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The Use of the Wide-Awake Local Anesthesia No Tourniquet Technique in Foot and Ankle Injuries
Abstract
Purpose
Although the wide-awake anesthesia no tourniquet (WALANT) technique has demonstrated high efficacy, safety, patient satisfaction, and cost-effectiveness in hand surgery, there are limited data on its use in foot and ankle surgery. This study aimed to evaluate the efficacy of the WALANT technique in selected foot and ankle injuries in terms of intra- and post-operative characteristics.
Material and methods
Patients with foot and ankle injuries who underwent surgery with the WALANT technique were evaluated in this retrospective study. A total of 31 patients (22 male / 9 female) with a mean age of 40 ± 16 years were evaluated for the type of injury, underlying comorbidities, American Society of Anesthesiologists Classification (ASA) score, intraoperative visual analog pain (VAS) and anxiety (VAS-A) scores, duration of operation, complications, need for intensive care and duration of hospitalization.
Results
There were 15 patients with medial malleolus fracture, 5 with lateral malleolus fracture, 5 with Achilles tendon ruptures, 2 with proximal phalangeal fracture, and 1 with Lisfranc injury, medial malleolus + syndesmotic injury, deltoid ligament + syndesmotic injury and fifth metatarsal fracture. ASA I-II score was determined in 27 patients and ASA III score in 4. The mean operation time was 36.6 ± 7 minutes, and the mean length of hospital stay was 8.3 ± 6.1 hours. The median VAS pain score was 1 (range,0-4), the median VAS-A score was 1 (range, 0-3) and no patient needed further anesthetics during the operation. No patient needed intensive care unit stay and no complications were observed in any patient.
Conclusion
The WALANT technique was seen to provide satisfactory anxiety and pain scores, acceptable complications, and a short length of hospital stay in patients with foot and ankle injuries. Simple foot and ankle injuries can be managed successfully with this technique through adequate hemostasis without a tourniquet.
Level of evidence: Level IV
... PNB is a safe and effective option for managing diabetic foot ulcers, offering benefits without increasing postoperative risks. The study conducted by Bilgetekin et al. [12] retrospectively analyzed the effectiveness of the WALANT (Wide-Awake Local Anesthesia No Tourniquet) technique in 31 patients with foot and ankle injuries, including 22 men and nine women with a mean age of 40 ± 16 years. The treated injuries included 15 medial malleolus fractures, five lateral malleolus fractures, five Achilles tendon ruptures, two proximal phalanx fractures, and less common ones, such as Lisfranc and fifth metatarsal fractures. ...
... Bilgetekin et al. [12] and Çetin et al. [13] focused on the WALANT technique for foot and ankle procedures. Both studies highlighted its effectiveness in controlling pain and anxiety, with high patient satisfaction and rapid hospital recovery. ...
... This method allows surgical interventions to be performed without the need for a tourniquet and with the patient awake under local anesthesia. Studies such as those by Bilgetekin et al. [12] and Çetin et al. [13] have documented positive results, including significant reductions in intraoperative pain, lower incidence of postoperative complications, and faster hospital recovery. Therefore, implementing WALANT could enhance the patient experience and optimize clinical outcomes in podiatric practice. ...
Background and Objectives: Local anesthesia is essential in podiatry, ensuring painless procedures. Technological and pharmacological advances require us to stay updated on the safest and most effective techniques. Lidocaine and bupivacaine are common anesthetics in this field, with the choice of technique tailored to each procedure. To evaluate the effectiveness and safety of local anesthesia techniques in reducing pain in podiatric procedures. Materials and Methods: A systematic review followed PRISMA guidelines, searching for studies in PubMed, Scopus, and Web of Science published in the last 10 years in English and Spanish. Studies focused on local anesthesia in podiatry were included, excluding those unrelated or without validated results. Results: Of 485 initial studies, nine were selected that met all criteria. These studies demonstrated the efficacy and safety of various local anesthesia techniques, such as WALANT and ultrasound-guided peripheral nerve blocks, highlighting their effectiveness in pain control and patient satisfaction. Conclusions: Local anesthesia techniques are effective in reducing pain in podiatric procedures. The safety of these techniques is high, with few serious complications. Local anesthesia without a tourniquet and specific techniques, such as subparaneural injection, are effective for pain control. Individual patient factors and surgeon experience influence results.
... In addition to its use in reducing the operating theatre burden of elective hand/wrist surgeries, WALANT has also been described with relative success in open reduction internal fixation of distal radius fractures, metacarpal/phalangeal fractures and extensive soft tissue procedures such as spaghetti wrist reconstruction [4][5][6]. Lately, some authors have reported the use of WALANT in foot and ankle surgeries, especially uni-malleolar fractures, metatarsal fractures, and Achilles tendon repair [7][8][9]. However, the indications for WALANT in foot and ankle surgery are far less diverse and prevalent as compared to its indications in hand and wrist surgery [10]. ...
... There is also evidence that a standard dose of local anaesthetic might be less effective in patients with a history of chronic opioid (mis)use [21]. Also, patients with anxiety surrounding the idea of wide-awake anaesthesia might not be suitable for the procedure [7]. ...
... WALANT provides adequate anaesthesia in surgeries of the foot and ankle; this has been demonstrated in multiple reports by various authors [7,18,22,23]. In addition to providing anaesthesia, WALANT is quite effective in providing a bloodless field during surgery [22]. ...
Wide-awake surgery of the hand was surrounded by a lot of apprehension, mainly over concerns around using epinephrine near digits and its potential to cause digital ischemia and necrosis. With multiple reports underlining its safety and effectiveness, it is now being widely adopted in hand and wrist surgery. The British Society for Surgery of the Hand has already published guidelines on operating outside of main theatres, with an emphasis on wide awake local anaesthesia no tourniquet (WALANT). However, the same cannot be said for its use in foot and ankle procedures. There have been a handful of reports describing WALANT in bony and soft tissue procedures of the foot and ankle, with varied success. We aim to describe the scope of WALANT in these procedures and explore in detail its current role in the domain of lower extremity wide-awake surgery.
... Apart from these, with the COVID-19 epidemic, it has been seen that more importance should be given to alternative anesthesia options [10]. The wide-awake local anesthesia with no tourniquet (WALANT) technique, initially employed for minor hand and wrist procedures, has expanded to larger surgeries like distal radius fractures, ulna and olecranon fractures, clavicle fractures, and foot-ankle injuries [11][12][13][14][15][16][17][18][19]. It offers costeffectiveness, increased patient satisfaction, and reduced risks linked with systemic anesthesia [20]. ...
... Objective evaluations were conducted using the NPRS during the injection and intraoperative period, and the Visual Analog Scale (VAS) score for pain in the postoperative period. Throughout the surgery, the patients' Time to operation in days 2 (1-3) Follow-up duration in months 18 (12)(13)(14)(15)(16)(17)(18)(19)(20)(21)(22)(23)(24)(25)(26)(27)(28)(29)(30) Data are presented as n (%) or median (range). ...
... Similarly, Wright et al. compared WALANT to general anesthesia in forefoot surgeries, finding that the WALANT technique was well-tolerated by patients and associated with significantly reduced postoperative pain and anxiety [14]. Bilgetekin et al. reported effective pain control and shorter hospital stays with the WALANT technique, providing adequate hemostasis without the need for a tourniquet in surgeries for simple foot and ankle injuries [15]. Bajuri et al. demonstrated that the WALANT technique is a safe and effective method for various lower extremity surgeries, including both soft tissue and bone procedures, with good pain management [27]. ...
Objective: Patellar fractures, which account for approximately 1% of all fractures, frequently require surgical intervention for significant displacement. Traditional anesthesia methods pose various risks and complications, especially for patients with comorbidities. This study aims to evaluate the safety and feasibility of wide-awake local anesthesia no tourniquet (WALANT) for patellar fracture fixation. Methods: A retrospective evaluation was conducted on a total of 8 patients who underwent patellar fracture fixation using the WALANT technique between 2020 and 2022. Patient demographics, clinical findings, and postoperative outcomes were collected. Peroperative pain was assessed using the Numerical Pain Rating Score (NPRS) and Visual Analogue Scale (VAS). Outcomes, including bleeding, complications, and the Lysholm Knee Score at 12 months postoperatively, were evaluated. Results: The median age at surgery for a total of 8 patients, 6 males and 2 females, was 56 years (range: 38-73). The median surgery duration was 52 minutes (range, 38-73) , and postoperative pain onset was 160 minutes (range, 130-220). Minimal intraoperative bleeding was observed in most cases. Patient satisfaction with WALANT was high, with median VAS scores of 1 (range, 0-3) at 2 hours and 3 (range, 1-5) at 24 hours post-surgery. The median hospital stay was 2 (range, 1-7) days. One patient experienced a superficial skin infection. At 12 months postoperatively, the Lysholm Knee Score indicated satisfactory functional outcomes. Conclusion: This study is the first to explore WALANT for patellar fracture fixation. WALANT provides safe, effective anesthesia, high patient satisfaction, effective pain management, and shorter hospital stays. It benefits patients with comorbidities and offers an alternative to traditional anesthesia. Further research is needed to validate these findings and support wider use.
... Pamuk et al., [2] in a comparative study with regional anesthesia, applied the technique in metatarsal osteotomies and achieved adequate anesthetic efficacy with acceptable pain scores. Bilgetekin et al., [11] in foot and ankle surgery, achieved good pain control and shorter hospital stay. Simple foot and ankle injuries were managed successfully with WALANT through adequate hemostasis without a tourniquet. ...
... Similarly, we used additional solution in a patient who was operated for a lateral malleolar fracture. The reason for this may be applying the solution to the contralateral cortex of the fibula in the lateral malleolus fracture as described by Bilgetekin et al. [11] is difficult in the preoperative period. In the current study, in Group A, additional solution was needed in three of the foreign body removal surgeries. ...
