Comparison of infraclavicular block and wide-awake local anesthesia with no tourniquet for hand surgery: A prospective randomized controlled study

Abstract

Background:

The aim of this study was to compare the wide awake local anesthesia no tourniquet (WALANT) technique and the infraclavicular brachial plexus block (ICB) in terms of effectiveness, safety, and patient satisfaction in hand and upper extremity surgeries.

Methods:

The patients were randomized into 2 groups as WALANT and ICB. The pain levels of the patients before, during, and after surgery were questioned and recorded according to the visual analog scale (VAS). Their satisfaction levels were evaluated using the Likert scale. The duration of anesthesia administration, onset of anesthesia effect, intraoperative additional analgesic needs, total duration of anesthesia effect, postoperative analgesic needs, length of hospital stay, total surgical duration, hospitalization costs and complications were evaluated.

Results:

ICB (group 1) was applied to 28 (50.9%), while WALANT (group 2) was applied to 27 (49.1%) of the patients. The mean anesthesia application time and postoperative hospital stay duration in Group 1 was significantly higher than Group 2. The satisfaction levels and the VAS scores were found to be statistically similar in both groups. The mean duration of anesthesia application and the total anesthesia duration was significantly shorter in group 2. It has been determined that there is a significant lower cost in group 2.

Conclusion:

The WALANT anesthesia technique may be an alternative to ICB in hand surgery operations due to its fast application, onset time, similar VAS score and patient satisfaction, and low cost.

1. Introduction

Over the past 2 decades, significant advancements in anesthesia have transformed the landscape of hand and upper extremity surgery, particularly with the growing emphasis on ambulatory surgical care. These developments have enabled a broader range of procedures to be safely and effectively performed in outpatient settings, offering numerous benefits such as reduced hospital stay, lower overall healthcare costs, improved patient throughput, and enhanced patient satisfaction.^[1] As the demand for day-case surgeries continues to increase, the selection of optimal anesthesia techniques has become a critical factor in ensuring perioperative safety, pain control, and patient comfort.^[2]

Regional anesthesia has emerged as a cornerstone of modern upper extremity surgery, with techniques such as the ICB offering reliable surgical anesthesia and extended postoperative analgesia. The ICB, performed under ultrasound guidance, provides dense sensory and motor blockade of the distal upper extremity while minimizing the risk of phrenic nerve involvement, which is particularly beneficial in patients with respiratory comorbidities.^[3,4] This technique has been associated with decreased opioid consumption, lower pain scores, and earlier functional recovery compared to general anesthesia or less targeted regional blocks.^[5]

In parallel with the development of advanced regional blocks, there has been growing interest in the wide awake local anesthesia no tourniquet (WALANT) technique.^[6,7] WALANT relies on the combined use of local anesthetic and epinephrine to achieve effective surgical anesthesia without the need for a tourniquet or sedation. This approach allows for intraoperative patient participation, facilitates assessment of tendon tension and joint mobility during the procedure, and eliminates the risks associated with general anesthesia and regional blocks.^[8] WALANT is particularly well-suited for soft tissue surgeries of the hand and fingers and has been shown to reduce operating room turnover time, anesthesia-related complications, and postoperative monitoring requirements.^[1,6]

Despite the widespread use of both techniques, there remains a lack of consensus in the literature regarding their relative advantages and limitations across different surgical contexts.^[1] While ICB offers superior analgesia in many cases, it requires specialized equipment and expertise, and carries risks such as nerve injury, local anesthetic systemic toxicity, or vascular puncture. WALANT, on the other hand, is simple, cost-effective, and ideal for resource-limited settings, but may not be suitable for all patients or procedures, particularly those involving proximal incisions or longer operative durations.^[2,4,7]

The present study aims to provide a comprehensive comparison of the ICB and WALANT techniques in the context of hand and upper extremity surgery. By evaluating outcomes this study seeks to contribute meaningful evidence to guide anesthesia selection in ambulatory orthopedic practice.

