Lateral Tibiocalcaneal Angle As a Determinant for Percutaneous Achilles Tenotomy for Idiopathic Clubfeet

Early Radiographic Characteristics of the Lateral Talocalcaneal Angle and its Predictive Significance for Relapse in Patients With Idiopathic Clubfoot Treated With the Ponseti Method

In order to evaluate the early radiographic characteristics of the lateral talocalcaneal (L-TC) angle in patients with idiopathic clubfoot (ICF) and to investigate its prognostic significance for relapse after initial treatment with the Ponseti method. We retrospectively included 151 patients (96 males and 55 females; 227 feet) with ICF treated at our Institution between January 2005 and December 2014. The age at initial treatment was less than 6 months, and radiographs were obtained within 3 months of the Achilles tenotomy (mean age: 2.3 months; range: 0.77-6.8). All patients were followed up for at least 7 years (range, 7-18). The participants' feet were classified into 3 groups: relapsed (Group A), not relapsed (Group B), and normal foot groups which consisted of healthy feet in patients with unilateral ICF (Group C). All angle measurements were expressed in degrees. Forty-seven ICF feet in 33 patients relapsed, while 180 feet in 118 patients did not, and the age at relapse was 5.92 ± 1.91 years. Seventy-five normal feet were included in Group C. The average L-TC angle in Group A and B patients was 33.57° ± 12.05° and 39.37° ± 12.55°, respectively, while Group C was 49.61° ± 9.11°. A significant difference was found among the 3 groups of patients (F = 31.48, p < .001). The L-TC angle cut-off value below which a recurrence could be predicted was 36.1° (sensitivity, 74.47%). The L-TC angle of ICF patients treated using the Ponseti method were reduced compared to normal feet. An L-TC angle of <36.1° has relative value in predicting ICF relapse.

Clubfoot: Congenital Talipes Equinovarus

Congenital talipes equinovarus (CTEV), also known as clubfoot, is a common musculoskeletal entity that affects one to two per 1000 live births worldwide. Imaging modalities including radiography, US, and MRI have emerged as valuable tools for the diagnosis, treatment, and monitoring of CTEV. The deformity is characterized by midfoot cavus, forefoot adductus, and hindfoot varus and equinus. The Ponseti method of manipulation and serial casting is the standard treatment of CTEV. Radiography shows the anatomy, position, and relationships of the different bones of the foot. US allows accurate assessment of cartilaginous and bony structures, in addition to its inherent advantages such as absence of ionizing radiation exposure. One of the indications for US is to monitor the response to Ponseti method treatment. MRI enables visualization of bones, cartilage, and soft tissues and allows multiplanar evaluation of deformities, providing a comprehensive imaging analysis of CTEV. An integrated approach that combines clinical examination and imaging findings is essential for effective management of CTEV. The authors provide a comprehensive overview of CTEV with a review of imaging modalities to help evaluate CTEV, focusing on radiography, US, and MRI. Using this article as a guide, radiologists involved in the assessment and treatment of CTEV can contribute to the management of the condition. ©RSNA, 2024 Supplemental material is available for this article.

Radiographic Impact on the Clinical Decision Making of Achilles Tenotomy in Clubfoot: In Search of an Objective Cut-Off Value

BACKGROUND

We tried to determine whether the indication of Achilles tenotomy (AT) in clubfoot patients based on clinical evaluation could be confirmed radiographically, and to find an objective radiographic cut-off value for its indication.

METHODS

Eighty-six clubfeet from 60 patients, (26 bilateral and 34 unilateral) were included. A standard Ponseti treatment regimen was applied. Group 1 comprised patients who underwent AT immediately after serial plaster casting (26 feet). Group 2 comprised patients who underwent AT during the follow-up period (48 feet). Group 3 comprised patients who were assumed to have a corrected foot and did not undergo AT (12 feet). Group 4 comprised the healthy sides of the unilateral cases (34 feet).

