Each Clubfoot is Different, Mother of All Clubfoot Innovations (An Incredible Unity in Diversity, with Cure-All, Fusion 4-in-1 Surgical Concept)

Background: Author published a comprehensive research article on trimorphic extreme clubfoot deformities [1], offering, all-inclusive, triple/ quadruple surgical techniques, a far reaching solution, which received tremendous Global attention. This generic name (trimorphic extreme clubfoot deformities) was given, by the author, to scores of brand names in literature, reporting 95% failures post-surgeries with contemporary techniques. “Each Clubfoot Is Different” an important discovery therein, was prominently considered, for grading of results, any bony fusion and improving the patient’s psycho-physico-socio-economics, helping indirectly their countries economy. The research in this entity is unending, each being different, therefore increasing awareness highly important. This will increase the demand for these surgeries and thereby a need for learning these comprehensive techniques through available internet channels and setting things going. Conjoint Posterior


Introduction
Global response. This research had been carried out in trimorphic deformities (a new name), with its equally matchless, infallible, surgical solution. To recapitulate 2018 article briefly, clubfoot remained unsolved, in spite of vast literature, with high prevalence rate of 95% failures, in neglected deformities with scores of brand names and no acceptable surgical solution [2][3][4]. Author researched this grey area in, need based, three phases, clustering all such brand names as trimorphic extreme deformities (three hierarchic grades), with an aim to improve upon contemporary surgical techniques. Posteromedial 3D skin contractures, in increasing severity, were discovered as the reasons for universal failures, which were corrected by all-inclusive, innovative, graded, expansion of fasciocutaneous chamber for increasingly severe/ rigid deformities.
First phase, in two stages, was the longest and continued for 25-30 years, including years of building a strong foundation of critical analysis of prevalent failures in literature. 1 st stage was study of patho-anatomy, in 15 clubfeet of stillborn foetuses, published 1981 [5], discovering skin contracture as primary cause, reinforced by years of clinical observations. Second stage was a successful clinical study of 100, grade 1, extreme deformities, treated by DOrso Lateral Rotation skin flap (DOLAR technique -an acronym) 1987 [6].
Second phase continued for about 10-15 years, in grade 2 deformities in older children, requiring more skin expansion, adding Z-plasty also in Rotation flap, in the same incision, as 2-in-1 incision. This was named as DOLARZ technique [7].
Third phase, still continuing, in grade 3 deformities, are mostly adolescents/ adults, requiring even more skin expansion, adding VY-plasty also in the same incision, as 3-in-1 incision, named DOLARZ-E,. E means extended, because it is not only VY-plasty, but extended too many other skin procedures used and described later in surgical steps. For still more expansion, fourth plastic surgery procedure i.e. fillet flap was also added in same incision, as 4-in-1, for correcting World's First, Octopus Clubfoot (a new name), published [1,8].
Third phase has been the most significant, opening floodgates with unending new research possibilities. An unbelievable revelation, Mother of all discoveries/ inventions, i.e. "Each Clubfoot is Different" also emerged in this phase. An equally incredible realization of their infallible, all-inclusive 4-in1 treatment protocol, also unfolded, which was stamped as a universal surgical concept, with an unparalleled Unity in Diversity. This firm assertion was a flashback on rediscovery of excellent correction in 2016 of Octopus Clubfoot [9], World's First and most extreme Clubfoot deformity in 18 years old female. If this can be corrected, then any and every other must also be correctible. This exotic patient had good media coverage: an interview by London UK media at Link: "dailymail. co.uk/health octopus clubfoot", https://www.hindustantimes. com/punjab/girl-with-eight-toes"; and Asian Age "Indian teen born with deformed foot can finally wear shoes www.asianage.com/ newsmakers/180617/indian-teen", viral on Google search.

