The Orthobullets Podcast Podiums | Hand | Bold Statements: Hand Surgery Should Never Be Done in the OR
Aug 28, 2025
Dr. Kate Nellans, an orthopedic surgeon known for her advocacy of office-based hand surgeries, discusses the revolutionary WALANT technique. She delves into the controversial shift from operating rooms to office settings, highlighting its acceleration during the COVID-19 pandemic. Nellans emphasizes patient safety and procedural effectiveness, questioning the traditional norms of anesthesia usage. With insights on evaluating financial factors and practical logistics, she shares the benefits and challenges of this emergent surgical practice.
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Epinephrine Myth Debunked
- Historical fear of epinephrine in digits came from older mixtures that caused necrosis, not modern lidocaine-epinephrine.
- Modern series (Lalonde) report extremely low digit-loss rates with proper technique.
Rare Digital Necrosis Cases
- Despite broad safety data, rare modern cases of digital necrosis after lidocaine+epinephrine have occurred and required amputations.
- These examples remind clinicians to remain cautious and prepared for complications like ischemia.
Always Have Phentolamine Ready
- Never perform WALANT without having phentolamine available as a reversal agent for vasoconstriction.
- Consider alternatives like short tourniquet use or awake procedures without tumescent epi when appropriate.