Anal fistula can be a challenging condition to manage, with complex fistulas presenting even greater difficulties. The primary concerns in treating this condition are a risk of damage to the anal sphincters, which can compromise fecal continence, and refractoriness to treatment, as evidenced by a high recurrence rate. Furthermore, the treatment of complex anal fistula involves several additional challenges. Satisfactory solutions to many of these obstacles remain elusive, and no consensus has been established regarding the available treatment options. In summary, complex anal fistula has no established gold-standard treatment, and the quest for effective therapies continues. This review discusses and highlights groundbreaking advances in the management of complex anal fistula over the past decade.

OBJECTIVEFractures of the capitellum and trochlea constitute less than 1% of all elbow fractures and a shear fracture involving the capitellum and extending medially into most of the trochlea is rarely reported. Type IV capitellum fracture is still controversial in regard to its radiographic appearance, surgical approach and osteosynthesis. We report 10 cases of type IV capitellum fracture with a view to elucidating its clinical features and treatment outcome.

METHODSWe treated 10 patients of type IV capitellum fracture with a mean age of 32 years. A uniform surgical approach and postoperative rehabilitation were followed.

RESULTSNine patients presented to us after a mean of 4 days of injury and one patient was nonunion after 6 months of injury who had been treated conservatively by a bone setter. Double arc sign was absent in 6 cases. Intraoperatively 6 capitellotrochlear fragments were devoid of soft tissue attachments. By Mayo Elbow Performance Score evaluation, 7 patients got excellent, 2 good and 1 fair results. One patient with associated elbow dislocation developed heterotopic ossification. There was no case of avascular necrosis, osteoarthrosis or fixation failures.

CONCLUSIONSType IV capitellum fractures are rare and belong to complex articular injuries. A good functional outcome can only be achieved with open reduction and stable internal fixation followed by early mobilization. Preoperative radiographic assessment and computed tomography help surgeons in choosing the right surgical approach and implants. Good surgical technique and stable internal fixation are the keys to early mobilization and good functional outcome.

Purpose: Complex anal fistulas can recur after clinical healing, even after a long interval which leads to significant anxiety. Also, ascertaining the efficacy of any new treatment procedure becomes difficult and takes several years. We prospectively analyzed the validity of Garg scoring system (GSS) to predict long-term fistula healing. Methods: In patients operated for cryptoglandular anal fistulas, magnetic resonance imaging was performed preoperatively and at 3 months postoperatively to assess fistula healing. Scores as per the GSS were calculated for each patient at 3 months postoperatively and correlated with long-term healing to check the accuracy of the scoring system. Results: Fifty-seven patients were enrolled, but 50 were finally included (7 were excluded). These 50 patients (age, 41.2±12.4 years; 46 men) were followed up for 12 to 20 months (median, 17 months). Forty-seven patients (94.0%) had complex fistulas, 28 (56.0%) had recurrent fistulas, 48 (96.0%) had multiple tracts, 20 (40.0%) had horseshoe tracts, 15 (32.0%) had associated abscesses, 5 (10.0%) were suprasphincteric, and 8 (16.0%) were supralevator fistulas. The GSS could accurately predict long-term healing (high positive predictive value, 31 of 31 [100%]) but was not very accurate in predicting nonhealing (negative predictive value, 15 of 19 [78.9%]). The sensitivity in predicting healing was 31 of 35 (88.6%). Conclusion GSS accurately predicts long-term fistula with a high positive predictive value (100%) but is less accurate in predicting nonhealing. This scoring system can help allay anxiety in patients and facilitate the early validation of innovative procedures for anal fistulas.