Material and Methods
Evolution of 4-IN-1 Concept: This has been an evidence based research, since over 50 years. Firm evidence is derived from National and International plastic surgery literature [10][11][12][13][14][15][16][17][18][19][20][21][22] of cadaveric dissections, animal experiments and clinical experience. There is extensive vascular and lymphatic microcirculation, in the subfascial and suprafascial planes, with countless perforators arising from the deepest to most superficial planes. This was convincing enough for phased unification of the four plastic surgery procedures for MEGA skin expansion, as needed, in extreme deformities. One must remain outside in suprafascial plane, avoiding injury to perforators. Considering the site and size of gaps, distal based VY island flaps of various sizes, are designed in the same incision; in front, below or behind the medial malleolus. When old surgical scars are present, there may occasionally be marginal necrosis, without affecting the correction of deformity, due to extremely good vascular network of collaterals by perforators.

Each clubfoot is different
This is an evidence based new concept, mentioned briefly in SICOT Publication and with some more detail in author's book. More differently innovative thoughts have been added during the last about two years. Each clubfoot is different with countless variables, even in the same patient with increasing age. With endless variations, it will be more appropriate to call it clubfoot disease: Classification: These differences are multifactorial, modified by static and dynamic influences, working throughout life. Dynamic factors work through foot/ leg muscles and physical activity, modifying static factors throughout life. Both these are primary in uncorrected virgin deformities. Secondary factors get added with conservative and surgical treatments. For better understanding, a comprehensive classification has been proposed:

A.
At Birth: the usual four components of deformity, e.g. equinus, adduction, inversion and cavus are different in every case. Foot being a multi-arthrodial structure, there is coupling effects with unlimited combinations, at different ages. a) Equinus: Traditionally equinus is defined as plantarflexion of foot at ankle only, while mid-foot plantar-flexion is called cavus and at toes it is called plantarflexion at distal foot. There is no mention of heel (calcaneal) plantar flexion. Equinus, being a plantar-flexion movement, it should include heel plantar-flexion, cavus and toes flexion also. Author viewed all these, as part of equinus for better surgical management.

Copyright © Mittal RL
OPROJ.000655. 7(1).2020 b) Adduction; varyingly at tarsals, metatarsals and even toes, typically in first metatarsal, quite often in others, 2 nd to 5 th metatarsals. c) Inversion; from a few degrees to 180 degrees. d) Cock-up Deformity of big toe; often present in association with extreme medial cavus with fall of 1 st metatarsal head and hyperextended big toe, sometimes in other toes also. B.
Weight bearing effect: directly proportional to deforming elements.

C.
Weight of the patient & duration of weight bearingdirectly related.
D. Amount of physical activity-directly related.

E.
Previous treatment: conservative and surgical. Deformity increases with more scars.

F.
Effect of age-Deformity keeps increasing with age, making correction more difficult.
H. Radiological variations in inter-osseous relationships in every case with age.

I.
Other congenital defects in foot or other parts e.g. triple plus dislocation, hammer toe; shortening 4 th toe; coalitions; AGMC; polydactyly; hallux varus including varus in other digits as pandigitus varus. ; unusual congenital skin contractures; congenital constriction bands; genu varum, valgum and windswipe deformity; shortening and/ or hypoplasia of lower limb ( Figure 2).   a) Delayed milestones-Standing and walking age is delayed, directly proportional to severity of deformity, being more delayed in bilateral than unilateral deformities. b) Psycho-physico-socio-economic handicap: Awkward gait, low or no earning, marital problems of difficulty in match finding/after effects; Inferiority complex; c) Painful walking due to inflamed Bursa, bunion, ulcer, painful plantar horn and limping. h) Post trauma to leg: compartment syndrome, ischaemia and increased deformity; Crush injury in congenital clubfoot leading to unstable scar and increased deformity. All these have been seen by the author, treated and published [1,8]. L.
Post-operative clinical and radiological pictures. A good clinical correction can have radiological under-correction and vice versa. M. Assessment protocols; with myriad variables, none of the popular assessment protocols could be applicable, unless the number of variables are within manageable limits as described by their proponents, which is unlikely. Patient satisfaction level is the best assessment criteris of surgical results.
N. Unforeseen and yet to be discovered in future, as each clubfoot is different.
Each deformity is a separate entity, requiring individual assessment and treatment planning, without a copy paste attitude.