RESULTS

Both Group 1 and Group 2 showed significant improvement after tenotomy (p = 0.002). In order to differentiate between the normal and AT groups according to the pre-tenotomy angle, we obtained an optimal cut-off value of >85° according to the Youden index, a sensitivity of 96%, a specificity of 91.2%, a positive predictive value of 95.9%, a negative predictive value of 91.2%, and an accuracy rate of 94.4% (AUC: 0.983; p < 0.001).

CONCLUSIONS

Feet with a lateral tibio-calcaneal angle > 85° can be considered pathologic and accepted as candidates for AT.

Indication for Achilles Tenotomy in Congenital Clubfoot: Effectiveness of Using the Tibio-Plantar Fascia Angle as a Radiographic Parameter

Congenital clubfoot is one of the most common deformities in children, and currently, the Ponseti method is used worldwide because of its favorable short-term results. With the Ponseti method, the indication for Achilles tenotomy is traditionally based on only physical examination findings; however, some surgeons have also utilized plain radiographs. Because using physical examinations to determine the degree of hindfoot dorsiflexion for the indication of tenotomy can lead to underestimation. We developed and utilized the effectiveness of the tibio-plantar fascia angle (Ti-P angle) in the lateral maximum dorsiflexion view in determining the need for Achilles tenotomy. A retrospective analysis of consecutive 26 patients with congenital idiopathic clubfeet (37 feet) was performed. Whether Achilles tenotomy was indicated was determined based on physical examination for a former period (Group P). For the latter period, whether tenotomy was indicated was determined by referencing radiographs (Group X). No significant differences were found in any of the background factors or severity between Group P and Group X. Cases with larger tibiocalcaneal and Ti-P angles were more likely to require Achilles tenotomy or additional soft tissue release. An angle of more than 72° of the Ti-P angle demonstrated adequate specificity for the indication of Achilles tenotomy. The radiographic lateral tibio-plantar fascia angle is useful for deciding whether a tenotomy needs to be performed.

Can immediate postoperative radiographs predict outcomes in pediatric clubfoot?

BACKGROUND

The goal of treatment for pediatric idiopathic clubfoot is to enable the patient to comfortably walk on his or her soles without pain. However, currently accepted treatment protocols are not always successful. Based on the abnormal bone alignment reported in this disease, some studies have noted a correlation between radiographic characteristics and outcome, but this correlation remains debated.

AIM

To assess the correlation between immediately postoperative radiographic parameters and functional outcomes and to identify which best predicts functional outcome.

METHODS

To predict the outcome and prevent early failure of the Ponseti's method, we used a simple radiographic method to predict outcome. Our study included newborns with idiopathic clubfoot treated with Ponseti's protocol from November 2018 to August 2022. After Achilles tenotomy and a long leg cast were applied, the surgeon obtained a single lateral radiograph. Radiographic parameters included the tibiocalcaneal angle (TiCal), talocalcaneal angle (TaCal), talofirst metatarsal angle (Ta1st) and tibiotalar angle (TiTa). During the follow-up period, the Dimeglio score and functional score were examined 1 year after surgery. Additionally, recurring events were reported. The correlation between functional score and radiographic characteristics was analyzed using sample and multiple logistic regression, and the optimal predictor was also identified.

RESULTS

In total, 54 feet received approximately 8 manipulations of casting and Achilles tenotomy at a mean age of 149 days. The average TiCal, TaCal, Ta1st, and TiTa angles were 75.24, 28.96, 7.61, and 107.31 degrees, respectively. After 12 mo of follow up, we found 66% excellent-to-good and 33.3% fair-to-poor functional outcomes. The Dimeglio score significantly worsened in the poor outcome group (P value < 0.001). Tical and TaCal showed significant differences between each functional outcome (P value < 0.05), and the TiCal strongly correlated with outcome, with a smaller angle indicating a better outcome, each 1 degree decrease improved the functional outcome by 10 percent. The diagnostic test revealed that a TiCal angle of 70 degrees predicts an inferior functional outcome.

