Abstract
Background: Traditionally, surgical repair of phalanx fractures was performed under general anesthesia. However, the emergence of regional and local anesthesia, otherwise known as Wide-awake Local Anesthesia No Tourniquet, provides an alternative approach where general anesthesia is undesirable. The choice of anesthetic approach resides with clinicians, though it is important to factor in the evidence that regional/local provides not only an alternative anesthesia approach but also potentially avoids comorbidities associated with general anesthesia. This study hypothesizes that the use of local/regional anesthesia for phalanx fracture/dislocation has comparable outcomes to general anesthesia and provides for fewer adverse events. Methods: To answer the research purpose, the investigators designed and implemented a retrospective cohort study of consecutive cases reported to the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database between January 1, 2015, and December 31, 2019. The study population included patients in the NSQIP database who underwent operative fixation of a phalanx fracture or dislocation in 2 cohorts, those with local/regional anesthesia or general anesthesia. The predictor variables were preoperative patient demographic data, including age, gender, surgical specialty, elective surgery, diabetes, smoking, hypertension, and open wound. Results: A total of 2831 patients were identified in the NSQIP database between January 1, 2015, and December 31, 2019. Local/regional anesthesia was performed in 13% of patients with the remaining 87% receiving general anesthesia. Surgical site occurrences were not clinically significant between the 2 groups. Overall, 30-day post-operative complications in the local/regional cohort included one patient with a deep vein thrombosis (0.03%) and pulmonary embolus (0.02%). Overall, 30-day post-operative complications in the general anesthesia cohort included pneumonia (0.12%) and stroke (0.08%). Conclusions: Surgery using the regional/local anesthesia techniques for patients with phalanx fractures or dislocations is safe and can be used in situations where general anesthesia is undesirable as post-operative 30-day complications are similar to those with general anesthesia.
Keywords: WALANT, phalanx fracture, phalanx dislocation, local/regional anesthesia, upper extremity, local anesthesia
Résumé
Contexte: La réparation chirurgicale des fractures de phalanges se faisait traditionnellement sous anesthésie générale. Cependant, l’émergence de l’anesthésie régionale et locale, également appelée anesthésie locale sur patient éveillé sans garrot (WALANT) offre une alternative lorsqu’une anesthésie générale n’est pas souhaitable. Le choix de l’approche anesthésique dépend des cliniciens bien qu’il soit important de prendre en compte le fait que l’anesthésie régionale/locale offre non seulement une autre approche, mais qu’elle peut aussi éviter les comorbidités associées à l’anesthésie générale. Cette étude a posé comme hypothèse que le recours à l’anesthésie locale/régionale pour les fractures/dislocations de phalanges obtenait des résultats comparables à l’anesthésie générale et était associée à moins d’événements indésirables. Méthodes: Pour répondre à l’objectif de la recherche, les chercheurs ont conçu et mis en place une étude rétrospective de cohorte de cas consécutifs déclarés dans la base de données du Programme national d’amélioration de la qualité chirurgicale (NSQIP) de l’American College of Surgeons entre le 1er janvier 2015 et le 31 décembre 2019. La population de l’étude a inclus les patients de la base de données NSQIP ayant subi la réparation chirurgicale d’une fracture ou d’une dislocation de phalange dans deux cohortes : une cohorte de patients opérés sous anesthésie locale/régionale et une cohorte de patients opérés sous anesthésie générale. Les variables prédictives étaient les données démographiques préopératoires des patients incluant leur âge, sexe, la spécialité chirurgicale, la chirurgie programmée, l’existence d’un diabète, de tabagisme, d’hypertension et d’une plaie ouverte. Résultats: Au total, 2831 patients ont été identifiés dans la base de données NSQIP entre le 1er janvier 2015 et le 31 décembre 2019. Une anesthésie locale/régionale a été réalisée chez 13 % des patients; une anesthésie générale a été utilisée pour les autres 87 % des patients. L’emplacement du site chirurgical n’a pas eu une signification clinique entre les deux groupes. Globalement, les complications postopératoires à 30 jours dans la cohorte d’anesthésie locale/régionale ont inclus un patient ayant une TVP (0,03 %) et une embolie pulmonaire (0,02 %). Globalement, les complications postopératoires dans la cohorte d’anesthésie générale ont inclus des pneumonies (0,12 %) et un AVC (0,08 %). Conclusion: La chirurgie faisant appel aux techniques d’anesthésie locale/régionale pour les patients atteints de fractures ou de luxations de phalanges est sécuritaire et peut être utilisée dans les cas où l’anesthésie générale n’est pas souhaitable puisque les complications postopératoires à 30 jours sont comparables à celles de l’anesthésie générale.