... Pamuk et al. [2] reported one superficial infection in 15 patients who underwent metatarsal osteotomy using the WALANT technique. Bilgetekin et al. [11] reported no complications related to the WALANT technique in foot and ankle injuries, Similarly, Li et al. [12] did not report any complications related to the WALANT technique in the treatment of ankle fractures. In the present study, numbness was observed in one of the two patients who underwent foreign body removal, and persistent pain and tenderness were seen in the other. ...
Objectives:
This study aims to investigate the effectiveness of wide-awake local anesthesia with no tourniquet (WALANT) technique in both bony and soft tissue procedures in lower extremities.
Patients and methods:
Between January 2021 and December 2022, a total of 29 patients (20 males, 9 females; mean age: 34.6±20.2 years; range, 14 to 82 years) who were operated for lower extremity pathologies with the WALANT technique in our clinic were included. The patients were divided into two groups: lower extremity soft tissue surgeries in Group A (n=10) and bone tissue surgeries in Group B (n=19). Postoperative pain onset time, pain score, the amount of intraoperative bleeding, need for additional solution, use of cautery, and the amount of bleeding in the surgical field were compared within groups. The Visual Analog Scale (VAS) was used to evaluate pain.
Results:
There was no significant difference between the two groups in terms of age (p=0.265), sex (p=0.107), and surgical side (p=0.700). There was no significant difference between the two groups in terms of intraoperative bleeding at the discretion of the surgeon (p=0.701). There was no significant difference in the use of additional solution (p=0.105), cautery usage (p=0.522), pain onset time (p=0.636), and VAS scores (p=0.735) between the two groups.
Conclusion:
Our study results suggest that the WALANT technique is an effective and safe method in selected lower extremity surgeries. It is of utmost importance to apply the technique correctly to prevent complications that may occur.
... According to the current literature, WALANT in foot and ankle surgery is not routinely used, despite its obvious benefits in hand surgery, with scarce research on the topic [10][11][12][13][14][15][16]. Tarsal tunnel decompression is a procedure used in challenging patients with diabetic neuropathy with concomitant peripheral artery disease (PAD) [17][18][19][20][21][22][23][24]. ...
... Several studies have demonstrated the benefits of WALANT in terms of efficiency and patient comfort, particularly in hand and foot surgeries [15,16]. Conversely, spinal anesthesia remains a reliable option, especially in cases requiring prolonged operative time or when patient comorbidities contraindicate adrenaline use [30]. ...
Background: Wide-Awake Local Anesthesia No Tourniquet (WALANT) is revolutionizing surgery by providing a bloodless field without tourniquet use, reducing risks, costs, and enhancing patient comfort. While extensively used in hand surgery, its application in foot and ankle procedures, particularly for high-risk patients with diabetic neuropathy and peripheral artery disease (PAD), remains underexplored. This study evaluates the safety, efficacy, and outcomes of WALANT for tarsal tunnel decompression in such patients. Methods: Between March 2022 and April 2024, 32 patients with diabetic neuropathy and PAD underwent Dellon decompression of the tarsal tunnel. Five received spinal anesthesia with a tourniquet, while 27 underwent WALANT. Outcomes assessed included operative time, Visual Analogue Scale (VAS) pain scores, posterior tibial artery blood flow (via Doppler ultrasonography), and complications. Data were collected preoperatively, immediately postoperatively, and at six and nine months. Results: WALANT reduced operative time (40 ± 8 min vs. 65 ± 10 min) and required fewer personnel (four vs. six). VAS scores improved significantly in the WALANT group (from 8.65 ± 0.84 preoperatively to 1.21 ± 0.24 at nine months). Posterior tibial artery blood flow also showed superior improvements with WALANT (5.30 ± 0.65 cm3/s vs. 2.50 ± 0.45 cm3/s). Minor wound healing delays were noted in two WALANT cases; no major complications occurred. Conclusion: WALANT offers a safe, efficient alternative to spinal anesthesia for tarsal tunnel decompression in high-risk patients, minimizing ischemic risks, enhancing vascular outcomes, and reducing postoperative pain.
... Gradually, the WALANT technique has gained popularity and is currently being used in a variety of clinical contexts including fixation of olecranon or ulnar shaft fractures, and repair of tendon injuries [11][12][13] . There have also been reports describing successful utilization of this technique for the management of foot and ankle injuries such as syndesmotic injuries, malleolar fractures, phalangeal and metatarsal fractures and even Lisfranc injuries [14] . ...
... The WALANT technique has achieved tremendous appeal in upper limb and hand surgery especially in well-structured outpatient settings due to its advantages, superior outcomes, and patient satisfaction [ 12 , 21 ]. The WALANT technique is effectively utilized to treat foot and ankle injuries [14] . It is substantially easier to employ in the clavicle due to the collarbone's shallow depth and lack of surrounding muscles [15] . ...
Clavicle fractures are common fractures with a rate of 2-5 percent among fractures. Mid-shaft fractures of the clavicle are more common than the other sites of the clavicle. Traditionally, surgical fixation of clavicle fractures has been performed under General Anesthesia (GA). The purpose of this study was to assess the effects of WALANT on intraoperative bleeding, pain control during and after surgery, postoperative complications and patients’ function. In the current study, 30 patients with clavicle fractures were surgically fixed using the WALANT technique. The obtained results showed that it could be an effective technique for pain control during the operation and also early postoperative period. Moreover, the WALANT technique could be considered safe in patients who are at risk for GA because of medical comorbidities, cervical spine injuries, or other factors that make intubation difficult.
... La técnica WALANT ha demostrado alta eficacia, seguridad y satisfacción en el paciente, así como coste-efectividad en cirugía de mano. Sin embargo, poca literatura menciona su uso en pie y tobillo (7) . Bilgetekin et al. evaluaron un total de 31 pacientes a los que se les realizó cirugía de pie y tobillo con WALANT, concluyendo que esta técnica genera resultados satisfactorios con bajo nivel de ansiedad y dolor en el paciente, así como una tasa baja de complicaciones y una estancia media baja (7) . ...
... Sin embargo, poca literatura menciona su uso en pie y tobillo (7) . Bilgetekin et al. evaluaron un total de 31 pacientes a los que se les realizó cirugía de pie y tobillo con WALANT, concluyendo que esta técnica genera resultados satisfactorios con bajo nivel de ansiedad y dolor en el paciente, así como una tasa baja de complicaciones y una estancia media baja (7) . ...
... [8][9][10] In recent years, it has also found use in interventions for the lower extremities. [6,7] It has been reported in studies on hand and wrist surgery that the development of new and more local regional anesthesia methods instead of TA methods reduces the length of stay in the hospital and reduces the operating costs. [11][12][13] However, information on the use of WALANT in foot and ankle surgery is limited. ...
... It has been reported that the WALANT application also shortens the duration of hospital stay in the surgical margin of foot and ankle traumas. [6,7] In our study, it was observed that there was no significant change in the length of hospital stay when compared with TA. We think that this is because hallux valgus operations are performed as outpatient surgeries in many centers. ...
Objectives:
The issue of performing a hallux valgus operation with the wide-awake local anesthesia with no tourniquet (WALANT) technique has not been evaluated before. The objective of this study was to compare the clinical results of patients who underwent the WALANT technique during hallux valgus operation and patients who underwent the procedure with traditional anesthesia (TA).
Patients and methods:
In this cross-sectional, retrospective study, 34 patients (17 males, 17 females; mean age: 46.1±8.3 years; range, 36 to 62 years) who underwent first metatarsal osteotomy with the diagnosis of hallux valgus disease between November 1, 2018, and June 1, 2020, were divided into two groups according to the surgical approach determined by patient choice: the WALANT group and the TA group. Demographic characteristics, Visual Analog Scale (VAS) scores for pain and anxiety, postoperative satisfaction levels, and complications were recorded.
Results:
There was no significant difference between the groups in terms of demographic characteristics. The VAS pain score during needle insertion was significantly higher in the WALANT group compared to the TA group (p<0.001). Conversely, the VAS anxiety score was significantly higher in the WALANT group compared to the TA group (p<0.001). The median follow-up time was 5.4 months (interquartile range, 5-6 months).
Conclusion:
This is the first study demonstrating that adequate anesthetic efficacy can be achieved with the WALANT technique for the hallux valgus operation. Acceptable pain scores can be achieved with this technique, and costs are reduced.
... Because tourniquet is required, the Achilles surgery is usually performed with, either a popliteal block, spinal anesthesia or general anesthesia. Classically, local anesthesia has not been considered as an option, and therefore, surgical departments have traditionally relied on an anesthesiologist to do these procedures [1,2]. The COVID-19 pandemic has obligated to redeploy medical teams, mainly anesthetists and intensivists. ...
... The use of lidocaine and epinephrine in this technique produces hemostasis and anesthesia, which obviates the need for a pneumatic tourniquet during the operation. Additional advantages of this technique include comfort for patient and surgeon, reduced time of theatre, cost savings, and the patient is fully conscious during the operation[2,[4][5][6]. ...
... Standard applications of the wide awake local anaesthesia no tourniquet technique have been adapted from Lalonde (2016) and focus on procedures within the field of hand surgery; while the potential applications of wide awake local anaesthesia no tourniquet surgery taken from case reports have been adapted from other authors (Wong et al, 2017;Huang et al, 2018;Ahmad et al, 2020;Bilgetekin et al, 2020;Xu et al, 2021). ...
... There are opportunities to explore the use of wide awake local anaesthesia no tourniquet surgery within the acute management of digital trauma and other orthopaedic subspecialties. Despite the limited data on the scope for the use of the wide awake local anaesthesia no tourniquet technique in foot and ankle operations, early studies have demonstrated similar satisfactory results in the management of simple injuries (Poggetti et al, 2018;Li et al, 2019;Bilgetekin et al, 2020). ...
