SLR - May 2021 - Lauren N. Kerr

Ankle Fracture Fixation with Use of WALANT (Wide Awake Local Anesthesia with No Tourniquet) Technique

Reference: Tahir M, Chaudhry EA, Ahmed N, Mamoon AH, Ahmad M, Jamali AR, Mehboob G. Ankle Fracture Fixation with Use of WALANT (Wide Awake Local Anesthesia with No Tourniquet) Technique. J Bone Joint Surg Am. 2021 Mar3;103(5):397-404. Doi: 10.2106/JBJS.20.00196

Level of Evidence: Therapeutic Level IV

Scientific Literature Review

Reviewed By: Lauren N. Kerr, DPM
Residency Program: AMITA Health St. Joseph Hospital – Chicago, IL

Podiatric Relevance: Wide awake local anesthesia with no tourniquet (WALANT) is a cost-effective surgical technique that has become increasingly popular among Orthopedic Surgeons during hand surgeries including tendon repair, carpal tunnel, and distal radial fractures. The purpose of this study was to evaluate and assess the WALANT technique for open reduction and internal fixation (ORIF) of ankle fractures. 

Methods: Fifty-eight patients over a two-year time period were evaluated in this study. All ankle fractures were classified according to the AO classification and 44-B/44-C fractures were included. Exclusion criteria included: patients anxious about WALANT, vasculitis, Raynaud’s disease, peripheral vascular disease, anticoagulation therapy, or history of polytrauma. Furthermore, open, Maisonneuve, talar or posterior malleolar fractures requiring fixation were excluded. Fractures requiring closed reduction in the Emergency department received a hematoma block consisting of 1 percent lidocaine plain, were manipulated, casted, and post-reduction films and CT were obtained. The average time from injury to surgery was five days. The solution used intra-operatively for WALANT technique in this study was comprised of: 30mL of 0.9 percent normal saline and 30 milliliters of 2 percent lidocaine with 1:100,000 epinephrine. Five milliliters of the solution was injected subcutaneously 1 centimeter proximal and distal to the planned incision(s). Average delay was 20 minutes following injection to allow for adequate vasoconstriction and anesthetic effects. Vital signs and VAS pain score were monitored intra-operatively and additional anesthetic solution was given as needed. 

Results:
• 39 males, 19 females
• Mean age 46.79 
• According to AO classification, 81 percent were 44-B, 19 percent were 44-C fractures
• Average blood loss was 29 milliliters with a mean operative time of 59 minutes 
• Mean time to union post-operatively was 16 weeks with an AOFAS Ankle-Hindfoot Score of 86.38
• Complications:
• 3 patients (5.2 percent) developed non-unions 
• 2 patients had postoperative infections
• 1 diabetic patient developed osteomyelitis 

Conclusions: Minimal literature exists discussing the utilization of the WALANT technique in lower extremity surgeries. This technique has grown in popularity among Orthopedic surgeons in hand surgery and has thus changed the paradigm of using epinephrine in hand surgeries. This shift in the paradigm has increased interest to evaluate WALANT technique for foot and ankle procedures. Numerous studies have shown that WALANT technique is both cost-effective and a safe alternative for patients with multiple comorbidities. General anesthesia poses a multitude of risks and requires extensive preoperative testing. WALANT technique decreases these risks and pre-operative testing for the patient. One of the biggest advantages of the WALANT technique is the patient is awake and alert. The surgeon is able to assess the stability of the fixation construct and evaluate for any implant impingement intra-operatively. However, WALANT technique does not come without considerations. There is no tourniquet use which increases the risk of intra-operative bleeding. On the upside, this decreases the risk of post-operative pain, neuropraxia, and hospital stay which are relatively common complications seen with prolonged tourniquet use. In conclusion, the WALANT technique provides surgeons with a relatively safe and cost-effective option for ankle fractures and further studies should be done.

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