SLR - June 2019 - Dalton M. Ryba

Open Reduction and Internal Fixation of Ankle Fracture Using Wide-Awake Local Anesthesia No Tourniquet Technique

Reference: Li, Y., Chen, C., Lin, K., Tarng, Y., Hsu, C. and Chang, W. (2019). Open Reduction and Internal Fixation of Ankle Fracture Using Wide-Awake Local Anesthesia No Tourniquet Technique. Injury, [online] In press. Available at: [Accessed 17 Apr. 2019].

Scientific Literature Review
Reviewed By: Dalton M. Ryba, DPM
Residency Program: John Peter Smith Hospital, Fort Worth, TX

Podiatric Relevance: Use of a tourniquet intraoperatively has been associated with several complications, including nerve injury, compartment syndrome, DVT and pain. Tourniquet use is common in podiatric surgery, although some argue this is primarily out of convenience to the surgeon. Yet, many would contend tourniquet use is warranted in open management of ankle fractures. The authors of this article provide an alternative anesthesia technique in managing ankle fractures where tourniquet use is omitted, with the aim to reduce postoperative pain and to facilitate recovery.

Methods: A level 4 prospective case series of 13 adults (nine male, four female; mean age 59.8) who sustained uni- (five), bi- (five) or trimalleolar (three) ankle fractures were treated with the wide-awake local anesthesia no tourniquet (WALANT) procedure by a single orthopaedic surgeon. Injuries requiring posterior malleolar fixation were excluded from the study, along with patients who sustained Maisonneuve fractures of the fibula or open injuries. The described WALANT protocol utilizes a 1 percent Lidocaine mixed with 1:40:000 Epinephrine solution for local anesthesia. Utilizing a 27g needle, 3–5 ml of solution is used to perform a hematoma block initially. Then, 5–10 ml of solution is injected 1 cm proximal and distal to each planned incision line. Adequacy of anesthesia was assessed prior to incision, ensuring a NPRS score of 0. Standard fracture reduction and fixation technique was then performed. If syndesmotic fixation was required, an addition 5–10 ml of solution was utilized in the syndesmosis.

Results: Thirteen adult patients were treated with the novel WALANT procedure for closed uni-, bi- or trimalleolar fractures. All patients in the study underwent surgical incision with an initial NPRS score of 0. Two of the 13 patients required 5 ml of additional local anesthesia. The toxic dose of 7 mg/kg lidocaine with epinephrine was never exceeded. No local or systemic toxicity complications were encountered. Conversion to alternative anesthesia methods was not required in any of the 12 cases. Average bleeding volume was 9.23 +/- 4.94 ml.

Conclusions: WALANT protocol is utilized in wrist and hand surgery to reduce common tourniquet-associated complications, including nerve injury, arterial spasm and pain. Yet, according to the authors, the WALANT protocol has rarely been reported in foot and ankle literature. Herein, the authors provide a novel technique in ankle fracture fixation, which eliminates the risk of tourniquet-associated complications and provides adequate perioperative pain control and hemostasis. Additionally, regarding use in ankle fracture fixation, the authors of this study claim the advantage of active ROM intraoperatively as needed from the patient to assess anatomic reduction. The authors warn of the risks of WALANT, including chondrotoxicity and increased incidence of vasovagal reaction in local. 

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