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Abstract

Introduction:

The wide-awake-local-anaesthesia-no-tourniquet (WALANT) technique is increasingly used in hand surgery, avoiding general or regional anaesthesia and upper arm tourniquets. Clinical and economic benefits have been shown especially for trigger finger and carpal tunnel release; however, its impact on fracture treatment warrants evaluation.

Methods:

We conducted a single-centre retrospective analysis of 921 metacarpal and phalangeal hand operations for fracture treatment, including both fixation and removal of metalwork. The operation time and cost of procedures performed under WALANT were compared with those using regional anaesthesia (RA) with brachial plexus block. Reimbursement for the procedures were compared with the cost.

Results:

The WALANT technique significantly reduced the operation time and treatment cost compared with RA. However, we found that the reimbursement structure did not fully cover the procedural expenses in either group. Despite this, WALANT reduced financial deficits, demonstrating superior cost-effectiveness.

Conclusion:

In addition to reducing operative time and overall procedural costs, WALANT decreased dependence on anaesthesia capacity, thereby improving the efficiency of surgical workflows. This approach also promotes a more sustainable model of healthcare delivery by minimizing resource consumption and simplifying logistics. Moreover, its cost-effectiveness may enhance the long-term economic feasibility of reimbursement and funding systems within modern healthcare structures.

Level of evidence:

Keywords

Cost-effectiveness economic analysis local anaesthesia metacarpal surgery phalangeal surgery public healthcare re-imbursement WALANT

Introduction

In 2023, healthcare expenditure in Germany reached a record high of €500.8 billion, 12.0% of the country’s gross domestic product (GDP), equivalent to €6013 per capita (Destatis, 2025). Germany has the most expensive healthcare system in Europe; worldwide, only the United States spends a higher percentage of its GDP on healthcare (16.6%) (OECD, 2023). To ensure sustainability, healthcare systems must reduce costs or optimize resource use to maintain affordability.

The wide-awake-local-anaesthesia-no-tourniquet (WALANT) technique allows procedures to be performed under local anaesthesia with epinephrine, without sedation or a tourniquet, with patients fully awake and responsive during the operation (Lalonde et al., 2005). Previous concerns about impairment of finger perfusion from the use of adrenaline have been dispelled (Moog et al., 2021).

Over the past two decades, there has been an increase in the number of scientific papers reporting the increasingly diverse procedures that can be performed under WALANT, including tendon grafts and trapeziectomy (Codding et al., 2017; Feldman et al., 2020; Gueffier et al., 2021; Kazmers et al., 2018; Lalonde and Martin, 2014; McKee and Lalonde, 2017; Sawhney et al., 2024; Tang et al., 2019). The COVID-19 pandemic then contributed to the broader adoption of WALANT, avoiding the need for intubation (Alves et al., 2021).

Moreover, WALANT improves efficiency by eliminating the need for an anaesthetist and allowing surgery outside the main operating theatre (Turcotte et al., 2021). It reduces anaesthetic risks associated with regional or general anaesthesia, as patients remain conscious with intact protective reflexes (Huang et al., 2018). Cost-effectiveness has been confirmed by multiple studies across a variety of soft tissue procedures, most commonly trigger or carpal tunnel release (Alter et al., 2018; Bravo et al., 2022; Codding et al., 2017; de Boccard et al., 2021, 2025; Lalonde and Martin, 2014; Lin et al., 2021; Maliha et al., 2019). Fracture treatment requires more complex infrastructure, including fluoroscopy and implants.

The aim of this study was to evaluate the cost-effectiveness of WALANT in hand surgery, focusing on fracture management of the metacarpals and proximal phalanges.