Mots clés: WALANT, fracture de phalange, luxation de phalange, anesthésie locale/régionale, membre supérieur, anesthésie locale
Introduction
Traditionally, surgical repair of phalanx fractures was performed under general anesthesia. However, the emergence of regional and local anesthesia, otherwise known as Wide-awake Local Anesthesia No Tourniquet (WALANT), provides an alternative approach where general anesthesia is undesirable. The choice of anesthetic approach resides with clinicians, though it is important to factor in the evidence that regional/local provides not only an alternative anesthesia approach but also potentially avoids comorbidities associated with general anesthesia.
Studies have suggested that patients undergoing regional anesthesia for outpatient hand surgery have exhibited a more favorable post-surgical course such as a decrease in post-anesthesia symptoms, most notably nausea, vomiting, and requirement of opioids. Regional/local anesthesia patients have also been shown to experience shorter recovery times and subsequently faster hospital discharges.1,2 For hospital systems, the regional/local technique has shown clinical advantages such as reduced nursing demand and subsequent cost savings compared to general anesthesia. 1
Regarding outcomes and complications, previous studies have compared WALANT to non-WALANT outcomes and complications have demonstrated low complication rates (Table 1). Most notably a retrospective analysis of 424 patients undergoing WALANT hand procedures versus non-WALANT within a 3-year time period demonstrated an overall complication rate of 2.8% with no adverse events being observed during the use of WALANT. These complications were not attributed to the use of local anesthetic. 3 Another study examining complications between 39 patients undergoing WALANT and 37 patients undergoing general anesthesia for trigger finger release demonstrated no difference in intraoperative and post-operative complication rates as well as no difference in infection rates between the groups. 4
Table 1.
Previous Studies on WALANT and Fractures.
| Author and Year | Title | Conclusion |
|---|---|---|
| Ruterana et al, 2022 | WALANT technique versus locoregional anesthesia in the surgical management of metacarpal and phalangeal fractures: Lessons from the Covid-19 crisis | WALANT safe in hand fracture surgery |
| Steve et al, 2022 | Low Infection Rate for Hand Fractures Managed with Surgical Fixation under Wide-Awake Local Anesthesia with No Tourniquet in Minor Surgery | WALANT has low infection rates (3.4%) in hand fracture surgery |
| Lin et al, 2021 | Plate osteosynthesis of single metacarpal fracture: WALANT technique is a cost-effective approach to reduce post-operative pain and discomfort in contrast to general anesthesia and wrist block | WALANT and wrist block had decreased anesthesia time and post-operative nausea/ vomiting than general anesthesia |
Abbreviation: WALANT, Wide-awake local anesthesia no tourniquet.
The primary outcome of this study is to report overall complication rates in a local/regional anesthesia cohort versus overall complication rates in a general anesthesia cohort. Secondary outcomes include quantifying total operative time between the groups. We hypothesize that the use of local/regional anesthesia for phalanx fracture/dislocation has comparable outcomes to general anesthesia and provides for fewer adverse events.
In this study, we outline patient population demographics, within a large national surgical database, who have received regional/local anesthesia for phalanx fracture/dislocation repair. We compare outcomes and complications between regional/local and general anesthesia patient populations to determine the safety of these procedures with the use of local/regional anesthesia.
