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Trauma Case Rep
Trauma Case Rep
Trauma Case Reports
2352-6440
Elsevier

S2352-6440(24)00136-5
10.1016/j.tcr.2024.101113
101113
Case Report
Management of humeral shaft nonunion using the WALANT technique
Tadayon Niki a
Biglari Farsad b
Mehrvar Amir c
Okhovatpour Mohammad Ali c
Kafiabadi Meisam Jafari meisamjafarikafiabadi@gmail.com
bd⁎
Pashazadeh Mohammad Parsa e
a Assistant professor of Vascular Surgery, Department of General & Vascular Surgery, Shohada Tajrish Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
b Department of Orthopedic Surgery, Clinical Research Development Unit of Shohada-e Tajrish Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
c Department of Orthopedics, Taleghani Hospital Research Development committee, Medical school, Shahid Beheshti University of medical sciences, Tehran, Iran
d Physiotherapy Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
e School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
⁎ Corresponding author at: Department of Orthopedic Surgery, Shohada-e Tajrish Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran. meisamjafarikafiabadi@gmail.com
16 9 2024
12 2024
16 9 2024
54 10111314 9 2024
© 2024 The Authors. Published by Elsevier Ltd.
2024

https://creativecommons.org/licenses/by-nc/4.0/ This is an open access article under the CC BY-NC license (http://creativecommons.org/licenses/by-nc/4.0/).
Humeral shaft nonunion is a challenging orthopedic condition that often requires surgical intervention for successful healing. In this case report, we present a 53-year-old male patient who presented with a humeral shaft nonunion, Underlying Systemic Disorders, and Arteriovenous fistula. The patient had a history of a previous humeral shaft fracture managed with open reduction and internal fixation but developed nonunion despite appropriate initial treatment. The complexity of this case was compounded by the patient's preference for a minimally invasive approach and the desire to avoid general anesthesia due to underlying medical conditions.

Keywords

Fracture
Humerus
Nonunion
Technique
Walant
Wide awake
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pmcIntroduction

Humeral shaft nonunion is a complex orthopedic condition, as discussed in the previous article [1]. In certain cases, complications such as nonunion or hardware failure can arise, necessitating further surgical procedures. Patients with End Stage Renal Disease (ESRD) and Diabetes mellitus (DM) are more prone to nonunion and have a higher risk of mortality and complications during surgery [2,3]. Surgeons, especially plastic and orthopedic surgeons, use different methods such as General Anesthesia (GA) and regional block to anesthetize patients during operations [4]. However, since 2013, there has been a new technique called Wide Awake Local Anesthesia no Tourniquet (WALANT). The WALANT technique offers a bloodless field, significant cost and time reduction compared to GA, fewer post-operative pain requiring fewer narcotics, and reduced hospital stay [[5], [6], [7]]. Another advantage of WALANT over other techniques is that it eliminates the need for a pneumatic tourniquet [8]. In this article, we present a case involving a 53-year-old man with nonunion of right humeral shaft fracture accompanied by device failure, systemic disorders, and arteriovenous fistula (AVF). The challenges were DM, ESRD, AVF in the same limb, the patient's condition, and optimal anesthesia methods. This report focuses on the utilization of the Wide Awake Local Anesthesia No Tourniquet (WALANT) technique for the procedure, highlighting its potential advantages in complex cases such as this.

Anatomy

A 53-year-old male presented with pain and deformity in his right arm. In past medical history, he was ESRD on thrice-weekly hemodialysis, diabetes mellitus (DM), hypertension, and a previous right humeral shaft fracture treated with open reduction and internal fixation. Physical examination revealed the presence of an arteriovenous fistula (AVF) and a scar from prior surgery (Fig. 1). His medication regimen included losartan, insulin, atorvastatin, aspirin (ASA), calcium, and vitamin D. The patient's laboratory test results are displayed in Table 1.Fig. 1 Presence of an arteriovenous fistula (AVF) and a scar from a prior surgery.

Fig. 1

Table 1 Patient's laboratory test results.

