Article

Clubfoot Classification: Correlation With Ponseti Cast Treatment

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Abstract

Many different clubfoot classification systems have been proposed, but no single one is universally accepted. Two frequently cited systems, developed by Dimeglio/Bensahel and Catterall/Pirani, are often used for evaluation purposes in the treatment of idiopathic clubfoot. Our hypothesis was that the initial scores would be positively correlated with the number of casts required for clubfoot correction, indicating to us that the more severe score would require more casts, and therefore truly show the accuracy and usefulness of the scoring system. From May 2000 to April 2008, 123 patients (185 feet) with idiopathic clubfeet were treated. All patients were below 60 days of age (mean 15.3 d, range: 2 to 57 d) at the time of their initial evaluation, and had not received prior clubfoot treatment. All cast placements were under the supervision of the same pediatric orthopedic surgeon. Initial correction was achieved in all patients. The mean number of casts required for correction was 5.1 (range: 2 to 8). On the basis of number of casts required, no significant differences were found in final total scores (Dimeglio/Bensahel P=0.14 and Catterall/Pirani P=0.44), indicating a similar level of correction for all feet. The Dimeglio/Bensahel and Catterall/Pirani classification systems were both similarly, poorly correlated with the number of casts needed [Spearman rank correlation coefficients (rs)=0.34 vs. 0.33]. The 2 components with the highest correlations were equinus (rs=0.39) and forefoot adduction (rs=0.35) for the Dimeglio/Bensahel system and coverage of the lateral head of the talus (rs=0.40) and rigid equinus (rs=0.39) for the Catterall/Pirani system. When using the initial scores, both the Dimeglio/Bensahel and Catterall/Pirani classification systems had a low correlation with the number of Ponseti casts required. Analysis of the individual components revealed variability in the coefficients, with some having low-to-moderate correlation and others having none. There was no difference between the Dimeglio/Bensahel and Catterall/Pirani classification systems when measuring their correlation with the number of Ponseti casts required for clubfoot correction. An improved classification system is needed to predict the length of treatment and, ultimately, the risk of recurrence. Prognostic Level IV.

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... The Pirani score is one of the popular systems for classification of severity in clubfoot [1] . The initial Pirani scores have been investigated for correlation to the number of casts required for clubfoot correction with variable results [1][2][3][4][5] . In tertiary care settings where in house Obstetric and Pediatric services are robust, children often come as early as the date of birth for consultation with the Orthopaedic surgeon. ...
... There was no linear relationship between initial Pirani scores and number of corrective casts in this study. In another study by Chu et al. (185 feet; mean age 15.3 days), the mean number of casts required were 5.1 [2] . The average Pirani scores versus number of casts were 2/2, 4/3, 5/4, 5.5/5, 5.5/6, 5.5/7, and 6/8. ...
... The average Pirani scores versus number of casts were 2/2, 4/3, 5/4, 5.5/5, 5.5/6, 5.5/7, and 6/8. The initial Pirani scores correlated poorly (r =0.33) with number of casts required for clubfoot correction [2] . In a study on the use of Ponseti method in clubfoot in toddlers, the number of casts in younger children was less compared to older children (one to two years, six to ten casts; two to three years, nine to12 casts) [15] . ...
... There are different classification systems used to determine the severity and outcome of treatment, such as DiMeglio/Bensahel classification system 2,3 Catterall/Pirani classification system, 4 Ponseti, and Smoley classification system, 4,5 Harrold and Walker classification system 6 and the International Club Foot Study Group 13. ...
... There are different classification systems used to determine the severity and outcome of treatment, such as DiMeglio/Bensahel classification system 2,3 Catterall/Pirani classification system, 4 Ponseti, and Smoley classification system, 4,5 Harrold and Walker classification system 6 and the International Club Foot Study Group 13. ...
... Out of these systems, the commonly used ones are the DiMeglio/Bensahel and the Catterall/Pirani systems. 4 Between the two, the Pirani scoring system is a simple and easy method to determine the severity and monitor the progress of treatment of club foot. ...
Article
BACKGROUND Pirani scoring system is one of the classification systems in management of club foot which is simple and easy to use. However, there is paucity of studies using Pirani system to determine the severity and monitor progress in the treatment of club foot. We therefore set out with the aim of assessing severity and monitoring the progress of treatment using the Pirani scoring system. The Pirani scoring system, together with the Ponseti method of club foot management, was assessed for its predictive value. METHODS It was a hospital-based prospective study of 57 club foot in 41 patients designed to evaluate the role of Pirani score in deformity assessment and management of club foot by Ponseti method. Consecutive patients presenting at the outpatient department at SVRRGGH, Tirupati with idiopathic club foot, and in-patients department with idiopathic club foot were recruited into the study. Informed consent was obtained from parents/guardians of the patients that were recruited in the study. This was a prerequisite for obtaining the ethical approval. Data collected from the study groups was entered into a worksheet, and analysis was performed using the statistical package for social sciences (SPSS) software for windows version 21. Significant statistical inferences were drawn at p & lt ; 0.05. RESULTS The correlation between the midfoot score, hindfoot score, Pirani score and the number of casts to achieve correction was significant (P = 0.001). Also, there was correlation between the Pirani score and the need for tenotomy (P = 0.001); between the number of casts to achieve correction and the need for tenotomy (P = 0.001). Moreover, the progress of treatment can be monitored with the Pirani score (P = 0.001). CONCLUSIONS Pirani scoring system is a simple, easy, quick and reliable system to determine severity and monitor progress in the treatment of club foot with excellent interobserver variability. KEYWORDS Pirani Score, Club Foot, Ponseti Method
... 8 These findings were also recorded by Gao and Chu. 4,16 Despite these findings, the authors concluded that 92% of patients with an initial Pirani score >4 would need at least four casting sessions and that two components, posterior crease, and rigid equinus, had the highest correlation with the total number of casts required for correction (r 0.09 and 0.16). 4,15,16 The Pirani score uniformly decreases with good outcomes of Ponseti casting. ...
... 4,16 Despite these findings, the authors concluded that 92% of patients with an initial Pirani score >4 would need at least four casting sessions and that two components, posterior crease, and rigid equinus, had the highest correlation with the total number of casts required for correction (r 0.09 and 0.16). 4,15,16 The Pirani score uniformly decreases with good outcomes of Ponseti casting. 4,5,9,16,17 ...
... 4,15,16 The Pirani score uniformly decreases with good outcomes of Ponseti casting. 4,5,9,16,17 ...
Article
Introduction. Congenital talipes equinovarus (CTEV), also called clubfoot, is one of the most common orthopedic congenital anomalies. However, there is no formal study of the condition here in the Philippines, and data is sparse regarding the epidemiology, treatment, and outcomes in similar third-world countries. Methods. Retrospective review of data of clubfoot patients seen at the Philippine General Hospital (PGH) Clubfoot Clinic from 2006 up to the present. Results. Records from 75 patients treated at the PGH Clubfoot Clinic from 2010-2016 were reviewed. Idiopathic clubfoot comprised 76% of the patients, while syndromic clubfoot comprised 24%. A good outcome of the Ponseti method was seen in 82% and 88% of the idiopathic and syndromic clubfoot patients, respectively. Idiopathic clubfoot cases that had good outcomes required an average of 11.84 casts to tenotomy or bracing, which was not statistically significant compared to 9.55 average sessions for syndromic clubfoot (p=0.21). The initial Pirani scores for both cases were not significantly different (p=0.95). Idiopathic cases with poor outcomes needed less casting sessions (4.45) because the decision to operate was made early. Age was not found to significantly affect the outcome of treatment for idiopathic clubfoot (p=0.20) and syndromic clubfoot (p=0.64). Conclusion. Ponseti casting was found to be effective in treating both idiopathic and syndromic clubfoot patients. The number of sessions did not differ significantly between the two.
... Studies have recommended that the approach should begin within the first 15 days of life. 24,26 We believe that the higher mean age among our patients occurred because our institution is a regional referral hospital for CCF treatment and thus the children came to us already at a greater age than is recommended. ...
... 12,28 Other authors, in recently published papers, have shown results better than 90%. 16,24,26 We believe that the higher frequency of satisfactory results in GII may be related to evolution of the learning curve, the shorter follow-up and better adherence to treatment among the children, due to good availability of information and the explanatory class on the method that was given to their parents. ...
... However, other studies have shown even lower means, like five plaster casts. 22,26 This decline in the number of plaster casts provides evidence of improvement in the way in which the method is implemented. ...
Article
Full-text available
Objective: To evaluate outcomes of 229 idiopathic clubfeet (ICF) treated using the Ponseti method, from 2001 to 2011, comparing two groups with different follow-ups. Method: 155 patients (229 ICF) were treated separated in two groups: Group I: 72 patients (109 ICF - 47.6%) with a follow up of 62 to 128 months (mean of 85). Group II: 83 patients (120 ICF - 52.4%) with a follow up of 4 to 57 months (mean of 33.5). We have considered satisfactory outcomes for cases which correction of all deformed components, without surgery. Results: Mean age for the initial assessment was 5.4 months in Group I and 3.2 in Group II. Satisfactory outcomes were obtained in 85.4% in Group I and 97.5% in Group II. Mean cast placements were 9.5 in Group I and 7 in Group II. 67% were submitted to percutaneous Achilles tenotomy in Group I and 65% in Group II. Deformity relapses, when using abducted braces, occurred in 41 (37.6%) feet from Group I; 11 were treated surgically. In Group II, 17 feet relapsed (14.1%); three of them were submitted to surgery. Conclusion: The method was successful in both groups, in low number of complications. The results were statistically superior in Group II when deformity correction, cast placements, relapses and surgery indication.
... It has been recommended that treatment should begin within first 15 days of life. 26 Herzenberg et al found the mean number of caststo be seven, another study found a mean of five corrective casts. [26][27] In contrast, this study foundan average of three and six corrective casts required, including the four year review cohort. ...
... 26 Herzenberg et al found the mean number of caststo be seven, another study found a mean of five corrective casts. [26][27] In contrast, this study foundan average of three and six corrective casts required, including the four year review cohort. Recently, with more experience and an adopted evidencebased modification, WFL has begun changing plaster casts at shorter intervals. ...
... Recently, with more experience and an adopted evidencebased modification, WFL has begun changing plaster casts at shorter intervals. 13 The tenotomy rate in this study was 80%, comparing favourably with 67% in Laara et al, 9 57% in Chu et al. 26 It should be noted that Dr Ponsetiadvised and performed the tenotomy in more than 90% of cases. 9 Parents' satisfaction is an important factor in any paediatric condition requiring their cooperation for effective intervention. ...
Article
Full-text available
Background: Every year in Bangladesh an estimated 3500-4000 children are born with a clubfoot deformity, which is approximately one of every 1000 children born in Bangladesh. Left untreated, the condition leads to lifelong deformity causing individual disability and potential unproductivity. Affected children grow up as burden to the family and ultimately leads to significant poverty.
... J Evid Based Med Healthc, pISSN -2349-2562, eISSN -2349-2570 / Vol. 8 / Issue 16 / Apr. 19,2021 Page 1069 ...
