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

Duration and outcome of orthotic treatment in children with clubfoot - a four-year follow-up national register study of Swedish children born between 2015 and 2017

BACKGROUND

The Ponseti method for treating clubfoot consists of initial treatment with serial casting accompanied by achillotenotomy if needed, followed by the maintenance phase including treatment with a foot abduction orthosis (FAO) for at least four years. This study aimed to examine the duration, course, and outcome of orthotic treatment in children with clubfoot.

METHODS

321 children with clubfoot, born between 2015 and 2017, registered in the Swedish Pediatric Orthopedic Quality Register (SPOQ), were included in this prospective cohort study. Data on deformity characteristics and orthotic treatment were extracted. For children with bilateral clubfoot, one foot was included in the analysis.

RESULTS

Of the 288 children with isolated clubfoot, 274 children (95.5%) were prescribed an FAO, and 100 children (35%) changed orthosis type before 4 years of age. Of the 33 children with non-isolated clubfoot, 25 children (76%) were prescribed an FAO, and 21 children (64%) changed orthosis type before 4 years of age. 220 children with isolated clubfoot (76%), and 28 children with non-isolated clubfoot (84%) continued orthotic treatment until 4 years of age or longer. Among children with isolated clubfoot, children ending orthotic treatment before 4 years of age (n = 63) had lower Pirani scores at birth compared to children ending orthotic treatment at/after 4 years of age (n = 219) (p = 0.01). It was more common to change orthosis type among children ending orthotic treatment before 4 years of age (p = 0.031).

CONCLUSIONS

The majority of children with clubfoot in Sweden are treated with an FAO during the maintenance phase. The proportion of children changing orthosis type was significantly greater and the Pirani score at diagnosis was lower significantly among children ending orthotic treatment before 4 years of age. Long-term follow-up studies are warranted to fully understand how to optimize, and individualize, orthotic treatment with respect to foot involvement and severity of deformity.

LEVEL OF EVIDENCE

II.

A 5-years results of the Ponseti method in the treatment of congenital clubfoot: a retrospective study

BACKGROUND

Clubfoot is a common congenital deformity affecting mobility of children. It leads to pain and disability. The Ponseti treatment method is non-surgical method for the correction of clubfoot. There is variation from country to country in how the result of clubfoot management is measured and reported. This study aimed to assess the 5-years results of the Ponseti method in the treatment of congenital clubfoot which was performed for children aged under 2 years in western Amhara, Ethiopia.

OBJECTIVES

The objective of this study was to assess a 5-years results of the Ponseti method in the treatment of congenital clubfoot among under 2-years old children in Felege Hiwot Referral Hospital, Bahir-Dar, Ethiopia, from 2015 to 2019 G.C.

METHODS

A facility-based retrospective cross-sectional study was conducted. After receiving letter of ethical clearance from the University, IRB board, the data were collected from medical record/charts of patients' who received Ponseti treatment, and the collected data were entered and analyzed with Statistical Package for Social Sciences version 21. The results were presented with texts and tables.

RESULTS

A total of 200 children with 256 congenital clubfeet involved in the study. Among the total study subjects, 143 (71.5%) had unilateral clubfeet. The 5-years results of the Ponseti method in the treatment of congenital clubfoot conducted in 200 children with clubfeet were 187 (93.5%) with 95% (CI 90-99.5). Among the study participants, males were 66.5% (almost two times from females).

CONCLUSIONS AND RECOMMENDATIONS

According to the results from a 5-years data showed that the Ponseti method in the treatment of congenital clubfoot was successful with a success rate of 93.5%. We recommend that children with congenital clubfeet should be managed with Ponseti treatment method timely.

Congenital talipes equinovarus: A literature review

Congenital talipes equinovarus (CTEV) is a congenital disability characterized by leg deformities in the cavus, adducts, varus, and equinus. The etiology of CTEV is poorly understood, despite its incidence ranging from 0.76 to 3.49 cases per 1000 live births in Indonesia. CTEV involves the fixation of the foot in the adducts, varus, and equinus with concurrent soft tissue anomalies. Despite advances in treatment, disability often persists. Theoretical models have been proposed for neurological, vascular, connective tissue, bone, and muscular causes; however, the currently available data suggests that mild cases are associated with intrauterine position. CTEV's etiology appears to involve a hereditary component, as its prevalence varies by ethnic group. Genetic factors have been identified in 24–50% of cases, depending on the community studied. Based on a complex segregation analysis, the most plausible inheritance pattern is a single large-effect gene interacting with a polygenic background.

