Trimorphic extreme clubfoot deformities and their management by triple surgical skin expanders- DOLAR, DOLARZ and DOLARZ-E (evidence based mega-corrections without arthrodesis)
Extreme congenital club foot deformities are common in developing countries, presenting at birth, persisting in children, adolescents and adults; as untreated/under-corrected by conservative and/or surgical means. Scores of confusing names exist in literature for such deformities with no good treatment available; mostly advocating unacceptable arthrodesis. The author researched this grey area for more than 40 years and successfully innovated improved surgical corrections, more acceptable to patients.
All were given a generic name: “extreme deformities”, with 3 hierarchic grades. each 3D (trimorphic) because of their common aim: a good correction. The author started with anatomical dissections in clubfeet (zero cost), consistently reinforced with solid clinical background. Heterogeneous skin contractures, congenital with/without scars, were discovered as the primary cause with cramped deeper tissues and evolved, evidence based, 3D enlargement of skin chamber by triple expanding incisions: DOrso-LAteral Rotation skin flap (DOLAR- acronym) for grade I, DOLAR + Z-plasty (DOLARZ) for grade II and DOLAR + Z + VY-plasty (DOLARZ-E) for grade III, E means Extended. Patient satisfaction level (excellent, good, fair/poor) had been considered for grading results, rather than scoring systems because each clubfoot is different with countless variables.
Results & conclusions
The author operated 1080 feet during the last 40 years with long term follow up, six months to 30 years, with an average of 12½ years. The results obtained were: excellent/good (96%) and fair/poor (4% including superficial skin necrosis only in 3%, evidence based). Triple surgical skin expansion consistently resulted in longer, flexible, joints sparing, good shaped, better functioning foot; even in adults.
KeywordsClubfoot:- extreme deformities Obstinate deformities trimorphic Skin contractures Mega-corrections Three-in-one, Triple surgical skin expanders DOLAR/DOLARZ and DOLARZ-E surgical techniques Correction without arthrodesis Octopus clubfoot Osseous coalitions Arthrogryposis Subtotal subtalar release
Arthrogryposis multiplex congenita
Conjoint posterior capsule
Complete subtalar release
Disability associated life years
- Ex Fix
Flexor digitorum longus
Flexor hallucis longus
Global burden of disease
Inferior tibiofibular syndesmosis
Multi-point soft tissue distractor
Posterior part deltoid ligament
Posterior talo-fibular ligament
Partial subtalar release
Patellar tendon bearing
Subtotal subtalar release
Soft tissue correction
Scars of 2 past surgeries
Wind swipe deformity
Introduction & review of literature
Fifteen patients with Gr3 extreme clubfoot deformities from 1Y to 45Y treated by triple techniques with excellent results
Fig no, name, age, sex, and side
Result as patient satisfaction, follow up
AS, 1YMC, Rt
Gr3, absent mid-MTs, flail toes. Unique forefoot plantar skin contracture.
1st stage- DOLAR, 2nd plantar v-y plasty & innovative DMPSTD. & 3rd minor v-y plasty 2nd toe.
Good, FU 4Y (personal communication)
P,2½YM,BL, Fig2 .lat x-rays a&b, Fig3 ai-vi AP x-rays in aiii.
Gr3, callos, CC & TN disl & other bones in x-rays &, acute cavovarus, GR
Gr3 Rt > Lt,. callos,
hyper acute EQ4 Rt
DOLARZ-E BL, K-wires
Excellent, FU 1Y.
See surgical scars
Gr3 adherent scars2
DOLARZ-E, K-wires. Hidden equinus also corrected
Excellent FU 3Y
KFS, mutidefs, webbed neck, cerv. Fusion, Gr3, callos, acuteCV(EQ4),TN/CN/CC disls
FU 1¼ Y
Gr3, scars1, Lt > Rt, GR, clumsy gait, IC
DOLARZ- E (small
PTSG -highlighted) No arthrodesis
Excellent, GR also ok,
Gr3, EQ3 (CV), Scars1 GR, PS, increasing pain, locking, posterior subluxation, clumsy gait, apprehensive falling down.
DOLARZ-E - Foot
No arthrodesis. knee corrected by itself without any intervention.
Excellent, GR also ok, FU 5 Y
RK 18 YF
Gr3, 8 toes-octopus clubfoot double callos, 2½"short/ HP LL, coalitions, acute HV ankle & subtalar moving, WSD
DOLARZ-E, excision extra toes, no arthrodesis. HV also corrected, fixed with K-wire.
Walking with 2″ shoe raise, needs
Gr3, Scars2 Rt > Lt, EQ3 (CV),
Stress # 5MT Rt, Cock up BT, painful walking
Rt foot DOLARZ-E,
Stress # also healed
RS, 23YM Rt
Fig. 5 ai-ii
Gr3, EQ3 (CV), IC, smaller ugly foot (marital problem).