... 12,18 The Pirani score and Dimeglio classification can predict the recurrences, the number of casts required, and need for tenotomy, but cannot predict compliance with the foot abduction orthosis which is mandatory for a successful outcome in the long term. 19 Verbal reports concerning the use of the brace were used by us as the primary means of assessment. We have seen 53 children were not compliant with the brace and in many studies, poor compliance with a brace was the commonest cause of relapse. ...
Article
Full-text available
BACKGROUND Though the Ponseti method has become the popular and standard of care for clubfoot correction, relapse of clubfoot deformity following correction is not uncommon. The relapsed feet can progress from flexible to rigid if left untreated and can become as severe as the initial deformity. The purpose of this study was to analyse the relapse pattern in clubfeet that have undergone treatment with the Ponseti method. METHODS Between 2015 and 2017, 78 children (134 feet), 58 boys and 20 girls were included in this study. It was a prospective observational study of relapse patterns in idiopathic clubfoot after one year of completion of the Ponseti method of treatment. Pirani scoring system was used to identify the relapse. RESULTS Dynamic, fixed, and complete relapse patterns were observed in this study. Patients were categorised into two groups - bilateral and unilateral. In the bilateral group, 18 children (36 feet i.e. 23 %) had decreased ankle dorsiflexion, 5 had (10 feet i.e. 6 %) rigid equinus, 22 had (44 feet i.e., 29 %) dynamic forefoot adduction or supination and 5 had (10 feet i.e. 6 %) fixed adduction in forefoot and midfoot. Six children from the bilateral group showed complete relapse. Among the unilateral group, 8 children (8 feet i.e. 36 %) presented with decreased ankle dorsiflexion, 4 had (4 feet i.e. 18 %) rigid equinus relapse, 6 had (6 feet i.e. 27 %) dynamic forefoot adduction or supination and 4 had (4 feet i.e. 18 %) showed fixed forefoot adduction. CONCLUSIONS Dynamic forefoot adduction or supination pattern is common to relapse pattern in the bilateral group and dynamic hind-foot relapse was common in the unilateral group. Age at initial presentation, initial Pirani score, and the number of casts required were not significantly related to the incidence of relapse.
... In practice, the casting period and the recurrence of the deformity are among the common concerns of the parents. However, there are controversies about the correlation between these two parameters and the initial severity of the deformity measured by Dimeglio and Pirani scoring systems [4,5,[7][8][9]. ...
... Chu et al. studied on patients with clubfoot with different severities. They reported a low correlation between the total number of casts till the initiation of foot abduction orthosis and the two initial scoring systems [7]. However, in this study, we only entered patients with severe or very severe clubfoot who went under tenotomy. ...
Article
Full-text available
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.
... The task of Achilles tenotomy is to prevent occurrence of iatrogenic rocker-bottom foot deformity. [9][10][11][12][13] . In our study, tenotomy was applied in 53 of 67 feet (79.1%). ...
... They noted that the assessment can be done successfully after a long learning period, but there may be differences in the assessment of different observers. Chu et al evaluated the correlation between the number of casts and Dimeglio and Pirani scores in 185 feet of 123 patients [11] . They found a low correlation between both classification systems and the number of casts required to correct clubfoot. ...
Article
Full-text available
Objective: The aim of this study is to compare the clinical and radiological assessment of the Pirani and Diméglio scoring systems in clubfoot evaluation, as well as the efficiency of the Ponseti method. Design: Prospective study Setting: Subjects: Between 2010 and 2012, 41 patients (67 feet) who were diagnosed with idiopathic clubfoot and treated by the Ponseti method were evaluated clinically and radiographically. Clubfoot severity was assessed using both the Pirani score and the Dimeglio score, with each component of the scores documented. Interventions: Ponseti method was performed for conservative treatment. Standard casting procedure was followed during treatment and each clubfoot was scored with using Dimeglio and the Pirani classification system at every visit. In accordance with the data obtained, clinical and radiological improvements were evaluated from the beginning to the end of casting. Main outcome measure: Our hypothesis is to determine which most widely used clinical clubfoot scoring classification system is more consistent with radiologic evaluation and therefore, superior to each other and indicates both clinical and radiologic correction accurately. As secondary earning, effectiveness of Ponseti method on clubfoot was evaluated also. Results: The average Diméglio score was 13.58. The average Pirani score was 6.3 (0.5-9.0). Conclusion: The Diméglio and Pirani scoring systems, which are based on physical examination and used in clinical evaluation, are extremely effective in showing the clinical improvement.
... However, they do not account for the crucial factor of patient compliance with the FAbB, which is essential for achieving long-term successful outcomes. 8,15,[18][19][20][21][22][23][24][25][26][27] The number of casts required for casting phase was determined by Pirani score in our study. ...
... The Pirani score, developed by Pirani et al., is one of the numerous classification systems of clubfoot, and is a useful tool for the initial and follow up assessments of the disease [11,15,[29][30][31][32]]. The Pirani system had been validated and proven reliable to accurately quantify the severity of a clubfoot deformity, and is now routinely used in describing the outcomes of treatment [11,33]. ...
Article
Full-text available
Abstract Background: Congenital talipes equinovarus imposes some functional compromise on the foot, resulting in structural adaptation or modification of the local anatomy in conformity with the direction of the structural stress that subserves the abnormal function. The success or otherwise of treatment is a measure of the degree of reversal of these structural adaptations and functional deficits. The aim of this study was to evaluate the early treatment outcome in the background of late presentation among subjects in a new clubfoot program of a Nigerian university teaching hospital. Methodology: A 6-month prospective, descriptive and health facility-based cross-sectional study of early treatment outcome of congenital talipes equinovarus among children in a Nigerian university teaching hospital is presented. Results: Sixty-seven children met the inclusion criteria and were recruited for this study. There was a slight preponderance of males over the females, with a male to female ratio of 1.6: 1. The mean age of the study population was 31.6 ± 23.64 months. In 45 (67.2%) children, the clubfoot was bilateral and unilateral in 22 (32.8%). Idiopathic clubfoot was the commonest variant at the rate of 70.1%. Thirty-nine (58.2%) had percutaneous tenotomy (Achilles tendon tenotomy), while 28 (41.8%) did not. The mean of the total initial Pirani score (4.61±1.18) was higher than that of the total final Pirani score (0.81 ± 0.49), with p < 0.001. The mean Pirani score of the left foot (4.78 ± 1.08) in the subjects who had percutaneous tenotomy was higher than that of subjects (3.83 ± 1.88) who did not have percutaneous tenotomy (p = 0.03). The odd of subjects with callosity to achieve correction at 10 or more cast was 11.8 times that of the subjects without callosity. On a logistic regression model, total initial Pirani score and callosity were independently significant (p < 0.05) in being associated with ≥10 castings for correction. For a unit increase in total initial Pirani score, the relative risk ratio of requiring ≥10 cast was 3.49 when the other variables are held constant in the logistic regression model. The relative risk ratio of requiring ≥10 cast for correction increased by 1.03 for a unit monthly increase in the age of the subject. Conclusion: Late presentation of clubfoot for treatment was common in this study. The Pirani score remained a reliable tool for assessing severity and monitoring treatment of clubfoot, and was valid across all age groups of clubfoot subjects seen in this study. In this study, it predicted the need or otherwise for percutaneous tenotomy, and correlated positively with the number of casting sessions required for correction. Keywords: congenital clubfoot; late presentation; pirani score
... There was no correlation between the severity of the Pirani score and time until tenotomy, meaning that the greater severity of the foot is not an indication that patient will need more casts until correction. 23,24 This is a relevant fact as the progression of correction depends more on how the foot will answer to treatment than to practitioner's expertise. Patient's age, which often drives families away from less invasive treatment and may be a demotivating factor for the orthopedic surgeon to start the treatment, was not related to the number of casts (patients age from 14 to 180 days old). ...
Article
Full-text available
Objective Evaluate whether the experience of the surgeon could reduce Ponseti treatment time, and a number of cast changes, and the evolution of the Pirani Score. Methods 2 reference centers were evaluated. At Institution 1, 254 patients with idiopathic clubfoot (403 feet) were included, and at Institution 2, 32 patients (51 feet). At institution 1 (mentor), 3 intervals of 5 years each were analyzed. At the Institution 2 (trainee), 1 interval of 5 years was analyzed. Results Patients treated by the mentor had fewer casts compared with the trainee (p < 0.001). At Institution 1, the three mentor intervals showed differences in the number of casts (p < 0.05). A statistically significant difference was observed only in the first mentor interval (2000 to 2005, average of 3.47 casts) compared with the 2 other intervals (2005 to 2010; average of 2.6 casts and 2011 to 2015; average of 2.79 casts; p < 0.0001). Pirani score decreases the most until the third clinic visit. Conclusion The mentor’s greater expertise was associated with fewer casts and shorter time to obtain correction in isolated clubfoot, especially right after the first 5 years of practice. Progression of the Pirani score in both institutions occurs between the first and the third casts. Level of Evidence III; Therapeutic Study, Retrospective Comparative Study. Keywords: Learning Curve; Clubfoot; Education; Medical; Inservice Training
... After delivery, decisions related to the type of treatment depend on the Demiglio scoring system conducted by experienced orthopedic surgeons, which is a typical scoring method with high intraand interobserver reliability [10][11][12]. The four major components-equinus, varus, derotation of the calcaneal block, and forefoot adduction are assessed by manual examination and are used to evaluate reducibility. ...
Preprint
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Prenatal diagnosis of clubfoot traditionally relied on two-dimensional ultrasonography. To enhance diagnosis and predict postnatal outcomes, we examined the parameters that differentiate pathological clubfoot using three-dimensional ultrasonography. In our retrospective study, we examined the findings of prenatal ultrasound and the postnatal outcomes of pregnancies with suspected congenital clubfoot between 2018 and 2021. Based on the three-dimensional perspective, we measured the angles of varus, equinus, calcaneopedal block and forefoot adduction and compared the sonographic variables between the postnatal treated and non-treated groups. We evaluated 31 pregnancies (47 feet) with suspected clubfoot using three-dimensional ultrasonography. After delivery, a total of 37 feet (78.7%) underwent treatment involving serial casting only or additional Achilles tenotomy. The treated group showed significantly greater hindfoot varus deviation (60.5° vs. 46.6°, p=0.026) and calcaneopedal block deviation (65.6° vs. 26.6°, p <0.05) compared to the non-treated group. The calcaneopedal block had an area under the curve of 0.98 with a diagnostic threshold of 46.2 degrees (sensitivity of 97%, specificity of 90%, positive predictive value of 97%, and negative predictive value of 90%). During prenatal evaluation of clubfoot using three-dimensional ultrasonography, the calcaneopedal block deviation has the potential to predict postnatal treatment.
... After delivery, decisions related to the type of treatment depend on the Demiglio scoring system conducted by experienced orthopedic surgeons, which is a typical scoring method with high intra-and inter-observer reliability [12][13][14]. The four major components, equinus, varus, derotation of the calcaneal block, and forefoot adduction, are assessed by manual examination and are used to evaluate reducibility. ...
