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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.
We studied 24 children (40 feet) to demonstrate that a physiotherapist-delivered Ponseti service is as successful as a medically-led programme in obtaining correction of an idiopathic congenital talipes equinovarus deformity. The median Pirani score at the start of treatment was 5.5 (mean 4.75; 2 to 6). A Pirani score of 5 predicted the need for tenotomy (p < 0.01). Of the 40 feet studied, 39 (97.5%) achieved correction of deformity. The remaining foot required surgical correction. A total of 25 (62.5%) of the feet underwent an Achilles tenotomy, which was performed by a surgeon in the physiotherapy clinic. There was full compliance with the foot abduction orthoses in 36 (90%) feet. Continuity of care was assured, as one practitioner was responsible for all patient contact. This was rated highly by the patient satisfaction survey.
Presented here is a retrospective clinical audit of clubfoot patients to determine the value of the Pirani clubfoot scoring system at initial presentation in the estimation of subsequent relapse.
All clubfoot patients treated by the same surgeon from 2002 to 2006 were included. The treatment adhered to the standard protocol, involving weekly stretching and casting until the foot was corrected, followed by Achilles tenotomy and plasters for 3 weeks. Thereafter, the child was placed in a foot abduction splint. The severity of clubfoot was assessed using the Pirani scoring system, consisting of two sub-scores-the midfoot contracture score (MFCS) and the hindfoot contracture score (HFCS). The MFCS and HFCS can each be 0.0-3.0, giving rise to a total Pirani score (TPS) of 0.0-6.0. Any recurrent deformity was classed as a relapse.
Sixty-one clubfoot patients were treated. Five patients were lost to follow-up and six patients were excluded due to the presence of identified syndromes or having had primary treatment elsewhere. A total of 80 clubfeet were included. There were 17 relapses. The average interval between the initiation of foot abduction splint and relapse was 23 months. The median TPS was 3.5 in the no relapse group and 5.0 in the relapse group. The median MFCS was 1.5 in the no relapse group and 2.0 in the relapse group. The median HFCS was 2.0 in the no relapse group and 3.0 in the relapse group. Higher TPS and HFCS were statistically significant when the relapse group was analysed against the no relapse group (P = 0.05 × 10(-4) and 0.02 × 10(-4), respectively).
Higher Pirani scores were associated with the late relapse group. The TPS and HFCS were shown to be statistically significant predictors of potential relapse. Closer follow-up is advised for patients at risk of relapse.
The clubfoot assessment protocol (CAP); description and reliability
of a structured multi-level instrument for follow-up
Hanneke Andriesse*1, Gunnar Hägglund1 and Gun-Britt Jarnlo2
This tool can be easily used within the clinical setting, used for monitoring developtment of a post treatment TEV. On assessment deteriation can be measured and referral made upon results.
Taken from Article
Background: In most clubfoot studies, the outcome instruments used are designed to evaluate classification or long-term
cross-sectional results. Variables deal mainly with factors on body function/structure level. Wide scorings intervals and total sum
scores increase the risk that important changes and information are not detected. Studies of the reliability, validity and
responsiveness of these instruments are sparse. The lack of an instrument for longitudinal follow-up led the investigators to
develop the Clubfoot Assessment Protocol (CAP).
The aim of this article is to introduce and describe the CAP and evaluate the items inter- and intra reliability in relation to patient
Methods: The CAP was created from 22 items divided between body function/structure (three subgroups) and activity (one
subgroup) levels according to the International Classification of Function, Disability and Health (ICF). The focus is on item and
Two experienced examiners assessed 69 clubfeet in 48 children who had a median age of 2.1 years (range, 0 to 6.7 years). Both
treated and untreated feet with different grades of severity were included. Three age groups were constructed for studying the
influence of age on reliability. The intra- rater study included 32 feet in 20 children who had a median age of 2.5 years (range, 4
months to 6.8 years).
The Unweighted Kappa statistics, percentage observer agreement, and amount of categories defined how reliability was to be
Results: The inter-rater reliability was assessed as moderate to good for all but one item. Eighteen items had kappa values >
0.40. Three items varied from 0.35 to 0.38. The mean percentage observed agreement was 82% (range, 62 to 95%). Different
age groups showed sufficient agreement. Intra- rater; all items had kappa values > 0.40 [range, 0.54 to 1.00] and a mean
percentage agreement of 89.5%. Categories varied from 3 to 5.
Conclusion: The CAP contains more detailed information than previous protocols. It is a multi-dimensional observer
administered standardized measurement instrument with the focus on item and subgroup level. It can be used with sufficient
reliability, independent of age, during the first seven years of childhood by examiners with good clinical experience.
A few items showed low reliability, partly dependent on the child's age and /or varying professional backgrounds between the
Interobserver reliability in Pirani clubfoot severity scoring between a paediatric orthopaedic surgeon and a physiotherapy assistant.
Shaheen S, Jaiballa H, Pirani S. J Pediatr Orthop B. 2012 Feb 14.