Wide awake local anaesthesia no tourniquet, also known as WALANT, is the practice of performing surgery under local anaesthetic in the absence of a tourniquet. This technique uses the vasoconstrictive effects of adrenaline and the local anaesthetic effects of lignocaine to establish a Bier block with haemostatic control. Permitting active patient participation intraoperatively, wide awake local anaesthesia no tourniquet surgery improves patient compliance with rehabilitation and yields higher patient satisfaction. With reduced cost and equipment requirements, this method improves accessibility for patients and productivity for healthcare institutions. This is of particular benefit within the current COVID-19 climate, as wide awake local anaesthesia no tourniquet technique provides a means of overcoming restrictions to theatre access and anaesthetic support. This review delves into the current uses of wide awake local anaesthesia no tourniquet surgery, outlining the initial conception of the practice by Canadian surgeons. The advantages and disadvantages are considered, and potential future applications of this technique are discussed.
... [8][9][10][11][12] Wide-awake local anesthesia no tourniquet (WALANT) surgery is well established in hand surgery and is now becoming increasingly used in foot and ankle surgery; however, the indications and techniques for WALANT in foot and ankle surgery are still being defined. [13][14][15][16][17][18] The purpose of the present report is to describe the surgical technique for performing IONT with the Arthrex (Naples, Florida, US) Nanoscope nano tendoscopy system for the diagnosis and treatment of common peroneal tendon pathologies. Attention is paid to techniques for obtaining adequate local anesthesia and performing in-office peroneal tendoscopy, indications, and the advantages of performing these procedures in the office rather than the operating room (Video 1). ...
... Although WALANT surgery is well established in hand surgery, there has been a recent trend toward the use of WALANT in other areas, particularly foot and ankle surgery. [13][14][15][16][17][18] One study examining the use of WALANT in 30 patients who underwent foot and ankle surgery surveyed the patients after surgery and found that 87% would undergo their surgery under WALANT again and would recommend it to someone else. 13 Another prospective comparative study of general anesthesia versus WALANT found decreased postoperative pain and improved postoperative patient experience with WALANT compared to general anesthesia. 14 There are numerous benefits of WALANT including savings in cost and scarce operating room resources, the ability to avoid preoperative medical clearance, as well as insurance precertification for surgery, and obviating the need for an anesthesiologist. ...
In-office needle tendoscopy (IONT) can be used for the diagnosis and treatment of several peroneal tendon pathologies including peroneal tendon tendinopathy, tears, and instability. Benefits of IONT for peroneal tendon disorders include the ability to dynamically evaluate peroneal tendon stability, quicker patient recovery, reduced cost, and improved patient satisfaction. Several studies have suggested that tendoscopic treatment may avoid several complications related to open treatment of peroneal tendon pathologies, including scar formation and groove stenosis. The purpose of the present report is to describe the technique for performing IONT for common peroneal tendon pathologies. This Technical Note describes the techniques for obtaining adequate anesthesia and performing IONT, indications, and advantages of performing these procedures in the office rather than in the operating room.
... Li et al 43 reported no complications when using WALANT for ORIF of ankle fractures. Bilgetekin et al 44 used WALANT for medial malleolus fractures, lateral malleolus fractures, Achilles tendon ruptures, Lisfranc injury, medial malleolus + syndesmotic injury, deltoid ligament + syndesmotic injury, and fifth metatarsal fractures. The authors reported a median visual analog pain score of 1 (range 0-4) during surgery and no complications. ...
... The authors reported a median visual analog pain score of 1 (range 0-4) during surgery and no complications. 44 Poggetti et al 45 conducted a randomized study of 60 patients who underwent distal fibula hardware removal. Compared to the locoregional anesthesia with the tourniquet group, the WALANT group experienced significantly reduced postoperative pain and no difference in postoperative complication rates. ...
The wide-awake local anesthesia with no tourniquet (WALANT) technique has become popularized for various hand/upper extremity procedures. Before surgery, patients receive local anesthetic, consisting of lidocaine with epinephrine, and remain awake for the entire procedure. The purpose of this review was to investigate the advantages, diverse application, outcomes, cost benefits, use in challenging environments, patient considerations, and contraindications associated with WALANT.
Methods:
A comprehensive review of the literature on the WALANT technique was conducted. Search terms included: WALANT, wide-awake surgery, no tourniquet, local anesthesia, hand, wrist, cost, and safety.
Results:
The WALANT technique has proven to be successful for common procedures such as flexor tendon repair, tendon transfer, trigger finger releases, Depuytren disease, and simple bony procedures. Recently, the use of WALANT has expanded to more extensive soft-tissue repair, fracture management, and bony manipulation. Advantages include negating preoperative evaluation and testing for anesthesia clearance, eliminating risk of monitored anesthesia care, removal of anesthesia providers and ancillary staff, significant cost savings, and less waste produced. Intraoperative evaluations can be performed through active patient participation, and postoperative recovery and monitoring time are reduced. WALANT is associated with high patient satisfaction rates and low infection rates.
Conclusions:
The WALANT technique has proven to be valuable to both patients and providers, optimizing patient satisfaction and providing substantial healthcare savings. As its application continues to grow, current literature suggests positive outcomes.
... Studies on the use of local anesthetics in the treatment of ankle sprains indicate that while these injections are common in sports medicine, their effects on recovery and muscle activity are nuanced [62,63]. Research shows that local anesthetic injections, such as lidocaine, do not significantly suppress muscle activity or alter firing patterns in the muscles surrounding the ankle, which is crucial for maintaining dynamic stability during recovery from sprains [64,65]. Despite their frequent use in professional sports to facilitate quicker returns to play, the overall efficacy and safety of local anesthetic injections in managing ankle sprains remain under-researched, highlighting the need for further studies to better understand their role in the treatment process and recovery outcomes. ...
Background
Various treatment approaches for individuals with ankle sprains can reduce treatment costs and enhance recovery. This study aimed to compare the efficacy of spring ankle braces with splints and casts in treating ankle sprains.
Materials and methods
This cross-sectional study involved 60 patients diagnosed with ankle sprains at the orthopedic clinic of Imam Khomeini Hospital in Jiroft in 2022. Following diagnosis confirmation through additional examinations and imaging, patients with ankle sprains not requiring surgery were selected and placed in two groups: one treated with spring ankle braces and the other with splints or casts. Both groups underwent a 4-week treatment regimen, comprising 30 individuals each. Data were collected and analyzed using SPSS version 26.
Results
The average age of patients was 32.5 ± 13.4 years. Of the ankle sprain patients, 56.7% were male. Patients reported the highest satisfaction levels with the plaster cast treatment method. A statistically significant relationship was found between patient satisfaction and the treatment methods of spring ankle braces and plaster casting (P < 0.05). Patients treated with plaster casts reported the lowest pain levels, with a significant relationship between pain levels and the two treatment methods (P < 0.05). Range of motion results were similar for both treatment methods, while the cast treatment showed the highest incidence of skin complications. A significant relationship was observed between spring ankle braces and plaster casts regarding skin complications (P < 0.05).
Conclusion
Treating ankle sprains with plaster casts leads to higher satisfaction and lower pain levels compared to using spring ankle braces.
... They successfully treated these injuries under WALANT, without patients requiring additional anaesthesia. 53 In an RCT, Borg 54 They reported that the WALANT group patients were more comfortable during surgery and more satisfied (as measured by the Short-Form Health Questionnaire SF-12) one year post-surgery, despite similar surgical outcomes in both groups, although potential reasons for this were not elaborated on. Surgery performed under WALANT was more cost-effective. ...
Citation: Rocher AGL, O'Connor M, Koch O. Wide awake local anaesthesia no tourniquet: a review of current concepts. SA Orthop J. 2022;21(3):172-179. http://dx.doi. Abstract Background
... Non-elective procedures such as distal radius fractures [10] and spaghetti wrist [11] have been performed under WALANT with similar success. Moreover, WALANT surgery for lower extremity operations such as foot and ankle injuries has been successfully reported [12][13][14][15]. Multiple publications have demonstrated wide-awake local anesthesia as a safe option for open reduction and internal fixation (ORIF) of clavicle fractures [16][17][18]. ...
Introduction
Over the past two decades, wide-awake local anesthesia no-tourniquet (WALANT) surgery has gained substantial popularity, challenging conventional assumptions regarding the safety of epinephrine. This report investigates the unprecedented expansion of the wide-awake local anesthesia technique beyond hand surgeries. It meticulously documents its successful application in a peri-implant proximal humerus fracture, presenting a fresh perspective on its safety and viability for managing intricate orthopedic injuries.
Case Report
The subject of this study is a 61-year-old HIV-positive male with a history of recurrent falls, seeking treatment for a peri-implant proximal humerus fracture. Electing the wide-awake local anesthesia option due to financial constraints, the patient underwent a successful surgery. The technique employed involved precise administration of local anesthetic, facilitating fracture reduction, and plate replacement. Notably, the emphasis was placed on active patient participation during intraoperative assessment.
Conclusion
This report extends the recognized utility of WALANT surgery beyond hand surgeries, demonstrating its versatility and potential transformative impact on health-care delivery. The study underscores the pivotal role played by wide-awake local anesthesia surgery in addressing challenges related to health-care accessibility. It presents a promising avenue for future orthopedic interventions and positions itself as a safe and viable option for patients in underserved areas globally.
... Bilgetekin et al. observed that WALANT technique provided a short length of hospital stay in patients with foot and ankle injuries and affirmed that simple foot and ankle injuries could be managed successfully with this technique through adequate hemostasis without a tourniquet [2]. ...
The Wide-Awake Local Anesthesia No Tourniquet (WALANT) Approach to Dellon Triple decompression involves the use of local anesthetic with epinephrine and no tourniquet. This study shows that WALANT is a safe and effective procedure and can be performed in an outpatient setting for the decompression of the common peroneal nerve in the knee, tibial nerve in the ankle and deep peroneal nerve in the dorsum of the foot in diabetic patients with superimposed nerve compressions to diabetic neuropathy. WALANT technique demonstrated to be a safe procedure to surgically treat diabetic patients with superimposed compressive neuropathy to diabetic neuropathy in the lower limbs and had no complications.
