Patella Fracture Fixation Via Wide Awake Local Anesthesia No Tourniquet (Walant) Technique

Abstract

Introduction: Fractures of the patella constitute an estimated 1% of all acute orthopaedic fractures. The fracture fixation is usually performed under general or spinal anesthesia with tourniquet use. We describe a novel approach of anaesthesia for patella fracture fixation using the WALANT technique. Methods: We presented a case of 22 years old male with right knee pain following a road traffic accident. Examination revealed tenderness on his right knee with extensor mechanism failure, and radiograph showed comminuted 3 parts patella fracture, requiring fixation. Adequate information regarding WALANT was given and he agreed. Results: Open reduction and internal fixation were done using tension band wiring (TBW) technique and screw fixation. WALANT mixture was given 30 minutes prior to skin incision. Visual analog score (VAS) was 0 throughout the surgery. He was able to do active range of movement (ROM) of the knee intraoperatively after the fixation. Discussion: The solution used was mixture of 50ml lignocaine 2% (for local anesthesia), 1ml of adrenaline 0.18% (for hemostasis), 10ml of sodium bicarbonate 8.4% (to buffer the solution) and diluted with 50ml normal saline for tumescent anesthesia effect. Safe dosage of lignocaine with adrenaline is 7mg/kg. 10ml of mixture injected subcutaneously over mid-axial longitudinal incision site and 30 ml of mixture injected at patella borders and fracture site subperiosteally. We waited 30 minutes to allow adrenaline to reach maximal vasoconstriction and provide dry operative field. Without usage of tourniquet, we avoid complications such as hematoma and post operation swelling. WALANT also permits active motion of knee intraoperatively, which is particularly helpful in post TBW patella patient. [Figure: see text][Figure: see text][Figure: see text][Figure: see text] Conclusion: WALANT is a safe option for patients undergoing patella fracture fixation. It gave a painless surgical experience to the patient and offer another option for high risk patients for general / spinal anaesthesia. References: Lalonde D. Wide Awake Hand Surgey (2016): pg 3-32

Recommendations from the ICM-VTE: Trauma

“…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 complications 339 . Li et al, described a prospective case series of 13 patients using WA-LANT for malleolar fractures and no complications, including VTE, were reported 340 .…”