The Ponseti method, now regarded as the standard of care for congenital clubfoot, is equally effective whether provided by orthopaedic surgeons or orthopaedic paramedics. Therefore, it is particularly suitable for under-resourced nations with lack of surgeons and physicians. At the Sudan Clubfoot Clinic, physiotherapy assistants (3-year diploma nurses with additional physiotherapy experience) are part of the Ponseti clubfoot treatment team, with the role of assessing the degree of deformity by the Pirani score to assist the team in providing treatment. However, the reliability of Pirani scores measured by physiotherapy assistants in this context is unknown. After obtaining informed consent, we measured the interobserver reliability between a physiotherapy assistant and an orthopaedic surgeon in measuring Pirani scores in 91 virgin clubfeet in 54 infants (41 males and 13 females) at the Sudan Clubfoot Clinic. Scores were measured independently before the onset of treatment and analysed by the κ statistic for interobserver reliability. The κ statistic was 0.61 for posterior crease, 0.72 for empty heel, 0.51 for rigid equinus, 0.54 for the hid-foot score, 0.57 for medial crease, 0.54 for curved lateral border, 0.56 for lateral head of talus, 0.50 for the midfoot score and 0.50 for the total score. The mean percentage of agreement of both observers for all Pirani components was 83%. We found moderate to substantial interobserver reliability for the Pirani clubfoot severity score and all its subcomponents. Properly trained physiotherapy assistants are efficient in assessing the degree of severity of clubfoot. This is particularly useful in developing countries, where orthopaedic surgeons are few. Clubfoot treatment can be made more affordable by using paramedical healthcare workers such as physiotherapy assistants.
Club foot is a common congenital abnormality, and a complex deformity. In the past twenty years, the deformity has been better classified by considering the different components of deformity. The Pirani scoring system is widely used - and analagous standardised photographic views can be used to document this condition and its progress. Here I describe four views that aid in deformity assessment, correlating to component deformities assessed in the Pirani score.
Inter-rater reliability of physiotherapists using the Pirani scoring system for clubfoot: comparison with a modified five-point scale.
Harvey, Nicole J.; Mudge, Anita J.; Daley, Deborah T.; Sims, Susan K.; Adams, Roger D. Journal of Pediatric Orthopaedics B: August 20, 2014
This study examines inter-rater reliability between physiotherapists using the Pirani scoring system for clubfoot, and whether the addition of two scale points to give a modified five-point severity scale improves reliability. A total of 65 infant feet were assessed by two raters, with 21 different rater combinations used. The Pirani scoring system was found to be a reliable assessment tool when used by physiotherapists to score clubfoot, with a minimum of fair to good inter-rater reliability demonstrated across all clinical signs. The modified five-point scale proved significantly more reliable than the three-point scale; however, the benefit is not sufficient to warrant varying the original three-point scale.
Background The gold standard of care of clubfoot is the Ponseti method of serial manipulation and casting, followed by percutaneous tendo-achilles tenotomy. In our setting, registrars work in district hospitals where they run Ponseti clubfoot clinics with little or no specialist supervision. They use the Pirani score to serially assess improvement of the deformity during casting and to determine whether the foot is ready for tenotomy.
Purpose of Study To test the inter-observer reliability of the Pirani score, and whether it can be used by non-specialist doctors running Ponseti clubfoot clinics.
Methods Ethics permission was obtained from our institution. This is a prospective study where patients under the age of one year with idiopathic clubfoot were recruited from clubfoot clinics at our institution, over a period of four months. Following a training session using the original description of the score, each foot was independently assessed using the Pirani score by two paediatric orthopaedic surgeons, two orthopaedic registrars and two medical officers. The inter-observer reliability was assessed using the Fixed-marginal Kappa statistic and Percentage agreement. The first 15 feet were used as a learning curve, and hence excluded from final analysis.
Results 73 feet in 37 patients with idiopathic clubfoot (25 boys, 12 girls) under the age of 1 year were included in the study. The Kappa statistic and percentage agreement for the six variables of the Pirani score were determined. Whilst the overall agreement was determined by the Kappa statistic to be slight to fair, the two consultants were found to have a higher inter-observer reliability than the registrars and medical officers.
Conclusion Our results conflict with previously published studies in that the inter-observer reliability of the Pirani score was poor. In addition, we feel that this score cannot be reliably used by non-specialist doctors running Ponseti clubfoot clinics.
A number of grading systems for severity of clubfoot have been reported in the literature, but none are universally accepted. The aim of this study was to find the correlation between 2 of the most widely utilized classification systems (the Pirani score and the Dimeglio score) with number of Ponseti casts required to achieve initial clubfeet correction.
A retrospective study of prospectively collected data was performed. All clubfeet assessed at our dedicated clubfoot clinic from January 2007 to December 2011 were included. Clubfoot severity was assessed using both the Pirani score and the Dimeglio score. The total number of casts was calculated from the first cast to the time of initiation of the foot abduction orthosis.
