Wide Awake Hand Surgery

By: Michael D. Smith, MD

Would it be nice to have the option of undergoing anesthesia or being offered the “wide awake” alternative similar to when you are having a dental procedure? As a new hand and upper extremity surgeon, I often meet patients that for one reason or another would like to have surgery to correct their problem but are nervous about or don’t want to undergo anesthesia. Some patients have difficulty in arranging for a ride to pick them up after they had undergone the sedation or others believe they are too “high risk” to undergo anesthesia secondary to a significant cardiac or pulmonary co-morbidity. For these patients, I have begun to offer the possibility to have their surgery done under Wide Awake, Local Anesthesia with No Tourniquet or WALANT as it’s known within the hand surgery community. This technique can be used for a variety of hand surgeries such as carpal tunnel syndrome, trigger finger and excisions of mucous cysts.

WALANT utilizes 1% lidocaine with 1:100,000 epinephrine buffered with 8.4% sodium bicarbonate to provide both local anesthesia to the hand or digit and to also provide hemostasis. This allows the surgeon to avoid using a tourniquet, which is often the most painful aspect of the surgery for patients that are having a procedure done under light sedation.

For years, medical students have been taught to never inject lidocaine with epinephrine into the fingers for fear of causing irreversible ischemia and digit necrosis. The familiar adage of no epinephrine into “fingers, nose, penis and toes” was well ingrained into my head by the time I had graduated from medical school in 2010. Dr. Don Lalonde, a hand surgeon from New Brunswick, Canada, has published his results of over 2000 cases using epinephrine in the finger and has been at the forefront of debunking this commonly held myth. Dr. Lalonde has also published his research into the myth and there is evidence that origin of the myth stems from the use of procaine (Novocaine) in the early 1900’s before the introduction of lidocaine in 1948. Procaine started with a pH of 3.6 and became more acidic as it sat on the shelf. It is highly likely the reports of digit necrosis after “epinephrine” injection in the early 1900’s were actually cases of highly acidic procaine causing the digit necrosis.

Dr. Lalonde has a new adage, “If the fingertip is pink before the lidocaine with epinephrine, it will be pink after the lidocaine with epinephrine.” In addition, there is a reversal agent, phentolamine that can reverse the hemostatic effects of epinephrine injections within an hour or two.

Some of the advantages of WALANT hand surgery include:

●Little to no pre-operative testing, as the only two medications being administered are lidocaine and epinephrine.

●Patients are able to drive themselves home, as they have had no sedation or anesthesia.

●Patients do not need to fast or change medication schedules before the procedure; which is especially helpful in my diabetic patients.

●Patients do not need to endure a tourniquet, even for five minutes.

In my practice, patients are sometimes nervous about being awake during their surgery, but oftentimes they find that the worry about “being awake” is much worse than the reality. In truth, I find the opportunity to talk with my patients during their surgery is a great avenue to build my relationship with the patient, but also to reiterate the post-operative protocol I would like for them to follow. I think most of my patients that have undergone WALANT would agree that it made their surgical experience simpler and more enjoyable.


Michael D. Smith, MD

Hand and Upper Extremity Surgeon
Southlake Orthopaedics Sports Medicine and Spine Center, PC
www.southlakeorthopaedics.com