SLR - November 2023 - Dobronevsky
Title: Wide-Awake Local Anesthetic No Tourniquet Surgery of the Foot and AnkleReference: D. Joshua Mayich, Wide-Awake Local Anesthetic No Tourniquet Surgery of the Foot and Ankle, Orthopedic Clinics of North America, Volume 54, Issue 4, 2023
Level of Evidence: Level VII
Reviewed by: Lina Dobronevsky, DPM
Residency Program: Northwell LIJ Forest Hills – Forest Hills, NY
Podiatric Relevance: this is a literature review and author’s own experience with wide-awake local anesthetic no tourniquet (WALANT) surgery in performing orthopedic foot and ankle surgery (OFAS). Author bases his research on success of WALANT in hand surgery. Citing multiple benefits of WALANT – such as in-office settings in place of OR and post-operative pain improvement, the author describes his technique with performing WALANT type procedures. Relative to podiatric surgeries – further research is needed to study pain variation in tourniquet vs no tourniquet (or decreased tourniquet time). For many podiatry patients with multiple co-morbidities, the risk of anesthesia is increased. As an example, Charcot patients often present with ESRD on dialysis or with severe heart disease. Oftentimes, wound patients will also need vascular procedures requiring anesthesia involvement. Using local anesthetic only wound remove the risk of anesthesia making the procedure safer for high-risk podiatry patients. For elective type podiatric procedures in patients that are not high risk may be performed in-office setting with local anesthesia avoiding unnecessary costs.
Methods: 30 cases are reviewed in this paper along with literature review. The author describes his technique for using WALANT and reviews the literature on the topic. He uses 6 “core tenants” for surgery with local anesthetic only. Epinephrine is used to achieve hemostasis. Opioid use post-operatively is avoided or greatly reduced by the author. Of note – not every patient is a candidate for WALANT. Anxious patients may require anxiolytics. As well, most patients were either very keen on having only local anesthesia and usually had only forefoot surgery. Absolute contraindication to using WALANT were patients with documents peripheral vascular disease since use of epinephrine is part of the author’s procedures. Use of bupivacaine necessitates knowledge of advanced cardiac life support and access to antidote.
Results: 30 WALANT cases are promising but problems were found especially with revisional cases where the soft tissue envelope presented with complications. Literature review of WALANT type surgeries focuses on choosing proper candidates and did not have a definitive conclusion. While deemed safe by the author, the use of WALANT technique is surgeon dependent.
Conclusions: WALANT has clear advantages for podiatric patients in terms of cost and reducing anesthesia risk for patients with multiple co-morbidities. For high-risk podiatry patients, presence of PVD may be encountered and use of WALANT will either need to be adjusted or canceled. In arthroscopic, MIS podiatric surgery, and elective cases in general – WALANT has clear advantages as shown by the author where OR is avoided, and post-op pain is improved.