Recently, the incidence of distal radius fractures has increased.1 They are among the most common injuries treated by orthopedic surgeons, representing 17.5% of all fractures.2 Distal radius fractures follow a bimodal distribution regarding age, occurring more frequently in younger patients after high-energy mechanisms of injury and in older patients after lower-energy trauma because of osteoporosis.3 Because they permit earlier return to work and normal daily activities, volar locking plates are commonly used to treat distal radius fractures.4 The surgery is usually performed with brachial plexus anesthesia or general anesthesia (GA), and a tourniquet is used to control blood loss. Because of its advantages over GA, eliminating the need for and adverse effects of sedation medication, brachial plexus anesthesia is the first choice for upper extremity surgery. However, ultrasound-guided axillary brachial plexus block is technically demanding and requires special equipment.
In 2014, Lalonde5 described wide-awake local anesthesia no tourniquet (WALANT) surgery. Since then, WALANT has been applied to various hand surgeries, such as wrist arthroscopy for triangular fibrocartilage complex repair,6 tendon repair or transfer,7–9 transverse carpal ligament release for carpal tunnel syndrome,10 radial forearm perforator flap,11 and internal fixation or implant removal for metacarpal fractures.12,13 In addition to lidocaine for local anesthesia, the technique requires epinephrine infiltration for vasoconstriction to minimize bleeding and maintain effective hemostasis with a clear view of the surgical field.5 The WALANT technique provides an alternative for patients who cannot endure GA or tolerate tourniquet use. Further, WALANT is more cost-effective because it eliminates recovery from GA drugs and the preoperative testing required for sedation.14 Moreover, it eliminates the pain caused by the tourniquet.15 Intraoperative monitoring is not necessary because localized lidocaine and epinephrine have few adverse effects.16 However, there are no reports of open reduction and internal fixation (ORIF) for distal radius fractures performed under WALANT. Because ORIF of distal radius fractures requires a wider surgical field and includes more bony procedures, such as drilling and reduction, determining the anesthetic and hemostatic effectiveness of WALANT remains an issue.
The current study compared the perioperative variables and clinical outcomes of ORIF for distal radius fractures performed with WALANT vs GA with tourniquet.
Materials and Methods
The study received institutional review board approval. This retrospective study, performed between January 2015 and February 2017, reviewed 62 cases of distal radius fractures treated with ORIF using a volar locking plate (2.4 mm LCP Distal Radius System; Synthes, Solothurn, Switzerland) performed by a single surgeon (C.-Y.C.). Included were adult patients with acute traumatic injury, closed and unilateral distal radius fractures who underwent surgery with either WALANT or GA with tourniquet at the authors' institution. Exclusion criteria were (1) any associated injury in other organs, (2) multiple fractures, and (3) combined accessory wrist arthroscopic procedure. A total of 47 patients were included in the study. Fractures were classified according to the AO/OTA system. Among the included 47 patients, 21 underwent ORIF with WALANT and 26 underwent ORIF with GA with tourniquet.
The goal of WALANT is to deliver lidocaine and epinephrine molecules wherever there is likely to be incision or dissection. In this study, the WALANT protocol started with hematoma block via a 3- to 5-mL 1% lidocaine injection from the dorsal site into the fracture site to minimize the discomfort caused by later sterilization and manipulation procedures performed to the fractured wrist.17–20 Previously, Lalonde and colleagues reported that the optimal time delay between local epinephrine injection and incision to minimize bleeding depends on the maximal vasoconstriction,21 which occurs approximately 25.9 minutes after injection of 1:100,000 epinephrine beneath the skin.22 In the current study, a subcutaneous injection of approximately 5 to 10 mL of 1% lidocaine mixed with 1:40,000 epinephrine was administered directly onto the operative volar side of the distal radius, with the dose of the injection depending on the size of the injured wrist.
The fractured wrist was then sterilized and prepared for surgery while the surgeon waited for the hemostatic effect. The time delay between local anesthetic with epinephrine and incision was approximately 18 minutes. Following a Henry approach, the procedure started with a longitudinal incision over the volar wrist, with subsequent identification of the flexor carpi radialis. The ulnar retraction of the flexor carpi radialis and flexor pollicis longus was performed to expose the pronator quadratus.23 An additional 5 mL of 1% lidocaine mixed with 1:40,000 epinephrine was then injected beneath the pronator quadratus. The surgery was halted for approximately 30 seconds to allow the local anesthetic to take effect within the pronator quadratus, which was later split and elevated to reduce the fracture. This was followed by plate placement, drilling procedures, and screw fixations (Figure 1).
