The classification of congenital talipes equinovarus

Outcome of Atypical & Complex Clubfoot Managed by Modified Ponseti Method-A Prospective Study

Atypical or complex clubfoot constitutes a small number of cases. Due to the difference in complexity of anatomy, standard deformity correction by Ponseti is not effective. Hence a modified Ponseti method was advised which focuses on deformity differences for treatment. We conducted a prospective study to analyze the outcome in atypical or complex clubfoot treated with the modified Ponseti method. All the children of age less than 1 year were included in the study with atypical or complex clubfoot. Every case was treated according to the modified Ponseti method and tenotomy. Pirani scores were measured at pretreatment, each visit, before application of a brace, and at the latest follow-up. Statistical analysis of all continuous and categorical variables was done. A total of 30 patients (47 feet) were included in the study. Mean Pirani score improved from 5.69 at presentation to 0.45 at time of brace application and latest follow-up 0.34 (p < .001). Six patients (9 feet) had a relapse which was managed with recasting. The mean Pirani score of relapse was 0.72, which after correction reduced to 0.11 (p = .008). Six patients had cast-related complications which were managed with conservative treatment. With an increase in popularity of the Ponseti method, a greater number of complex clubfoot cases are seen due to inadequate reduction or slippage of cast or improper cast application techniques. All these need to be identified at an early age. This helps in proper treatment and improves the quality of life as well as foot appearance.

Evaluation of results of ponseti technique in idiopathic clubfoot using clinical evaluation and radiological assessment

Background:

Congenital clubfoot (congenital talipes equinovarus) occurs in approximately one in 1000 live births and is one of the most common congenital birth defects. The Ponseti method is at present a well-established method of treatment for idiopathic clubfoot deformities.

Aim:

The aim of the present study was to evaluate the results of serial casting in clubfoot deformity with Ponseti method on the basis of Pirani's scoring and radiological findings before and after completion of treatment.

Materials and Methods:

A total of 30 patients were enrolled in the study and were treated with Ponseti's casting after grading the severity of deformity clinically by Pirani's scoring and radiological assessment by calculating the talo-first metatarsal angle in anteroposterior (AP) view and talocalcaneal angle in AP and lateral views. The same clinical and radiological assessment was done at the end of treatment before putting a patient on foot abduction orthosis (FAO).

Results:

The average number of casts applied before full correction was 5.56 (range: 5–8). The average duration of treatment was about 6.65 weeks before the patient was put on FAO. Pirani score significantly improved from an average of 5.50 (range: 4–6) on presentation to 0.24 (range: 0–2) after correction of deformity.

Conclusion:

The Ponseti method is an excellent method for the correction of all four deformities associated with congenital idiopathic clubfoot, and we found that the addition of radiographic to clinical evaluation helps in the better assessment of correction. It provides statistically significant results both clinically as measured by Pirani severity score and radiologically assessed by talocalcaneal and talo-first metatarsal angle.

Predictive ability of scoring systems towards casting in treatment of idiopathic clubfoot by the Ponseti method in infants

A prospective study to find a correlation between the severity of clubfoot and the number of casts required for the correction was conducted. The relationship of early relapse with the severity of the deformity was also studied. A total of 42 infants (61 feet) with primary and idiopathic clubfeet were included in the study. Previously treated and clubfeet due to secondary causes were excluded. All clubfeet were treated by the Ponseti method, and the Pirani score, Dimeglio score and Foot Bimalleolar (FBM) angle were taken at presentation and before every casting and at 6 months of follow-up. The average age of the child at presentation was 24 days, the average initial Pirani score was 4.172, the average initial Dimeglio score was 14.36 and the average FBM angle was 63.87 degrees. The average number of corrective casts given was 5.08 (range 2-8). The regression analysis showed a low correlation between Pirani and Dimeglio scores with the number of casts. There was no correlation between FBM angle and casting. Eleven of the 61 feet had a relapse (18%). Ten of 11 relapsed feet had a midfoot Pirani score of equal to or more than 2. The regression analysis shows a low correlation between Pirani and Dimeglio scores with the number of casts. There was no correlation between FBM angle and casting. Midfoot score equal to or more than 2 is a significant risk factor for relapse.

Correlation of radiographic parameters with clinical correction in idiopathic congenital talipes equinovarus undergoing Ponseti treatment

PURPOSE

Idiopathic congenital talipes equinovarus is the most commonly encountered congenital deformity of the foot. Ponseti technique of manipulation is the treatment of choice. The Pirani classification is a reliable scoring system for clinical evaluation of clubfeet. The role of radiographic parameters in the evaluation and treatment of clubfeet is still controversial. The aim of this study was to evaluate the correlation of radiological parameters with clinical correction in patients with idiopathic clubfeet undergoing correction using Ponseti method.

METHODS

Between March 2018 and March 2019, 42 feet in 27 patients with idiopathic clubfeet were treated in our hospital. We used the Pirani scoring system for clinical evaluation. Anteroposterior and lateral views of the feet were taken before and after correction and at the last follow-up. The anteroposterior view was evaluated for the talocalcaneal angle and talo-first metatarsal angle, while the lateral view was only evaluated for the talocalcaneal angle.

RESULTS

Twelve were boys (44.4%), and 15 were girls (55.6%). The deformity was bilateral in 15 patients (55.6%) and unilateral in 12 patients (44.4%). The average age was three months. According to the Pirani score, the mean Pirani Total score was 4.4 before correction and reduced to 0.4 after correction. The mean talocalcaneal angle in anteroposterior and lateral views was 15.1° and 7.8° before correction, increased to 32.7° and 31.8° after correction, respectively. The mean talocalcaneal index increased from 23.2 before correction to 64.5 after correction. The mean talo-first metatarsal angle in anteroposterior view improved from 25.7° before correction to - 1.6° after correction. The relation between the differences in Pirani scores before and after correction and the differences in measured radiographic parameters before and after correction revealed a statistically significant correlation.

