A prospective study on the role of foot evertor muscle activity in recurrence of clubfoot

BACKGROUND

Even after corrective casting and bracing, clubfoot recurrence is challenging throughout childhood, with around 14-40 % recurrence rates. Most of the literature on recurrence was attributed to various factors, and minimal research was conducted to know the role of foot evertor muscle activity and its stimulation benefits. This study aimed to assess the role of foot evertor muscle activity in idiopathic congenital clubfoot recurrence by using clinical, sonographic, and electromyographic parameters.

METHODS

A prospective cohort study was conducted at our tertiary care hospital from 2020 to 2022. The patient's demographic data, Pirani, Dimeglio, Clinical Evertor Muscle Activity scores, sonographic cross-sectional areas of leg muscle, and evertor motor activity using surface electromyography were recorded in adherence to the pre-defined intervals.

RESULTS

In total, 51 patients (51 feet) were included in the study, and the overall recurrence rate was 27.5 % (14/51). In this study, around 47 % (24/51) of children had mild or poor clinical evertor activity; among them, 58 % (14/24) children had a recurrence, and the insufficient clinical evertor activity and recurrence were strongly correlated (p = 0.01). Evertor muscle cross-sectional area ratio, motor unit potentials, and recruitment were comparatively less in the recurred group; however, only the cross-sectional area ratio was statistically significant (p = 0.02).

CONCLUSION

Early detection of evertor muscle weakness can help to individualize the treatment plans by predicting recurrence. Therefore, it should be included in routine clinical evaluations. Further research is required to determine the advantages of evertor muscle-strengthening activities in preventing idiopathic clubfoot deformity.

LEVEL OF CLINICAL EVIDENCE

A prospective cohort study, Level of evidence-II.

Effectiveness of Ponseti technique in management of arthrogrypotic clubfeet - a prospective study

BACKGROUND

Clubfoot constitutes roughly 70 percent of all foot deformities in arthrogryposis syndrome and 98% of those in classic arthrogryposis. Treatment of arthrogrypotic clubfoot is difficult and challenging due to a combination of factors like stiffness of ankle-foot complex, severe deformities and resistance to conventional treatment, frequent relapses and the challenge is further compounded by presence of associated hip and knee contractures.

METHOD

A prospective clinical study was conducted using a sample of nineteen clubfeet in twelve arthrogrypotic children. During weekly visits Pirani and Dimeglio scores were assigned to each foot followed by manipulation and serial cast application according to the classical Ponseti technique. Mean initial Pirani score and Dimeglio score were 5.23 ± 0.5 and 15.79 ± 2.4 respectively. Mean Pirani and Dimeglio score at last follow up were 2.37 ± 1.9 and 8.26 ± 4.93 respectively. An average of 11.3 casts was required to achieve correction. Tendoachilles tenotomy was required in all 19 AMC clubfeet.

RESULT

The primary outcome measure was to evaluate the role of Ponseti technique in management of arthrogrypotic clubfeet. The secondary outcome measure was to study the possible causes of relapses and complications with additional procedures required to manage clubfeet in AMC an initial correction was achieved in 13 out of 19 arthrogrypotic clubfeet (68.4%). Relapse occurred in 8 out of 19 clubfeet. Five of those relapsed feet were corrected by re-casting ± tenotomy. 52.6% of arthrogrypotic clubfeet were successfully treated by the Ponseti technique in our study. Three patients failed to respond to Ponseti technique required some form of soft tissue surgery.

CONCLUSION

Based on our results, we recommend the Ponseti technique as the first line initial treatment for arthrogrypotic clubfeet. Although such feet require a higher number of plaster casts with a higher rate of tendo-achilles tenotomy but the eventual outcome is satisfactory. Although, relapses are higher than classical idiopathic clubfeet, most of them respond to re-manipulation and serial casting ± re-tenotomy.

