Correlation of foot bimalleolar angle with Pirani score to assess the severity of congenital talipes equinovarus deformity

Predictive ability of scoring systems towards casting in treatment of idiopathic clubfoot by the Ponseti method in infants

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. 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. 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. 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.

Assessment of severity of clubfoot in walking children by combined multiple tools: A new classification system

INTRODUCTION

Clubfoot is one of the most common congenital deformities that cause mobility impairment. In developing countries, however, due to lack of appropriate medical care, treatment is either not initiated or incompletely performed. Due to lack of consensus for evaluation of deformities in such patients, there is no standardized treatment protocol yet developed. So, a new evaluation system is devised to assess the deformity in untreated or previously managed conservatively clubfoot of walking children.

METHODS

It was a prospective, observational study, conducted from December 2017 to July 2019. Patients from age 1-5 years, with unilateral deformity and previously managed conservatively were included. Patients having atypical clubfoot, syndromic clubfoot, or previously surgically intervened were excluded. Pre-treatment severity was graded with Diméglio score. Anthropometric, Foot Imprinting, Radiographic angles, and Ultrasonographic measurements were taken. Parameters taken were assessed and correlated with gradings of Diméglio score.

RESULTS

37 patients with mean age of 2.14 ± 0.87 years were included. Diméglio score was 11.57 ± 2.15 with 28 patients in 'severe' category. Talocalcaneal index and Tibiocalcaneal angle were correlating with the equinus whereas Bean shape ratio and Talocalcaneal index were correlating with varus deformity. Derotation of calcaneoforefoot block gradings correlating with Foot bimalleolar angle, Talo-first metatarsal angle, and MMN (medial malleolus to navicular distance) Ratio. FBM (Foot Bimalleolar) Angle, Talo-first metatarsal angle, MMN Ratio, and Medial soft tissue thickness were correlating with forefoot adduction. Following the correlation, a new classification system was devised to assess the severity of deformity at presentation.

CONCLUSION

It is essential to develop an objective methodology to evaluate the severity of the clubfoot; whether the foot is responding to manipulation and casting; to detect the early signs of recurrences and predict the outcomes. The evaluation system should take into consideration the complex characteristics of the deformity and its three-dimensional aspects.

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

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

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

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

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

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

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

Comparative Analysis between Podography and Radiography in the Management of Idiopathic Clubfeet by Ponseti Technique

INTRODUCTION

Idiopathic clubfoot is one of the most common and oldest congenital foot anomalies. There are controversies regarding its optimum management protocol and methodologies to be employed for its functional outcome evaluation. This paper attempts to propose a simple, reasonable and easily reproducible technique of podography for clinical and functional evaluation of clubfoot treated by the popular Ponseti technique.

AIM

To compare the Foot Bimalleolar (FBM) angle method (podography) and radiography with respect to management of idiopathic clubfoot by Ponseti's Technique and its functional evaluation.

MATERIALS AND METHODS

Sixty feet of 48 patients with idiopathic clubfoot deformity were assessed in terms of FBM by podography (foot print on paper and FBM angle drawing) and radiologically; before starting treatment, after 6 weeks and at 6 monthly intervals with a maximum follow up period of 4.8 years (Range 1.2 to 4.8 years). Mean age at start of treatment was 1.5 years (2 months to 2.5 years). Functional evaluation was done by Magone's scoring system.

RESULTS

After treatment, 92 percent patients had good correction (FBM greater than 70 degrees) which correlated well with post treatment Magone's score of greater than 80 (good to excellent) in nearly 85 percent of cases. Radiologically, talocalcaneal angles in both the views improved in only 60 percent of cases.

CONCLUSION

Radiological criteria show inconsistent correlation with functional outcome for feet treated by Ponseti's Technique. Podography (FBM angle analysis) is a very simple, objective, cost effective, radiation free, easily reproducible and highly reliable clinical criterion for the assessment of deformity correction in club foot by Ponseti's Technique with an excellent correlation with functional outcome.

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

BACKGROUND

Congenital talipes equinovarus (clubfoot) is one of the most common congenital pediatric orthopedic foot deformity, which varies in severity and clinical course. Assessment of severity of the club foot deformity is essential to assess the initial severity of deformity, to monitor the progress of treatment, to prognosticate, and to identify early relapse. Pirani's scoring system is most acceptable and popular for club foot deformity assessment because it is simple, quick, cost effective, and easy. Since the scoring system is subjective in nature it has inter- and intra-observer variability, it is widely used. Hence, the interobserver variability between orthopedic surgeons in assessing the club foot severity by Pirani scoring system.

MATERIALS AND METHODS

We assessed the interobserver variability between five orthopedic surgeons of comparable skills, in assessing the club foot severity by Pirani scoring system in 80 feet of 60 children (20 bilateral and 40 unilateral) with club foot deformity. All the five different orthopedic surgeons were familiar with Pirani clubfoot severity scoring and Ponseti cast manipulation, as they had already worked in CTEV clinics for at least 2 months. Each of them independently scored, each foot as per the Pirani clubfoot scoring system and recorded total score (TS), Midfoot score (MFS), Hind foot score (HFS), posterior crease (PC), emptiness of heel (EH), rigidity of equnius (RE), medial crease (MC), curvature of lateral border (CLB), and lateral head of talus (LHT). Interobserver variability was calculated using kappa statistic for each of these signs and was judged as poor (0.00-0.20), fair (0.21-0.40), moderate (0.41-0.60), substantial (0.61-0.80), or almost perfect (0.81-1.00).

RESULTS

The mean age was 137 days (range 21-335) days. The mean Pirani score was 3.86. We found the overall consistency to be substantial for overall score (total score kappa - 0.71) and also for midfoot (0.68) and hindfoot (0.66) separately. The consistency was least for the emptiness of heel (kappa - 0.39), and best for rigidity of equnius (kappa - 0.68) and rest of the parameters were moderate (kappa between 0.40 and 0.60).

CONCLUSION

The Pirani scoring system had got substantial reliability in assessing the clubfoot deformity even when the reliability test was extended to five different orthopedic surgeons simultaneously.