Anal Fistula

Reconstruction surgeries are of two type arthroscopic and open reconstruction depending on orthopedic surgeon’s choice and extent of injury. Time of surgery is debatable topic. Surgery immediately after injury has been associated with increased fibrous tissue leading to loss of motion (arthofibrosis) after surgery (1). According to some surgeon surgery should be delayed until swelling goes down, gain range of motion in knee and can strongly contract (flex) front of thigh muscle (quadriceps)(1). In adults age is not a factor in surgery though overall condition of body may be. People with medical conditions may consider non surgical treatment option because surgery carries greater risk. These include use of painkillers and anti inflammatory medications and bracing for 1 to 2 weeks with ice, elevation and programmed physiotherapy. A new non surgical treatment option is Platelet rich plasma injection, in this procedure blood of the patient is taken platelets are separated by centrifuge and injected I the injured tissue to augment healing. It is useful in both acute and chronic soft tissues injuries. Choice completely depends upon patient choice and level of activity patient having after surgery (2). Many orthopedic surgeons use arthroscopic surgery rather than open surgery for ACL injuries because: 1. It is easy to see and work on the knee structures. 2. It uses smaller incisions than open surgery. 3. It can be done at the same time as diagnostic arthroscopy (using arthroscopy to find out about the injury or damage to the knee). 4. It may have fewer risks than open surgery (3). During arthroscopic ACL reconstruction, the surgeon makes several small incisions—usually two or three—around the knee. Sterile saline (salt) solution is pumped into the knee through one incision to expand it and to wash blood from the area. This allows the doctor to see the knee structures more clearly. The surgeon inserts an arthroscope into one of the other incisions. A camera at the end of the arthroscope transmits pictures from inside the knee to a TV monitor in the operating room. Surgical drills are inserted through other small incisions. The surgeon drills small holes into the upper and lower leg bones where these bones come close together at the knee joint. The holes form tunnels through which the graft will be anchored. If you are using your own tissue, the surgeon will make another incision in the knee and take the graft (replacement tissue). The graft is pulled through the tunnels that were drilled in the upper and lower leg bones. The surgeon secures the graft with hardware such as screws or staples and will close the incisions with stitches or tape. The knee is bandaged, and you are taken to the recovery room for 2 to 3 hours.3 Physical rehabilitation after ACL surgery may take several months to a year. The length of time until you can return to normal activities or sports is different for every person. It takes most people at least 6 months to return to activity after surgery (4). ACL reconstructive surgery remains the gold standard for repairing this common knee injury. The AAOS reports that about 82 to 90 percent of ACL reconstruction surgeries yield excellent results and full knee stability. ACL reconstruction surgery is generally safe. Complications that may arise from surgery or during rehabilitation (rehab) and recovery include following (6, 7). 0.75% (104) of the consecutive patient cohort had a wound complication recorded (5). • Problems related to the surgery itself. These are uncommon but may include:  Numbness in the surgical scar area.  Infection in the surgical incisions. 0.25% (35) underwent a further procedure to wash out the infected knee joint (5).  Damage to structures, nerves, or blood vessels around and in the knee.  Blood clots in the leg. DVT and PTE rates were 0.30% (42) and 0.18% (25) respectively with on 90 days(5)  The usual risks of anesthesia.  There were no in-hospital deaths(5) • Problems with the graft tendon (loosening, stretching, re-injury, or scar tissue). The screws that attach the graft to the leg bones may cause problems and require removal. • Limited range of motion, usually at the extremes. For example, you may not be able to completely straighten or bend your leg as far as the other leg. This is uncommon, and sometimes another surgery or manipulation under anesthesia can help. Rehab attempts to restore a range of motion between 0 degrees (straight) and 130 degrees (bent or flexion). It's important to be able to get your knee straight so you can walk normally. • Grating of the kneecap (crepitus) as it moves against the lower end of the thigh bone (femur), this may develop in people who did not have it before surgery. This may be painful and may limit your athletic performance. In rare cases, the kneecap may be fractured while the graft is being taken during surgery or from a fall onto the knee soon after surgery. • Pain, when kneeling, at the site where the tendon graft was taken from the patellar tendon or at the site on the lower leg bone (tibia) where a hamstring or patellar tendon graft is attached. • Repeat injury to the graft (just like the original ligament). Repeat surgery is more complicated and less successful than the first surgery. 1.36% (190) were readmitted to an orthopedic ward within 30 days (5)

