WALANT Technique Scaphoid Fracture and Wrist Surgery With Field Sterility

INTRODUCTION: FIELD STERILITY HAND FRACTURE REDUCTION OUTSIDE OF THE MAIN OPERATING ROOM In Calgary, we moved most hand surgery fracture fixation cases outside of the main operating room more than 30 years ago. We have been performing these cases in a minor procedure room with pure local anesthesia, no sedation, and field sterility. We have found this to be a much more efficient, cost-effective way to manage our minor trauma than the main operating room environment. These cases come directly to our procedure room from the emergency department via the plastic surgeons on call. Our procedure room is staffed with a unit clerk, and a single circulating nurse can be available to scrub. Procedure room nursing staff is available to help us perform these cases in the daytime hours 7 days a week. We and other authors have published our low rates with field sterility fracture fixation in minor procedure rooms, which are no higher than the main operating room.1–3 Field sterility, for our purposes, consists of a surgical mask, sterile surgical gloves, chlorhexidine preparation of the patient’s hand, draping with sterile surgical towels, and a sterile cover (bowel bag) where the hand rests on the mini C-arm. (See Video 1 [online], which displays minor surgery setup along with preparation and draping of the patient for wide-awake local anesthesia no tourniquet [WALANT] field sterility scaphoid fixation.) Sterile surgical instruments and sets are available for a wide variety of hand and soft tissue cases. {"href":"Single Video Player","role":"media-player-id","content-type":"play-in-place","position":"float","orientation":"portrait","label":"Video 1","caption":"displays minor surgery setup along with preparation and draping of the patient for wide-awake local anesthesia no tourniquet [WALANT] field sterility scaphoid fixation.","object-id":[{"pub-id-type":"doi","id":""},{"pub-id-type":"other","content-type":"media-stream-id","id":"1_9c3s4zy7"},{"pub-id-type":"other","content-type":"media-source","id":"Kaltura"}]} OUR MINOR PROCEDURE ROOM CASE MIX In addition to fractures, we perform flexor and extensor tendon repairs, abscess irrigation and debridement, complex laceration repairs, digital nerve repairs, and local and pedicled flaps for trauma reconstruction. We also perform elective procedures such as proximal row carpectomy and carpal and cubital tunnel release, as well as skin cancer excision and reconstruction that include skin grafts and flaps, including forehead flaps. Scaphoid fixation in the minor surgery setting is limited to procedures that do not require bone grafting. We perform these in the main operating theater under general anesthesia. OUR LOCAL ANESTHESIA TECHNIQUE We use 20 mL of 1% lidocaine with 1:100,000 epinephrine for a combination of nerve blocks and periscaphoid infiltration. One of the authors (D.H.L.) also uses 20 mL, but without targeted nerve blocks. He injects minimally painful tumescent local anesthesia around the scaphoid from proximal to distal, first into the soft tissues both volarly and dorsally, and then finally in the joint. After infiltration, the local anesthetic is given time to take effect while we perform the case setup. We do not give preoperative systemic analgesia or antibiotics. (See Video 2 [online], which shows a combination of radial, ulnar, median, anterior interosseous, and posterior interosseous targeted nerve blocks as well as tumescent local anesthesia in the scaphoid region to perform WALANT screw fixation of a scaphoid fracture.) {"href":"Single Video Player","role":"media-player-id","content-type":"play-in-place","position":"float","orientation":"portrait","label":"Video 2","caption":"shows a combination of radial, ulnar, median, anterior interosseous, and posterior interosseous targeted nerve blocks as well as tumescent local anesthesia in the scaphoid region to perform WALANT screw fixation of a scaphoid fracture.","object-id":[{"pub-id-type":"doi","id":""},{"pub-id-type":"other","content-type":"media-stream-id","id":"1_wbu2z93o"},{"pub-id-type":"other","content-type":"media-source","id":"Kaltura"}]} WALANT SCREW FIXATION OF THE SCAPHOID We use a mini C-arm to mark appropriate landmarks for the volar approach with a marking pen. A percutaneous K-wire is positioned at the base of the thumb carpometacarpal joint and advanced through the scaphoid to its distal pole. One K-wire is placed for screw advancement, and a second is added for rotational stability. A third K-wire is introduced to the distal aspect of the scaphoid to measure screw length. Appropriate screw length is determined, and a 2.4-mm self-drilling, self-tapping headless compression screw is placed along the initial wire. Final images are used to confirm screw placement with mini fluoroscopy. Once satisfied with the position, K-wires are removed, and the hand is bandaged and splinted. (See Video 3 [online], which shows the patient featured in Videos 1 and 2 undergoing closed reduction and internal fixation treatment of the scaphoid fracture.) {"href":"Single Video Player","role":"media-player-id","content-type":"play-in-place","position":"float","orientation":"portrait","label":"Video 3","caption":"shows the patient featured in Videos 1 and 2 undergoing closed reduction and internal fixation treatment of the scaphoid fracture.","object-id":[{"pub-id-type":"doi","id":""},{"pub-id-type":"other","content-type":"media-stream-id","id":"1_37rirvto"},{"pub-id-type":"other","content-type":"media-source","id":"Kaltura"}]} CONCLUSIONS: THE POTENTIATING POWER OF WALANT AND FIELD STERILITY WALANT improves safety and patient comfort in populations that may be at heightened risk by eliminating the risks and inconveniences of sedation: intravenous insertion, nausea, vomiting, aspiration pneumonia, urinary retention, and malignant hyperthermia. Furthermore, by forgoing general anesthesia, extubation, and time in the postoperative recovery room, surgical efficiency is augmented, allowing for more procedures to be performed in an allotted time. At our center, it is common to perform 10–15 walking wounded-type procedures, as described earlier, in a single 10-hour minor procedure day. In comparison, in the main operating room, it is common to perform 3–4 similar procedures in a day. Coupling WALANT with field sterility, WALANT advantages are potentiated. Furthermore, with proper targeted nerve blocks and surgical setup, the technical challenges of the procedure are no greater than when done in the main operating theater. There is rapidly increasing evidence demonstrating that WALANT and field sterility are suitable techniques for performing many procedures that were previously performed in the main operating theater.4,5 (See Video 4 [online], which demonstrates dressing and splinting the patient, as well as discussing discharge instructions with the patient who does not require postanesthetic observation, which optimizes efficiency. The patient’s perspective is shared.) {"href":"Single Video Player","role":"media-player-id","content-type":"play-in-place","position":"float","orientation":"portrait","label":"Video 4","caption":"demonstrates dressing and splinting the patient, as well as discussing discharge instructions with the patient who does not require postanesthetic observation, which optimizes efficiency. The patient’s perspective is shared.","object-id":[{"pub-id-type":"doi","id":""},{"pub-id-type":"other","content-type":"media-stream-id","id":"1_waa9m8xp"},{"pub-id-type":"other","content-type":"media-source","id":"Kaltura"}]} DISCLOSURE The authors have no financial interest to declare in relation to the content of this article.

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