LT, Fig. 5 bi-iv
Gr3, extreme inversion, large oblong callos, HP, reversed foot gait 1800.
Excellent correction. Plantigrade foot. FU 6 M
Fig. 5 ci-viii
Gr3, AMC, BL DOLAR at 8 Y Lt excellent, RT. cong IT,TMT coalitions, partial correction, 2nd op. refused. Painful plantar horn 2 y back& GT ray amputated by other surgeon. Came to me after 25Ys
PH Pain >ed., multiple defs, foot/ankle stiff, not walking, FD 4 toes Xray- pan-fusions/ deformed. DL wedges excision IT &Toes fusion done.
Walking pain free
with a PTB & padded shoes
RS 24 YM
Extreme Grade II Lt foot with extensive adherent scar of 2 Surg, IT &T MT coalition, ITF fusion & exostosis in C.T.
1st stage- excision scars & DOLARZ, 2nd stage: inter-tarsal arthrodesis
Excellent result at 3 Y FU
Fig. 5 di-ii
Severe BL Grade III Defs, elephant shoes. Happy family. RSA, #s BB both legs, BL ILNs, united (x-rays). Clubfoot Defs. (ischaemic) > ed., EQ5, difficult & painful walking, necessitating surgery.
3 stage BL triple fusion for maximum foot length 1st stage- DOLARZ with ITFS division, 2nd - minimal resection triple fusion & 3rd stage-full correction.
Excellent satisfaction & fine zigzag scar at 10 years follow up
KR 45YM,Rt Fig. 5 ei-iv
Gr3, RSA 20 Y back, healed with IT fusions & scars, Rec. ulcer DL side.
DOLARZ-E with 3ple fusion, double VY plasty, PTSG
FU1Y, Excellent satisfied pt. See scars. Freely walking about
This research is in three stages/generations, with distinct timeline and completely evidence based. First generation technique in two parts: Part 1 was started around the mid-1970s by studying the patho-anatomy of clubfeet in stillborn foetuses, from skin to deeper tissues with double purpose: Firstly, to clarify reported patho-anatomical controversies; some blaming muscle defects primarily [7, 22], others attributing bones [10, 19] or combined muscles/bones [3, 20, 24] and still others TN subluxation/dislocation [20, 24], but none mentioning skin; secondly, to consolidate opinion about anatomical hurdles causing failures. Fifteen clubfeet were dissected, 16 was the highest number reported till then , mostly one or two dissections. Skin contracture in 3D with smaller room was discovered as the primary cause and jammed soft tissues/osteo-articular structures as secondary, which was constantly reinforced with clinical innovations. Without skin expansion, deeper correction is unthinkable. Subcutaneous skin expanders implantation have been reported in clubfoot with limited role in children , not in extreme deformities. Part II: A new surgical technique, DOrsoLAteral Rotation skin flap (DOLAR) in Gr1 deformities, expanded skin in 3D, permitting extensive soft tissue release with comfortable realignment of deeper tissues. Anatomical dissections/clinical case series were documented in reputed peer reviewed journals [IJO1981;15-2;129-35 & JFAS(AP)2014;1(2):72-77] and author recieved the best original research award in 1988 from Indian orthopaedic association. Al-Khooly etal 2013  cited with complete reference in their bibliography and successfully used surgical technique of author's 1st Gen i.e. DOrsolateral LAteral Rotation (DOLAR) skin flap (Internat orthop- SICOT 1987) for correction of resistant clubfeet, but maintained initially for 4 weeks with an external fixator instead of plaster cast, with excellent/good results. Others cited this report and used modified fascio-cutaneous flaps and reported with limited role in children only and not in extreme deformities [11,13].
Second generation technique: With increasing awareness, Gr2 extreme deformities in older children/adolescents/adults started presenting for treatment. The focus was again on further 3D skin expansion, incorporating one to three Z-plasties in DOLAR incision depending upon severity, with more extensive deeper dissection. Triple arthrodesis could be avoided in the majority. This was named the DOLARZ technique (DOLAR + Z-plasty). A large series was completed with long term follow up and highly satisfied patients. The author received another National Award from Indian Orthopaedic Association in 2013 and published an article in International journal [Int Orthop 1987;11(3):189-92.PMID:3623754].
Third generation technique: With more awareness, Gr3 deformities in children, adolescents and adults with scars/other complications, started presenting. Therefore, V-Y plasty was added to DOLAR + Z incision (three-in-one expansile incision), besides additional procedures: a small Thiersch graft, a distant relaxing incision and non-skin surgical steps. Hence, this was named DOLARZ-E, E stands for extended.
