351
        • Chatterjee A.
        • McCarthy J.E.
        • Montagne S.A.
        • Leong K.
        • Kerrigan C.L.
        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: 245-248
        • Kazmers N.H.
        • Presson A.P.
        • Xu Y.
        • Howenstein A.
        • Tyser A.R.
        Cost implications of varying the surgical technique, surgical setting, and anesthesia type for carpal tunnel release surgery.
        J Hand Surg Am. 2018; 43: 971-977.e1
        • LaBove G.
        • Davison S.P.
        Cost analysis of an office-based surgical suite.
        Plast Reconstr Surg Glob Open. 2016; 4: e803
        • Carr L.W.
        • Morrow B.
        • Michelotti B.
        • Hauck R.M.
        Direct cost comparison of open carpal tunnel release in different venues.
        Hand (N Y). 2019; 14: 462-465
        • Nguyen C.
        • Milstein A.
        • Hernandez-Boussard T.
        • Curtin C.M.
        The effect of moving carpal tunnel releases out of hospitals on reducing United States health care charges.
        J Hand Surg Am. 2015; 40: 1657-1662
        • Warrender W.J.
        • Lucasti C.J.
        • Ilyas A.M.
        Wide-awake hand surgery: principles and techniques.
        JBJS Rev. 2018; 6: e8
        • Alter T.H.
        • Warrender W.J.
        • Liss F.E.
        • Ilyas A.M.
        A cost analysis of carpal tunnel release surgery performed wide awake versus under sedation.
        Plast Reconstr Surg. 2018; 142: 1532-1538
        • LeBlanc M.R.
        • Lalonde D.H.
        • Thoma A.
        • et al.
        Is main operating room sterility really necessary in carpal tunnel surgery? A multicenter prospective study of minor procedure room field sterility surgery.
        Hand (N Y). 2011; 6: 60-63
        • Zhang J.X.
        • Gray J.
        • Lalonde D.H.
        • Carr N.
        Digital necrosis after lidocaine and epinephrine injection in the flexor tendon sheath without phentolamine rescue.
        J Hand Surg Am. 2017; 42: e119-e123
        • Bruce A.M.
        • Spencer J.M.
        Surgical myths in dermatology.
        Dermatol Surg. 2010; 36: 512-517
        • Denkler K.
        A comprehensive review of epinephrine in the finger: to do or not to do.
        Plast Reconstr Surg. 2001; 108: 114-124
        • Fitzcharles-Bowe C.
        • Denkler K.
        • Lalonde D.
        Finger injection with high-dose (1 : 1,000) epinephrine: does it cause finger necrosis and should it be treated?.
        Hand (N Y). 2007; 2: 5-11
        • Schnabl S.M.
        • Ghoreschi F.C.
        • Scheu A.
        • Kofler L.
        • Häfner H.M.
        • Breuninger H.
        Use of local anesthetics with an epinephrine additive on fingers and penis – dogma and reality.
        J Dtsch Dermatol Ges. 2021; 19: 185-196
        • Thomson C.J.
        • Lalonde D.H.
        • Denkler K.A.
        • Feicht A.J.
        A critical look at the evidence for and against elective epinephrine use in the finger.
        Plast Reconstr Surg. 2007; 119: 260-266
        • Lalonde D.H.
        Latest advances in wide awake hand surgery.
        Hand Clin. 2019; 35: 1-6
        • Hanssen A.D.
        • Amadio P.C.
        • DeSilva S.P.
        • Ilstrup D.M.
        Deep postoperative wound infection after carpal tunnel release.
        J Hand Surg Am. 1989; 14: 869-873
        • Ariyan S.
        • Watson H.K.
        The palmar approach for the visualization and release of the carpal tunnel. An analysis of 429 cases.
        Plast Reconstr Surg. 1977; 60: 539-547
        • Halvorson A.J.
        • Sechriest V.F.
        • Gravely A.
        • DeVries A.S.
        Risk of surgical site infection after carpal tunnel release performed in an operating room versus a clinic-based procedure room within a Veterans Affairs Medical Center.
        Am J Infect Control. 2020; 48: 173-177
        • Jagodzinski N.A.
        • Ibish S.
        • Furniss D.
        Surgical site infection after hand surgery outside the operating theatre: a systematic review.
        J Hand Surg Eur Vol. 2017; 42: 289-294
        • Albert M.G.
        • Rothkopf D.M.
        Operating room waste reduction in plastic and hand surgery.
        Plast Surg (Oakv). 2015; 23: 235-238
        • Thiel C.L.
        • Fiorin Carvalho R.
        • Hess L.
        • et al.
        Minimal custom pack design and wide-awake hand surgery: reducing waste and spending in the orthopedic operating room.
        Hand (N Y). 2019; 14: 271-276
        • Alves 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: 274-276
        • Nolan G.S.
        • Kiely A.L.
        • Madura T.
        • Karantana A.
        Wide-awake local anaesthesia no tourniquet (WALANT) vs regional or general anaesthesia for flexor tendon repair in adults: protocol for a systematic review and meta-analysis.
        Syst Rev. 2020; 9: 264
        • Teo I.
        • Lam W.
        • Muthayya P.
        • Steele K.
        • Alexander S.
        • Miller G.
        Patients’ perspective of wide-awake hand surgery — 100 consecutive cases.
        J Hand Surg Eur Vol. 2013; 38: 992-999
        • Evangelista T.M.P.
        • Pua J.H.C.
        • Evangelista-Huber M.T.P.
        Wide-awake local anesthesia no tourniquet (WALANT) versus local or intravenous regional anesthesia with tourniquet in atraumatic hand cases in orthopedics: a systematic review and meta-analysis.
        J Hand Surg Asian Pac Vol. 2019; 24: 469-476