CONCLUSION

The TiCal, derived from lateral radiographs immediately after Achilles tenotomy, can predict functional outcome at 1 year postoperatively, justifying its use for screening patients who need very close follow-up.

The Predictive Value of Radiographs and the Pirani Score for Later Additional Surgery in Ponseti-Treated Idiopathic Clubfeet, an Observational Cohort Study

There are few validated predictors of the need for additional surgery in idiopathic clubfeet treated according to the Ponseti method. Our aim was to examine if physical examination (Pirani score) and radiographs at the age of three months (after initial correction of the clubfeet) can predict the future need for additional surgery. In this retrospective cohort study, radiographs of idiopathic clubfeet were made at the age of three months. The Pirani score was determined at the first cast, before tenotomy, and at the age of three months. Follow-up was at least five years. The correlation between the radiograph, Pirani score, and the need for additional surgery was explored with logistic regression analysis. Parent satisfaction was measured with a disease-specific instrument. The study included 72 clubfeet (50 children) treated according to the Ponseti method. Additional surgery was needed on 27 feet (38%). A larger lateral tibiocalcaneal angle (i.e., equinus) and a smaller lateral talocalcaneal angle (i.e., hindfoot varus) at the age of three months were correlated with the need for additional surgery. Higher Pirani scores before tenotomy and at the age of three months also correlated with additional surgery. Parent satisfaction was lower in patients who needed additional surgery. Both the Pirani scores and the lateral radiographs are predictive for future additional surgery.

Are early antero-posterior and lateral radiographs predictive of clubfoot relapse requiring surgical intervention in children treated by Ponseti method?

Purpose

To investigate the value of antero-posterior and lateral radiographs in predicting clubfoot relapse after treatment with the Ponseti method.

Methods

This was a retrospective review of 104 children (157 feet) younger than 3 months of age with idiopathic clubfoot treated using the Ponseti method at our institution between January 2007 and December 2014. All patients underwent Achilles tenotomy and were divided into two groups according to the need for further surgery to correct the deformity: relapsed group (24 patients; 36 feet) and non-relapsed group (80 patients; 121 feet). All antero-posterior and lateral foot radiographs were performed less than 3 months after Achilles tenotomy. The talo-calcaneal (TC-AP) and talus-first metatarsal (TM-AP) angles were measured in the antero-posterior view, while the tibio-calcaneal (TIC-L), talus-first metatarsal (TM-L), and talo-calcaneal (TC-L) angles were measured in the lateral view. The multi-factor logistic regression model of the stepwise selection method was used to predict the relapse of clubfoot deformity from the potential predictive values.

Results

The mean age at initial plain radiography examination was 99.45 ± 21.54 days. Differences in TC-AP, TM-AP, TC-L, and TIC-L between the two groups were statistically significant. However, only TM-AP and TIC-L were included in the "risk of relapse" formula using the multi-factor logistic stepwise selection method.

Conclusion

Early antero-posterior and lateral radiographs in children younger than 3 months of age at initial Ponseti treatment have positive predictive value for relapse. Reduced TM-AP angle and increased TIC-L were associated with an increased risk of relapse.

Level of evidence

level III.

Prognostic factors for recurrent idiopathic clubfoot deformity: a systematic literature review and meta-analysis