Use of Ankle Dorsiflexion and the Dimeglio and Pirani Scores in Predicting Relapse of Clubfoot Treated With the Ponseti Method

Although Dimeglio and Pirani scores are frequently employed to rate the severities of clubfoot and to evaluate treatment outcomes, it is unclear if these scores predict relapse after treatment. Ankle dorsiflexion has been suggested in recent years to be a promising predictor of relapse. The aim of this study was to investigate ankle dorsiflexion and Dimeglio and Pirani scores in predicting the relapse of clubfoot after treatment with the Ponseti method. We included patients with clubfoot previously treated by the Ponseti method, and retrospectively analyzed their initial ankle dorsiflexion, Pirani and Dimeglio scores, number of castings, and the occurrence of relapse. We analyzed 218 feet of 176 infants with clubfoot who showed an incidence of relapse of 17.0% (30/176). The mean initial Pirani and Dimeglio scores of the feet showing recurrence were significantly higher than individuals with non-recurrence (p < .001 each). We observed a robust association between Pirani and Dimeglio scores and the recurrence of clubfoot at the last follow-up (γ = 0.53, p = .001). In contrast, ankle dorsiflexion was negatively correlated with recurrence of clubfoot (γ = -0.21, p = .001). Dimeglio scores significantly predicted the recurrence of clubfoot (p = .014). Receiver operating characteristic curve analysis exhibited slightly better performance regarding the Dimeglio score relative to the Pirani score and ankle dorsiflexion in predicting recurrence. Ankle dorsiflexion and Pirani and Dimeglio scores were related to recurrence in patients with clubfoot. However, the Dimeglio score reflected superior accuracy in predicting the prognosis of clubfoot treated with the Ponseti method.

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.

A modification of the Ponseti method for clubfoot management: a prospective comparative study

PURPOSE

We aimed to compare our parent-based exercise programem's efficacy with the foot abduction brace (FAB) Ponseti manipulation as a retention programme.

METHODS

We conducted this prospective multicentre cohort study between August 2009 and November 2019. The included children were allocated into one of two groups according to the retention protocol. The Pirani and Laaveg-Ponseti scores were used to assess the feet clinically and functionally. Radiological assessment was performed using standing anteroposterior and lateral radiographs of the feet. We assessed the parents' satisfaction and adherence to the retention method. SPSS version 25 was used for the statistical analysis.

RESULTS

A total of 1265 feet in 973 children were included. Group A included 637 feet managed with FAB, while group B included 628 feet managed with our retention programme. All patients were followed up to the age of four years. At the final follow-up, Pirani scores in group A participants were excellent, good and poor in 515, 90, and 32 feet, respectivel, while in group B the scores were excellent, good and poor in 471, 110 and 44 feet, respectively. The mean total score of Laaveg-Ponseti was 87.81 (sd 19.82) in group A and 90.55 (sd 20.71) in group B (p = 0.02). Group B participants showed higher satisfaction with the treatment method (p = 0.011) and more adherence to the treatment (p = 0.013).

CONCLUSION

The deformity's recurrence related to the brace's non-compliance in the Ponseti method might be reduced by substituting the brace with our home-based daily stretching exercises.

LEVEL OF EVIDENCE

II.

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.

Prenatal diagnosis of isolated clubfoot: Diagnostic accuracy and long-term postnatal outcomes

OBJECTIVE

To evaluate concordance between prenatal and postnatal diagnosis of congenital talipes equinovarus (cTEV), rates of surgery and postnatal outcomes in relation to the prenatal classification of severity.

STUDY DESIGN

This is a retrospective observational cohort study on fetuses with a prenatal diagnosis of cTEV between 2004 and 2018. All cases of isolated cTEV in singleton pregnancies were included. Postnatally, the Ponseti method was applied. Children were followed-up postnatally for at least two years, with a specific focus on neurodevelopmental outcome.

RESULTS

The cohort included 81 fetuses with a prenatal diagnosis of cTEV confirmed postnatally in 86.4% of cases. Concordance between prenatal and postnatal assessment was good for both laterality and degree of severity (k = 0.61 and 0.66, respectively). The average Pirani score, number of casts and rates of Achilles tendon tenotomy were higher for III degree cTEV (p < 0.001). Within this group only, the rate of relapse was 11% and the rates of major surgery was 6%. The postnatal outcome was normal in 68.6% newborns, while 14% of cases had a diagnosis of minor additional findings and 17% had an impairment of neurological development. None of the outcome was statistically correlated to the prenatal assessment of laterality or degree.

