A Systematic Review and Meta-Analysis of Randomized Controlled Trials Comparing WALANT to Traditional Anesthesia in Hand Surgery.

Abstract

Wide-Awake Local Anesthesia No Tourniquet (WALANT), offers a promising alternative to non-WALANT techniques, including tourniquet-assisted local or general anesthesia in upper limb surgeries. This systematic review and meta-analysis (SRMA) evaluated pain scores and complication rates in surgeries performed under WALANT vs tourniquet use. Following PRISMA guidelines, this PROSPERO-registered (CRD42023412583) SRMA searched Medline, Embase, Cochrane, Web of Science, and Scopus through November 2024, including randomized controlled trials (RCTs) comparing WALANT and tourniquet use in upper limb surgeries. Pain scores during injection, intra- and postoperatively, and complication rates, were analyzed. Eleven RCTs with 794 patients (400 WALANT, 394 tourniquet) were analyzed. WALANT significantly reduced intraoperative pain (SMD -2.56, 95% CI -3.76 to -1.36, p < 0.01) and early postoperative pain (0-6 hours; SMD -1.37, 95% CI -2.61 to -0.12, p < 0.01). The reduction in early postoperative pain did not exceed the established MCID of 1.6. Similarly, reductions in pain during injection (SMD -1.05, 95% CI -2.27 to 0.16, I2 = 92%) and in the late postoperative period (6-12 hours; SMD -0.83, 95% CI -1.10 to -0.57) did not reach the threshold for clinical significance. Overall complication rates were similar between groups (RR 0.80, 95% CI 0.57 to 1.12) and remained consistent regardless of sodium bicarbonate use (RR 0.71, 95% CI 0.40 to 1.26). WALANT is a safe and effective alternative to the non-WALANT techniques, including tourniquet-assisted local or general anesthesia method for upper limb surgeries, offering significant pain reduction that exceeds the MCID intraoperatively.