Materials and Methods
Study Design and Sample
To answer the research purpose, the investigators designed and implemented a retrospective cohort study of consecutive cases reported to the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database between January 1, 2015, and December 31, 2019. Our institution did not require IRB approval for this deidentified, population-based, retrospective descriptive study. To be included in this study sample, patients must be (a) ≥ the age of 18, (b) who underwent operative fixation of a phalanx during the study period under local, regional, or general anesthesia. Patients were identified with the current procedural terminology (CPT) codes for phalanx fractures and/ or dislocations. The following CPT codes were used: 26706, 26715, 26727, 26735, 26746, 26765, 26776, and 26785. Each patient had only one associated CPT code/procedure. Patients were excluded as study subjects if they were (a) under the age of 18 (b) or did not have a fracture/dislocation of the hand that involved the phalanx during the study period and (c) underwent multiple procedures during the index operation. The NSQIP dataset is a risk-adjusted, non-administrative, surgical outcomes database that collects 30-day post-operative patient outcomes data. 5
Variables
The study population included patients in the NSQIP database who underwent operative fixation of a phalanx fracture or dislocation in 2 cohorts, those with local/regional anesthesia or general anesthesia. The patients were allocated to each group based on the “Principal Anesthesia Technique” recorded in the NSQIP database. These techniques included local anesthesia, regional anesthesia, and general anesthesia. The predictor variables were preoperative patient demographic data, including age, gender, surgical specialty, elective surgery, diabetes, smoking, hypertension, and open wound. The primary outcomes are the incidence of 30-day post-operative surgical site–related complications, overall complications, and total surgical time. Post-operative surgical site complications included superficial surgical site infections (SSIs), deep incisional SSI, organ/space SSI, and wound dehiscence. These were combined and termed surgical site occurrences. Overall, 30-day post-operative complications included pneumonia, unplanned intubation, myocardial infarction, pulmonary embolus, deep vein thrombosis, and stroke.
Data Collection
Certified surgical clinical reviewers (SCRs) collect data regarding more than 250 clinical variables, including preoperative risk factors, intraoperative variables, 30-day post-operative mortality, and 30-day post-operative morbidity from each participating site. 5 To maintain the quality of data abstraction, SCRs are mandated to complete various standardized online training modules, followed by a yearly certification exam that focuses on various aspects and processes of the program including instructions on coding and perioperative procedural definitions. They also provided access to an online decision support system that shares specialized resources and enables individualized, case-based troubleshooting. 5 Each surgical procedure is assigned a primary post-operative diagnosis using International Classification of Diseases codes (ICD) and a primary surgical procedure code using CPT codes. Fracture CPTs included: Open CPT 26746, 26765, and 26735 and percutaneous CPT 26727. Dislocation CPTs included: Open 26715, 26785 and percutaneous 26776, 26706. NSQIP utilizes a systematic, risk-weighted sampling strategy to minimize bias and ensure data quality. It routinely audits participating hospitals and SCR's to ensure inter-rater reliability which have demonstrated disagreement rates of less than 2.5% for all assessed program variables. 5
Data Analyses
Descriptive statistics were reported as a mean or median and standard deviation for continuous variables or frequency and percentage for categorical variables, respectively. Comparisons of proportions were performed with an “N-1” Chi-squared test. A Student t test was used to determine any statistical significance in mean operating times. Before performing any tests, statistical significance was defined with a P value <.05. All statistical analyses were performed using commercially available software (JMP 16, SAS, Inc.).
Results
A total of 2831 patients were identified in the NSQIP database between January 1, 2015, and December 31, 2019. Local/regional anesthesia was performed in 13% of patients with the remaining 87% receiving general anesthesia.
In the local/regional anesthesia cohort of 369 patients, 58% were male. Local/regional anesthesia patients were under the care of orthopedic surgery (66.4%), plastic surgery (33.3%), or general surgery (0.2%) with the majority of procedures being elective (81.0%). In the 2462 general anesthesia cohort, 61% were male. Patients were under the care of orthopedic surgery (73%), plastic surgery (25.5%), or general surgery (1.5%) with the majority of procedures being elective (78.1%). Differences in surgical subspecialty were significant (P < .001) with the majority of local/regional as well as general anesthesia patient phalanx fractures/dislocations being repaired by orthopedic surgery followed by plastic surgery. Within each cohort, there was only a 1% reoperation rate.
