Wide-Awake Local Anesthesia No Tourniquet: From Elective Hand Surgery to Fracture Fixation. A Systematic Review, Meta-Analysis, and Narrative Synthesis

Background WALANT is well established in elective hand surgery, where it has demonstrated favorable clinical outcomes and improved perioperative efficiency. More recently, its use has expanded to selected upper-extremity fracture procedures, but whether the benefits are maintained remains uncertain. This systematic review combined meta-analysis and narrative synthesis to evaluate the clinical outcomes, safety, patient-reported outcomes, and perioperative efficiency of WALANT across elective hand surgery and fracture fixation. Objective To evaluate the contemporary evidence for WALANT across elective and acute upper-extremity surgery and determine whether the established benefits of elective surgery are preserved in selected fracture procedures. Methods A systematic review and meta-analysis was conducted according to PRISMA 2020. PubMed, Embase, and the Cochrane Library were searched for comparative studies published between January 2018 and November 2025. Risk of bias was assessed using RoB2 and ROBINS-I. Random-effects meta-analysis and structured narrative synthesis were performed. Results Sixteen studies met the inclusion criteria. Meta-analysis showed no significant differences in complications (RR 0.37, 95% CI 0.12–1.16) or revision procedures (RR 0.88, 95% CI 0.19–4.15). Functional outcomes were comparable across elective and acute procedures. WALANT consistently improved perioperative efficiency (MD −11.2 minutes, 95% CI −15.4 to −6.9), and subgroup analyses demonstrated that the favorable findings established in elective surgery were largely maintained in selected fracture fixation procedures. Conclusions The favorable outcomes established for WALANT in elective hand surgery appear to be maintained in selected acute upper-extremity fracture procedures, supporting its role as a safe and resource-efficient option across selected upper-extremity surgery.