CONCLUSIONS

The accuracy of prenatal ultrasound for isolated cTEV is 86% with a false positive diagnosis of 14%. The grade of cTEV assigned prenatally correlates to postnatal severity and longer orthopedic rehabilitation in terms of number of casts and need of surgery. The assessment of the correlation between cTEV and neurological impairment requires further prospective studies on larger cohorts.

Can clubfoot scoring systems predict the number of casts and future recurrences in patients undergoing Ponseti method?

Background

Congenital clubfoot is one of the common congenital orthopaedic deformities. Pirani and Dimeglio scoring systems are two classification systems for measuring the severity of the clubfoot. However, the relation between the initial amount of each of these scores and the treatment parameters is controversial.

Methods

Patients with severe and very severe idiopathic clubfoot undergoing Ponseti treatment were entered. Their initial Pirani and Dimeglio scores, the number of castings as a short-term treatment parameter, and the recurrences as a long-term parameter until the age of three were prospectively documented.

Results

One hundred patients (143 feet) with mean age of 9.51 ± 2.3 days including 68 males and 32 females and the mean initial Pirani score of 5.5 ± 0.5 and the mean initial Dimeglio score of 17.1 ± 1.6 were studied. The incidence of relapse was 8.4 %( n = 12). The mean initial Pirani score (P < 0.001) and the mean initial Dimeglio score (P < 0.003) of the feet with recurrence were significantly more than the non-recurrence feet. The mean number of casts in the recurrence group (7 ± 0.9) was significantly more than the feet without recurrences (6.01 ± 1.04) (P = 0.002). The ROC curve suggested the Pirani score of 5.75 and the Dimeglio score of 17.5 as the cut-off points of these scores for recurrence prediction.

Conclusion

In our study, Pirani and Dimeglio scores are markedly related with more number of casts and recurrence in patients with severe and very severe clubfoot. Also, we have introduced new cut-off points for both classification systems for prediction of recurrence. To the best of our knowledge, this finding has not been introduced into the English literature.

Is the Denis Browne Splint a Myth? A Long-Term Prospective Cohort Study in Clubfoot Management using Denis Browne Splint Versus Daily Exercise Protocol

The Ponseti technique is successful in idiopathic clubfoot management. However, the leading cause of relapse and recurrence is nonadherence to the Denis Brown bracing protocol. This necessitates more extensive soft tissue surgeries. Based on a detailed up-to-date search, we have found that no other studies provide such a modified Ponseti technique. This study is unique, as it depends on using specific stretching exercises instead of bracing during management. Between August 2009 and June 2019, a consecutive series of 194 isolated idiopathic clubfoot patients (251 feet) were included in this study. The mean follow-up was 93 months (range 72 to 146), mean 91.8 months. All patients underwent a clinical and functional assessment using the Laaveg-Ponseti score and radiological assessments. There were 132 boys (68.1%) and 62 girls (31.9%), a male-to-female ratio of 2:1. The mean age at initiation of treatment was 14.9 days. According to the Laaveg-Ponseti score, 51.7% yielded excellent results, 35.3% yielded good results, 11.55% yielded fair results, and 1.59% yielded poor results. Bracing noncompliance has been identified as a major cause for treatment failure. This presented exercise protocol not only eliminates the need for bracing and reduces the cost for the affected individuals but also provides excellent clinical and radiographic end results, comparable to the original treatment protocol using the Denis Brown brace.

Correlation of age and severity scores to the number of Ponseti casts in Indian infants with clubfeet

PURPOSE

World over, age and various severity scores are among the foremost variables studied in relation to the number of casts in clubfoot. We studied the correlation between child's age at presentation, initial Pirani, Dimeglio scores to the number of Ponseti casts in Indian clubfoot children. Further, we matched Pirani versus Dimeglio scores at different severities of deformity to derive a correlation between them.

