Maintaining Access to Orthopaedic Surgery During Periods of Operating Room Resource Constraint: Expanded Use of Wide-Awake Surgery During the COVID-19 Pandemic

Abstract

Introduction: Wide-awake local anesthesia no tourniquet (WALANT) presents a nonstandard anesthetic approach initially described for use in hand surgery that has gained interest and utilization across a variety of orthopaedic procedures. In response to operating room resource constraints imposed by the COVID-19 pandemic, our orthopaedic service rapidly adopted and expanded its use of WALANT.

Methods: A retrospective review of 16 consecutive cases performed by 7 surgeons was conducted. Patient demographics, surgical details, and perioperative outcomes were assessed. The primary end point was WALANT failure, defined as intraoperative conversion to general anesthesia.

Results: No instances of WALANT failure requiring conversion to general anesthesia occurred. In recovery, one patient (6%) required narcotics for pain control, and the average postoperative pain numeric rating scale was 0.6. The maximum pain score experienced was 4 in the patient requiring postoperative narcotics. The average time in recovery was 42 minutes and ranged from 8 to 118 minutes.

Conclusion: The WALANT technique was safely and effectively used in 16 cases across multiple orthopaedic subspecialties, including three procedures not previously described in the literature. WALANT techniques hold promise for use in future disaster scenarios and should be evaluated for potential incorporation into routine orthopaedic surgical care.

Figure 1

Preoperative and postoperative imaging of unstable trimalleolar equivalent ankle fracture with syndesmotic injury. Preoperative imaging presented in (A) demonstrates trimalleolar ankle fracture with syndesmotic injury. (B) Postoperative imaging after open reduction and internal fixation with 3.5 × 22-mm lag screw placed perpendicular to the fracture angle, with a 6-hole distal fibular locking plate placed and fit to the lateral aspect of the distal fibula. The patient had a positive intraoperative cotton test for widening. The syndesmosis was reduced, and a tightrope was drilled across the fibula with the supplied guide parallel to the ankle joint. Medially, suture repair of the deltoid ligament and medial malleolar fracture through the tibial periosteum was performed. LT = left, MG = radiology tech.

Figure 2

Preoperative and postoperative imaging of closed displaced fracture of the clavicle. Preoperative imaging presented in (A) demonstrates closed displaced fracture of the clavicle. (B) Postoperative imaging after open reduction and internal fixation with clavicle plate plus interfragmentary compression of the main fracture fragments. A butterfly piece was cerclaged using #2 FiberWire.