{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,5,15]],"date-time":"2026-05-15T23:25:40Z","timestamp":1778887540967,"version":"3.51.4"},"reference-count":35,"publisher":"BMJ","issue":"8","license":[{"start":{"date-parts":[[2023,8,28]],"date-time":"2023-08-28T00:00:00Z","timestamp":1693180800000},"content-version":"unspecified","delay-in-days":27,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"DOI":"10.13039\/501100000272","name":"National Institute for Health Research","doi-asserted-by":"crossref","award":["NIHR203610"],"award-info":[{"award-number":["NIHR203610"]}],"id":[{"id":"10.13039\/501100000272","id-type":"DOI","asserted-by":"crossref"}]}],"content-domain":{"domain":["bmj.com"],"crossmark-restriction":true},"short-container-title":["BMJ Open"],"accepted":{"date-parts":[[2023,7,26]]},"published-print":{"date-parts":[[2023,8]]},"abstract":"<jats:sec>\n                    <jats:title>Introduction<\/jats:title>\n                    <jats:p>Flexor tendons are traditionally repaired under either general anaesthesia (GA) or regional anaesthesia (RA), allowing for the use of an arm tourniquet to minimise blood loss and establish a bloodless surgical field. However, the use of tourniquets exposes the patient to certain risks, including skin, muscle and nerve injuries. A recent advancement in anaesthesia delivery involves the use of a wide-awake approach where no sedation nor tourniquets are used (wide-awake local anaesthesia no tourniquet (WALANT)). WALANT uses local anaesthetic with epinephrine to provide pain relief and vasoconstriction, reducing operative bleeding. Several studies revealed potential benefits for WALANT compared with GA or RA. However, there remains a paucity of high-quality evidence to support the use of WALANT. As a result of this uncertainty, the clinical practice varies considerably. We aim to evaluate the feasibility of WALANT as an alternative to GA and RA in patients undergoing surgical repair of flexor tendon injuries. This involves addressing factors such as clinician and patient support for a trial, clinical equipoise, trial recruitment and dropout and the most relevant outcomes measures for a future definitive trial.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods and analysis<\/jats:title>\n                    <jats:p>WAFER is a multicentre, single-blinded, parallel group, randomised controlled trial (RCT) to assess the feasibility of WALANT versus RA and GA. The target population is patients with acute traumatic flexor tendon injuries, across 3 major hand surgery units in England involving a total of 60 participants. Outcome assessors will be blinded. The primary outcome will be the ability to recruit patients into the trial, while secondary outcomes include difference in functional outcome, patient-reported outcome measures, health-related quality of life, cost-effectiveness and complication rates.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Ethics and dissemination<\/jats:title>\n                    <jats:p>Ethical approval was obtained from the London\u2014City and East Research Ethics Committee (22\/PR\/1197). Findings will be disseminated through peer-reviewed publication, conferences, patient information websites and social media networks.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Trial registration number<\/jats:title>\n                    <jats:p>ISRCTN identifier: 15052559.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1136\/bmjopen-2023-075440","type":"journal-article","created":{"date-parts":[[2023,8,28]],"date-time":"2023-08-28T05:15:20Z","timestamp":1693199720000},"page":"e075440","update-policy":"https:\/\/doi.org\/10.1136\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":5,"title":["WAFER trial: a study protocol for a feasibility randomised controlled trial comparing wide-awake local anaesthesia no tourniquet (WALANT) to general and regional anaesthesia with tourniquet for flexor tendon repair"],"prefix":"10.1136","volume":"13","author":[{"given":"Muholan","family":"Kanapathy","sequence":"first","affiliation":[{"name":"Division of Surgery and Interventional Science, University College London, London, UK"},{"name":"Department of Plastic and Reconstructive Surgery, Royal Free NHS Foundation Trust