Internal fixation of metacarpal fractures using wide awake local anesthesia and no tourniquet

Evaluating patient satisfaction with WALANT for hand surgery: a comprehensive questionnaire-based study

INTRODUCTION

There has been an increase in the popularity of the wide-awake local anesthesia no-tourniquet (WALANT) procedure for various upper limb surgeries. The present study aims to conduct a comprehensive analysis of the satisfaction levels of 106 patients, considering factors such as age, gender, comorbidities, and the specific procedures they underwent.

METHOD

The present study was a retrospective cohort study conducted to analyze the overall satisfaction of a cohort of 106 patients who underwent various surgical procedures of the hand between 2018 and 2023. The satisfaction was assessed with a questionnaire comprising 13 questions/statements adjusted to a standard Swiss grading system (from 1 = I strongly agree to 6 = I strongly disagree).

RESULTS

Overall satisfaction with WALANT was high, with most patients expressing positive experiences. Patients with hypertension reported similar satisfaction levels compared to those without, while diabetic patients experienced significantly higher anxiety levels during the procedure (p > 0.05).

CONCLUSION

WALANT exhibits versatility as an anesthesia choice, demonstrating efficacy in both routine and complex hand surgeries. Our survey-based study reveals a high satisfaction level across diverse procedures. When assessing the correlation between WALANT satisfaction and patient comorbidities, hypertension displayed no significant impact, while diabetic patients reported heightened anxiety. Importantly, patient satisfaction remained consistently high even within the subgroup with comorbidities. Our results underscore WALANT's reliability in upper limb surgery, showcasing its usefulness and positive outcomes across a broad range of patients and surgical procedures.

New Frontiers in Wide-Awake Surgery

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 Anesthetic No Tourniquet in Hand and Wrist Surgery: Current Concepts, Indications, and Considerations

Background

Traditionally, the use of a pneumatic arterial tourniquet was requisite for safe and effective surgery of the hand. The use of arterial tourniquets necessitates the use of regional or general anaesthesia. Wide-awake local anaesthetic no tourniquet (WALANT) has emerged as a novel technique to overcome the limitations of tourniquet use in conjunction with regional/general anaesthesia. This review aimed to examine the safety and effectiveness of WALANT and provide guidance for surgeons with limited WALANT experience.

Methods

A literature review of MEDLINE was performed up to March 2021 to identify all articles related to the use of WALANT in hand surgery. Any article reporting original data related to the use of WALANT was eligible for inclusion.

Results

A total of 101 articles were identified through database searching. Of these, 79 met full inclusion criteria and described the use of WALANT in 19 elective and trauma procedures. Current data suggest that WALANT is safe and effective for use in a range of procedures.

Conclusions

WALANT surgery is increasing in popularity as evidenced by the variety of surgical indications reported in the literature. There is limited comparative data on the cost-effectiveness of WALANT compared to conventional methods. Current data suggest that WALANT is safe, better tolerated by patients and associated with direct and indirect cost savings.

Wide-awake local anesthesia and no tourniquet (WALANT) in upper limb fractures

Wide-awake local anesthesia and no tourniquet (WALANT), first used for hand surgery, has been sparingly described for use in fracture fixation of the upper limb. We present our experience using this technique. 26 patients with upper limb fractures (3 distal radius, 6 radial shaft, 11 ulnar shaft, and 6 olecranon fractures) were operated on using WALANT by three orthopedic surgeons. We used 35-40ml of 2% Lignocaine with 1:80000 Adrenaline(7mg/kg) diluted with normal saline. Numeric Pain Rating (NPR) scoring was done during injection and per-operatively, and the Likert scale was used for the surgeon's satisfaction. The average NPR score was reported as 0.65 (1-3) during injection and 0.15 (0-2) preoperatively. All three surgeons reported excellent satisfaction in all the cases operated on. No complication occurred due to anesthesia. WALANT is a much simpler option and can be safely used in place of general anesthesia or regional blocks for fixation of fractures of the upper limb, with added advantages of no need for a tourniquet and better intraoperative assessment of fracture fixation.