Article
Full-text available
Prenatal diagnosis of clubfoot traditionally relied on two-dimensional ultrasonography. To enhance diagnosis and predict postnatal outcomes, we examined the parameters that differentiate pathological clubfoot using three-dimensional ultrasonography. In our retrospective study, we examined the findings of prenatal ultrasound and the postnatal outcomes of pregnancies with suspected congenital clubfoot between 2018 and 2021. Based on the three-dimensional perspective, we measured the angles of varus, equinus, calcaneopedal block, and forefoot adduction and compared the sonographic variables between the postnatal treated and non-treated groups. We evaluated 31 pregnancies (47 feet) with suspected clubfoot using three-dimensional ultrasonography. After delivery, a total of 37 feet (78.7%) underwent treatment involving serial casting only or additional Achilles tenotomy. The treated group showed significantly greater hindfoot varus deviation (60.5° vs. 46.6°, p = 0.026) and calcaneopedal block deviation (65.6° vs. 26.6°, p < 0.05) compared to the non-treated group. The calcaneopedal block had an area under the curve of 0.98 with a diagnostic threshold of 46.2 degrees (sensitivity of 97%, specificity of 90%, positive predictive value of 97%, and negative predictive value of 90%). During prenatal evaluation of clubfoot using three-dimensional ultrasonography, the calcaneopedal block deviation has the potential to predict postnatal treatment.
... The Pirani score, developed by Pirani et al., is one of the numerous classification systems of clubfoot, and is a useful tool for the initial and follow up assessments of the disease [11,15,[29][30][31][32]]. The Pirani system had been validated and proven reliable to accurately quantify the severity of a clubfoot deformity, and is now routinely used in describing the outcomes of treatment [11,33]. ...
Article
Full-text available
Background: Congenital talipes equinovarus imposes some functional compromise on the foot, resulting in structural adaptation or modification of the local anatomy in conformity with the direction of the structural stress that subserves the abnormal function. The success or otherwise of treatment is a measure of the degree of reversal of these structural adaptations and functional deficits. The aim of this study was to evaluate the early treatment outcome in the background of late presentation among subjects in a new clubfoot program of a Nigerian university teaching hospital. Methodology: A 6-month prospective, descriptive and health facility-based cross-sectional study of early treatment outcome of congenital talipes equinovarus among children in a Nigerian university teaching hospital is presented. Results: Sixty-seven children met the inclusion criteria and were recruited for this study. There was a slight preponderance of males over the females, with a male to female ratio of 1.6: 1. The mean age of the study population was 31.6 ± 23.64 months. In 45 (67.2%) children, the clubfoot was bilateral and unilateral in 22 (32.8%). Idiopathic clubfoot was the commonest variant at the rate of 70.1%. Thirty-nine (58.2%) had percutaneous tenotomy (Achilles tendon tenotomy), while 28 (41.8%) did not. The mean of the total initial Pirani score (4.61±1.18) was higher than that of the total final Pirani score (0.81 ± 0.49), with p < 0.001. The mean Pirani score of the left foot (4.78 ± 1.08) in the subjects who had percutaneous tenotomy was higher than that of subjects (3.83 ± 1.88) who did not have percutaneous tenotomy (p = 0.03). The odd of subjects with callosity to achieve correction at 10 or more cast was 11.8 times that of the subjects without callosity. On a logistic regression model, total initial Pirani score and callosity were independently significant (p < 0.05) in being associated with ≥10 castings for correction. For a unit increase in total initial Pirani score, the relative risk ratio of requiring ≥10 cast was 3.49 when the other variables are held constant in the logistic regression model. The relative risk ratio of requiring ≥10 cast for correction increased by 1.03 for a unit monthly increase in the age of the subject. Conclusion: Late presentation of clubfoot for treatment was common in this study. The Pirani score remained a reliable tool for assessing severity and monitoring treatment of clubfoot, and was valid across all age groups of clubfoot subjects seen in this study. In this study, it predicted the need or otherwise for percutaneous tenotomy, and correlated positively with the number of casting sessions required for correction. Keywords: congenital clubfoot; late presentation; pirani score
... eir correlation was weak. [12] ere was a positive correlation between the age at initiation of treatment and the number of cast. e higher the age at presentation, the higher the number of cast needed to achieve correction. ...
Article
Full-text available
Objectives The Ponseti method is the mainstay of treatment of congenital talipes equinovarus deformity. This study aims to assess the relationship between the severity of the clubfoot deformity and the time it takes to correct the deformity using Dimeglio scoring system (DSS) with Ponseti protocol. Material and Methods A prospective observational study carried out for 15 months at the outpatient department of the National Orthopedic Hospital Enugu. Data collected included age at presentation, sex, laterality, grade of deformity, number of casts, and time to correction before the commencement of bracing. Those selected were clinically assessed using the DSS. Data obtained were analyzed using SPSS version 22.0. The association between time, the number of casts to correction, age of presentation, and severity to the time of correction of deformity was also determined. Results A total of 70 patients (116 feet) were recruited for the study. The mean age at presentation was 21 weeks with a male-to-female ratio of 3:2. The mean DSS at presentation was 10.72. The mean number of casts required to achieve correction was 5, with the last cast left in place for 3 weeks, which gave a mean correction time of 7 weeks. Severe deformity required more cast for correction. There is a weak relationship between age and time to correction. Conclusion Increase in the severity of the clubfeet was associated with longer correction time and a weak correlation with age at presentation. Dimeglio scoring is an effective, grading, and monitoring system.
... Although a positive correlation is reported between TFS at initial assessment and the number of casts required for correction, the correlation ranges from weak to strong (r = 0.12 to 0.72). [8][9][10][11][12][13][14] Although the need for tenotomy is also positively correlated with TFS at initial assessment, there is a lack of consensus on the cutoff score used for prediction. 9,14-16 Furthermore a lower TFS at initial assessment does not eliminate the need for a tenotomy. ...
Article
Background: The Pirani scale is used for the assessment of Ponseti-managed clubfoot. Predicting outcomes using the total Pirani scale score has varied results, however, the prognostic value of midfoot and hindfoot components remains unknown. The purpose was to (1) determine the existence of subgroups of Ponseti-managed idiopathic clubfoot based on the trajectory of change in midfoot and hindfoot Pirani scale scores, (2) identify time points, at which subgroups can be distinguished, and (3) determine whether subgroups are associated with the number of casts required for correction and need for Achilles tenotomy. Methods: Medical records of 226 children with 335 idiopathic clubfeet, over a 12-year period, were reviewed. Group-based trajectory modeling of the Pirani scale midfoot score and hindfoot score identified subgroups of clubfoot that followed statistically distinct patterns of change during initial Ponseti management. Generalized estimating equations determined the time point, at which subgroups could be distinguished. Comparisons between groups were determined using the Kruskal-Wallis test for the number of casts required for correction and binary logistic regression analysis for the need for tenotomy. Results: Four subgroups were identified based on the rate of midfoot-hindfoot change: (1) fast-steady (61%), (2) steady-steady (19%), (3) fast-nil (7%), and (4) steady-nil (14%). The fast-steady subgroup can be distinguished at the removal of the second cast and all other subgroups can be distinguished at the removal of the fourth cast [H (3) = 228.76, P < 0.001]. There was a significant statistical, not clinical, difference in the total number of casts required for correction across the 4 subgroups [median number of casts 5 to 6 in all groups, H (3) = 43.82, P < 0.001]. Need for tenotomy was significantly less in the fast-steady (51%) subgroup compared with the steady-steady (80%) subgroup [H (1) = 16.23, P < 0.001]; tenotomy rates did not differ between the fast-nil (91%) and steady-nil (100%) subgroups [H (1) = 4.13, P = 0.04]. Conclusions: Four distinct subgroups of idiopathic clubfoot were identified. Tenotomy rate differs between the subgroups highlighting the clinical benefit of subgrouping to predict outcomes in Ponseti-managed idiopathic clubfoot. Level of evidence: Level II, prognostic.
... Some studies showed moderate to good accuracy of the pre-Pirani and the pre-Dimeglio score in predicting the number of casts and the requirement of tenotomy, [8][9][10] whereas other studies found a poor correlation. 11,12 As we lack study in our setup, we were interested in determining the factors that could predict the need for tenotomy in treating idiopathic clubfoot using the Ponseti method. Our study suggests that the higher the pre-Pirani score, the higher the chances of tenotomy, similar to other studies. ...
Article
Introduction: Parents of children with clubfoot are likely to inquire about the need for tenotomy and about any factors that may be predictive. The present study was done to identify factors that may help predict the need for tenotomy in children undergoing Ponseti treatment for idiopathic clubfoot. Methods: A prospective observational study was conducted on patients under 5 years of age with idiopathic clubfoot and no previous treatment history treated at Hospital and Rehabilitation Centre for Disabled Children. The relationship between the Pirani score, Dimeglio score, age, and passive ankle dorsiflexion (DF) and the need for heel cord tenotomy was analyzed using appropriate statistical methods. Results: Of 83 patients (125 feet) with a mean age of 6 months, 93 feet (74.4%) required a percutaneous tenotomy. The mean initial Pirani and Dimeglio score for 125 club feet was 4.5 (SD=1.68) and 13.5 (SD=6.1), respectively. The mean initial passive ankle DF was −40.4 (SD=22.31). The Dimeglio (P=0.000), Pirani scores (P=0 .000), and passive ankle DF (P=0.000) showed significant association with the need for tenotomy. Conclusions: This study shows a strong association between initial Pirani and Demiglio scores and initial passive ankle DF as predictive of a heel cord tenotomy. However, age, sex, and laterality were not associated with the need for tenotomy.
... findings encapsulate and confirm what has been reported by other authors: more casting required (average of 7), 100% rate of Achilles lengthening, and a relapse rate of 53%. 22 Half of the relapses were managed by repeat casting and/or repeat tenotomy, but 4 feet required extensive surgical releases. ...
Article
Full-text available
Along with syndromic or neuromuscular clubfoot, complex (“atypical”) clubfoot represents a category of clubfoot that is difficult to treat using the Ponseti method. It is important to identify this type of foot early because the treatment and prognosis are different from that of idiopathic clubfoot. Some cases can be seen from birth while other cases are iatrogenically caused, but in both instances the anatomic features and treatment are the same. In infantile cases, consideration to complex idiopathic clubfeet should be given with the anatomic presence of a deep plantar crease and hyperextended first toe. In iatrogenic cases, the provider may be alerted by cast failure and slippage. Parents should be made aware of the increased difficulty in treating complex clubfoot, and be prepared for additional cast time, early or repeat Achilles tenotomy, or difficulty with brace wear.
... The Pirani score (PS) is extensively used in the clinical settings to assess the severities of clubfoot deformity. In the current clubfoot management practice, the number of casts needed to repair clubfoot is determined by the Pirani score at the outset [6][7][8] . ...
