Surgical Correction of Clawtoe Deformity Following Harvesting of Vascularized Fibula Graft

Introduction: Complications following the harvesting of free vascularized fibula grafts (FVFG) are rare. We present our results on patients who developed claw deformity of the great and lesser toes. We discuss the etiology of clawtoe deformity and the surgical correction of this condition.

Methodology and Material: Between 1980 and 2013 we performed 167 fibular grafts at our institution. Nine patients developed clawtoe deformity in the donor side foot after the harvesting of FVFG. They comprised 6 males and three females with an average age of 32 years (range 6-72 years). The affected toes in 8 patients were 1 and 2, or 1, 2 and 3. All toes were affected in the remaining patient. Four patients underwent z-lengthening of the flexor hallucis longus at the medial malleolus of the ankle, while 4 underwent cutting of the tendons. Remaining one patient did not hope to undergo surgery. The average time period between harvesting of FVFG and the occurrence of clawtoe deformity was 3.2 months (range 2-6 months) and the average follow-up time was 31 months (range 5-47 months).

Results: Claw deformity of affected toes was successfully corrected in all patients by release of the flexor hallucis longus. Full extension of the affected toes was achieved by the time of final follow-up. Flexion of the interphangeal joint was preserved in all patients except one who underwent cutting of the tendon beneath the metatarsophalangeal joint.

Conclusions: Lengthening or cutting of the flexor hallucis longus tendon at the medial malleolus successfully corrects clawtoe deformity following the harvesting of FVFG. Even after cutting the tendon, flexion of the great toe is possible by interconnection with the flexor digitorum longus tendon.