The Effect of WALANT vs Sedation on Opioid Use Following Upper Extremity Orthopedic Surgery

Grace Eddy

Thomas Jefferson University

SUMMARY POINTS

• In the climate of the opioid crisis, there is a need to determine factors influencing opioid use after upper extremity surgery.

• Wide Awake Local Anesthesia No Tourniquet (WALANT) is an effective form of anesthesia for upper extremity surgery.

• For certain upper extremity surgeries, WALANT can provide comparable pain relief to sedation-based techniques.

• There is inconsistent data on the superiority of WALANT versus monitored anesthesia care in terms of postoperative opioid use. 

• Local anesthesia may result in less opioid use than local anesthesia with sedation for all upper extremity surgeries. 

ANALYSIS

Background

Opioid use and its consequences have gained significant attention in recent years. From 1999–2020, more than 564,000 people died from an overdose involving any opioid, including prescription and illicit opioids (Figure 1). Opioid addiction and overdose deaths have become pressing public health concerns, warranting a greater understanding of the factors influencing opioid use (1). 

Upper extremity surgeries (UES) are common surgical interventions that require postoperative pain management (2). Although opioids have historically been the primary analgesic prescribed for managing postoperative pain, the potential for diversion and abuse requires providers to utilize treatment strategies that minimize opioid use. Despite efforts to do so, there is limited research exploring perioperative factors that affect opioid use after UES. 

Wide-awake Local Anesthesia No Tourniquet (WALANT) utilizes local anesthetic and hemostatic agents to create optimal conditions for hand surgery (3). The present analysis reviews the impact of local anesthesia such as WALANT versus traditional sedation on opioid use following UES.

Figure 1. Three Waves of Opioid Overdose Deaths. SEE ARTICLE from CDC (1)

Analysis

Multiple studies have investigated differences in postoperative pain outcomes in patients undergoing UES between those who receive sedation and those who receive local anesthesia only. In a 2017 prospective cohort study of patients undergoing open carpal tunnel release (CTR), Tulipan et al. reported that patients under monitored anesthesia care (MAC), a type of sedation, reported significantly lower pain levels compared to WALANT patients during their two-week follow-up. However, no significant differences in pain outcomes were observed between the two groups at the three-month mark (5). The same group conducted a similar study on endoscopic CTR the following year, which demonstrated no statistically significant difference in postoperative pain outcomes between the local anesthesia with sedation and local anesthesia groups at the 2-week or 3-month time points (6). Selection bias should be considered when evaluating the two aforementioned studies, as anesthesia type was chosen through a patient-physician discussion rather than randomly. 

In 2021, a randomized control trial by Via et al. showed no difference in postoperative pain following bilateral CTR between local-only anesthesia and sedation groups (7). A prospective study by Dar et al. compared mean visual analog scale scores for all hand surgeries between patients who received WALANT versus those who received MAC. The average postoperative pain score for the WALANT group was recorded as 0.37, which was lower than the average scores of patients who received MAC, both with and without postoperative opioid usage (8). This indicates that for all hand surgeries, WALANT may result in better postoperative pain control than MAC, regardless of opioid use.

Beyond postoperative pain, a handful of studies have investigated opioid use following UES. A prospective study by Miller et al. evaluating opioid consumption following open CTR and trigger finger release (TFR) surgeries found results suggesting that opioid consumption was similar between patients that received WALANT and those that received MAC (9). This data was supported by another study by Chapman et al, which prospectively evaluated opioid consumption following CTR. This study found that among all cases performed, there was no statistically significant difference in the mean number of opioid pills consumed between patients receiving WALANT versus MAC (10). Opioid utilization following all UES was prospectively studied by Kim et al., who found that patients receiving local anesthesia consumed less opioid pills on average than did those receiving local anesthesia with sedation (11). In 2021, Aultman et al. evaluated the effect of WALANT versus MAC on CTR postoperative outcomes, including opioid use. This prospective study identified that on average 5.5 less morphine milligram equivalents (MME) were prescribed following WALANT and that 3.6 more MMEs remained at first postoperative visit (12). The above studies carry conflicting results regarding the effect of WALANT vs MAC on opioid use following UES. 

Author and Year	Method	Purpose	Sample	Key Finding
Tulipan (2017)	Prospective cohort	Investigate WALANT vs MAC outcomes for open CTR	81 WALANT, 149 MAC	MAC pain < WALANT pain @ 2 weeks, MAC pain = WALANT pain @ 3 months
Tulipan (2018)	Prospective cohort	Investigate local vs local + sedation outcomes for endoscopic CTR	62 local only, 94 local with sedation	local pain = local + sedation pain @ 2 weeks, 3 months
Via (2020)	Randomized trial	Compare local vs local + sedation patient experience for bilateral CTR	31	local pain = local + sedation pain postop
Dar (2021)	Prospective cohort	Compare WALANT vs MAC postop pain for UES	94 WALANT, 125 MAC	WALANT pain < MAC pain postop
Miller (2017)	Prospective cohort	Compare WALANT vs MAC postop opioid consumption for TFR and open CTR	181 WALANT, 235 MAC	WALANT opioid consumption = MAC opioid consumption
Chapman (2017)	Prospective cohort	Compare WALANT vs sedation postop opioid consumption for CTR	78 WALANT, 198 sedation	WALANT opioid consumption = MAC opioid consumption
Kim (2016)	Prospective cohort	Evaluate opioid consumption patterns following UES	286 local only, 601 local + sedation	local only opioid consumption < local + sedation opioid consumption
Aultman (2021)	Prospective cohort	Compare WALANT vs MAC and open CTR vs endoscopic CTR pain outcomes	31 WALANT, 62 MAC	WALANT opioid consumption < MAC opioid consumption