Material and methods

Study population

This retrospective study included patients who underwent hand fracture fixation or removal of metalwork at a university hospital in Germany over a 9 year period. Patients were identified using International Classification of Diseases codes and Operations and Procedure codes. To ensure comparability of reimbursement, only patients with statutory health insurance, financed by the national health fund, were included in the study. Patients with private health insurance were excluded, since additional costs may be charged, depending on the individual insurance plan. Additional exclusions were: patients under the age of 10; those undergoing multiple procedures; patients with a prolonged inpatient stay (> 3 days) to avoid cost bias from complications; and cases which could not be billed completely owing to overdue payment deadlines or incomplete documentation. Patients were then grouped according to type of anaesthesia: WALANT or regional anaesthesia (RA) using brachial plexus block.

Analysed procedures and diagnoses

The International Classification of Diseases and Operations and Procedure codes used to identify the patients are presented in the Supplementary Table 1. Four categories of metacarpal and phalangeal procedures were analysed: K-wire removal; plate removal; closed reduction with K-wiring; and open reduction with plate fixation. Plate fixation was performed in both inpatient and day-case settings, whereas all others were treated as day cases only. Because of different reimbursement systems for inpatients and day cases, plate fixation was analysed separately to ensure comparability.

Data extraction

For each case, we recorded sex, age, operative time, defined as time from incision to skin closure, diagnosis related group (DRG) codes used for inpatient billing, length of stay and the reimbursement received from statutory insurance. The total costs included theatre and personnel costs, cost of materials including local anaesthesia, laboratory, radiology, anaesthesia, inpatient stay and other expenses. The financial profit was defined as the difference between total costs and reimbursement.

Statistics

A normal distribution was confirmed using quintile–quintile plots. The mean values of the populations were compared using unpaired, two-tailed Welch’s t-tests. Fisher’s exact tests were used to analyse the gender distribution of the individual patient groups. A p-value of p < 0.05 was considered statistically significant.

Results

Patient demographics

A total of 921 cases were included. Of these, 643 patients were treated under regional anaesthesia and 278 under WALANT. The types of procedure under each technique are shown in Table 1. The gender distribution showed a generally higher proportion of male patients in each surgical group regardless of the anaesthesia type, indication a valid group comparability.

Table 1.

Patient and procedure characteristics.

Procedure	n WALANT (RA)	Mean age (years)	Operative time (min)	Total costs (€)	Reimbursement (€)	Net balance (€)
K-wire removal	99 (160)	44 (42)	19 (27)	424 (974)	257 (381)	–167 (−593)
Plate removal	31 (73)	40 (41)	31 (38)	560 (949)	400 (494)	–160 (−455)
K-wire fixation	77 (204)	44 (38)	27 (38)	598 (1300)	493 (741)	–105 (−566)
Plate fixation (day case)	29 (76)	39 (41)	48 (61)	961 (1787)	509 (680)	−452 (−1107)
Plate fixation (inpatient)	42 (130)	53 (43)	53 (78)	1526 (2526)	2564 (2425)	+1038 (−101)

Data is presented as means of WALANT (RA); bold indicates significance of p < 0.05 (WALANT vs. RA). Detailed SD values and cost components are provided in Supplementary Table 2.

RA, Regional anaesthesia; WALANT, wide-awake-local-anaesthesia-no-tourniquet.

Surgery time and surgery costs

Across all procedural groups, operations performed under WALANT had shorter operation times compared with those under RA. The reductions were greatest for K-wire removal and closed reduction with K-wire fixation, where operative time decreased by 28 and 29% respectively. Open reduction with plate fixation demonstrated a 22% reduction in operation time for day case and 33% for inpatient procedures. In contrast, plate removal showed a smaller, non-significant reduction of 17%. Within the WALANT group, operation times were similar for day-case and inpatient procedures. In the RA group, however, inpatient cases took 29% longer than day-case procedures (Table 1).

In line with these time savings, surgical costs were lower across most WALANT procedures. Wire removal costs were reduced by 24%, while K-wire and plate fixation costs were decreased by 27 and 22–29%, respectively, depending on whether the procedure was conducted as a day case or inpatient. Only plate removal procedures showed a 15% higher cost under WALANT, although this difference was not statistically significant (Supplementary Table 2).

