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

Introduction: Fracture of the tibia are the most common long bone fracture, with an incidence greater than 75,000 per year in the US1. With the recent breakthrough of operation under WALANT (Wide Awake Local Anaesthesia No Tourniquet) technique. We reported a patient with midshaft tibia fracture who underwent plating under the WALANT technique Methodology: 18 yearold gentleman sustained a closed fracture of his left tibia after his motorbike skidded. He wascounselled for the surgery to be done under the wide-awake technique as we have limited operating theatre time for the case to be done under general/regional anaesthesia. Preoperatively, the WALANT solution is prepared using 50 cc lidocaine 2%, 1cc of epinephrine, 10cc of sodium bicarbonate 8.4% then dilute into 50 cc normal saline. Total of 50 cc WALANT solution was injected along the planned skin incision and at subperiosteum 30 minutes before operation started. Result: Pain score patient remain 0-3/10 during and after removal of backslab, throughout the surgery and postoperatively. The use of epinephrine for hemostasis provide good surgical field view since there is minimal bleeding. Postoperatively the anaesthesia effect lasted for 6 hour and was patient able to move the leg straight away without have to keep lying in bed for 6 hours after spinal or drowsiness from sedation. Conclusion: Plating of tibia under WALANT is a good alternative for patient who have financial difficulty, high risk operation under general anaesthesia, hospital which have limited slot for operation under general anaesthesia and etc. Additionally, the strength and stability of the plate can be assessed intraoperatively by asking the patient to actively move his limb. Reference: Praemer A, Furner S, Rice DP. Musculoskeletal Conditions in the United States. Park Ridge, IL: American Academy of Orthopaedic Surgeons; 1992.

15 Years Review of Gastrocnemius Flap Done in Department of Orthopaedics, Hospital Tengku Ampuan Afzan, Kuantan

Introduction: Gastrocnemius flap is the workhorse for wound coverage in the proximal tibia. It can be perform by general orthopaedic surgeon because it is done without the need of microscopic instrumentation. Its coverage can be extended to cover the knee and midshaft of tibia when skin overlying it is included in the flap. Materials and method: From July 2002 till January 2017, 47 patients underwent gastrocnemius flap in our hospital (26 muscular and 21 musculocutaneous flap). 41 flaps were raised from medial, 5 lateral and 1 from both muscle belly. There were 41 males and 6 females with the mean age of 21.4 years old (range 13-82). The flaps were done to cover upper third (29), upper half (6), midshaft tibia (6), knee (2) and distal femur (1). The initial problems were open fracture (30), infection following plating (9), necrotising fasciitis (4), degloving injury (2), pin site infection (1) and melioidosis (1). Eight patients have underlying Diabetes mellitus, 2 Hepatitis B, 3 HIV or 1 COAD. Two patients have sciatic nerve palsy. Results: There was no flap necrosis. Complications include persistence infection in 6 patients which require repeated debridement (5), below knee amputation (1), advancement of flap (1) and additional fasciocutaneous flap (1). Two patients with gastrocnemius musculocutaneous flap had partial failure of skin graft that heals with dressing. One patient develops transient peroneal nerve palsy following the lateral gastrocnemius transfer. Conclusion: Gastrocnemius flap is a reliable and safe procedure in orthopaedic surgery. Problems that occur are associated with inadequate debridement and underestimate the size of flap required.

IGF-I and pamidronate increase bone mineral density in ovariectomized adult rats

Effects induced by insulin-like growth factor I (IGF-I) and/or the bisphosphonate pamidronate (APD) on bone mineral density (BMD) of the lumbar spine and proximal and midshaft tibia were studied in adult rats made osteopenic by ovariectomy, using dual-energy X-ray absorptiometry. IGF-I, which was administered by osmotic minipumps implanted subcutaneously for 6 wk, caused a dose-dependent increase of BMD at the three investigated sites. A 4-wk course of IGF-I, followed by intermittent cyclical APD administration, induced significant increases of BMD at the levels of spine and proximal tibia. At midshaft tibia, where cortical bone predominates, BMD was increased by IGF-I only. In conclusion, IGF-I increased BMD at sites with trabecular and/or cortical bone, whereas the APD influence was mainly detectable in the former site only.