Journal of

Orthopaedic
Article Surger y
Journal of Orthopaedic Surgery
25(2) 1–8
ª The Author(s) 2017
Use of the Pirani score in monitoring Reprints and permissions:
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progression of correction and in guiding DOI: 10.1177/2309499017713916
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indications for tenotomy in the

Ponseti method: Are we coming
to the same decisions?

Manuele Lampasi1, CN Abati1, S Stilli2 and G Trisolino2

Abstract
Purpose: The Pirani score is widely used in the treatment of idiopathic clubfoot. Some authors recommended to base
decision for Achilles tenotomy in Ponseti method on this score (hindfoot score [HFS] > 1, once reducibility of lateral head
of talus (LHT) is zero) instead of originally described indications (dorsiflexion < 10–15 once complete abduction is
achieved). Yet correspondence of these indications has not been evaluated. Aim of this study was to verify whether in a
cohort, where decision is based on dorsiflexion, the Pirani score corresponds to the limits suggested. Secondarily, to
describe temporal variation in Pirani score along treatment, which has not been previously investigated. Methods: In a
prospective study, 79 idiopathic clubfeet in 47 cases consecutively treated with Ponseti method by a single orthopaedic
surgeon were evaluated at each casting session with Pirani system; score progression and scores at time of decision to
perform tenotomy were determined. Results: HFS and its subcomponents showed minimal improvement during sub-
sequent sessions of casting and then rapid correction with tenotomy. Medial crease resolved rapidly. Midfoot score and its
remaining subcomponents corrected gradually. Total Pirani score showed initially a progressive correction and then a
more abrupt improvement with tenotomy. At the time of decision to perform tenotomy, in 8 (10.1%) of 79 cases, the
decision whether or not to perform tenotomy based on dorsiflexion would have been different based on the cut-offs for
Pirani score suggested. Conclusion: Using Pirani score in guiding indication for tenotomy may imply different decisions in
a portion of cases, which should be considered when comparing series.

Keywords
clubfoot, Ponseti method, Pirani score, tenotomy

Introduction number of casts required for clubfoot correction and the

Numerous scoring systems have been proposed to rate
idiopathic clubfoot at presentation.1 The ideal features
of any classification scoring system include reliability,
feasibility in a clinical setting and ability to monitor
correction, predict appropriate treatment, recurrence rate
and long-term outcome.1,2
The system proposed by Pirani et al.,3 now routinely
used in most centres, is easily and quickly feasible in clin-
ical setting without the need for technical equipment4,5 and
has been proven reliable.2–4,6–8
The utility of this scoring system at the initial evaluation
has been largely accepted.5,9 Its ability in predicting the
need for tenotomy in the Ponseti method has been investi-
gated with variable results.1,5,10–14 Initial Pirani score has
1
Department of Paediatric Orthopaedics and Traumatology, Anna Meyer
Children’s Hospital, Viale Pieraccini 24, Florence, Italy
2
Department of Paediatric Orthopaedics and Traumatology, Rizzoli
Orthopaedic Institute, via Pupilli 1, Bologna, Italy
Corresponding author:
Manuele Lampasi, Department of Paediatric Orthopaedics and
Traumatology, Anna Meyer Children’s Hospital, Viale Pieraccini 24,
50139 Florence, Italy.
Email: manuele.lampasi@gmail.com

