OrthoBuzz previously covered WALANT (wide awake, local anesthesia, no tourniquet) surgery, and we very recently featured a JBJS study about treating ankle fractures in a limited-resource environment. These 2 concepts unite in a JBJS study by Tahir et al., which reports on WALANT surgery for ankle fractures in Pakistan.
WALANT surgery has enjoyed increasingly broad dissemination throughout the world since its popularization by Canadian hand surgeon Don Lalonde. Considering its origins, WALANT has been adopted most enthusiastically by the hand-surgery community, but it has been applied successfully to other anatomic regions. WALANT principles are particularly relevant in settings where anesthetic resources and expertise may be limited, such as hospitals where monitoring equipment that helps ensure safe general anesthesia is not readily available.
Tahir et al. used WALANT during open reduction/internal fixation (ORIF) in 58 patients (average age of 47 years) with a distal fibula fracture; 62% of those fractures were OTA-classified as 44C2. Among the excellent results in this cohort were a mean intraoperative VAS pain score of 1.24 and a mean operative time of <1 hour. These findings point to the potential for safely using WALANT techniques during ORIF of other fracture types.
The authors emphasize, however, that “each patient should be individually assessed by the operating surgeon,” not only for injury characteristics that contraindicate WALANT, such as substantial swelling, but also for anxiety and psychological disorders. Consequently, Tahir et al. recommend that surgeons undertaking WALANT procedures have a backup anesthetist available so they can convert to general anesthesia in cases of patient anxiety.
Marc Swiontkowski, MD
OrthoBuzz occasionally receives posts from guest bloggers. This guest post comes Christopher Dy, MD, MPH in response to his recent participation in the virtual Annual Meeting of the American Society for Surgery of the Hand.
The year 2020 has brought with it many “firsts.” For example, due to the COVID-19 pandemic, the Annual Meeting for the American Society for Surgery of the Hand (ASSH) was moved from San Antonio to a virtual platform. Kudos to the Annual Meeting chairs (Dawn Laport, MD and Ryan Calfee, MD), ASSH president Martin Boyer, MD, and the ASSH staff for constructing an amazing experience. Here are some general take-homes from my first-ever virtual conference experience:
- A virtual conference provides attendees with a ton of flexibility and customization. While there are often “conflicting,” concurrent sessions during an in-person meeting where I have to decide between 2 sessions, the virtual ASSH meeting format offered the ability to go back and watch prior courses and lectures. When we (hopefully) go back to in-person meetings, it would help if more sessions were recorded and made available to attendees on demand.
- The virtual conference requires a lot more pre-meeting preparation for all parties involved, especially presenters. Because the sessions that would normally occur in the large, main halls were hosted on a professionally run platform with A/V engineers, presenters were required to attend more than a few “tech” rehearsals, as well as submit their presentation slides 4 to 6 weeks in advance. I admit that it was harder for me to present from slides that didn’t feel as fresh, since I couldn’t revise them the night before!
- While it was convenient to view most of the meeting from my couch (or exercise bike), I really miss the in-person interactions with colleagues and friends that you get while moving between sessions. It’s also harder to pull yourself away from your family and your practice when you are “participating” in a meeting from home or office.
Here are 4 technical things I learned from the sessions I attended, largely biased toward my personal interests. I encourage readers to leave comments by clicking on the “Leave a Comment” button in the box next to the title.