Hospital, London, UK"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-0961-4004","authenticated-orcid":false,"given":"Ryan","family":"Faderani","sequence":"additional","affiliation":[{"name":"Department of Plastic and Reconstructive Surgery, Royal Free NHS Foundation Trust Hospital, London, UK"},{"name":"Faculty of Medical Sciences, University College London, London, UK"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Juliette","family":"Bray","sequence":"additional","affiliation":[{"name":"Department of Plastic and Reconstructive Surgery, Royal Free NHS Foundation Trust Hospital, London, UK"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Hakim-Moulay","family":"Dehbi","sequence":"additional","affiliation":[{"name":"University College London Institute of Clinical Trials and Methodology, London, UK"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Monica","family":"Panca","sequence":"additional","affiliation":[{"name":"Comprehensive Clinical Trials Unit, University College London, London, UK"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-7859-1646","authenticated-orcid":false,"given":"Cecilia","family":"Vindrola-Padros","sequence":"additional","affiliation":[{"name":"Department of Targeted Intervention, University College London, London, UK"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Anjana","family":"Prasad","sequence":"additional","affiliation":[{"name":"Department of Anaesthesia, Royal Free NHS Foundation Trust Hospital, London, UK"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Nicola","family":"Burr","sequence":"additional","affiliation":[{"name":"Department of Plastic and Reconstructive Surgery, Royal Free NHS Foundation Trust Hospital, London, UK"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Norman R","family":"Williams","sequence":"additional","affiliation":[{"name":"Division of Surgery and Interventional Science, University College London, London, UK"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Yazan","family":"Al-Ajam","sequence":"additional","affiliation":[{"name":"Department of Plastic and Reconstructive Surgery, Royal Free NHS Foundation Trust Hospital, London, UK"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Waseem","family":"Bhat","sequence":"additional","affiliation":[{"name":"Department of Plastic and Reconstructive Surgery, Leeds Teaching Hospitals NHS Trust, Leeds, UK"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Jason","family":"Wong","sequence":"additional","affiliation":[{"name":"Blond McIndoe Laboratories, Division of Cell Matrix Biology and Regenerative Medicine, Faculty of Biology Medicine and Health, The University of Manchester, Manchester, UK"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Afshin","family":"Mosahebi","sequence":"additional","affiliation":[{"name":"Division of Surgery and Interventional Science, University College London, London, UK"},{"name":"Department of Plastic and Reconstructive Surgery, Royal Free NHS Foundation Trust Hospital, London, UK"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Dariush","family":"Nikkhah","sequence":"additional","affiliation":[{"name":"Department of Plastic and Reconstructive Surgery, Royal Free NHS Foundation Trust Hospital, London, UK"},{"name":"Faculty of Medical Sciences, University College London, London, UK"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"239","published-online":{"date-parts":[[2023,8,28]]},"reference":[{"key":"2025120600581965000_13.8.e075440.1","doi-asserted-by":"publisher","DOI":"10.1016\/j.jhsa.2008.01.015"},{"key":"2025120600581965000_13.8.e075440.2","unstructured":"BSSH . Hand surgery in the UK. Report of a working party. 2017. Available: https:\/\/www.bssh.ac.uk\/professionals\/hand_surgery_in_the_uk.aspx [Accessed 25 Oct 2021]."