Background and purpose - After initial clubfoot correction through Ponseti treatment, recurrence rates range from 26% to 48%. Even though various factors have been associated with increased recurrence risk, systematic assessments of the prognostic capacity of recurrence risk factors and their clinical relevance are lacking. Therefore we assessed clinically relevant prognostic factors for recurrent idiopathic clubfoot deformity after initial correction through Ponseti treatment. Methods - PubMed, Embase, Cinahl, and Web of Science were systematically searched for studies investigating the association between clinically relevant factors and recurrence rates. Prognostic factors were qualitatively assessed and included in the meta-analysis if ≥ 2 studies investigated the same factor and methods were comparable. Results - 34 articles were included in the qualitative synthesis, of which 22 were also included in the meta-analysis. Meta-analysis revealed that poor evertor muscle activity (OR = 255, 95% CI 30-2,190), brace non-compliance (OR = 10, CI 5-21), no additional stretching (OR = 31, CI 10-101), more casts (OR = 3.5, CI 1.6-7.8), lower education level of parents (OR = 1.8, CI 1.2-2.6), non-marital status of parents (OR = 1.8, CI 1.1-3.0), and higher Dimeglio scores (OR = 1.9, CI 1.2-3.3) were associated with higher recurrence rates. Interpretation - Brace non-compliance and poor evertor muscle activity have been identified as main recurrence risk factors and are therefore important to be closely monitored during clinical follow-up of clubfoot patients. Adding additional stretching during the bracing protocol might be promising in the quest to prevent relapse, but scientific evidence for clear clinical treatment recommendations is still limited.

Relapses in clubfoot treated with Ponseti technique and standard bracing protocol- a systematic analysis

PURPOSE

The analysis determined the relapses in clubfoot children treated with Ponseti technique and standard bracing protocol and their correlation with overall follow up duration using pooled data from various series. It also tested the prescribed timelines of 5 and 7 years for slow-down/cessation of relapses in clubfoot children.

METHODS

A systematic literature search was performed for articles published in "Pubmed (includes Medline indexed journals)" electronic databases using key words: "Clubfoot or CTEV or congenital talipes equinovarus", "Ponseti" for years 1st January 2001 to 15th November 2020. Included were studies that addressed treatment of idiopathic clubfoot using the standard Ponseti technique, followed a well defined brace protocol (maintenance of corrected deformity using a central bar based brace and prescribed duration mentioned), reported a minimum mean follow up of 4 years and having relapse as one of their outcome measure. Studies reporting Ponseti technique for non-idiopathic clubfoot, child's age older than 1 year at the time of primary treatment, clubfoot with previous interventions before Ponseti treatment, where relapse and residual deformities were not identified distinctly in follow up, abstract only publications, letter to the editors, case reports, technique papers and review articles were excluded. The following characteristics of clubfoot patients in the selected articles were included for analysis: Patient numbers/feet treated with Ponseti technique; follow up years (<5; 5-7 and >7 years; overall) and corresponding relapse percentages for patients.

RESULTS

There were total 2206 patients in the included 24 studies. Average follow up was 6 years. The average relapse rates for clubfoot patients in the pooled data stood at 30%. The overall relapse rates increased with a longer follow up and the curve befitted a linear regression equation with weak positive correlation (Pearson correlation coefficient = 0.08). The relapse rates in follow up categories of <5 years (26.6 ± 15.6%), 5-7 years (30.8 ± 16.3%) and >7 years (28.4 ± 6.2%) were similar statistically (Analysis of variance, ANOVA).

CONCLUSIONS

Approximately 1 in 3 clubfoot patients suffer relapse post Ponseti technique and standard bracing protocol. A weak positive correlation was observed for relapses when correlated with increasing follow up years. The relapses however tend to slow down after initial growth years. There is a need to educate the care receivers regarding the possibility of late relapses despite proper Ponseti treatment and accordingly to keep them under supervised follow up for longer periods.

Relapse Rates in Patients with Clubfoot Treated Using the Ponseti Method Increase with Time: A Systematic Review

BACKGROUND

The Ponseti method is the preferred technique to manage idiopathic clubfoot deformity; however, there is no consensus on the expected relapse rate or the percentage of patients who will ultimately require a corrective surgical procedure. The objective of the present systematic review was to determine how reported rates of relapsed deformity and rates of a secondary surgical procedure are influenced by each study's length of follow-up.

METHODS

A comprehensive literature search using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines was performed to identify relevant articles. The definition of relapse, the percentage of patients who relapsed, the percentage of feet that required a surgical procedure, and the mean duration of follow-up of each study were extracted. Pearson correlations were performed to determine associations among the following variables: mean follow-up duration, percentage of patients who relapsed, percentage of feet that required a joint-sparing surgical procedure, and percentage of feet that required a joint-invasive surgical procedure. Logarithmic curve fit regressions were used to model the relapse rate, the rate of joint-sparing surgical procedures, and the rate of joint-invasive surgical procedures as a function of follow-up time.