2. Materials and methods

The study was conducted prospectively, randomized, and single-center after obtaining the necessary Ethics Committee approval (date: July 12, 2022, number: 2011-KAEK-26/770). Between May 2022 and May 2023, patients scheduled for hand surgery were included in the study. An informed consent was obtained from each participant. Patients who did not want to participate in the study and did not provide a consent form were not included in the study. Patients between the ages of 18 and 70, with American Society of Anesthesiologists (ASA) classes I to III, planned for surgery for a single indication, and with surgical durations between 20 and 60 minutes were included in the study. Exclusion criteria were patients with ASA > III, patients planned for bilateral surgery, patients with local infection, patients with a neurological disorder affecting the same upper extremity, patients with a history of allergy to local anesthetic drugs, patients with a history of opioid use in the past month, and patients who were unable to understand the study and provide adequate answers to the questions. The costs of surgery was obtained by calculating service costs in hospital records.

2.1. Randomization

Necessary consents were obtained from the patients in accordance with the inclusion and exclusion criteria. The patients were randomized into 2 groups, ICB (group 1), WALANT (group 2). Randomization was performed using a computer program (Microsoft Excel RANDBETWEEN function), and the attending anesthesiologist learned which anesthesia application would be performed immediately before the surgery.

2.2. Preparation before anesthesia

Preoperative routine anesthesia preparations for all patients have been completed. Demographic data (age, height, weight, smoking, and additional medical information) have been recorded. Information regarding the anesthesia and surgical procedure to be performed on the patients has been provided. If there is no known allergy in the patients, approximately 30 minutes before the surgery, after the intravenous access is established, 1 gram of cephalosporin is administered for the purpose of infection prophylaxis. Blood pressure, heart rate, and peripheral oxygen saturation (SpO2) were monitored.

2.3. WALANT

The WALANT solution was prepared as follows: 50 mL of 1 mg/1 mL epinephrine + 2% lidocaine + 39 cc of 0.9% isotonic NaCl + 10 mL of 8.4% sodium bicarbonate.^[7] The surgical area was sterilized with polyvinyl-iodine. Using a 27-gauge syringe, the solution was applied around the incision site, sometimes from a single point and sometimes from several different points, until whitening of the skin was observed. Care was taken not to exceed the maximum dose of 7 mg/kg. The surgical procedure began 20 to 30 minutes after the WALANT application. An example figure has been shown from patients who have undergone WALANT application (Fig. 1).

Figure 1.

Preoperative marking and local anesthetic infiltration in a patient undergoing WALANT technique. The image demonstrates surface anatomical landmarks, including the palmar crease and radial digital line, with visible blanching of the skin following subcutaneous injection, indicating effective vasoconstriction and field block. WALANT = wide awake local anesthesia no tourniquet.

2.4. ICB

In the supine position, the head was positioned in the opposite direction of the blocked side. The axillary artery and cords of the brachial plexus were visualized by ultrasound. Using an 80 mm long 21 G Stimuplex needle, a mixture of 10 cc 0.5% bupivacaine and 2% lidocaine was injected around the 3 cords with intermittent aspiration for control purposes. An example figure has been shown from patients who have undergone ICB application (Fig. 2).

Figure 2.

Patient positioned supine for ultrasound-guided ICB. The image shows anatomical landmarks including the clavicle and coracoid process, along with the intended needle insertion trajectory toward the infraclavicular fossa for accurate placement adjacent to the brachial plexus cords.

2.5. Clinical evaluation

Patients who could not achieve sufficient pain control were either sedated or switched to general anesthesia and were excluded from the study. The pain levels of the patients before, during, and after surgery were questioned and recorded according to the visual analog scale (VAS). Their satisfaction levels were evaluated using the Likert scale,^[9] and they were asked whether they would prefer the same anesthesia method if another operation was planned. The duration of anesthesia administration, onset of anesthesia effect, intraoperative additional analgesic needs, total duration of anesthesia effect, postoperative analgesic needs, length of hospital stay, total surgical duration, and complications were evaluated. Cost analysis included direct surgical expenses, anesthesia-related charges, and postoperative recovery costs which were calculated and compared between both groups. Patients with incomplete financial records or additional procedures during the same admission were excluded.

2.6. Statistical analysis

All the statistical analyses were performed using IBM SPSS for Windows, version 28.0 (SPSS Inc, Chicago). The data distribution of normality was analyzed using a Kolmogorov–Smirnov test. A chi-squared test was used for the nonparametric data, and Student t-test was used for the numerical independent groups. A P-value <.05 was considered statistically significant.