Patient comorbidities analyzed within the local/regional anesthesia group as well as general anesthesia patients included diabetes, smoking status, hypertension, and open wounds. In the local/regional cohort, 21% of patients were smokers, 20% had hypertension, and 8.1% were diabetic. The majority of wounds were closed wounds prior to the index operation (97.2%).
In the general anesthesia cohort, 24.6% of patients reported smoking, 14.5% having hypertension, and 6.0% having diabetes. The majority of the wounds were closed wounds (97.4%).
Comparing local/regional and general anesthesia patients, surgical specialty (P < .001), age (P < .05), and hypertension (P < .05) were statistically significant between the patient cohorts. The patient populations that are likely to receive general anesthesia over local anesthesia are younger with fewer comorbidities which were statistically significant. Complete demographic findings are summarized in Table 2.
Table 2.
Demographics.
| Local/Regional | General | P value | ||
|---|---|---|---|---|
| Patients | 369 | 2462 | ||
| Average age (±SD) [years] | 43.5 (±17.8) | 39.8 (±16.7) | <.01 | |
| Gender | Male | 213 (57.7%) | 1503 (61.0%) | .23 |
| Female | 156 (42.3%) | 959 (39.0%) | ||
| Diabetes | Yes | 30 (8.1%) | 140 (6.0%) | .12 |
| No | 339 (91.9%) | 2322 (94%) | ||
| Smoker | Yes | 79(21.4%) | 606 (24.6%) | .19 |
| No | 290 (78.6%) | 1856 (75.4%) | ||
| Hypertension | Yes | 73 (19.8%) | 357 (14.5%) | <.05 |
| No | 296 (80.2%) | 2105 (85.5%) | ||
| Elective Surgery | Yes | 299 (81.0%) | 1922 (78.1%) | |
| No | 69 (18.7%) | 533 (21.6%) | .36 | |
| Unknown | 1 (.03%) | 7 (0.03%) | ||
| Reoperation | Yes | 4 (1.1%) | 31 (1%) | 1 |
| No | 365 (98.9%) | 2431 (99%) | ||
| Surgical Specialty | General Surgery | 1 (0.2%) | 36 (1.5%) | <.001 |
| Plastic Surgery | 123 (33.3%) | 629 (25.5%) | ||
| Orthopedics | 245 (66.4%) | 1797 (73.0%) | ||
| Open Wound | Yes | 10 (2.7%) | 65 (2.6%) | .86 |
| No | 359 (97.2%) | 2397 (97.4%) |
Bold values represents P<.05.
Surgical site occurrences were not clinically significant between the 2 groups. Overall, 30-day post-operative complications in the local/regional cohort included one patient with a deep vein thrombosis (0.03%) and pulmonary embolus (0.02%). Overall, 30-day post-operative complications in the general anesthesia cohort included pneumonia (0.12%) and stroke (0.08%). The results are summarized in Table 3.
Table 3.
Complications Reported Between the Years 2015 and 2019.
| Local/Regional | General | |||
|---|---|---|---|---|
| Patients | N = 369 | N = 2462 | P value | |
| Surgical site occurrences | Superficial | 9 (2.4%) | 43 (1.7%) | .4 |
| Deep | 0 | 1 (0.04%) | 1 | |
| Organ space | 0 | 6 (.24%) | 1 | |
| Wound disruptions | 0 | 1 (0.03%) | 1 | |
| Complications | Pneumonia | 0 | 4 (0.12%) | 1 |
| Unplanned intubation | 0 | 0 | 0 | |
| Myocardial infarction | 0 | 0 | .74 | |
| Pulmonary embolus | 1 (0.2%) | 0 | .13 | |
| Deep vein thrombosis | 1 (0.3%) | 0 | .13 | |
| Stroke | 0 | 2 (0.08%) | 1 | |
| Overall complication rate | 11 (2.9%) | 57 (2.3%) |
In the regional/local cohort, the mean time for open surgery for dislocation was 49 min and for percutaneous surgery was 19 min. In the general anesthesia cohort, the mean time for open dislocation surgery was 54 min and in the percutaneous cohort 40 min. There was a statistically significant difference in total operative time between the percutaneous groups (P < .001). In the regional/local cohort, the mean time for open surgery for fracture was 59 min and for percutaneous surgery was 32 min. In the general anesthesia cohort, the mean time for open fracture on surgery was 66 min and in the percutaneous cohort 33 min. There was a statistically significant difference in total operative time between the open fracture cohorts (P < .05). Results are summarized in Tables 4 to 7.