The wide-awake local anesthesia no tourniquet technique for distal radius fracture. Hematoma block via 3- to 5-mL 1% lidocaine injection from the dorsal site into the fracture site (A). Subcutaneous injection with 1% lidocaine mixed with 1:40,000 epinephrine was administered onto the operative volar side of the distal radius (B). An additional 5 mL of 1% lidocaine mixed with 1:40,000 epinephrine was injected beneath the pronator quadratus (C). Testing the impingement of wrist joint and tendon function before wound closure (D).
Patients having GA with a tourniquet underwent a series of preoperative examinations and an anesthesia risk evaluation. After adequate preparation, they received GA under careful monitoring by anesthesia specialists and nurses. A tourniquet with pressure of 230 mm Hg was applied to control blood loss. Surgery was performed according to the same approach used for the patients having WALANT.
Postoperative Care and Follow-up
Postoperative care was standardized for both groups and included a consecutive rehabilitation program. All of the patients were admitted to the hospital and stayed at least 1 night. Postoperative pain control medication for all patients consisted of the combination of regular oral tramadol (37.5 mg) and acetaminophen (325 mg) twice a day. Patients were immobilized for 1 week with a short-arm splint to protect the injured wrist. Once the splint was removed, patients were instructed to perform passive wrist motion with flexion and extension for 1 month. After 1 month, they started actively training to increase range of motion. During follow-up, no implant was removed after union in either group.
For both groups, collected data included operative time, blood loss, pain evaluated via visual analog scale score on postoperative day 1, and length of postoperative hospitalization. The amount of blood loss was determined by the amount of blood in a suction container in the operating room according to the record. The visual analog scale score for pain around the perioperative field of the wrist was evaluated by the clinical physician (C.-Y.C.) the first morning postoperatively. All patients were followed for 12 months. Their outcome, including the maximum range of motion of wrist extension and flexion using a goniometer, the time to achieve bone union, and the Mayo wrist score for clinical outcomes, was recorded during this time.24 At 12 months postoperatively, the injured limb was assessed for pain intensity (maximum, 25 points), functional status (maximum, 25 points), range of motion (maximum, 25 points), and grip strength (maximum, 25 points). Based on the total score, clinical results were stratified as excellent (90 to 100 points), good (80 to 90 points), satisfactory (60 to 80 points), or poor (<60 points).
Statistical analyses were performed using the Statistical Package for the Social Sciences version 22 (IBM, Armonk, New York). The independent t test was used to compare continuous variables, and the chi-square test was used to compare categorical variables. P<.05 indicated statistical significance. Results were presented as mean±standard deviation for continuous variables and as either number or ratio for discrete variables.
Patients' demographic information and fracture classification are listed in Table 1. No significant differences were found between the 2 groups regarding sex (P=.805), age (P=.499), or distribution of fracture classification (P=.202).
Patient Demographics and Fracture Classification
Perioperative and postoperative data are listed in Table 2. No significant difference was found between the WALANT and the GA groups regarding operative time (P=.214). However, the mean time from arrival in the operating room to start of the incision was significantly shorter in the WALANT group compared with the GA group (25.38±4.59 minutes vs 37.31±11.16 minutes, P<.001). Regarding pain severity on postoperative day 1, the mean visual analog scale score was significantly lower in the WALANT group than in the GA group (1.95±0.67 vs 3.27±1.28, P<.001). Furthermore, patients undergoing WALANT surgery had a significantly shorter mean postoperative hospitalization than those undergoing surgery with GA (1.38±0.50 days vs 2.46±0.71 days, P<.001). However, the mean volume of blood lost was significantly greater in the WALANT group than in the GA group (22.62±6.82 mL vs 8.62±9.23 mL, P<.001). No significant difference was found between the groups regarding the mean time to bone union (20.76±4.35 weeks vs 22.46±4.17 weeks, P=.180). All patients returned to their previous work or daily activity approximately within 6 months after injury.
Perioperative and Postoperative Data
The clinical outcomes at 12 months postoperatively are listed in Table 3. The mean maximum wrist extension was 50.24°±9.28° in the WALANT group and 49.42°±6.22° in the GA group, with this difference not being significant (P=.721). The mean maximum wrist flexion was 67.14°±9.95° in the WALANT group and 71.35°±8.19° in the GA group, with this difference not being significant (P=.119). No significant differences were found between the groups regarding the functional outcome 12 months after surgery as reflected by the mean Mayo wrist score of 86.67±7.13 in the WALANT group and 84.04±7.35 in the GA group (P=.223).
Clinical Outcomes at 12 Months Postoperatively
These results indicate that most patients successfully achieved functional recovery of the injured wrist. During follow-up, no patients required secondary interventions such as bone grafting or shock wave treatment, and all reached union status.