3. Results

Sixty-eight patients were planned for the study, but 5 patients were excluded because they could not be followed regularly, and 6 patients were excluded because they could not tolerate the WALANT application and ICB was applied. As a result, 57 patients were included in the study. ICB was applied to 28 (50.9%) of the patients, while WALANT was applied to 27 (49.1%) of the patients. There was no statistically significant difference between the groups in terms of age, gender, BMI and ASA score (P > .05). Type of diseases were showed in Table 1 and most of the surgeries were for soft tissue tumors in group 1 and trigger finger in group 2 (Table 1).

Table 1.

Demographic and disease-specific characteristics of the patients.

Variable	Entire study population	Group 1 (ICB)	Group 2 (WALANT)	P
Age, year, (mean ± SD)	50.2 ± 16.3	49.7 ± 16.6	50.8 ± 16.3	.612
Gender, n (%)
Female	37 (67.3)	18 (64.3)	19 (70.4)	.631
Male	18 (32.7)	10 (35.7)	8 (29.6)
BMI, kg/cm2, (mean ± SD)	28.6 ± 6.5	28.0 ± 7.4	29.3 ± 5.4	.577
ASA, n (%)
I	16 (29.1)	9 (32.1)	7 (25.9)	.754
II	36 (65.5)	18 (64.3)	18 (66.7)
III	3 (5.5)	1 (3.6)	2 (87.4)
Type of surgery, n (%)
Bone fracture	4 (7.3)	4 (14.3)	0 (0)	.268
Soft tissue tumor	16 (29.1)	9 (32.1)	7 (25.9)
Carpal tunnel syndrome	8 (14.5)	3 (10.7)	5 (18.5)
Trigger finger	13 (23.6)	4 (14.3)	9 (33.3)
Implant removal	2 (3.6)	1 (3.6)	1 (3.7)
Dupuytren disease	4 (7.3)	2 (7.1)	2 (7.4)
Joint arthrodesis	3 (5.5)	1 (3.6)	2 (7.4)
Bone tumor surgery	5 (9.1)	4 (14.3)	1 (3.7)

ASA = The American Society of Anesthesiologists physical status classification system, BMI = body mass index, n = number, SD = standard deviation, WALANT = wide awake local anesthesia no tourniquet.

The mean anesthesia application time was found to be 23.4 ± 9.4 minutes in all patients. In Group 1, this data was found to be 31.4 ± 6 minutes, while in Group 2 it was 15 ± 2.4 minutes. The mean anesthesia application time in Group 1 was significantly higher than in Group 2 (P < .001). The mean surgery time was 42 ± 28.4 minutes in all patients. In Group 1, it was 52.8 ± 33 minutes, while in Group 2 it was 30.8 ± 17.1 minutes, and statistically higher in Group 1 (P = .002). When postoperative hospital stay durations were evaluated, the mean was found to be 1.1 ± 0.4 days in all patients. In Group 1, it was 1.3 ± 0.6 days, while in Group 2 it was 1 ± 0 days, and significantly higher in Group 1 (P = .004).

The satisfaction levels of patients with the applied anesthesia, whether they would prefer the same anesthesia method, and the VAS scores are shown in Table 2. The data in this table were found to be statistically similar in both groups (P > .05).

Table 2.

Subjective outcomes of patients.

Variable	Entire study population	Group 1 (ICB)	Group 2 (WALANT)	P
Patient satisfaction level, (mean ± SD)	4.5 ± 0.6	4.6 ± 0.6	4.5 ± 0.6	.764
Same method choice, n (%)
Yes	53 (96.4)	27 (96.4)	26 (96.3)	.979
No	2 (3.6)	1 (3.6)	1 (3.7)
Preoperative VAS, (mean ± SD)	3.4 ± 2.7	3.4 ± 3.0	3.3 ± 2.4	.860
Early postoperative VAS, (mean ± SD)	0.2 ± 0.7	0.2 ± 0.8	0.2 ± 0.7	.901
Late postoperative VAS, (mean ± SD)	1.1 ± 1.9	1.3 ± 2	0.9 ± 1.7	.491
Perioperative VAS change, n (%)
Increase	2 (3.6)	1 (3.6)	1 (3.7)	.876
Decrease	5 (9.1)	2 (7.1)	3 (11.1)
No change	48 (87.3)	25 (89.3)	23 (85.2)

n = number, SD = standard deviation, VAS = visual analogue scale, WALANT = wide awake local anesthesia no tourniquet.