Table 4.
Total Operative Times, Mean Time in Minutes.
| Surgical technique | Local/Regional | General | P value | |
|---|---|---|---|---|
| Dislocation | Open | N = 21 | N = 124 | .36 |
| Mean time 48.5 (± 27.0) | Mean time 54.5 (± 30.1) | |||
| Percutaneous | N = 19 | N = 40 | <.001 | |
| Mean 16.5 (± 7.06) | Mean 33.2 (± 29.5) | |||
| Fracture | Open | N = 200, | N = 1412 | <.05 |
| Mean time 58.6 (± 35.1) | Mean time 66.3 (± 41.8) | |||
| Percutaneous | N = 131 | N = 884 | .19 | |
| Mean 31.2 (± 16.9) | Mean 33.3 (± 20.0) |
Bold values represents P<.05.
Table 7.
Fracture Versus Dislocation Complications.
| Fracture N = 2629 |
Dislocation N = 202 |
P value | ||
|---|---|---|---|---|
| Surgical site occurrences | Superficial | 46 (0.88%) | 6 (1.02%) | .27 |
| Deep | 1 (0.04%) | 0 | 1.00 | |
| Organ space | 6 (0.23%) | 0 | 1.00 | |
| Wound disruptions | 1 (0.04%) | 0 | 1.00 | |
| Complications | Pneumonia | 4 (0.15%) | 0 | 1.00 |
| Unplanned intubation | 0 | 0 | 0 | |
| Myocardial infarction | 0 | 0 | 0 | |
| Pulmonary embolus | 1 (0.04%) | 0 | 1.00 | |
| Deep vein thrombosis | 1 (0.04%) | 0 | 1.00 | |
| Stroke | 2 (0.08%) | 0 | 1.00 | |
| Overall complication rate | 124 (4.72%) | 6 (2.9%) |
Table 6.
Percutaneous Fracture and Dislocation Demographics.
| Fracture n = 1017 |
Dislocation n = 57 |
P value | ||
|---|---|---|---|---|
| Average age (±SD) [years] | 41.1 ± 17.4 | 41.1 ± 15.4 | .51 | |
| Gender | Male | 572 (56%) | 33 (58%) | .89 |
| Female | 445 (44%) | 24 (42%) | ||
| Diabetes | Yes | 65 (7%) | 6 (11%) | .06 |
| No | 952 (93%) | 51 (89%) | ||
| Smoker | Yes | 227 (22%) | 14 (25%) | .74 |
| No | 790 (78%) | 43 (75%) | ||
| Hypertension | Yes | 177 (17%) | 6 (11%) | .21 |
| No | 840 (83%) | 51 (89%) | ||
| Elective surgery | Yes | 847 (83%) | 45 (78%) | |
| No | 170 (17%) | 12 (22%) | .37 | |
| Unknown | N/A | N/A | ||
| Reoperation | Yes | 17 (1%) | 0 | 1 |
| No | 1000 (99%) | 57 (100%) | ||
| Surgical specialty | General surgery | 15 (2%) | 1 (2%) | <.001 |
| Plastic surgery | 227 (22%) | 25 (44%) | ||
| Orthopedics | 775 (76%) | 31 (54%) | ||
| Open wound | Yes | 16 (2%) | 1 (2%) | .61 |
| No | 1001 (98%) | 56 (98%) |
Bold values represents P<.05.
