JBJS | Treatment of Extrinsic Flexion Deformity of the Toes Associated with Previous Removal of a Vascularized Fibular Graft*

The Journal of Bone & Joint Surgery, Volume 82, Issue 1

Articles | January 01, 2000

Treatment of Extrinsic Flexion Deformity of the Toes Associated with Previous Removal of a Vascularized Fibular Graft*

YOSHINORI TAKAKURA, M.D.†; HIROSHI YAJIMA, M.D.†; YASUHITO TANAKA, M.D.†; TAKESHI KOMEDA, M.D.†; SUSUMU TAMAI, M.D.†, NARA, JAPAN

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Investigation performed at the Department of Orthopaedic Surgery, Nara Medical University, Nara

The Journal of Bone & Joint Surgery. 2000; 82:58-61

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Abstract

Background: Complications from vascularized fibular bone-grafting are infrequent. We saw six patients who had a painful flexion deformity of the great and lesser toes after a free vascularized fibular graft had been obtained from the ipsilateral leg. In this report, we discuss our management of these patients.

Methods: Painful flexion deformity of the toes that had developed in six adults after removal of a free vascularized fibular graft was treated by cutting of the flexor hallucis longus alone in three patients, by lengthening of the flexor hallucis longus alone in one, and by cutting of both the flexor hallucis longus and the flexor digitorum longus in two.

Results: After an average duration of follow-up of six years and eleven months, the flexion deformity of the great and lesser toes had decreased or disappeared, leading to improved or full extension of the digits. Preoperative and postoperative measurements of muscle strength for plantar flexion of the interphalangeal joints did not change appreciably.

Conclusions: Cutting or lengthening of the flexor hallucis longus behind the ankle provides an adequate release of digital flexion deformities that occur after removal of a vascularized fibular bone graft.

Figures in this Article

Introduction

Introduction | Materials and Methods | Results | Discussion | References

Flexion contracture of the toes may be caused by a wide variety of neurological diseases, such as cerebral palsy and Charcot-Marie-Tooth disease, and it can also result from compartment syndrome of the leg^{3,4,6,10,12,13,15}. To the best of our knowledge, our 1994 report of claw toe that developed in five patients following trauma to the leg was the first report of such a finding¹⁷. As far as we know, there has been, since then, one case report of a claw-toe deformity of the great toe caused by entrapment following a bimalleolar fracture of the tibia and the fibula¹⁰ and one report of two cases of claw-toe deformity following vascularized fibular grafting¹. Since our initial study, we have managed six patients in whom flexion deformity of the toes developed after the removal of a free vascularized fibular graft. The present report describes these patients and discusses treatment of the flexion deformities.

*No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. No funds were received in support of this study.

†Department of Orthopaedic Surgery, Nara Medical University, Kashihara, Nara 634-8522, Japan. E-mail address for Dr. Takakura: takanori@sikasenbey.or.jp.

*No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. No funds were received in support of this study.

†Department of Orthopaedic Surgery, Nara Medical University, Kashihara, Nara 634-8522, Japan. E-mail address for Dr. Takakura: takanori@sikasenbey.or.jp.

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FIG1-A:: Figs. 1-A, 1-B, and 1-C: Case 3, a thirty-five-year-old man with flexion deformity of the great, second, and third toes of the left foot that had developed fourteen months following removal of a vascularized fibular graft from the ipsilateral leg. The deformity was corrected by cutting of the flexor hallucis longus. Fig. 1-A: Preoperative photograph of the foot with the ankle in the neutral position, showing the flexion deformity affecting not only the great toe but also the second and third toes.

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FIG1-B:: Fig. 1-B: Preoperative photograph of the foot with the ankle in plantar flexion, showing reduction of the flexion deformity of the toes.

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FIG1-C:: Fig. 1-C: Photograph of the foot with the ankle in the neutral position, made three months postoperatively, showing complete hyperextension of the great toe and lesser toes. The operative wound (arrow) is seen posterior to the medial malleolus.

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TABLE I: DATA ON THE PATIENTS

Case

Gender, Age (yrs.)

Donor Side

Initial Injury or Disease

Duration Between Removal of Graft and Index Op. (mos.)

Method of Treatment

Duration of Follow-up (mos.)

Passive Range of Motion of First Interphalangeal Joint (Dorsiflexion/ Plantar Flexion) (degrees)

Toes Involved by Flexion Deformity

Strength of Flexor Hallucis Longus^7,14(grade)

Preop.

Postop.

Preop.

Postop.

Preop.

Postop.