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2 Journal of Orthopaedic Surgery 25(2)
been suggested to correlate with the risk of relapse,
whereas its influence on the long-term outcome is still
unclear.15
In addition, it has been advocated that the Pirani score
can assist throughout the treatment process, particularly in
tracking treatment progress and in guiding the indication
for Achilles tenotomy.5,6,11,16–20 Yet, these features have
been poorly investigated.
The aim of this study was to describe the progression
of correction along the Ponseti treatment using the
Pirani scoring system and to analyse the Pirani score
at the moment when the indication for Achilles tenot-
omy is evaluated.
Methods
We performed a retrospective analysis of prospectively
collected data, investigating idiopathic congenital clubfeet
consecutively treated from October 2013 to October 2015
with the Ponseti method by a single-trained orthopaedic
surgeon, as a part of a prospective longitudinal study.21
Postural deformities, age greater than 6 months at presenta-
tion and patients treated with an accelerated protocol,22
were excluded from the study. Clubfeet categorized as
non-idiopathic at presentation or at successive evaluations
were not included.
All feet were treated by the same paediatric orthopae-
dic surgeon according to the method described by
Ponseti.23 Progressive correction of the deformity was
achieved by means of weekly sessions of manipulations
and casting (plaster of Paris long-leg cast) and finally
the equinus was addressed. A percutaneous Achilles
tenotomy was performed under general anaesthesia if
the foot could not be dorsiflexed to 15 once complete
abduction was achieved and a final cast was applied for
20 days. After removal of last cast, a foot abduction
brace (Mitchell–Ponseti brace) was applied 23 h/day for
3 months and gradually reduced to naptime and night-
time wear until 4–5 years of age.21
For each clubfoot, evaluation of the Pirani score3 was
performed by the same clinician before the first cast appli-
cation and after cast removal at each successive visit. The
Pirani scoring system takes into consideration six different
components of clubfoot deformity: posterior crease (PC),
emptiness of the heel (EH), rigidity of equinus (RE), medial
crease (MC), curvature of the lateral border (CLB) of the
foot and reducibility of the lateral part of the head of the
talus (LHT). Each component is scored on a three-point
scale (0 ¼ No abnormality, 0.5 ¼ Moderate abnormality
and 1 ¼ Severe abnormality): the sum constitutes a total on
a six-point scale (total score, TS), where higher scores
indicate a more severe deformity. TS is divided into two
subtotal scores, representing midfoot (midfoot score
[MFS]: summing up MC, CLB and LHT) and hindfoot
contracture (hindfoot score [HFS]: summing up PC, EH
and RE), each ranging from 0 to 3.
The clinician familiarized himself with the scoring sys-
tem before the study was commenced. A score sheet with
pictures and explanations was used to report the scores.
Evaluations were not blinded with regard to previous ses-
sions since details of previous examinations were usually
available at the time of following evaluation.
Approval of the institutional review board was obtained.
Families were informed that data would be submitted for
publication and gave their consent.
The SPSS for Windows version 22 (IBM SPSS Inc.,
Chicago, Illinois, USA) was used for statistical analysis.
Feet undergoing (tenotomy group) and not undergoing
Achilles tenotomy (non-tenotomy group) were compared
with regard to MFS, LHT and HFS at the time when the
decision was made whether to perform tenotomy or not
(thus before tenotomy for tenotomy group and before appli-
cation of the foot abduction brace for non-tenotomy group).
After evaluating normality of the data distribution and
using Levene’s test for equality of variances, the student’s
t test was used to analyse the differences in the scores
between the two groups. A p-value < 0.05 was considered
to be significant.
For each case, we calculated the number of casts
required for correction and divided cases in groups accord-
ing to the number of casts. For each group, mean scores of
each component, subtotal score and TS at each visit were
calculated and plotted on a graph.
Results
A total of 79 idiopathic clubfeet in 47 patients (37 male,
10 female, 15 unilateral, 32 bilateral) met the criteria and
were analysed. Mean age at first cast was 30.6 days (range:
5–168 days). Mean Pirani score was 4.8 (range: 2–6). Mean
number of casts was 4.4 (range: 2–7). Achilles tenotomy
was performed in 84.8% of clubfeet treated (67 of 79 feet)
at a mean age of 62 days (range: 47–191). Initial correction
was achieved in all feet (mean Pirani score at last cast
removal: 0.41 + 0.47, range 0–1.5). Only minor complica-
tions (skin irritations) were experienced during the correc-
tion phase.
At the time of decision to perform tenotomy or not, MFS
was lower than 1 in all feet, with a statistically significant
difference (p ¼ 0.004) between non-tenotomy group (mean
MFS is 0.00) and tenotomy group (0.06 + 0.16, range
0–0.5). LHT was 0 in 95% of feet (75 of 79), with a non-
significant difference (p ¼ 0.0.391) between non-tenotomy
group (mean LHT is 0.00) and tenotomy group (0.03 +
0.12, range 0–0.5).
HFS was significantly (p ¼ 0.000) lower in non-
tenotomy group (0.83 + 0.39, range 0.5–1.5) than in
tenotomy group (2.25 + 0.69, range 0.5–3). Two
(16.7%) of 12 feet in non-tenotomy group had HFS > 1
(at subsequent follow-up feet showed complete correc-
tion and TS 0). Six (9.0%) of 67 feet in tenotomy group
had HFS  1.
Lampasi et al.
Figure 1. Progression of PC correction. PC: posterior crease.
Figure 2. Progression of empty heel parameter.
The number of casts required for correction was calcu-
lated, and cases were divided into groups: two-cast group
included 7 feet, three-cast 10 feet, four-cast 25 feet, five-
cast 22 feet, six-cast 12 feet and seven-cast 3 feet. Different
patterns of correction were recorded by plotting respective
scores on graphs.
PC usually disappeared after Achilles tenotomy or just a
minor improvement was recorded earlier (Figure 1). EH
showed no (or minimum) improvement throughout the
casting sessions (Figure 2). A considerable improvement
was recorded after Achilles tenotomy, but in 39 feet (of 79),
final EH was > 0.
RE did not improve until discontinuation of the final
cast in feet requiring more than five casts; in feet requiring
less than six casts, a progressive improvement was
recorded, but most of the correction was achieved after last
cast removal (Figure 3).
3
MC resolved rapidly and was completely corrected after
the first one/two casts (Figure 4).
LHT and CLB corrected gradually throughout the
course of treatment (Figures 5 and 6).
As regards subtotal scores, HFS showed minimal
improvement during subsequent sessions of casting,
remaining 2.5 until last cast in most feet requiring tenot-
omy, and then showed rapid correction (Figure 7); MFS
showed gradual improvement along the casting sessions
(Figure 8).
TS showed initially a progressive correction and then a
more abrupt improvement of 2–3 points with the tenotomy
(Figure 9).
As regards progression of TS in every single foot, the
score improved in comparison with previous casting in
81.6% (283) of 347 sessions, was unchanged in 18.4%
(64/347) and never increased; among these, in seven
4 Journal of Orthopaedic Surgery 25(2)