Discussion
The field of hand surgery comprises a wide spectrum of injuries ranging from mangled hands to carpal tunnel syndrome, and with the incidence of hand injury rising, the treatment of upper extremity repair has advanced to meet the needs of this patient population. 6 The technique of WALANT for treatment of hand trauma as well as elective hand surgery was pioneered by Dr Donald H. Lalonde over a decade ago, has begun to replace traditional anesthetic techniques for certain surgical procedures given its advantages over general anesthesia. Today, WALANT is commonly used for trigger finger release, tendon repair, as well as carpal tunnel release with the potential to be used in more complex bony and soft tissue procedures. 7
To determine the safety of regional/local anesthesia in phalanx fracture repair after surgery compared to general anesthesia, our study explored 30-day complication rates between each cohort, respectively. Analysis revealed low post-operative complication rates in both cohorts. We identified 2831 patients of which 369 underwent local/regional and 2462 underwent general anesthesia. Patients were placed into these categories without any other variables being included, therefore, creating a heterogeneous population. There may be some intrinsic selection bias as we note that patients in the regional/local tend to be older but given this is an investigational study this could simply be a correlation.
For our primary outcome, the overall surgical site occurrence rate in the local regional group was 2.2% and, in the general anesthesia group was 2.17%. There was no difference in surgical site occurrences between the 2 cohorts. Complications such as pneumonia, deep vein thrombosis, stroke, and pulmonary embolism were not significant between the local/regional anesthesia and general anesthesia cohorts. There was a statistically significant difference in the surgical specialty performing the operation as to whether local/regional or general anesthesia was used. There is a greater proportion of plastic surgeons in our study that used local/regional anesthesia compared to orthopedic surgery. There are numerous reasons as to why a surgeon would choose a specific type of anesthesia such as comorbidities, extent of injury, or comfort with the procedure. It is hard to determine the cause of this association and will require future studies to examine with more detail the patient populations in which these surgeons are operating.
Although age was found to be statistically significant, the average age difference was 3 years, it is unlikely to be clinically significant. However, in regard to elderly patients undergoing surgery in general, increased incidence of complications in elderly has been noted in literature with hypertension and dyspnea being the most frequent risk factors for complication. 8 The other patient characteristics including hypertension and surgical specialty could be investigated further to determine whether these play a role in our principal outcomes as well as secondary outcomes.
When analyzing open fractures versus open dislocations, there were 2 variables that demonstrated significance: age and hypertension. Although there are statistical differences between these 2 variables, there is likely to be little clinical difference. When looking at our primary and secondary outcomes there were no statistically significant differences in complication rates in the fracture versus dislocation cohorts. The data are presented in Tables 5 to 7.
Table 5.
Open Fracture and Dislocation Cohort.
| Fracture n = 1612 |
Dislocation n = 145 |
P value | ||
|---|---|---|---|---|
| Average age (±SD) [years] | 39.2 ± 16.2 | 47.3 ± 19.5 | <.0001 | |
| Gender | Male | 1012 (63%) | 99 (68%) | .20 |
| Female | 600 (37%) | 46 (32%) | ||
| Diabetes | Yes | 87 (5%) | 12 (8%) | .17 |
| No | 1612 (95%) | 133 (92%) | ||
| Smoker | Yes | 406 (25%) | 38 (26%) | .76 |
| No | 1206 (75%) | 107 (74%) | ||
| Hypertension | Yes | 214 (13%) | 33 (23%) | <.05 |
| No | 17139843 (87%) | 112 (77%) | ||
| Elective surgery | Yes | 1228 (76%) | 101 (70%) | |
| No | 376 (23%) | 44 (30%) | .14 | |
| Unknown | 8 (1%) | N/A | ||
| Reoperation | Yes | 17 (1%) | 1 (0.7%) | 1 |
| No | 1595 (99%) | 144 (99.3%) | ||
| Surgical specialty | General surgery | 19 (1%) | 2 (1%) | .42 |
| Plastic surgery | 465 (29%) | 35 (24%) | ||
| Orthopedics | 1128 (70%) | 108 (75%) | ||
| Open wound | Yes | 55 (3%) | 3 (2%) | .62 |
| No | 1557 (97%) | 142 (98%) |
Bold values represents P<.05.
