What’s New in Wide-Awake Local Anesthesia No Tourniquet (WALANT) Hand Surgery?

Abstract

Wide-awake local anesthesia no tourniquet (WALANT) has evolved from a novel technique to an increasingly adopted anesthetic strategy in hand surgery. In the post-coronavirus disease (COVID)-19 era, there has been a marked expansion in WALANT-related literature, necessitating synthesis of contemporary evidence to guide clinical practice. This narrative review examines recent WALANT studies organized into six thematic domains: comparative trials versus traditional anesthesia, use in the pediatric population, patient satisfaction and experience, environmental impact, cost comparison and value-based care, and applications beyond the hand and wrist. Comparative studies consistently demonstrate that WALANT provides noninferior functional outcomes and complication rates relative to regional and general anesthesia, with improved intraoperative pain and similar early postoperative pain. Pediatric data support feasibility and high satisfaction in appropriately selected patients, particularly adolescents. Patient satisfaction is uniformly high, with strong willingness to repeat WALANT procedures. WALANT pathways also reduce solid waste and carbon emissions, particularly when procedures are performed outside the main operating room. Cost analyses demonstrate substantial savings driven by decreased anesthesia use and site-of-service optimization. Expanding indications now include proximal upper extremity procedures and select nonupper extremity surgeries, reflecting increasing surgeon experience and confidence. WALANT represents a mature, evidence-supported care pathway that aligns clinical outcomes with patient-centered experience, environmental sustainability, and cost efficiency. Its greatest impact is realized when integrated into procedure room-based workflows with careful patient selection and standardized technique. Future efforts should focus on refining indications, optimizing patient experience, and expanding scalable implementation across diverse practice settings.

The field of wide-awake local anesthesia no tourniquet (WALANT) hand surgery continues to expand and mature. In the post-coronavirus disease (COVID)-19 era, there has been a marked surge in WALANT-related publications, creating both opportunity and challenge for the practicing hand surgeon attempting to remain current with clinically meaningful advances. Organized thematically, this review synthesizes recent literature with an emphasis on studies that have immediate implications for clinical practice.

The adoption of the WALANT technique closely follows the trajectory of Rogers’ Diffusion of Innovation theory, where the COVID-19 pandemic served as a definitive tipping point (Fig. 1).¹ Prior to 2020, WALANT was primarily in the “Innovators” and “Early Adopters” phase, characterized by a modest volume of 10–30 manuscripts annually that focused largely on safety profiles, epinephrine use, and early anecdotal reports. However, the systemic pressures of the pandemic, specifically, the need to bypass main operating theaters, minimize aerosol-generating procedures, and reduce hospital stays, accelerated its transition into the “Early Majority” phase. This transition is quantitatively evidenced with an increase to approximately 70–100+ publications per year over the last 5 years.

Figure 1.

Application of the Diffusion of Innovation theory to the adoption of the wide-awake local anesthesia no tourniquet (WALANT) technique. The black bell curve illustrates the distribution of adopter categories, while the red S-curve represents the cumulative clinical penetration. Key chronological milestones are highlighted: the initial conceptualization (2005), the transition into the early adopter phase (2015), and the tipping point (2020) coinciding with the COVID-19 pandemic, which catalyzed the onset of the Early Majority phase. Adapted from Rogers¹ (2003).

Concurrently, there has been a surge in high-level prospective and comparative trials or systematic reviews and meta-analyses examining pain, patient experience, and functional outcomes following WALANT relative to traditional anesthesia techniques.

Accordingly, this review is organized around six contemporary themes: (1) systematic reviews and comparison trials between WALANT and traditional anesthetic strategies; (2) use of WALANT in the pediatric population; (3) patient satisfaction and experience; (4) environmental impact; (5) cost comparison and value-based care; and (6) continued advancement of applications outside of the hand.

Theme 1: Comparison Trials and Systematic Reviews

The most consequential shift in the post-COVID-19 WALANT literature has been the rapid growth of prospective comparative studies designed to test whether WALANT delivers equivalent (or superior) perioperative outcomes compared with tourniquet-based local anesthesia, regional anesthesia, sedation, or general anesthesia. Across procedure types, the signal is consistent: WALANT is at least noninferior for safety and functional outcomes, while offering measurable advantages in intraoperative pain (especially vs tourniquet-based strategies), logistics, and cost—with more mixed results for longer-term pain and patient-reported outcomes.

