WALANT vs Axillary Block for Dual‑Mobility TMC Prosthesis

A small prospective observational cohort compared wide-awake local anesthesia no tourniquet (WALANT) with an ultrasound-guided axillary brachial plexus block during implantation of a dual‑mobility TMC prosthesis for thumb basal joint arthritis. The report included 21 patients, split between WALANT (n=11) and axillary block (n=10). During surgery, the authors described similar patient-reported analgesia between techniques, presented as a between-group comparison rather than an equivalence claim. The study was framed as an exploratory assessment in routine practice, comparing local field infiltration without a tourniquet with a regional block strategy for the same arthroplasty procedure.

The authors describe a prospective, observational, non-randomized comparison conducted at two hospitals, with group assignment based on patient preferences and clinical considerations. WALANT was delivered as field infiltration using 1% mepivacaine combined with epinephrine (1:100,000) and sodium bicarbonate, followed by a waiting period before incision; no sedatives, additional analgesics, or tourniquet were used. The block group received premedication and an ultrasound-guided axillary brachial plexus block with ropivacaine (0.5–0.7%), with tourniquet use per protocol. Pain was recorded on a 0–10 VAS during anesthetic administration, during surgery, and 3 hours after the procedure; induction pain was reported as 3.18±2.89 versus 2.20±2.37 (p=0.393). Intraoperative pain was reported as 2.27±1.79 with WALANT versus 2.00±2.71 with axillary block (p=0.898), which the authors describe as not statistically different.

Pain outcomes were assessed through 3 hours postprocedure. Over this early window, the authors reported no anesthetic failures, no conversions to general anesthesia, and no neurologic or ischemic complications in either group.

Within this cohort, the authors also reported no cases requiring procedure suspension because of pain or bleeding. In the context of concerns about ischemia, they similarly reported no neurologic complications and no ischemic complications in either group during early follow-up. These observations were presented descriptively as a short-term safety profile for the two anesthetic approaches in this small sample.

Early postoperative pain at 3 hours differed numerically between groups, with the authors reporting a non-significant trend toward lower pain in the axillary brachial plexus block group (VAS 3.00±3.08) compared with WALANT (VAS 4.36±2.54; p=0.244). The protocols used different local anesthetics (mepivacaine for WALANT and ropivacaine for axillary block), and postoperative pain at 3 hours numerically favored the block group. The authors also described workflow-related observations associated with WALANT, including operating without a tourniquet and the opportunity for intraoperative functional testing with a cooperative patient. The paper notes limitations including small sample size, non-random allocation, and brief early follow-up, which the authors characterize as making the findings preliminary and hypothesis-generating.

Key Takeaways:

• The cohort report described similar intraoperative VAS-measured analgesia between WALANT and axillary block during dual-mobility trapeziometacarpal arthroplasty.
• At 3 hours postprocedure, postoperative pain values numerically favored the block group.
• No failures, conversions, or neurologic/ischemic complications were reported over the 3-hour follow-up window; the authors also described the findings as preliminary given the small, non-randomized sample.