RESULTS

Forty-six studies met the inclusion criteria. Four distinct definitions of relapse were identified. The reported relapse rates varied from 3.7% to 67.3% of patients. The mean duration of follow-up was strongly correlated with the relapse rate (Pearson correlation coefficient = 0.44; p < 0.01) and the percentage of feet that required a joint-sparing surgical procedure (Pearson correlation coefficient = 0.59; p < 0.01). Studies with longer follow-up showed significantly larger percentages of relapse and joint-sparing surgical procedures than studies with shorter follow-up (p < 0.05).

CONCLUSIONS

Relapses have been reported to occur at as late as 10 years of age; however, very few studies follow patients for at least 8 years. Notwithstanding that, the results indicated that the rate of relapse and percentage of feet requiring a joint-sparing surgical procedure increased as the duration of follow-up increased. Longer-term follow-up studies are required to accurately predict the ultimate risk of relapsed deformity. Patients and their parents should be aware of the possibility of relapse during middle and late childhood, and, thus, follow-up of these patients until skeletal maturity may be warranted.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

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.

Congenital talipes equinovarus: a systematic review of relapse as a primary outcome of the Ponseti method

AIMS

The Ponseti method is the benchmark treatment for the correction of clubfoot. The primary rate of correction is very high, but outcome further down the treatment pathway is less predictable. Several methods of assessing severity at presentation have been reported. Classification later in the course of treatment is more challenging. This systematic review considers the outcome of the Ponseti method in terms of relapse and determines how clubfoot is assessed at presentation, correction, and relapse.

PATIENTS AND METHODS

A prospectively registered systematic review was carried out according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Studies that reported idiopathic clubfoot treated by the Ponseti method between 1 January 2012 and 31 May 2017 were included. The data extracted included demographics, Ponseti methodology, assessment methods, and rates of relapse and surgery.

RESULTS

A total of 84 studies were included (7335 patients, 10 535 clubfeet). The relapse rate varied between 1.9% and 45%. The rates of relapse and major surgery (1.4% to 53.3%) and minor surgery (0.6% to 48.8%) both increased with follow-up time. There was high variability in the assessment methods used across timepoints; only 57% of the studies defined relapse. Pirani scoring was the method most often used.

CONCLUSION

Recurrence and further surgical intervention in idiopathic clubfoot increases with the duration of follow-up. The corrected and the relapsed foot are poorly defined, which contributes to variability in outcome. The results suggest that a consensus for a definition of relapse is needed. Cite this article: Bone Joint J 2019;101-B:639-645.

Early radiographic risk factors for rigid relapse in idiopathic clubfoot treated with the Ponseti method

BACKGROUND

This study aimed at identifying early risk factors for rigid relapse in idiopathic clubfoot using foot radiographs.

METHODS

Thirty-four patients with 43 idiopathic clubfeet treated with the Ponseti method were retrospectively reviewed.

RESULTS

There were seven rigid relapse recalcitrant to manipulation and requiring extensive soft-tissue release. Three radiograabphic measurements on the maximum dorsiflexion lateral (MD-Lat) radiograph, talocalcaneal (TaloCalc-Lat), tibiocalcaneal (TibCalc-Lat), and calcaneus-first metatarsal (CalcMT1-Lat) angles, showed significant differences between patients with and without rigid relapse. The TaloCalc-Lat and CalcMT1-Lat angles showed significant hazard ratio for rigid relapse by multivariate survival analysis. Clubfeet demonstrating TibCalc-Lat>90° and CalcMT1-Lat<5° have a 24.9-fold odds ratio to develop rigid relapse compared to those demonstrating TibCalc-Lat≤90° or CalcMT1-Lat≥5°.