An anal fissure is a tear or open sore (ulcer) that develops in the lining of the large intestine, near the anus. Anal fissures are quite common, with around 1 in every 10 people affected at some point in their life. They affect both sexes equally and people of all ages can get them. But children and young adults between 10 and 30 years of age are more likely to get anal fissures.[5] Anal fissure symptoms The most common symptoms of anal fissures are: • Sharp excruciating burning pain on defecation. • Minute bleeding resulting in bright red spot on feces and toilet paper Most people delay treatment because of embracement resulting in complications but a timely visit to a GP results in early recovery on conservative management. Diagnosing anal fissures Anal fissure are solely diagnose on clinical history and examination. History includes inquiry about sign and symptoms as well as bowl habits and inquiry about general health. Examination is done slightly separating the buttocks and ulcer can be visualized around anal rim under proper illumination. Digital rectal examination procedure in which your doctor will insert a gloved finger in the anus to examine in inside of the anal canal and rectum. However it is avoided because of excruciating pain that patient experience an deserve only of complicated cases and preferably done under local anesthesia to reduce pain during examination What causes anal fissures? Anal fissures are caused by damage to the anal canal lining resulting in tear and painful ulcer development most cases are caused by long standing constipation. As constipated person passes hard compact stool it can damage the anal canal lining. Other possible causes of anal fissures include: • persistent diarrhea • inflammatory bowel disease (IBD), such as Crohn's disease and ulcerative colitis ( long standing inflammatory conditions of the bowel) • pregnancy and childbirth • occasionally, a sexually transmitted infection (STI), such as syphilis or herpes, which can infect and damage the anal canal • having unusually tight anal sphincter muscles, which can increase the tension in your anal canal, making it more susceptible to tearing In many cases, no clear cause can be identified.

Indication: this procedure is used for diagnosis as well as theraputic purpose thus indication is divided into Diagnostic indication: 1) Pain, swelling, stiffness, instability of the ankel joint that remain unexplained. 2) locking and popping symptoms of ankle joint Therapeutic Indication: 1) articular or soft tissue injury. 2) soft tissue or bone impingement and instability. 3) Inflammation of lining membranes of the joint(Synovitis). 4) inflammation of tendons (tendinitis) 5) Joint infection (septic arthritis) 6) Surgical immobilization of joint (arthrodesis) 7) Adhesion inside joints (intra articular bands) Contraindication: Absolute contraindication: 1) Active local soft tissue infection. 2) Severe degenerative (Wear & tear) joint disease. 3) Poor vascular supply the leg. Relative Contraindication: 1) Moderate degenerative (wear and tear) joint disease. 2) Severe Edema (swelling). Procedure: it is usually performe when conservative measurement fails to treat the underlying condition.These includes use of pain medication like (NSAIDS), Ankle braces, heel lift or wedge Patient preparation involve history examination and blood test including CBC(complet blood count) with ESR(erythrocyte sedimentation rate) , C-reactive protein (CRP), coagulation profile , in case of infection joint aspiration is done for culture and sensitivity, radiological investigation like X-ray, Ct-scan and MRI. After proper analgesia and anesthesia either local or Regional, a blood less field is achieved by the use of the tourniquet just above the ankle or by using high inflow out flow system that also improve visualization and irrigate the debris material.Small incisions are then made for portals, which are small tubes which are placed in different area around ankle for the instruments and camera to be placed in. after that the surgeon the perform the procedure like removal of inflamed synovial membranes and debris after ankle joint soft tissue or bone injury. at the end the portals and instruments are removed and the small incisions are stitched closed and bandaged. After procedure depending upon the patient condition and surgeons choice some are allowed to bear weight with crutches while others may be placed in an immobilizer for as long as six weeks.In case of extensive surgery or remodeling ankle is put in cast to prevent early mobilization and promote healing and if arthroscopy is performed only for diagnostic purpose simple splint is enough.