M, 42

Open fract. of leg, skin defect

Flexor hallucislongus and flexor digitorum longus cut

134

-60/60(contracture)

-5/65

1, 2, 3, 4, 5

2, 3

M, 44

Chondro- sarcoma of femur

Flexor hallucislongus lengthened

-40/45

0/55

1, 2, 3

None

M, 35

Osteomyelitis of femur

Flexor hallucislongus cut

-50/55

0/60

1, 2, 3

None

F, 57

Incomplete amputaton of leg

Flexor hallucislongus and flexor digitorum longus cut

-50/50(contracture)

0/55

1, 2, 3, 4, 5

None

F, 19

Osteomyelitis of tibia

Flexor hallucislongus cut

-55/55(contracture)

-5/55

1, 2, 3, 4, 5

2, 3

M, 47

Necrosis of femoral head

Flexor hallucislongus cut

-55/55(contracture)

0/60

1, 2, 3, 4

None

Mean

41 ± 12.8

14 ± 5.8

83 ± 35.4

-52 ± 6.8/ 53 ± 5.2

-2 ± 2.6/ 58 ± 4.1

2.7 ± 0.5

2.5 ± 0.5

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TABLE I: DATA ON THE PATIENTS

Case

Gender, Age (yrs.)

Donor Side

Initial Injury or Disease

Duration Between Removal of Graft and Index Op. (mos.)

Method of Treatment

Duration of Follow-up (mos.)

Passive Range of Motion of First Interphalangeal Joint (Dorsiflexion/ Plantar Flexion) (degrees)

Toes Involved by Flexion Deformity

Strength of Flexor Hallucis Longus^7,14(grade)

Preop.

Postop.

Preop.

Postop.

Preop.

Postop.

M, 42

Open fract. of leg, skin defect

Flexor hallucislongus and flexor digitorum longus cut

134

-60/60(contracture)

-5/65

1, 2, 3, 4, 5

2, 3

M, 44

Chondro- sarcoma of femur

Flexor hallucislongus lengthened

-40/45

0/55

1, 2, 3

None

M, 35

Osteomyelitis of femur

Flexor hallucislongus cut

-50/55

0/60

1, 2, 3

None

F, 57

Incomplete amputaton of leg

Flexor hallucislongus and flexor digitorum longus cut

-50/50(contracture)

0/55

1, 2, 3, 4, 5

None

F, 19

Osteomyelitis of tibia

Flexor hallucislongus cut

-55/55(contracture)

-5/55

1, 2, 3, 4, 5

2, 3

M, 47

Necrosis of femoral head

Flexor hallucislongus cut

-55/55(contracture)

0/60

1, 2, 3, 4

None

Mean

41 ± 12.8

14 ± 5.8

83 ± 35.4

-52 ± 6.8/ 53 ± 5.2

-2 ± 2.6/ 58 ± 4.1

2.7 ± 0.5

2.5 ± 0.5

Materials and Methods

Introduction | Materials and Methods | Results | Discussion | References

At our institution, between January 1976 and December 1997, 185 patients had removal of a vascularized fibular graft to treat a variety of problems. Flexion deformity of the toes developed on the donor side in six (3 percent) of these patients. The deformity developed quickly, at a mean of 4.6 weeks (range, 3.0 to 6.4 weeks) after removal of the graft, and it did not respond to a program of active and passive stretching exercises. In all patients, the flexion deformity became more evident with full dorsiflexion of the ankle, and it could not be corrected passively with the ankle in the neutral position (Fig. 1-A). During plantar flexion of the ankle, the deformity disappeared in two patients and was reduced substantially in four (Fig. 1-B). The deformity of the great toe could be corrected passively with the ankle in full plantar flexion in all patients. The flexion deformity affected the great toe in every patient; the second and third toes in two patients; the second, third, and fourth toes in one patient; and all of the lesser toes in three patients (Table I). Each patient had pain because of the toe rubbing against the shoe in the region of the interphalangeal joint of the great toe or the proximal interphalangeal joint of the lesser toes during standing and walking. One patient had a painful corn in the region of the interphalangeal joint of the great toe. The corn resolved two months after the operation. No other deformity, such as pes equinus or pes cavus, was present in any of the feet.

Muscle strength in plantar flexion was measured preoperatively and postoperatively with use of a conventional manual muscle-testing method. The strength was categorized as grade 5 if it was normal or excellent (100 percent), grade 4 if it was good (75 percent), grade 3 if it was fair (50 percent), grade 2 if it was poor (25 percent), grade 1 if it was trace (10 percent), and grade 0 if it was absent (0 percent)^7,14. The passive range of motion of the interphalangeal joint of the great toe was measured with the ankle held in the neutral position before and after the operation.

The length of time between removal of the vascularized fibular graft and the operation to correct the flexion deformity ranged from four months to one year and nine months, with an average of fourteen months (Table I).

