Thomas Volk, Jeffrey Mojica, Azlina Amir Abbas.

Response/Recommendation: Whether wide-awake local anesthesia no tourniquet (WALANT) for tibia/fibula fracture fixation has a risk of venous thromboembolism (VTE) compared to other techniques for tibia/fibula fracture is unknown. We recommend using anticoagulant prophylaxis as per existing thromboprophylaxis guidelines, independent of the technique used.

Strength of Recommendation: Moderate.

Rationale: WALANT is a surgical technique that was first described by Dr. Donald H. Lalonde for surgery of the wrist and hand¹. To perform the technique, the surgeon injects a lidocaine and epinephrine mixture into the operative site. The lidocaine provides surgical anesthesia and allows the patient to remain comfortably awake during the procedure. The epinephrine assists in hemostasis and eliminates the need for a tourniquet¹. Aside from wrist and hand surgery, WALANT has been successfully used for plate fixation of distal radius fractures² and clavicular fractures³. The successful application of WALANT for upper extremity fracture repair has prompted investigations in its utility for lower extremity fractures.

The literature on WALANT for lower extremity fractures is limited. We identified a case report, published as an abstract from a scientific meeting describing the use of WALANT in a patient that underwent plating of a proximal tibia fracture. The authors did not report any complications⁴. Li et al., described a prospective case series of 13 patients using WALANT for malleolar fractures and no complications, including VTE, were reported⁵. Bilgetekin et al., performed a retrospective chart review of 31 patients that underwent WALANT for foot and ankle surgery⁶. Of these patients, 20 had malleolar fractures and no complications, including VTE, were reported. Poggetti et al., studied the use of WALANT for the removal of distal fibula implants⁷. In their study, 60 patients were scheduled for distal fibula hardware removal following open reduction internal fixation and were randomized to receive either WALANT or a stimulation-guided sciatic and femoral nerve block with tourniquet. The primary outcome was not defined, and like the previous studies, no VTE were reported⁷. Overall, these studies are limited by their small size, heterogeneity, and lack of power to detect VTE complications. As a result, the risk of VTE in patients receiving WALANT for tibia/fibula fracture fixation remains poorly defined and we are unable to recommend a specific anticoagulant regimen for thromboprophylaxis

References:

1.         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

2.         Huang Y-C, Hsu C-J, Renn J-H, et al. WALANT for distal radius fracture: open reduction with plating fixation via wide-awake local anesthesia with no tourniquet. J Orthop Surg Res. 2018;13(1):195. doi:10.1186/s13018-018-0903-1

3.         Ahmad AA, Ubaidah Mustapa Kamal MA, Ruslan SR, Abdullah S, Ahmad AR. Plating of clavicle fracture using the wide-awake technique. J Shoulder Elbow Surg. 2020;29(11):2319-2325. doi:10.1016/j.jse.2020.03.003

4.         Shamsudin Z, Ahmad A, Ahmad A. Patella Fracture Fixation Via Wide Awake Local Anesthesia No Tourniquet (Walant) Technique. Orthopaedic Journal of Sports Medicine. 2020;8(5_suppl5):2325967120S00087. doi:10.1177/2325967120S00087

5.         Li Y-S, Chen C-Y, Lin K-C, Tarng Y-W, Hsu C-J, Chang W-N. Open reduction and internal fixation of ankle fracture using wide-awake local anaesthesia no tourniquet technique. Injury. 2019;50(4):990-994. doi:10.1016/j.injury.2019.03.011

6.         Bilgetekin YG, Kuzucu Y, Öztürk A, Yüksel S, Atilla HA, Ersan Ö. The use of the wide-awake local anesthesia no tourniquet technique in foot and ankle injuries. Foot Ankle Surg. 2021;27(5):535-538. doi:10.1016/j.fas.2020.07.002

7.         Poggetti A, Del Chiaro A, Nicastro M, Parchi P, Piolanti N, Scaglione M. A local anesthesia without tourniquet for distal fibula hardware removal after open reduction and internal fixation: the safe use of epinephrine in the foot. A randomized clinical study. J Biol Regul Homeost Agents. 2018;32(6 Suppl. 1):57-63.