Tranexamic acid as an alternative to epinephrine in WALANT carpal tunnel release: a randomized clinical trial

Carpal tunnel release can be performed using the WALANT (Wide-Awake Local Anesthesia No Tourniquet) technique, in which epinephrine is commonly used to improve intraoperative hemostasis. However, concerns regarding vasoconstrictor-related complications persist. This study aimed to compare tranexamic acid (TA) with epinephrine for bleeding control during WALANT carpal tunnel release.

A prospective randomized study including 53 patients with carpal tunnel syndrome was conducted. Patients were randomized to WALANT with epinephrine (n = 27) or tranexamic acid (n = 26). Surgical time, intraoperative hemostasis, patient satisfaction, and postoperative complications were recorded. Clinical outcomes were assessed using specific clinical tests and the Boston Carpal Tunnel Questionnaire preoperatively and at 30 days.

No severe bleeding or ischemic complications were observed in either group. One infection occurred in the epinephrine group requiring surgical debridement. Greater difficulty in achieving intraoperative hemostasis was observed in the TA group, resulting in longer surgical times (29.3 ± 10.5 min vs. 21.4 ± 6.9 min; P < 0.001). Patient satisfaction and functional outcomes were high and comparable between groups.

Carpal tunnel release performed using the WALANT technique with either epinephrine or tranexamic acid was associated with similar short-term functional improvement and patient satisfaction. No major complications were observed in either group. However, the use of tranexamic acid was associated with greater difficulty in achieving intraoperative hemostasis and longer surgical times.

The trial protocol is available in the trial registry at Brazilian Clinical Trials Registry (ReBec) under registration number RBR2njtg49, date of registration 11/07/2025 (retrospectively registered). https://ensaiosclinicos.gov.br/rg/RBR2njtg49 .