Comparison between wide-awake local anaesthesia no tourniquet surgery and traditional local anaesthesia surgery for limb operations

Background: In traditional local anaesthesia surgeries, tourniquets are used to reduce blood loss. However, it may induce tourniquet pain. If a long tourniquet time is anticipated, regional or general anaesthesia may be required. Wide-awake local anaesthesia no tourniquet (WALANT) surgery suggests blood loss can be controlled by the use of adrenaline instead of a tourniquet. This study aims to investigate the difference in patient's pain perception, satisfaction and hemostasis control between two groups of patients, the WALANT group, who underwent WALANT surgery, and the traditional group, who underwent traditional local anaesthesia with tourniquet surgery. Methods: This was a prospective cohort study of patients who underwent common orthopaedic local anaesthesia surgeries in a regional hospital between January 2020 and December 2020. Operations were performed by two groups of surgeons: WALANT group and traditional group. Data were collected via questionnaires which included patients’ demographics, diagnosis and operation type, surgeon experience, dosage and type of local anaesthesia use, tourniquet use, operation time, hemostasis status, difficulty of operation, patient's pain perception (pain during LA injection, wound site pain during operation, tourniquet pain, post-operative pain) and satisfaction. The data were analysed by Mann–Whitney U test with SPSS. Results: A total of 143 questionnaires were collected. The WALANT group suffered from less wound site pain during operation ( p = 0.008), less tourniquet pain ( p < 0.001) and less post-operative pain ( p < 0.001). WALANT group had a longer operation time ( p = 0.002). Both the traditional group and WALANT group were commented to have good haemostasis with a median score of 1 and 2, respectively, although the difference in hemostasis control value was significant ( p < 0.001). Conclusion: WALANT surgery was safe and could achieve similar hemostasis with no limitation of tourniquet time and could significantly reduce post-operative pain compared with traditional local anaesthesia with tourniquet use. Level of evidence: Level II.

Complications Following Intramedullary Screw Fixation for Metacarpal Fractures: A Systematic Review

PURPOSE

There has been a recent increase in the use of intramedullary screws (IMS) for the surgical treatment of metacarpal fractures. While IMS fixation has been shown to produce excellent functional outcomes, postoperative complications have yet to be fully explored in a comprehensive way. This systematic review quantified the incidence, treatment, and results of complications following IMS fixation for metacarpal fractures.

METHODS

A systematic review was performed using PubMed, Cochrane Central, EBSCO, and EMBASE databases. All clinical studies that documented IMS complications following metacarpal fracture fixation were included. Descriptive statistics were analyzed for all available data.

RESULTS

Twenty-six studies were included: 2 randomized trials, 4 cohort studies, 19 case series, and 1 case report. Among the 1,014 fractures studied, 47 complications were reported across all studies (4.6%). Stiffness was the most common, followed by extension lag, loss of reduction, shortening, and complex regional pain syndrome. Other complications included screw fracture, bending, and migration; early-onset arthrosis; infection; tendon adhesion; hypertrophic scar; hematoma; and nickel allergy. Eighteen of the 47 (38%) patients with complications underwent revision surgery.

CONCLUSIONS

Complications following IMS fixation of metacarpal fractures are relatively uncommon.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Expanding the applications of intramedullary cannulated screw fixation in the hand

OBJECTIVES

Intramedullary cannulated headless compression screw fixation (ICHCS) is gaining popularity for managing metacarpal and phalangeal fractures, but is still relatively new to the surgical landscape. We aim to further illustrate its utility and versatility by presenting the outcomes of such fractures treated with ICHCS at two tertiary plastic surgery centres. Primary objectives were to assess functional range of motion, patient-reported outcomes, and complication rates.