Article
Full-text available
Abstract. – OBJECTIVE: Clubfoot is a growing public health concern in Bangladesh, with the incidence of approximately 0.64 to 6.8 in every 1000 live births. For over a decade, Ponseti method has been considered a gold standard for treating the clubfoot. Despite few studies have been estimating the number of casts required to correct the clubfoot deformities by Ponseti method, the subject of interest has always remained. Therefore, this current study aimed to investigate the significant predictive factors for the number of casts required to correct congenital clubfoot. PATIENTS AND METHODS: In this retrospective cohort study, we used Bayesian Poisson Regression Model to investigate the influencing factors that could predict how many casts are needed to correct the clubfoot. We included 69 patients with 99 affected feet, who completed their corrective phase of treatment in the Ponseti method. For this cohort study, we integrated only pre-tenotomy casting data with no age restrictions. We used Bayesian Poisson regression analysis technique to estimate the predictive factors. RESULTS: In Bayesian Poisson model, age was the most influencing predictive factor (24.3%) for increasing the number of castings to correct the clubfoot deformity. The clubfoot offspring of the ≤1-year-old was positive, and the incidence rate increased significantly with the casting number. The number of Ponseti casts in male clubfoot children was 28% higher than in female, and this was marginally statistically significant. There was no marked change estimated in the pattern of clubfoot, foot involvement and Pirani score of the severity. CONCLUSIONS: We concluded that the age factor may influence the number of casts required for the correction of clubfoot and specifically ≤ 1-year-old children are highly impacted. Treating clubfoot at an early age is suggested in this study to increase the success of clubfoot treatment and decrease the risk of relapse.
... 11,12,13 En definitiva, el presente trabajo confirma que el éxito del manejo del PEVAC por el método Ponseti está directamente relacionado con la adherencia al tratamiento por parte del paciente y sus padres, coincidiendo con otros estudios. 14,15,16 También lo confirma como el estándar de oro en el tratamiento de los pacientes con esta patología, debido a la cantidad de recursos humanos y materiales necesarios para realizarlo. Gaytán-Fernández S y cols. ...
Article
Introduction: Congenital talipes equino varus (club foot) is a frequent congenital deformity of the foot. The Ponseti method is the gold standard for treatment. It consists of foot manipulation with weekly serial cast, minimally invasive surgery and Dennis-Brown bar up to five years. Objective: To describe the follow-up of patients with PEVAC treated using the Ponseti method. Material and methods: Descriptive, longitudinal study, during 2013-2019, in patients with PEVAC managed with Ponseti method. We included patients with uni- or bilateral club foot, under two years of age, without prior surgery, whose parents signed informed consent. Patients with other malformations were excluded. Serial weekly cast was placed for 4-8 weeks, a tenotomy of the Achilles tendon was performed, and cast for three more weeks; then reverse footwear with Dennis-Brown bar. The revisions were recorded at day zero, at eight weeks and every three months up to five years of age. Correction of deformity and pain on walking was assessed. Results: There were 22 patients; 17 (77.3%) corrected more than 90% of the deformity, with adequate functionality and 86.3% without pain on gait, mean follow-up 3.9 years (1-7 years); six patients relapsed (27.27%) due to poor attachment, one re-treated with cast, and five with anterior tibial transfer, all successfully. Conclusions: The club foot managed with Ponseti method corrects more than 90% of the deformity and without or minimal pain with good adherence to treatment. We had a 27.27% recurrence in our series.
... 11,12,13 En definitiva, el presente trabajo confirma que el éxito del manejo del PEVAC por el método Ponseti está directamente relacionado con la adherencia al tratamiento por parte del paciente y sus padres, coincidiendo con otros estudios. 14,15,16 También lo confirma como el estándar de oro en el tratamiento de los pacientes con esta patología, debido a la cantidad de recursos humanos y materiales necesarios para realizarlo. Gaytán-Fernández S y cols. ...
Article
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Introducción: El pie equinovaro aducto congénito (PEVAC) es una deformidad congénita frecuente del pie. El método Ponseti es el estándar de oro para el tratamiento. Consiste en la manipulación del pie con yesos seriados semanales, una cirugía mínimamente invasiva y barra Dennis-Brown hasta los cinco años. Objetivo: Describir el seguimiento de los pacientes con PEVAC tratados mediante método Ponseti. Material y métodos: Estudio descriptivo, longitudinal, durante 2013-2019, en pacientes con PEVAC manejados con método Ponseti. Se incluyeron pacientes con PEVAC uni- o bilateral, menores de dos años, sin cirugía previa, cuyos padres firmaron consentimiento informado. Se excluyeron pacientes con otras malformaciones. Se colocó yeso semanal seriado por cuatro a ocho semanas, se realizó tenotomía del tendón de Aquiles y yeso por tres semanas más; luego calzado de horma inversa con barra Dennis-Brown. Se registraron las revisiones al día cero, a las ocho semanas y cada tres meses hasta los cinco años de edad. Se valoró la corrección de la deformidad y el dolor a la marcha. Resultados: Fueron 22 pacientes; 17 (77.3%) corrigieron más de 90% de la deformidad, con adecuada funcionalidad y 86.3% sin dolor a la marcha, seguimiento medio de 3.9 años (uno a siete años); seis pacientes tuvieron recidiva (27.27%) por mal apego, uno retratado con yesos y cinco con transferencia de tibial anterior, todos con éxito. Conclusiones: El PEVAC manejado con método Ponseti corrige más de 90% de la deformidad y sin o mínimo dolor con buen apego al tratamiento. Tuvimos una recidiva de 27.27% en nuestra serie.
... There are many assessment scoring systems to classify CTEV according to severity, such as DiMeglio and Pirani scores. Recent studies have exposed that there is no correlation between severity and the complexity of the treatment, and so the prognosis of the scoring systems is being questioned [10][11][12]. ...
Article
Full-text available
Introduction: The Congenital talipes equinovarus (CTEV), also known as clubfoot has an incidence of 1 or 2 per 1.000 live births in Europe. Nowadays, the predominant treatment is Ponseti Method, which includes manipulation and casting. Objective: To analyses and compare with a control group, the quality of life, function and podiatric measures of the patient with CTEV treated with the Ponseti Method 18 years after treatment. Materials and Methods: A comparative study of 12 adolescent CTEV patients (19 feet) and a Control. Inclusion criteria in CTEV group: Having being treated with Ponseti method, no surgical releases and more than 18 y.o. Laaveg - Ponseti score and SF - 36 are used for quality of life and functionality. The maximum pronation test, the supination resistance test, Lunge’s test and FPI used as podiatric assessment Results: Everyone got an evaluation between excellent and good in the Laaveg - Ponseti test. In the SF - 36 questionnaire the results obtained were similar between the groups. but the podiatric evaluation was clearly different. Only 4 from the 12 CTEV patients had been treated by a podiatrist. Discussion: The study shows similar results between both groups, Concerning the Laaveg - Ponseti test both groups display similar results and in the SF - 36 test the results showed a slight improvement in the Clubfoot group, however the results are not statistically significant. The podiatric evaluation results are different between both groups. Despite function of clubfeet after Ponseti Method in adolescents is very good we can detect mild structural changes with podiatric tests. Conclusion: In terms on functionality and quality of life there are no significative differences between clubfeet and control cases but podiatric evaluation shows statistical differences between both groups. Level of Evidence: II Or 2b (Oxford Level of evidence). Keywords: Clubfoot; Adolescent; Ponseti Method; Function; Quality of Life; Podiatry
... Chu et al, reported that the Catterall/Pirani and Demeglio/Bensahel classifications had low correlation with the number of Ponseti casts needed for the correction of CTEV and suggested that it is necessary to develop new classifications to help predict the time of treatment and the risk of relapse. 51 However, Dyer and Davis reported that the Pirani score has a predictive value, and those with scores higher than four tend to require more than four casts for correction. 52 We believe that this score presents a lower value in neglected cases and has a poor predictive or prognostic value, but it may occasionally be useful during treatment follow-up. ...
Article
Objective: Ponseti method is suitable to treat neglected clubfoot after the walking age. However, limited evidence exists on its effectiveness, outcomes and rate of relapse. Methods: 429 clubfeet in 303 patients with no previous treatment and older than one-year were treated with the Ponseti method in 15 centers from seven countries. The median age at treatment onset was three years, and the median follow-up of 1.3 years. Standard Ponseti Method was applied. Bilateral abduction brace was recommended after casting. Patients were classified according to group ages (<2 years, 2-4 years, >4-8years, >8 years). Feet were evaluated by Pirani score and a clinical outcome classification. Relapses were described in a subset of 103 clubfeet with minimal follow-up of two years. Results: Ponseti method was able to correct the deformity in 87% (373 of 429) of neglected clubfeet, after a mean of 6.8 casts. Residual equinus was treated with percutaneous sectioning of the Achilles tendon in 356 (83%) of 429 clubfeet. A bilateral foot abduction brace was prescribed and used in 70% of children. Relapses occurred in 31% (32 of 103) of clubfeet and were associated with age less than 4 years at treatment onset, and bracing noncompliance. Conclusion: The Ponseti method is effective to correct neglected clubfeet. Relapses occurred in one-third of clubfeet, mainly in children younger than four years and in noncompliance with the brace. Our study reinforces the recommendation for the Ponseti method with no major modification to treat neglected clubfoot in patients after walking age.Level of Evidence: IV.
... In our study, we used the Pirani score as a target parameter to describe the severity of deformity, consisting of midfoot and hindfoot contracture part, and can range from 0 to 6 points [14]. However, this classification is not to be viewed without criticism. ...
Article
Full-text available
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 (TE) 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.
... In our study, we used the Pirani Score as a target parameter to describe the severity of deformity, consisting of midfoot and hindfoot contracture part and can range from 0 to 6 points (14). However, this classi cation is not to be viewed without criticism. ...
Preprint
Full-text available
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 weather 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 (TE) 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. The 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.
... In our study, we used the Pirani Score as a target parameter to describe the severity of deformity, consisting of midfoot and hindfoot contracture part and can range from 0 to 6 points (14). However, this classification is not to be viewed without criticism. ...
Preprint
Full-text available
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 weather 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 (TE) 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) and. During treatment, mental resilience improved (p = 0.015) significantly. The Spearmann 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.
... These scores have variable reproducibility 10,11 and are not prognostic. 12,13 Classification of clubfoot later in its treatment course becomes increasingly challenging. Both the Pirani and Dimeglio scores have been adapted, albeit still in a descriptive fashion, for use in the later stages of treatment but have not been validated. ...
Article
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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.
Article
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Resumo O pé torto congênito é uma deformidade complexa, frequente e que pode ser desafiadora mesmo em mãos experientes. O método de Ponseti continua sendo universalmente aceito como padrão ouro para o tratamento e ótimos resultados são esperados na maioria dos casos com o manejo adequado da técnica. As recidivas continuam sendo um problema e estão associadas principalmente à não adesão ao uso da órtese. No entanto, outros fatores podem influenciar o risco de recidiva e contribuir para um resultado insatisfatório. A transferência do tibial anterior equilibra as forças deformantes e ajuda na correção, desde que o pé seja flexível. A deformidade recidivada não será corrigida espontaneamente, requer tratamento. Procedimentos cirúrgicos adjuvantes devem fazer parte do arsenal terapêutico do ortopedista.