WALANT versus local or locoregional anesthesia: superior intraoperative pain outcomes with WALANT

Pain has been the most frequently studied endpoint, and the best synthesized evidence to date comes from a meta-analysis or randomized trials (11 randomized controlled trials; 794 patients) demonstrating that, compared to local anesthesia with a tourniquet, WALANT significantly reduces intraoperative pain.² Another anesthesiologist-led meta-analysis reported significant reduction in intraoperative pain scores in the WALANT group.³ Similarly, in a meta-analysis about carpal tunnel release, WALANT group experienced significantly lower pain levels during surgery.⁴ One exception in the recent literature is a prospective randomized trial on carpal tunnel decompression.⁴ Although WALANT group reported a statistically significant lower intraoperative pain score than the local anesthesia with a tourniquet group, it did not meet minimal clinically important difference thresholds. However, the authors noted that all surgeries were performed by experienced surgeons and their findings might not apply to other procedures that could potentially have a longer duration.⁵

WALANT versus regional anesthesia: comparable pain and satisfaction in many settings

Comparisons against regional techniques are increasingly common, reflecting real-world decision points in ambulatory hand surgery. A recent prospective study evaluating WALANT versus a brachial plexus regional-based approach for carpal tunnel release assessed pain alongside grip strength and postoperative sleep quality, underscoring the growing tendency to move beyond immediate perioperative pain toward function and recovery metrics.⁶ Although WALANT significantly reduced surgical time, all other metrics were similar. In distal radius fracture fixation, a comparative study of WALANT versus infraclavicular brachial plexus blockade reported lower postoperative pain scores, faster return to work, and higher satisfaction in the WALANT cohort, along with perioperative efficiency advantages.⁷

Taken together, these studies suggest that when regional anesthesia is used primarily to optimize postoperative analgesia, WALANT can be competitive, particularly when surgeons use thoughtful field blocks, allow adequate epinephrine onset time, and pair WALANT with a deliberate postoperative analgesic plan.8, 9, 10, 11

Functional outcomes and complications: generally equivalent across anesthesia strategies

Beyond pain, the emerging comparative literature has increasingly included functional outcomes (eg, grip strength, patient-reported outcome measures, return to work) and safety endpoints (eg, complications, reoperation, rupture for tendon surgery). Across the available prospective trials and systematic reviews, functional outcomes are typically similar, and complication profiles appear comparable when procedures are appropriately selected for WALANT and performed with reproducible technique.^2,12, 13, 14, 15, 16

Practical takeaways for the hand surgeon

The best-supported conclusion from contemporary comparative trials is that WALANT offers its clearest advantage in avoiding tourniquet-related discomfort and improving intraoperative pain, while delivering similar safety and medium-term outcomes for many common procedures. Where studies detect difference in pain or satisfaction, the clinician’s task is to determine whether the magnitude crosses the threshold of meaningful benefit for a given patient and procedure—rather than relying on statistical significance alone.²

Theme 2: Use of WALANT in the pediatric population

The pediatric WALANT literature has shifted from early feasibility reports to a more structured body of evidence focused on patient selection, perioperative efficiency, pain control, and opioid avoidance. Although younger children remain a selective cohort, multiple contemporary series now support WALANT as a practical option—particularly in adolescents—when expectations, preparation, and procedure choice are aligned.

What the aggregate evidence shows

A 2025 systematic review focused on adolescent hand surgery synthesized the available outcomes literature and identified 166 WALANT cases with an average patient age of 14 years (range 7–20). Across heterogenous procedures, the review concluded that WALANT is feasible in appropriately selected adolescents and may improve pain scores and resource utilization metrics (eg, surgical throughput/length of stay), while acknowledging that the evidence base remains limited in size and dominated by retrospective designs.¹⁷

Larger single-center pediatric experience: feasibility plus efficiency and analgesic advantages

A key 2025 pediatric hospital experience reported 223 upper limb procedures performed under WALANT (ages 7–20) without monitored anesthesia care, with a pragmatic perioperative pathway that did not require preoperative fasting. In this series, WALANT implementation was associated with shorter surgical and recovery room times, lower pain scores, and reduced narcotic requirements, without concern for short-term complications. The data support WALANT as a scalable model in a pediatric setting when the team has a reproducible workflow.¹⁸

Procedure-specific data: ganglion excision as a “gateway” pediatric indication

Procedure-level evidence is another area of focus. A 2025 study evaluating WALANT for pediatric dorsal and volar ganglion excision concluded that the technique can be used successfully in this setting, with benefits that parallel the adult experience. Although retrospective and procedure specific, this type of study is valuable because it defines realistic “on-ramp” operations (short, predictable, low physiologic stress) for broader pediatric adoption.¹⁹

