Application of WALANT in Diaphyseal Plating of Forearm Fractures: An Observational Study.

Purpose: Wide-Awake Local Anesthesia No Tourniquet (WALANT) is a novel anesthesia technique in distal radius and ankle fracture fixation. However, to date, there are limited studies in diaphyseal plating of forearm fractures under WALANT. This research is to study the feasibility of the use of WALANT technique in plating of diaphyseal fractures of the forearm as well as peri-operative outcomes. Methods: Sixty-one adult patients who underwent diaphyseal plating of the forearm under WALANT between the period of January 2019 and January 2021. It consists of 31 radius fractures, 15 ulna fractures and 15 ipsilateral radius and ulna fractures. Outcomes evaluated were duration of stay, peri-operative numerical pain rating scale, peri-operative blood pressure and heart rate, visual analogue scale for anxiety, blood loss, surgery duration, adverse effect, patient's satisfaction and any complications at 6 months follow up. Results: Fifty-four patients (88.5%) were male and 7 patients (11.5%) were female with a mean age of 31.7 years (SD = 13.564). Thirty-eight out of 61 patients were totally pain free throughout the surgery. Ten (13%) patients reported pain during muscle dissection, 14 (18%) patients reported pain during bone manipulation and 12 (16%) patients reported pain during bone drilling. There was no significant difference in pain score between radius and ulna bones (P > .05). There was a significant change in blood pressure after LA infiltration (P < .01). The mean estimated blood loss was 27.39 ml (SD = 11.44) and the mean duration of post-surgery hospital stay was 1 day (SD = 1.026). Fifty-six patients (92%) recommended diaphyseal plating of the forearm under WALANT. None of the patients required conversion to general anesthesia and had any adverse events or infection during 6 months follow up. Conclusions: Diaphyseal plating of the forearm under WALANT is a feasible alternative anesthesia technique and is well tolerated by patients. Type of study/level of evidence: Therapeutic III.

Prospective Evaluation of Pain and Anxiety Levels Between Wide-Awake Local Anesthesia No Tourniquet and General Anesthesia With Tourniquet in Excision of Wrist Ganglions.

Purpose: Excision of wrist ganglions is a common procedure in hand surgery. Our objective was to determine whether the type of anesthesia (general anesthesia [GA] vs wide-awake local anesthesia no tourniquet [WALANT] technique) would affect patient satisfaction regarding intraoperative pain control, postoperative pain management, and anxiety. Methods: This was a prospective study with patients divided into either the WALANT or GA cohort. The waiting time for surgery, Amsterdam Preoperative Anxiety and Information Scale, blood pressure, and heart rate were measured. Postsurgical questionnaires with the visual analog scale were completed. The surgeon's feedback on the ease of ganglion stalk visibility and usage of diathermy as a measure of a bloodless field was recorded. Patients reported the amount of analgesia consumed and overall satisfaction with the operation via the Surgical Satisfaction-8 questionnaire. Results: A total of 42 patients underwent wrist ganglion excision in 2 orthopedic centers over a period of 2 years, with 21 undergoing GA and 22 undergoing WALANT. The GA group was more anxious about anesthetic use with a higher demand for information about GA (P = .04). The duration of surgery was significantly shorter in the WALANT group and with a lower diathermy usage (P < .001). There was no difference in terms of surgical difficulty and stalk visualization. The visual analog scale pain score was significantly lower in the WALANT group than in the GA group immediately after surgery (P = .04) and on discharge (P = .004). While at home for 2 weeks, the WALANT group (mean = 2.91 tablets) consumed significantly fewer analgesic tablets than the GA group (mean = 6.25 tablets). However, both groups were satisfied with their experience. Conclusions: Wide-awake local anesthesia no tourniquet technique in the excision of ganglions provides another option of anesthesia with painless experiences, and no pain rebound after surgery. Patients were less anxious about WALANT than GA. Excision can be performed without diathermy usage with similar visualization of the stalk. Type of study/level of evidence: Therapeutic II.