CONCLUSION

Radiographic parameters showed a statistically significant correlation with the clinical outcome. Thus, evaluation of clubfeet correction treated by Ponseti technique can rely mainly on clinical scores with limited utilization of radiological assessment.

Interobserver Reliability of Pirani and Dimeglio Scores in the Clinical Evaluation of Idiopathic Congenital Clubfoot

BACKGROUND

Dimeglio (DimS) and Pirani (PirS) scores are the most common scores used in congenital talipes equinovarus (CTEV) clinical practice. The aim of this study was to evaluate the interobserver reliability of these scores and how clinical practice can influence the clinical outcome of clubfoot through the DimS and Pirs.

METHODS

Fifty-four feet were assessed by six trained independent observers through the DimS and PirS: three consultants (OS), and three residents (RS) divided into three pediatric orthopaedic surgeons (PeO) and three non-pediatric orthopaedic surgeons (NPeO).

RESULTS

The PirS and DimS Scores were strongly correlated. In the same way, OS and RS, PirS, and DimS scores were strongly correlated, and the interobserver reliability ranked "good" in the comparison between PeO and NPeO. In fully trained paediatric orthopaedic surgeons, an "excellent" interobserver reliability was found but was only "good" in the NPeO cohort.

CONCLUSIONS

In conclusion, after careful preparation, at least six months of observation of children with CTEV, PirS and DimS proved to be valid in terms of clinical evaluation. However, more experience with CTEV leads to a better clinical evaluation.

Congenital Talipes Equinovarus: Results of Treatment and Are We Bracing Effectively?

The aim of this retrospective study was to assess our management of Congenial Talipes Equinovarus (CTEV) in relation to national standards published by the British Society for Children's Orthopaedic Surgery (BSCOS). A secondary aim was to evaluate if a more tailored bracing regime than advocated in the traditional Ponseti technique, would be appropriate for some cases of CTEV. One hundred and thirty-three feet in 96 patients were treated between June 2006 and January 2016. All patients were clinically assessed prospectively by the senior author at initial presentation using the Harrold & Walker classification system. A combination of the senior author's database, Elogbook and trust IT systems were used for data collection. The results of Ponseti surgical procedures such as tendoachilles release and tibialis transfer fell within the BSCOS guidelines. The rate of radical subtalar surgical release was higher than advocated (12.3%) which was partly due to the number of primary syndromal patients in the series. There was a significantly lower mean time spent in bracing of 14.3 months (95% confidence interval 14.8-19.3) compared to recommended national guidelines. There was a clinically significant difference in the lower relapse rate of female patients compared to male patients and also a higher propensity of surgical intervention in male patients. In addition, there was a statistically significant difference in both time spent in bracing, between H&W classifications and between patients who had bracing removed pre walking age or post walking age. This potentially demonstrates a more tailored bracing regime may be possible when applied to less severely affected feet and the condition may be more benign in female cases.

Sport Ability during Walking Age in Clubfoot-Affected Children after Ponseti Method: A Case-Series Study

Background: The Ponseti method (PM) of manipulative treatment for congenital talipes equinovarus (CTEV) or clubfoot became widely adopted by pediatric orthopedic surgeons at the beginning of the mid-1990s with reports of long-term successful outcomes. Sports are crucial for children’s development and for learning good behavior. This study aimed to evaluate the sports activity levels in children treated with PM and to assess the different outcomes, according to gender and bilaterality. Methods: A total of 25 patients (44 feet) with CTEV treated by the PM were included in the study. The patients were clinically evaluated according to the Clubfoot Assessment Protocol, American Orthopedic Foot and Ankle Society, Ankle–Hindfoot score, the Foot and Ankle Disability Index (CAP, AOFAS, and FADI, respectively), and FADI Sport scores. Results: The overall mean CAP, AOFAS, FADI, and FADI Sport scores were 97.5 ± 6.4 (range 68.75–100), 97.5 ± 5.8 (range 73.00–100), 99.9 ± 0.6 (range 97.1–100), and 100, respectively. Gender and bilaterality did not affect outcome (p > 0.05). Conclusions: The data confirmed good-to-excellent outcomes in children with CTEV managed by PM. No limitations in sport performance or activity could be observed. In particular, male and female patients and patients with unilateral or bilateral involvement performed equally well.

Assessment of severity of clubfoot in walking children by combined multiple tools: A new classification system

INTRODUCTION

Clubfoot is one of the most common congenital deformities that cause mobility impairment. In developing countries, however, due to lack of appropriate medical care, treatment is either not initiated or incompletely performed. Due to lack of consensus for evaluation of deformities in such patients, there is no standardized treatment protocol yet developed. So, a new evaluation system is devised to assess the deformity in untreated or previously managed conservatively clubfoot of walking children.

METHODS

It was a prospective, observational study, conducted from December 2017 to July 2019. Patients from age 1-5 years, with unilateral deformity and previously managed conservatively were included. Patients having atypical clubfoot, syndromic clubfoot, or previously surgically intervened were excluded. Pre-treatment severity was graded with Diméglio score. Anthropometric, Foot Imprinting, Radiographic angles, and Ultrasonographic measurements were taken. Parameters taken were assessed and correlated with gradings of Diméglio score.