WALANT varies from traditional general anesthesia in that patients remain awake throughout the procedure which allows for favorable outcomes for both the patient and hospital systems such as decreased length of stay for patients with subsequent cost savings as well as decreased nursing/staffing demands for hospitals. Most notably, WALANT requires less care preoperatively, intraoperatively, and post-operatively with earlier discharge from the hospital and increased patient satisfaction without compromising patient safety.9,10 As demonstrated in our study, surgical repair of dislocation using a percutaneous surgical technique showed a significant reduction in operating times; local/regional anesthesia cohorts had a mean time of 19 min as compared to the general anesthesia cohort with a mean time of 33.2 min (P < .0001). The time required for open surgical repair of fractures also demonstrated significance (P < .05) with a mean time of 66 min in the general anesthesia cohort and 59 min in the local/regional. It is possible that these differences in times could be accounted for by the complexity of the procedure which cannot be determined by our data set. There is a question as to utilizing regional blocks versus general anesthesia in the setting of hand surgery as well. Literature has demonstrated that while regional anesthesia demonstrates favorable outcomes, regional blocks, such as brachial plexus block, while effective, is associated with longer induction time that general anesthesia and regional anesthesia. 1 Both this and the findings of this study, exemplify the utility and benefit of local/regional anesthesia. This synergistic relationship associated with local/regional anesthesia use, meaning benefit for both patients and hospital systems, allows for optimized patient care, as well as reductions in costs for hospital systems.9,11
Patients who have undergone WALANT have noted increased satisfaction in the streamlined preparation of surgery which is attributable to no fasting requirement as well as no requirement of anesthesia provider's preoperative clearance which patients traditionally would have had to undergo should they require general anesthesia.9,11 Patient satisfaction and other clinical outcomes measured by questionnaires such as Single Assessment Numeric Evaluation have observed patients reporting a faster recovery with the use of WALANT as well as a lack of anesthetic side effects such as nausea and vomiting and effective pain management with reduced post-operative opioid use. 11 With general anesthesia, the literature reporting disadvantages and risks is extensive, noting the most common risks being nausea, vomiting, and with more serious complications being myocardial infarction and exacerbation of underlying disease. 12 In our study, we found very few 30-day post-operative complications in either cohort.
WALANT has its own potential disadvantages such as longer induction time and/or technique-related failure as well as difficulties achieving the desired level of local/regional anesthesia and delayed onset of effect.1,13 With the safety of WALANT being exhibited in literature, there is a question as to why the widespread use of WALANT has not been adopted. Recent literature has hypothesized that this may be due to concerns regarding loss of jobs for operating room staff as well as concerns about patients’ comfortability with being awake as surgery is performed. 7
This study has limitations. We used a national database that has its own interobserver variability despite the routine audits from the overseeing body. The database is limited to CPT codes and ICD codes for procedure identification; therefore, we are unable to provide a definitive treatment algorithm in terms of type of specific phalanx fracture, nondisplaced, transverse, and oblique, among others. Despite these limitations, we believe that this study demonstrates the safety in terms of 30-day post-operative complications between the use of local/regional versus general anesthesia for phalanx fractures and dislocations. This study is exploratory looking for associations between overall complication rates between the anesthesia cohorts. This study will allow more detailed questions to be answered with future studies such as specific anesthesia protocols, further detail on fracture and dislocation patterns, and their influence on post-operative outcomes.
Another limitation of this study is the lack of clarity of the anesthesia protocols used by providers. This would provide valuable insight into providing recommendations for providers; this is something that future studies should evaluate.
Conclusion
Surgery using the regional/local anesthesia techniques for patients with phalanx fractures or dislocations is safe and can be used in situations where general anesthesia is undesirable as post-operative 30-day complications are similar to those with general anesthesia.
Footnotes
Author Contributions: Matthew D Rich contributions included: research formulation, data analysis, and writing. Anna Rauzi contributions included: data analysis and writing. Thomas J Sorenson contributions included: data collection and writing. Christopher Hillard contributions included: Data analysis and research guidance. Ashish Y Mahajan contributions included: Data analysis and research guidance.
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding: The author(s) received no financial support for the research, authorship, and/or publication of this article.
ORCID iD: Matthew D. Rich https://orcid.org/0000-0002-6183-5883
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