Additional costs

In addition to surgical costs, additional expenses such as material costs, laboratory costs, radiology costs and miscellaneous costs were combined and analysed. These were reduced in all WALANT procedures; however, this only reached statistical significance for K-wire removal, fixation and inpatient plate fixation (Supplementary Table 2).

Total costs

Total costs, including surgical, anaesthesia, additional and inpatient expenses, were significantly lower for WALANT, with savings between 40 and 56%, greatest for K-wire removal and fixation (Table 1).

Reimbursement and profit results

Reimbursement differed between day case and inpatient. Day-case operations performed under RA achieved higher reimbursement, typically 19–33% more than the WALANT group, owing to the additional lump sum granted for anaesthesia. Inpatient procedures, reimbursed under the DRG system, showed no significant difference in reimbursement between WALANT and RA, as both techniques receive identical DRG-based payments (Table 1).

Despite these lower reimbursements for day cases, the overall financial balance was clearly more favourable for WALANT. Inpatient plate fixation under WALANT achieved a mean profit of about €1000 per case, while the RA group showed a mean loss of around €100. For day-case procedures, losses were consistently reduced under WALANT: by about 60% for K-wire removals (a reduction of roughly €425 per case), 65% for plate removals and up to 81% for K-wire fixation, which showed the smallest remaining deficit. Plate fixation performed as a day case also benefited, with losses halved compared with RA procedures (Table 1).

Overall, although WALANT day-case procedures generate lower reimbursement because of the absence of anaesthesia costs, the reduced total costs resulted in a significantly improved financial outcome across all surgical categories.

Discussion

This study shows that WALANT reduces operative time, overall costs and hospital financial losses compared with RA. The effect was consistent across all day-case procedures, with the greatest benefit observed in plate fixation. Inpatient plate fixation was the only procedure to achieve a net profit under WALANT. These findings highlight the potential of WALANT to improve both the clinical and economic efficiency of hand surgery in a tertiary care hospital setting.

When comparing our results with existing literature, several consistent patterns emerge. Many studies have confirmed the safety, feasibility and cost-effectiveness of WALANT in various types of hand surgery. In contrast to our results, Lin et al. (2021) found no difference in the surgical time in a cohort of 63 patients undergoing metacarpal plate fixation, but a significantly shorter preparation time for anaesthesia with WALANT. Conversely, Yen et al. (2020) found significantly shorter operating times for arthroscopic ganglion excision under WALANT. Our study also shows that K-wire removal, as well as K-wire and plate fixation, are significantly faster using the WALANT technique.

Several factors may have influenced these time differences. The use of a tourniquet is associated with additional surgical steps such as haemostasis after removal. Inflation and deflation, however, occurred outside the measured operative time, and therefore have no influence. More likely, the difference reflects a combination of factors: before the introduction of theatre management protocols in 2019, the point of operative time measurement sometimes included preparatory steps; interruption of RA cases to give supplementary sedation while operation time continued to run; and potential selection bias, with more complex or anxious patients treated under RA. On the other hand, limited WALANT capacity meant that some minor cases were still performed under RA.

Previous studies have shown that WALANT procedures can lead to cost savings by decreasing the amounts of materials used and avoiding otherwise mandatory preoperative examinations. This study has shown lower additional costs in the WALANT group for K-wire removal and fixation, and inpatient plate fixation, consistent with other studies (Far-Riera et al., 2019, 2023; Lalonde and Martin, 2014; Leblanc et al., 2007; Rhee et al., 2017; Segal et al., 2022).

Anaesthetic costs accounted for approximately 70% of the cost difference between WALANT and RA in our cohort, with anaesthetic costs ranging from €439 to €596. Applied across the study period, this resulted in a direct saving potential of €35,603 per year with the use of WALANT instead of RA.

Few studies report on the cost of WALANT fracture management. Gillis and Williams (2017) reported a significant reduction of around CAD$200 for closed fracture under WALANT in an operating theatre. Chen et al. (2025) calculated additional anaesthetic costs of approximately USD$350 for plate fixation of phalangeal fractures. In our cohort, the use of WALANT yielded total cost savings between 41 and 59%, with the greatest per-patient savings seen for plate fixation (€1000 inpatient; €826 day case) and K-wire fixation (€702). Our study expands on existing evidence by demonstrating consistent cost savings for both fixation and implant removal procedures.