... There is increased interest in the role of tourniquets in other foot and ankle procedures. Bilgetkin reported on their "wide-awake local anaesthesia no tourniquet technique" for foot and ankle injuries with successful outcomes [39]. However, in another recent study exploring the use of a tourniquet in calcaneal fractures, Zaid found improved surgical visualisation and reduced intraoperative blood loss [40]. ...
... WALANT has been popularized as a means of anesthesia in many procedures, such as plate fixation of fractures 7 and ankle surgery. 8,9 The coronavirus 2019 pandemic helped WALANT spread rapidly because of its many benefits. 10 Pure local anesthesia without sedation can be a safer option in patients with multiple medical comorbidities, or where general or spinal anesthesia may not be advisable or available. ...
We successfully performed minimally painful injection of tumescent local anesthesia to eliminate the need for the tourniquet and sedation for a below-knee amputation in a frail patient with multiple medical comorbidities in Mombasa, Kenya. Minimal pain injection of WALANT (wide awake local anesthesia no tourniquet) pure local anesthesia can be a good alternative for lower limb amputation in frail patients when safe sedation services are unavailable or unaffordable in many countries.
... C'est un vasodilatateur qui agit au niveau des récepteurs α1 et α2. [9]. ...
Haubanage d'une fracture de la patella sous WALANT : à propos d'un cas Résumé : La prise en charge chirurgicale de certaines fractures en situation d'urgence peuvent souffrir des contre-indications relatives à l'anesthésie générale ou locorégionale. Le recourt à la WALANT(Wide Awake Local Anesthesia No Tourniquet) offre une véritable alternative à l'anesthésie conventionnelle, avec des résultats comparables. Nous rapportons une observation d'un patient schizophrène, sans domicile fixe et démunie ; qui a bénéficié d'un haubanage de la patella sous WALANT avec des suites post opératoires favorables. Mots clef : fracture de la patelle, haubanage, WALANT Abstract: The surgical management of certain fractures in emergency situations may suffer from relative contraindication to general or spinal anesthesia. The use of WALANT (Wide Awake Local Anesthesia No Tourniquet) offers a real alternative to conventional anesthesia, with comparable results. We report an observation of a schizophrenic patient, homeless and with no financial resource; who benefited with a tension band wiring of a fracture of the patella under WALANT with favorable postoperative outcomes.
... This finding could be related to the vasoconstrictive properties of epinephrine used in the WALANT solution. 14,15 Although the results of the current study and the previously published articles approved the efficiency and safety of WALANT use for various minor surgeries, orthopedic surgeons should be vigilant of proper patient selection for this technique. ...
... They successfully treated these injuries under WALANT, without patients requiring additional anaesthesia. 53 In an RCT, Borg 54 They reported that the WALANT group patients were more comfortable during surgery and more satisfied (as measured by the Short-Form Health Questionnaire SF-12) one year post-surgery, despite similar surgical outcomes in both groups, although potential reasons for this were not elaborated on. Surgery performed under WALANT was more cost-effective. ...
Background Wide awake local anaesthesia no tourniquet (WALANT) is a local anaesthetic technique that employs lignocaine combined with adrenaline to maintain a pain-free and bloodless field during surgery on an awake patient, without the use of a tourniquet. Methods This article is a narrative review of the literature on the use of this mode of anaesthesia in orthopaedic and hand surgery. Results The review summarises the existing research pertaining to WALANT. It discusses the anaesthetic solution constituents, administration technique and applications of WALANT, highlighting the safety profile and benefits to patients and healthcare systems alike. Conclusion The WALANT technique is safe, economical, and acceptable to patients. It should form part of the orthopaedic surgeon’s armamentarium. Future research should investigate the benefits of intraoperative functional assessment of the awake patient. Level of evidence: Level 5.
... However, little literature mentions its use in foot and ankle [7]. and economic advantages compared to traditional techniques with regional block and tourniquet [8]. ...
Forefoot surgery usually requires tourniquet use and anaesthesia is performed using a popliteal or ankle anaesthetic block. Therefore , surgical departments require an anaesthesiologist to trust them with this procedure. The elective nature of forefoot surgery and the lack of anaesthesiologists resulting from the COVID 19 pandemic, has forced Foot and Ankle specialists to dig into other alternatives , in order to continue their surgical practice and to avoid the growth of the waiting list. The wide-awake local anaesthesia non-tourniquet, which was originally described for upper limb surgery, has recently been adjusted to Foot and Ankle surgery. It does not require sedation, nor regional or general anaesthesia and since the patient is wide-awake, they will be able to fully collaborate during the procedure. The use of lidocaine and adrenaline described on the WALANT technique allows us to obtain a local anaesthesia and vasoconstriction. This method permits the surgeon to move forward into surgery with a completely awake patient and no need of tourniquet giving the advantage of a full motor function assessment intraoperatively. WALANT has been proven to be a safe, effective and affordable technique when it comes to foot and ankle surgery. Having gone through a lack of anaesthesiologists, surgery rooms and hospital resources during SARS-CoV2, WALANT emerged and now represents an acceptable alternative to consider and continue to treat selected cases of foot and ankle surgeries.
... Percentage of patient (%) according to comorbidity. Even a less complicated surgery like total knee replacement would cause a mean total blood loss of about 1.0-1.5 liter when general anaesthesia with tourniquet is used (10). The mean LOS following WALANT surgery recorded in this study was 3.35 ± 1.16 days. ...
Lower limb surgery is usually performed under general or regional anaesthesia in normal operating room setting. However, when the surgery need to be performed in situations where there are limited resources and equipment, especially during a pandemic outbreak, in battlefields or area of disaster occurrence, the wide-awake local anaesthesia no tourniquet (WALANT) surgery can be utilised. This study aims to assess the efficacy of performing lower limb surgery using WALANT technique. A randomised cross-sectional study was designed to assess the effectiveness of WALANT in lower limb surgery, particularly in terms of duration of anaesthesia, Hamilton Anxiety Rating Scale (HAM-A), pain visual analogue scale (VAS), duration of surgery, amount of estimated blood loss (EBL) and total length of stay (LOS). A total of 91 patients requiring lower limb surgery were recruited, with only 83 patients completed the VAS pain assessment for all time points of the study. Mean age of patients was 52.1 ± 14.9 years. Mean VAS score were 1.19 ± 1.53 and 1.46 ± 1.86, preoperatively and intraoperatively. Mean VAS score were 0.55 ± 1.52, 0.60 ± 1.41, and 1.06 ± 1.69 at 2, 4, and 6 h post-surgery, respectively. Majority (79; 86.8%) of patient has preoperative anxiety score that was <17. Mean surgery duration was 65.28 ± 39.02 min, mean EBL was 91.34 ± 78.94 cc, whereas mean LOS was 3.35 ± 1.16 days. EBL was a weak predictor of postoperative pain. In conclusion, WALANT technique for lower limb surgery is effective and safe.
... Li et al., described a prospective case series of 13 patients using WA-LANT for malleolar fractures and no complications, including VTE, were reported 340 . Bilgetekin et al., performed a retrospective chart review of 31 patients that underwent WALANT for foot and ankle surgery 341 . Of these patients, 20 had malleolar fractures and no complications, including VTE, were reported. ...
Routine venous thromboembolism (VTE) prophylaxis is not routinely needed in patients with a single lower extremity (LE) fracture who do not require surgery. The need for VTE prophylaxis in patients with isolated LE fracture is restricted to high-risk individuals with significant medical comorbidities, severely limited activity or other coagulopathic risk factors.
Strength of Recommendation: Moderate.
Delegates vote: Agree 95.65% Disagree 4.35% Abstain
0.00% (Strong Consensus).
Based on available literature, administration of routine VTE prophylaxis for patients with isolated LE injuries, even if immobilized, does not seem to be supported. However, VTE prophylaxis in the forms of mechanical or chemical treatment may need to be considered for high-risk patients (see risk stratification) with isolated LE injury.
Age > 70 years, limited mobility in and out of hospital, immobilization, previous history of VTE, high body mass index (BMI), oral contraceptive pill intake, and air-travel have been reported as risk factors, particularly when two or more are present.
... Li et al., described a prospective case series of 13 patients using WA-LANT for malleolar fractures and no complications, including VTE, were reported 340 . Bilgetekin et al., performed a retrospective chart review of 31 patients that underwent WALANT for foot and ankle surgery 341 . Of these patients, 20 had malleolar fractures and no complications, including VTE, were reported. ...
Recommendations from the International Consensus Meeting (ICM) for Venous Thromboembolism (VTE): Trauma
Humeral shaft nonunion is a challenging orthopedic condition that often requires surgical intervention for successful healing. In this case report, we present a 53-year-old male patient who presented with a humeral shaft nonunion, Underlying Systemic Disorders, and Arteriovenous fistula. The patient had a history of a previous humeral shaft fracture managed with open reduction and internal fixation but developed nonunion despite appropriate initial treatment. The complexity of this case was compounded by the patient's preference for a minimally invasive approach and the desire to avoid general anesthesia due to underlying medical conditions.
Background:
The wide-awake local anesthesia no tourniquet (WALANT) technique, which is based on the local infiltration of lidocaine and epinephrine, is widely used in hand and wrist surgery. However, few studies have been conducted on the cost-benefit analysis of phalanx fracture surgery using the WALANT technique. This study aimed to investigate the clinical condition, time spent on anesthesia and operation. We also perform an economic analysis among general anesthesia, local anesthesia with a tourniquet, and the WALANT technique for plate fixation of phalanx fractures.
Methods:
This retrospective study included all patients with single phalanx fractures who underwent open reduction internal fixation with plating between January 2015 and December 2019. Patients were divided into three groups according to the anesthesia method: general anesthesia with a tourniquet (GA group), local anesthesia with a tourniquet (LA group), and the WALANT technique (WALANT group). Data, including demographics, anesthesia and surgical time, postoperative pain score, and vomiting ratio, were collected and analyzed.