The duration of anesthesia effect and other findings are shown in Table 3. The mean duration of anesthesia application in group 1 was found to be 7.2 ± 2.9 minutes, while in group 2 it was 3.9 ± 1.8 minutes. It was determined that this duration was significantly shorter in group 2 (P < .001). When the onset times of the anesthetic effect were examined, the mean duration was found to be 12.7 ± 3.5 minutes in group 1 and 10 ± 1.4 minutes in group 2, and again it was determined that this duration was significantly shorter in group 2 (P < .001). When the total anesthesia duration was evaluated, it was found to be significantly shorter in group 2 compared to group 1 (P < .001) (Table 3).

Table 3.

Other outcomes of patients.

Variable	Entire study population	Group 1 (ICB)	Group 2 (WALANT)	P
Anesthesia application time, minute, (mean ± SD)	5.6 ± 2.9	7.2 ± 2.9	3.9 ± 1.8	<.001
Onset of anesthetic, minute, (mean ± SD)	11.4 ± 3	12.7 ± 3.5	10 ± 1.4	<.001
Intraoperative analgesic need, n (%)
No	51 (92.7)	25 (89.3)	26 (96.3)	.513
Midazolam 2 mg	3 (5.5)	2 (7.1)	1 (3.7)
Propofol 40 mg + Midazolam 2 mg	1 (1.8)	1 (3.6)	0 (0)
Postoperative analgesic need, n (%)
No	46 (83.6)	21 (75)	25 (92.6)	.112
Paracetamol	6 (10.9)	5 (17.9)	1 (3.7)
Paracetamol + Aldolan	2 (3.6)	2 (7.1)	0 (0)
Paracetamol + NSAID	1 (1.8)	0 (0)	1 (3.7)
Total anesthesia time, (mean ± SD)	62.5 ± 31.2	79 (34.7)	45.4 (13.1)	<.001

P < .05 was defined as significant and defined bold.

n = number, NSAID = non-steroid antiinflammatory drug, SD = standard deviation, WALANT = wide awake local anesthesia no tourniquet.

No perioperative complications were experienced in any of the patients, while in group 2, only 1 patient (3.6%) had continued hypesthesia in the median nerve pathway after surgery, which completely resolved by the 3rd week. An analysis of total hospitalization and operative expenses revealed that the average cost was $46.12 in Group 1 and $30.76 in Group 2. The difference was statistically significant, with lower costs observed in Group 2 (P = .002).

4. Discussion

In this prospective randomized controlled study, we compared 2 commonly used anesthesia techniques in hand surgery – ICB and WALANT – with respect to perioperative efficiency, patient satisfaction, pain control, and cost-effectiveness. Our results demonstrated that both techniques provided comparable levels of patient satisfaction and postoperative pain relief, with no statistically significant differences in VAS scores or subjective comfort. However, WALANT was found to be significantly superior in terms of anesthesia administration time, onset of anesthetic effect, total anesthesia duration, and postoperative hospital stay. Notably, the total surgical cost in the WALANT group was substantially lower than that of the ICB group. These findings suggest that WALANT not only offers clinical efficacy comparable to ICB but also presents considerable logistical and economic advantages in ambulatory hand surgery settings.

The application of ICB requires an experienced anesthesiologist for peripheral nerve blocks, as well as the use of ultrasound equipment, which may limit its practicality in certain settings. In contrast, the WALANT technique can be performed using simpler equipment, making it more accessible and easier to implement in routine hand surgeries.

It has been observed that some surgical procedures can be easily performed without the use of a tourniquet with the WALANT technique. It is especially believed to be advantageous in distal hand surgery and minimally invasive procedures.^[10] In our study, effective analgesia has been provided with WALANT in many different procedures. It has been successfully applied in procedures such as soft tissue tumor excision, carpal tunnel syndrome, trigger finger, Dupuytren contracture, and joint arthrodesis.