RESULTS

37 patients with mean age of 2.14 ± 0.87 years were included. Diméglio score was 11.57 ± 2.15 with 28 patients in 'severe' category. Talocalcaneal index and Tibiocalcaneal angle were correlating with the equinus whereas Bean shape ratio and Talocalcaneal index were correlating with varus deformity. Derotation of calcaneoforefoot block gradings correlating with Foot bimalleolar angle, Talo-first metatarsal angle, and MMN (medial malleolus to navicular distance) Ratio. FBM (Foot Bimalleolar) Angle, Talo-first metatarsal angle, MMN Ratio, and Medial soft tissue thickness were correlating with forefoot adduction. Following the correlation, a new classification system was devised to assess the severity of deformity at presentation.

CONCLUSION

It is essential to develop an objective methodology to evaluate the severity of the clubfoot; whether the foot is responding to manipulation and casting; to detect the early signs of recurrences and predict the outcomes. The evaluation system should take into consideration the complex characteristics of the deformity and its three-dimensional aspects.

A systematic review of reported outcomes following Ponseti correction of idiopathic club foot

AIMS

To analyze outcomes reported in studies of Ponseti correction of idiopathic clubfoot.

METHODS

A systematic review of the literature was performed to identify a list of outcomes and outcome tools reported in the literature. A total of 865 studies were screened following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, and 124 trials were included in the analysis. Data extraction was completed by two researchers for each trial. Each outcome tool was assigned to one of the five core areas defined by the Outcome Measures Recommended for use in Randomized Clinical Trials (OMERACT). Bias assessment was not deemed necessary for the purpose of this paper.

RESULTS

In total, 20 isolated outcomes and 16 outcome tools were identified representing five OMERACT domains. Most outcome tools were appropriately designed for children of walking age but have not been embraced in the literature. The most commonly reported isolated outcomes are subjective and qualitative. The quantitative outcomes most commonly used are ankle range of motion (ROM), foot position in standing, and muscle function.

CONCLUSIONS

There is a diverse range of outcomes reported in studies of Ponseti correction of clubfoot. Until outcomes can be reported unequivocally and consistently, research in this area will be limited. Completing the process of establishing and validating COS is the much-needed next step.Cite this article: Bone Joint Open 2020;1-8:457-464.

Clubfoot treatment with Ponseti method-parental distress during plaster casting

Background

Clubfoot is one of the most prevalent musculoskeletal congenital defects. Gold standard treatment of idiopathic clubfoot is the conservative Ponseti method, including the reduction of deformity with weekly serial plaster casting and percutaneous Achilles tenotomy. It is well known that parents of children with severe and chronic illnesses are mentally stressed, but in recent studies regarding clubfoot treatment, parents were only asked about their satisfaction with the treatment. Largely unknown is parental distress before and during plaster casting in clubfoot.

Therefore, we want to determinate first, how pronounced the parents’ worries are before treatment and if they decrease during the therapy. Second, we hypothesized that parents faced with an extreme deformity (high Pirani score), reveal more distress, than parents whose children have a less pronounced deformity (low Pirani score). Therefore, we wanted to investigate whether the Pirani score correlates with the parents’ mental resilience in relation to the therapy of the child as a global distress parameter.

Methods

To answer this question, we developed a questionnaire with the following emphases: Physical capacity, mental resilience, motion score, parents score, and child score with point scores 1 (not affected) to 6 (high affected). Subsequently, we interviewed 20 parents whose children were treated with clubfeet and determined the Pirani score of the infants at the beginning (T₀) and at the end (T_E) of the treatment with plaster casting.

Results

High values were obtained in child score (Mean (M) = 3.11), motion score (M = 2.63), and mental resilience (M = 2.25). During treatment, mental resilience improved (p = 0.015) significantly. Spearman correlation coefficient between Pirani score (T₀) and mental resilience (T₀) is 0.21, so the initial hypothesis had to be rejected.

Conclusion

The issues of the children are in the focus of parental worries concerning clubfoot treatment, especially the assumed future motion and the assumed ability to play with other children. Particular emphasis should be placed on educating parents about the excellent long-term results in the function of the treated feet especially as this topic shows the greatest parental distress.

Brace Yourselves: Outcomes of Ponseti Casting and Foot Abduction Orthosis Bracing in Idiopathic Congenital Talipes Equinovarus

BACKGROUND

Foot abduction orthoses (FAO) are believed to decrease recurrence following treatment of congenital talipes equinovarus (CTEV) as described by Ponseti. The purpose of this project is to examine the outcomes of FAO bracing following treatment by the Ponseti method in a cohort of idiopathic CTEV patients.

METHODS

After IRB approval, a cohort of patients aged 3 to 46 days with idiopathic CTEV was identified in a previous prospective study of brace compliance by family report and sensor. Dimeglio score and family demographic information were collected. Initial treatment was by the Ponseti method, with or without Achilles tenotomy. Following correction, patients had three months of full-time FAO bracing during which parents kept a log of compliance. Patients were followed until recurrence (need for further treatment) or age 5.

RESULTS

In total, 42 patients with 64 affected feet met the above criteria and were included in the final analysis. Twenty-six feet (40%) went on to develop recurrence requiring further treatment, including casting, bracing, or surgery. Because of poor tolerance of the original FAO, 20 feet were transitioned to an alternative FAO, and 14 of these (70%) went on to recur (P<0.01). The casting duration (P=0.02) had a statistically significant relationship to recurrence. Patients who were casted for 9 weeks or more had a higher rate of recurrence (57.1% vs. 27.8%; P=0.02). Age at treatment start, Dimeglio score, demographic factors, and compliance during full-time bracing, whether by report or sensor, did not show a significant relationship with recurrence.

CONCLUSIONS

The study showed a statistically significant relationship between the difficulty of CTEV correction and the risk of recurrent deformity requiring treatment. This relationship could be used to provide prognostic information for patients' families. Caregiver-reported compliance was not significantly related to recurrence.

LEVEL OF EVIDENCE

Level III-Prognostic Retrospective Cohort Study.