Figure 3. Rigid equinus correction.

Figure 4. MC correction. MC: medial crease.

Figure 5. Correction of reducibility of LHT. LHT: lateral part of the head of the talus.
Lampasi et al. 5

Figure 6. Correction of CLB of the foot. CLB: curvature of the lateral border.

Figure 7. HFS correction. HFS: hindfoot score.

Figure 8. MFS correction. MFS: midfoot score.

6 Journal of Orthopaedic Surgery 25(2)
Figure 9. TS progression. TS: total score.
circumstances, the score remained unchanged for two
consecutive sessions and in one circumstance for three
sessions.
Discussion
The Ponseti method (including serial casting, percutaneous
Achilles tenotomy and bracing)23 currently represents the
gold standard for clubfoot treatment and provides initial
complete correction in most cases (reported correction rates
of 89–98%).9,24–26
The two scoring systems that are most commonly used
to track progression of correction with the Ponseti method
are the Dimeglio score27 and the Pirani score.3 The utility
of the former in tracking progression has been previously
analysed. 21,28 With regard to Pirani score, its use is
described by most authors not only for initial evaluation
but also in the subsequent steps of correction.6,12,16–20 Yet
its temporal progression and the one of its constitutive
parameters has been poorly investigated.16,18,19 Visual rep-
resentation of the scores on a graph may represent a para-
digm roadmap of treatment, thus supporting inexperienced
practitioners for expected results following each cast.28
We recorded typical patterns for each parameter. As
regards hindfoot parameters, they tended to show only
minor improvement with subsequent casts. Particularly,
EH and PC improved for the most part at discontinuation
of the final cast. RE showed a slight progressive improve-
ment in feet requiring less than six casts, but generally most
of the correction was achieved after Achilles tenotomy.
This is intuitive, since equinus is supposed to be the last
deformity to be corrected.28 Yet it has been demonstrated in
MRI studies29 (and it is commonly experienced in applying
casts) that correction of equinus occurs more gradually
throughout the casting sessions as automatic result of cor-
rection of the midfoot variables.28 This feature has been
confirmed using the Dimeglio score,21,28 which therefore
seems to be more sensitive in monitoring equinus than the
Pirani score.
As a result, HFS showed only slight improvement dur-
ing subsequent sessions of casting and abrupt correction
after Achilles tenotomy.
MC was completely corrected after the first one/two
casts. Persistence or appearance of MC over a certain num-
ber of casts should raise suspicion on the right progression
of correction.
The only parameters showing gradual improvement that
followed the clinical correction provided by the Ponseti
method were LHT, CLB and consequently MFS, with the
latter reaching zero in almost all cases.
TS documented an improvement in 81.6% of the ses-
sions, and progression was gradual throughout the treatment
(mostly due to MFS) with a more abrupt improvement of
2–3 points with the tenotomy (due to HFS).
At last cast removal, TS frequently resulted above zero,
despite correction could be considered complete, as
reported by other authors.1,11,30,31 This was mostly due to
persistence of EH above zero (49.4% of feet). The inci-
dence of persistence of this feature has been poorly inves-
tigated (only Adegbehingbe et al.30 described rate in their
experience: 22% of cases) and longer follow-up will be
needed to verify if this implies higher risk of recurrence.
Yet it is commonly experienced and it has been shown30
that empty heel pad has a tendency to remodel over time to
a normal shape; its persistence at the end of treatment
should not be considered an indication for further proce-
dures30 and correction is considered complete even with an
empty heel above zero at the point of fitting into the abduc-
tion brace.31
In order to analyse the utility of Pirani scoring system in
guiding the indication for Achilles tenotomy, we looked for