METHODS

We included 90 idiopathic clubfeet in 55 infants and scored them according to Pirani and Dimeglio grading systems. Syndromic, neurological, surgically intervened, atypical or complex clubfeet were excluded from the study. The number of casts before percutaneous tenotomy was counted. Correlations were calculated between corrective casts and age, Pirani, Dimeglio scores and their individual components.

RESULTS

Mean age of children was 63.7 days and average number of casts applied was 3.2. Age at presentation and number of casts had no correlation with r = 0.034 (p < 0.001). The correlation between initial Pirani score (average 5.39) and Dimeglio score (average 13.4) to number of casts was 0.35 (p < 0.001)and 0.56 (p < 0.0001) respectively. Among individual components of Pirani score, medial crease and rigid equinus had maximum correlation to the number of casts whereas empty heel sign had the lowest. For Dimeglio score, equinus and varus correlated the most and posterior crease the least. Pirani and Dimeglio scores were highly correlated (r = 0.87) to each other except for very supple or severe deformity.

CONCLUSIONS

In infancy, the age at presentation had no bearing on number of casts. Both scoring systems had positive correlation in terms of corrective casts for our population. The Dimeglio fared slightly better than Pirani scores.

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.

Accelerated Ponseti method: First experiences in a more convenient technique for patients with severe idiopathic club feet

BACKGROUND

Congenital Idiopathic Talipes Equinovarus (CTEV), or clubfoot, is a complex deformity that involves pathological anatomy in the foot with ankle equinus, hindfoot varus, midfoot cavus and forefoot adductus [1]. Universal agreement is established about Ponseti technique as the initial management for this deformity. This preliminary study aims to investigate the possibility of having a braceable foot through a proposed accelerated Ponseti method by which, manipulations, 5 castings and Achilles tendon tenotomy are implemented in a week.

METHODS

This study included 11 patients with 16severe congenital idiopathic clubfeet treated by an accelerated Ponseti method. The method involves manipulation of the deformed foot, and 1st casting in one day, with the 2nd, 3rd, 4th, 5th castings in the 4th, 5th, 6th, 7th day post-manipulation. After the 4th cast removal, Achilles tenotomy was performed with subsequent three-week casting for all patients. Nonparametric tests were used for comparing the Pirani scores before starting the treatment and after removal of final cast.

RESULTS

Five patients had bilateral club foot deformity. Average age at treatment was 54.8 days (range 8-150days). All patients, who had severe congenital idiopathic club feet with a Pirani score of 6, underwent the accelerated Ponseti technique. After removal of the three-week cast, the scores median was 0.59, (range 0-1.5), indicating a correction of the deformity and having braceable feet in all patients without experiencing any short-term complication.

CONCLUSIONS

The first step accelerated Pnoseti technique was found to be safe and effective for initial correction of severe idiopathic clubfoot deformity in children below three months of age , though it is an initial study that needs more studies with more follow up data.

Influence of Beginning Time of Casting for Clubfoot Treatment by Ponseti Method in Different Age Group Infants: A Retrospective Study

BACKGROUND

The clubfoot is one of the commonly found congenital deformities in newborn. The Ponseti method is the most effective nonoperative clubfoot management method. It is based on understanding of pathoanatomy of clubfoot. For classifying severity of clubfoot, Pirani score is used. The number of cast required for clubfoot correction is dependent on its initial Pirani score. This study aimed on how the number of cast for correction of clubfoot deformity depends on starting time of casting and pretreatment Pirani score.

MATERIALS AND METHODS

This study comprises of 200 patients with 297 affected foot nonoperatively managed with Ponseti technique of casting. We measured initial and final Pirani scores of patients with different age groups.

RESULTS

We found that initial severity was less in 0-1 month age group children but mean casting number was more while initial severity was more in 1-2 month age group, the mean number of casting was less. Tenotomy requirement was also less in 1-2 month age group.

CONCLUSION

We concluded that casting according to the Ponseti method should be started in 1-2 months age group which shows better results than the other age groups in clubfoot.

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.