Results:
A total of 62 patients were included in this study. Of the 62 patients, 15 were included in the GA group, 32 in the LA group, and 15 in the WALANT group. No complications were reported during surgery or follow-up in either group. The GA group exhibited a significantly longer anesthesia time than the other two groups, with an average of 32.4 min. However, no significant difference in surgical time was observed among the three groups. The WALANT group exhibited a significantly lower postoperative pain score than the other two groups. The additional cost of general anesthesia was approximately 350 US dollars (USD), accounting for approximately one-third to one-fourth of the total expenses for phalanx surgery.
Conclusion:
Open reduction with plate fixation of phalanx fractures using the WALANT technique and local anesthesia was cost-effective compared with general anesthesia. Patients who underwent phalanx fracture surgery using the WALANT technique experienced less pain on the first postoperative day than those who underwent surgery using general or local anesthesia with a tourniquet because of the adequate tumescent technique and not using a tourniquet during surgery.
Amaç: Wide Awake Local Anesthesia No Tourniqet (WALANT) yöntemi lokal anestezi altında turnikesiz olarak ekstremite cerrahilerinde kullanılan bir tekniktir. Bu araştırmanın amacı, üst ekstremite cerra-hilerinde WALANT tekniğinin etkinliğini ve kemik ve yumuşak doku cerrahilerinin karşılaştırmasınıkar-şılaştırmasını incelemektir. Materyal ve metod: Mayıs 2021 ile Nisan 2023 arasında, WALANT tekniği kullanılarak üst ekstremite cerrahisi geçiren 39 hasta çalışmaya dahil edildi. Hastalar iki gruba ayrıldı: grup A yumuşak doku ameli-yatları ve grup B kemik doku ameliyatları. Gruplar arasında postoperatif ağrı başlangıç zamanı, ağrı skoru, intraoperatif kanama, ek solüsyon gereksinimi, koter kullanımı ve cerrahi alanındaki kanama miktarı açısından karşılaştırma yapıldı. Cerrahi işlem sırasında ağrı seviyelerini değerlendirmek için Görsel Analog Skala (VAS) kullanıldı. Bulgular: İki grup arasında yaş, cinsiyet ve operasyon yapılan taraf açısından belirgin farklılık bulunma-dı. Her iki grup hastalarında, cerrahın değerlendirmesine göre ameliyat sırasında benzer bir kanama miktarı izlendi. Ek solüsyon ihtiyacı, koter kullanımı, ağrı başlangıç zamanı ve VAS skorları açısından gruplar arasında farklılık gözlenmedi. Sonuç: WALANT tekniği, uygun şekilde seçilmiş hastalarda üst ekstremite kemik ve yumuşak doku operasyonlarında kullanılabilen etkili ve güvenli bir yöntemdir. Genel veya geniş bölgesel anestezi yerine lokal anestezi altında turnike olmaksızın kanamasız bir ameliyat cerrah ve hasta konforu açısın-dan etkilidir. Tekniğin uygun bir şekilde uygulanması, olası komplikasyonları önlemek açısından önemlidir.
Learning Objectives
After studying this article, the participant should be able to: 1. Explain the most important benefits of wide-awake surgery to patients. 2. Tumesce large parts of the body with minimal pain local anesthesia injection technique to eliminate the need for sedation for many operations. 3. Apply tourniquet-free surgery to upper and lower limb operations to avoid the sedation required to tolerate tourniquet pain. 4. Move many procedures out of the main operating room to minor procedure rooms with no increase in infection rates to decrease unnecessary cost and solid waste in surgery.
Summary
Three disruptive innovations are changing the landscape of surgery: (1) minimally painful injection of large-volume, low-concentration tumescent local anesthesia eliminates the need for sedation for many procedures over the entire body; (2) epinephrine vasoconstriction in tumescent local anesthesia is a good alternative to the tourniquet and proximal nerve blocks in extremity surgery (sedation for tourniquet pain is no longer required for many procedures); and (3) evidence-based sterility and the elimination of sedation enable many larger procedures to move out of the main operating room into minor procedure rooms with no increase in infection rates. This continuing medical education article explores some of the new frontiers in which these changes affect surgery all over the body.
Wide-awake local anesthesia no tourniquet is named the WALANT technique.
WALANT has had a major positive impact on cost, convenience, ecology, patient satisfaction, access to surgical care, and outcomes in hand surgery in the last 20 years.
Safe and efficient application of the technique is based on two principles.
The first principle is the tumescent injection of a large volume low concentration 0.25–1% lidocaine, with 1:100 000–1:400 000 epinephrine.
The second principle of WALANT is that the proper injection should be almost painless, with the patient only feeling the first needle poke of a tiny 30G needle.
This wide awake patient approach reduces pain, neuropraxia, and systemic side effects of sedation with preservation of motor control, thereby aiding balanced reconstruction in hand surgery.
Background:
Like many surgical subspecialties, there have been frequent advancements and discoveries in the field of hand and upper extremity surgery. With a rapidly growing literature base, it can be difficult to remain updated on the latest recommendations.
Methods:
A comprehensive literature search was completed on PubMed using MeSH terms. Topics included nutrition management, anticoagulation, immunosuppressive medication management, antibiotic use, skin preparation, splinting, tourniquet use, and suture choice. Data from articles with a level of evidence 1A-3 C were included.
Results:
A total of 42 articles were identified and reviewed to provide evidence for recommendations regarding various aspects of pre-, intra-, and post-operative care.
Conclusions:
The objective of this manuscript is to serve as a resource for evidence-based recommendations by the findings of recent evidence related to perioperative care in elective hand surgery. Additional studies are required in certain areas of the literature in order to provide stronger recommendations.
Background:
The purpose of this study was to evaluate the impact of using virtual reality masks for the management of preoperative anxiety and its impact on postoperative and predischarge anxiety as well as postoperative analgesia during outpatient hallux valgus surgery.
Methods:
From June 2020 to September 2021, preoperative anxiety of patients scheduled for a percutaneous hallux valgus surgery were analyzed using the State Trait Anxiety Inventory (STAI) questionnaire completed during the consultation. All patients with major anxiety, defined as a STAI score above 40, were included in a randomized prospective comparative single-center study. Sixty patients were included in the study and randomized into 2 arms of 30 patients according to whether or not they underwent a preoperative hypnosis session with a virtual reality mask before surgery.
Results:
There was an improvement in the postoperative (42.5 vs 45.2, P < .04) and predischarge (25.3 vs 30.2 P < .03) anxiety scores in the group that used the mask before the procedure. There was a notable decrease in immediate higher-level postoperative analgesics such as morphine or ketamine (3.3% vs 26.6%, P < .03) in the arm using the mask.
Conclusion:
In this study cohort undergoing percutaneous hallux valgus surgery, we found that use of a virtual reality hypnosis mask before surgery modestly reduced postoperative and predischarge anxiety as well as early postoperative consumption of higher-level analgesics in adults with significant preoperative anxiety.
Level of evidence:
Level II, prospective cohort study.
Waste in medicine can be defined narrowly by including only physical waste. It can be defined widely by including the concept of wasting time, energy, money and waste of materials. We will provide an overview of waste mitigation and how it can be a union between saving money and protecting the environment.
Wide-awake, local anesthesia, no tourniquet (WALANT) is a technique that removes the requirement for operations to be performed with a tourniquet, general/regional anesthesia, sedation or an anesthetist. We reviewed the WALANT literature with respect to the diverse indications and impact of WALANT to discuss the importance of future surgical curriculum integration. With appropriate patient selection, WALANT may be used effectively in upper and lower limb surgery; it is also a useful option for patients who are unsuitable for general/regional anesthesia. There is a growing body of evidence supporting the use of WALANT in more complex operations in both upper and lower limb surgery. WALANT is a safe, effective, and simple technique associated with equivalent or superior patient pain scores among other numerous clinical and cost benefits. Cost benefits derive from reduced requirements for theater/anesthetic personnel, space, equipment, time, and inpatient stay. The lack of a requirement for general anesthesia reduces aerosol generating procedures, for example, intubation/high-flow oxygen, hence patients and staff also benefit from the reduced potential for infection transmission. WALANT provides a relatively, but not entirely, bloodless surgical field. Training requirements include the surgical indications, volume calculations, infiltration technique, appropriate perioperative patient/team member communication, and specifics of each operation that need to be considered, for example, checking of active tendon glide versus venting of flexor tendon pulleys. WALANT offers significant clinical, economic, and operative safety advantages when compared with general/regional anesthesia. Key challenges include careful patient selection and the comprehensive training of future surgeons to perform the technique safely.
Distal upper limb surgery is performed under WALANT (Wide Awake Local Anesthesia No Tourniquet) in many outpatient centers because the benefits are numerous: simple, low-cost technique, with fast turnover and short length of stay. In view of a paucity of data concerning patient satisfaction, this non-randomized cohort study was designed to compare EVAN-LR anesthesia satisfaction questionnaire results (information, pain, expectation, attention, discomfort: 0-100 points) between patients receiving WALANT or axillary nerve block (AxB). After IRB approval, patients (>18 years, stable ASA 1-3) scheduled for outpatient distal upper limb surgery were prospectively enrolled in the two groups. At discharge, patients in both groups received standard information on postoperative recovery and care, with a multimodal analgesic regime (acetaminophen and ketoprofen for 5 days). The primary endpoint was EVAN-LR score before discharge. Secondary endpoints were pain relief and side-effects over a 7-day period. Results were recorded as median and 25-75% interquartile range. Propensity-score-matched analysis was performed. Over the study period, from October 2019 to November 2020, 183 patients were included; 48 WALANT patients were propensity-score matched to 48 AxB patients. Pre-procedural APAIS anxiety score was lower in the WALANT than the AxB group: 9 (IQR, 6-12) vs 12 (IQR, 8-14) (p = 0.01). EVAN-LR scores were similar between the WALANT (78 [72-82]) and the AxB group (73[67-80]. Incidences of paresthesia and of pain (NRS pain score, opioid rescue) were similar. WALANT patients had shorter length of stay: 135 (110-175) min vs 170 (110-250) min (p = 0.01). The present study demonstrated that WALANT was associated with a high level of patient satisfaction. For clinical relevance and quality of care, WALANT should be proposed in first line for distal limb surgery.