Correlation of scores with number of Ponseti casts required for clubfoot correction in the older child

BACKGROUND

We examined the correlation between initial Pirani and Dimeglio scores and their individual components to the number of casts for older clubfoot children.

METHODS

Twenty seven patients (39 feet) aged 2-11 years with idiopathic clubfeet were treated using the Ponseti technique and correlation with number of corrective casts calculated. The number of cast required was counted from application of primary cast to the time of initiation of the foot abduction orthosis.

RESULTS

Average 8.45 ± 2.31 (range, 4-13) casts were used for treatment. A low correlation (r = 0.203) was identified when total Dimeglio score was compared with the number of casts. No correlation was identified for Pirani score (r = 0.023). Among individual components, only cavus deformity had a significant positive correlation to cast numbers.

CONCLUSIONS

The Pirani and Dimeglio classifications still remain the most widely practiced clubfoot severity grading systems for the older clubfoot child. However, their prognostic value to predict the total cast duration from initial severity remains questionable.

Interobserver reliability of Diméglio and Pirani score and their subcomponents in the evaluation of idiopathic clubfoot in a clinical setting: a need for improved scoring systems

PURPOSE

Diméglio (DimS) and Pirani (PirS) scores are the most commonly used scoring systems for evaluation of clubfoot, with many centres performing both. Interobserver reliability of their global score has been rated high in a few studies, but agreement of their subcomponents has been poorly investigated. The aim of the study was to assess interrater reliability of global scores and of items in a clinical setting and to analyse overlapping features of the two scores.

METHODS

Fifty-six consecutive idiopathic clubfeet undergoing correction using the Ponseti method were independently evaluated at each casting session by two trained paediatric orthopaedic surgeons using both scores. Interobserver reliability of collected data was analysed; a kappa coefficient > 0.60 was considered adequate.

RESULTS

For DimS and PirS, the Pearson correlation coefficients were 0.87 and 0.91 (p < .0001) respectively, and kappa coefficients were 0.23 and 0.31. Among subcomponents, kappa values were rated > 0.60 only for equinus and curvature of lateral border in PirS; muscular abnormality in DimS was rated 0.74 but a high prevalence index (0.94) indicated influence of scarce prevalence of this feature. All other items showed k < 0.60 and were considered to be improved.For overlapping features: posterior and medial crease showed similar agreement in the two systems, items describing equinus and midfoot adduction were much more reliable in PirS than in DimS.

CONCLUSIONS

In a clinical setting, despite a high correlation of evaluations for total scores, the interobserver agreement of DimS and PirS was not adequate and only a few items were substantially reliable. Simultaneous use of two scores seemed redundant and some overlapping features showed different reliability according to criterion or scale used. Future scoring systems should improve these limitations.

LEVEL OF EVIDENCE

Level I - Diagnostic studies.

Dimeglio Score Predicts Treatment Difficulty During Ponseti Casting for Isolated Clubfoot

BACKGROUND

The Dimeglio score (DS) is widely used to assess clubfoot severity, but its ability to predict long-term outcomes following Ponseti treated isolated clubfoot (IC) is controversial. This study tested the association between the initial DS and its individual parameters with the number of Ponseti clubfoot casts required to achieve correction and the rate of early recurrence following treatment.

METHODS

Data were retrospectively collected from patients who underwent treatment of IC between March 2012 and March 2015 and were followed for ≥2 years. DSs were collected at the initial casting visit. The number of Ponseti casts required to achieve clubfoot correction before tenotomy and recurrence of deformity were collected as the primary outcome variables. Recurrence was defined as any loss of correction leading to repeat casting or tenotomy during the bracing phase. Negative binomial and logistic regression analyses were used to test the association between the 8 Dimeglio parameters and number of casts and incidence of recurrence, respectively.

RESULTS

A total of 53 patients (37 male and 16 female) were included in the study. The median number of casts required to achieve an acceptable correction was 5 (range, 2 to 16). The incidence of recurrence was 24.53% (13/53). An increase in derotation, varus, equinus, muscle condition, and total DSs at the initial cast visit were associated with a significant (P<0.05) increase in the number of casts required to achieve an acceptable correction. The derotation parameter [rate ratio: 1.30, 95% confidence interval (CI): 1.13-1.50, P=0.0003] was most strongly associated with number of casts. Total DSs at initial visit was the only variable significantly associated with the incidence of deformity recurrence (odds ratio: 1.36, 95% confidence interval: 1.01-1.84, P=0.0482).

CONCLUSION

Initial DS is correlated with the number of casts required for correction in Ponseti treated IC. DS may help physicians establish realistic expectations for families with regard to the length of treatment and the possibility of recurrence following Ponseti treatment.

LEVEL OF EVIDENCE

Level II-retrospective prognostic study.

Interobserver Reliability of Pirani Clubfoot Severity Scoring between an Orthopedic Surgeon, a Resident Doctor, and a Nonmedical Counsellor at a Clubfoot Clinic

BACKGROUND

Ponseti method is the gold standard treatment for idiopathic congenital clubfoot. Pirani clubfoot severity score is a vital tool in assessing treatment of clubfoot. This study determines whether, after a short training in the Pirani scoring, a nonmedical personnel can be as accurate as a doctor in assessing the degree of deformity in clubfoot.

MATERIALS AND METHODS

This was a prospective observational study from January to September 2016. Pirani scoring of all children ≤6 months was done by the counsellor, an orthopedic resident, and a consultant separately. All the three members of the team were blinded of the other's score. The Pirani scoring of the consultant was taken as the most correct. The data were analyzed for interobserver reliability using the kappa statistic and point-by-point interobserver agreements.