- Innovation continues for distal nerve transfers to treat peripheral nerve palsy. Professor Jayme Bertelli from Brazil gave talks demonstrating both technical aspects and his own results following transfers such as ECRL [extensor carpi radialis longus]-to-AIN [anterior interosseous nerve], distal AIN to distal PIN [posterior interosseous nerve], and opponens pollicis to adductor pollicis. I am eager to read more about these transfers and get into the cadaver lab to refine my surgical technique. (Precourse 03 and Symposium 18)
- The debate about “supercharging” (reverse end-to-side) nerve transfers continues. There is laboratory evidence supporting the role of a supercharged nerve transfer in preserving the distal muscle unit and the distal nerve stump. However, there is controversy regarding whether it is benign and/or beneficial to have 2 “competing” sources of muscle innervation, in cases where the “native” nerve reaches the distal target after the axons coming from the supercharged transfer have been placed. While many surgeons have adopted supercharged nerve transfer into their practice, there is far more laboratory and clinical research needed to substantiate this practice and refine the indications for use. (Precourse 03 and Symposium 11)
- Utilization of wide-awake, local-anesthesia, no-tourniquet (WALANT) hand surgery continues to grow. Surgeons are performing a growing number of different surgeries (including fracture cases and complex tendon transfers) with WALANT, and some are doing these cases in procedure rooms or offices rather than in a formal operating room. These changes are driven by both surgeon and patient preference, as well as potential cost advantages for both parties. For surgeons, there is a potential for increased revenue with WALANT, but this can come with logistical challenges such as stocking sterile trays and making sure that medications are available. The trend toward increasing utilization of WALANT in procedure rooms and in surgeons’ offices is likely to continue. (Instructional courses 24 and 56 and related OrthoBuzz post)
- Teaching in the operating room has shifted. Many current trainees prefer to use videos for case preparation rather than focusing on book chapters, technique articles, or primary literature. Consequently, there is a growing embrace of video among hand-surgeon educators. Videos that are short, discuss indications, and provide rationale for technique-related decisions are favored. Today’s trainees are also less likely to respond well to the classic Socratic method of teaching and may need more overtly delivered feedback. (Instructional courses 10 and 36)
Christopher Dy, MD, MPH is a hand and wrist surgeon, an assistant professor of orthopaedic surgery at Washington University School of Medicine in St. Louis, and a member of the JBJS Social Media Advisory Board.
Most everyone has seen the auto-insurance TV ad where the deep-voiced man asserts, “Safe drivers save 40%.” Insurance savings notwithstanding, patients frequently ask orthopaedic surgeons when they can return to safe driving after surgery. Of course, the answer depends partly on the patient’s ability to drive safely before surgery, but most of the orthopaedic research on this topic has focused on lower extremities. In the September 16, 2020 issue of The Journal, Orfield et al. take a detailed look at the driving question after wide-awake, local-anesthetic, no-tourniquet (WALANT) surgery of the hand.
Twelve right-handed patients drove 18 miles under baseline conditions and completed various parking tasks during the first 45- to 55-minute test. The instrumented vehicle they drove obtained kinematic data automatically, and behavioral responses were recorded on video cameras. Then the same subjects completed the same driving exercise in the same vehicle—but this time after having their right hand injected with 10 mL of 1% lidocaine over the volar wrist, and another 10 mL into the carpal tunnel. To further simulate WALANT conditions, researchers applied a bulky hand dressing to each participant’s right hand. The WALANT-modeled driving test included a simulated “surprise event” that required avoidance maneuvers. Researchers analyzed before-and-after data on a variety of kinematics, including braking, acceleration, right and left turning, and proportion of time spent driving with each or both hands.
Overall, Orfield et al. found no evidence of a negative impact on driving fitness in the simulated WALANT state. In fact, the subjects braked harder and steered more smoothly in the WALANT-modeled state, an indication that they perceived they might be impaired. Not surprisingly, participants in the WALANT-modeled state spent decreased time using both hands (from 72% to 62%), while left-hand-only driving increased from 2% to 16% of the time. All participants reported that they felt safe to drive with a numb, bandaged right hand.
These noninferiority findings suggests that WALANT patients are no worse off with immediate driving after the surgical procedure than they were beforehand. The authors are quick to point out that these findings should not be generalized beyond right-handed people driving a passenger car with an automatic transmission in the United States. Still, this study gives us some evidence-based data to better inform patients undergoing common hand procedures now frequently performed under WALANT conditions, such as trigger-finger and carpal-tunnel release. However, we can’t guarantee they will save on their auto insurance.
Click here to view a 3-minute “Author Insight” video with study co-author Peter J. Apel, MD, PhD.
Matthew R. Schmitz, MD
JBJS Deputy Editor for Social Media