MATERIALS AND METHODS

All patients with metacarpal or phalangeal fractures treated with ICHCS (n = 49) between September 2018 and December 2020 were retrospectively reviewed. Outcomes were active ranges of motion (TAM), QuickDASH scores (obtained via telephone), and complication rates. Two-tailed Student's t-tests evaluated differences between centres.

RESULTS

TAMs were available for 59% (n = 34/58) of fractures; 70.7% were metacarpal and 29.3% were phalangeal. The mean cohort metacarpal TAMs and phalangeal TAMs were 237.7° and 234.5°, respectively. QuickDASH scores were available for 69% (n = 34/49) of patients. The mean cohort score for metacarpal fractures was 8.23, and 5.13 for phalangeal. Differences between the two centres were statistically significant (p < 0.05). Two complications occurred, giving an overall complication rate of 3.45%.

CONCLUSION

Our results corroborate previous reports on ICHCS, further demonstrating its versatility and capacity to provide excellent outcomes. More prospective, comparative studies are needed to fully determine the suitability of ICHCS.

Safety of wide-awake local anesthesia with no tourniquet (WALANT) in for lower limb surgery: A potential alternative in times of emergency

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.

WALANT: A Discussion of Indications, Impact, and Educational Requirements

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.

Adapting to the COVID-19 pandemic: A survey of UK and European hand surgery units

Hand surgery services had to rapidly adapt to the coronavirus disease 2019 (COVID-19) pandemic. The aim of the Reconstructive Surgery Trials Network #RSTNCOVID Hand Surgery survey was to document the changes made in the UK and Europe and consider which might persist. A survey developed by the Reconstructive Surgery Trials Network, in association with the British Association of Hand Therapists, was distributed to hand surgery units across the UK and Europe after the first wave of COVID-19. It was completed by one consultant hand surgeon at each of the 44 units that responded. Adult and paediatric trauma were maintained but elective services stopped. Consultations were increasingly virtual, and surgery was more likely to be under local anaesthetic and in a lower resource setting. Many of the changes are viewed as being beneficial. However, it is important to establish that they are clinically and cost effective. These survey results will help prioritise and support future research initiatives.

A Fourteen-year Review of Practice Patterns and Evidence-based Medicine in Operative Metacarpal Fracture Repair

The American Board of Plastic Surgery has been collecting practice data on metacarpal fracture operative repair since 2006 as part of its Continuous Certification process. These data allow plastic surgeons to compare their surgical experience to national trends. Additionally, these data present the opportunity to analyze those trends in relation to evidence-based medicine.

WALANT technique versus locoregional anesthesia in the surgical management of metacarpal and phalangeal fractures: Lessons from the Covid-19 crisis

Wide Awake Local Anesthesia No Tourniquet (WALANT) is an anesthetic method which uses a local injection of anesthetic and epinephrine, avoiding use of a tourniquet. During the COVID-19 pandemic, human and logistic resources had to be reorganized, and WALANT ensured resilience in our department to maintain access to surgical care. The objective of the present study was to compare hand function recovery 3 months after surgery for unstable metacarpal or phalangeal fracture under regional anesthesia versus WALANT. From November 2020 to May 2021, 36 patients presenting a metacarpal or phalangeal fracture requiring surgical treatment were included in a single-center study in a university hospital center. Nineteen patients underwent surgery under locoregional anesthesia with tourniquet, and 17 under WALANT. The main endpoint was functional recovery at 3 months on QuickDASH score. Need for complementary anesthesia, surgery duration, analgesic consumption, reintervention rate, and patient satisfaction were also assessed. There was no significant difference between groups in functional recovery at 3 months or on the secondary endpoints. In the COVID-19 context, WALANT proved to be a safe and effective method in hand fracture surgery, ensuring access to surgical care. It should be included in surgical training to optimize day-to-day surgical care and face future crises.

