Early experience with WALANT in revision carpal tunnel release using hypothenar fat pad transposition and collagen wrap

Background Wide awake local anaesthesia no tourniquet (WALANT) has gained wide acceptance in Hand Surgery. However, to our knowledge, published series on revision carpal tunnel release (CTR) have generally been performed under general or regional anaesthesia with tourniquet. WALANT has an established and expanding evidence base for primary nerve decompression surgery, yet its application to complex revision nerve surgeries, especially with adjuvant soft tissue reconstruction, has not previously been reported. Methods We report a single case of revision CTR using the triple therapy approach—comprising median nerve neurolysis, collagen nerve wrap, and hypothenar fat pad flap—performed entirely under WALANT. Results Despite operating within a well-vascularised scar field, epinephrine-mediated haemostasis was adequate throughout all stages of the procedure. In our view, WALANT offers specific and underappreciated technical advantages in the revision CTR setting that extend beyond cost-effectiveness of resources and avoidance of anaesthetic risk. The awake patient may possibly provide real-time sensory feedback during neurolysis. More importantly, following flap transposition and nerve wrapping, active digital and wrist range of motion intraoperatively can confirm unimpeded nerve excursion. Conclusions This report highlights the potential feasibility of performing complex revision CTR with adjuvant flap reconstruction without conventional anaesthesia in selected patients. Level of evidence IV