Patient selection and implementation: the recurring message

Across pediatric-focused reports, the most consistent “success factor” is selecting the right patient, with many authors emphasizing that the typical candidate is older (often >10 years), cooperative, and appropriately counseled, with a team that prepares the patient for what they will see, hear, and feel. Patients are encouraged to use smartphones, tablets, or noise-canceling headphones to watch movies or listen to music during the operation to minimize anxiety.^17,20 A practical pediatric WALANT guide and an adolescent experience study both frame WALANT as a pathway that can broaden access when preparation is deliberate.^20,21

Practice-facing takeaway

Pediatric WALANT is no longer a novelty; the emerging evidence supports it as safe and feasible in selected children—especially adolescents—and suggest it can improve efficiency, early pain experience, and opioid exposure. The limiting variable is rarely the anesthetic itself; it is almost always patient selection, expectation setting, and a standardized workflow.¹⁷

Theme 3: Patient Satisfaction and Experience

Beyond traditional clinical endpoints, patient satisfaction and overall perioperative experience have emerged as central outcomes in the contemporary WALANT literature. Although comparative trials frequently include satisfaction as a secondary endpoint (Theme 1), a growing subset of studies now explicitly examine patient-reported experience, expectations, and psychosocial modifiers, reflecting a broader shift toward patient-centered care.

High satisfaction across procedures and anesthetic comparisons

Across randomized and prospective comparative trials, WALANT consistently demonstrates high patient satisfaction that is comparable to—or exceeds—that of regional anesthesia, monitored anesthesia care, and general anesthesia.²² The primary driver of this superior experience is the elimination of the tourniquet, a component often cited by patients as the most distressing aspect of conventional limb surgery.^22,23 Factors beyond pain alone, such as avoidance of fasting, faster discharge, and preserved autonomy, contribute meaningfully to the patient experience.^24,25 Furthermore, by bypassing sedation and general anesthesia, patients avoid classic perioperative complications, such as nausea, vomiting, urinary retention, and aspiration pneumonia.^25,26

Investigations reinforce these findings. A recent meta-analysis of patient satisfaction reported similar postoperative pain and operating room time, yet higher patient satisfaction among individuals treated with WALANT, highlighting that experiential benefits can exist even when traditional perioperative metrics appear equivalent.²² A separate prospective study similarly demonstrated high satisfaction rates following WALANT for hand procedures, supporting its acceptability across diverse patient populations.²⁷

Experience-focused outcomes: anxiety, expectations, and willingness to repeat

Preoperative anxiety is a prevalent concern among patients undergoing WALANT surgery, predominantly centered on the anticipated local anesthetic injection and uncertainty regarding the adequacy of the anesthetic.28, 29, 30, 31, 32 Furthermore, the clinical operating room environment, including the sensory triggers of surgical sounds and the mention of instruments such as “scalpels”, can exacerbate patient distress.28, 29, 30, 31, 32 Many practical tips have been reported for an improved patient experience that emphasizes empathy, reassurance, and patient inclusion to reduce anxiety and to increase patient compliance (Table).29, 30, 31 Clinical studies consistently demonstrate that the actual WALANT experience often exceeds patient expectations; consequently, the vast majority of patients report they would choose the technique again and would recommend it to others.^27,28,33, 34, 35

Table 1.

Common Operating Room Phrases and Patient-Centered Alternatives During WALANT Surgery