CONCLUSIONS

The TaloCalc-Lat, TibCalc-Lat, and CalcMT1-Lat angles on the MD-Lat radiograph immediately before the tenotomy, probably representing intrinsic tightness of the midfoot and/or hindfoot, are significant risk factors for rigid relapse in patients treated with the Ponseti method.

[Recent progress in foot and ankle surgery]

The article focuses on the recent progress in foot and ankle surgery, including the diagnosis of disease, treatment protocols, outcomes, and evaluation tools as well as other innovations. New and accurate diagnostic modalities and measurements have undergone a breakthrough. Diagnostic modalities tend to be simpler and less expensive. Measurement tools also change to simpler and more accurate. The accuracy and efficacy of surgery and the minimally invasive method have become more popular and important. New treatments and basic research have also made breakthroughs.

Radiographic Prognostic Factors for Selective Soft Tissue Release After Ponseti Failure in Young Pediatric Clubfoot Patients

BACKGROUND

Selective soft tissue release (SSTR), which includes a combination of abductor hallucis, tibialis posterior, and Achilles lengthening, has been used in patients with recurrent clubfoot deformity after Ponseti treatment. The aim of this study was to investigate the prognostic factors for recurrence of clubfoot deformity after SSTR.

METHODS

Consecutive patients with idiopathic clubfoot and residual or recurrent deformity after Ponseti treatment underwent SSTR between 2005 and 2013. The clinical and radiologic characteristics before and after SSTR were analyzed. The ability of radiologic factors to predict recurrence of clubfoot deformity was assessed using multivariate analysis. Rigid deformities of forefoot adduction, and hindfoot varus, and equinus were examined separately. Forty-three patients with 64 clubfeet were included.

RESULTS

Postoperative improvement in the talo-first metatarsal angle on the anteroposterior view, the talocalcaneal angle on the lateral view, and the tibiocalcaneal angle on the lateral view independently predicted recurrence after SSTR. Additionally, the preoperative talocalcaneal angles on the anteroposterior and lateral views were also significant predictors, but these angles did not significantly improve after SSTR.

CONCLUSIONS

SSTR seems to be an effective surgical modality only in milder deformities. Among patients with poor talocalcaneal angles, a high percentage required further surgery. The present results may be useful for the choice of SSTR or more extensive surgery.

LEVEL OF EVIDENCE

Level III, retrospective case-control study.

Comparison of Dimeglio and Pirani score in predicting number of casts and need for tenotomy in clubfoot correction using the Ponseti method

PURPOSE

The Dimeglio and the Pirani scores are largely used to rate clubfoot at presentation and monitor correction. To date, the accuracy of these scores in predicting appropriate treatment is controversial. The aim of this study was to investigate the accuracy of Dimeglio and Pirani scores in predicting the number of casts and the need for tenotomy in clubfoot correction using the Ponseti method.

METHODS

Ninety-one consecutive feet (54 patients; mean age at presentation: 28 ± 15 days) undergoing clubfoot correction using the Ponseti method were prospectively followed from first casting to correction. All feet were scored according to the Dimeglio and Pirani score. The relationships between the two scores, the number of casts and the need for tenotomy were analysed.

RESULTS

Initial correction was achieved in all feet. Both Dimeglio (r = .73; p value < .0005) and Pirani scores (r = .56; p value < .000) showed good association with the number of casts. Multiple linear regression showed a high collinearity of the two scores but a more significant contribution of the Dimeglio score. Among subcomponents, hindfoot score, midfoot score, varus and muscular abnormality were independent predictors of the number of casts. Both Dimeglio and Pirani scores were significantly associated with the need for tenotomy (p value = .0000), and odds ratios and cut-off points were calculated. The receiving operator curve (ROC) analysis showed slightly better performance of the Dimeglio in comparison with the Pirani score in predicting the need for tenotomy, but the difference between the two areas under the curve (AUC) was not significant (p = .48).

