ORIGINAL ARTICLE
Correlation of Pirani and Dimeglio Scores With Number
of Ponseti Casts Required for Clubfoot Correction
Ryan Gao, MBChB,* Matthew Tomlinson, MBChB,* and Cameron Walker, PhDw
Background: A number of grading systems for severity of club-
foot have been reported in the literature, but none are univer-
sally 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.
Methods: 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.
Results: 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.
Conclusions: 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.
Level of Evidence: Prognostic study level II.
Key Words: clubfeet, Ponseti, congenital talipes equinovarus
(J Pediatr Orthop 2014;34:639–642)
I diopathic congenital talipes equinovarus, or clubfoot, is
one of the most common musculoskeletal deformities
affecting the foot in the newborn. The etiology of clubfoot
is not entirely understood. Although the majority of cases
occur as isolated congenital deformities, a small pro-
portion of clubfeet are associated with neuromuscular
disorders or related syndromes.1
The goal of the treatment of clubfoot is mainly
focused on achieving a functionally sound, pain-free, and
cosmetically acceptable foot. Numerous surgical and
conservative treatment methods have been tried and
From the *Middlemore Hospital; and wDepartment of Engineering
Science, University of Auckland, Auckland, New Zealand.
The authors declare no conflicts of interest.
Reprints: Ryan Gao, MBChB, Middlemore Hospital, 26A Highland
Road, Mount Albert, Auckland, 1640 Otahuhu, New Zealand.
E-mail: ygao921@gmail.com.
Copyright r 2014 by Lippincott Williams & Wilkins
J Pediatr Orthop  Volume 34, Number 6, September 2014
tested since the days of Hippocrates with varying success
rates. The Ponseti serial casting technique, first reported
in the 1950s by Ignacio Ponseti, has been shown to be a
robust noninvasive method of treating clubfoot.2 The
technique involves serial manipulation and casting of the
clubfeet. The majority of patients undergo a percutaneous
Achilles tenotomy before the final cast application to
achieve maximal correction. Medium-term to long-term
results of patients treated with the Ponseti method have
shown 90% patient satisfaction.3 In another study, 78%
of patients treated with the Ponseti technique had good to
excellent outcome 30 years after initial treatment.4
To date, there is no consensus on the method of
grading the severity of clubfoot. Numerous classification
systems have been reported in the literature. Two of the
most widely utilized scoring systems are the Pirani score
and the Dimeglio score. Both scoring systems are based
on clinical assessment and can be carried out with relative
ease in the outpatient clinic setting. Excellent inter-
observer reliability has been reported for both the Pirani
score and Dimeglio score.5,6 However, conflicting reports
have been published with regard to the correlation be-
tween the Pirani score and the duration of the Ponseti
serial casting treatment regime. A study in 2006 involving
70 clubfeet successfully treated by the Ponseti method
showed that there was a significant positive correlation
between the initial Pirani score and number of weekly
casts required to correct the deformity.7 On the contrary,
Chu et al8 showed through their study of 185 clubfeet that
there was no significant correlation between the Pirani
score and Dimeglio score with the number of Ponseti
casts required for clubfoot correction. This study was
designed to further elucidate the potential correlation
between the Pirani score and Dimeglio score with number
of Ponseti casts needed for clubfoot correction.
METHODS
A retrospective review of prospectively collected
data was carried out after approval from the local ethics
committee. Infants with clubfoot referred to our dedi-
cated clubfoot clinic between January 2007 and December
2011 were identified. The patients were excluded from the
analysis if they were noncompliant with treatment; if
there were any other associated neuromuscular disorders
or related syndromes; or if clinic records were not suffi-
cient to provide enough information relating to treatment
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Gao et al J Pediatr Orthop  Volume 34, Number 6, September 2014