Surgical steps
There are scores of surgical steps needed to correct extreme deformities. The usual surgical steps needed in a virgin uncorrected deformity are summed up as an extensive PMPDLR. However, other steps, needed sometimes, are also described, details varying in the wider trimorphic domain.

Skin incision
For Grade 1, it is a dorsolateral Rotation skin flap (DOLAR) as a single procedure, or as 2-in-1 i.e. DOLAR + Z-plasty on the medial side in Grade 2, (one or more Zs). In grade 3, VY-plasty is added (3-in-1) and occasionally fillet flap can be added as 4-in-1 [1] in any appropriate case. Many times decision has to be taken at the operation table itself. Besides the four plastic surgery procedures, many other skin procedures have been used, for correcting diverse rigid deformities, especially when old scars are excised and wound closure is not possible; these are: proximal relaxing incision, one or more lazy z or v to lengthen skin, Thiersch grafts for minor skin defects, double VY-plasties: either side by side or above and below, circular Z-plasties in CCBs in 4 sections; separate VY-plasties; a distal medial one to correct hallux varus, dorsal for hyperextended toes and plantar for hammer toes.

Muscles & tendons releases
Abductor hallucis, Steindler's, tibialis posterior insertions; FHL & FDP at Henry's knot releases, Z-lengthening of distal heel cord or proximal in case of distal scar, lengthening of tibialis anterior or extensor halluces longus in their contractures ; Ligaments/ capsules: spring ligament, CPC, Kendrick's TMT mobilization, ITC release, medial and plantar IT and TMT ligaments releases; Osseous: DL wedge resection from cuboid and if required, from cuneiforms, open wedge osteotomy of medial cuneiform with a bone graft from cuboid and talo-navicular reduction. Multiple K-wires fixations are done to maintain correction. Wound closure is done after manipulating the flaps to get maximum skin chamber enlargement. Details of all deeper releases of muscles, tendons, ligaments, capsules and bones can be read in author's publications [1,6,8]. In under-corrected and relapsed cases with adherent scars of earlier surgeries, conventional surgery is not possible, due to dense adhesions and obscurity of deeper structures. However, besides excising the scars, the basic concept of PMPDLR remains the same, remaining close to bones, avoiding injury to neurovascular structures and achieving a good correction.

Results and Conclusion
In diverse situations, our aim is to achieve the best possible correction without arthrodesis by innovative modifications, many times decided at the operation table. The rational concept of unified 3 and 4-in-1 skin expanding techniques will always make it possible, in spite of, EACH CLUBFOOT BEING DIFFERENT. This has been very well proved, in variety of cases in earlier publications [1,6,8] and many more recent ones in Table 1 in this article. Learning the techniques is not difficult form various publications of author and youtube videos at author's channel "Patiala Clubfoot Foundation". These are more cost effective than others and giving far better results, more satisfying to patients on long term. Immediate surgical operative costs are much less, besides the lifelong gain in psychophysico-socio-economics of the patients (Figure 5 & 6). Abbreviations of Table 1