Table 1Patient's blood test	
	Result	Normal range	
HbA1c	7.9	<5.7	
Urea	70.2	15–45	
Creatinine	4.6	0.5–1.5	
HGB	9.9	12.5–16	
HCT	32.0	34–47	
MCH	25.06	27–35	
MCHC	30.94	31–37	
RDW	14.4	11–14	
LDL	45	<100	
Phosphorus	5.3	25–5.0	
Fe	33	40–120	
TIBC	206	250–450	

Radiographic examination revealed a failed implanted plate with no evidence of union in the humeral shaft fracture (Fig. 2). The causes of non-union may be the patient's underlying complication and inappropriate length of the previous plate, as well as excessive manipulation of the soft tissue during the patient's previous surgery.Fig. 2 Radiographic examination revealed a union in the humeral shaft fracture.

Fig. 2

Indications/contraindications

The complexity of the case was heightened by the risk of severe intraoperative bleeding due to the arteriovenous fistula, underlying systemic disorders, and due to the impossibility of using a tourniquet, necessitating careful consideration of the treatment approach.

Technique

After transferring the patient to the operating room in sterile conditions, WALANT solution (Table 2) was injected at one-centimeter intervals along the length of the previous surgical incision (Fig. 3). The injection was performed by the chief surgeon and the patient was consulted beforehand and the operation was started after ensuring that the patient was pain-free. After twenty minutes, an incision was made at the same scar site, radial nerve was explored, reaching the nonunion area. Initially, the broken plate and screws were removed (Fig. 4). The fixation was then achieved using two new plates. During the surgery, suction was not used, and blood loss was assessed based on the bloody surgical gauze method (Fig. 5). At three points during the procedure, the patient experienced pain (Visual Analog Score = 3) necessitating injections into deep tissues for pain management. As the patient was awake during the procedure, she immediately expressed her pain. At these three points, the prepared solution was injected into the deep tissue and the procedure was continued after complete anesthesia. The surgical procedure resulted in a bleeding rate of 30 cc, and the duration of the surgery was 90 min. Two days after the surgery, the patient was discharged from the hospital, and elbow and shoulder movements were initiated for them. The clinical and radiographic results of the patient, nine months post-surgery, are presented in the accompanying figures. The patient is pain-free (Visual Analog Score = 0) and has a complete union, and you can see her range of motion in the figures (Fig. 6, Fig. 7, Fig. 8, Fig. 9).Table 2 WALANT solution.

Table 2WALANT solution components	
	Volume	Concentration	
Lidocaine	25 ml	1 %	
Epinephrine	0.5 ml	0.1	
Sodium bicarbonate	2.5 ml	7.5 %	
Normal saline	72 ml	0.9 %	
Total	100		

Fig. 3 WALANT solution injection.

Fig. 3

Fig. 4 Exploration of the radial nerve.

Fig. 4

Fig. 5 Surgical bleeding assessment.

Fig. 5

Fig. 6 Post-operation anteroposterior radiography of the patient.

Fig. 6

Fig. 7 Post-operation lateral radiography of the patient.

Fig. 7

Fig. 8 Patient range of motion 9 M after surgery.

Fig. 8

Fig. 9 Patient range of motion 9 M after surgery.

Fig. 9

Expected outcomes

The WALANT technique involves the use of local anesthesia and epinephrine to achieve both anesthesia and hemostasis. It allows patients to be awake and cooperative during the procedure, reducing the risks associated with general anesthesia [9]. The absence of a tourniquet in this technique further minimizes ischemic complications. The use of the WALANT technique in orthopedic procedures has gained attention due to its potential benefits, including reduced anesthesia-related complications and improved patient satisfaction [10]. In this case, the technique allowed the surgical team to perform the plate replacement with the patient fully conscious, enabling real-time assessment of arm function and stability, providing effective anesthesia, reducing bleeding rate, facilitating real-time patient feedback, and mitigating the risks associated with other anesthesia methods. This method is recommended in patients with many underlying problems, although other anesthetic methods such as regional block alone or together with a local injection may be among the options.