Situation	Common Operative Room Phrase (Stress-Provoking)	Preferred WALANT Language (Stress-Reducing)	Why the Alternative Helps
Injection Preparation	“I’m going to put the needle in now.”	“You’ll feel a small pinch or a little pressure.”	Avoids triggering needle anxiety and focuses on the expected sensation
Pain reassurance	“This won’t hurt.”	“My goal is to make this as comfortable as possible.”	Maintains trust by avoiding unrealistic promises
Starting incision	“Knife.”/”Scalpel.”	“Let’s begin” or “We’re starting now.”	Avoids alarming terminology associated with cutting instruments
Instrument requests	“Give me the bone cutter.”	“Hand me that small instrument.”	Graphic instrument names can provoke anxiety in awake patients
Staff correction or conflict	“You’re doing that wrong.” Or other public corrections of trainees	“Let’s adjust that technique.”	Prevents patient concern about competence or conflict
	Loud or rushed instructions	Calm, soft voice	Tone strongly influences perceived safety and comfort
Face draping	Ignoring that the drape is uncomfortable on an awake patient’s face	Either do not use a drape or tent the drape only on the side of the surgery, leaving the ceiling and side away from the patient free	Prevents a feeling of claustrophobia
Staff conversation	Talking about weekend plans or complaints	Patient-inclusive conversation	Keeps patients engaged and reassured rather than excluded
Assessing anxiety	“Are you nervous?”	“Are you excited about getting this fixed?”	Reframes the emotional context and opens constructive dialogue
Unexpected sensation	“That’s normal.”	“You may feel some pressure, but you should not feel pain—please tell me if you do.”	Encourages patient communication and reinforces control
Silence during surgery	No conversation	Calm conversation, light humor, or music.	Silence can increase hypervigilance and anxiety Distraction techniques such as music reduce anxiety and improve comfort
Unexpected finding	“That’s surprising.”/”Whoa!”/”That’s strange!”	“Interesting” or no comment and calmly continue the procedure.	Words implying surprise may signal to the patient that something abnormal or wrong occurred
Technical difficulty	“Oops.”/”Uh-oh.”	No comment and calmly continue the procedure.	Expressions suggesting error may trigger immediate patient anxiety
Complication	“This isn’t right.”	Neutral communication or quiet internal discussion.	Statements implying a problem can alarm awake patients
Bleeding discussion	“There’s a lot of bleeding.”	Avoid discussion of bleeding unless clinically necessary	Commentary about blood volume can provoke distress in awake patients
Negative language or profanity	Swear words or expressions of frustration	Maintain calm, professional language	Negative tone suggests loss of control or difficulty
Ending surgery	“We’re done.”	“Everything went very well—you did great.”	Reinforces positive experience and patient confidence

Influence of mental health on WALANT experience

An important emerging concept is the interaction between baseline mental health status and WALANT experience. A study evaluating mental health factors in patients undergoing WALANT found that anxiety, depression, and pain catastrophizing were associated with higher perceived pain and lower satisfaction, independent of surgical variables.³⁶ These findings underscore that patient experience is not solely determined by anesthetic technique, and they reinforce the importance of screening, expectation management, and tailored counseling.

Practice-facing takeaway

Collectively, the literature supports WALANT as a highly acceptable and well-tolerated anesthetic strategy from the patient perspective. Satisfaction is consistently high, willingness to repeat WALANT is strong, and experiential advantages—autonomy, avoidance of fasting and sedation, rapid recovery—often persist even when pain outcomes are similar to traditional anesthesia. Optimizing the patient experience hinges less on the pharmacology itself and more on patient selection, education, and intraoperative communication.

Theme 4: Environmental impact of WALANT and procedure location

Sustainability has emerged as a meaningful, if previously underappreciated, dimension of perioperative decision-making. As health care systems increasingly recognize the operating room as a major source of institutional waste and greenhouse gas emissions, WALANT—particularly when paired with migration of appropriate cases out of the main operating room—has been shown to confer substantial environmental advantages.

Solid waste generation and procedure setting

The health care industry is a significant producer of solid waste, with hospitals serving as the second largest contributor of trash in the United States, following only the food industry.³⁷ A 2025 solid waste evaluation comparing identical hand procedures performed in a hospital operating room, ambulatory surgery center, and clinic-based procedure room demonstrated a stepwise reduction in waste generation with less resource-intensive environments: approximately 4.6 kg per case in the hospital operating room, 2.6 kg in the ambulatory surgery center, and 0.7 kg in the clinic.³⁸ Moving routine hand surgeries from a main operating room to a clinic setting can reduce solid waste by as much as 85% or approximately 3.9 kg per case.³⁸ This is largely due to clinic-based procedures using minor field sterility rather than full operating room sterility. Shifting from full operating room draping and gowns to minimal field sterility (mask, gloves, and a small drape) estimated to generate as little as one-tenth of the waste produced in standard theaters.³⁹ These findings highlight that environmental benefit is driven not only by anesthetic choice but also by procedure location, a variable that WALANT uniquely enables.

Carbon footprint reduction with WALANT

The transition to WALANT techniques significantly reduces the carbon footprint of surgical procedures by eliminating harmful anesthetic gases, minimizing solid waste generation, and reducing facility energy consumption.⁴⁰ A single operating room can potentially produce 2,300 kg of waste per year, and processing 1 kg of clinical waste produces approximately 3 kg of CO₂.⁴¹ Performing carpal tunnel release surgery in a clinic room instead of a main OR results in a 5-fold reduction in supply-associated greenhouse gas emissions.³⁸ Operating rooms typically consume three to six times more energy than standard clinical areas because of specialized lighting and high-volume heating, ventilation, and air conditioning requirements.^38,42 Moving routine cases to clinic-based procedure rooms (that do not require laminar airflow or complex ventilation) reduces energy expenditure.

