Results of Surgical Treatment of Distal Radius Fractures under the Walant Anesthesia Technique: A Report of 12 Cases ()
1. Introduction
The term WALANT refers to an anesthesia technique whose principle, similar to that of tumescent local anesthesia, is based on the infiltration of a solution of local anesthetics combined with a vasoconstrictor (adrenaline) into the surgical site, making it possible to avoid the need for a pneumatic tourniquet. Concept initially described by dermatologist Jeffrey Klein in cosmetic surgery [1], it was under the impetus of Donald Lalonde, a Canadian hand surgeon, that WALANT was developed and promoted from the 1980s [2].
This technique of anesthesia by tumescence of the hand with xylocaine, which does without a tourniquet thanks to adrenaline, allows the patient, fully conscious during the operation, to make voluntary movements with his hand at the request of the surgeon.
The patient can then adapt the surgery and begin giving post-operative instructions to the patient. The patient’s attention is then maximized, and the “link” between patient and caregiver is not broken during the procedure. [3].
This technique is not known in Guinea where general anesthesia and, to a lesser extent, locoregional anesthesia (LRA) are the only techniques for any thoracic limb surgery. We report the functional results in the per and immediate postoperative period of surgical management of fractures of the distal end of the radius under the WALANT.
2. Methodology
2.1. Series
We included patients over 18 years of age admitted in emergency for wrist trauma. We did not include patients with allergy to any component of the anesthetic solution, diabetics with advanced neuropathy, and patients with pathological vascular conditions.
Figure 1. Front and side X-ray of a 32-year-old patient showing a distal radius fracture associated with a fracture of the right ulnar styloid.
Figure 2. Radiological control.
A total of 12 patients with distal radius fractures were collected (Figure 1, Figure 2). There were 9 women and 3 men, a sex ratio of 3. The mean age was 49 years, with a range from 22 to 80 years.
2.2. Anesthetic Solution
The local anesthetic solution used by our team is obtained by mixing 9 ml of 1% lidocaine, 1 ml of adrenaline and 20 ml to 30 ml of physiological serum.
2.3. Infiltration Technique
The local anesthetic solution used varied from 30 ml to 40 ml.
The anesthetic solution was administered as follows:
For skin opening: 10 ml on the incision line;
For the fracture: 10 ml in the fracture site, 7 ml on the proximal fragment and 7 ml on the distal(subperiosteally).
In case of association of ulnar styloid fracture, 2 ml of solution was administered in the focus for painless reduction. We wait 30 minutes after infiltration of the anesthetic solution to begin debridement and/or reduction and pinning. Throughout the procedure, patients were asked if they felt any pain. This technique allowed us to achieve hemostasis and painlessness throughout the surgery (trimming, reduction, pinning). The osteosynthesis technique consisted of placing two to three 18/10 Kirchner pins followed by a plaster cast.
2.4. Methods for Evaluating Results
To evaluate the results of this study, we used the Visual Analogue Scale (VAS) and intraoperative wrist joint mobility (Figure 3). The VAS is a method of assessing pain intensity using a ruler with two sides: a patient side and a caregiver side. The score ranges from 0 (no pain) to 10 (maximum imaginable pain). It is a simple, reproducible self-assessment scale, sensitive to variations in pain intensity, offering a choice of response that cannot be remembered by the patient from one assessment to another.
In the immediate operating room, we asked for patient satisfaction.
Questions asked to patients upon leaving the operating room:
Did you have any pain during the anesthesia: YES NO
If yes (0 = completely painless, to 10 = most unbearable pain possible)
Figure 3. Wrist mobility.
If no (0 = absolutely not bothersome, to 10 = extremely unpleasant)
What overall satisfaction score would you give regarding the method of anesthesia?
0 = very dissatisfied to 10 = completely satisfied: …….………………………….?
Did you have any pain during surgery: YES NO
If yes: 0 = completely painless to 10 = most unbearable pain possible.
Furthermore we have calculated the average time to surgical treatment, the average duration of intervention and the time spent in the recovery room.
3. Results
The average time for surgical treatment was 8 hours.
The mean VAS during the surgical procedure was 2.3 (+/−1.6).
The average intervention time was 17 minutes.
Dorsiflexion was between 60 - 70 (9 patients), 50 - 60 (3 patients); palmar flexion between 60 - 80 (10 patients), 58 (2 patients). The inclinations were on average 13 radial and 38 ulnar.
The time spent in the recovery room was on average 30 minutes.
The patient satisfaction rate was 96%.
The average length of hospital stay was 2 days.
4. Discussion
The local anesthetic solution used ranged from 30 ml to 40 ml. After administering the anesthetic solution without a tourniquet, we waited 30 minutes to begin trimming and/or reduction and pinning. This technique allowed us to achieve hemostasis and painlessness throughout the surgery (trimming, reduction, pinning).
Adrenaline-induced vasoconstriction is observed after a delay of approximately 25 minutes between infiltration and surgery. This is the time required to reach the peak of the vasoconstrictor effect of adrenaline and thus obtain the best operating conditions [4].
For Lalonde [5], the discomfort of the tourniquet is very unpleasant and unnecessary for patients.
Studies by Iqbal et al. [6] indicate that the use of a tourniquet causes unnecessary pain intraoperatively with little identifiable benefit compared to the same surgery without the use of a tourniquet. In studies by Lee DC [7] and Ruxasagulwong S [8], it has been shown that removing the need for a tourniquet by adding adrenaline is less painful for patients with lower VAS scores, in addition to reducing total blood loss.
In our study, the average intervention time was 17 minutes and the patient satisfaction rate was 96%. The absence of pain and the patient’s participation in the procedure explains this result. Indeed, he maintains control of his limb and helps with the installation and preparation of the limb for the procedure. It can also [9] at the surgeon’s request, perform intraoperative mobilizations in order to test a tendon repair, validate the positioning of osteosynthesis material or a joint prosthesis.
Hugo Z’s studies [10] showed advantages related to the WALANT technique by anesthesiologists: the absence of motor block, surgeon satisfaction and patient comfort. Accelerated discharge from hospital and safety of use were also put forward.
A randomized study [11] compared WALANT with local intravenous anesthesia[] (ALRIV or Bier block) and showed superiority of WALANT in terms of peri- and post-operative pain control, duration in the operating room and use of post-operative analgesics. Several studies, with large groups of patients and using the mixture proposed by Donald Lalonde’s team, have shown an absence of risk of necrosis [2] [5]. Rare clinical cases published recently [12]-[14], report the appearance of digital necrosis after infiltration of adrenaline solution (10 ug/mL). It should be noted, however, that the patients concerned presented with particular vascular conditions (Raynaud’s syndrome, severe arteriopathy).
5. Conclusion
WALANT is a reliable, inexpensive, and safe technique. It allows for intraoperative wrist functional assessment. Today, it should be part of our therapeutic arsenal in the surgical treatment of EDR fractures.
Authors’ Contribution
Sory S: main author, designer of the data sheet, initiation of the work and writing of the article;
Diallo AMF: Using files and filling out forms;
Tafsir C: Using files and filling out forms;
Diouf AB: Statistical study;
Amira A: Statistical study;
Koivogui B: Statistical study;
Alhassane, B: Correction;
Leopold L: Correction.