Discussion
Extreme clubfoot deformities have been a life time research area of author, pursued in three phases, since over 50 years. It can very well be compared with the story of famous Chinese bamboo tree, establishing strong root system for many years before it sprouts up [23]. Similarly, this research took many years (about 15 to get firmly rooted) and rationalized for execution, before the experimental and three phased (grade 1-3) clinical studies.
It has emerged, as a need based research, from highly prevalent under-corrections/ relapses of over 95%, in extreme deformities (a new generic name given by author), reported in literature with scores of confusing brand names of neglected deformities treated by contemporary surgical techniques, including the popular ones.
"Each Clubfoot is Different" is the SOUL of this research, a powerful Mother innovation, with potential for changing Global thinking about clubfoot. This was an afterthought in the third phase of this research, an unprecedented powerful Grassroots discovery, now a grown up tree with its umbrella of countless branches and leaves, each different, yet all connected with the roots. So are the countless, varied deformities getting unified in their all-inclusive surgical concept. This discovery, with potential for changing global thinking about clubfoot, emerged from highly prevalent under-corrections/relapses of over 95%, reported in literature, with scores of confusing names. The contemporary surgical techniques, including the popular ones: Ponseti's and Illizarov's, do not succeed in extreme deformities. Ponseti technique succeeds in mild and moderate deformities, if his guidelines of right age, type of deformity, casting technique, bracing and follow up are strictly followed,. Being labour intensive, these are neglected by care givers as well as recipients, with numerous pitfalls, reported by Ponseti himself in details in their own articles [5,6], in author's book and many others. In spite of Ponseti's advice against using in more rigid/ severe deformities, vast majority are still doing and failing. First eight cases in Table 1, in this article, are testimony to this assertion. Heel cord tenotomy does more harm than good. It leads to dull white irregular collagen in the gap with adhesions all round, with persisting under-corrected varus and later on relapses (Table 1, Figure 5; cases (1-4,6,15)). Bones grow, but scars do not and hence increasing relapses with age, emphatically asserted by Ponseti himself, and quoted by author [8].
Heterogeneous skin contractures, primary alone or with surgical scars, have always remained neglected, with imperative need for correction. The cramped cell-like room has to be enlarged in 3D, giving proper head and leg space to each occupant and accommodate all in orderly position. This became realty with the invention of triple or even quadruple surgical mega skin expanding incision, each in 3D, as FUSION 3 or 4-in-1. The four plastic surgery procedures of Rotation flap, Z-plasty, VY-plasty and Fillet flap are commonly used as single procedures. Author merged all four procedures into an unprecedented single incision for maximum fascio-cutaneous chamber expansion. It is abundantly, evidence based and time tested too. This was in three phases, as need based procedures, because, with spreading awareness, more and still more severe/rigid deformities presenting for treatment, requiring increasing skin expansion. The extensive deeper soft tissue and osseous releases get reattached in the foot in the corrected position and stabilize. With increasing grade of deformity, they are used as single, 2-in-1, 3-in-1 or 4-in-1, without any bony fusion in vast majority, getting a longer, good looking, flexible and better functioning foot on long term than by other techniques. In still more rigid deformities, some other skin procedures, as detailed in surgical steps, may also be used; as in case No. 13 Table 1, when wound closure was not possible 2 relaxing incisions were given and raw areas were covered with Thiersh grafts from adjacent part of lower leg with uneventful wound healing and patient normal at 5 months follow up (Figure 6. I-IV enlarged views) After treating the world's First, most rigid/ severest deformity, OCTOPUS CLUBFOOT in 2016, these surgical techniques, of Fusion 4-in-1, have now become an imprinted all-inclusive surgical concept, correcting any and every deformity. Learning this evidence based concept is not difficult for clubfoot enthusiasts. This surgical concept is like a Master Key opening all locks.
Working out the economics, WHO documents of 2004 and 2008 [23], on congenital anomalies including clubfoot, quote a very high loss of DALYs of 25.3-38.8 million globally. As regards GBD, congenital anomalies, including clubfoot, ranked as 17 th cause of GBD. Feet are an organ of locomotion for daily living and earn livelihood. Extreme clubfooted, especially bilateral, will earn less or nothing, adding to GBD. These surgical techniques are not costlier than others. Global clubfoot community in LMICs, with over 80% population, is looking towards us expectantly for a better deal and giving them a full meal with lesser cost, rather than costlier half meal. They are not difficult to learn, giving far better results with ROZY feet having pleasing looks improving earning capacity for entire life, boosting psycho-physico-socio-economics of patients [24]. Foot gets stabilized in about 6 months.
To conclude, this is the Mother of all clubfoot inventions, emanating from the earlier publications on extreme clubfoot deformities, unifying the beads in a Rosary or pearls in a necklace "Each Clubfoot is Different" is a remarkable discovery, even more is its incredible/ unsurpassed "Unity in Diversity" manifested by their treatment protocol of 4-in-1 concept. In a broader sense, it is just like: Each human being is different, yet human race is one. The Global clubfoot community in LMICs, with over 80% population, is looking towards us expectantly to fulfill their dreams.