Discussion

One of the key conclusions of the papers analyzed relates to postoperative pain outcomes. The study by Tulipan et al. suggests that although there may be short-term variations in pain experience, the overall pain outcomes between WALANT and sedation approaches tend to converge over time. Similarly, the study on endoscopic CTR conducted by the same group did not find any significant differences in pain outcomes between the local anesthesia with sedation and local anesthesia-only groups at both the two-week and three-month time points. These findings imply that for certain UES, WALANT can provide comparable pain relief to sedation-based techniques.

These findings were not replicated when the same research topic was investigated across all hand surgeries. The lower average pain score recorded for the WALANT group when compared to the MAC group in Dar et al.’s study implies superior postoperative pain management of this technique. It is worth considering the factors that may contribute to the observed differences in pain outcomes, such as the specific surgical procedure, individual patient characteristics, and variations in the administration of anesthesia.

Beyond pain outcomes, the studies reviewed differences in postoperative opioid use. The study by Miller et al. and the study by Chapman et al. both found that there were no statistically significant differences in opioid consumption between patients receiving WALANT and those receiving MAC for CTR. However, the finding from the study by Aultman et al. that a greater number of MMEs remained at the patients' first postoperative visit after CTR under MAC suggests that WALANT may contribute to a decreased reliance on opioids for postoperative pain management. When this research topic was expanded to all UES, as was done by Kim et al., the findings suggested that the use of local anesthesia resulted in less postoperative opioid use than did sedation. Due to inconsistencies in these findings, further investigation into differences in postoperative opioid use between WALANT and MAC-assisted UES is warranted, especially through a randomized control trial in order to provide a higher level of evidence for a causal relationship.

REFERENCES

1. Understanding the Opioid Overdose Epidemic | Opioids | CDC. Accessed June 19, 2023. https://www.cdc.gov/opioids/basics/epidemic.html

2. Labrum JT 4th, Ilyas AM. Perioperative Pain Control in Upper Extremity Surgery: Prescribing Patterns, Recent Developments, and Opioid-Sparing Treatment Strategies. Hand (N Y). 2019;14(4):439-444. doi:10.1177/1558944718787262

3. Fish MJ, Bamberger HB. Wide-Awake Local Anesthesia No Tourniquet (WALANT) Hand Surgery. [Updated 2023 Apr 17]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK570646/

4. Garmon EH, Huecker MR. Topical, Local, and Regional Anesthesia and Anesthetics. In: StatPearls. Treasure Island (FL): StatPearls Publishing; April 9, 2023.

5. Tulipan JE, Kim N, Abboudi J, et al. Open Carpal Tunnel Release Outcomes: Performed Wide Awake versus with Sedation. J Hand Microsurg. 2017;9(2):74-79. doi:10.1055/s-0037-1603200

6. Tulipan JE, Kim N, Ilyas AM, Matzon JL. Endoscopic Carpal Tunnel Release with and without Sedation. Plast Reconstr Surg. 2018;141(3):685-690. doi:10.1097/PRS.0000000000004113

7. Via GG, Esterle AR, Awan HM, Jain SA, Goyal KS. Comparison of Local-Only Anesthesia Versus Sedation in Patients Undergoing Staged Bilateral Carpal Tunnel Release: A Randomized Trial. Hand (N Y). 2020;15(6):785-792. doi:10.1177/1558944719836237

8. Dar QA, Avoricani A, Rompala A, et al. WALANT Hand Surgery Does Not Require Postoperative Opioid Pain Management. Plast Reconstr Surg. 2021;148(1):121-130. doi:10.1097/PRS.0000000000008053

9. Miller A, Kim N, Ilyas AM. Prospective Evaluation of Opioid Consumption Following Hand Surgery Performed Wide Awake Versus With Sedation. Hand (N Y). 2017;12(6):606-609. doi:10.1177/1558944716677536

10. Chapman T, Kim N, Maltenfort M, Ilyas AM. Prospective Evaluation of Opioid Consumption Following Carpal Tunnel Release Surgery. Hand (N Y). 2017;12(1):39-42. doi:10.1177/1558944716646765

11. Kim N, Matzon JL, Abboudi J, et al. A Prospective Evaluation of Opioid Utilization After Upper-Extremity Surgical Procedures: Identifying Consumption Patterns and Determining Prescribing Guidelines. J Bone Joint Surg Am. 2016;98(20):e89. doi:10.2106/JBJS.15.00614

12. Aultman H, Roth CA, Curran J, et al. Prospective Evaluation of Surgical and Anesthetic Technique of Carpal Tunnel Release in an Orthopedic Practice. J Hand Surg Am. 2021;46(1):69.e1-69.e7. doi:10.1016/j.jhsa.2020.07.023