Life-cycle assessments focused on carpal tunnel release have further quantified the environmental effect of WALANT. A recent study demonstrated an approximately 60% reduction in carbon footprint when carpal tunnel release was performed in a procedure room under WALANT compared with traditional operating room-based pathways.⁴³ Importantly, reductions were primarily attributable to lower energy consumption, fewer disposable supplies, and elimination of anesthetic-related materials.⁴³

Multiple additional analyses across hand and upper extremity procedures corroborate these findings, consistently showing that WALANT pathways generate less solid waste, fewer disposable items, and lower overall emissions compared with operating-room–based surgery using monitored anesthesia care or general anesthesia. Collectively, these data position WALANT as a tangible strategy for reducing the environmental burden of common hand procedures.^40,42,44, 45, 46, 47, 48

Practice-facing takeaway

From a sustainability standpoint, WALANT offers more than patient-level advantages. When combined with migration of appropriate cases to clinic-based or procedure room settings, WALANT can meaningfully reduce solid waste, energy utilization, and carbon emissions. These environmental benefits align closely with parallel reductions in cost and resource utilization, forming a natural bridge to the next thematic area: cost comparison and value-based care.

Theme 5: Cost comparison and value-based care

Parallel to its environmental advantages, WALANT has consistently demonstrated cost savings across a wide range of procedures, practice settings, and health care systems, positioning it as a high-value strategy in contemporary hand surgery. Importantly, savings are not limited to anesthetic supply costs alone but extend to decreased use of main operating room resources, reduced staffing requirements, lower material consumption, elimination of preoperative testing, minimized recovery room utilization, and improved perioperative throughput.

Direct procedural cost comparisons

Several recent comparative studies have quantified per-case cost differences between WALANT and traditional anesthetic pathways. For endoscopic carpal tunnel release, WALANT was associated with a mean total cost of $1,341compared with $1,634 for monitored anesthesia care, representing a meaningful per-case reduction.⁴⁹ Another study comparing costs during trapeziometacarpal joint replacement found WALANT to be nearly 19% less expensive than regional anesthesia.¹⁰ Similarly, a 2024 cost analysis of carpal tunnel release found that cases performed with monitored anesthesia care were approximately 35% more expensive than those performed under WALANT, driven primarily by anesthesia-related charges and operating room resource utilization.⁵⁰ In the United States, performing trigger finger release in a procedure room with WALANT resulted in a 77% cost reduction, saving approximately $3,344.46 per case compared to procedures performed in the main operating room.⁵¹

System-level savings through site-of-service optimization

Beyond individual procedural costs, WALANT enables migration of many procedures from the main operating room to procedure rooms or clinic-based settings, amplifying economic impact. Within a military health system, transitioning appropriate hand procedures from the operating room to a procedure-room model resulted in an estimated $232,411 in cost savings over a 4-month period, without compromising short-term outcomes.⁵² Similar findings have been reported internationally, where moving common hand procedures from a sedated main operating room environment to a local anesthesia procedure room model has resulted in substantial cost reductions while maintaining safety and patient satisfaction.53, 54, 55 These findings reinforce that site of service is a dominant driver of cost and that WALANT serves as a key enabler of this structural shift in surgical care delivery.

In the United States, an additional systems-level factor may further enhance the economic advantages of WALANT. In 2020, the Association of periOperative Registered Nurses updated national guidance to state that staffing for local anesthesia procedures may consist of a single RN circulator who simultaneously monitors, assess, and documents patient care while circulating.⁵⁶ This change substantially reduces staffing requirements and associated costs, further supporting the efficiency of procedure room-based WALANT pathways.

Dissemination of WALANT in the African continent

Beyond high-income systems, WALANT has demonstrated transformative economic implications in low-resource settings. In many lower-income economies, access to surgery is limited by the cost of anesthesiology teams and operating room infrastructure. WALANT has been described as a practical solution to the “vicious cycle of poverty and surgery,” wherein patients are unable to afford care and health systems lack the infrastructure to deliver it efficiently.⁵⁷ Since 2020, WALANT dissemination across Africa and other low-resource regions has accelerated. More than 25 educational webinars and hands-on courses have been delivered to African hand surgeons over the past 6 years. WALANT has now been adopted in at least 75 hospitals across eight East African countries, with the goal of reducing procedural costs and increasing surgical access.⁵⁷ In Kenya alone, 15 hospitals reported collective savings of approximately US $128,000 for economically disadvantaged patients during their initial years of WALANT implementation.⁵⁷ These data suggest that WALANT not only reduces costs but also makes surgery both affordable and accessible.