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CTEV is a congenital disability characterized by leg deformities in the cavus, adducts, varus, and equinus.

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In Indonesia, its incidence ranges from 0.76 to 3.49 cases per 1000 live births.

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Genetic factors have been identified in 24–50% of cases, depending on the community studied.

Epidemiology of clubfoot in Sweden from 2016 to 2019: A national register study

Background

This study aimed to estimate the birth prevalence of children born with isolated or non-isolated clubfoot in Sweden using a national clubfoot register. Secondarily we aimed to describe the clubfoot population with respect to sex, laterality, severity of deformity, comorbidity and geographic location.

Methods

A national register, the Swedish Pediatric Orthopedic Quality register, was used to extract data on newborn children with clubfoot. To calculate the birth prevalence of children with isolated or non-isolated clubfoot between 1^st of January 2016 and 31^st of December 2019, we used official reports of the total number of Swedish live births from the Swedish Board of Statistics. The Pirani score and predefined signs of atypical clubfoot were used to classify clubfoot severity at birth.

Results

In total 612 children with clubfoot were identified. Of these, 564 were children with isolated clubfoot, generating a birth prevalence of 1.24/1000 live births (95% confidence interval 1.15–1.35). About 8% were children with non-isolated clubfoot, increasing the birth prevalence to 1.35/1000 live births (95% confidence interval 1.25–1.46). Of the children with isolated clubfoot, 74% were boys and 47% had bilateral involvement. The children with non-isolated clubfoot had more severe foot deformities at birth and a greater proportion of clubfeet with atypical signs compared with children with isolated clubfoot.

Conclusion

We have established the birth prevalence of children born with isolated or non-isolated clubfoot in Sweden based on data from a national register. Moreover, we have estimated the number of children born with atypical clubfeet in instances of both isolated and non-isolated clubfoot. These numbers may serve as a baseline for expected birth prevalence when planning clubfoot treatment and when evaluating time trends of children born with clubfoot.

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.

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.

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.

Developmental dysplasia of the hip and clubfoot treated by Pavlik and Ponseti methods

Children having both typical developmental dysplasia of the hip (DDH) and clubfoot are rare, and early treatments of both conditions are recommended. The aim of this study was to evaluate the effects of the Ponseti method of clubfoot treatment on hips with DDH. After institutional review board approval, we identified children treated by the Ponseti and Pavlik methods between 2003 and 2016. During the Ponseti method treatment, the duration of manipulations, number of casts, tenotomies performed, and days in clubfoot orthosis were recorded. During DDH treatment, we registered duration for Pavlik and hip brace usage. Hips had dynamic sonography and radiographic evaluations. The cases were grouped according to the combination of DDH and clubfoot treatments: (a) concurrent, (b) sequential, and (c) hip observation. Seven cases of DDH and clubfoot were identified. The average number of Ponseti casts was 5.8 (range: 4-8 casts). The average number of days following the post-Achilles-tenotomy casting to the end of clubfoot bracing was 870 days (range: 90-1605 days). Eleven (four bilateral cases and three unilateral) clubfeet were corrected initially by the Ponseti method. The average number of days for Pavlik harness treatment was 74 (range: 10-126 days). Additionally, a hip orthosis was utilized in three children for an average of 131 days. At follow-up, all children had a high femoral neck-shaft angle averaging 152° (range: 144°-164°). One child (case 5) developed avascular necrosis of the femoral head, Kalamchi type I. Children with typical and nonsyndromic DDH and clubfoot treated by Pavlik harness and Ponseti methods are associated with abnormal hip development (coxa valga).

The PBS Score - a clinical assessment tool for the ambulatory and recurrent clubfoot

PURPOSE

The signs for clubfoot relapse are poorly defined in the literature and there is a lack of a scoring system that allows assessment of clubfeet in ambulatory children. The aim of this study is to develop an easy to use, reliable and validated evaluation tool for ambulatory children with a history of clubfoot.