RESULTS

One hundred and fifteen clubfeet in 75 children (48 males and 27 females) with an average age of 96 days were included in the study. Differences between the means of scores for each severity component of the deformity including the sum of midfoot scores, hindfoot scores, and total foot scores were <0.1. There was fair-to-substantial interobserver reliability of all the subcomponents when scores from the three independent observers were analyzed.

CONCLUSION

Our study successfully demonstrates that after a short training, Pirani score can be successfully used in assessing clubfoot severity by a nonmedical counsellor.

The hybrid method for the treatment of congenital talipes equinovarus: preliminary results on 92 consecutive feet

Over the past 4 years, our pediatric orthopedic unit has developed a new hybrid protocol combining the advantages of Ponseti's method and the French functional physiotherapy method. Sixty-one patients (92 feet) completed treatment. Clubfoot was unilateral in 30 (49.2%) patients and bilateral in 31 (50.8%) patients. The mean Dimeglio score at the start of treatment was 13.5/20 (range: 6/20-19/20). All patients had clinical and radiographic follow-up for at least 2 years (range: 2-4 years). If orthopedic treatment was ineffective and feet showed no improvement, further surgery was performed. Posterior release was performed in eight (8.7%) feet. Clinical evaluation at the last follow-up found a mean dorsal flexion of 20°±5° (range: 5°-35°). The hybrid method is a combination approach applying the strengths of Ponseti's method, that is, serial casting, and the French physiotherapy method, that is, manipulations and radiographs, to achieve long-term correction with a foot that is fully functional and pain free.

The Ponseti technique and improved ankle dorsiflexion in children with relapsed clubfoot: a retrospective data analysis

This study quantifies the change in passive ankle range of motion following modified Ponseti casting in children with relapsed idiopathic clubfoot. Fifty-three cases (feet) were retrospectively reviewed, with 6-month follow-up data available for 72% of participants. The median improvement in dorsiflexion was 15° (95% confidence interval: 12.5°-17.5°, P≤0.05), with 85% achieving dorsiflexion≥10°. At the 6-month follow-up, dorsiflexion remained significantly improved and 12 feet (32%) presented with subsequent relapse. Nine were referred for further casting and three were recommended for extra-articular surgery. Repeat modified Ponseti management clinically and statistically improves passive ankle dorsiflexion in relapsed idiopathic clubfoot.

Interobserver variability in Pirani clubfoot severity scoring system between the orthopedic surgeons

BACKGROUND

Congenital talipes equinovarus (clubfoot) is one of the most common congenital pediatric orthopedic foot deformity, which varies in severity and clinical course. Assessment of severity of the club foot deformity is essential to assess the initial severity of deformity, to monitor the progress of treatment, to prognosticate, and to identify early relapse. Pirani's scoring system is most acceptable and popular for club foot deformity assessment because it is simple, quick, cost effective, and easy. Since the scoring system is subjective in nature it has inter- and intra-observer variability, it is widely used. Hence, the interobserver variability between orthopedic surgeons in assessing the club foot severity by Pirani scoring system.

MATERIALS AND METHODS

We assessed the interobserver variability between five orthopedic surgeons of comparable skills, in assessing the club foot severity by Pirani scoring system in 80 feet of 60 children (20 bilateral and 40 unilateral) with club foot deformity. All the five different orthopedic surgeons were familiar with Pirani clubfoot severity scoring and Ponseti cast manipulation, as they had already worked in CTEV clinics for at least 2 months. Each of them independently scored, each foot as per the Pirani clubfoot scoring system and recorded total score (TS), Midfoot score (MFS), Hind foot score (HFS), posterior crease (PC), emptiness of heel (EH), rigidity of equnius (RE), medial crease (MC), curvature of lateral border (CLB), and lateral head of talus (LHT). Interobserver variability was calculated using kappa statistic for each of these signs and was judged as poor (0.00-0.20), fair (0.21-0.40), moderate (0.41-0.60), substantial (0.61-0.80), or almost perfect (0.81-1.00).

RESULTS

The mean age was 137 days (range 21-335) days. The mean Pirani score was 3.86. We found the overall consistency to be substantial for overall score (total score kappa - 0.71) and also for midfoot (0.68) and hindfoot (0.66) separately. The consistency was least for the emptiness of heel (kappa - 0.39), and best for rigidity of equnius (kappa - 0.68) and rest of the parameters were moderate (kappa between 0.40 and 0.60).

CONCLUSION

The Pirani scoring system had got substantial reliability in assessing the clubfoot deformity even when the reliability test was extended to five different orthopedic surgeons simultaneously.

Initial treatment of congenital idiopathic clubfoot: Prognostic factors

BACKGROUND

The initial treatment of congenital idiopathic clubfoot (CIC) is nonoperative. Either the French physiotherapy method or the Ponseti casting method may be used. Whether either method is superior over the other remains unclear. However, the method used initially is not the only determinant of the final outcome.

OBJECTIVE

The primary objective was to identify determinants of the final outcome as evaluated based on the need for surgical treatment and on the Ghanem-Seringe score.

HYPOTHESIS

Factors associated with the final outcome can be identified.

METHODS

Between 2004 and 2011, 100 CICs in 79 patients were treated in two centres, 47 using the French method and 53 the Ponseti method. The Dimeglio grade was determined at baseline and the Ghanem-Seringe score at last follow-up. Surgical procedures (if any), splinting duration, and rehabilitation therapy duration were recorded. The two groups showed no statistically significant differences for Dimeglio grade distribution, time from birth to treatment initiation, or mean follow-up.

RESULTS

Factors significantly associated with a poor outcome by univariate analysis were use of the Ponseti method (P=0.0027), older age at last follow-up (P=3×10^-4), initial Dimeglio grade (P=7×10^-5), and need for surgery (P=10^-5); no significant effect was found for splinting duration, rehabilitation duration, bilateral involvement, or antenatal diagnosis. By multivariate analysis, factors independently associated with a poor prognosis were older age at last follow-up, Dimeglio grade, and need for surgery.

