Both misoprostol and laminaria were equally effective in inducing proper cervical priming prior to operative hysteroscopy with minimal time of cervical dilatation. Nevertheless, misoprostol may be superior due to easy application, reduced cost, and patient convenience and acceptability.

Introduction: Fractures of the patella constitute an estimated 1% of all acute orthopaedic fractures. The fracture fixation is usually performed under general or spinal anesthesia with tourniquet use. We describe a novel approach of anaesthesia for patella fracture fixation using the WALANT technique. Methods: We presented a case of 22 years old male with right knee pain following a road traffic accident. Examination revealed tenderness on his right knee with extensor mechanism failure, and radiograph showed comminuted 3 parts patella fracture, requiring fixation. Adequate information regarding WALANT was given and he agreed. Results: Open reduction and internal fixation were done using tension band wiring (TBW) technique and screw fixation. WALANT mixture was given 30 minutes prior to skin incision. Visual analog score (VAS) was 0 throughout the surgery. He was able to do active range of movement (ROM) of the knee intraoperatively after the fixation. Discussion: The solution used was mixture of 50ml lignocaine 2% (for local anesthesia), 1ml of adrenaline 0.18% (for hemostasis), 10ml of sodium bicarbonate 8.4% (to buffer the solution) and diluted with 50ml normal saline for tumescent anesthesia effect. Safe dosage of lignocaine with adrenaline is 7mg/kg. 10ml of mixture injected subcutaneously over mid-axial longitudinal incision site and 30 ml of mixture injected at patella borders and fracture site subperiosteally. We waited 30 minutes to allow adrenaline to reach maximal vasoconstriction and provide dry operative field. Without usage of tourniquet, we avoid complications such as hematoma and post operation swelling. WALANT also permits active motion of knee intraoperatively, which is particularly helpful in post TBW patella patient. [Figure: see text][Figure: see text][Figure: see text][Figure: see text] Conclusion: WALANT is a safe option for patients undergoing patella fracture fixation. It gave a painless surgical experience to the patient and offer another option for high risk patients for general / spinal anaesthesia. References: Lalonde D. Wide Awake Hand Surgey (2016): pg 3-32

Avulsion fracture of medial epicondyle fractures accounted for 30.77% of elbow fractures. Fixation is needed when the fragment displaced significantly. These cases were usually done under general anaesthesia / regional anaesthesia. We describe a novel technique of using WALANT to proceed with this surgery. Methods: A combination of lignocaine, 1:100000 epinephrine and 10:1 sodium bicarbonate with a safe limit of 7mg/kg for lignocaine and epinephrine is used. The operation was done with continuous visual analog score and vital signs monitoring until postoperatively. Range of motion and blood loss was monitored post fixation intraoperatively. In every patients who undergo an operation under WALANT technique, we will provide , IV Dynastat 40mg BD x 1/7, T Celebrex 200mg BD and T PCM 1g PRN x 1/52. Discussion: The limitation faced during the procedure is that, the local anaesthesia cannot reach the second cortex of the humerus. The problem arises when the drill bit touches the second cortex of the bone which will cause pain to the patient. To remedy this, we injected 5ml of the solution to the expected trajectory of the screw at the far cortex. However, the procedure does not need to go through second cortex of the bone, so this limitation is manageable. Results: Patient’s pain score remain 0-2 after administration of solution, throughout the surgery and postoperatively. Estimated blood loss was 80cc and range of motion was full post fixation intraoperatively. Conclusion: Screw fix medial epicondyle under WALANT is a good alternative for patients with multiple comorbids and high risk for surgery to be done under general anaesthesia. Patient remain comfortable throughout the procedure and post operatively. Range of motion can be assessed post fixation intaraoperatively thus allow light exercise post operatively which is good to prevent elbow stiffness. References: Ahmad AA., Yi LM., Ahmad AR Plating of Distal Radius Fracture Using the Wide-Awake Anesthesia Technique. Journal of Hand Surgery. (2018) 43 (11) , pp 1045. el- 1045.e5 -1045.e5