METHODS

A total of 52 feet (26 children, 41 clubfeet, 11 unaffected feet) were assessed. Three surgeons used the seven-item PBS Score to rate hindfoot varus, standing and walking supination, early heel rise, active/passive ankle dorsiflexion and subtalar abduction blinded to the other examiners. All parents answered the modified Roye score questionnaire prior to the clinical assessment. Correlation between the mean PBS Score and the Roye score was evaluated using Spearman's rank correlation coefficient. Interobserver reliability was tested using weighted and unweighted Cohen's Kappa coefficients.

RESULTS

The Spearman's rank correlation coefficient for correlation between mean PBS Score and Roye score was 0.73 (moderate to good correlation).The interobserver agreement for the total PBS Score resulted in an intraclass correlation coefficient of 0.93 (almost perfect agreement).

CONCLUSION

The PBS score is an easy to use, clinical assessment tool for walking age children with clubfoot deformity. It includes passive and active criteria with a very good interobserver reliability and moderate to good validity.

LEVEL OF EVIDENCE

Level I - Diagnostic study.

Developing a Three-Dimensional (3D) Assessment Method for Clubfoot-A Study Protocol

Background: Congenital talipes equinovarus (CTEV) or clubfoot is a common pediatric congenital foot deformity that occurs 1 in 1,000 live births. Clubfoot is characterized by four types of foot deformities: hindfoot equinus; midfoot cavus; forefoot adductus; and hindfoot varus. A structured assessment method for clubfoot is essential for quantifying the initial severity of clubfoot deformity and recording the progress of clubfoot intervention.

Aim: This study aims to develop a three-dimensional (3D) assessment method to evaluate the initial severity of the clubfoot and monitor the structural changes of the clubfoot after each casting intervention. In addition, this study explores the relationship between the thermophysiological changes in the clubfoot at each stage of the casting intervention and in the normal foot.

Methods: In this study, a total of 10 clubfoot children who are <2 years old will be recruited. Also, the data of the unaffected feet of a total of 10 children with unilateral clubfoot will be obtained as a reference for normal feet. A Kinect 3D scanner will be used to collect the 3D images of the clubfoot and normal foot, and an Infrared thermography camera (IRT camera) will be used to collect the thermal images of the clubfoot. Three-dimensional scanning and IR imaging will be performed on the foot once a week before casting. In total, 6–8 scanning sessions will be performed for each child participant. The following parameters will be calculated as outcome measures to predict, monitor, and quantify the severity of the clubfoot: Angles cross section parameters, such as length, width, and the radial distance; distance between selected anatomical landmarks, and skin temperature of the clubfoot and normal foot. The skin temperature will be collected on selected areas (forefoot, mid foot, and hindfoot) to find out the relationship between the thermophysiological changes in the clubfoot at each stage of the casting treatment and in the normal foot.

Ethics: The study has been reviewed and approved on 17 August 2016 by the Sydney Children's Hospitals Network Human Research Ethics Committee (SCHN HREC), Sydney, Australia. The Human Research Ethics Committee (HREC) registration number for this study is: HREC/16/SCHN/163.

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 Correlation of Pirani and Dimeglio Scoring Systems for Ponseti Management at Different Levels of Deformity Severity

The Pirani and Dimeglio scoring systems both have excellent inter-observer and intra-observer reliability, but no research has been conducted to determine their inter-observer reliability and their relationship at different levels of deformity. A total of 173 idiopathic clubfoot cases were reviewed using Pirani and Dimeglio scoring systems, and the number of casts needed was also recorded. For clubfeet with a cast number equal to 2 or 7 and 8, the inter-observer reliability of the two scoring systems was poor or moderate, and there was no correlation between the two scoring systems. There was also no correlation between the Dimeglio scoring score with the number of casts for grade II or IV clubfeet. A binary regression of the number of casts on initial Pirani or Dimeglio scores showed that there was a Quadratic or Cubic relation between the scores and the cast numbers. In conclusion, in the case of mild and very severe clubfoot deformity, the interobserver reliability and its ability to predict the number of casts needed for clubfoot deformity correction was poor. A more objective evaluation system may be required.