The literature is full of reports with innumerable conservative/surgical procedures and their modifications. Ponseti’s casting technique with percutaneous TA tenotomy , is good if started within the first month, with the right regimen and long term bracing in small children only, but not in extreme deformities. Others having limited role in children are PMR, PSTR and CSTR [23, 24, 25], CC fusion , TMT mobilisation , TP, Tib.A transplants [7, 23], Illizarov techniques . Complex problems of residual deformities management in childhood operated clubfeet with deteriorating function in adulthood have been highlighted . In extreme deformities, arthrodesis or talectomy have been recommended [4, 17, 24]. Polydactyly and osseous coalitions [5, 21] can also occur with clubfoot, creating difficulties. The primary aim has been to treat, hitherto neglected “extreme deformities”, achieving a longer/flexible foot without fusion with high acceptability.
Material & methods
Surgery was performed in varied extreme deformities at all ages, with over 50% older children, adolescents and adults. The earliest age for surgery was about one year (walking age), with the majority of older children (8 years & above), adolescents/adults coming in recent years. Each case was assessed clinically and radiologically by TC angle  for TN subluxation/dislocation. Steindler’s plantar release was done in all; modified Evan’s procedure was done mostly after four years, sometimes earlier.
Morbid anatomy & evidence based correction
3D skin contracture
Ligamentous & capsular contractures
A. CPC of ankle & subtaloid joints: Posterior capsule, PPDL and PTFL, the trio form a contracted/continuous sheet spanning both joints; producing rigid hidden heel equinus, which is improperly understood. Five examples are: a: Rocker bottom foot in serial casting, b: break at weaker point on treating by Ex. Fix. c: GR in under-corrected clubfoot (Fig. 2e), d: decreased TC angle in lateral skiagram and e: after TAL, feet plantigrade on standing, but sitting with knees flexed causes heel raised from ground as hidden equinus (Fig. 2g). In contrast, normally feet are fully plantigrade on sitting on feet. Correction: Besides TA lengthening; complete division of CPC, from medial to lateral and opening both ankle & subtaloid joints will correct hidden equinus too (Fig. 2h/inset).
B. Spring (PCN) ligament- Normally, it is a triangular structure between S.T and navicular supporting talar head underneath at its middle articular area (Fig. 2i). In clubfoot PCN ligament is contracted with navicular touching ST with cavo-varus & TN dislocation (Fig. 2j–l). Correction: complete division from lateral to medial side restores spring ligament space, correcting cavo-varus and TN reduction.
C. ITC ligament (lateral contracture) evidence: Decreased TC angle by rotation of calcaneum & talus in opposite directions due to pull of TP (Fig. 2l). Correction: Divide it in the sinus tarsi from lateral side by a tenotomy knife, blindly, from anterior to posterior, making talus sufficiently manipulable, but not completely, to restore TC angle. This is called subtotal subtalar release (SSR).
Most often present, but not always. Evidence (Fig. 2a,b,l). Correction: After all releases, talar head is pulled medially by curved artery forceps, navicular pushed laterally in front of talar head, TC angle & spring ligament space restored and navicular fixed with K-wire from front with talus. This further increases medial foot length. After TN reduction, severe medial cavus with cock-up great toe (EQ3&4) is corrected by K-wire fixation.
CC hump & callosity
It is present since birth in extreme deformities callosity forms due to weight bearing, increasing with age (Figs. 2j and 3ai&bi). Correction: Modified Evan’s, i.e., D.L. wedge is excised of from cuboid & sometimes other tarsals (joints sparing). Only S.TC is ineffective over four years sometimes even in younger children.
Conventionally defined as PF at ankle, has been viewed as a complex deformity in a new perspective, comprising five hierarchic components: i. PF at ankle, ii. At heel (hidden equinus), iii. At IT & TMT joints (cavus), iv At MP & IP joints and v. Rarely over-sized talus vis-à-vis ankle mortis in old/severe deformities (Figs. 1f- EQ. 1-5 and 5di-ii). All level PFs, i.e. EQ. 1-5, need correction for fully plantigrade foot. Correction: the majority can be corrected without triple arthrodesis by triple techniques. Only Gr3 long standing deformities in adults, especially scarred or extensive coalitions will need fusions.
These are additional congenital defects: coalitions, polydactyly, constriction bands etc. In uncorrected or under-corrected cases: hallux varus, clumsy gait, low/no earning capacity, marital problems (before or after marriage), painful walking (inflamed bursa, callosity), symptomatic GR with posterior subluxation/painful locking, heterogeneous scars, early O.A knee, hip & spine, after effects of severe trauma, HV, plantar horn and stress fracture. All these have been seen by the author. Correction is need based.
Well padded BK POP cast is given with foot in under-correction to forestall circulatory embarrassment, fully corrected at two/three fortnightly casts. Total immobilisation is for 2 to 3 months.