and number of casts applied. A total of 119 infants with

161 clubfeet were eligible to be included in the study.
Three patients were excluded from the study due to
noncompliance with the treatment regime and 2 patients
were excluded due to insufficient clinical records on how
many Ponseti casts were required to achieve full correc-
tion. Clubfoot severity was assessed using both the Pirani
score and Dimeglio score with each component of the
scores documented. The majority of patients were as-
sessed by the senior author or in a minority of cases, by
one of the senior orthopaedic residents trained by the
senior author. Ponseti cast treatment was initiated at the
time of the first clinic appointment. Although the ma-
jority of Ponseti casts were applied by the senior author, a
small proportion of patients had their casts applied by
pediatric orthopaedic surgeons and clubfeet clinic nurses
trained in the Ponseti technique. The total number of
casts was calculated from the first cast to the time of
initiation of the foot abduction orthosis. The foot ab-
duction orthosis was applied 3 weeks after percutaneous
Achilles tenotomy. In patients who did not require
FIGURE 1. Age at initial clubfeet casting compared with
Achilles tenotomy, the brace was applied once the foot
number of casts required to achieve full correction.
was fully corrected.
Statistical Analysis the scale used by Chu et al8 was adopted for descriptive
The relationship between the Pirani score, Dimeglio purposes. Correlation coefficients of <0.20 were consid-
score, and the number of Ponseti casts for each patient ered as having no correlation. In contrast, correlation
was established using the Spearman rank correlation coefficients of between 0.80 and 1 were considered as
coefficient. Individual components of the Pirani and having high correlation. Correlation coefficients that fall
Dimeglio scores were tested for any correlation to the between the extremes were considered as having low (0.21
total number of casts used. Point biserial correlation co- to 0.40), moderate (0.41 to 0.60), or marked (0.61 to 0.80)
efficients were calculated for posterior crease, medial correlations.
crease, and cavus, and the number of casts.
Dimeglio Score
RESULTS A low correlation (rs 0.21) was identified when the
total Dimeglio score was compared with the number
Demographics of casts (Table 2). The 2 individual components of the
The mean age at the time of initial evaluation and Dimeglio score with the highest correlations with the
initiation of casting was 18 days (range, 2 to 40 d). There
did not seem to be any association between age at initial
casting and the number of casts required to achieve full
correction (Fig. 1). There were twice as many male than
female infants. Eighty percent of patients were of Maori
or Polynesian decent. Thirty-five percent of patients suf-
fered from bilateral clubfeet. In total, 138 feet (86%)
underwent percutaneous Achilles tenotomy.
Spread of Data Points
Figures 2 and 3 show that there was a representative
spread of data points with respect to the number of casts
required to achieve initial clubfeet correction compared
with the Pirani and Dimeglio scores.
Correlation
Initial clubfeet correction was achieved in all in-
fants. The mean number of casts required for initial
correction was 5.8 (range, 2 to 10 casts). Table 1 depicts
an overview of each classification type compared with the
number of casts necessary for full clubfeet correction for FIGURE 2. Spread of data points comparing Pirani score and
all the patients. With regard to correlation coefficients, number of casts required to achieve full correction.

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J Pediatr Orthop  Volume 34, Number 6, September 2014 Correlation of Pirani and Dimeglio Scores

TABLE 2. Correlation Coefficient for Total Dimeglio Score and

Individual Components and Number of Casts
Dimeglio Score rs
Varus 0.08*
Calcaneopedal block 0.15*
Adduction 0.17*
Equinus 0.21*
Medial crease 0.01w
Posterior crease 0.05w
Poor muscle condition 0.01w
Cavus 0.11w
Total score 0.21
Low correlation between Dimeglio score and number of casts required for
initial clubfeet correction.
*Spearman correlation coefficient.
wPoint biserial correlation coefficient.

