Vol 2 | Issue 1 | January-April 2025 | page: 18-21 | Prasad Chaudhari, Aaishree Shetty, Sachin Kale, Arvind Vatkar, Sushant Srivastava, Dushyant Vasisht, Akhil Gailot

Authors: Prasad Chaudhari [1], Aaishree Shetty [1], Sachin Kale [1], Arvind Vatkar [2], Sushant Srivastava [3], Dushyant Vasisht [1], Akhil Gailot [1]

[1] Department of Orthopaedics, Dr D Y Patil Hosital, Nerul, Navi Mumbai, India,
[2] Department of Orthopaedics, MGM Medical College, Belapur, Navi Mumbai, Maharashtra, India,
[3] Department of Orthopaedics, Mat Gujri Memorial Medical College and Lions Seva Kendra Hospital Kishanganj, Bihar, India.

Address of Correspondence
Dr. Arvind Vatkar,
Department of Orthopaedics, MGM Medical College, Belapur, Navi Mumbai, Maharashtra, India.
E-mail: vatkararvind@gmail.com

Abstract

Introduction- WALANT, an alternative to traditional anesthesia methods, allows surgery under local anesthesia without a tourniquet for Dsital end radius (DER) fracture fixation, despite its potential for reducing hospital stays, higher costs, and potential complications.
Material and methods- A prospective randomised study at D Y Patil University School of Medicine compared WALANT and traditional anesthesia for treating 15 patients in each cohort with DER fractures, assessing functional outcomes, pain, complications, and cost differences.
Results- The age distribution of patients in the WALANT group was similar to the traditional group, with 40% aged 41-50 and 60% male. Diabetes mellitus prevalence was similar, but hypertension was significantly higher in the WALANT group. Road traffic accidents were more common in the WALANT group (53.3%) compared to the traditional group (33.3%). Left-side injuries were slightly more common in the traditional group (60%), while right-side injuries were slightly more frequent in the WALANT group (53.8%). Associated injuries were present in 46.7% of patients in the traditional anesthesia group, whereas none were reported in the WALANT group.
Conclusion- For DER fracture fixation, WALANT is a safe, affordable, and efficient substitute for standard anaesthesia. It provides similar functional results, fewer side effects, and a quicker recovery time, making it a good choice in environments with limited resources.
Keywords: Distal Radius Fractures, Anesthesia, Local, Orthopedic Procedures, Pain, Postoperative, Patient Satisfaction, Treatment Outcome.

Introduction
Distal end radius (DER) fractures are among the most common orthopedic injuries, accounting for 17.5 % of fractures treated in emergency departments. [1] These fractures are especially prevalent in elderly individuals with osteoporosis and younger patients following high-energy trauma. [2]
Conventionally, DER fractures requiring surgery have been managed using general anesthesia or regional nerve blocks. [3] However, standard anaesthesia procedures for distal end radius fractures are linked with longer hospital stays, which raises healthcare expenses. Furthermore, they carry the risk of anesthesia-related problems, making other techniques such as WALANT more appealing.
A novel approach called wide awake local anesthesia no tourniquet (WALANT) has gained popularity in hand and wrist surgeries. WALANT uses local anesthesia (lidocaine + epinephrine) to allow awake surgery without a tourniquet. This technique has been widely used for soft tissue procedures (e.g., carpal tunnel release and tendon repairs), but its application in DER fracture fixation remains less explored. [3,4]
WALANT in distal end radius fractures has various benefits, including reduced anaesthesia risks, shorter hospital stays, intraoperative active mobility evaluation, and cost-effectiveness.

Study objective
This study aims to compare the functional outcomes of DER fractures treated using WALANT versus traditional anesthesia methods, providing evidence for its safety, efficacy, and cost-effectiveness.

Aims and objectives
Primary objective
The study compares the functional results of patients who had distal end radius fracture fixation under WALANT versus standard anaesthesia.
Secondary objectives
This study measures post-operative pain by comparing acute pain levels between WALANT and standard approaches. Furthermore, it examines the problems related with WALANT and compares the cost-effectiveness of both procedures.

Materials and Methods
Study design and setting- This prospective randomised trial was carried out at D Y Patil University School of Medicine in Navi Mumbai. The research lasted two years, from March 2022 to March 2024.
Participants and grouping- A total of 30 patients were enrolled, with 15 treated with WALANT and 15 with standard anaesthesia.

Inclusion criteria
Patients aged over 16 years with diagnosed DER fractures, experiencing pain and limited range of motion, were included in the study. All participants provided informed consent and committed to attending follow-up appointments.

Exclusion criteria
Patients with open fractures, polytrauma including multiple limb injuries, or a history of surgery on the same forearm in the previous 12 months were excluded. Additionally, people with neurological problems affecting the leg were excluded from the research.
Treatment procedures- The WALANT group had local anaesthesia without a tourniquet. The cocktail of anasthetic medications used is a combination of 1% lidocaine, 1:100,000 epinephrine, and 8.4% sodium bicarbonate (10:1 ratio) is used for anesthesia. To ensure patient safety, we strictly adhere to the maximum lidocaine dose of 7 mg/kg with epinephrine. A total of 40 mL of the prepared solution is used for the procedure. The technique of giving the injection in WALANT technice is mentioned in figure. Whereas the conventional group received general or regional anaesthesia with a tourniquet, with both groups adhering to standard post-operative care and rehabilitation protocols. (Fig. 1)

Outcome measures- Forearm function was evaluated using the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire and the Michigan Hand Outcomes Questionnaire, which assesses function, activities of daily living, discomfort, aesthetics, and satisfaction. Goniometry was also used to assess flexion, extension, pronation, and supination.
Follow-up protocol- Patients were followed up at 2, 4, and 6 weeks after surgery to assess recovery status. Each visit included assessments using the DASH and Michigan Hand Outcomes Questionnaire, goniometric measurements, and a clinical examination for healing and complications.
Data analysis- SPSS v25.0 was used to conduct statistical analysis on functional results, range of motion, and patient satisfaction in the two groups.