Plate osteosynthesis of single metacarpal fracture: WALANT technique is a cost-effective approach to reduce postoperative pain and discomfort in contrast to general anesthesia and wrist block

BACKGROUND

The WALANT (wide-awake local anesthesia with no tourniquet) technique was based on local infiltration of lidocaine and epinephrine. This technique has rapidly gained popularity in recent years and can perform most hand operations. This study aimed to investigate the time spent on anesthesia and operation and perform an economic analysis among general anesthesia, wrist block with a tourniquet, and the WALANT technique for the internal fixation of metacarpal fractures.

METHODS

We retrospectively reviewed all the single metacarpal fractures managed with the same procedure, open reduction, and internal fixation with the plate between January 2015 and December 2019. They were divided into three groups according to the method of anesthesia: (1) general anesthesia (GA group), (2) wrist block with a tourniquet (WB group), and (3) WALANT technique (WALANT group). We collected and analyzed patient demographic data, perioperative or postoperative complications, number of hospital days, and postoperative functional recovery assessment.

RESULTS

A total of 63 patients met the inclusion criteria, including 24 in the GA group, 28 in the wrist block group using a tourniquet, and 11 in the WALANT group. There were no complications during the operation and follow-up in each group. The GA group had an average of 32.8 min of anesthesia time, significantly longer than the other two groups. However, there is no significant difference regarding surgical time among the presenting three groups. The discomfort of vomiting and nausea after surgery occurred in 20 patients in the GA group (38.1%). Nevertheless, there was no postoperative vomiting and nausea present in both the WB and WALANT groups. Most patients achieved full recovery of pre-injury interphalangeal and metacarpophalangeal motion at the final assessment of functional recovery.

CONCLUSIONS

The patients undergoing metacarpal fixation surgery under WALANT or WB had significantly less anesthesia time and postoperative vomiting and nausea. Moreover, there was no difference in surgical time and intraoperative complications. The time-related reduction improved the utilization of the operation room for additional cases. The reduction of the preoperative examination, anesthesia fee, postoperative recovery room observation, and hospitalization can effectively reduce medical costs. Furthermore, the WALANT group is more acceptable because of no tourniquet, which commonly causes discomfort.

How to Minimize the Pain of Local Anesthetic Injection for Wide Awake Surgery

After reading this article, the participant should be able to (1) almost painlessly inject tumescent local anesthesia to anesthetize small or large parts of the body, (2) improve surgical safety by eliminating the need for unnecessary sedation in patients with multiple medical comorbidities, and (3) convert many limb and face operations to wide awake surgery. We recommend the following 13 tips to minimize the pain of local anesthesia injection: (1) buffer local anesthetic with sodium bicarbonate; (2) use smaller 27- or 30-gauge needles; (3) immobilize the syringe with two hands and have your thumb ready on the plunger before inserting the needle; (4) use more than one type of sensory noise when inserting needles into the skin; (5) try to insert the needle at 90 degrees; (6) do not inject in the dermis, but in the fat just below it; (7) inject at least 2 ml slowly just under the dermis before moving the needle at all and inject all local anesthetic slowly when you start to advance the needle; (8) never advance sharp needle tips anywhere that is not yet numb; (9) always inject from proximal to distal relative to nerves; (10) use blunt-tipped cannulas when tumescing large areas; (11) only reinsert needles into skin that is already numb when injecting large areas; (12) always ask patients to tell you every time they feel pain during the whole injection process so that you can score yourself and improve with each injection; (13) always inject too much volume instead of not enough volume to eliminate surgery pain and the need for "top ups."

Wide-awake Local Anesthesia with No Tourniquet: An Updated Review

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.

Management of metacarpal fractures

The metacarpal fractures are common fractures which are treated by orthopaedic surgeons, plastic surgeons and hand surgeons equally. These are seen in young adults who have active life style. These have a major impact in life style of the patients if these are not treated adequately. The management of the fractures vary among surgeons to surgeons; two surgeons in the same centre can have a different treatment plan for a fracture. There are no standard guidelines for the treatment and it ranges from conservative management, Kirschner's wire (K-wires), plates and screws. This review article is about the management of metacarpal fractures where the commonly done procedures are reviewed.