Article
Background: Although the Ponseti method has been used with great success in a variety of nonidiopathic clubfoot deformities, the efficacy of this treatment in clubfeet associated with Down syndrome remains unreported. The purpose of this study is, therefore, to compare treatment characteristics and outcomes of clubfoot patients with Down syndrome to those with idiopathic clubfoot treated with the Ponseti method. Methods: An Institutional Review Board-approved, retrospective review of prospectively gathered data were performed at a single pediatric hospital over an 18-year period. Patients with either idiopathic clubfeet or clubfeet associated with Down syndrome who were less than 1 year of age at the outset of treatment were treated by the Ponseti method, and had a minimum of 2 year's follow-up were included. Initial Dimeglio score, number of casts, need for heel cord tenotomy, recurrence, and need for further surgery were recorded. Outcomes were classified using the Richards classification system: "good" (plantigrade foot +/- heel cord tenotomy), "fair" (need for a limited procedure), or "poor" (need for a full posteromedial release). Results: Twenty clubfeet in 13 patients with Down syndrome and 320 idiopathic clubfeet in 215 patients were identified. Average follow-up was 73 months for the Down syndrome cohort and 62 months for the idiopathic cohort. Down syndrome patients presented for treatment at a significantly older age (61 vs. 16 d, P=0.00) and with significantly lower average initial Dimeglio scores than the idiopathic cohort (11.3 vs. 13.4, P=0.02). Heel cord tenotomy was performed in 80% of the Down syndrome cohort and 79% of the idiopathic cohort (P=1.00). Recurrence rates were higher in the Down syndrome cohort (60%) compared with the idiopathic group (37%), but this difference was not statistically significant (P=0.06). Need for later surgical procedures was similar between the 2 cohorts, though recurrences in the Down syndrome group were significantly less likely to require intra-articular surgery (8.3% vs. 65.5%, P=0.00). Clinical outcomes were 95% "good," 0% "fair," and 5% "poor" in the Down syndrome cohort and 69% "good," 27% "fair," and 4% "poor" in the idiopathic cohort (P=0.01). Conclusions: Despite the milder deformity and an older age at presentation, clubfeet associated with Down syndrome have similar rates of recurrence and may have better clinical outcomes when compared with their idiopathic counterparts. When deformities do relapse in Down syndrome patients, significantly less intra-articular surgery is required than for idiopathic clubfeet. Level of evidence: Level III.
Book
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Proper notification is the first step towards the organization of national surveillance of congenital anomalies. By strengthening our existing system, we will be able to evaluate the real impact of anomalies on populations, in addition to producing useful information to promote prevention and care measures adjusted to the reality of each part of the world. For this, it is essential that professionals and institutions recognize the importance of congenital anomalies in the context of public health and register all those diagnosed at birth in official information systems.
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La notificación adecuada en los sistemas de información oficiales es el primer paso hacia el establecimiento de una vigilancia nacional de anomalías congénitas. Fortaleciendo los sistemas existentes, será posible evaluar el impacto real de las anomalías en las poblaciones, además de producir información útil para promover medidas de prevención y atención ajustadas a la realidad de cada lugar. Por tanto, es fundamental que los profesionales e instituciones reconozcan la importancia de las anomalías congénitas en el contexto de la salud pública y registren a todas las anomalías congénitas diagnosticadas al nacer en los sistemas oficiales de información.
Article
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Clubfoot or known as Talipes Equinovarus (TEV), is a common anomaly in world population of newborn. This condition was reported in many studies as isolated anomaly but may come with other associated congenital anomalies. This review aims to further discuss the classification of TEV, its etiopathogenesis and how to diagnosis with all kind of VACTERL associated anomaly together with TEV. Many studies show a range of incidence between 1.1-4.5 per 1000 live birth per year and there is a chance of its condition followed by multiple congenital anomalies. Even though, this anomaly was an idiopathic condition, but still there is multifactorial etiology for its in which revealed through many studies also. Nevertheless, the orthopedic management of TEV with or without other congenital conditions still continue to develop to make a better improvement for the patients.
Article
Introduction Clubfoot, mainly CTEV, is a complex three-dimensional deformity challenging physicians from ancient times. Among a thousand babies born, one to six suffer from clubfoot deformity; that is, in India alone, around 35,000 need treatment for clubfoot annually. This review summarizes the various practices of clubfoot assessment, noninvasive treatment, and engineering aspects of clubfoot treatment. The shortcomings of assessment methods and challenges with implementation of treatment methods are also presented. Methods A narrative review of all related research papers available to authors was carried out. Results Various clubfoot assessment methods have been developed to help physicians understand the severity of the problem and predict treatment parameters. The Pirani score and Dimeglio score are used predominantly for the assessment of deformity. However, these methods suffer from implementation-related limitations. Noninvasive methods, namely, Kite's method, functional physiotherapy method, and Ponseti method, are used in practice for treatment. The Ponseti method is the most popular with parents and physicians and is considered the gold standard for the treatment of clubfoot. However, it also suffers from various implementation issues, like treatment cost and lack of experts, particularly in low- and middle-income countries (LMICs). Engineers are using various technologies like computer-aided design (CAD)/computer-aided engineering (CAE) and additive manufacturing for modeling and analysis of clubfoot. Engineers have also attempted to develop corrective and maintenance orthosis for CTEV treatment. Conclusions Because newer and newer technologies are becoming accessible for interdisciplinary use, there is a need to apply contemporary technologies, especially to develop a corrective orthosis so that the current challenges of clubfoot assessment and treatment are addressed. The corrective orthosis should be based on Dr Ponseti's insights into clubfoot biomechanics. Clinical Relevance There is a need to explore contemporary technologies like data acquisition and CAD/CAE to address CTEV assessment–related issues. A corrective orthosis based on the understanding of the foot biomechanics for treatment can solve the various implementation-related challenges of the Ponseti method, particularly in low-resource settings.
Article
Clubfoot or talipes equinovarus deformity is one of the most common anomalies affecting the lower extremities. This review provides an update on the outcomes of various treatment options used to correct clubfoot. The ultimate goal in the treatment of clubfoot is to obtain a fully functional and pain-free foot and maintain a long-term correction. The Ponseti method is now considered the gold standard of treatment for primary clubfoot. Relapse is common after primary treatment with the Ponseti method, and other interventions are discussed that are used to provide for long-term successful outcomes.
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O principal objetivo deste livro é fornecer informações teóricas, epidemiológicas e práticas sobre as anomalias congênitas no Brasil, de modo a fortalecer o registro delas no Sistema de Informações Sobre Nascidos Vivos (Sinasc) e possibilitar a qualificação das políticas de saúde. Esta é a primeira edição do livro Saúde Brasil: anomalias congênitas prioritárias para a vigilância ao nascimento, elaborado pela Coordenação-Geral de Informações e Análises Epidemiológicas (Cgiae), do Departamento de Análise em Saúde e Vigilância de Doenças Não Transmissíveis (DASNT), da Secretaria de Vigilância em Saúde (SVS) do Ministério da Saúde, em parceria com a Universidade Federal do Rio Grande do Sul (UFRGS) e o Hospital das Clínicas de Porto Alegre (HCPA), e que também contou com a participação de um grupo de especialistas na temática .
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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.
Article
Background: Amniotic band syndrome (ABS) is a congenital disorder resulting in fibrous bands that can cause limb anomalies, amputations, and deformities. Clubfoot has been reported in up to 50% of patients with ABS. The purpose of this study is to compare treatment characteristics and outcomes of clubfoot patients with ABS to those with idiopathic clubfoot treated with the Ponseti method. Methods: An Institution Review Board (IRB) approved retrospective review of prospectively gathered data was performed at a single pediatric hospital over a 20-year period. Patients with either idiopathic clubfeet or clubfeet associated with concomitant ABS who were <1 year of age and treated by the Ponseti method were included. Initial Dimeglio score, number of casts, need for heel cord tenotomy, recurrence, and need for further surgery were recorded. Outcomes were classified as "good" (plantigrade foot±heel cord tenotomy), "fair" (need for a limited procedure), or "poor" (need for a full posteromedial release). Results: Forty-three clubfeet in 32 patients with ABS, and 320 idiopathic clubfeet in 215 patients were identified. Average age at last follow up was not different between ABS and idiopathic cohorts (7.4 vs. 5.2 y, P=0.233). Average Dimeglio score was lower in the ABS cohort (12.3 vs. 13.7, P=0.006). Recurrence rate was significantly higher in the ABS (62.8%) compared with idiopathic cohort (37.2%) (P=0.001). Clinical outcomes were significantly better in the idiopathic cohort (69.4% "good", 26.9% "fair", 3.8% "poor") compared with the ABS cohort (41.9% "good", 34.9% "fair", and 23.3% "poor") (P<0.001). Within the ABS cohort, no significant differences in clinical outcomes were found based upon location, severity, or presence of an ipsilateral lower extremity band. Conclusion: Clubfeet associated with ABS have higher rates of recurrence, a greater need for later surgery, and worse clinical outcomes than idiopathic clubfeet. This information may prove helpful in counseling parents of infants with ABS associated clubfeet. Level of evidence: Level III.
Article
Objectives: A prospective study to find a correlation between the severity of clubfoot and the number of casts required for the correction was conducted. The relationship of early relapse with the severity of the deformity was also studied. Materials and methods: A total of 42 infants (61 feet) with primary and idiopathic clubfeet were included in the study. Previously treated and clubfeet due to secondary causes were excluded. All clubfeet were treated by the Ponseti method, and the Pirani score, Dimeglio score and Foot Bimalleolar (FBM) angle were taken at presentation and before every casting and at 6 months of follow-up. Results: The average age of the child at presentation was 24 days, the average initial Pirani score was 4.172, the average initial Dimeglio score was 14.36 and the average FBM angle was 63.87 degrees. The average number of corrective casts given was 5.08 (range 2-8). The regression analysis showed a low correlation between Pirani and Dimeglio scores with the number of casts. There was no correlation between FBM angle and casting. Eleven of the 61 feet had a relapse (18%). Ten of 11 relapsed feet had a midfoot Pirani score of equal to or more than 2. Conclusion: The regression analysis shows a low correlation between Pirani and Dimeglio scores with the number of casts. There was no correlation between FBM angle and casting. Midfoot score equal to or more than 2 is a significant risk factor for relapse.
Article
Clubfoot, or talipes equinovarus, is the most common pediatric orthopedic deformity requiring treatment. Although the deformity may appear to be severe, particularly when first discovered after birth, treatment is successful in the vast majority of cases. This article describes the diagnostics, classification, pathological anatomy and treatment of clubfoot. In addition, the treatment alternatives to the widely used Ponseti method are presented and the counselling for parents of affected children is discussed.
Article
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.