Background
Surgery around the ankle is increasingly embedded in outpatient treatment concepts. Unfortunately, the classic “ankle block” as a concept of regional anesthesia is inappropriate for surgery around the ankle because the injection sites are too distal to block this specific region.
Methods
The “high ankle block” avoids this disadvantage by dislocating the injection points 15 cm proximal to the malleoli. Three of five peripheral nerves necessary to perform the block can be reached by a circumferential subcutaneous wall. The Posterior Tibial Nerve and the Deep Peroneal Nerve are addressed by an ultrasound guided approach.
Results
The efficacy of the technique is highlighted by a case series (3 cases) in which the new blockade was used as a stand-alone procedure, i.e. without additional general anesthesia.
Conclusions
The “high ankle block” may serve as an ultrasound guided expansion to the classic techniques, extending the operative spectrum to the ankle region.
A 48-year-old man with drug addiction presented with gangrene of the right hand following an inadvertent intra-arterial administration of crushed dihydrocodeine tartrate (DF 118) tablets (GlaxoSmithKline S.A.) dissolved in water; the solution was injected into his right antecubital fossa. After 3 weeks of pain, paresthesia, and cyanosis, his right hand became gangrenous. We performed a right forearm amputation by use of the wide-awake local anesthesia no tourniquet technique. After surgery, his wound healed well, and he was successfully fitted with a hand prosthesis.
Resumen
Introducción: El aumento de la prevalencia de osteoporosis asociado al envejecimiento y a los accidentes deportivos y de tráfico, son los responsables del incremento de las fracturas de tobillo. Este hecho pone de manifiesto la necesidad de protocolizar su asistencia para proporcionar un mayor beneficio clínico al paciente y una disminución de costes al sistema.
Objetivo y métodos: En la actualidad, no existe un marco común para la implantación de protocolos y circuitos internos en los centros españoles para la realización de fracturas de tobillo por la vía de la cirugía mayor ambulatoria (MOS), objetivo que persigue el presente documento de posicionamiento. Para ello se revisa la evidencia clínica y económica de la MOS, el entorno local y las estrategias para su implementación, haciendo referencia a las fracturas de tobillo.
Evidencia clínica y económica: Los resultados mostraron una mejor relación coste-beneficio en pacientes ambulatorios respecto a la tradicional hospitalización, con complicaciones y tasas de reingreso menores y, por tanto, ahorro de costes significativos.
Barreras y estrategias: Se revisan las barreras generales y específicas, así como las estrategias y los circuitos para la correcta implementación.
Resultados: Los resultados muestran una reducción de las tasas de complicaciones y reingresos, así como un ahorro de costes. Supone una mejor relación coste-beneficio en la atención ambulatoria en comparación con la hospitalización tradicional.
Resumen
Introducción
El aumento de la prevalencia de osteoporosis asociado al envejecimiento y a los accidentes deportivos y de tráfico, son los responsables del incremento de las fracturas de tobillo. Este hecho pone de manifiesto la necesidad de protocolizar su asistencia para proporcionar un mayor beneficio clínico al paciente y una disminución de costes al sistema.
Objetivo y métodos
En la actualidad, no existe un marco común para la implantación de protocolos y circuitos internos en los centros españoles para la realización de fracturas de tobillo por la vía de la cirugía mayor ambulatoria (CMA), objetivo que persigue el presente documento de posicionamiento. Para ello se revisa la evidencia clínica y económica de la CMA, el entorno local y las estrategias para su implementación, haciendo referencia a las fracturas de tobillo.
Evidencia clínica y económica
Los resultados mostraron una mejor relación coste-beneficio en pacientes ambulatorios respecto a la tradicional hospitalización, con complicaciones y tasas de reingreso menores y, por tanto, ahorro de costes significativos.
Barreras y estrategias
Se revisan las barreras generales y específicas, así como las estrategias y los circuitos para la correcta implementación.
Resultados
Los resultados muestran una reducción de las tasas de complicaciones y reingresos, así como un ahorro de costes. Supone una mejor relación coste-beneficio en la atención ambulatoria en comparación con la hospitalización tradicional.
Posicionamiento
La implantación de la CMA contribuye a mejorar la calidad asistencial, la satisfacción del paciente y del equipo asistencial, así como la optimización de recursos. Las fracturas de tobillo en pacientes seleccionados tanto por la patología de base, riesgo anestésico y tipo de fractura pueden intervenirse de manera satisfactoria en régimen de CMA.
Objective:
To explore the value of wide-awake local anesthesia no tourniquet (WALANT) technique in the treatment of acute Achilles tendon rupture.
Methods:
In a prospective randomized controlled trial, 48 patients with acute Achilles tendon rupture who met the criteria between March 2020 and October 2020 were randomly divided into two groups according to 1∶1 distribution, with 24 cases in each group. The study group used WALANT technique and the control group used epidural anesthesia with tourniquet for channel-assisted minimally invasive repair (CAMIR). There was no significant difference between the two groups in gender, age, injured side, cause of injury, distance from broken end of Achilles tendon to calcaneal tubercle, and time from injury to hospitalization ( P>0.05). The operating room use time (from patients entering the operating room to leaving the operating room), intraoperative blood loss, hospital stay, and the highest pain score [using Numerical Rating Scale (NRS)] during operation and at 1 day after operation were recorded and compared between the two groups. The tourniquet adverse reactions in the control group were recorded. The functional recovery was evaluated by the scoring method of American Orthopedic Foot and Ankle Society (AOFAS) at 12 months after operation.
Results:
The operation was successfully completed in both groups. The operating room use time and hospital stay in the study group were significantly less than those in the control group ( P<0.05), but the difference in the intraoperative blood loss between the two groups was not significant ( t=0.429, P=0.670). There was no significant difference in the highest NRS score during operation between the two groups ( t=1.671, P=0.101); the highest NRS score in the study group at 1 day after operation was significantly lower than that in the control group ( t=-6.384, P<0.001). In the control group, 13 patients had different degrees of tourniquet adverse reactions, including tourniquet regional pain, local swelling, blisters, thigh numbness, and discomfort. The patients in both groups were followed up 12-18 months, with an average of 13.9 months. The motor function of all patients returned to normal at 12 months after operation. The difference in AOFAS scores between the two groups was not significant ( t=0.345, P=0.731). There was no complication such as sural nerve injury, local infection, and secondary rupture in both groups.
Conclusion:
The application of WALANT combined with CAMIR technique in the treatment of acute Achilles tendon rupture has good anesthetic and effectiveness, avoids the adverse reactions of tourniquet, and reasonably saves social medical resources.
Purpose
Wide-awake local anesthesia no-tourniquet (WALANT) hand surgery has gained popularity because of its cost savings, safety, favorable outcomes, and high patient satisfaction. However, the wide-awake nature of the technique causes many patients to experience anxiety during the procedure. Nonorthopedic studies have reported the anxiolytic effects of intraprocedural music in a variety of wide-awake medical procedures. This prospective randomized controlled trial investigated the effects of wearing noise-canceling headphones and listening to music on patient anxiety during WALANT hand surgery.
Methods
Institutional review board approval was obtained. Patients were randomized to one of the following groups: (1) a headphones group that wore noise-canceling headphones and listened to music (genre of their choice) during the surgery, or (2) a control group that neither wore noise-canceling headphones nor listened to music during surgery. Patient anxiety was assessed on a 10-point visual analog scale before, during, and after surgery. All patients completed an overall experience questionnaire after surgery.
Results
Fifty patients were enrolled, with 25 in each group. Both the groups were similar in terms of patient characteristics, diagnosed anxiety, and preoperative level of anxiety. The headphones group was found to have significantly less intraoperative anxiety (1.02 vs 2.32, respectively; P = .017) and a significantly greater net decrease in anxiety from the preoperative to intraoperative level (−1.78 vs −0.56, respectively; P = .033) than the control group. In the headphones group, 92% (23/25) of patients stated that they would recommend wearing noise-canceling headphones and listening to music to other WALANT hand surgery patients. All (50/50) patients in both groups reported that they would choose to undergo WALANT hand surgery again if needed for the same problem.
Conclusions
The use of noise-canceling headphones with music during WALANT hand surgery significantly decreases intraoperative patient anxiety. This intervention represents an effective, safe, and inexpensive nonpharmacologic measure to improve patient anxiety and overall experience with WALANT hand surgery.
Type of study/level of evidence
Therapeutic I.
The "Wide Awake Local Anesthesia No Tourniquet" (WALANT) technique is gaining popularity in hand surgery owing to its benefits of reduced cost, shorter hospital stay, improved safety, and the ability to perform active intraoperative examinations. The aim of this study is to analyze the cost savings and efficiency of performing A1 pulley release for treatment of trigger finger using the WALANT technique in a major city hospital procedure room (PR) as compared with the standard tourniquet, operating room (OR) approach.
Methods:
Patients who underwent trigger finger release between 2012 and 2017 were identified. Demographic and procedural information were obtained. Patients were followed for an average of 82 and 242 days in the PR and OR groups, respectively.
Results:
Thirty-nine PR and 37 OR patients were identified. Case length and turnover time were shorter in the PR group [21.4 ± 7 versus 23.5 ± 14.3 min (P = 0.942) and 31.1 ± 11.1 and 65.3 ± 17.7 min (P < 0.001), respectively). The cost of the instrument tray utilized was calculated as 993.79 in the PR. Cost per minute for all personal services in the OR was calculated to be $44/min, a cost that was virtually absent in the PR. Complication rates did not differ between both groups.