CONCLUSION

This study confirms the major prognostic significance of initial severity (Dimeglio grade) on the final outcome. The data do not firmly establish that one method is superior over the other. Nevertheless, the need for percutaneous Achilles tenotomy with the Ponseti method leads us to prefer the French physiotherapy method.

LEVEL OF EVIDENCE

IV, retrospective study.

Current conservative management and classification of club foot: A review

Clubfoot, known as congenital talipes equinovarus, is one of the complex paediatric foot deformity with the incidence of 1 in every 1000 live births. It consists of four complex foot abnormalities such as forefoot adductus, midfoot cavus, and hindfoot varus and ankle equinus. There are a number of surgical techniques (soft tissue releases, arthrodesis) used to correct clubfoot. However currently the conservative management (manipulation, serial casting, and braces) of clubfoot is considered as the best choice and it is widely accepted among orthopaedists. Clubfoot treated with surgical techniques might suffer various complications such as soft tissues contractures, neurovascular complications, infections, and shortening of the limbs. Although conservative method is generally considered as an effective method, it is still challenging to cure clubfoot in advance stages. Also, the classification of the initial severity of clubfoot is essential to evaluate the outcome of the treatment. In this review, the aim is to review the different types of conservative method and the assessment of clubfoot severity.

Correcting Congenital Talipes Equinovarus in Children Using Three Different Corrective Methods: A Consort Study

Equinus, varus, cavus, and adduction are typical signs of congenital talipes equinovarus (CTEV). Forefoot adduction remains a difficulty from using previous corrective methods. This study aims to develop a corrective method to reduce the severity of forefoot adduction of CTEV children with moderate deformities during their walking age. The devised method was compared with 2 other common corrective methods to evaluate its effectiveness. A Dennis Brown (DB) splint, DB splint with orthopedic shoes (OS), and forefoot abduct shoes (FAS) with OS were, respectively, applied to 15, 20, and 18 CTEV children with moderate deformities who were scored at their first visit according to the Diméglio classification. The mean follow-up was 44 months and the orthoses were changed as the children grew. A 3D scanner and a high-resolution pedobarograph were used to record morphological characteristics and plantar pressure distribution. One-way MAVONA analysis was used to compare the bimalleolar angle, bean-shape ratio, and pressure ratios in each study group. There were significant differences in the FAS+OS group compared to the DB and DB+OS groups (P < 0.05) for most measurements. The most salient differences were as follows: the FAS+OS group had a significantly greater bimalleolar angle (P < 0.05) and lower bean-shape ratio (P < 0.01) than the other groups; the DB+OS and FAS+OS groups had higher heel/forefoot and heel/LMF ratios (P < 0.01 and P < 0.001) than the DB group. FAS are critical for correcting improper forefoot adduction and OS are important for the correction of equinus and varus in moderately afflicted CTEV children. This study suggests that the use of FAS+OS may improve treatment outcomes for moderate CTEV children who do not show signs of serious torsional deformity.

Correlation of Pirani and Dimeglio scores with number of Ponseti casts required for clubfoot correction

BACKGROUND

A number of grading systems for severity of clubfoot have been reported in the literature, but none are universally accepted. The aim of this study was to find the correlation between 2 of the most widely utilized classification systems (the Pirani score and the Dimeglio score) with number of Ponseti casts required to achieve initial clubfeet correction.

METHODS

A retrospective study of prospectively collected data was performed. All clubfeet assessed at our dedicated clubfoot clinic from January 2007 to December 2011 were included. Clubfoot severity was assessed using both the Pirani score and the Dimeglio score. The total number of casts was calculated from the first cast to the time of initiation of the foot abduction orthosis.

RESULTS

The mean number of Ponseti casts required to achieve initial correction was 5.8 (range, 2 to 10 casts). A low correlation (rs 0.21) was identified when the total Dimeglio score was compared with the number of casts. No correlation (rs 0.12) was identified between the Pirani score and the number of casts.

CONCLUSIONS

The Dimeglio and Pirani scores remain the most widely accepted clubfoot severity grading systems. However, their prognostic value remains questionable, at least in the early treatment stages.

LEVEL OF EVIDENCE

Prognostic study level II.

Consanguineous marriage and increased risk of idiopathic congenital talipes equinovarus: a case-control study in a rural area

BACKGROUND

The purpose of this study is to evaluate if there is any relationship between consanguineous marriages and idiopathic congenital talipes equinovarus (CTEV).

METHODS

A case-control study on CTEV screening was conducted in a rural eastern city of Turkey between 2009 and 2011 and a total of 28 cases (infants with idiopathic CTEV) and 575 controls (healthy infants) were recruited. Sociodemographic status of the infants, including gestational age and birth weights, maternal characteristics and, if any, the degree of consanguinity, were recorded. As an inclusion criterion, only singleton, full-term, live births were accepted. A backward stepwise logistic regression model was used to evaluate the relationship between idiopathic CTEV and parental consanguinity. Unadjusted and adjusted odds ratios (OR) with 95% confidence interval (CI) were calculated.

RESULTS

Among maternal and infant characteristics, significant risk factors for idiopathic CTEV in the regression analysis were work status (employed), consanguineous marriage, sex (male), and gestational age (>42 wk). Babies born to first-cousin parents had >4 times the risk of idiopathic CTEV [OR, 4.138, (95% CI, 1.484, 11.538)] and the risk for those born to distant relatives was 2.9 times higher [OR, 2.941, (95% CI, 1.070, 8.087)] than for children of unrelated parents.