The paired t test was used to compare the preoperative and postoperative findings.

Operative Procedure

A slightly curved skin incision was made posterior to the medial malleolus (Fig. 1-C), and the neurovascular bundle was retracted to expose the flexor hallucis longus tendon. Initially, adhesions of the flexor hallucis longus were released, but this did not improve the passive range of motion of the digits in any patient. Consequently, the flexor hallucis longus was lengthened (if the deformity had been present for six months or less) or cut (if the deformity had been present for more than six months) in the region of the posterior process of the talus. When lengthening or cutting of the flexor hallucis longus sufficiently corrected the flexion deformity of the great toe and the affected lesser toes, the flexor digitorum longus was left untouched. However, in two patients, the flexion deformity of the lesser toes persisted after the release of the flexor hallucis longus; the flexor digitorum longus was then cut adjacent to the medial malleolus. Thus, the flexor hallucis longus alone was lengthened in one patient, the flexor hallucis longus alone was cut in three, and both the flexor hallucis longus and the flexor digitorum longus were cut in two (Table I).

Results

Introduction | Materials and Methods | Results | Discussion | References

Preoperatively, the flexion contracture of the interphalangeal joint of the great toe ranged from 40 to 60 degrees. Four of the six patients had a fixed deformity of the interphalangeal joint before the operation, and two had 5 degrees of joint motion (Table I). With the patient under anesthesia and after the releases were performed, the flexion deformity was corrected completely. However, after awakening from the anesthesia, three of the patients had a slight deformity of the great toe, which gradually decreased with weight-bearing and walking until it had completely disappeared by three months postoperatively.

The postoperative follow-up period ranged from two years and one month to eleven years and two months, with an average of six years and eleven months. After the operation, the flexion deformity of the interphalangeal joint of the great toe decreased in all six patients. The mean passive range of motion of the interphalangeal joint with the ankle in the neutral position improved from 2 ± 2.6 degrees preoperatively to 57 ± 4.1 degrees postoperatively (p < 0.001). The mean dorsiflexion of the interphalangeal joint improved from -52 ± 6.8 degrees preoperatively to -2 ± 2.6 degrees postoperatively (p < 0.001). The mean passive plantar flexion of the interphalangeal joint measured 53 ± 5.2 degrees preoperatively and 58 ± 4.1 degrees postoperatively (p < 0.05). The improved dorsiflexion arc reflects a change from a flexed position before the operation to the neutral position after the operation.

The flexion deformity of the lesser toes also decreased in all patients, although a slight deformity persisted for as long as three months in two patients and two patients had a persistent flexion deformity of the lesser toes.

Overall, the operation led to a decrease in the deformity in all of the patients; all were very satisfied with the operative result.

Discussion

Introduction | Materials and Methods | Results | Discussion | References

Few complications have been reported after the removal of the fibula for use as a vascularized graft, which is an increasingly common procedure in orthopaedic surgery. To our knowledge, Taylor et al.¹⁸ reported, in 1975, on the first two patients who were managed with a free vascularized fibular graft. They noted isolated weakness of the extensor hallucis longus in both patients. The etiology of the weakness was believed to be an injury to the peroneal nerve at the time that the fibula was removed. Lee et al.⁹ reported on ten adults who had been managed with a free vascularized fibular graft, and they noted that three of the ten had weakness of flexion of the great toe; however, they noted no cases of flexion deformity. In contrast, Han et al.⁵ reported that three of their 132 patients who had been managed with a vascularized fibular graft had an isolated contracture of the flexor hallucis longus. In the present study, the flexion deformity always involved the first, second, and third toes and sometimes involved the other lesser toes. The deformity became evident three to six and one-half weeks postoperatively and could not be corrected passively when the ankle was held in neutral or dorsiflexion. The deformity disappeared, and the toes could be extended passively to neutral during plantar flexion of the ankle. We believe that this flexion deformity was caused by a deficiency of elasticity attributable to adhesion of the muscle of the flexor hallucis longus in the leg. The location and morphology of the flexor hallucis longus muscle within the deep posterior compartment make it susceptible to ischemia. Furthermore, the flexor hallucis longus tends to be more strongly affected by an ischemic change than other muscles within this compartment of the leg¹⁶.

Bohay and Manoli¹ reported two cases of multiple claw-toe deformity following ipsilateral removal of a free vascularized fibular graft. The deformity was treated effectively with flexor tenotomy at the level of the proximal interphalangeal joint. Despite the apparent involvement of both the flexor hallucis longus and the flexor digitorum longus in creating the deformity, we obtained a good result in four patients simply by cutting or lengthening the flexor hallucis longus behind the ankle. This improvement probably occurred because the flexor hallucis longus branches out in the sole of the foot to connect to the flexor digitorum longus^2,4,8,11,17. According to most anatomical studies^2,3,11, the flexor hallucis longus branches out not only to the second and third toes but also to the fourth and fifth toes. In fact, it is extremely rare for the flexor hallucis longus not to branch at all.