Discussion

The case of humeral shaft nonunion in a patient with multiple systemic comorbidities, such as End Stage Renal Disease (ESRD), Diabetes Mellitus (DM), and the presence of an arteriovenous fistula (AVF), presents significant surgical challenges. These conditions increase the risk of complications, including impaired bone healing, susceptibility to infection, and heightened intraoperative bleeding risk. In such complex situations, selecting an appropriate surgical and anesthetic approach is critical to improving patient outcomes [11,12].

Traditional methods for treating nonunion, especially in patients with systemic conditions, typically involve General Anesthesia (GA) or regional anesthesia combined with a pneumatic tourniquet. However, these approaches may not be ideal for patients with ESRD and AVF, as they increase the risk of ischemic complications, especially with tourniquet use, and pose additional risks from GA, such as post-operative respiratory issues or cardiovascular strain [13].

The use of the Wide Awake Local Anesthesia No Tourniquet (WALANT) technique in this case offers a more viable alternative. WALANT has gained popularity in recent years due to its multiple advantages, including avoiding the risks associated with GA, reducing the need for hospitalization, and enabling intraoperative feedback from the patient. In this case, WALANT allowed the surgical team to operate on a conscious patient, providing immediate pain management when required and allowing for real-time assessment of arm movement and function. This is a distinct advantage in orthopedic surgery, as it can help to ensure proper alignment and stability during fracture fixation, as demonstrated by the patient's positive outcomes post-operatively.

Another notable benefit of WALANT is the elimination of a pneumatic tourniquet, which is particularly significant in patients with AVF, as it reduces the risk of vascular complications. The bloodless field provided by the combination of local anesthesia and epinephrine enabled the surgeons to control bleeding effectively, despite the patient's high risk of hemorrhage. The minimal blood loss during the surgery (30 cc) is a testament to the efficacy of this technique in controlling intraoperative bleeding without the need for suction or more invasive hemostatic methods.

This case also highlights the importance of patient-centered care. The patient's systemic conditions required careful consideration of anesthesia options and the surgical approach, underscoring the need for personalized treatment strategies in complex cases. By employing WALANT, the surgical team was able to balance the need for effective pain control, hemostasis, and real-time patient involvement without exposing the patient to unnecessary risks from GA or regional blocks.

Moreover, the successful outcome of this procedure, as evidenced by the complete bone union and restoration of function nine months post-surgery, supports the growing body of evidence that WALANT is an effective and safe technique for managing complex orthopedic cases. While WALANT is traditionally used in hand and wrist surgeries, this case expands its application to more challenging long bone fractures, particularly in patients with significant comorbidities.

However, it is essential to note that WALANT may not be suitable for all patients or procedures. The patient's systemic disorders, particularly DM and ESRD, are known to impair healing, and while this patient achieved a successful outcome, careful monitoring and post-operative management were necessary to ensure bone healing and prevent infection. Additional studies and case reports are needed to further validate the use of WALANT in complex orthopedic cases involving long bones, but its application, in this case, suggests that it could be a valuable tool in the armamentarium of orthopedic surgeons.

Complications

the WALANT technique demonstrated multiple advantages in this case, including reduced risk of anesthesia-related complications, effective intraoperative pain control, minimal blood loss, and real-time patient feedback, leading to a favorable outcome. Its application in patients with significant systemic conditions, such as ESRD and DM, shows promise for reducing the complexity and risk of surgical interventions, especially in challenging orthopedic procedures.

Funding

None.

Consent for publication

Written informed consent was obtained from the patient for the publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.

Ethical statement

Not applicable.

Research location

Shohada-e Tajrish Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran.

CRediT authorship contribution statement

Niki Tadayon: Conceptualization. Farsad Biglari: Data curation. Amir Mehrvar: Data curation. Mohammad Ali Okhovatpour: Writing – original draft. Meisam Jafari Kafiabadi: Writing – review & editing, Conceptualization. Mohammad Parsa Pashazadeh: Conceptualization.

Declaration of competing interest

The author(s) declare no potential conflicts of interest concerning this article's research, authorship, and/or publication.

Data availability

The authors confirm that the data supporting the findings of this study are available within the article [and/or] its supplementary materials.

Acknowledgments

None.
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