The WALANT technique has been used for various hand surgeries, particularly in soft tissue repair or reconstruction.5–10 In addition, finger fractures have reportedly been treated using closed reduction and percutaneous pinning with an image intensifier.12 This technique has several advantages, including simple surgical preparation, no risk related to GA, and less time in the postoperative recovery room. Theoretically, it reduces medical costs in terms of examinations and preoperative evaluation of GA, shortens hospitalization, and saves medical resources.
The wrist surgeries performed in the current study involved not only soft tissue dissection but also bony procedures, such as open reduction with forceps and manipulation with limb traction. Unlike finger fractures, which may only need fixation with percutaneous pinning or open reduction at a small anesthetized area, orthopedic surgeons have to manage blood loss from a relatively larger area in the distal radius, and the tourniquet is widely applied to effectively minimize bleeding. Achieving well-controlled bleeding and not interfering with the surgical field without the tourniquet is significant. The WALANT protocol used in this study included 1:40,000 epinephrine, a concentration higher than those previously reported to ensure a hemostatic effect during the whole operation.5 In the current study, the time delay between the administration of a local anesthetic plus epinephrine injection and the incision was 18 minutes, which allowed sufficient time for presurgical sterilization and draping of the injured limb. The time was calculated from injection to incision. Time spent waiting for the hemostatic effect was used for sterilization and preparation for the operation. Although Lalonde and colleagues reported that the time between injection and the maximal vasoconstriction was 25.9 minutes, the patients in the current study undergoing the WALANT procedure had acceptable hemostatic effects in less time.
The safety of epinephrine use in hand surgeries has been previously established.25 Epinephrine infiltration may cause vasoconstriction, and distal finger cyanosis has been reported. However, procaine acidity was found to be the culprit in finger loss.26,27 Otherwise, epinephrine-induced cardiac ischemia is rarely reported, even with high doses (1:1000).28 No complications, such as finger necrosis, palpitations, or allergies, were found in the current 21 cases.
In this study, the WALANT group had a shorter mean time from arrival to incision than the GA group. Time from arrival to incision is defined as the time interval between the patient's arrival in the operating room and the performance of incision. The fact that the WALANT technique does not require an anesthesiologist or the application of a tourniquet contributes to a shorter interval. The pain severity on postoperative day 1 was worse in the GA group. The physiological reactive hyperemia occurs at tourniquet deflation due to the extreme vasodilatation, which promotes bleeding beyond the amount usually observed from a surgical incision without tourniquet use.29 Based on the authors' clinical observation without scientific measurement, the bleeding caused by the release of the tourniquet may give rise to surgical wound hematoma formation, ecchymosis, swelling, and even more local pain. On the other hand, the WALANT group achieved hemostatic control without tourniquet use, and the bony procedures, such as drilling and screwing, were performed without discomfort owing to the initial hematoma block combined with preventive injection underneath the pronator quadratus muscle. Patients subjected to GA had longer postoperative hospitalization, possibly due to postoperative nausea and vomiting after sedation, and greater use of opioids for tourniquet pain and discomfort around the wound. In the current study, the use of the WALANT technique was associated with greater blood loss. Ruxasagulwong et al30 conducted a prospective trial regarding common minor orthopedic hand soft tissue surgery, including carpal tunnel syndrome, de Quervain's disease, and trigger finger. They found more surgical field bleeding in the wide-awake group with pressure-free tourniquet application. However, in the group with conventional tourniquet use, blood loss was significantly greater due to vasodilatation, with a moderate amount of bleeding following tourniquet release for bleeding check prior to skin suture. Therefore, during the entire course, including the postoperative period, blood loss in the GA group is certainly not less. Postoperative occult bleeding by oozing was not calculated in the current study. Even if the WALANT technique is associated with more bleeding, the mean was only 22.62 mL, which did not interfere with the surgery. There was no significant difference in the time to union, wrist range of motion, and functional scores between the 2 groups of the current study.
With health care costs continuing to rise,31 reported savings and improvements in patient satisfaction need to be discussed.32 The health care system in Taiwan has started to bundle the payment of selected orthopedic diagnosis-related groups. To reduce medical costs, hospitals receive a single index code with payment for a particular diagnosis-related group. The WALANT technique is associated with greater cost-efficiency because it eliminates the need for sedation and anesthetists, preoperative examinations, and postoperative anesthesia recovery. Moreover, the results of the current study reveal that it also shortens hospital stay. Some patients, such as those with uremia and ipsilateral wrist fractures and arteriovenous shunts, should not be subjected to tourniquet applications. Individuals who are not candidates for GA, such as those who experience difficulties in extubation and those with cardiovascular problems, chronic occlusive pulmonary disease, or severe congestive heart failure, could benefit from the use of the WALANT technique. In addition to the benefits mentioned above, WALANT allows physicians to perform surgery and directly examine range of motion of injured limbs. Discussion regarding rehabilitation plans, wound care, and return to work after surgery offered patients a feeling of safety and built their confidence toward recovery.5,33
The current study had several limitations. It was retrospective. The number of relevant cases was small because WALANT was instituted for distal radius fractures just 3 years ago.