Conclusion:
Performing A1 pulley release for treatment of trigger finger using the WALANT technique is both cost effective and time efficient compared to performing the same procedure in the main OR of a major city public hospital.
Objective
The use of wide-awake local anesthesia with no tourniquet (WALANT) is becoming an excellent alternative for elective hand surgeries and hand surgeries involving minor trauma. Although the use of WALANT for some soft tissue surgeries has become the state of the art, data regarding bony procedures, such as fracture management, under WALANT are limited. This study was performed to assess the WALANT technique for open reduction and internal fixation of distal radius fractures.
Methods
Five patients with displaced distal radius fractures were enrolled in the study. WALANT was carried out about 30 minutes prior to the first incision. Surgery was performed in the normal fashion, and the fractures were fixed using anatomic locking plates. After surgery, the patients were admitted overnight for observation and pain assessment, and they were discharged within 24 hours postoperatively. Intraoperative and postoperative complications were recorded. Follow-up was performed in our outpatient clinic. No abnormalities were recorded.
Results
All patients underwent a successful painless surgery. No extra bleeding or other complications were recorded.
Conclusion
The WALANT technique offers a simple and safe alternative to traditional anesthetic techniques for open reduction and plating of distal radius fractures.
Background:
Acute Achilles tendon rupture (AATR) is a frequent injury occurring dominantly in young to middle-aged males. Outcomes and complications between percutaneous and open repair are still controversial. Thus, the purpose of this meta-analysis is to evaluate the outcomes and complications of these two operative methods.
Materials and methods:
We searched multiple databases: PubMed, Web of Science, EMBASE and the Cochrane Library up to October 2016. Two reviewers independently screened the studies for eligibility, evaluated the quality and extracted data from eligible studies, with confirmation by cross-checking. The major results and conclusions were concluded, and the different complication rates and functional outcomes were compared. Meta-analysis was processed by Rev Man 5.3 software.
Results:
Five randomized controlled trials (RCTs) and seven retrospective cohort studies involving 815 patients met the inclusion criteria. The sural nerve injury rate in the percutaneous group was significantly higher (RR = 3.52, 95%CI 1.45 to 8.57, P = 0.006). However, deep infection rate in the open group was higher (RR = 0.33, 95%CI 0.11 to 0.96, P = 0.04) and subgroup analysis of five RCTs showed no significant difference (RR = 0.42, 95%CI 0.09 to 2.10, P = 0.29). No significant difference was seen regarding the rate of re-rupture. The time of operation in the percutaneous group was shorter (RR = -1.99, 95%CI -3.81 to -0.80, P = 0.001). American Orthopedic Foot and Ankle Society (AOFAS) ankle-hindfoot score showed statistically different in the two groups. Other functional outcomes were similar in the two groups.
Conclusions:
Percutaneous repair has the advantages of operation time, deep infection and AOFAS score. The functional outcomes were similar in two treatment groups except AOFAS score. Despite the higher incidence of sural nerve injury, we still believe that percutaneous repair is superior to open repair for treating AATR.
Purpose:
Open fibrin gluing is reported to enable anatomical reconstruction with less soft tissue compromise than suture repair. Our main objective was to compare the complication rate, function, pain and disability of the two operative approaches of percutaneous suture using the Paessler technique and open fibrin gluing.
Methods:
Sixty-four patients (two centres, retrospective cohort study, 2000-2009) who had undergone acute Achilles tendon repair with either percutaneous suture (n = 27; 44 years) or open fibrin glue (n = 37; 45 years) took part in a follow-up examination after a median of 63 months (range, six to 180). Ankle range of motion, calf and ankle circumferences and return to work and sports activities were evaluated. Isokinetic und sonographic evaluation results were retrieved.
Results:
Complications were noted in 22 patients (34 %). Delayed wound healing without evidence of surgical site infection was found in three patients in the fibrin group and two patients in the suture group. Postoperative scar tenderness described as pain at the rim of the shoe was significantly more frequent in the suture group (p = 0.03). Re-rupture requiring re-operation occurred in one patient. Transient paresthesia of the heel occurred in 12 patients. No sural nerve lesions were reported. There was no significant difference between groups regarding lower leg circumference, disability, or function. Ultrasound and isokinetic measurements did not reveal a significant difference between the two methods.
Conclusions:
The present study suggests that open fibrin gluing is a reasonable alternative to percutaneous repair of acute ruptures of the Achilles tendon and both techniques can yield reliably good results.
This is a review article of the wide-awake approach to hand surgery. More than 95% of all hand surgery can now be performed without a tourniquet. Epinephrine is injected with lidocaine for hemostasis and anesthesia instead of a tourniquet and sedation. This is sedation-free surgery, much like a visit to a dental office. The myth of danger of using epinephrine in the finger is reviewed. The wide awake technique is greatly improving results in tendon repair, tenolysis, and tendon transfer. Here, we will explain its advantages.
Background
This study compared the results of regional blocks containing a single anesthetic, bupivacaine, with those containing bupivacaine and 3 additives (buprenorphine, clonidine, and dexamethasone) in patients undergoing foot and ankle surgery.
Methods
Eighty patients undergoing foot and ankle surgery over a 9-month period were prospectively enrolled and randomized to receive a peripheral nerve block containing either a single anesthetic (SA) or one with 3 additives (TA). Patients, surgeons, and anesthesiologists were blinded to the groups. Patients maintained pain diaries and were evaluated at 1 and 12 weeks postoperatively. Fifty-six patients completed the study.
Results
The TA group had a longer duration of analgesic effect than the SA group (average 82 vs 34 hours, P < .05). Forty-eight hours after surgery, 93% of SA blocks, compared with 34% of TA blocks, had completely worn off. The TA group had a longer duration of sensory effects. At 3 months, 10 of 26 (38.5%) TA patients, compared with 3 of 30 (10%) SA patients, reported postoperative neurologic symptoms. Pain scores in both groups were not statistically different at 1 week or 3 months after surgery. Patients in both groups were similarly satisfied with their blocks.
Conclusion
Both types of nerve blocks provided equivalent pain control and patient satisfaction in patients undergoing foot and ankle surgery. The 3-additive agent blocks were associated with a longer duration of pain relief and a longer duration of numbness, as well as higher rates of postoperative neurologic symptoms. Longer pain relief may be obtained at the cost of prolonged sensory deficits.
Level of Evidence
Level II, prospective comparative study.
Hardware removal after surgical treatment fracture is one of the most common procedures in orthopaedic daily activity. A percentage from 14.5 to 21 of total removal involves the ankle joint. Trying to reduce the important socio-economic impact of this surgical procedure, we thought to perform it using the Wide Awake Local Anaesthesia Without Tourniquet (WALANT), a particular technique presented by D. Lalonde that associated a local anaesthetic drug with epinephrine in order to obtain an effective haemostatic effect despite the lack of a tourniquet. Nowadays, the WALANT efficiency and safety in hand surgery is widely demonstrated in literature but there are no data about its use in lower limb extremity surgeries. Authors performed a randomized study with 60 patients whom underwent distal fibula hardware removal between 2014 and 2016; they were divided into two groups: Group A under loco-regional anaesthesia with tourniquet and Group B under WALANT. We did not find significant differences in term of maximum pain level felt during the anaesthesiologic and surgical procedure. However, the use of WALANT significantly reduced post-operative pain levels. The WALANT procedures also reduced the number of hospitalization days. No differences in term of post-operative complication rates were found. In conclusion, the WALANT can be considered as a suitable option for distal fibula hardware removal in selected patients; it shows important clinical and economic advantages compared to the traditional loco-regional anaesthesia with tourniquet. This study also lays the foundation for the use of the WALANT beyond the field of hand surgery only.
Introduction:
Ankle fractures frequently occur and must be treated with open reduction for long-term stability. The existing anaesthesia methods include general anaesthesia, spinal and epidural anaesthesia, peripheral nerve block and local anaesthesia with IV sedation. However, each method has its inherent risks and potential costs, and the use of a tourniquet is inevitable. Therefore, the wide-awake local anaesthesia no tourniquet (WALANT) technique provides an alternative method for equivalent haemostasis and pain control without the use of a tourniquet.
Patients and methods:
We prospectively enrolled 13 consecutive patients (9 males and 4 females) who presented ankle fractures and required ORIF from January 2017 to December 2017. The fracture types of the 13 patients included lateral malleolar fracture (three patients), bimalleolar fracture (two patients), bimalleolar equivalent fracture (three patients), medial malleolar fracture (two patients) and trimalleolar fracture (three patients; articular surface involvement <25%). We used a solution of 1% lidocaine mixed with 1:40,000 epinephrine for WALANT.
Results:
All patients underwent surgery if they exhibited an initial numerical pain rating scale (NPRS) score of 0 without using a tourniquet. Only two patients required an additional 5 ml of local anaesthesia due to NPRS score elevation during the surgery; no dose exceeded the safe limit of 7 mg/kg. No local complications occurred, and no shifts to other anaesthesia methods were required due to the failure of WALANT.
Conclusions:
WALANT simplified surgical preparations and provided a safe and reliable method for ankle fracture management. Because the use of a tourniquet was not required, reduced postsurgical pain was observed. Moreover, the use of local anaesthesia resulted in more satisfied patients and facilitated easier recovery.
Injection of tumescent local anesthesia should no longer be painful. WALANT anesthesia, strong sutures, a slightly bulky repair, intraoperative testing of active movement, and judicious venting of the A2 and A4 pulleys improve results in flexor tendon repair. WALANT K wire finger fracture reduction permits intraoperative testing of K wire stability with active movement to facilitate early protected movement at 3 to 5 days after surgery. WALANT can decrease costs and garbage production while increasing accessibility and affordability. Several surgeons have found no infection difference when the K wires are inserted with full operating room sterility versus field sterility.