Hemorrhoids or piles are swelling inside rectum or around the anus, lower parts of your digestive system, containing engorged blood vessels. (Veins) Mostly asymptomatic but when symptoms occur they include: 1. bleeding after passing a stool – the blood is usually bright red 2. itchy bottom 3. a lump hanging down outside of the anus, which may need to be pushed back in after passing a stool 4. a mucus discharge after passing a stool 5. soreness, redness and swelling around your anus These lumps are usually painless unless there blood supply is severely compromised Causes Although cause is unclear, but there is association of in blood pressure in vessels in and around the anus, when the pressure increases it cause the vessels to swell and inflamed. Most important cause of such high pressure is prolong constipation. Long term diarrhea can also increase the chances of getting hemorrhoid. Other risk factors includes 1. obesity 2. age – with advancing age body supporting tissue gets weaker resulting in hemorrhoids 3. Pregnancy – pregnancy its self exert pressure on the pelvic blood vessels thus causing them to engorge and inflamed resulting in piles 4. Family history 5. Strenuous exercises like weight lifting etc 6. persistent cough or repeated vomiting 7. prolonged sitting position Prevention of hemorrhoids Hall mark of the preventing hemorrhoids is to reduce the risk factor causing it for example pregnancy related hemorrhoid mostly gets resolved after delivery. Life style modification also reduces stress on the vessels and prevents hemorrhoids. These includes These can include: 1. increase the fiber content of food by using fruits, vegetables, whole grain rice whole wheat pasta and bread pulses beans nuts and oats 2. drinking plenty of fluids but avoiding caffeine and alcohol 3. avoid resisting the urge to defecate as it makes stool hard and then inturns exert pressure during passage through anus 4. avoiding medication causing constipation like painkillers containing codeine 5. losing weight 6. regular exercise These measures reduce the risk of having hemorrhoids treatment options are discussed below in case of severe or complicated cases. Diagnosis: Based completely on history and clinical examination. History includes inquiry about symptoms mentioned above and bowl habits and stool consistency. Examination is of two types 1. Digital Rectal Examination (DRE): using finger to feel any abnormalities in the anal canal or rectum. 2. proctoscopy: a proctoscope is a thin hollow tube with light at the end to visualize the entire anal canal. Types of hemorrhoids : Depending on location: 1. Internal hemorrhoids: in the upper 2/3 of the anal canal usually painless 2. External hemorrhoids : in the lower 1/3 of the anal canal near anus … usually painful Depending on size and severity: 1. First degree: small inside swelling of the anal lining not visible from outside 2. Second degree: slightly large swelling that come out on straining (usually defecting) and goes back it self 3. Third degree: one or more swelling that hand down from anus and can be pushed back manually(reducible) 4. Fourth degree: large lumps that can’t be pushed back ( irreducible).

A cholecystectomy is mostly performed to treat gallstones which are small stone formed for no reasons in the gallbladder consisting of cholesterol or bile salt. Risk factors include 4F i.e Female, Fertile Forty and Family (history). These stone may cause blockage of bile duct in turn causing and irritation of gallbladder resulting in sharp pain in the abdomen in the right upper quadrant associated with vomiting, indigestion and sometimes fever. Cholecystectomy is usually performed through a minimal invasive procedure known as laproscopic cholecystectomy. Open cholecystectomy is the choice of the surgeon either before or during the laproscopic cholecytectomy strictly based on patient safety. Cholecystectomy is primarily indicated in following conditions; • Stone in gall bladder (cholelithiasis) • Stone in the bile duct(choledocolithiasis) • Gallbladder calcification (porcelain gallbladder) • Inflammation of gall bladder (cholecystitis) • Inflammation of pancrease due to stone blockage (biliary pancreatitis) • Lack of movement of bilary channels (bilary dyskinesia) • Gallbladder cancer Indications for Consideration of Prophylactic Cholecystectomy • Risk factors for carcinoma.1 • Anomalous pancreatic–biliary ductal junctions.[1] • Choledochal cysts.[1] • Gallbladder adenomas.1 • Native North or South American background.2 • Porcelain gallbladder.1 • Solitary gallbladder polyp larger than 1 cm.2 Other indications • Choledocholithiasis.2 • Gallstones larger than 3 cm.2 • Patient lives in remote location from health care facility.2 • Sickle cell disease/spherocytosis.1 • Transplant or immunosuppressant therapy.2 • Young age.3 How to perform the procedure: Under general anesthesia, so the patient is asleep throughout the procedure. Using a cannula (a narrow tube-like instrument), the surgeon enters the abdomen in the area of the belly-button.A laparoscope (a tiny telescope) connected to a special camera is inserted through the cannula, giving the surgeon a magnified view of the patient’s internal organs on a television screen. Other cannulas are inserted which allow your surgeon to delicately separate the gallbladder from its attachments and then remove it through one of the openings. An X-ray called a cholangiogram may be performed during the operation to identify stones which may be lodged in the bile channels or to verify the anatomy of structures that have been identified. If the surgeon finds one or more stones in the common bile duct, he/she may remove them with a special scope, may choose to have them removed later through an endoscope placed through the mouth into the stomach using a procedure called ERCP or may convert to an open operation in order to remove all the stones during the operation.After the surgeon removes the gallbladder, the small incisions are closed with absorbable stitches or with surgical tape or glue.

A splenectomy is removal of the spleen. It is usually needed to treat blood disorders, injury to the spleen from trauma, or when the spleen becomes too pig. The surgery is done under general anaesthetic and can be either keyhole or open. Short term complications that can happen are bleeding, injury to nearby organs, and infection of the surgical scar. The biggest long-term complication is infection, as the spleen is not there anymore to develop immune cells. Vaccination should be given beforehand, and antibiotics should be given after to lower the risk of getting an infection.