WAFER Trial and Beyond: Comparative Efficacy and Pragmatic Implications of WALANT versus General and Regional Anesthesia in Flexor Tendon Repair

Highlights

• The WAFER trial establishes the feasibility and safety of WALANT compared with general/regional anesthesia (GA/RA) involving tourniquet use for flexor tendon repair.
• Functional outcomes including range of motion and complication rates are comparable between WALANT and GA/RA, with no significant differences in tendon rupture rates.
• WALANT demonstrates significant intra-operative cost savings and a signal for earlier return to work, underscoring economic and patient-centered benefits.
• Adjuncts such as dexmedetomidine may further optimize analgesia in WALANT, enhancing postoperative pain control and reducing opioid requirements.

Background

Flexor tendon injuries represent a frequent and challenging subset of hand trauma requiring meticulous surgical repair to restore optimal function. Conventionally, repairs are performed under general or regional anesthesia, typically with an arm tourniquet to achieve a bloodless field. However, tourniquet use can provoke complications including nerve injury and postoperative pain. Over the past decade, there has been growing adoption of wide-awake local anesthesia no tourniquet (WALANT) techniques, which utilize local anesthetic with epinephrine to provide analgesia and vasoconstriction, eliminating the need for sedation and tourniquets. This facilitates intraoperative tendon testing and patient education, potentially improving outcomes and efficiency. Nevertheless, high-quality comparative data between WALANT and traditional anesthesia modalities remain limited, impeding consensus and guideline integration.

Key Content

Chronological Development of Evidence

The earliest substantive retrospective evidence, such as a 2022 study analyzing 151 patients, indicated comparable rates of tendon rupture, adhesions, infection, and functional results among WALANT, regional, and general anesthesia cohorts, with added procedural advantages under WALANT (Hand Surg Rehabil 2022;41(1):125-130, PMID: 34700023). More recent randomized controlled trials (RCTs) have aimed to address residual uncertainties.

In 2024, a rigorous single-surgeon RCT in zone II flexor tendon repairs (J Hand Surg Am 2024;49(11):1095-1103, PMID: 39115486) demonstrated no significant differences in functional outcomes measured by Strickland and Glogovac criteria, rupture rates, or Disabilities of the Arm, Shoulder, and Hand (DASH) scores between WALANT and general anesthesia groups at 6 months. This supports equivalence in clinical efficacy.

In parallel, a notable systematic review and meta-analysis (J Hand Microsurg 2024;16(5):100157, PMID: 39669734) consolidated data from five studies encompassing 624 fingers. It reported no significant differences between WALANT and traditional anesthesia for rupture rates (OR 1.027, p=0.95), adhesions/tenolysis (OR 0.601, p=0.424), or re-operation rates (OR 1.193, p=0.659). Additionally, WALANT showed superior range of motion outcomes (OR 1.641, p=0.046), strengthening the evidence base for its functional benefits.

The landmark WAFER trial (Plast Reconstr Surg. 2026 Jul 1; PMID: 42312591) provided multicenter, assessor-blinded RCT data comparing WALANT versus GA/RA with tourniquet in 60 patients undergoing flexor tendon repair. Though total active motion (TAM) scores favored GA/RA slightly (67.6 vs 60.3, SEs overlapping), differences were modest and clinically acceptable. Tendon rupture incidence was similar (2 vs 3 cases). Importantly, patient-reported outcomes measured via the Michigan Hand Questionnaire (MHQ) were consistently higher in the WALANT group, congruent with earlier meta-analysis findings.

Cost-Effectiveness and Economic Impact

Embedded health economic analyses from the WAFER trial revealed 54% reduction in intra-operative costs with WALANT compared to GA/RA (-£398 per case; 95% CI -£509 to -£287). Productivity analysis demonstrated a clinically meaningful earlier return to work in the WALANT cohort (3.0 vs 6.7 weeks), an outcome with tangible socioeconomic benefits.

Analgesic Adjuncts within WALANT

Novel adjuncts have been evaluated to optimize WALANT analgesia. A 2024 RCT from BMC Anesthesiology (PMID: 38539076) showed that adding dexmedetomidine to lidocaine significantly decreased morphine consumption and delayed analgesic requirement postoperatively, indicating enhanced pain control. This development is promising for improving patient comfort and minimizing opioid reliance within WALANT protocols.

Expert Commentary

The convergent evidence from retrospective cohorts, meta-analyses, and RCTs including the robust WAFER trial underpins the clinical viability of WALANT for flexor tendon repair. While slight differences in active range of motion exist, they are not likely to alter clinical decision-making given the safety profile and functional outcomes equivalence.

The intraoperative ability to test tendon glide and repair integrity under WALANT is a unique advantage not replicable under GA/RA, potentially reducing secondary procedures. Patient engagement during surgery may improve adherence to rehabilitation protocols and satisfaction scores, consistent with the higher MHQ scores reported.

The significant cost savings and earlier return to work confer substantial value-based advantages, particularly pertinent in healthcare systems prioritizing resource optimization.

Limitations include the relatively small sample size of RCTs to date and heterogeneity in rehabilitation protocols across studies. The risk of patient discomfort with awake surgery requires careful patient selection and counseling.

Mechanistically, epinephrine-induced vasoconstriction in WALANT improves visualization without tourniquet-associated ischemia, minimizing nerve and muscle injury risks experienced with prolonged cuff inflation.

Conclusion

The evolving evidence, most notably from the multicenter WAFER trial, positions WALANT as a safe, cost-effective, and functionally comparable alternative to general and regional anesthesia with tourniquet use in flexor tendon repair. Its benefits in intraoperative assessment, patient satisfaction, and earlier return to work endorse its broader clinical adoption.

Future high-powered, multicenter RCTs with standardized rehabilitation and longer-term follow-up will further clarify subtle differences and consolidate guideline recommendations. Exploring multimodal analgesic adjuncts like dexmedetomidine will optimize patient experience.

In summary, WALANT represents a paradigm shift in hand surgery anesthesia, coupling operative precision with patient-centered care and health system efficiency.

References

• Faderani R et al. WAFER Trial: A randomized controlled trial comparing Wide-awake Local Anesthesia No Tourniquet to General and Regional Anesthesia with tourniquet for Flexor Tendon Repair. Plast Reconstr Surg. 2026 Jul 1;PMID: 42312591.
• Suresh SP et al. WALANT vs standard anaesthesia in the management of flexor tendon injuries: A systematic review and meta-analysis. J Hand Microsurg. 2024 Sep 13;16(5):100157. PMID: 39669734.
• Storm E et al. Outcomes of Zone II Flexor Tendon Repair Under General Versus Wide Awake Local Anesthesia: A Randomized Controlled Trial. J Hand Surg Am. 2024 Nov;49(11):1095-1103. PMID: 39115486.
• Almahameed R et al. The value of local dexmedetomidine as an adjuvant to ultrasound-guided wide awake local anesthesia no tourniquet (WALANT) in flexor tendon repair surgeries: a randomized controlled trial. BMC Anesthesiol. 2024 Mar 27;24(1):120. PMID: 38539076.
• Wormald JCR et al. Operative outcomes for wide awake local anesthesia versus regional and general anesthesia for flexor tendon repair. Hand Surg Rehabil. 2022 Feb;41(1):125-130. PMID: 34700023.