Factors Associated With Claw Toe Deformity Following Vascularized Fibula Flap Harvesting: A Retrospective Analysis of Potential Risk Factors and Preventive Strategies

Abstract

Background

Claw toe deformity at the donor site is a complication following vascularized fibula flap surgery. Despite its potential to necessitate further surgery, the factors contributing to this complication are not well understood. Therefore, this study aimed to identify factors associated with this complication and propose potential preventive strategies.

Patients and Methods

This retrospective study analyzed 40 cases of vascularized fibula flap harvesting conducted between 2010 and 2022. The presence of claw toe deformity was evaluated, and various patient and surgical factors were analyzed. Postoperative magnetic resonance imaging (MRI) and intraoperative indocyanine green angiography images were also assessed.

Results

Claw toe deformity was observed in 25% of patients, with a significantly higher incidence among those undergoing primary wound closure (p = 0.018). Age (p = 0.595), body mass index (p = 0.482), smoking status (p = 0.157), diabetes (p = 0.556), peripheral arterial disease (p > 0.999), preoperative chemotherapy (p = 0.715), operative time (p = 0.080), harvested fibula length (p = 0.981), skin paddle size (p = 0.695), and horizontal width of skin flap (p = 0.906) were not significantly associated with claw toe deformity. The cutoff values for primary wound closure were identified as a skin flap horizontal width of 3.5 cm and a horizontal width-to-circumference ratio of 10.4%. MRI revealed signal changes in the flexor hallucis longus on T2-weighted images in all six cases with claw toe deformity and in 6 of the 12 cases without deformity. Indocyanine green angiography revealed ischemia in the flexor hallucis longus in all six examined cases; however, four of these cases did not develop claw toe deformity.

Conclusion

This study emphasizes the importance of the wound closure method and skin flap size in primary closure for preventing claw toe deformity after vascularized fibula flap procedures. These findings may contribute to improved postoperative outcomes.