Surgery
Lending a hand to elective recovery
In recent years, hand surgery has been moving out of the traditional setting, with surgeons increasingly seeking out innovative ways of working to deliver more efficient treatment to their patients. Mark Lee discusses the WALANT approach to hand surgery and other evolving trends, which are moving the discipline forward.
The benefits associated with conducting hand surgery in a less than traditional setting of an operating theatre (room) have been well documented over the years. But the more recent evolutions within hand surgery have taken this much further still, to cater for the ever-growing list of elective surgery requirements – with four procedures (Dupuytren’s, Carpal tunnel, Cubital tunnel and trigger finger) predicted to grow from 104,652 in 2015, to 170,166 by 2030.1 As of April 2025, the elective surgery waiting
list for England stood at 7.39 million, with many waiting longer than the 18-week target for 92% of patients.2
A brief history Following the Second World War, on both sides of the Atlantic, a keener focus had developed on
hand surgery, to utilise the growing knowledge in treating injured military personnel from an orthopaedic and plastic surgery perspective. The work of Sterling Bunnell in the US, which
led to the founding of The American Society for Surgery of the Hand in 1946 and Guy Pulvertaft, whose experience had accumulated by treating local fishermen in Grimsby UK prior to the Second World War eventually resulted in the formation of The British Society for Surgery of the Hand in 1968. Between 1944 and 1947, Sterling Bunnell in conjunction with US Army Surgeon General, Dr. Norman T. Kirk, helped to establish nine military hand surgery centres across the US. The Kleinert Kutz Hand Care Centre, Louisville, Kentucky and Northwestern Medicine Center for Surgery of the Hand, Chicago, Illinois are regarded as the oldest publicly available within the US, with centres appearing at a
similar time in places like Skåne University Hospital in Malmö, Sweden. The International Federation of the Societies
for Surgery of the Hand formed in 1966, which to date has 65 members from around the world. With the first hospital-based day (ambulatory) surgery unit opening in 1951 and between the 1960s and 80s day (ambulatory) surgery progressively gaining more acceptance, this presented new opportunities for hand surgery. Identified by The National Audit Commission in 1990, the UK’s first “basket” of 25 day (ambulatory) procedures included excision of Dupuytren’s contracture and Carpal tunnel decompression.
A changing practice Once elements of hand surgery had left the traditional setting of a main hospital operating theatre (room) and with day (ambulatory) surgery centres appearing as stand-alone units more frequency, often utilising mobile operating platforms rather than operating tables, this drove clinicians, over the years that followed, to expand on the idea that hand surgery doesn’t necessarily have to be undertaken utilising traditional methods. Clinical teams realised that dispensing with operating platforms of any kind for hand surgery, choosing instead a patient transport stretcher, had the effect of decreasing manual handling, increasing patient and healthcare staff safety and wellbeing, reducing costs and improving efficiency. In combination with this, medical facilities outside of the main hospital or day (ambulatory) setting started to offer carpal tunnel release through primary care health centres (office).
WALANT The term WALANT was first introduced by Dr. Jerry Rubin (US), a hand and plastic surgeon, in 2011, but the technique was developed by Dr. Donald Lalonde (Canada), proposing the concept in 2005. WALANT refers to ‘Wide Awake Local Anaesthesia No Tourniquet’ and involves local
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