Wide-Awake Anesthesia for Olecranon Fracture Fixation.

Introduction: Wide-awake local anesthesia and no tourniquet (WALANT) has come a long way. It has been reported to be successful in the surgery of distal radius and ulna fractures. We report a case of olecranon fracture plating under WALANT. Methods: Surgery was performed with the patient fully conscious where tumescent anesthesia was injected into the surgical site without application of tourniquet 30 minutes before the first incision. Posterior approach to the elbow was used, and the fracture was fixed with anatomical locking plates. Results: The surgery was successfully completed without pain. The numerical pain rating score was 0 throughout the surgery. Conclusions: The use of WALANT for surgical fixation can be expanded beyond the hand and wrist. This is a safe and simple option for patients at high risk of general anesthesia, producing similar surgical outcomes without intraoperative and postoperative complications.

The Smashed-Up Shoulder: A Case of Complex Ipsilateral Scapula, Clavicle and Proximal Humerus Fractures With Complete Brachial Plexus Injury.

Simultaneous ipsilateral fractures involving all the bones around the shoulder girdle, namely, the scapula, clavicle and humerus, are rare. We describe an interesting case of a 31-year-old patient who presented after a motor vehicle accident with excruciating pain over his left shoulder and a flail left upper limb. Radiographs and computed tomography (CT) scan revealed the presence of comminuted left scapula, clavicle and proximal humerus fractures. He was also diagnosed with a complete brachial plexus injury of the left shoulder. The patient underwent a tedious surgery involving screw fixation and plating of the scapula, clavicle and proximal humerus. Despite achieving stable fixations of the shoulder and radiographic union of all the fractures, he did not recover from the complete brachial plexus injury 14 months after the trauma. The presence of ipsilateral clavicle, scapula and humerus fracture suggests involvement in high-energy trauma, and therefore, associated injuries especially neurovascular compromise should not be missed. Despite its rarity, management of this complex injury should always be individualised to ensure optimal functional outcomes are achieved.

Plating of clavicle fracture using the wide-awake technique.

BACKGROUND: Fixation of clavicle fractures has now become a more popular option as it provides better outcome compared with conservative management. Wide-awake local anesthesia no tourniquet (WALANT) has been effectively used in plating of distal radius and olecranon fractures. This paper expands the usage of WALANT into the shoulder girdle, namely plating of the clavicle that has not been described. The operation is typically performed under general anesthesia. METHODS: We report a case series of 16 patients who successfully underwent fixation of the clavicle under the wide-awake technique. The clavicle fractures were grouped under the AO Fracture Classification. The WALANT solution comprised 1% lidocaine, 1:100,000 epinephrine, and 10:1 sodium bicarbonate. A total of 40 mL was injected in each patient with 10 mL subcutaneously along the clavicle followed by 30 mL subperiosteally at multiple intervals and directions. RESULTS: The Numerical Pain Rating Score was 0 during WALANT injection and during surgery except for 2 patients with Numerical Pain Rating Scores of 1 and 2, respectively, during reduction. CONCLUSION: We conclude that clavicle plating under WALANT is a good alternative option of anesthesia.

Plating Distal Radius Fractures Using Wide-Awake Local Anesthesia No Tourniquet (WALANT) Versus General Anesthesia: A Cohort Study.

Purpose: This study compared outcomes of plating distal radius (DR) fractures using wide-awake local anesthesia no tourniquet (WALANT) versus general anesthesia (GA). Methods: From March 2018 to March 2019, 20 patients with DR fracture underwent plating using WALANT whereas 20 patients who underwent plating under GA were used as controls. Outcomes evaluated were pain control, waiting time for the operation, hemodynamic changes, blood loss, the occurrence of adverse effects of medications used in WALANT and GA, and the duration of postoperative stay. Results: The WALANT group experienced a significantly shorter waiting time for surgery (6 vs 20 days; P < .001) and a shorter postoperative stay (1 vs 2 days; P = .009) compared with the GA group. They also reported mild to no pain during surgery. The groups were similar with regard to blood pressure, blood loss, and operative time. None in the WALANT group required conversion to GA during surgery and no adverse effects were reported. Conclusions: The WALANT approach is a viable alternative to GA for plating of DR fractures. Type of study/level of evidence: Therapeutic III.