Results
Demographics and baseline characteristics- According to the age distribution, 40% of patients in the WALANT group were between the ages of 41 and 50, whereas 40% of patients in the conventional anaesthesia group were between the ages of 51 and 60. There was no statistically significant difference in the two groups’ age distributions (P = 0.52). Patients in the WALANT group were 60% male, whereas 53.3% of patients in the standard group were female. Additionally, there was no statistically significant difference in the gender distribution (P = 0.46).
Co-morbidities- Diabetes mellitus prevalence was similar in both groups (P = 0.409), while hypertension was significantly higher in the WALANT group (P < 0.001).
Mode of injury- Road traffic accidents were more common in the WALANT group (53.3%) compared to the traditional group (33.3%), but the difference was not statistically significant (P = 0.37).
Side of injury- Left-side injuries were slightly more common in the traditional group (60%) compared to the WALANT group (46.7%). Conversely, right-side injuries were slightly more frequent in the WALANT group (53.8%), but the difference was not statistically significant (P = 0.46).
Associated injuries- Associated injuries were present in 46.7% of patients in the traditional anesthesia group, whereas none were reported in the WALANT group. This difference was statistically significant (P = 0.002).

Functional and clinical outcomes
Patients in the WALANT group reported lower postoperative pain levels and experienced a faster recovery compared to those in the traditional anesthesia group. Additionally, patient satisfaction scores were higher, and complications were fewer in the WALANT group.

Discussion
Advantages of WALANT- Compared to conventional anaesthesia techniques, the WALANT methodology led to quicker recovery, shorter hospital stays, and less postoperative discomfort. Additionally, it made the surgery more convenient for patients by eliminating the necessity for lengthy medical testing and pre-operative fasting. Furthermore, WALANT improved the patient experience by actively participating in surgery, which decreased treatment costs because of the shorter hospital stay.

Comparison with traditional methods
Although the two groups’ functional outcomes were comparable, WALANT made it possible for them to resume their regular activities more quickly. It was a more economical and resource-efficient option than conventional anaesthesia techniques. Additionally, by removing hazards associated with anaesthesia, WALANT decreased problems.

Challenges and limitations of WALANT- WALANT may not be suitable for highly anxious patients, as some individuals experience minor intraoperative pain and anxiety. Additionally, the technique can slightly reduce surgical field visibility due to minimal bleeding control.

Clinical implications- WALANT has the potential to become a preferred technique for treating distal end radius (DER) fractures due to its numerous advantages. However, further studies are needed to evaluate long-term outcomes and facilitate wider adoption in clinical practice.

Conclusion
For distal end radius (DER) fractures, WALANT is a safe, efficient, and economical substitute for conventional anaesthesia that provides similar functional results at a lower cost and with a shorter hospital stay. WALANT is a promising orthopaedic surgical procedure, as patients reported reduced problems and increased satisfaction. Future studies should concentrate on long-term patient outcomes and wider use, especially in areas with low resources where accessibility and affordability are important considerations.

References

1. Ochen Y, Peek J, van der Velde D, Beeres FJP, van Heijl M, Groenwold RHH, et al. Operative vs Nonoperative Treatment of Distal Radius Fractures in Adults: A Systematic Review and Meta-analysis. JAMA Netw Open [Internet]. 2020 Apr 1;3(4):e203497. Available from: http://dx.doi.org/10.1001/jamanetworkopen.2020.3497
2. MacIntyre NJ, Dewan N. Epidemiology of distal radius fractures and factors predicting risk and prognosis. J Hand Ther [Internet]. 2016 Apr-Jun;29(2):136–45. Available from: http://dx.doi.org/10.1016/j.jht.2016.03.003
3. Koval K, Haidukewych GJ, Service B, Zirgibel BJ. Controversies in the management of distal radius fractures. J Am Acad Orthop Surg [Internet]. 2014 Sep;22(9):566–75. Available from: http://dx.doi.org/10.5435/JAAOS-22-09-566
4. Morris MT, Rolf E, Tarkunde YR, Dy CJ, Wall LB. Patient Concerns About Wide-Awake Local Anesthesia No Tourniquet (WALANT) Hand Surgery. J Hand Surg Am [Internet]. 2022 Dec;47(12):1226.e1–1226.e13. Available from: http://dx.doi.org/10.1016/j.jhsa.2021.08.026

How to Cite this article: Chaudhari P, Shetty A, Kale A, Srivastava S, Vasisht D, Gailot A. Comparative Study on WALANT versus Traditional Methods for Distal End Radius Fractures. Journal of Orthopaedic Complications | January-April 2025;2(1):18-21.

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