CONCLUSIONS

Consanguineous marriage was significantly associated with an increased risk of idiopathic CTEV. This association remained significant even after adjusting for potential confounding variables. To obtain more accurate results, a population-based screening study with an increased number of cases and controls should be performed in future studies.

LEVEL OF EVIDENCE

Case-control study investigating the effect of a patient characteristic on the outcome of disease (level-III).

Interobserver reliability in Pirani clubfoot severity scoring between a paediatric orthopaedic surgeon and a physiotherapy assistant

The Ponseti method, now regarded as the standard of care for congenital clubfoot, is equally effective whether provided by orthopaedic surgeons or orthopaedic paramedics. Therefore, it is particularly suitable for under-resourced nations with lack of surgeons and physicians. At the Sudan Clubfoot Clinic, physiotherapy assistants (3-year diploma nurses with additional physiotherapy experience) are part of the Ponseti clubfoot treatment team, with the role of assessing the degree of deformity by the Pirani score to assist the team in providing treatment. However, the reliability of Pirani scores measured by physiotherapy assistants in this context is unknown. After obtaining informed consent, we measured the interobserver reliability between a physiotherapy assistant and an orthopaedic surgeon in measuring Pirani scores in 91 virgin clubfeet in 54 infants (41 males and 13 females) at the Sudan Clubfoot Clinic. Scores were measured independently before the onset of treatment and analysed by the κ statistic for interobserver reliability. The κ statistic was 0.61 for posterior crease, 0.72 for empty heel, 0.51 for rigid equinus, 0.54 for the hid-foot score, 0.57 for medial crease, 0.54 for curved lateral border, 0.56 for lateral head of talus, 0.50 for the midfoot score and 0.50 for the total score. The mean percentage of agreement of both observers for all Pirani components was 83%. We found moderate to substantial interobserver reliability for the Pirani clubfoot severity score and all its subcomponents. Properly trained physiotherapy assistants are efficient in assessing the degree of severity of clubfoot. This is particularly useful in developing countries, where orthopaedic surgeons are few. Clubfoot treatment can be made more affordable by using paramedical healthcare workers such as physiotherapy assistants.

Radiography and sonography of clubfoot: A comparative study

BACKGROUND

Congenital talipes equinovarus is a common foot deformity afflicting children with reported incidence varying from 0.9/1000 to 7/1000 in various populations. The success reported with Ponseti method when started at an early age requires an imaging modality to quantitate the deformity. Sonography being a radiation free, easily available non-invasive imaging has been investigated for this purpose. Various studies have described the sonographic anatomy of normal neonatal foot and clubfoot and correlated the degree of severity with trends in sonographic measurements. However, none of these studies have correlated clinical, radiographic and sonographic parameters of all the component deformities in clubfoot. The present study aims to compare the radiographic and sonographic parameters in various grades of clubfoot.

MATERIALS AND METHODS

Thirty-one children with unilateral clubfoot were examined clinically and graded according to the Demeglio system of classification of clubfoot severity. Antero-posterior (AP) and lateral radiographs of both normal and affected feet were obtained in maximum correction and AP talo-calcaneal (T-C), AP talo-first metatarsal (TMT) and lateral T-C angles were measured. Sonographic examination was done in medial, lateral, dorsal and posterior projections of both feet in static neutral position and after Ponseti manouever in the position of maximum correctability in dynamic sonography. Normal foot was taken as control in all cases. The sonographic parameters measured were as follows : Medial malleolar- navicular distance (MMN) and medial soft tissue thickness (STT) on medial projection, calcaneo-cuboid (C-C) distance, calcaneo-cuboid (C-C) angle and maximum length of calcaneus on lateral projection, length of talus on dorsal projection; and tibiocalcaneal (T-C) distance, posterior soft tissue thickness and length of tendoachilles on posterior projection. Also, medial displacement of navicular relative to talus, mobility of talonavicular joint (medial view); reducibility of C-C mal alignment (lateral view); talonavicular relation with respect to dorsal/ ventral displacement of navicular (dorsal view) and reduction of talus within the ankle mortise (posterior view) were subjectively assessed while performing dynamic sonography. Various radiographic and sonographic parameters were correlated with clinical grades.

RESULTS

MMN distance and STT measured on medial view, C-C distance and C-C angle measured on lateral view and tibiocalcaneal distance measured on posterior view showed statistically significant difference between cases and controls. A significant correlation was evident between sonographic parameters and clinical grades of relevant components of clubfoot. All radiographic angles except AP T-C angle were significantly different between cases and controls. However, they did not show correlation with clinical degree of severity.

CONCLUSION

All radiographic angles except AP T-C angle and sonographic parameters varied significantly between cases and controls. However, radiographic parameters did not correlate well with clubfoot severity. In contrast, sonography not only assessed all components of clubfoot comprehensively but also the sonographic parameters correlated well with the severity of these components. Thus, we conclude that sonography is a superior, radiation free imaging modality for clubfoot.

Correlation of foot bimalleolar angle with Pirani score to assess the severity of congenital talipes equinovarus deformity

Various reported scores for congenital talipes equinovarus are presented with observer variations and lack in objective evidence of severity of deformity. Anteromedial foot bimalleolar angle (FBM), an objective assessment of deformity and correction, was correlated and compared with Pirani scores 0.5-2, 2.5-4, 4.5-6 as grouped I to III for mean and SD in 244 club feet in 137 children. The mean FBM angles of groups I to III were 79.72°, 68.4°, and 53.27°, respectively. The FBM angle gives an objective assessment of the severity of deformity and can be used as objective evidence of improvement/deterioration of deformity.