Pirani-related indications for tenotomy in the literature. In
online manuals of Ponseti method,18,19 it is stated that
tenotomy would be indicated when HFS is higher than 1,
Lampasi et al.
MFS is lower than 1 and LHT is zero. Yet even papers
describing the use of Pirani score in the evaluation of club-
foot usually do not base the indication on this score but
mainly on originally proposed limits of dorsiflexion higher
than 10/15  with complete abduction, 11–13,15,22,32
which is our behaviour as well. We performed a posteriori
an analysis to verify whether the above-mentioned Pirani-
based indications corresponded to the original guidelines.
We found that in most of the cases, the indications corre-
sponded. In particular, the limits of coverage of the head of
the talus and MFS < 1 were almost always respected (these
are prerequisites for correction both in tenotomy and in
non-tenotomy group), and the HFS was significantly higher
in the tenotomy (mean HFS 2.25 + 0.69) than in the non-
tenotomy group (mean 0.83 + 0.39) with the limits of HFS
> 1 respected in 89.9% of feet. Yet the limit of HFS could
not be regarded as strict, since in a few feet, the tenotomy
was not performed despite an HFS > 1 and other few feet
underwent tenotomy despite an HFS  1. These data do not
imply superiority of one system with respect to the other
one (longer-term follow-up would be required), but show
that, in a portion of cases, surgeons basing their indications
on Pirani score may take different decisions in comparison
with surgeons using dorsiflexion. For example, a foot with
full correction of abduction, MFS ¼ 0, dorsiflexion to 5 ,
RE ¼ 0.5, EH ¼ 0, PC ¼ 0 and HFS ¼ 0.5 does or does not
undergo tenotomy according to the criterion used; this
could explain part of the variability of tenotomy rate
reported in the literature in different series.
Since the assessment of PC,4 empty heel sign4,8 and
dorsiflexion33 is not completely reliable, the use of a
dorsiflexion lateral radiograph of the foot has been pro-
posed to rule out cases with midfoot breakage and ele-
vated calcaneus and more objectively determine the
need for tenotomy.33 This could be of value particularly
in case of doubt (e.g. persistence of EH and PC in front
of satisfying dorsiflexion).
The strength of our study is that all feet have been
treated by a single trained orthopaedic surgeon with the
same method and represent consecutive cases of a prospec-
tive study. Main weaknesses are that assessment and treat-
ment were performed by the same person and that
evaluations were usually not blinded with regard to previ-
ous evaluation; nevertheless, since Pirani score was
recorded only for descriptive purposes and did not seem
to have influenced treatment in this series, we feel that this
bias was not significant. In addition, long-term follow-up
will be needed to ascertain whether the initial correction
obtained could be maintained; yet interest of the article was
in the dynamics of correction and not in subsequent rate of
recurrence, and initial correction was obtained in all cases.
In conclusion, our article described the progression of
clubfoot correction using Ponseti method according to the
Pirani score and showed that MFS tends to correct gradu-
ally, HFS improves only at the end of treatment and TS acts
as a result of these two patterns. The use of the limits of
7
Pirani score suggested in the literature instead of dorsiflex-
ion in guiding indication for tenotomy may imply a differ-
ent decision in a small number of cases, which should be
considered when evaluating different series.
Author’s note
This study was conducted at the Department of Pediatric
Orthopedics and Traumatology, Rizzoli Orthopaedic Institute,
Bologna, Italy.
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with
respect to the research, authorship, and/or publication of this
article.
Funding
One of the authors (CN Abati) received a grant from CEDISS
Security Engineering, a private donor without profit interest.
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