What's New in Wide-Awake Local Anesthesia No Tourniquet (WALANT) Hand Surgery?

Wide-awake local anesthesia no tourniquet (WALANT) has evolved from a novel technique to an increasingly adopted anesthetic strategy in hand surgery. In the post-coronavirus disease (COVID)-19 era, there has been a marked expansion in WALANT-related literature, necessitating synthesis of contemporary evidence to guide clinical practice. This narrative review examines recent WALANT studies organized into six thematic domains: comparative trials versus traditional anesthesia, use in the pediatric population, patient satisfaction and experience, environmental impact, cost comparison and value-based care, and applications beyond the hand and wrist. Comparative studies consistently demonstrate that WALANT provides noninferior functional outcomes and complication rates relative to regional and general anesthesia, with improved intraoperative pain and similar early postoperative pain. Pediatric data support feasibility and high satisfaction in appropriately selected patients, particularly adolescents. Patient satisfaction is uniformly high, with strong willingness to repeat WALANT procedures. WALANT pathways also reduce solid waste and carbon emissions, particularly when procedures are performed outside the main operating room. Cost analyses demonstrate substantial savings driven by decreased anesthesia use and site-of-service optimization. Expanding indications now include proximal upper extremity procedures and select nonupper extremity surgeries, reflecting increasing surgeon experience and confidence. WALANT represents a mature, evidence-supported care pathway that aligns clinical outcomes with patient-centered experience, environmental sustainability, and cost efficiency. Its greatest impact is realized when integrated into procedure room-based workflows with careful patient selection and standardized technique. Future efforts should focus on refining indications, optimizing patient experience, and expanding scalable implementation across diverse practice settings.