Clubfoot classification: correlation with Ponseti cast treatment

BACKGROUND

Many different clubfoot classification systems have been proposed, but no single one is universally accepted. Two frequently cited systems, developed by Dimeglio/Bensahel and Catterall/Pirani, are often used for evaluation purposes in the treatment of idiopathic clubfoot. Our hypothesis was that the initial scores would be positively correlated with the number of casts required for clubfoot correction, indicating to us that the more severe score would require more casts, and therefore truly show the accuracy and usefulness of the scoring system.

METHODS

From May 2000 to April 2008, 123 patients (185 feet) with idiopathic clubfeet were treated. All patients were below 60 days of age (mean 15.3 d, range: 2 to 57 d) at the time of their initial evaluation, and had not received prior clubfoot treatment. All cast placements were under the supervision of the same pediatric orthopedic surgeon. Initial correction was achieved in all patients.

RESULTS

The mean number of casts required for correction was 5.1 (range: 2 to 8). On the basis of number of casts required, no significant differences were found in final total scores (Dimeglio/Bensahel P=0.14 and Catterall/Pirani P=0.44), indicating a similar level of correction for all feet. The Dimeglio/Bensahel and Catterall/Pirani classification systems were both similarly, poorly correlated with the number of casts needed [Spearman rank correlation coefficients (rs)=0.34 vs. 0.33]. The 2 components with the highest correlations were equinus (rs=0.39) and forefoot adduction (rs=0.35) for the Dimeglio/Bensahel system and coverage of the lateral head of the talus (rs=0.40) and rigid equinus (rs=0.39) for the Catterall/Pirani system.

CONCLUSIONS

When using the initial scores, both the Dimeglio/Bensahel and Catterall/Pirani classification systems had a low correlation with the number of Ponseti casts required. Analysis of the individual components revealed variability in the coefficients, with some having low-to-moderate correlation and others having none. There was no difference between the Dimeglio/Bensahel and Catterall/Pirani classification systems when measuring their correlation with the number of Ponseti casts required for clubfoot correction. An improved classification system is needed to predict the length of treatment and, ultimately, the risk of recurrence.

LEVEL OF EVIDENCE

Prognostic Level IV.

Treatment of clubfoot with the Ponseti method: a comparison of casting materials

BACKGROUND

Popular initial treatment for congenital clubfoot includes the use of serial manipulations and casting as described by Ponseti et al. Plaster of Paris and semirigid fiberglass are 2 materials commonly used for casting. To our knowledge, no study to date has compared the clinical results of these 2 materials. The objective of this randomized prospective study was to compare the effectiveness of these materials in the initial management of clubfoot.

METHODS

All clubfeet presenting to the 2 senior authors' outpatient clinics over a 15-month period were offered enrollment. Patients were randomly assigned for treatment with either plaster or semirigid fiberglass casts. The severity of the clubfoot deformity was documented using the scoring system devised by Diméglio et al. Serial casts were applied according to the technique described by Ponseti et al. At the completion of nonsurgical treatment, the final clubfoot severity was documented.

RESULTS

A total of 42 clubfeet in 34 patients were enrolled in the study. After exclusion of 3 patients, 13 patients (16 feet) received fiberglass, and 18 patients (23 feet) received plaster casts. The mean baseline severity scores of the 2 groups were not significantly different. The mean final severity score was significantly higher in the feet treated with fiberglass than those treated with plaster (6.4 vs 4.1; P = 0.037). There was a trend toward higher scores for cast tolerance, durability, and parent satisfaction in the fiberglass group, but this did not reach significance.

CONCLUSIONS

This study supports the use of plaster casting with the Ponseti technique. The use of plaster casts resulted in a statistically lower Diméglio-Bensahel score at the completion of serial casting. There was a trend toward higher patient satisfaction in the fiberglass-treated group. Whether this difference has an effect on long-term outcomes and recurrence remains to be studied.

LEVEL OF EVIDENCE

Level II. Nonblinded randomized controlled prospective study.

The role of the Pirani scoring system in the management of club foot by the Ponseti method

The Pirani scoring system, together with the Ponseti method of club foot management, was assessed for its predictive value. The data on 70 idiopathic club feet successfully treated by the Ponseti method and scored by Pirani's system between February 2002 and May 2004 were analysed. There was a significant positive correlation between the initial Pirani score and number of casts required to correct the deformity. A foot scoring 4 or more is likely to require at least four casts, and one scoring less than 4 will require three or fewer. A foot with a hindfoot score of 2.5 or 3 has a 72% chance of requiring a tenotomy. The Pirani scoring system is reliable, quick, and easy to use, and provides a good forecast about the likely treatment for an individual foot but a low score does not exclude the possibility that a tenotomy may be required.

Continuous passive motion versus immobilisation in a cast after surgical treatment of idiopathic club foot in infants

Continuous passive motion has been shown to be effective in the conservative treatment of idiopathic club foot. We wished to determine whether its use after operation could improve the results in resistant club feet which required an extensive soft-tissue release. There were 50 feet in the study. Posteromedial lateral release was performed in 39 feet but two were excluded due to early relapse. The mean age at surgery was eight months (5 to 12). Each foot was assigned a Dimeglio club foot score, which was used as a primary outcome measure, before operation and at 6, 12, 18 and 44 months after. Nineteen feet were randomly selected to receive continuous passive motion and 18 had standard immobilisation in a cast.

After surgery and subsequent immobilisation in a cast the Dimeglio club foot score improved from 10.3 before to 4.17 by 12 months and to 3.89 at 48 months. After operation followed by continuous passive motion the score improved from 9.68 before to 3.11 after 12 months, but deteriorated to 4.47 at 48 months. Analysis of variance adjusted for baseline values indicated a significantly better score in those having continuous passive motion up to one year after surgery, but after 18 and 48 months the outcomes were the same in both groups.