Reimbursement differences between day cases and inpatient procedures resulted in lower revenue for all day-case surgeries in the WALANT groups. Day-case surgery and anaesthesia costs are reimbursed separately, with higher overall revenue when an anaesthetist is required. For inpatient procedures, revenue for both WALANT and RA procedures are reimbursed based on the same DRGs.

This study has shown a general financial loss across all operations. The only procedure with an actual profit was inpatient plate fixation performed under WALANT, which was responsible for an overall positive financial outcome in the WALANT group (Table 2). Owing to recent policy changes, these operations are now almost always reimbursed as day-case procedures. Inpatient stays are only allowed in rare cases. As a result, the operations that previously generated profit will no longer appear in this form. Despite this shift, WALANT still provides clear economic advantages by reducing the financial loss of day cases by 73%.

Table 2.

Overview of cost-revenue analysis.

	WALANT			Anaesthesia			Overall
	Costs	Revenue	Results	Costs	Revenue	Results	Results
Total	187.900	192.112	4.212	929.706	602.454	−327.252	−323.040
Mean	676	691	15	1446	937	−509	−494
Total DC	123.808	84.424	−39.384	601.326	287.204	−314.122	−353.506
Mean DC	525	358	−167	1172	560	−612	−779

Total and mean values of costs, revenues and results of all patients in the WALANT and anaesthesia groups as well as total and mean values of all day-case (DC) procedures and overall results in €.

This study has several limitations. It was retrospective and single-centre, relying on the specific billing and reimbursement structures of a German university hospital, which limits wider generalizability. Selection bias cannot be fully excluded, as more complex or anxious patients were more likely to be treated under RA. Variability in operation time documentation before 2019 may also have influenced time comparisons. Future prospective, multicentre studies are needed to validate these findings and explore patient-reported outcomes and long-term cost implications.

In conclusion, the implementation of WALANT in hand surgery was associated with shorter operative times, lower costs and reduced hospital losses compared with regional anaesthesia. By improving resource efficiency and supporting more sustainable models of care, WALANT represents a valuable strategy for both clinicians and healthcare institutions seeking to optimize the economic and operational delivery of hand surgery services.

Supplemental Material

sj-doc-1-jhs-10.1177_17531934251409627 – Supplemental material for Economic benefits of WALANT anaesthesia in metacarpal and phalangeal fracture surgery

Supplemental material, sj-doc-1-jhs-10.1177_17531934251409627 for Economic benefits of WALANT anaesthesia in metacarpal and phalangeal fracture surgery by Benjamin Trautz, Philipp Moog, Inessa Suhova, Jun Jiang, Oliver Schöffski, Hans-Guenther Machens and Haydar Kükrek in Journal of Hand Surgery (European Volume)

Supplemental Material

sj-doc-2-jhs-10.1177_17531934251409627 – Supplemental material for Economic benefits of WALANT anaesthesia in metacarpal and phalangeal fracture surgery

Supplemental material, sj-doc-2-jhs-10.1177_17531934251409627 for Economic benefits of WALANT anaesthesia in metacarpal and phalangeal fracture surgery by Benjamin Trautz, Philipp Moog, Inessa Suhova, Jun Jiang, Oliver Schöffski, Hans-Guenther Machens and Haydar Kükrek in Journal of Hand Surgery (European Volume)

Footnotes

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Ethical considerations

This study was conducted in accordance with the Declaration of Helsinki and the approval of the Ethics Committee of the Technical University of Munich (reference number: 2024-384-S-NP; date of approval: 6 August 2024).

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Informed consent

Informed consent was waived due to the retrospective nature of the study and all the procedures being performed were part of the routine care.

ORCID iDs

Benjamin Trautz

Jun Jiang

Haydar Kükrek

Supplemental material

Supplemental material for this article is available online.

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