Office-based Orthopaedic Surgery: WALANT and Beyond
Office-based orthopaedic surgery (OBOS) was historically limited to superficial mass excisions and other minor surgeries that could be done within the time constraints of a tourniquet. The development of wide-awake local anesthesia with no tourniquet (WALANT) removed that constraint and expanded the scope of OBOS in fully awake patients. Considering that WALANT was developed within the field of hand surgery, hand surgeons are the leaders in OBOS and have enjoyed the most benefits. OBOS is not limited to hand surgery, however, and can be easily applied in foot and ankle surgery and other fields. OBOS currently includes a wide range of procedures such as carpal tunnel and trigger finger release, reduction and fixation of finger and distal radius fractures, flexor and extensor tendon repairs, Dupuytren’s contracture release, and cubital tunnel release.
Although WALANT and OBOS are closely related, they are not the same, as WALANT can be done in any setting. They both have the benefits of eliminating general anesthesia as well as sedation and prerequisites, such as preoperative workup (e.g., laboratory testing, electrocardiogram [EKG], chest X-ray), medical clearance, and preoperative history and physical examinations. Add to that the benefit of extra time for patient education during surgery. For many patients, though, wide-awake surgery is still performed at the hospital and follows hospital protocols. OBOS comes with its own set of benefits and deserves its own consideration. For a start, surgery can be done during the same office visit.
Transitioning to OBOS eliminates the need to change into patient gowns and remove accessories; needle sticks and intravenous (IV) lines; application of EKG leads; application of an electrocautery patch; and removal of all later on. Patients do not need to follow the instructions “nothing by mouth.” Monitor beeps are replaced with music. Surgery is done in a comfortable recliner instead of on an operating table. With no sedation nor narcotics, patients can leave immediately. Often, patients can drive themselves home. In short, patients walk in, have surgery, and walk out. They are usually surprised when they learn of the aforementioned OBOS perks.
At the surgeon level, the most obvious OBOS benefit is the elimination of many pre-, intra-, and postoperative routines that are irrelevant for wide-awake surgery. There is no need for last-minute testing (pregnancy tests), and documentation is a lot simpler. There is no need to wait for other providers (anesthesiologists) to visit with the patient before the procedure. The whole process is a simple stop for consent, followed by a walk over to the procedure room. This can all occur during the initial visit. The result is reduced burden on surgeons as well as nursing staff and faster care and throughput.
At the facility level, OBOS requires less staffing, time, and space, as it eliminates significant portions of perioperative nursing services. I have seen a more than 50 percent decrease in time spent by patients in the facility. OBOS requires fewer supplies compared to standard operating room (OR) packages and thus generates less surgical waste. This allows better allocation of resources and creates cost savings to the healthcare system and payers. Our service demonstrated a more than 60 percent decrease in facility charges compared to the outpatient surgery department. OR availability can be a major incentive to switch to OBOS, as OBOS frees up ORs for other surgeries. Volume is important to make ORs cost-effective and should be assessed by the practice administrator. Rooms used for OBOS can be shared by multiple surgeons and nonsurgeons such as pain specialists and can be used for other purposes such as electrodiagnostic testing. Professional fees are equivalent to hospital-based surgery, but facility fees are lower in comparison.
Office-based surgery has two requirements: a dedicated, well-equipped procedure room and a willing, well-prepared surgeon.
The procedure room is a dedicated room that is properly equipped and compliant with current regulations, as specified by state and federal laws as well as The Joint Commission, Centers for Medicare & Medicaid Services, and other regulatory bodies. It should also be compliant with institutional bylaws and infection-control standards. It should be equipped with a basic operating setup, including a light source, recliner chair, sterile drapes, supplies and instruments, and a surgical table. Other resources such as a mini C-arm, a tourniquet, and bipolar cautery may be required.*
The surgeon requirements include the ability to operate on an awake and fully aware patient. I was once told, “There are no ‘oops’ in surgery.” This idiom has new meaning in OBOS, as patients can be disturbed by innocent discussions such as benign frustration with equipment. Patients listen to and participate in conversations, so OBOS etiquette is more refined than in the OR. The surgeon has to be comfortable with vasovagal or anxiety reactions, should they occur. Lastly, the surgeon has to be able to handle potential intraoperative difficulties, such as patient discomfort due to positioning. Whereas intubated patients do not complain about body aches, awake patients do.
I routinely screen patients for shoulder and back pain and even invite them to try the chair to make sure they will be comfortable during surgery (especially during a cubital tunnel release, which requires shoulder external rotation). Preoperative evaluation, consent, and administration of local anesthesia can be done in a regular office room before and between cases to optimize the efficiency of the procedure room. The patient is then escorted to the procedure room and prepped and draped for surgery. Once surgery is completed, the patient is routinely released home directly from the procedure room.
OBOS is surgery and should be compliant with all surgical and medicolegal standards, including a fully executed and documented informed consent process. It also requires prior authorization. Liability concerns are the same as those with OR surgery, with minor variations. The WALANT surgical field is “wet” and different for the untrained eye, which may increase complications. There is a risk of not being able to complete the procedure as planned. There may also be an increased risk of infection, as no preoperative antibiotics are given (no IV). The literature does not describe an increase in any of those risks and supports no need for antibiotics for soft-tissue surgeries of the hand. Our service has not experienced any increase in complications and has had no OBOS-related litigation.
For a successful OBOS program, you must have sufficient volume. Tourniquet-dependent OBOS may not be enough to make the room cost-effective. Adopting WALANT, on the other hand, multiplies the number of surgeries and is highly recommended. Incorporating WALANT into surgical practice should occur in a stepwise fashion, starting in the OR. As confidence builds, the tourniquet and general anesthesia can be eliminated gradually, followed by a transition to OBOS.
WALANT is one of the most impactful recent developments in orthopaedic surgery, and its benefits can only be multiplied when extended to OBOS. The convenience and cost savings of OBOS are being noticed, and the continued shift in payment models will make OBOS increasingly relevant in the near future. Future development may include limited expansion into large joints (shoulder and knee) and ultrasound-guided procedures.
*I do not use a tourniquet nor electrocautery, and I use a headlight exclusively. Surgeon preferences and needs vary.
Shafic A. Sraj, MD, is an orthopaedic hand and upper-extremity surgeon at West Virginia University. He has been the lead surgeon championing wide-awake surgery and OBOS in the Department of Orthopaedics since 2016.
- Lalonde DH: Conceptual origins, current practice, and views of wide awake hand surgery. J Hand Surg Eur Vol 2017;42:886-95.
- Tosti R, Fowler J, Dwyer J, et al: Is antibiotic prophylaxis necessary in elective soft tissue hand surgery? Orthopedics 2012;35:e829-33.
- Bykowski MR, Sivak WN, Cray J, et al: Assessing the impact of antibiotic prophylaxis in outpatient elective hand surgery: a single-center, retrospective review of 8,850 cases. J Hand Surg Am 2011;36:1741-7.