of the most widely utilized classification systems, the

Dimeglio and Pirani scoring systems, have proven track
FIGURE 3. Spread of data points comparing Dimeglio score records with regard to interobserver and intraobserver
and number of casts required to achieve full correction. reliability. However, their prognostic value remains
unclear.6–8,12
number of casts were equinus (rs 0.21) and adduction In a study involving 70 clubfeet, the authors did not
(rs 0.17). find any linear relationship between the initial Pirani
score and number of casts. However, they concluded that
Pirani Score a cutoff score of 4 seemed to be an important marker. The
For the Pirani score, no correlation (rs 0.12) was authors found that 92% of clubfeet with scores of Z4
identified between the total score and the number of casts required at least 4 casts. In contrast, only 11% of clubfeet
(Table 3). The individual components with the highest with a score of <4 required Z4 casts.7 In our study, no
correlations were posterior crease (rs 0.09) and rigid correlation was identified between the total Pirani score
equinus (rs 0.16). or any of its individual components with the number of
casts.
Chu et al8 studied the correlation between Dimeglio
DISCUSSION and Pirani scores with the number of Ponseti casts re-
Classification systems for disease processes should quired to achieve initial correction in 185 clubfeet. Similar
ideally have high intraobserver and interobserver reli- to our findings, the authors concluded that both scores
ability and show clinical relevance. Over the years, an were poorly correlated with the number of casts required
array of different classification systems for clubfeet has to complete treatment of clubfeet using the Ponseti
been proposed, but none are universally adopted.8–11 Two method.
Despite having poor short-term prognostic value, the
TABLE 1. Classification Types Compared With Number of Casts Dimeglio score was found to have significant correlation
No. Casts
with outcomes at 2 years of age for patients who received
Ponseti treatment.12 In this study, the Dimeglio scores
2 3 4 5 6 7 8 9 10 were divided into 3 main categories based on severity.
Pirani score
<2 1 2 1 0 0 0 0 0 0
2-2.5 1 1 2 3 2 2 0 1 1
3-3.5 0 1 8 8 7 5 4 1 0 TABLE 3. Correlation Coefficient for Total Pirani Score and
4-4.5 0 2 8 7 18 8 8 3 0 Individual Components and Number of Casts
5-5.5 0 2 7 5 13 7 7 0 0
6 0 0 4 2 2 3 1 1 0
Pirani Score rs*
Dimeglio score Empty heel 0.01
5-6 1 0 1 1 0 1 0 1 2 Lateral head of talus 0.07
7-8 0 1 2 1 3 1 2 0 1 Lateral curvature 0.08
9-10 1 2 10 9 7 7 1 0 0 Medial crease 0.08
11-12 0 2 8 9 8 5 3 0 0 Posterior crease 0.09
13-14 0 1 6 3 11 8 5 2 0 Rigid equinus 0.16
15-16 0 2 2 1 12 3 7 2 0 Total score 0.12
17-18 0 0 1 2 0 2 1 0 0
No correlation between Pirani score and number of casts required for initial
An overview of each classification type compared with the number of casts clubfeet correction.
required for initial clubfeet correction. *Spearman correlation coefficient.

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Gao et al
A score of 6 to 10 indicated a moderate severity, a score
between 11 and 15 indicated severe deformity, and a score
of Z16 was categorized as very severe. The authors con-
cluded that at 2 years of age, those children whose feet
were categorized as moderate did better than those with
severe or very severe feet. Similarly, the patients with
severe feet did better than those with very severe feet.
Clubfeet is a common pediatric orthopaedic prob-
lem in New Zealand due to its large Maori and Poly-
nesian population base. The unique ethnic makeup in this
country combined with the disproportionally high prev-
alence of clubfeet in Maori and Polynesian patients (7/
1000 compared with 0.57/1000 in Chinese populations1)
resulted in the strikingly high percentage of Maori and
Polynesian patients in this study (80%). Furthermore, the
Maori and Polynesian babies in our study had higher
mean severity scores (Dimeglio score 11.8 points; Pirani
score 4.2 points) compared with babies from other eth-
nicities (Dimeglio score 11.5 points; Pirani score 3.8
points). This disparity in the severity between different
ethnicities may have influenced our study findings. In-
terestingly, our finding in severity score between eth-
nicities is contrary to what was observed by Haft et al13 in
2007 where they studied recurrence rate of clubfeet in 51
patients (63% Polynesians). The authors found that the
Polynesian babies had lower mean Pirani score (4.6
points) than their white counterparts (5.0 points).
Limitation
One potential limitation with our study is that not
all the measurements were taken by the same person.
However, previous studies showed high interobserver
correlation for Pirani and Dimeglio scores.5,14–17
CONCLUSIONS
It is well documented that the Ponseti serial casting
method is effective, safe, and reliable. However, prog-
nostic indicators are lacking. Many scoring systems have
been developed to rate the severity of clubfeet; however,
these scoring systems have not been found to be helpful in
assisting with treatment decisions or to predict the need
for components of treatment. Clinicians, with the current
evidence available, are not able to predict based on
clubfoot severity, how many casts are likely to be required
to achieve correction. A literature search looking at cor-
relation between 2 of the most commonly used scoring
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J Pediatr Orthop  Volume 34, Number 6, September 2014
systems, the Dimeglio and Pirani scores, has yielded
conflicting results.
Our study findings, viewed in the context of the
literature, show that the prognostic value for both the
Dimeglio score and Pirani score remain questionable, at
least in the early treatment stages.
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