},{"key":"2025120600581965000_13.8.e075440.3","doi-asserted-by":"publisher","DOI":"10.1097\/01.sap.0000168884.88016.e1"},{"key":"2025120600581965000_13.8.e075440.4","doi-asserted-by":"crossref","first-page":"e99","DOI":"10.1016\/j.jhsa.2016.11.022","article-title":"Zone II Flexor tendon repairs in the United States: trends in current management","volume":"42","author":"Gibson","year":"2017","journal-title":"J Hand Surg Am"},{"key":"2025120600581965000_13.8.e075440.5","doi-asserted-by":"publisher","DOI":"10.2106\/JBJS.I.00634"},{"key":"2025120600581965000_13.8.e075440.6","doi-asserted-by":"crossref","first-page":"1576","DOI":"10.1016\/j.bjps.2019.05.014","article-title":"'WALANT carpal tunnel release: technical considerations and pain outcomes'","volume":"72","author":"Nikkhah","year":"2019","journal-title":"J Plast Reconstr Aesthet Surg"},{"key":"2025120600581965000_13.8.e075440.7","doi-asserted-by":"publisher","DOI":"10.1016\/j.jhsa.2005.05.006"},{"key":"2025120600581965000_13.8.e075440.8","doi-asserted-by":"publisher","DOI":"10.1016\/j.jhsa.2013.07.017"},{"key":"2025120600581965000_13.8.e075440.9","unstructured":"National Health Service . Anaesthesia. NHS Evidence; 2018. Available: https:\/\/www.nhs.uk\/conditions\/anaesthesia [Accessed 25 Oct 2021]."},{"key":"2025120600581965000_13.8.e075440.10","doi-asserted-by":"publisher","DOI":"10.1093\/bja\/aeq273"},{"key":"2025120600581965000_13.8.e075440.11","doi-asserted-by":"crossref","first-page":"847","DOI":"10.1097\/EJA.0000000000001259","article-title":"Patient satisfaction with intravenous regional anaesthesia or an Axillary block for minor ambulatory hand surgery: A randomised controlled study","volume":"37","author":"Teunkens","year":"2020","journal-title":"Eur J Anaesthesiol"},{"key":"2025120600581965000_13.8.e075440.12","doi-asserted-by":"crossref","first-page":"2309499017739499","DOI":"10.1177\/2309499017739499","article-title":"Perceived comfort during minor hand surgeries with wide awake local anaesthesia no tourniquet (WALANT) versus local anaesthesia (LA)\/Tourniquet","volume":"25","author":"Gunasagaran","year":"2017","journal-title":"J Orthop Surg (Hong Kong)"},{"key":"2025120600581965000_13.8.e075440.13","doi-asserted-by":"crossref","first-page":"7","DOI":"10.1016\/j.jhsg.2019.09.011","article-title":"Wide-awake local anesthesia for minor hand surgery associated with lower opioid prescriptions, morbidity, and costs: A nationwide database study","volume":"2","author":"Lalchandani","year":"2020","journal-title":"J Hand Surg Glob Online"},{"key":"2025120600581965000_13.8.e075440.14","doi-asserted-by":"publisher","DOI":"10.1097\/PRS.0b013e3181e60489"},{"key":"2025120600581965000_13.8.e075440.15","doi-asserted-by":"crossref","first-page":"125","DOI":"10.1016\/j.hansur.2021.10.312","article-title":"Operative outcomes for wide awake local anesthesia versus regional and general anesthesia for flexor tendon repair","volume":"41","author":"Kadhum","year":"2022","journal-title":"Hand Surg Rehabil"},{"key":"2025120600581965000_13.8.e075440.16","doi-asserted-by":"crossref","DOI":"10.1186\/s12891-020-03482-0","article-title":"A cost and efficacy analysis of performing arthroscopic excision of wrist ganglions under wide-awake anaesthesia versus general anaesthesia","volume":"21","author":"Yen","year":"2020","journal-title":"BMC Musculoskelet Disord"},{"key":"2025120600581965000_13.8.e075440.17","doi-asserted-by":"publisher","DOI":"10.1097\/SAP.0b013e3181db7784"},{"key":"2025120600581965000_13.8.e075440.18","doi-asserted-by":"crossref","first-page":"1250","DOI":"10.1002\/bjs.11670","article-title":"Immediate and long-term impact of the COVID-19 pandemic on delivery of surgical services","volume":"107","author":"S\u00f8reide","year":"2020","journal-title":"Br J Surg"},{"key":"2025120600581965000_13.8.e075440.19","doi-asserted-by":"crossref","first-page":"250e","DOI":"10.1097\/PRS.0000000000007070","article-title":"Response to the COVID-19 pandemic: managing plastic surgery patients safely","volume":"146","author":"Reissis","year":"2020","journal-title":"Plast Reconstr Surg"},{"key":"2025120600581965000_13.8.e075440.20","doi-asserted-by":"crossref","first-page":"e67","DOI":"10.1016\/j.surge.2020.06.015","article-title":"A protocol for wide awake local anaesthetic no tourniquet (WALANT) hand surgery in the context of the Coronavirus disease 2019 (COVID-19) pandemic","volume":"18","author":"Hobday","year":"2020","journal-title":"Surgeon"},{"key":"2025120600581965000_13.8.e075440.21","doi-asserted-by":"crossref","DOI":"10.1186\/s13643-020-01532-1","article-title":"Wide-awake local anaesthesia no tourniquet (WALANT) vs regional or general anaesthesia for flexor tendon repair in adults: protocol for a systematic review and