A polyaxial fixation brace for the treatment of idiopathic congenital talipes equinovarus in newborns

BACKGROUND

Treatment of idiopathic congenital talipes equinovarus (CTEV) is challenging for pediatric orthopedic surgeons. The Ponseti method is an effective protocol for treatment due to its technique of manipulation, casting, and limited surgery. Plaster casting is an essential component of the Ponseti method. In this report, we describe a new brace that was developed for use in the treatment of clubfoot in newborns instead of a plaster cast.

METHODS

This retrospective study was performed in two orthopedic medical centers. Between January 2011 and October 2013, 89 newborns with CTEV (131 ft) underwent corrective treatment using fixation braces in the experiment group (E-group) in our hospital, and 107 newborns with CTEV (141 ft) underwent plaster casting in the control group (C-group) in another medical center. All patients were treated according to the Ponseti method after the application of the inclusion and exclusion criteria. Plaster casts were applied to patients in the C-group. The patients in the E-group received the custom-made polyaxial fixation braces instead of plaster casts. Prospective follow-up was performed for a mean duration of 36 months. The efficacy of the treatment was assessed using Pirani's scoring system. Chi-squared and independent t tests were used for statistical analyses.

RESULTS

In the E-group, 85 patients (125 ft) achieved good appearance within 3 months of treatment initiation (average, 1.7 months). Four patients (6 ft) required percutaneous Achilles tenotomy. Seven patients developed sores during treatment because of improper brace application, but all sores healed without scarring with timely treatment. In the C-group, 96 patients (123 ft) achieved good appearance within 3 months of treatment initiation (average, 1.6 months). Eleven patients (18 ft) required percutaneous Achilles tenotomy. Twenty-one feet developed sores during treatment because of plaster cast pressure on the dorsum of the feet. Sixteen sores healed without scarring with timely treatment, and 5 ft had obvious scars. The overall mean Pirani scores 1 year after treatment were 0.26 ± 0.06 in the E-group and 0.25 ± 0.03 in the C-group, and the Pirani scores 3 years after treatment were 0.23 ± 0.05 in the E-group and 0.22 ± 0.03 in the C-group. There were significant differences in the percutaneous Achilles tenotomy and skin sores but no significant difference in the Pirani scores between these two groups.

CONCLUSIONS

Our results showed that the new polyaxial fixation brace used in this study was an effective tool for the corrective treatment of CTEV in newborns. We propose the use of this brace as an alternative treatment for newborns.

Correlation of Foot Bimalleolar Angle and Ultrasonography in Assessing the Severity of Club Foot in Neonates Treated by the Ponseti Method

Introduction: Correlation of Pirani score and foot bimalleolar (FBM) angle has been used in few studies but correlation of FBM angle with ultrasonography has never been evaluated so they are being correlated in assessing the severity of clubfoot in neonates treated by Ponseti method. Material and Methods: Thirty-two feet with congenital talipes equinovarus (CTEV) deformity in neonates were prospectively treated by the Ponseti method. FBM angle and ultrasound parameters were measured three times i.e. at the time of initial presentation, at four weeks of treatment and at completion of treatment. The feet were divided according to the Pirani score in groups: one (0-2.0), two (2.5-4) and three (4.5-6). Correlation between FBM angle and ultrasound parameters were evaluated using Pearson correlation/regression. Results: Correlation between FBM angle and ultrasound parameters were statistically significant (p-value < 0.05). Conclusion: Ultrasound has the potential to accurately depict the pathoanatomy in clubfoot. FBM angle and ultrasound are objective methods to assess the severity of clubfoot. FBM angle and ultrasonography correlated in severity of deformity and correction achieved along the course of treatment.

Can the Pirani Score Predict the Number of Casts and the Need for Tenotomy in the Management of Clubfoot by the Ponseti Method?

Introduction: We assessed the role of the Pirani score in determining the number of casts and its ability to suggest requirement for tenotomy in the management of clubfoot by the Ponseti method.

Materials and Methods: Prospective analysis of 66 (110 feet) cases of idiopathic clubfoot up to one year of age was done. Exclusion criteria included children more than one year of age at the start of treatment, non-idiopathic cases and previously treated or operated cases.

