key: cord-0014976-nlctfhoz
authors: Masterton, Gary; Talwar, Cyrus
title: WALANT in plastic surgery trauma – why wait?
date: 2020-12-14
journal: J Plast Reconstr Aesthet Surg
DOI: 10.1016/j.bjps.2020.11.023
sha: b685aade788014104bb853a14b6e3204a0eeda78
doc_id: 14976
cord_uid: nlctfhoz

nan

Dear Sir,

We read with great interest the article on reorganisation to a local anaesthetic trauma service improves time to treatment during the COVID-19 pandemic -experience from a UK tertiary Plastic Surgery centre. 1 We commend the authors on their succinct work providing statistical evidence to support the widely perceived and observed reduction in trauma patients presenting to Plastic surgery departments within the UK during the COVID-19 pandemic. We found it intriguing that the authors were able to demonstrate that this reduction in trauma patient presentation to their centre was sustained until week 7 of the 'lock-down' and we wondered if this was reflective of other Plastic surgery departments with the UK. Perhaps this could be further explored by expanding their work to incorporate other Plastic surgery centres, both regionally and nationally. A more expansive, multicentre study could be performed, to gauge the impact that the COVID-19 pandemic 'lock-down' has had on the number of Plastic surgery trauma presentations throughout the UK. This is something we feel would not only be of interest but could be useful for service provision planning throughout impending local, or even future national 'lock-downs'.

We share the same sentiments as the authors, and are also advocates for the case appropriate, use of wide-awake local anaesthetic with no tourniquet (WALANT). We are unsurprised by the authors results demonstrating a reduction in treatment time with the use of WALANT in Plastic surgery trauma. We do however have some reservations about the use of WALANT in traumatic cases involving flexor tendon injuries and would like to examine the authors' data on this in more detail; to understand the zone and extent of tendon injuries. These procedures are more traditionally performed with a general anaesthetic (GA) as flexor tendon injuries can often involve a more extensive dissection to retrieve the retracted, proximal tendon end which can be more difficult 2 without the use of tourniquet; and would involve an evolving administration of local anaesthetic to facilitate each incision. We appreciate that there is a growing evidence base for the appropriate use of WALANT in some flexor tendon injuries. 3 We note that the authors do state that their service is consultant-led which would perhaps further support and facilitate WALANT in more complex flexor tendon injuries. However interrogation of the authors' data would be warranted to understand the nature of the flexor injuries included in this study which could perhaps encourage other Plastic surgical departments to review their own practice with regards to the use of WALANT in similar cases.

We were impressed with the authors overall results showing a significant improvement in timely service provision for plastic surgery trauma cases and would like to suggest that this work could be developed further by exploring the cost implications of WALANT versus GA in Plastic surgery trauma. There is already literature support for the use of WALANT with regards cost and efficiency. 4 With no need for anaesthetic colleagues, monitoring, anaesthetic drugs and prolonged recovery post-operatively; we believe that WALANT would undoubtedly demonstrate cost-effectiveness with respect to service provision for Plastic surgery trauma. In addition a further consideration could be made by the authors to develop and incorporate a patient satisfaction survey to gain some quantitative data that could be utilised to further support the wide spread development and implementation of WALANT services throughout Plastic surgery departments within the UK.

None. 

Reorganisation to a local anaesthetic trauma service improves time to treatment during the COVID-19 pandemic -experience from a UK tertiary Plastic Surgery centre

Primary repair of lacerated flexor tendons in" no man's land

Wide-awake primary flexor tendon repair, tenolysis, and tendon transfer

A cost and efficiency analysis of the WALANT technique for the management of trigger finger in a procedure room of a major city hospital