Transfer of ipsilateral fibula on vascular pedicle for treatment of congenital pseudarthrosis of the tibia.

BACKGROUND: Although the use of free vascularized fibula grafts has frequently been reported in the treatment of congenital pseudarthrosis of the tibia, the use of ipsilateral fibula graft on a vascular pedicle is uncommon. We reviewed the long-term results of this procedure in 11 patients. METHODS: The records of 11 patients who underwent transfer of the ipsilateral fibula on a vascular pedicle between 2.1 and 10.8 years of age were retrospectively reviewed. Average follow-up was 11 years after the index procedure. Seven patients had reached skeletal maturity. Clinical records and radiographs were reviewed to determine patient demographics, surgical parameters, union rate, refracture rate, residual deformity, and functional outcome. RESULTS: Eight patients (73%) achieved union at an average of 20.1 months. Additional bone grafting procedures were required in 4 patients with distal nonunions. There were 3 refractures (38%). Four patients eventually underwent amputation, and 1 patient had a persistent nonunion at final follow-up. Residual deformity included tibial valgus and procurvatum deformities, limb length discrepancy, and ankle valgus. Use of the ipsilateral fibula did not seem to increase the risk of ankle valgus. Functional outcomes were good in all but one patient. CONCLUSIONS: Use of the ipsilateral fibula as a pedicle graft provides reasonable results in healing congenital pseudarthrosis of the tibia. Patients should be monitored for the sequelae of this condition, including nonunion, refracture, shortening, and angular deformity, and treated accordingly. LEVEL OF EVIDENCE: Therapeutic Level IV.

Here's my phone number, don't call me: physician accessibility in the cell phone and e-mail era.

Physician accessibility, for example how available a doctor should be by cell phone or e-mail is an important issue that is not well understood. There can be large differences between the expectations of patients and the perspective of their providers. The rationale for providing accessibility has historical roots and relates to the very basis of the physician-patient relationship and the effects on patient outcomes. While patients may want this line of communication, physicians may worry about disruption from unexpected phone calls, being requested to provide advice without access to records and providing services without adequate remuneration among other concerns. Herein, we discuss the rationale for these concerns, and provide suggestions on how we might overcome them. We suggest a framework with guidelines on establishing and maintaining remote accessibility with patients in the context of a productive physician-patient relationship.

Variations of the flexor digitorum superficialis as determined by an expanded clinical examination.

PURPOSE: Current examination techniques do not detect the wide clinical variability of the flexor digitorum superficialis (FDS). Modification of current examination techniques may be necessary to detect anomalies and lead to more accurate diagnosis. We examined 500 subjects using an expansion of current techniques to elicit the range of variations in FDS function discernable on clinical examination. METHODS: FDS function was evaluated by asking subjects to flex the finger of interest while all other fingers were held fully extended at the metacarpophalangeal and interphalangeal joints. Isolated flexion at the proximal interphalangeal (PIP) joint indicated independent FDS function. Obligatory flexion at the distal interphalangeal (DIP) joint indicated flexor digitorum profundus (FDP) activity. Because FDS activity could not be evaluated if concurrent FDP activity was present, these fingers were designated as having FDP substitution. Difficulty isolating PIP joint flexion suggested connections to adjacent FDS or FDP, prompting the examiner to serially release adjacent fingers while observing for improvement in PIP or DIP range of motion. RESULTS: Independent FDS function was most consistently present in the ring and middle fingers, less so in the index finger, and least in the small finger. Variations included FDP substitution or connections to flexor tendons in 1 or 2 adjacent fingers with or without evidence of FDP substitution. Absent FDS function cannot be presumed in any subject based solely on clinical examination of a single digit. CONCLUSIONS: Current examination techniques are inadequate to discern among the multiple variations of FDS function. An expanded examination technique is recommended for accurate diagnosis of FDS function following flexor tendon injury.