Results: The initial Pirani score was (5.5±0.7) for the tenotomy group and the initial Pirani score was (3.3±1.6) for the non-tenotomy group. There was a significant difference between the initial Pirani score for the tenotomy and the non-tenotomy group with t= -7.9, df= 64 p<0.0001. The tenotomy group had a significantly higher number of casts (four to seven) compared to non-tenotomy group (two to five) t=-10.4, df=64, p<0.0001. Spearman’s rank correlation coefficient was significant and confirmed positive correlation between the initial Pirani score and the number of casts required to correct the deformity (r = 0.931, p<0.0001).

Conclusion: Initial high Pirani score suggests the need for greater number of casts to achieve correction and probable need for tenotomy. The number of casts required in achieving complete correction increases with increase in the initial Pirani score. The initial high hindfoot score (2.5-3) signifies the probable need of a minor surgical intervention of percutaneous tendoachilles tenotomy. Based on the initial Pirani score, parents can be informed about the probable duration of treatment and the need for tenotomy.

Ponseti Technique for the Management of Congenital Talipes Equinovarus in a Rural Set-Up in India: Experience of 356 Patients

Congenital talipes equinovarus (CTEV), also known as clubfoot, is a complex congenital deformity of the foot that, left untreated, can limit a person’s mobility by making it difficult and painful to walk. Worldwide, 80% of children born with clubfoot are in low- and middle-income countries. The management of clubfoot has a long history. Non-operative management did not become popular, as an increasing number of orthopaedists started leaning towards surgical treatment. The late Dr. Ignacio Ponseti developed a method of clubfoot correction that successfully realigns clubfoot in infants without extensive and major surgery. The aim of the study was to assess the functional outcome of CTEV management by the Ponseti technique, to study the severity of CTEV deformity using the Pirani score, and to evaluate the cost-effectiveness of the technique. A total of 356 cases with 402 feet with CTEV were treated by the Ponseti method. The average age of the children and the number of casts applied before full correction were 4.03 months and 6.91, respectively. There was a good functional outcome in 95.45% of cases (score > 30) at the last follow up. The management of CTEV by the Ponseti technique provides a good functional and cosmetic outcome. In a developing country like India, this technique is a safe, easy, economical method of clubfoot management.

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.

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.

Clinico-sonographical evaluation of idiopathic clubfoot and its correction by Ponseti method - A prospective study

BACKGROUND

Objective evaluation of infant with clubfoot is required as conventional imaging modality is of limited usefulness. Ultrasound shows to be a promising technique for assessing deformity and monitoring of clubfoot correction.

AIM

Study was done to evaluate the deformity sonographically; to assess the changes in these parameters after treatment by Ponseti method and to correlate these ultrasonographic variables with clinical Pirani score.

MATERIALS AND METHODS

82 feet in 54 children were observed. Clinical assessment was done using Pirani six point system and ultrasound machine with 7.5-12MHz linear transducer was used to measure several parameters and data obtained was assessed to derive correlation between sonographic parameters and clinical system.

RESULTS

Medial malleolus navicular distance (MMN) measured on medial view, calcaneo-cuboid distance (CCD) and calcaneo-cuboid angle (CCA) measured on lateral view, talar length (TAL) measured on dorsal view and tibio-calcaneal distance (TCL) measured on posterior view showed statistical significance. Sonographic parameters correlated statistically with Pirani scoring system on measuring Pearson correlation coefficient.

CONCLUSION

Ultrasound is a relatively simple, non invasive and widely available procedure that can improve pathomorphological documentation of nonossified clubfoot and its correction.

LEVEL OF EVIDENCE

Level II prospective study, as per guidelines for authors.

Ponseti Technique For Management Of Congenital Idiopathic Club Foot

BACKGROUND

Clubfoot or congenital talipes equinovarus, is a congenital deformity of the foot. It consists of cavus, adduction, varus and equinus. This is due to medial displacement of navicular and calcaneus around the talus. Talus is in equinus. Medial deviation of the head and neck of talus is due to force of calcaneus on talus.