CONCLUSIONS

A quite accurate prediction of the number of casts and the need for tenotomy can be performed in most cases. The Dimeglio score showed slightly better accuracy in predicting both steps of Ponseti treatment.

Use of the Pirani score in monitoring progression of correction and in guiding indications for tenotomy in the Ponseti method: Are we coming to the same decisions?

PURPOSE

The Pirani score is widely used in the treatment of idiopathic clubfoot. Some authors recommended to base decision for Achilles tenotomy in Ponseti method on this score (hindfoot score [HFS] > 1, once reducibility of lateral head of talus (LHT) is zero) instead of originally described indications (dorsiflexion < -10-15° once complete abduction is achieved). Yet correspondence of these indications has not been evaluated. Aim of this study was to verify whether in a cohort, where decision is based on dorsiflexion, the Pirani score corresponds to the limits suggested. Secondarily, to describe temporal variation in Pirani score along treatment, which has not been previously investigated.

METHODS

In a prospective study, 79 idiopathic clubfeet in 47 cases consecutively treated with Ponseti method by a single orthopaedic surgeon were evaluated at each casting session with Pirani system; score progression and scores at time of decision to perform tenotomy were determined.

RESULTS

HFS and its subcomponents showed minimal improvement during subsequent sessions of casting and then rapid correction with tenotomy. Medial crease resolved rapidly. Midfoot score and its remaining subcomponents corrected gradually. Total Pirani score showed initially a progressive correction and then a more abrupt improvement with tenotomy. At the time of decision to perform tenotomy, in 8 (10.1%) of 79 cases, the decision whether or not to perform tenotomy based on dorsiflexion would have been different based on the cut-offs for Pirani score suggested.

CONCLUSION

Using Pirani score in guiding indication for tenotomy may imply different decisions in a portion of cases, which should be considered when comparing series.

Nonoperatively Corrected Clubfoot at Age 2 Years: Radiographs Are Not Helpful in Predicting Future Relapse

BACKGROUND

Nonoperative treatment of idiopathic clubfoot is standard. The purpose of this study was to determine if measurements made on standing lateral radiographs of successfully treated clubfeet made at 18 to 24 months of age were predictive of late recurrence.

METHODS

Inclusion criteria were idiopathic clubfoot with an age at presentation of ≤3 months, nonoperative treatment resulting in a clinically plantigrade foot at 2 years of age, standing lateral radiograph of the involved foot made at 18 to 24 months of age, and a minimum age of 4 years at the time of follow-up. The radiographs were assessed for the talocalcaneal angle and the tibiocalcaneal angle, with measurements made by 2 trained practitioners. The average values of the 2 raters were used. The interobserver reliability was calculated using intraclass correlation coefficients (ICCs). A total of 211 patients with 312 clubfeet were evaluated. The average age at the time of follow-up was 8.0 years (range, 4.0 to 13.3 years). Results at the time of follow-up were rated as good (maintained plantigrade foot), fair (required limited surgery to maintain, or return to, a plantigrade position), or poor (required posteromedial release).

RESULTS

Over time, 75% of the feet had a good result, 19% had a fair result, and 6% had a poor result. With regard to radiographic assessment, the ICCs were 0.97 (talocalcaneal angle) and 0.98 (tibiocalcaneal angle), demonstrating excellent agreement between the raters. The mean talocalcaneal angle differed significantly between the feet with a good clinical outcome and those with a fair outcome (28° versus 24°; p < 0.02), but did not differ significantly between those with a good versus poor outcome (28° versus 26°), or a fair versus poor outcome (24° versus 26°). There were no significant differences in the mean tibiocalcaneal angle among the groups (86°, 90°, and 84°, respectively) (p = 0.17).

CONCLUSIONS

Most clubfeet that were clinically plantigrade at 2 years of age remained so, while one-fourth subsequently required some surgery for late recurrence, primarily limited procedures. The tibiocalcaneal angle and talocalcaneal angle from standing lateral radiographs made at 18 to 24 months of age were not helpful in predicting future relapse.

LEVEL OF EVIDENCE

Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.