Article
The aim of this study is to evaluate children in middle childhood with clubfoot treated with Ponseti method vs posterior-only release and to compare their results to a control group with 4 modules (physical examination, gait study, radiographic measurements, and questionnaires). From 01/01/2004 until 01/01/2009, 31 children (45 feet) were treated with the posterior-only release protocol and 22 patients (34 feet) were treated with the Ponseti method. In 2016, patients were evaluated and compared with 25 children without neuromuscular disorders. Parents completed 3 outcome questionnaires. Radiographs evaluated residual deformity and osteoarthritis. A physical examination and a 3-dimensional gait analysis were performed to evaluate range of motion, kinematic, and kinetic data. Recurrence rate was similar between treatment groups; however, type of surgery to treat residual deformity was more aggressive in the posterior-only release (91% required major surgery), p = .024. Radiographic examination showed similar residual deformity with greater hindfoot varus in posterior-only release (68%), p = .02. Reduced cadence, increased stance dorsiflexion, calcaneus gait and forced eversion prior to swing were the main characteristics of gait in posterior-only release. Four (11%) feet treated with posterior-only release vs 11 (33%) feet treated with Ponseti method had a normal gait, p = .016. Our study showed that biomechanical function and long-term outcomes of children in middle childhood treated with the Ponseti method more closely compare with healthy individuals than those treated using posterior-only surgical technique.
Article
Congenital talipo-equino-varus (CTEV) is one of the most common congenital deformities affecting children in India with an incidence of 1.19/1000 live births. Ponseti treatment regimen has been established as the gold standard of care for idiopathic clubfoot. Quantitative and qualitative analysis of the results of Ponseti management in early presenting idiopathic clubfoot cases, with a minimum follow-up of three years after correction. We retrospectively analysed the data of 122 children (comprising a total of 191 feet) who were treated for clubfoot by the standard Ponseti method with a minimum 3-year follow-up post-correction at our clinic. All cases were treated under the supervision of a single senior Paediatric Orthopaedic Surgeon. The mean age at onset of treatment was 2.3 months. Mean follow-up period was 4.2 years. The mean number of casts applied was 6.7. The mean duration of treatment until the application of splint was 9.5 weeks. The mean Pirani score at the commencement of treatment was 4.5. At the completion of treatment (around 3.6 years of age), the Dimeglio score was 'Benign' (Good) in 106 cases, 'Moderate' (Fair) in 11 cases and 'Severe/Very Severe' (Poor) in 5 cases. The P-value was calculated to be 0.8 for the sex-wise comparison of the treatment outcome. Ponseti method of nonoperative treatment for idiopathic clubfeet remains a gold standard for all cases treated during infancy. Identifying atypical clubfeet is important as their prognosis ought to be guarded. Despite facing problems at various stages of management, adhering to the basic treatment principles laid down by Ponseti helps in achieving good outcomes in majority. Level of Evidence: IV.
Article
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.
Article
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Objective: The objective of the study was to evaluate the incidence of nausea-vomiting according to the body mass index (BMI). Design: Prospective, case-control study Setting: Department of Anesthesiology and Reanimation, Konya Education and Research Hospital, Konya, Turkey Subjects: We prospectively enrolled 120 parturients with term pregnancy, aged 18 - 40 years and who were scheduled for elective caesarean section (C/S) under spinal anesthesia. Patients were divided into 2 groups, as obese (BMI ≥ 30) and non-obese (BMI < 30). We also recorded the incidence of nausea and vomiting within 15 minutes after spinal anesthesia. Intervention: Non-interventional Main outcome measure: We have investigated the effect of obesity on the incidence of nausea-vomiting in elective C/S under spinal anesthesia. Results: There were no significant differences between the two groups with regards to ASA physical status, age, gestational age and smoking, all measurement times (p = 0.495, p = 0.780, p = 0.268, p >0.05, respectively) and incidence of nausea-vomiting. Mean blood pressure was significantly lower in Group II compared to Group I at the beginning of surgery and 20th minute of the surgery (p <0.001 and p <0.001, respectively). Conclusions: In the study sample, pre-gestational and gestational BMI ≥30 kg/m2 was not a risk factor for nauseavomiting after spinal anesthesia in patients undergoing C/S. However, hypotension was found to significantly influence nausea-vomiting of the patients.
Article
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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
Article
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.
Article
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Placenta accreta is a common term used for defining a clinical condition which part or all of the placenta attaches to the myometrium that difficult to remove. Placenta accreta is a placental disorder which has been around for a long time and became a resurgence in Indonesia since 2016 with its incidence reached 2% and is still increasing until now. Placenta accreta is one of the most terrifying conditions faced by gynecologists and resulted in the increase of mortality and morbidity of pregnant women in Indonesia. In the United States, the incidence increased from less than 1 per 2000 pregnancies in 1980 to around 1 per 500 pregnancies until recently. The increased cases of placenta accreta is always directly proportional to the cesarean delivery rates.
Chapter
Embryological differentiation of the foot is noticeable by the fifth intrauterine week. By the end of the fifth week, condensation of the mesenchymal tissue has resulted in the formation of tarsal bone anlage (earliest developmental models). Tissue differentiation to precartilage and cartilage follows and all skeletal elements of the foot have begun to chondrify by 7 weeks with the exception of the distal phalanx of the little toe. By the end of the second month, the outline of each bone is becoming distinct [1–3]. Homogenous interzones develop at the ankle and between all tarsal, tarsal-metatarsal, metatarsal-phalangeal, and interphalangeal joints with the three-layered interzone developing earliest at the ankle and metatarsal-phalangeal joints at the end of the embryonic period (8 weeks). Cavitation with vascularized synovial tissue is seen in most joints of the foot at 9–11 weeks (early fetal period). A proximodistal sequence of development unfolds. By the end of the embryonic period (8 weeks), the foot resembles that of the adult in most details. All elements of the foot destined to become bone have begun to chondrify (except the distal phalanx of the little toe) by 7 weeks of embryonic life. Anomalies of the skeletal elements (such as tarsal coalition) form very early. The articular surfaces of the ankle joint and of the other joints of the foot reach a high degree of differentiation before the resorption phase of the interzone begins around 8 weeks of age. Hesser noted that the articular surfaces of the ankle joint reach a high degree of differentiation even before joint cavitation is complete [4]. The talonavicular and calcaneocuboid joints also reach close to their final shapes very early. Straus also stated that the joints of the foot are laid down in their definitive form by the ninth intrauterine week [5]. Cavitation of the interzone to form the synovial joints begins first at the ankle and progresses distally, forming last in the interphalangeal joints. O’Rahilly et al. further reviewed the skeletal development of the foot [6]. The prenatal development of the human foot has been well studied and described by Gardner et al. who reviewed the extensive developmental literature as well as assessing 184 human embryos and fetuses.
Article
Background: The Dimeglio score (DS) is widely used to assess clubfoot severity, but its ability to predict long-term outcomes following Ponseti treated isolated clubfoot (IC) is controversial. This study tested the association between the initial DS and its individual parameters with the number of Ponseti clubfoot casts required to achieve correction and the rate of early recurrence following treatment. Methods: Data were retrospectively collected from patients who underwent treatment of IC between March 2012 and March 2015 and were followed for ≥2 years. DSs were collected at the initial casting visit. The number of Ponseti casts required to achieve clubfoot correction before tenotomy and recurrence of deformity were collected as the primary outcome variables. Recurrence was defined as any loss of correction leading to repeat casting or tenotomy during the bracing phase. Negative binomial and logistic regression analyses were used to test the association between the 8 Dimeglio parameters and number of casts and incidence of recurrence, respectively. Results: A total of 53 patients (37 male and 16 female) were included in the study. The median number of casts required to achieve an acceptable correction was 5 (range, 2 to 16). The incidence of recurrence was 24.53% (13/53). An increase in derotation, varus, equinus, muscle condition, and total DSs at the initial cast visit were associated with a significant (P<0.05) increase in the number of casts required to achieve an acceptable correction. The derotation parameter [rate ratio: 1.30, 95% confidence interval (CI): 1.13-1.50, P=0.0003] was most strongly associated with number of casts. Total DSs at initial visit was the only variable significantly associated with the incidence of deformity recurrence (odds ratio: 1.36, 95% confidence interval: 1.01-1.84, P=0.0482). Conclusion: Initial DS is correlated with the number of casts required for correction in Ponseti treated IC. DS may help physicians establish realistic expectations for families with regard to the length of treatment and the possibility of recurrence following Ponseti treatment. Level of evidence: Level II-retrospective prognostic study.
Article
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We have assessed the reliability of four classification systems for club foot. Four observers evaluated nine children (18 feet) at different stages in the first six months of life, a total of 180 examinations. Each observer independently assessed all feet according to the classification systems described by Catterall, Diméglio et al, Harrold and Walker, and Ponseti and Smoley. The variation between observers was assessed using the kappa test which for no more agreement than chance has a value of 0, and for complete agreement between observers a value of 1. The kappa values varied between 0.14 and 0.77 depending on which classification system was used. The system of Diméglio et al was found to have the greatest reliability. Our findings suggest that current classification systems for the analysis of congenital talipes equinovarus are not entirely satisfactory.
Article
Full-text available
e have assessed the reliability of four classification systems for club foot. Four observers evaluated nine children (18 feet) at different stages in the first six months of life, a total of 180 examinations. Each observer independently assessed all feet according to the classification systems described by Catterall, Diméglio et al, Harrold and Walker, and Ponseti and Smoley. The variation between observers was assessed using the kappa test which for no more agreement than chance has a value of 0, and for complete agreement between observers a value of 1. The kappa values varied between 0.14 and 0.77 depending on which classification system was used. The system of Diméglio et al was found to have the greatest reliability. Our findings suggest that current classification systems for the analysis of congenital talipes equinovarus are not entirely satisfactory.
Article
Full-text available
Treatment with the Ponseti method corrects congenital idiopathic clubfeet in the majority of patients. However, some feet do not respond to the standard treatment protocol. We describe the characteristics and treatment results of these complex idiopathic clubfeet. We identified 50 patients (75 clubfeet) from 762 consecutive patients treated at five institutions. Clinically, complex clubfeet were defined as having rigid equinus, severe plantar flexion of all metatarsals, a deep crease above the heel, a transverse crease in the sole of the foot, and a short and hyperextended first toe. The Achilles' tendon was exceptionally tight and fibrotic up to the middle of the calf. Correction was achieved in all patients by modifying the Ponseti manipulation and casting technique. Correction required an average of five casts (range, 1-10 casts). Two patients (4%) not initially recognized as having complex clubfeet had a posterior release with tendo Achillis lengthening. There were seven relapses that responded to casting. Three patients had a second tenotomy. Modifying the treatment protocol for complex clubfeet successfully corrected the deformity without the need for extensive corrective surgery.
Article
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The outcome of clubfoot treatment is the result of several factors such as severity, type of treatment, and measurement instruments. We compared two intervention groups with two assessment procedures. 16 children were treated consecutively with intensive stretching according to the Copenhagen method and 16 children consecutively with casting according to the Ponseti technique, during their first 2 months of age. The need for surgery was then assessed. At 4 months of age, all children used a dynamic Knee Ankle Foot Orthosis. The Clubfoot Assessment Protocol (CAP) and the Dimeglio Classification System (DCS) were used and compared during treatment and at 2 years of age. According to the CAP (but not the DCS) the casting technique was superior in clubfoot correction, apparent as better mobility and better quality of motion at 2 years of age. These children also required less surgery. The orthotics management functioned well in both groups, with high compliance and maintenance or slight improvement of the clinical status except for morphology. DCS score changed over time but not between the groups. Because of its multidimensional and narrower scoring interval construct, the CAP enabled us to elucidate and evaluate different clinical functions. The casting technique according to Ponseti seems to be the better of the two for clubfoot correction, regarding mobility and quality of motion. The Clubfoot Assessment Protocol (but not the Dimeglio Classification System) was able to reveal differences between the Copenhagen and Ponseti treatment methods.