meta-analysis","volume":"9","author":"Nolan","year":"2020","journal-title":"Syst Rev"},{"key":"2025120600581965000_13.8.e075440.22","doi-asserted-by":"crossref","first-page":"569","DOI":"10.1177\/17531934211006279","article-title":"Development of the Manchester wide-awake hand trauma service in 2020: the patient experience","volume":"46","author":"Choukairi","year":"2021","journal-title":"J Hand Surg Eur Vol"},{"key":"2025120600581965000_13.8.e075440.23","doi-asserted-by":"publisher","DOI":"10.1016\/S0140-6736(12)62160-6"},{"key":"2025120600581965000_13.8.e075440.24","doi-asserted-by":"crossref","first-page":"186","DOI":"10.1016\/j.jhsg.2020.04.011","article-title":"Current trends in WALANT surgery: A survey of American society for surgery of the hand members","volume":"2","author":"Grandizio","year":"2020","journal-title":"J Hand Surg Glob Online"},{"key":"2025120600581965000_13.8.e075440.25","doi-asserted-by":"crossref","first-page":"2776","DOI":"10.1016\/j.bjps.2021.05.025","article-title":"WALANT protocol: stop before you block","volume":"74","author":"Zargaran","year":"2021","journal-title":"J Plast Reconstr Aesthet Surg"},{"key":"2025120600581965000_13.8.e075440.26","doi-asserted-by":"publisher","DOI":"10.1016\/j.hcl.2013.02.009"},{"key":"2025120600581965000_13.8.e075440.27","unstructured":"The British Society for Surgery of the Hand, Lacerations with flexor tendon involvement guildelines . BSSH standards of care in hand trauma. 2020. Available: https:\/\/www.bssh.ac.uk\/bssh_standards_of_care_in_hand_trauma_.aspx"},{"key":"2025120600581965000_13.8.e075440.28","doi-asserted-by":"publisher","DOI":"10.1016\/S0363-5023(98)80042-7"},{"key":"2025120600581965000_13.8.e075440.29","doi-asserted-by":"publisher","DOI":"10.2165\/00019053-199304050-00006"},{"key":"2025120600581965000_13.8.e075440.30","doi-asserted-by":"publisher","DOI":"10.1007\/s11136-011-9903-x"},{"key":"2025120600581965000_13.8.e075440.31","doi-asserted-by":"crossref","first-page":"29","DOI":"10.7748\/en.2021.e2065","article-title":"Hand injury: investigating the accuracy of referrals to a specialist trauma centre","volume":"29","author":"Faderani","year":"2021","journal-title":"Emerg Nurse"},{"key":"2025120600581965000_13.8.e075440.32","doi-asserted-by":"crossref","unstructured":"Vindrola-Padros C , Chisnall G , Polanco N , et al . Iterative cycles in qualitative research: introducing the RREAL sheet as an innovative process. SSRN Journal 2022;54. doi:10.2139\/ssrn.4162797","DOI":"10.2139\/ssrn.4162797"},{"key":"2025120600581965000_13.8.e075440.33","doi-asserted-by":"crossref","first-page":"2192","DOI":"10.1177\/1049732320951526","article-title":"Carrying out rapid qualitative research during a pandemic: emerging lessons from COVID-19","volume":"30","author":"Vindrola-Padros","year":"2020","journal-title":"Qual Health Res"},{"key":"2025120600581965000_13.8.e075440.34","unstructured":"Srivastava A , Thomson SB . Framework analysis: a qualitative methodology for applied policy research 2009."},{"key":"2025120600581965000_13.8.e075440.35","doi-asserted-by":"crossref","first-page":"2392","DOI":"10.1016\/j.bjps.2021.03.106","article-title":"Wide awake local anaesthetic no tourniquet (WALANT) technique in hand trauma surgery: a prospective study of efficacy and peri-operative patient experience","volume":"74","author":"Sawhney","year":"2021","journal-title":"J Plast Reconstr Aesthet Surg"}],"container-title":["BMJ Open"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/syndication.highwire.org\/content\/doi\/10.1136\/bmjopen-2023-075440","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,12,6]],"date-time":"2025-12-06T08:58:32Z","timestamp":1765011512000},"score":1,"resource":{"primary":{"URL":"https:\/\/bmjopen.bmj.com\/lookup\/doi\/10.1136\/bmjopen-2023-075440"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2023,8]]},"references-count":35,"journal-issue":{"issue":"8","published-online":{"date-parts":[[2023,8,28]]},"published-print":{"date-parts":[[2023,8]]}},"alternative-id":["10.1136\/bmjopen-2023-075440"],"URL":"https:\/\/doi.org\/10.1136\/bmjopen-2023-075440","relation":{},"ISSN":["2044-6055","2044-6055"],"issn-type":[{"value":"2044-6055","type":"print"},{"value":"2044-6055","type":"electronic"}],"subject":[],"published":{"date-parts":[[2023,8]]}}}