METHODS

This descriptive case series study was conducted at Orthopaedic unit, Ayub Teaching Hospital, Abbottabad from 1st August 2015 to 31st January 2016 to determine the frequency of idiopathic clubfoot correction, by using the Ponseti method. A total of 177, unilateral and bilateral clubfeet, from both genders were studied. Patients between age of 2 weeks to 2 years were included in the study. Basic pirani score six (06) who were previously untreated were included in the study. Syndromic patients, previously treated and patients with associated neuro-mascular disorders were excluded from the study. Patients who were corrected with serial castings, were put in foot abduction brace. Those who needed some sort of surgery underwent surgery. All the data was collected in the proforma and analysed by SPSS version 16.00.

RESULTS

A total of 177 clubfeet were included in the study. Mean age of the patients was 10.28±7.45 ranging from 2 weeks 2 years. There were 93 (52.5%) male and 84 (43.5%) female out of total 177 patients. Of these 20 patients were corrected with serial casting only while 150 patients underwent percutaneous tenotomy, which is a minor procedure and done on out -patient department basis. After correction, the feet were put in 70 degree of abduction in abduction brace. Only 7 patients required some sort of surgery, more than tenotomy.

CONCLUSIONS

Ponseti is very effective, economical and non-invasive way of treating congenital idiopathic clubfoot. Only resistant cases may need some sort of extensive surgery.

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.

Management of Idiopathic Clubfoot by Ponseti Technique in Children Presenting After One Year of Age

We conducted a study to determine the effectiveness of the Ponseti technique in the management of idiopathic congenital clubfoot in patients older than 1 year of age. A total of 19 patients with 28 clubfeet (16 males [84.2%], 3 females [15.8%]) were included in the present study. The mean age at presentation was 2.7 (range 1 to 3.5) years. The results of treatment using the Ponseti technique were evaluated using the Pirani and Dimeglio scoring systems. The mean precorrection total Pirani score was 4.84 (range 3.5 to 5.5) and the mean precorrection Dimeglio score was 12.96 (range 10 to 14). The mean postcorrection total Pirani score was 0.55 (range 0 to 1), and the mean postcorrection Dimeglio score was 2.32 (range 2 to 3). These differences were statistically significant (p < .001 and p < .001, respectively). In 92.8% of the feet, satisfactory correction of the deformity was achieved. The mean number of casts applied was 8 (range 5 to 12). All but 1 (3.6%) of the clubfeet required tenotomy to achieve correction. The mean follow-up duration was 2.7 (range 1.5 to 3.5) years. We have concluded that the Ponseti technique is an effective method for the management of idiopathic congenital clubfoot, even in toddlers.

Treatment of idiopathic clubfoot by ponseti technique of manipulation and serial plaster casting and its critical evaluation

BACKGROUND

Clubfoot has from long been an unsolved clinical challenge for the orthopedic surgeons. It is one of the commonest congenital deformities in children. More than 100,000 babies are born worldwide each year with congenital clubfoot. Around 80% of the cases occur in developing nations.

METHODS

Fifty three feet [mean Pirani score (total) 5.6] in 40 children were treated by the Ponseti method from June 2006 to December 2010. A prospective follow-up for a mean duration of 19.5 months (range 6-30 months) was undertaken. Evaluation of the deformity by Pirani score and goniometry was performed, before and after the treatment and the results were assessed through Wilcoxon signed rank test.

RESULTS

The average number of casts applied before full correction was 4.9. The duration of casts for more than 85% feet was <7 weeks. 94.3% patients needed tenotomy before full correction. There was a significant difference in the pre-treatment and the post-treatment Pirani score and goniometry values.

CONCLUSION

Ponseti method of manipulation and plaster casting is very effective in correcting clubfoot deformity. It is especially important in developing countries and well-trained physicians and health personnel can manage the cases effectively by manipulation and cast application.

Does the Pirani score predict relapse in clubfoot?

PURPOSE

Presented here is a retrospective clinical audit of clubfoot patients to determine the value of the Pirani clubfoot scoring system at initial presentation in the estimation of subsequent relapse.