Value-based care implications

When interpreted through a value-based lens (outcomes relative to cost), the emerging literature supports WALANT as a dominant strategy for many common hand procedures:

• 1.Clinical outcomes and complication rates are comparable to traditional anesthesia (Theme 1).
• 2.Patient satisfaction is high (Theme 3).
• 3.Environmental burden is reduced (Theme 4).
• 4.Direct and indirect costs are lower.

Together, these attributes align WALANT closely with contemporary institutional priorities centered on efficiency, sustainability, and high-quality ambulatory care.

Practice-facing takeaway

Across multiple study designs and health care environments, WALANT consistently demonstrates lower costs without sacrificing outcomes, largely by eliminating anesthesia-related expenditures and facilitating care in lower-resource settings. For health systems pursuing scalable, value-based solutions in hand surgery, WALANT represents one of the most mature and evidence-supported pathways currently available.

Theme 6: Expanding applications of WALANT beyond the hand

Although WALANT was initially developed for procedures within the hand, contemporary literature increasingly demonstrates its feasibility and advantages across a broader range upper and lower extremity surgeries. These developments reflect a paradigm shift: WALANT is no longer limited by anatomic location, but rather by appropriate patient selection, procedural predictability, and surgical team experience.

WALANT has now been successfully applied to a wide spectrum of musculoskeletal procedures, including fracture fixation, ligament reconstruction, peripheral nerve decompression and nerve transfers, hyperselective neurectomy, tendon transfers, soft tissue reconstruction with grafts and flaps, selected amputations, and foot and ankle interventions.^25,58, 59, 60, 61, 62, 63, 64, 65, 66, 67, 68, 69, 70, 71, 72, 73, 74, 75, 76, 77, 78, 79 Importantly, this expansion is particularly relevant for patients who are poor candidates for general anesthesia and for health care settings with limited access to anesthesiology resources or specialized operating room infrastructure.

Practice-facing takeaways

These expanding indications underscore a unifying principle: WALANT is fundamentally a method for achieving effective surgical anesthesia with minimal physiologic disruption. However, broader application should not be interpreted as universal applicability. Success depends on careful patient selection, appropriate procedural indications, meticulous anesthetic technique, and coordinated teamwork. When used appropriately, WALANT is a versatile anesthetic approach that extends beyond the hand.

Conclusion

The contemporary WALANT literature reflects a field that has progressed beyond proof-of-concept and into a phase of evidence-driven maturation. Across multiple comparative trials, WALANT demonstrates noninferior safety and functional outcomes relative to traditional anesthetic strategies, with consistent advantages in intraoperative comfort, perioperative efficiency, and resource utilization.

Perhaps most striking is the rapid expansion of WALANT into pediatric populations and procedures beyond the hand and wrist, signaling that awake surgery is no longer confined to narrow indications. Instead, WALANT has emerged as a versatile anesthetic platform adaptable to a broad spectrum of upper extremity—and select nonupper extremity —procedures when applied thoughtfully.

From a practice standpoint, several unifying principles emerge:

• 1.Outcomes first: For many common procedures, WALANT provides outcomes comparable to regional or general anesthesia, supporting its routine consideration.
• 2.Patient centered: High satisfaction hinges on careful patient selection, expectation setting, and intraoperative communication.
• 3.Value driven: WALANT consistently lowers cost and resource utilization while simultaneously reducing environmental impact.
• 4.Workflow enabled: The greatest benefits are realized when WALANT is paired with migration of appropriate cases to procedure-room or clinic-based settings.
• 5.Technique dependent: Success is grounded in meticulous injection technique, appropriate buffering and timing, and reproducible protocols.

Taken together, WALANT should be viewed not simply as an alternative anesthetic choice, but as a comprehensive care pathway that aligns patient experience, surgical quality, sustainability, and value-based care. As the evidence base continues to grow, the central question is no longer whether WALANT works, but rather which patients and procedures stand to benefit most—and how best to implement it within diverse practice environments.

Conflicts of Interest

No benefits in any form have been received or will be received related directly to this article.