Spinopelvic Fixation Supplemented With Gullwing Plate for Multiplanar Sacral Fracture With Spinopelvic Dissociation: A Case Series With Short Term Follow Up.

We describe a series of three patients who sustained multiplanar sacral fracture with spinopelvic dissociation treated with bilateral triangle osteosynthesis supplemented with a gullwing plate. Multiplanar sacral fracture causes the sacrum to divide into two parts which in severe cases, fracture displacement results in neurological injury. Spinopelvic fixation supplemented with a gullwing plate surgical treatment is still a viable option with an acceptable outcome. The average waiting time prior to surgery is 3 weeks.

Open Reduction and Internal Fixation of Extraarticular Scapular Neck and Body Fractures With Good Short Term Functional Outcome.

Background: The study aims to evaluate the short-term functional outcome of open reduction and internal fixation of extraarticular scapular neck and body fractures treated at our center over a period of 2-year duration at a tertiary referral center. Patients and Methods: Between October 2015 and October 2017, we operated on 20 extraarticular scapular neck and body fracture. Ten were available for a one-off assessment. The mean time to surgery was 10 days (range, 3-19 days) and one-off assessment was done within 6-24 months (mean, 13 months). Indications includes (1) medial/lateral displacement (M/L) ≥ 20 mm, (2) M/L ≥ 15 mm if angular deformity ≥ 30°, (3) Angular deformity ≥ 45°, (4) Double lesion of superior shoulder suspensory complex (SSSC), with displacement ≥10 mm in both lesion, (5) Glenopolar angle (GPA) ≤ 22°, and (6) open scapular fracture. The functional outcome was measured using range motion and strength. Patient-reported outcome was assessed using Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire and Short-Form-36 (SF-36) version 1. Results: All patients achieved radiological union at time of assessment. None of the patients had post-operative complications. The mean DASH score was 19.3 (range, 1.7-39.3). All subcategories of SF-36 questionnaire scores between 70 and 89.6, with exception to REE (role limitations due to emotional problems) and REP (role limitations due to physical health). The average range of motion for the injured shoulders; forward flexion 157°, abduction 114°, and external rotation 42°. The strength of operated and non-operated shoulders, respectively, 6.5 and 8.1 kgF of forward flexion, 5.5 and 7.2 kgF of abduction, and 4.1 and 6.3 kgF of external rotation. Conclusion: Open reduction and internal fixation of surgically indicated scapular neck and body fracture is feasible with predictably good functional outcome. The reduced external rotation ROM and strength may be due to the use of Classic Judet approach, however we do not enough data to support this.

Plating of Distal Radius Fracture Using the Wide-Awake Anesthesia Technique.

Fractures of the distal radius are one of the most common types of injuries encountered in hand surgery. Plate osteosynthesis is recommended for unstable fractures. Because distal radius fracture fixation is usually performed under general or regional anesthesia with the use of a tourniquet, this exposes patients, especially elderly people with extensive comorbidities, to adverse effects commonly associated with these forms of anesthesia. As such, many of these patients are unable to undergo surgery in a timely manner until they are deemed medically fit for surgery or anesthesia, and some may still be treated nonsurgically. Injecting local anesthetic of lidocaine and epinephrine into the surgical field and without using a tourniquet is known to be advantageous for various surgical procedures of the hand. However, this approach, also known as wide-awake local anesthesia no tourniquet (WALANT), has not been used in the fixation of fractures beyond the wrist. Using the WALANT approach as an alternative anesthetic for plating of distal radius fractures may enable patients who are normally denied surgery owing to their age or medical comorbidities to undergo plate fixation for the fractures. This article outlines the WALANT approach used for a single case of fixation of distal end radius fracture with a detailed description of the technique of administering local anesthesia.