Book
The Clubfoot: The Present and a View of the Future is a monumental source book of far greater magnitude and scope than has been written on this subject. This volume is a superb tool for pediatric orthopedists specializing in foot and ankle surgery who want to advance their knowledge of research, clinical management, and operative techniques in patients with clubfeet.
Article
Between January 1994 and November 1997, 17 children with 25 clubfeet were treated and evaluated. This group was divided into a group of only conservatively treated feet (group A, n = 13) and a group of feet which had conservative treatment and complementary operative treatment (group B, n = 12). Both groups were evaluated according to the Dimeglio classification method in which the objective clinical evaluation is scored only. This was performed for the starting-point (at presentation until 2 weeks after birth), with the necessary information received from the patient's files where all the passive limitations were recorded in a standardized way and also for the end-point (at the time of the follow-up). After comparing these results to each other, all 25 feet had improved after treatment and the operative group had improved more than the conservative group, however the end result was equal, because the operated feet were more severely deformed before the treatment. After treatment, the results were considered acceptable in 92% of the feet, comparable to 93%, 75-85%, 88%, 77%, and 96% in other studies. Moreover, the forefoot adduction was the most common residual sign in the treated feet, confirmed by results in other studies. We conclude that the Dimeglio method is an appropriate tool for the follow-up of clubfeet from birth to the end of treatment.
Article
Background: The nonoperative technique for the treatment of idiopathic congenital talipes equinovarus (clubfoot) described by Ponseti is a popular method, but it requires two to four years of orthotic management. The purpose of this study was to examine the patient characteristics and demographic factors related to the family that are predictive of recurrent foot deformities in patients treated with this method. Methods: The cases of fifty-one consecutive infants with eighty-six idiopathic clubfeet treated with use of the Ponseti method were examined retrospectively. The patient characteristics at the time of presentation, such as the severity of the initial clubfoot deformity, previous treatment, and the age at the initiation of treatment, were examined with use of univariate logistic regression analysis modeling recurrence. Demographic data on the family, including annual income, highest level of education attained by the parents, and marital status, as well as parental reports of compliance with the use of the prescribed orthosis, were studied in relation to the risk of recurrence. Results: The parents of twenty-one patients did not comply with the use of orthotics. Noncompliance was the factor most related to the risk of recurrence, with an odds ratio of 183 (p < 0.00001). Parental educational level (high-school education or less) also was a significant risk factor for recurrence (odds ratio = 10.7, p < 0.03). With the numbers available, no significant relationship was found between gender, race, parental marital status, source of medical insurance, or parental income and the risk of recurrence of the clubfoot deformity. In addition, the severity of the deformity, the age of the patient at the initiation of treatment, and previous treatment were not found to have a significant effect on the risk of recurrence. Conclusion: Noncompliance and the educational level of the parents (high-school education or less) are significant risk factors for the recurrence of clubfoot deformity after correction with the Ponseti method. The identification of patients who are at risk for recurrence may allow intervention to improve the compliance of the parents with regard to the use of orthotics, and, as a result, improve outcome. Level of Evidence: Prognostic study, Level II-1 (retrospective study). See Instructions to Authors for a complete description of levels of evidence.
Article
Abstract This paper evaluates the ability to predict the need for a tenotomy prior to beginning the Ponseti method. The purpose of this study was to determine how one might predict the need for tenotomy at the initiation of the Ponseti treatment for clubfeet. Fifty clubfeet in thirty-five patients were treated with serial casting. The feet were prospectively rated according to two different scoring systems (Pirani, et. al. and Dimeglio, et. al.). The decision to perform a tenotomy was made when the foot could not be easily dorsiflexed 15 degrees prior to application of the final cast. Tenotomies were performed in 36 of 50 feet (72%). Those that underwent tenotomy required a significantly greater number of casts (p<0.05). Of 27 feet with an initial Pirani score 5.0, 85.2% required a tenotomy and 14.8% did not. 94.7% of the Dimeglio Type III feet required tenotomies. At the time of the initial evaluation there was a significant difference between those that did and did not require a tenotomy for multiple components of the Pirani hind-foot score. Following removal of the last cast there was no significant difference between those that did and did not have a tenotomy. In conclusion, children with clubfeet who have an initial score of 5.0 by the Pirani system or are rated as Type III feet by the Dimeglio system are very likely to need a tenotomy. Those that needed a tenotomy were more severely deformed with regard to all components of the hindfoot deformity, not just equinus. At the end of treatment feet were equally well corrected whether or not they needed a tenotomy.
Chapter
This method of classification and evaluation of true clubfeet Figure 3.7 provides an index of severity that serves as a guide to prognosis, diagnosis, and treatment of clubfeet (Table 3.18 and Figure 3.8).1,2 Pretreatment assessment by clinical and roentgenographic methods provides a consistent and reproducible rating of a deformed clubfoot regardless of its designated category (classification) (Figure 3.7). The pretreatment assessment uses methods of examination that are based on readily measured characteristics that are recognized and defined during the usual examination of a clubfoot (Figure 3.9).
Article
The Ponseti casting technique is reported to have a high success rate in the treatment of idiopathic clubfoot. Non-operative treatment of clubfoot provides a lower complication rate, less pain, and higher function as the patient ages than operative treatment. To demonstrate serial post-treatment change in clubfeet over time, three clubfoot rating systems were utilized in the current study. Patients compliant with the Ponseti technique and treated before the age of 7 months, had a 92% success rate at an early follow-up after casting was completed. It is not the purpose of this article to analyze the long-term clubfoot treatment result but to establish tools which can be used to judge initial success with the Ponseti technique. Complications are few and minor, limited to equipment used and cast technique.
Article
The author recommends that all newborns with clubfeet have an ultrasound of the lumbosacral spine to make sure that there is not an intraspinal anomaly producing the deformity.
Article
Intended "for consumers of statistics… people who, in order to separate the chaff from the wheat, need a grasp of the fundamental concepts of statistics, an understanding of its terminology and most common forms, and an ability to evaluate findings." This is accomplished through 10 brief chapters covering the value of statistics, why measure, problems of distribution, central tendency, dispersion, and correlation. Included are problems and answers for each chapter, suggestions for further reading, tables for the normal curve, chi square, squares and square roots and procedures for computing square roots, and the "drop-nines" test for checking arithmetical computations. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Article
This Classic article is a reprint of the original work by Ignacio V. Ponseti and Eugene N. Smoley, Congenital Club Foot: The Results of Treatment. An accompanying biographical sketch on Ignacio V. Ponseti, MD, is available at DOI 10.1007/s11999-009-0719-8 and a second Classic article is available at 10.1007/s11999-009-0721-1 . This article is (c)1963 by the Journal of Bone and Joint Surgery, Inc., and is reprinted with permission from Ponseti IV, Smoley EN. Congenital Club Foot: The Results of Treatment. J Bone Joint Surg Am. 1963;45:261-344.
Article
Nine patients presenting during infancy were identified with clubfeet and absent anterior and lateral compartment functions. We considered these to be neurogenic clubfeet. All patients had the drop toe sign: resting posture of the toes in plantarflexion and absent active dorsiflexion movement after plantar stimulation of the foot. Two patients (three feet) underwent exploration of the peroneal nerve, which revealed anatomic abnormalities. Six patients required more casts than typical for initial correction of deformity; all but two had Achilles tenotomy. Four relapsed despite full-time bracing and eventually needed intraarticular surgery to achieve a plantigrade foot. Idiopathic absent peroneal nerve function is not a well-described entity in the clubfoot literature. All babies with clubfoot should be examined for the drop toe sign. When noted, the feet will likely be more difficult to correct initially, may need early Achilles tendon lengthening, will likely need permanent bracing, are likely to relapse and need intraarticular surgery, and may need multiple surgeries to remain plantigrade throughout growth. Level of Evidence: Level IV, diagnostic study. See the Guidelines for Authors for a complete description of levels of evidence.
Article
In the treatment of idiopathic clubfeet, the Ponseti method and the French functional method have been successful in reducing the need for surgery. The purpose of this prospective study was to compare the results of these two methods at one institution. Patients under three months of age with previously untreated idiopathic clubfeet were enrolled. All feet were rated for severity prior to treatment. After both techniques had been described to them, the parents selected the treatment method. Outcomes at a minimum of two years were classified as good (a plantigrade foot with, or without, a heel-cord tenotomy), fair (a plantigrade foot that had or needed to have limited posterior release or tibialis anterior transfer), or poor (a need for a complete posteromedial surgical release). Two hundred and sixty-seven feet in 176 patients treated with the Ponseti method and 119 feet in eighty patients treated with the French functional method met the inclusion criteria. The patients were followed for an average of 4.3 years. Both groups had similar severity scores before treatment. The initial correction rates were 94.4% for the Ponseti method and 95% for the French functional method. Relapses occurred in 37% of the feet that had initially been successfully treated with the Ponseti method. One-third of the relapsed feet were salvaged with further nonoperative treatment, but the remainder required operative intervention. Relapses occurred in 29% of the feet that had been successfully treated with the French functional method, and all required operative intervention. At the time of the latest follow-up, the outcomes for the feet treated with the Ponseti method were good for 72%, fair for 12%, and poor for 16%. The outcomes for the feet treated with the French functional method were good for 67%, fair for 17%, and poor for 16%. Nonoperative correction of an idiopathic clubfoot deformity can be maintained over time in most patients. Although there was a trend showing improved results with use of the Ponseti method, the difference was not significant. In our experience, parents select the Ponseti method twice as often as they select the French functional method.
Article
74 Cases are reported of congenital club foot (112 feet) treated from 1966 to 1972. After some hints on pathologic anatomy, surgical and conservation treatment, the case history is analytically studied. Three classes are established according to the seriousness of the deformity. In the 5 cases of the 1st class, results were good in 2 and fair in 3; in the 13 cases of the 2nd class, results were good in 8 and fair in 5; in the 41 cases of the 3rd class, results were good in 19, fair in 15, bad in 7. Good results were 49.2%; fair, 39%; and bad, 11.8%. The authors believe that congenital club feet of the 3rd class must be operated on during the first 3 mth of life, contrary to the method which was used until now. Before surgery a period of conservative treatment (manipulations, plaster) is necessary. Club feet of the 1st and 2nd class can still be treated according to the old method (manipulations and plaster up to 3 mth); if necessary, Achilloplasty and posterior capsulectomy must be performed. In case varism and supination still persist at the age of 3 mth, surgical operation according to Codivilla must be performed, as in club feet of the 3rd class.
