Electronic Letters to:

Children's Orthopaedics: P. J. Dyer and N. Davis The role of the Pirani scoring system in the management of club foot by the Ponseti method J Bone Joint Surg Br 2006; 88-B: 1082-1084 [Abstract] [Full text] [PDF]

eLetters: Submit a response to this article

Electronic letters published:

Authors' reply

Peter J Dyer, Naomi Davis   (6 December 2006)

Pirani scoring of club foot

Robert S JEFFERY   (3 October 2006)

Classification vs evaluation of club foot

Faisal N Hussain   (15 September 2006)

Authors' reply 6 December 2006
Peter J Dyer, Foundation Year 1 Doctor Stepping Hill Hospital Stockport, Naomi Davis Send letter to journal: Re: Authors' reply petedyer{at}doctors.org.uk Peter J Dyer, et al.	Sir, We would like to thank Mr Hussain for his response to our article. He reiterates the concerns of the paediatric orthopaedic world regarding the lack of one good system to describe both the deformities of club feet and evaluate the outcomes of treatment. Our paper was concerned only with the description of the initial deformity and recognition of how it changes during the casting phase of Ponseti management. Our aim was to determine the merits of the Pirani scoring system in terms of its ability to predict the likely required treatment by the Ponseti method. The Pirani scoring system has long been used in our Ponseti clinic and now appears to be the most prevalent scoring system used by practitioners of the Ponseti method around the world. It is quick and simple to use, easy to memorise and requires no specialist equipment. We did not seek to classify nor present our outcomes either in the short or long term. Certainly we agree that the Pirani scoring gives no functional measurement and is purely descriptive of the deformity. However, the group of patients involved in our study were in the first few months of life, prior to walking, when any functional scoring would be impossible. We believe that our article shows that the Pirani score attributed to a foot does indeed give an indication as to the likely management that will be required for the initial correction of a club foot. P.J. DYER, BSc Hons, Foundation Year One Doctor, N. DAVIS, BMed Sci, BM, BS, FRCS Ed(Tr & Orth), Consultant in Paediatric Orthopaedic Surgery, Stepping Hill Hospital, Stockport, UK.
Pirani scoring of club foot 3 October 2006
Robert S JEFFERY, Consultant Orthopaedic Surgeon Derriford Hospital, Plymouth, UK Send letter to journal: Re: Pirani scoring of club foot robert.jeffery{at}phnt.swest.nhs.uk Robert S JEFFERY	Sir, I read this article with interest, but I disagree with the authors' interpretation of the statistics presented in their paper. The authors conclude that they "found no significant linear relationship between the initial Pirani scores and the number of casts", having reported a Spearman's rank correlation coefficient of r = 0.72, p < 0.0005. Moreover, they describe a "positive correlation", rather than a difference in proportions, using the chi-squared test. The method of comparing the differences between the Pirani scores for the tenotomy and non-tenotomy groups is not described. If there was a normal distribution, the means could have been compared and the standard deviations given. As the distributions were non-parametric, the medians and range should be quoted and their ranks compared. R.S. Jeffery, Consultant Orthopaedic Surgeon, Derriford Hospital, Plymouth, UK.
Classification vs evaluation of club foot 15 September 2006
Faisal N Hussain, Orthopedics Surgeon FCPS Orth Pakistam Send letter to journal: Re: Classification vs evaluation of club foot fnhussain{at}hotmail.com Faisal N Hussain	Sir, I read with interest the articles on club feet published in the August 2006 issue and feel that they indicate the variety of opinions regarding their treatment. Both articles have very successfully defended their results scientifically. With regard to the article by Dyer and Davis, the difficulty we all face is perhaps due to the absence of an agreed method to 'classify' and 'evaluate' treatment outcomes in club foot treatment with uniformity. The authors have used the Pirani scoring method to evaluate their cases at the start of, as well as during, the treatment period and found a positive relationship between a high score and the need to perform a subcutaneous tenotomy. They have failed to appreciate the difference between an evaluation and a classification system. It would have been more helpful had they used one of the evaluation methods such as that of Dimeglio et al.2 Dimeglio devised two separate methods to classify and evaluate after treatment of club foot. The method for classification is a 20 point scale2 and the method he used to evaluate after treatment had a 50 point scale.3 A similar study by Colburn and Williams in 2003 has used the Dimeglio method3 for classification but evaluated the results of treatment using their own end point.4 They also used the Ponseti method for the conservative treatment of these feet. They appreciated the need for the use of separate methods for both purposes. My suggestion is based upon the opinion of Dimeglio et al,3 Cummings et al,5 and Ponseti.6 These have advocated the use of separate yardsticks for each of the purposes, especially Dimeglio et al who have compared at length the weight given to each element of deformity while evaluating the results of treatment by different authors.2 The Pirani score does not address the functional, radiological, global, gait pattern and muscle function of the foot which are very important in a child who is learning to walk.3 It is too simplistic to be of value in this regard, however, its value in predicting the need for a tendo Achillis tenotomy or the number of casts required cannot be denied. By the end of one year the children begin to walk or stand up with support. At this stage most authors who have published a long follow-up in relatively large scale studies have preferred to make a global evaluation which encompasses functional, as well as morphological, aspects. Radiological measurements are inaccurate in the children at the beginning of treatment but can be quite useful, especially for treated feet, when the cartilage of talus and calcaneum are better visualised. Shack and Eastwood1 have used the Pirani method to document and serially evaluate the results of treatment in their study “Early results of a physiotherapist-delivered Ponseti service”. However, they supplemented their outcome measure by adding radiological evaluation and muscle function. The resultant method is untested and raw with unknown validity. Both the teams of authors have used Ponseti methods for treatment. But the results cannot be compared easily because, like most club foot studies, each author has picked the yardstick of his choice to justify his findings. I think we need to evaluate statistically each of the regularly cited classification and evaluation methods for their validity and develop a universal CAP (Club foot Assessment Protocol).7 F.N. HUSSAIN FCPS Orth, Post Graduate Medical Institute, Lahore General Hospital, Lahore, Pakistan. 1. Shack N, Eastwood DM. Early results of a physiotherapist-delivered Ponseti service for the management of idiopathic congenital talipes equinovarus foot deformity. J Bone Joint Surg [Br] 2006;88-B:1085-1089. 2. Bensahel H, Dimeglio A, Souchet P. Final evaluation of clubfoot. J Pediatr Orthop B 1995;4:137-41. 3. Dimeglio A, Bensahel H, Souchet P, Mazeau P, Bonnet F. Classification of clubfoot. J Pediatr Orthop B 1995;4:129-136. 4. Colburn M, Williams M. Evaluation of the treatment of idiopathic clubfoot by using the Ponseti method. J Foot Ankle Surg 2003;42:259-267. 5. Cummings RJ, Davidson RS, Armstrong PF, Lehman WB. Congenital clubfoot: Instructional Course Lecture. AAOS. J Bone Joint Surg [Am] 2002;84-A:290-308. 6. Ponseti IV. Treatment of congenital clubfoot. J Bone Joint Surg [Am] 1992;74-A:448-453. 7. Andriesse H, Roos EM, Hägglund G, Jarnlo G-B. Validity and responsiveness of the Clubfoot Assessment Protocol (CAP). A methodological study. BMC Musculoskeletal Disord 2006;7:28.