Clinical impact of wide-awake local anesthesia no tourniquet (WALANT) in carpal tunnel release: a systematic review and meta-analysis of randomized controlled trials

BACKGROUND: Wide-awake local anesthesia no tourniquet (WALANT) is increasingly used in carpal tunnel release (CTR) because it avoids tourniquet-related discomfort and allows active intraoperative testing. Although WALANT improves perioperative experience, its effects on postoperative pain and functional recovery remain incompletely defined. Existing meta-analyses are limited by nonrandomized designs and heterogeneous hand procedures. METHODS: A systematic review and meta-analysis was conducted according to PRISMA guidelines. PubMed, Embase, and the Cochrane Library were searched for randomized controlled trials (RCTs) comparing WALANT with tourniquet-based anesthetic techniques for CTR. Outcomes included operative time, intraoperative pain, early postoperative pain, patient satisfaction, adverse events, and functional outcomes assessed using the Boston Carpal Tunnel Questionnaire (BCTQ). Random-effects models with prespecified subgroup and sensitivity analyses were applied. RESULTS: Eight RCTs were included. Operative time did not differ between WALANT and comparator techniques overall, although operative time was longer with WALANT in open procedures. WALANT was consistently associated with lower intraoperative pain. Early postoperative pain showed substantial heterogeneity across studies, with smaller differences observed in endoscopic procedures. Overall patient satisfaction was higher with WALANT. Adverse events were uncommon and comparable between groups. Functional outcomes were reported in two trials; pooled analysis demonstrated a statistically significant improvement in the BCTQ Functional Status Scale favoring WALANT (mean difference [MD] - 1.17), while no difference was observed in the Symptom Severity Scale. CONCLUSIONS: Based on RCTs, WALANT for carpal tunnel release is associated with lower intraoperative pain and higher overall patient satisfaction. Early postoperative pain was lower with WALANT, although findings were heterogeneous across studies. WALANT may also be associated with improved postoperative hand function. Future randomized studies should systematically report operative and tourniquet duration and incorporate standardized functional outcome measures.