BACKGROUND: Wide-awake local anesthesia no tourniquet (WALANT) has increasingly been used as an alternative to brachial plexus block (BPB) for upper extremity surgery; however, comparative evidence regarding analgesic efficacy, recovery outcomes, and patient satisfaction remains inconsistent. This systematic review and meta-analysis aimed to compare WALANT with BPB in upper extremity surgery, with intraoperative pain prespecified as the primary outcome. METHODS: , 2026. Comparative randomized and non-randomized studies evaluating WALANT versus BPB in adult patients undergoing upper extremity surgery were included. Risk of bias was assessed using RoB 2 and ROBINS-I tools, and certainty of evidence was evaluated using the GRADE approach. RESULTS: Fifteen studies involving 940 patients met the inclusion criteria. There was no significant difference in intraoperative pain between WALANT and BPB (MD 1.11, 95% CI -2.54 to 4.76). Postoperative pain scores were similar during the early postoperative period (0-2 h) and at 24 h; however, WALANT was associated with lower pain scores between 2 and 8 h postoperatively (MD -1.39, 95% CI -2.58 to -0.19). WALANT was also associated with a shorter length of hospital stay (MD -10.81 h, 95% CI -18.49 to -3.13). No significant differences were observed in complication rates, need for additional anesthesia or analgesia, or patient satisfaction. The certainty of evidence for key outcomes was rated as very low, primarily due to risk of bias, substantial heterogeneity, and imprecision. CONCLUSIONS: Based on very low-certainty evidence, WALANT appears to provide analgesic outcomes broadly comparable to BPB in upper extremity surgery and may be associated with shorter hospital stay. These findings should be interpreted cautiously and primarily considered hypothesis-generating, highlighting the need for well-designed randomized trials.
DOST et al. (Mon,) studied this question.