The mean number of Ponseti casts required to achieve initial correction was 5.8 (range, 2 to 10 casts). A low correlation (rs 0.21) was identified when the total Dimeglio score was compared with the number of casts. No correlation (rs 0.12) was identified between the Pirani score and the number of casts.
The Dimeglio and Pirani scores remain the most widely accepted clubfoot severity grading systems. However, their prognostic value remains questionable, at least in the early treatment stages.
The clubfoot classifications described by Pirani and by Dimeglio are in widespread use today in foot and ankle surgical practice and are used to differentiate between lesions and compare treatment results. The aim of the present study was to determine whether in an independent center, one or both classification systems can be implemented practically and in a reproducible manner. From January 2004 to January 2014, we conducted a prospective study concerning the classification systems for clubfoot. The study group included 280 children (411 feet). The mean Dimeglio score noted by the 2 examiners was 10.3 ± 0.69 and 10.6 ± 0.81 points for the 411 feet, respectively. The mean difference in the Dimeglio scoring system was 1.11 ± 0.43 points (95% confidence interval 1.5 points). The Pearson correlation coefficient was 0.85. The corresponding mean Pirani scores were 5.1 ± 0.23 and 5.3 ± 0.17 points for the 411 feet. The mean difference in the Pirani score was 0.65 points (95% confidence interval 0.45 points). The Pearson correlation coefficient was 0.89. The good correlation coefficient for the Dimeglio and Pirani systems recommends their simultaneous use in clubfoot examinations, because the aspects under investigation (reducibility and foot aspect) are both different and complementary.
To assess the strength of agreement for each of the Pirani assessment categories between an orthopaedic surgeon and allied health worker on scoring clubfeet.
The descriptive cross-sectional study was conducted at the Indus Hospital, Karachi, from November 2012 to June 2013, comprised children below 12 months of age with untreated unilateral or bilateral clubfoot deformity an allied health worker, who was a plaster technician, was given 1-week training in the Pirani Scoring method. The feet were scored by the surgeon and the paramedic independently. SPSS 21 was used for statistical analysis.
The study had 57 patients, and 92 feet were assessed. The difference between the means of score of each parameter, including the hind foot score and total score, was less than 0.09. The means of total score were found to be identical. Total Hind Foot Score was 0.48 and Total Score was 0.354. The statistical inter-observer reliability for all components was rated as substantial to moderate agreement except Equinus Rigidityand Total Score, which showed fair agreement.
Pirani scoring method for clubfoot assessment was found to be a reliable tool for use by plaster technicians for independent assessment of clubfoot. However, prior training and supervision in the early phase is necessary.
The Heel Pad in Congenital Idiopathic Clubfoot: Implications of Empty Heel for Clinical Severity Assessment.
Adegbehingbe OO, Asuquo JE, Joseph MO, Alzahrani M, Morcuende JA Iowa Orthop J. 2015;35:169-174.
Clubfoot has been evaluated in many ways, including the most common classifications of clubfoot, described by Caterrall and Piraniis based on six clinical signs. The purpose of this study was to gain better understanding of the heel pad in relation to the term "empty heel", and to propose modification of clubfoot severity scoring system based on "empty heel".
A combination of prospective study of 79 clubfoot patients treated with Ponseti method and literature review of heel pad anatomy and biomechanics. The setting was a university teaching hospital. The ethical research committee approved study protocol and informed consent of patients' parent obtained. The selection criteria included patients' diagnosed congenital idiopathic clubfoot, age < 2years, no history of previous treatment and tenotomy indicated. An evaluation of patient was assessed by orthopaedic surgeons trained on Ponseti method and has above 5 years experience. Data analysis performed on the age, sex, Pirani scores at onset of treatment, tenotomy, and 6 month after initial full correction.
One hundred and thirty-two clubfeet in 79 patients (56 males, 23 females) completed Ponseti protocol. The median age at presentation was 5.2 months (range 0.1-23.7 months). The mean right foot abduction after correction 57.30(S.D. 9.20), and for the left foot, was 56.30 (S.D. 9.40). The mean right foot dorsiflexion was -13.70 (S.D. 18.40) before correction while after correction, it was 20.00 (S.D. 4.50) and for the left, the mean was -8.50 (S.D. 9.60) before correction and 21.00 (S.D. 4.30) after correction. Eighteen (22.8%) patients (10 bilateral, 9 unilateral) had clubfeet with empty heel score above zero point at initial full correction (p<0.001). Clinic anatomy shows the heel pad is a solid complex structure existing in normal, moderate and severe atrophied form. Heel pad is attached tightly to calcaneus without a cavity for the calcaneus to drop.
Heel pad probably could replace "empty heel" in modify Pirani scoring system. Clinical indication for repeat tenotomy should be based on equinus, not on the feeling of an empty heel, and families can be advised that the heel pad has a tendency to remodel over time to a normal shape