Assessment Criteria & Grading of results
Assessment criteria: Patient satisfaction level; based on foot length, flexibility, looks and function has been considered for grading results, rather than any scoring system, because “each clubfoot is different” with evidence based countless variables due to severity, rigidity, differing deformity components at birth, varying with age, diverse surgical scars, additional congenital defects, above complicating issues and radiological under-corrections with normal looking operated foot. There are three patient satisfaction grades: excellent, good and fair/ poor. Results: In about 40 years, 1080 surgeries have been performed with adequate follow up in 800 feet, from six months to 30 years, and in 600 ft more than five years with an overall average of 12½ years. There was excellent/good patient satisfaction in 96%, which included insignificant marginal skin necrosis in 3%, not affecting the results (evidence based- BJPS , 1981, Apr;34(2):215-20). There was fair/poor patient satisfaction in 4% with complications of recurrence/overcorrection with or without infection.
Heterogeneous 3D skin contractures, have been considered as the most important obstacles in good correction. These may be only congenital (primary) or complicated with scars (secondary). In a smaller container, the contents have to be squeezed in, like a gymnast in small box or a closed contractured fist. Rotation flap, Z & VY-plasties are popular plastic surgery procedures and have been innovatively used as three-in-one skin expanders in clubfoot, enlarging the skin chamber longitudinally, horizontally and vertically. Addition of V-Y plasties in Gen3 technique is also evidence based on plastic surgery reports PMID 7236984 and many more.
These procedures offer numerous advantages: excising mega scars, better deeper release, restoring osteo-articular relationships, closing DL wedge defect, minimising osseous resections for maximum foot length, retaining mobility without arthrodesis. Unusual neglected cases, common in developing countries are also correctible to improve their psycho-socio-economic status, helping in reducing GBD.
Hypertrophied/contracted TP, with its nine tenacious insertions, has been underestimated. They pull the bones towards MM. It is, therefore, imperative to release all attachments along with CPC, spring, TMT, ITC ligaments & modified Evan’s procedure to realign the talus, including HV. A couple of K-wire fixations are needed to maintain correction. Arthrodesis is mostly avoidable with highly meticulous dissection.
Subtotal subtalar release: Multiple steps of extensive soft tissue/osseous release, meant for repositioning of talus vis-à-vis other bones is acronymed as SSR. Leaving some TC attachments (subtotal) in extreme deformities is considered better than Turco’s PSTR (1971) partial (without lateral) release or Simon’s CSTR, complete release (1985). In SSR, talus is adequately manipulable, more than partial, but less than complete and cannot go out of control. A new perspective for equinus, i.e. flexion deformities at five levels, described above, is important for total correction. Rarely, old standing Gr3 deformity in adults with EQ5 in one case, required ITFS division to retrace talus, enabling lesser osseous resections with excellent result (Table 1: case 14, Fig. 5d1,d2).
Assessment criteria have been based on patient satisfaction level, because “each clubfoot is different” with myriad variables depending upon: deformity components, age, weight bearing, syndromic/ others, previous surgeries, complications, radiological osteo-articular differences (Table1,Case2,CC & TN dislocations). No prevalent assessment criteria can be applicable.
To conclude: I do not find any real weaknesses in this study howover, to discus, it’s weaknesses can be: 1. Longer learning curve, because these techniques are meticulous/time consuming requiring experience; 2. Each clubfoot is different. Just as one size shoes cannot fit all feet, similarly each clubfoot. Each patient requires individual assessment and planning, often requiring ingenuity at the operation table itself; and 3. Foot cannot become normal anatomically, but this is true for other available procedures also.
Its strengths are: 1. Evidence based surgical techniques, consistently reinforced by clinical innovations for more than 40 years; 2. Long term follow up in a large diverse series with high percentage of excellent & good results and no adverse effect on corrections; 3. High patient satisfaction with a longer, flexible without fusion, good looking, better functioning foot and improved socio-economic status; 4. Effective for every type, rarest of the rare clubfoot, at all ages and; 5. The latest innovative addition of V-Y plasty (remaining superficial to deep fascia) in Gen3 technique is completely evidence based with minimal chances of skin necrosis with experience. There are many reports from India and abroad in plastic surgery journals proving good capillaries, arterioles, venules, lymphatics and neural networks deep and superficial to deep fascia with numerous perforators (Ponten B 1981 PMID7326984, Bhattacharya V doi. https://doi.org/10.4103/0970-0358.73424) with cross references. Meticulously performed, the Three-in-One techniques, are completely evidence based achieving the best possible cosmetic and functional corrections with minimal chances of failures.
Compliance with ethical standards
Conflict of interest
There is no conflict of interest.
This article does not contain any studies with human participants or animals performed by the author.
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