Article
The literature on clubfeet is inadequate because a common method language for assessing the deformity is lacking. Different severities of clubfoot deformity will give different results for a standard procedure: a less severe deformity can be corrected by limited releases, whereas a severe deformity requires radical procedures. This paper presents a language of assessment that has been used for a number of years. The importance of developing a language of assessment to be able to identify the various types of clubfoot deformity is important if the treatment of this condition is to develop within the field of pediatric orthopedics.
Article
One hundred and twenty-nine unselected club feet were classified at birth into three grades of severity; 123 were followed up. The results of primary treatment were analysed and it is shown that the bad feet did worst. Serial splinting in plasters achieved lasting correction in nine in ten mild club feet, in half of the moderately deformed, but in only one in ten of the severely affected. Surgical correction succeeded in two out of three of the resistant feet, but had to be repeated in the others.
Article
Clubfeet must be classified according to severity to obtain reference points, assess the efficacy of orthopaedic treatment, and analyze the operative results objectively. A scale of 0-20 was established on the basis of four essential parameters: equinus in the sagittal plane, varus deviation in the frontal plane and derotation around the talus of the calcaneo-forefoot (CFF) block and adduction of forefoot on hindfoot in the horizontal plane. Four grades of clubfeet can be individualized: (a) Benign feet so-called "soft-soft feet," grade I, similar to postural feet, with a score of 5 to 1 (these mild feet must be excluded from any statistics as they tend to increase good results); (b) moderate feet, so-called "soft > stiff feet," grade II (reducible but partly resistant, with a score of 5-10); (c) severe feet, so-called "stiff > soft feet," grade III (resistant but partly reducible, with a score of 10-15); and (d) very severe, pseudoarthrogryposic feet, so-called "stiff-stiff feet," grade IV (score of 15-20 points). To avoid risks of errors, our method is based on a very complete checklist and on diagrams. Our training material inculdes an audiovisual package.
Article
We conducted an independent assessment of two clubfoot-classification systems. In a blinded trial, two orthopaedists scored 55 feet by using the classification systems developed by Pirani et al. and by Dimeglio et al. Thirty-seven of the feet were also scored by a physical therapist. By using the 10-point classification described by Pirani, the two physician examiners tallied total scores that were within one point of one another 89% of the time. The mean difference between the scores assigned by the two examiners was 0.6 points. For the 20-point classification described by Dimeglio et al., total scores tallied by the two physician examiners were within two points of one another 91% of the time. The mean difference between the scores assigned by the two physician examiners was 1.4 points. Correlation coefficients were 0.90 (p = 0.0001) for the Pirani classification, and 0.83 (p = 0.0001) for the Dimeglio classification. Correlation coefficients were much lower for the first 15 feet scored and were also lower when the therapist's scores were included. Overall, both classification systems had very good interobserver reliability after the initial learning phase.
Article
Between January 1994 and November 1997, 17 children with 25 clubfeet were treated and evaluated. This group was divided into a group of only conservatively treated feet (group A, n=13) and a group of feet which had conservative treatment and complementary operative treatment (group B, n=12). Both groups were evaluated according to the Diméglio classification method in which the objective clinical evaluation is scored only. This was performed for the starting-point (at presentation until 2 weeks after birth), with the necessary information received from the patient's files where all the passive limitations were recorded in a standardized way and also for the end-point (at the time of the follow-up). After comparing these results to each other, all 25 feet had improved after treatment and the operative group had improved more than the conservative group, however the end result was equal, because the operated feet were more severely deformed before the treatment. After treatment, the results were considered acceptable in 92% of the feet, comparable to 93%, 75-85%, 88%, 77%, and 96% in other studies. Moreover, the forefoot adduction was the most common residual sign in the treated feet, confirmed by results in other studies. We conclude that the Diméglio method is an appropriate tool for the follow-up of clubfeet from birth to the end of treatment.
Article
Although the etiology of congenital clubfoot remains unknown, reproducible pretreatment grading now seems possible. However, the lack of an agreed-on and reproducible posttreatment evaluation system still hinders outcome studies of the treatment of clubfoot. The literature from about 1970 to 1990 contains enthusiastic reports on the correction of congenital clubfoot through extensive surgical release procedures. Over time, we have come to recognize the complications of such surgery, including recurrence, overcorrection, stiffness, and pain (WJ Shaughnessy, MD, P Dechet, MD, HB Kitaoka, MD, Vancouver, BC, Canada, unpublished data, 2000). Perhaps because of these findings, there is a renewed interest in nonsurgical techniques for the correction of congenital clubfoot. Recent studies have documented the effectiveness of the two leading techniques involving serial manipulation and cast treatment. The Ponseti technique appears to be effective and requires only a reasonable amount of time out of the lives of the patient and his or her parents. The technique frequently includes some minimally invasive surgery. The Kite and Lovell technique requires minimally invasive surgery less often but is more time consuming. French investigators and others have introduced new ideas that may reduce the need to immobilize the foot. The French approach requires fairly extensive physical therapy and demands substantial parental time and attention. It is not yet clear that the French technique is more successful in obviating the need for surgery than is expertly applied serial manipulation and cast immobilization. It also has not been proved that the long-term results of the French technique are better than those of serial manipulation and cast immobilization. It is probably that unless the French technique is found to substantially decrease the need for surgery, it will prove to be less cost effective than serial manipulation and cast immobilization. It is likely that a small number of clubfeet will require surgery even after expertly applied nonsurgical treatment. However, it is hoped that such surgery will be less extensive than procedures commonly performed in the recent past.
Article
The Ponseti casting technique is reported to have a high success rate in the treatment of idiopathic clubfoot. Non-operative treatment of clubfoot provides a lower complication rate, less pain, and higher function as the patient ages than operative treatment. To demonstrate serial post-treatment change in clubfeet over time, three clubfoot rating systems were utilized in the current study. Patients compliant with the Ponseti technique and treated before the age of 7 months, had a 92% success rate at an early follow-up after casting was completed. It is not the purpose of this article to analyze the long-term clubfoot treatment result but to establish tools which can be used to judge initial success with the Ponseti technique. Complications are few and minor, limited to equipment used and cast technique.
Article
The purpose of this study was to evaluate the efficacy of the Ponseti method in reducing extensive corrective surgery rates for congenital idiopathic clubfoot. Consecutive case series were conducted from January 1991 through December 2001. A total of 157 patients (256 clubfeet) were evaluated. All patients were treated by serial manipulation and casting as described by Ponseti. Main outcome measures included initial correction of the deformity, extensive corrective surgery rate, and relapses. Clubfoot correction was obtained in all but 3 patients (98%). Ninety percent of patients required </=5 casts for correction. Average time for full correction of the deformity was 20 days (range: 14-24 days). Only 4 (2.5%) patients required extensive corrective surgery. There were 17 (11%) relapses. Relapses were unrelated to age at presentation, previous unsuccessful treatment, or severity of the deformity (as measured by the number of Ponseti casts needed for correction). Relapses were related to noncompliance with the foot-abduction brace. Four patients (2.5%) underwent an anterior tibial tendon transfer to prevent further relapses. The Ponseti method is a safe and effective treatment for congenital idiopathic clubfoot and radically decreases the need for extensive corrective surgery. This technique can be used in children up to 2 years of age even after previous unsuccessful nonsurgical treatment.
Article
The purpose of this study was to determine how to predict the need for tenotomy at the initiation of the Ponseti treatment. Fifty clubfeet (35 patients) were prospectively rated according to Pirani and Dimeglio scoring systems. Tenotomies were performed in 36 of 50 feet (72%). Those that underwent tenotomy required significantly more casts (P = 0.005). Of 27 feet with initial Pirani scores > or = 5.0, 85.2% required a tenotomy and 14.8% did not; 94.7% of the Dimeglio Grade IV feet required tenotomies. Following removal of the last cast, there was no significant difference between those that did and did not have a tenotomy. Children with clubfeet who have an initial score of > or = 5.0 by the Pirani system or are rated as Grade IV feet by the Dimeglio system are very likely to need a tenotomy. At the end of casting, feet were equally well corrected whether or not they needed a tenotomy.
Article
Our purpose was to develop a sonographic technique for clubfoot examination using measured angles to establish a classification system according to severity. Ultrasonography of 24 newborns with 32 clubfeet and 13 newborns with 22 normal feet was performed and measurements obtained. Analysis of components of variance was conducted. Patients with clubfeet showed higher dispersion in 95% confidence intervals for all angles than did patients with normal feet. A sonographic classification system was established: IIa, slight clubfoot; IIb, moderate clubfoot; IIc, severe clubfoot; IId, very severe clubfoot. Sonographic findings can be used to objectively assess various degrees of clubfoot severity.
Article
The Pirani scoring system, together with the Ponseti method of club foot management, was assessed for its predictive value. The data on 70 idiopathic club feet successfully treated by the Ponseti method and scored by Pirani’s system between February 2002 and May 2004 were analysed. There was a significant positive correlation between the initial Pirani score and number of casts required to correct the deformity. A foot scoring 4 or more is likely to require at least four casts, and one scoring less than 4 will require three or fewer. A foot with a hindfoot score of 2.5 or 3 has a 72% chance of requiring a tenotomy. The Pirani scoring system is reliable, quick, and easy to use, and provides a good forecast about the likely treatment for an individual foot but a low score does not exclude the possibility that a tenotomy may be required.
Article
Nonoperative treatment of idiopathic clubfoot has become increasingly accepted worldwide as the initial standard of care. The Ponseti method has become particularly popular as a result of published short and long-term success rates in North America. The purpose of the current study was to examine the early rate of clubfoot recurrence following the use of the Ponseti treatment method in a New Zealand population and to analyze patient characteristics to identify factors predictive of recurrence. Fifty-one consecutive babies with a total of seventy-three clubfeet treated by the Ponseti technique were followed prospectively for a minimum of two years from the start of treatment. Recurrence, defined as the need for any subsequent operative treatment, was analyzed with respect to the severity at presentation, the time of presentation, the number of casts needed to obtain the initial correction, any family history of clubfoot, ethnicity, and the compliance with postcorrection abduction bracing. Recurrence was classified as minor, defined as requiring a tendon transfer or an Achilles tendon lengthening, or major, defined as requiring a full posterior or posteromedial surgical release to achieve a corrected plantigrade foot. Twenty-one (41%) of the fifty-one patients had a recurrence, which was major in twelve of them and minor in nine. The parents of twenty-six babies (51%) complied with the abduction bracing protocol, and only three of these children had a major recurrence. Compliance with abduction bracing was associated with the greatest risk reduction for recurrence (odds ratio, 0.2; p = 0.009). When the parents had not complied with the bracing protocol, the patient had a five times greater chance of having a recurrence. With the numbers studied, no significant relationships were found between recurrence and the severity at presentation, the time of presentation, the number of casts needed to obtain correction, ethnicity, or a family history of clubfoot. Compliance with the postcorrection abduction bracing protocol is crucial to avoid recurrence of a clubfoot deformity treated with the Ponseti method. When the parents comply with the bracing protocol, the Ponseti method is very effective at maintaining a correction, although minor recurrences are still common. When the parents do not comply with the bracing protocol, many major and minor recurrences should be expected.
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