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Getting Walant off the ground

How I got WALANT surgery off the ground At UConn Health

By Anthony Parrino M.D.
Assistant Professor of Orthopaedics

In starting my practice, I had the unique opportunity to return to my residency program as faculty. In fellowship, WALANT was a common practice and I wanted to utilize it in my practice. I was returning to an institution and geographic area where it was hardly utilized and would be a culture shock. My dilemma was how to get this off the ground and who I needed to convince that this was a great benefit to patients.

Myself

The most important person I needed to convince for WALANT was myself. If I didn’t fully believe this was for the better of the patient, then it was doomed to fail. I came up with discussion points with patients why this was better for them, and with time my presentation to them became smoother with infrequent hesitation from them to proceed in the manner. I also started with simpler cases (open carpals, triggers) but considered which procedures I would transition to WALANT as I demonstrated safety and outcomes.

Partners

Strength in numbers. If I could have my hand partners on board with a WALANT room then it would be easier to tailor the room. I didn’t need them to do the same exact cases utilizing WALANT, but if they supported it, then when there was pushback from other personnel then it would make the implementation easier. It was also helpful in problem solving and looking at it from different viewpoints.

Chairman / Chief

For an academic center, change can be hard to come by. I utilized my chairman as my big gun. At first when I brought up my desire to implement WALANT in my return, his response was ‘sure’, although I don’t think he fully understood it. As I started, it was my first topic I brought up in our meetings and he soon realized both the small and larger benefits to WALANT if implemented correctly. As I started WALANT, he was crucial to have in my corner when issues began with nursing and anesthesia and concerns they had. With literature to support me and the chairman in my corner, small hurdles that make a big difference (in my view) were overcome. Now nearly two years into WALANT, we are demonstrating the larger benefits, decreased complication rate and cost savings, that the hospital can utilize with insurance companies.

Anesthesia

This may not apply to all. This arose as I did not have the setup for office utilization and anesthesia ran the daily operations of the surgery center. The first concern was for patient safety and comfort. This concern was calmed with studies that support the safety of WALANT and also demonstrating good outcomes and comfort in the first several weeks of WALANT. Other comments that did throw me off guard were “you are taking away my easy cases” or “did I do something wrong”. I hadn’t considered their viewpoint when implementing WALANT. My response was that these are cases that can be done safely without anesthesia, and that their (anesthesia’s) skill set good be better utilized for tougher cases. Also, my transitioning these cases out of an operating room, and into a procedure room, hospital and staff resources could be better utilized. Slowly, they have appreciated its usefulness, especially in patients whose medical conditions could lead to adverse outcomes with general anesthesia or sedation.

OR Staff

This is the biggest factor for you, the surgeon. Identifying a nurse and surgical tech you work well with and enjoy talking to patients is key. This will make your day in the OR much more enjoyable and the patients more at ease. I didn’t want to have a nurse or tech that didn’t want to be in the WALANT room as no one would benefit from that. I made it clear to the supervisors that it was critical to have to same staff in the room each time and has made WALANT days the most enjoyable part of my practice. They know the procedure, my usual discussion points with patients during surgery, and can calm those with anxiety.

In the end

Looking back at starting WALANT at my academic center, I can say that there were some bumps in the road, but persistence is key. For me, I have now increased case complexity utilizing WALANT and I look forward to continue evolving. This is for the better of patients and as more and more patients go through procedures comfortably and have great outcomes, then those around you will appreciate its benefits…and maybe even seek it out for their own care.


Check out how to start Walant in your Hospital or Clinic at Walant.Surgery.

Walant K-wiring of finger fractures

...followed by early protected movement at 3-5 days like in flexor tendon repair

We all do early protected movement after flexor tendon repair. Why? It avoids the inevitable stiff, useless finger; that is why.

How many stiff useless fingers have come out of finger fractures that are K-wired?

Many. I certainly created more stiff fingers before I started early protected movement after K wiring my finger fractures.


How we do early protected movement for WALANT K-wired finger fractures: Reduce the finger fracture with K-wires with WALANT.


Get the awake patient to actively move the finger right after you insert the K-wires.

Look at the fracture and the K-wires move with a low power fluroroscope. Assess the stability of your K-wire fixation, and the ease of movement. If the fracture is moving too much, add another K-wire.


The goal is NOT rigid fixation.

The goal is functionally stable fixation, as in mandible fracture treatment. You only need enough stability that the fracture will heal in a good position of function.

Functional stability with k-wires

- During the surgery, educate the patient about immobilization and elevation for 3-5 days till you see him again in clinic with your therapist, or till the patient sees your therapist. Teach the patient that his hand is on strike above the heart until he sees the hand therapist. You do NOT want immediate movement in the first 3 days after surgery. Immediate movement encourages internal bleeding around the fracture, which will lead to callus and tendon trapping with more scar and more stiffness. Let the internal bleeding stop. Let the swelling come down. Let the work of flexion decrease. Let the friction decrease. Let the fracture get just a little sticky. Remember that collagen formation does not start till day 3 after wounding.


Most importantly, let the patient come off ALL pain killers, including acetaminophen and ibuprofen.

This will be pain-guided movement and pain-guided healing. Explain to the patient that we did not spend 2 billion years evolving pain because it is bad for us! For patient Sally, I tell her:


"Your pain is your body's only way to say to you: "Sally, would you stop that? I'm trying to heal in here and you are messing it up! Stop it! You need to listen to that little helpful voice in your head (the pain) to avoid taking your fracture apart and getting infection from the pins I just put into your finger. You can't hear your body talking to you if you have Advil or Tylenol in your ears!"


- By 3-5 days, in cooperative patients who are now off of all pain killers, your therapist begins pain-guided early protective movement just like in flexor tendon repair. The patient cannot do what hurts to avoid losing the reduction and to avoid K-wire infection. They only need to make up to half a fist at most; just enough to keep the tendons and joints around the fracture gliding so they don't get stuck. No more than 45 degrees of movement at MP, PIP, or DIP is required. The patient comes out of the immobilizing whole hand splint to do this protected movement several times per day, depending on the pain. They can stabilize the fracture with the fingers of his other hand if this decreases the pain. They do not put their hand below the level of his heart until it no longer hurts to do it.

Functional stability with k-wires

When the fracture is no longer tender to palpation, the fracture is healed in the sensate finger, and the K-wires can be removed.

This clinical healing sign is far more useful than Xray healing in finger fractures. Xray healing is useless in finger fractures. Anyone who has done finger malunion surgery has seen non-healed Xrays with very healed fractures. We remove K-wires between 2-4 weeks in most patients in whom the blood supply to the bones is good (closed reduction and K-wire fixation). If the periosteum is stripped with open reduction or open degloving injuries such as wood splitters or table saws, the K-wires will need to stay in longer because it takes longer to heal the bone.


"If I had a finger fracture, I would definitely have this method." - Don Lalonde

I am willing to bet that most other hand surgeons would go for it as well, if it was available. Contraindications would include patients who cannot get off pain killers, non-cooperative patients, grossly comminuted fractures with very little stability, and very unstable intraarticular fractures.
I have been doing this for many years and I promise you that if you try it, you will like it. The stiff finger is much less common. The only downside is loss of your reduction and the possible need to K-wire again. This is a minor price to pay compared to redoing a flexor tendon repair with a rupture after early protected movement in that scenario. I have only occasionally had to redo the K-wires because of this problem.
Find out more about how this technique is performed at the Walant University and go to the Trauma course.

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