We postulate that the mild recurrent deformity seen during the first three months after the operation in some of our patients may have been due to some degree of contracture of the intrinsic muscles related to the long-time contracture of the flexor hallucis longus.

In the current series, cutting or lengthening of the flexor hallucis longus alone was not sufficient to correct the deformity in two patients. This was probably due to adhesions or contracture of the flexor digitorum longus within the compartment. Cutting or lengthening of the flexor hallucis longus or cutting of both the flexor digitorum longus and the flexor hallucis longus did not seem to further weaken the power of plantar flexion in five of our six patients, perhaps because the patients had been relying on the intrinsic muscles to flex the toes.

Cutting or lengthening of the flexor hallucis longus alone (or occasionally cutting of both the flexor hallucis longus and the flexor digitorum longus) at the level of the ankle joint provided adequate release of a flexion deformity of the great and lesser toes that had resulted from removal of a free vascularized fibular graft in our small group of patients.

References

Introduction | Materials and Methods | Results | Discussion | References

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Chuinard, E. G., and Baskin, M.: Claw-foot deformity. Treatment by transfer of the long extensors into the metatarsals and fusion of the interphalangeal joints. J. Bone and Joint Surg.,55-A: 351-362, March 1973.55-A351 1973

Hamza, K. N., and Murray, C. M. M.: Fractures of the tibia. A report on fifty patients treated by intramedullary nailing. J. Bone and Joint Surg.,53-B(4): 696-700, 1971.53-B(4)696 1971

Han, C.-S.; Wood, M. B.; Bishop, A. T.; and Cooney, W. P., III: Vascularized bone transfer. J. Bone and Joint Surg.,74-A: 1441-1449, Dec. 1992.74-A1441 1992

Horne, G.: Pes cavovarus following ankle fracture. A case report. Clin. Orthop.,184: 249-250, 1984.184249 1984 [PubMed]

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Kawashima, T.; Kitagawa, T.; and Goto, H.: [The constitution of the flexor hallucis longus.]. Nichidai-ishi,19: 2545-2556, 1960.192545 1960

Lee, E. H.; Goh, J. C. H.; Helm, R.; and Pho, R. W. H.: Donor site morbidity following resection of the fibula. J. Bone and Joint Surg.,72-B(1): 129-131, 1990.72-B(1)129 1990

Leitschuh, P. H.; Zimmerman, J. P.; Uhorchak, J. M.; Arciero, R. A.; and Bowser, L.: Hallux flexion deformity secondary to entrapment of the flexor hallucis longus tendon after fibular fracture. Foot and Ankle Internat.,16: 232-235, 1995.16232 1995

Loth, E.: Beiträge zur Anthropologie der Negerweichteile (Muskelsystem), pp. 208-229. Stuttgart, Strecker and Schröder, 1912.

Matsen, F. A., III, and Clawson, D. K.: The deep posterior compartmental syndrome of the leg. J. Bone and Joint Surg.,57-A: 34-39, Jan. 1975.57-A34 1975

Owen, R., and Tsimboukis, B.: Ischaemia complicating closed tibial and fibular shaft fractures. J. Bone and Joint Surg.,49-B(2): 268-275, 1967.49-B(2)268 1967

Perry, J.; Fontaine, J. D.; and Mulroy, S.: Findings in post-poliomyelitis syndrome. Weakness of muscles of the calf as a source of late pain and fatigue of muscles of the thigh after poliomyelitis. J. Bone and Joint Surg.,77-A: 1148-1153, Aug. 1995.77-A1148 1995

Rorabeck, C. H., and Macnab, I.: The pathophysiology of the anterior tibial compartmental syndrome. Clin. Orthop.,113: 52-57, 1975.11352 1975 [PubMed]

Seddon, H. J.: Volkmann's ischaemia in the lower limb. J. Bone and Joint Surg.,48-B(4): 627-636, 1966.48-B(4)627 1966

Takakura, Y.; Maeda, M.; and Tamai, S.: Post-traumatic claw toe deformity due to a malfunction of the flexor hallucis longus. Foot Dis.,1: 43-49, 1994.143 1994

Taylor, G. I.; Miller, G. D.; and Ham, F. J.: The free vascularized bone graft. A clinical extension of microvascular techniques. Plast. and Reconstr. Surg.,55: 533-544, 1975.55533 1975

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