METHODS

All clubfoot patients treated by the same surgeon from 2002 to 2006 were included. The treatment adhered to the standard protocol, involving weekly stretching and casting until the foot was corrected, followed by Achilles tenotomy and plasters for 3 weeks. Thereafter, the child was placed in a foot abduction splint. The severity of clubfoot was assessed using the Pirani scoring system, consisting of two sub-scores-the midfoot contracture score (MFCS) and the hindfoot contracture score (HFCS). The MFCS and HFCS can each be 0.0-3.0, giving rise to a total Pirani score (TPS) of 0.0-6.0. Any recurrent deformity was classed as a relapse.

RESULTS

Sixty-one clubfoot patients were treated. Five patients were lost to follow-up and six patients were excluded due to the presence of identified syndromes or having had primary treatment elsewhere. A total of 80 clubfeet were included. There were 17 relapses. The average interval between the initiation of foot abduction splint and relapse was 23 months. The median TPS was 3.5 in the no relapse group and 5.0 in the relapse group. The median MFCS was 1.5 in the no relapse group and 2.0 in the relapse group. The median HFCS was 2.0 in the no relapse group and 3.0 in the relapse group. Higher TPS and HFCS were statistically significant when the relapse group was analysed against the no relapse group (P = 0.05 × 10(-4) and 0.02 × 10(-4), respectively).

CONCLUSIONS

Higher Pirani scores were associated with the late relapse group. The TPS and HFCS were shown to be statistically significant predictors of potential relapse. Closer follow-up is advised for patients at risk of relapse.

Comparison of Ponseti and Kite's method of treatment for idiopathic clubfoot

BACKGROUND

The manipulation and corrective cast application for club foot was known to be done by Kite's method. The Kite's method of manipulation (center of rotation of malaligned foot and fulcrum on cuboid) was modified by Ponseti (fulcrum on head of talus). Recently, Ponseti's method has gained popularity and vastly improved results are reported. We report randomized controlled trial where manipulation of club foot was done by Ponseti's and Kite's method and correction evaluated by Pirani score to compare the outcome of treatment.

MATERIALS AND METHODS

Sixty feet in 38 patients, 22 with bilateral and 16 with unilateral clubfeet in children less than two years of age and without any prior manipulation or surgical treatment were randomly allocated to the Ponseti (30 feet) and Kite (30 feet) methods of manipulation. This process resulted in the right and left feet of the same patient in 12 bilateral cases being compared with one another (Paired analysis). In the remaining 10 bilateral cases, four patients had both feet treated by Ponseti and six had both feet treated by Kite (unpaired analysis). Finally, in 16 unilateral cases, 10 feet were allocated to the Ponseti and six to Kite methods of manipulation (unpaired analysis). Feet were followed up weekly for 10 weeks for change of cast and recording of hindfoot, midfoot and total Pirani scores. Correction was measured as a difference between hindfoot, mid foot and total Pirani scores weekly from weeks 1 to 10 and corresponding baseline scores. Absolute correction and rate of correction in (i) bilateral clubfeet treated by Ponseti's method on one side and Kite's method on the other side in the same patient were compared using paired Student's t test and (ii) patients with unilateral clubfoot (where either of the methods was used) or those with bilateral clubfoot (where both feet treated by either of the two methods on both the sides) were compared using difference between means (mean correction by Ponseti minus mean correction by Kite) for magnitude of difference and unpaired Student's t test (if data was normally distributed) or Mann Whitney U statistics (otherwise) for significance of difference.

RESULTS

In 12 bilateral clubfeet, where one foot received Kite's method and the other Ponseti's manipulation, feet treated by Ponseti's technique showed faster rates of decrease in Pirani score (improvement) as compared to feet treated by Kite's method with the mean of difference between baseline and follow up scores showing significantly greater (P<0.05) difference from zero from fourth week onwards to up to 10 weeks. In unpaired analysis, both for unilateral or bilateral clubfeet, regardless of side, mean Pirani scores in Ponseti feet improved much faster than Kite feet but the difference achieved statistical significance only at the 10(th) week from the start of treatment.

CONCLUSIONS

Hind foot, midfoot and total Pirani scores reduce much faster with Ponseti than the Kite's method of manipulation of clubfoot. In paired analysis the difference becomes statistically significant at fourth week and in unpaired analysis at 10(th) week from the start of treatment.