The WALANT technique is a feasible and effective method for treating distal radius fractures through ORIF with a plate. It offers efficient immediate intervention, less postoperative pain, and shorter hospitalization. Although surgeries performed with a local hemostatic agent could contribute to more blood loss than those performed under GA with a tourniquet, blood loss is limited and does not interfere with the ORIF.
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- Pire E, Hidalgo Diaz JJ, Salazar Botero S, Facca S, Liverneaux PA. Long volar plating for metadiaphyseal fractures of distal radius: study comparing minimally invasive plate osteosynthesis versus conventional approach. J Wrist Surg. 2017;6(3):227–234. doi:10.1055/s-0037-1599791 [CrossRef]
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- Hagert E, Lalonde D. Wide-awake wrist arthroscopy and open TFCC repair. J Wrist Surg. 2012;1(1):55–60. doi:10.1055/s-0032-1312045 [CrossRef]
- Lalonde D, Martin A. Epinephrine in local anesthesia in finger and hand surgery: the case for wide-awake anesthesia. J Am Acad Orthop Surg. 2013;21(8):443–447. doi:10.5435/JAAOS-21-08-443 [CrossRef]
- Nakanishi Y, Omokawa S, Kobata Y, et al. Ultrasound-guided selective sensory nerve block for wide-awake forearm tendon reconstruction. Plast Reconstr Surg Glob Open. 2015;3(5):392E. doi:10.1097/GOX.0000000000000365 [CrossRef]
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- Gunasagaran J, Sean ES, Shivdas S, Amir S, Ahmad TS. Perceived comfort during minor hand surgeries with wide awake local anaesthesia no tourniquet (WALANT) versus local anaesthesia (LA)/tourniquet. J Orthop Surgery Hong Kong. 2017;25(3):1–4.
- Prasetyono TO. Tourniquet-free hand surgery using the one-per-mil tumescent technique. Arch Plast Surg. 2013;40(2):129–133. doi:10.5999/aps.2013.40.2.129 [CrossRef]
- Xing SG, Tang JB. Surgical treatment, hardware removal, and the wide-awake approach for metacarpal fractures. Clin Plast Surg. 2014;41(3):463–480. doi:10.1016/j.cps.2014.03.005 [CrossRef]
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- Lalonde D, Martin A. Tumescent local anesthesia for hand surgery: improved results, cost effectiveness, and wide-awake patient satisfaction. Arch Plast Surg. 2014;41(4):312–316. doi:10.5999/aps.2014.41.4.312 [CrossRef]
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Patient Demographics and Fracture Classification
|Sex, male/female, No.||8/13||9/17||.805a|
|Age, mean±SD, y||65.29±15.47||62.31±14.42||.499b|
|AO/OTA classification, No. (%)||.202a|
| A2||3 (14.3)||9 (34.6)|
| A3||6 (28.6)||5 (19.3)|
| B2||5 (23.8)||2 (7.7)|
| C1||3 (14.3)||1 (3.8)|
| C2||4 (19.0)||8 (30.8)|
| C3||0||1 (3.8)|
Perioperative and Postoperative Data
|Time from arrival to incision, min||25.38±4.59||37.31±11.16||<.001|
|Operative time, min||68.10±9.28||64.42±10.42||.214|
|Blood loss, mL||22.62±6.82||8.62±9.23||<.001|
|Postoperative day 1 visual analog scale score||1.95±0.67||3.27±1.28||<.001|
|Discharge after operation, d||1.38±0.50||2.46±0.71||<.001|
|Time to union, wk||20.76±4.35||22.46±4.17||.180|
Clinical Outcomes at 12 Months Postoperatively
|Wrist extension, mean±SD||50.24°±9.28°||49.42°±6.22°||.721a|
|Wrist flexion, mean±SD||67.14°±9.95°||71.35°±8.19°||.119a|
|Mayo wrist score, mean±SD||86.67±7.13||84.04±7.35||.223a|
|Functional stratification, No. (%)||.567b|
| Excellent||12 (57.1)||11 (42.3)|
| Good||6 (28.6)||9 (34.6)|
| Fair||3 (14.3)||6 (23.1)|