Wide Awake surgery under Local Anesthesia with No Tourniquet (WALANT) has revolutionized clinical hand surgery, improving clinical outcomes and reducing postoperative pain and morbidity. It can also be used to deepen scientific knowledge, because the unsedated patient, with sensation intact and without the adverse effects of tourniquet neurapraxia or paralysis, can follow commands and actively move the limb after tendon and nerve surgery. These movements can be correlated with fingertip force, tendon tension, nerve conduction and amplitude, and muscle sarcomere length measurements to develop new insights into the effectiveness of many different tendon and nerve procedures in the hand.
This article reviews the impact of wide-awake hand surgery without tourniquet on departmental settings and savings on patients’ medical cost, and efficiency of fellowship training and practice of junior hand surgeons in 3 units in 3 countries. The medical cost of the commonly performed procedures is decreased remarkably with this approach in the 3 units. Hand surgery fellowship training and practice of junior surgeons are benefited from this approach in 2 units in Turkey and Switzerland. Overall, this approach improves the surgeons’ and patients’ quality of life and its application is expanding to almost all procedures of hand surgery.
Wide-awake local anesthesia no tourniquet (WALANT) is used for various hand surgeries, but there are no reports of its use for distal radius fractures. The authors compared perioperative variables and clinical outcomes for volar plating for distal radius fractures with WALANT vs general anesthesia with tourniquet. This retrospective study included 47 patients who presented with distal radius fractures between January 2015 and February 2017. Twenty-one underwent surgical volar plating with WALANT, and 26 underwent surgical volar plating with general anesthesia with tourniquet. Patients were followed for 12 months. The 2 groups were compared regarding perioperative parameters and clinical outcomes, including perioperative field pain evaluated by visual analog scale score on postoperative day 1, range of motion 12 months postoperatively, and Mayo wrist score. The WALANT group had a lower mean visual analog scale score and a shorter mean hospitalization (both P<.001), but greater mean blood loss (P<.001). No significant differences were found regarding operative time (P=.214) or time to union (P=.180). At 12-month follow-up, no significant differences were found regarding wrist extension (P=.721), wrist flexion (P=.119), or Mayo wrist score (P=.223). Although both techniques permitted volar plating for distal radius fractures, WALANT allowed immediate intervention and led to less postoperative pain and shorter hospitalization. Although control of blood loss was worse with WALANT, blood loss was limited to a mean of 22.62 mL and did not interfere with the surgical field. [Orthopedics. 2019; 42(1):e93-e98.].
Objectives:
This study aims to compare the three most commonly used fixation techniques: tension-band wire fixation, partially threaded cannulated screws, and fully threaded cannulated headless compression screws.
Patients and methods:
Ninety patients with medial malleolus fractures were included in the study. Patients were divided into three groups. Group A included patients who underwent tension-band wire fixation (n=26), Group B partially threaded cannulated compression screws (n=32), and Group C fully threaded cannulated headless compression screws (n=32). The type of medial malleolus fracture, healing rates, implant-related complications, rate of infection, hardware removal, weight-bearing restrictions, mean interval time from the injury to the surgery, and Body Mass Indexes (BMIs) were investigated. The patients' radiographs (standard anteroposterior, lateral, and mortise) were reviewed. The American Orthopedic Foot and Ankle Society (AOFAS) scoring system was used for clinical evaluation.
Results:
No significant difference was observed between the three groups in terms of age, gender, BMI, follow-up period, and fracture type. Union rate for group C was significantly shorter than groups A and B. There was no implant failure or irritation in group C and this was statistically significant comparing to group A and B (p=0.037). However, there was no significant difference between group A and B (p=0.41). There were no significant differences in the three groups according to AOFAS. Patients with low BMI in groups A and B had a high rate of implant-related complications. There was a significant correlation between low BMI and implant-related complication (p<0.001).
Conclusion:
Union rate in the group who were operated with fully threaded cannulated headless compression screws was significantly shorter than the other groups. This study has shown that tension band wiring and partially threaded cannulated compression screws can cause irritation of soft tissues and pain over the hardware implantation site. Patients with low BMI are vulnerable for implant-related complications.
Wide-awake surgery has potential advantages for treating extensor or flexor tendon injury. We present a case of chronic extensor hallucis longus injury treated with turn-down reconstruction using wide-awake surgery with a selective nerve block. To the best of our knowledge, this is the first such case reported. The patient had dropped a knife proximal to the right hallux metatarsophalangeal joint. Because direct suturing was thought to be difficult, turn-down reconstruction was performed under a selective nerve block. At 8 months postoperatively, the hallux had 75° of extension in the metatarsophalangeal joint and -5° of extension in the interphalangeal joint, similar to those of the healthy foot. The Japanese Society for Surgery of the foot objective hallux scale score had improved from 87 to 100, and the subjective scores in the subcategories of pain and pain-related, physical functioning and daily living, and shoe-related in the self-administered foot evaluation questionnaire had improved from 82.8 to 94.4, 97.7 to 100, and 50 to 83.3, respectively. Turn-down reconstruction using wide-awake surgery with a selective nerve block can be used for chronic extensor hallucis longus rupture and can be expected to provide good results.
Background: A recent case series suggested that surgery with wide-awake local anesthesia is tolerated well by most foot and ankle patients. However, patients were assessed retrospectively and there was no comparison group to show the relative efficacy of this approach. The present study was conducted to address these concerns.
Methods: Perioperative pain and anxiety were assessed in 40 patients receiving forefoot surgery using either wide-awake local anesthesia or general anesthesia. Ratings were collected on the day of surgery using 11-point (0 to 10) numerical rating scales.
Results: Patients in the two anesthesia groups reported no differences in preoperative pain (p = .500) or anxiety (p = .820). Patients who received wide-awake local anesthesia reported lower levels of postoperative pain (p < .001) and anxiety (p < .001) than patients who received general anesthesia. They also reported little pain (M = 0.17, SD = 0.32) or anxiety (M = 1.33, SD = 1.74) during the operation.
Conclusion: Results indicate that surgery with wide-awake local anesthesia is tolerated well by most patients, and that it may have some benefit compared to surgery with general anesthesia.
Background: The “wide-awake” approach to foot and ankle surgery is characterized by a surgeon-administered mixture of local anesthetic and epinephrine. No tourniquet, sedation, or general anesthesia are required for surgery. This paper describes a retrospective survey of the initial patients to undergo wide-awake foot and ankle surgery at our center.
Methods: Thirty former wide-awake patients were surveyed about their perioperative anxiety, pain, and satisfaction.
Results: Twenty-seven of 30 patients (90%) completed the survey. Patients received a variety of forefoot, hindfoot, and lower leg procedures. In general, they reported a decrease in anxiety over the course of the perioperative period (p = 0.005). Pain fell from the preoperative to the intraoperative period, then rose to preoperative levels during recovery (p < 0.001). Most patients said that the surgery was better than expected (83%); would choose wide-awake surgery for a subsequent procedure (87%); and would recommend wide-awake surgery to someone who required surgery (88%).
Conclusions: Results indicate that the wide-awake approach to foot and ankle surgery causes little discomfort to patients who receive many common procedures. The removal of hindfoot hardware under local anesthesia is contraindicated.
A popliteal nerve block is a common analgesic procedure for patients undergoing surgery on their knee, foot, or ankle. This procedure carries less risk in a surgical setting compared with other forms of anesthesia such as a spinal block. Previous reports demonstrated few to no complications with the use of this nerve block, but it is unclear whether these data are consistent with the recent increase in use of this analgesic procedure for lower extremity surgery.
Retrospectively, a busy orthopedic foot and ankle practice performed a chart review examining for postoperative neuropathic complications possibly related to the popliteal nerve block. The 1014 patients who had undergone a popliteal block for foot and/or ankle orthopedic surgery were analyzed for short and long-term neuropathic complications. The collected data consisted of tourniquet time, pressure, and location as well as the method of finding the fossa nerve, adjuncts used, and patient medical history. Data were analyzed using chi-square, Fisher's exact, and t tests for analysis with a significance value of P < .05.
Of these 1014 patients, 52 patients (5%) developed deleterious symptoms likely resulting from their popliteal block, and 7 (0.7%) of these were unresolved after their last follow-up. No immediately apparent underlying causes were determined for these complications.
The frequency of a neuropathic complication following a popliteal nerve block was notably higher in the early postoperative period than indicated in the past. The proportion of patients with unresolved neuropathic symptoms at last follow-up is comparable to that previously reported in the literature.
Level IV, retrospective case series.
© The Author(s) 2015.
The minimally invasive tumescent local anesthesia technique used in wide-awake hand surgery is having an impact in hand surgery practice. Patients spend less time and money and get to speak to their surgeon and receive education during the surgery itself. Improvements in operations such as flexor tendon repair have happened, because surgeons can see movement during the case and make adjustments before the skin is closed. Surgeons can perform more cases in the same amount of time with fewer personnel. The cost of the surgery is decreased, as all expenses surrounding the provision of sedation are removed.
Traditionally, surgeons were taught that local anesthesia containing epinephrine should not be injected into fingers. This idea has since been refuted in many basic and clinical scientific studies, and today, injection of lidocaine plus epinephrine is widely used for digital and hand anesthesia in Canada. The key advantages of the wide-awake technique include the creation of a bloodless field without the use of an arm tourniquet, which in turn reduces the need for conscious sedation. The use of local anesthesia permits active motion intraoperatively, which is particularly helpful in tenolysis, flexor tendon repairs, and setting the tension on tendon transfers. Additional benefits of wide-awake anesthesia include efficiencies and cost savings in outpatient surgical case flow due to the absence of conscious sedation.
Wide-awake hand and wrist surgery: a new horizon in outpatient surgery abstract hemostasis instead of a tourniquet for hand surgery
- Lalonde
A prospective, randomized, controlled trial of forearm versus upper arm tourniquet tolerance
- Harris