It has been stated in the literature that maximum vasoconstriction activity occurs approximately 30 minutes after injection with the WALANT technique.^[6] In our study, a 30-minute waiting period was observed in both groups before surgery. However, due to its ability to be applied faster and have a shorter onset of action, WALANT can be preferred over ICB, especially in emergency surgical procedures.

It has been observed that the time spent in the hospital using the WALANT technique is much shorter than ICB. Additionally, it can contribute to reducing the workload in hospitals by being able to be planned without the need for preoperative anesthesia clinic examination and preparation. Another advantage is that it does not require adjustment for anticoagulant treatments.^[6]

In procedures performed with the WALANT technique, the average cost was $30.76, while in the ICB group, it was $46.12. Other studies in the literature have also shown that treatment can be completed at a lower cost with WALANT.^[11]

With the WALANT method, the surgeon can perform a joint examination during the intraoperative and early postoperative period and evaluate the effectiveness of the treatment in the early stages. Exercise for rehabilitation treatment can even be started within the case. However, since the patient’s hand mobilization is not restricted during the surgical period, they need to be cooperative in terms of maintaining movement.^[12,13] When considering surgical stress, the patient should be well-informed from this perspective. During the intraoperative period, peaceful silence should be provided in the operating room, and efforts should be made to reduce the patient’s anxiety.

In our study, no significant difference was found in terms of intraoperative and postoperative pain levels and satisfaction scores in both groups. However, it was observed that only 2 patients in the WALANT group had a postoperative opioid requirement, but no significant difference was found in terms of VAS scores. It has been shown that the WALANT technique yields better postoperative pain scores compared to axillary block, and it is thought that this may be related to tourniquet pain.^[3] The WALANT method has been found to have VAS scores similar to those of other studies in the literature compared to ICB.^[4]

Concerns regarding the safety of epinephrine use in hand and finger surgeries have historically focused on the potential for digital ischemia or necrosis, particularly when injected into areas with end-arterial circulation.^[2] These concerns trace back to isolated case reports published before 1950, a period in which anesthesia techniques and pharmacologic formulations were not as advanced or standardized as they are today. In the modern era, a growing body of evidence supports the safe and effective use of epinephrine-containing local anesthetic solutions in hand surgery, particularly in the context of the WALANT technique. Studies have consistently demonstrated that when used within recommended dosing limits and proper technique, the risk of ischemic complications is exceedingly low.^[6]

Furthermore, in the rare event of prolonged vasoconstriction or signs of compromised perfusion, phentolamine – a nonselective alpha-adrenergic antagonist – can be administered to reverse the vasoconstrictive effects of epinephrine. This agent has been shown to be effective in restoring digital blood flow without long-term sequelae. Importantly, in our study, no cases of digital ischemia, necrosis, or other epinephrine-related complications were encountered. Additionally, none of the patients required phentolamine rescue, further underscoring the safety of epinephrine use in WALANT when applied with appropriate precautions and dosing.

The fact that the study is single-centered and does not have the same type of surgery can be cited as a limitation. Due to the sample not being homogeneous and large enough, there may not have been a significant difference detected between the 2 groups. More clear data can be obtained through studies with a larger patient group.

5. Conclusion

The WALANT anesthesia technique may be an alternative to ICB in hand surgery operations due to its fast application, onset time, similar VAS score and patient satisfaction, and low cost.

Author contributions

Conceptualization: Selcan Akesen, Gokay Eken.

Data curation: Selcan Akesen, Yücel Bilgin.

Formal analysis: Elifgul Ulutas, Yücel Bilgin.

Funding acquisition: Yücel Bilgin.

Investigation: Saltuk Bugra Guler, Elifgul Ulutas, Yücel Bilgin.

Methodology: Gokay Eken, Saltuk Bugra Guler.

Project administration: Saltuk Bugra Guler.

Resources: Saltuk Bugra Guler, Elifgul Ulutas.

Software: Saltuk Bugra Guler, Elifgul Ulutas.

Supervision: Selcan Akesen.

Validation: Selcan Akesen.

Visualization: Selcan Akesen, Elifgul Ulutas.

Writing – original draft: Selcan Akesen, Gokay Eken, Yücel Bilgin.

Writing – review & editing: Selcan Akesen, Gokay Eken, Yücel Bilgin.