The Journal of Foot & Ankle Surgery 54 (2015) 582–585

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The Journal of Foot & Ankle Surgery

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A Clinical Evaluation of the Pirani and Dimeglio Idiopathic

Clubfoot Classifications
Dan Cosma, MD, PhD 1, Dana Elena Vasilescu, MD, PhD 2
1
Senior Lecturer, Department of Pediatric Orthopedics, University of Medicine and Pharmacy, Cluj-Napoca, Romania
2
Professor, Department of Pediatric Orthopedics, University of Medicine and Pharmacy, Cluj-Napoca, Romania

a r t i c l e i n f o a b s t r a c t

Level of Clinical Evidence: 2 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
Keywords:
children present study was to determine whether in an independent center, one or both classification systems can be
classification implemented practically and in a reproducible manner. From January 2004 to January 2014, we conducted a
clubfoot prospective study concerning the classification systems for clubfoot. The study group included 280 children
correlation (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% con-
fidence 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.
Ó 2015 by the American College of Foot and Ankle Surgeons. All rights reserved.

Classification systems are in widespread use today in orthopedic
practice and are used to differentiate between lesions and compare
treatment results. The evaluation of congenital clubfoot allows an
initial classification of the deformation and an estimate of the
treatment success rate. Previous research has shown that the
treatment result will depend on the initial deformation degree (1,2);
thus, the classification can help define the prognosis. Data quanti-
fication allows comparisons and facilitates monitoring of the
treatment success and the progression or regression of the
deformation.
At present, the published data have described 2 classification
systems (Dimeglio and Pirani) that are comprehensive and easy to
learn and apply in practice. Pirani et al (3) reported good applicability
of their system, with high accuracy of the interobserver type. Dime-
glio et al (4) reported the success of their system in describing club-
foot deformities, which was mainly based on the assessment of foot
reducibility.
Financial Disclosure: None reported.
Conflict of Interest: None reported.
Address correspondence to: Dan Cosma, MD, PhD, Department of Pediatric Or-
thopedics, University of Medicine and Pharmacy Cluj-Napoca, 46-50 Viilor Street, Cluj-
Napoca 400347, Romania.
E-mail address: dcosma@umfcluj.ro (D. Cosma).
The purpose of the present study was to determine whether, in an
independent center, one or both classification systems could be
implemented practically and in a reproducible manner.
Patients and Methods
The classification and treatment principles for clubfoot have been known and
implemented for 10 years in our service. From January 2004 to January 2014,
we initiated a prospective study concerning the classification systems in use for
clubfoot.
The parents of the patients provided informed consent before the patients were
included in the present study. The local ethical committee approved the research. The
study was performed in accordance with the ethical standards of the 1964 Declaration
of Helsinki.
The inclusion criteria for the present study were idiopathic bilateral or unilateral
clubfoot, no other congenital foot deformity, and no previous open surgery to treat the
deformity. The exclusion criteria were neurologic clubfoot and syndromic forms of
clubfoot related to various syndromes (eg, arthrogryposis multiplex congenita, mye-
lomeningocele). The data from 382 children (562 feet) were reviewed for the present
study, 232 males (60.73%) and 150 females (39.27%). Of the 382 children, 280 (411 feet)
met the inclusion criteria.
We analyzed the most widely used classification systems for clubfoot: Dimeglio
(Tables 1 to 3) and Pirani (Table 4).
Dimeglio et al (4) described a classification system that was based on the correction
obtained after applying a gentle reduction force on the deformed foot. Four parameters
are assessed, resulting in a maximum score of 16 for the stiffest foot. An additional 4
points result from the presence of 4 gravity signs (plantar crease, medial crease, cavus
retraction, and fibrous musculature).

1067-2516/$ - see front matter Ó 2015 by the American College of Foot and Ankle Surgeons. All rights reserved.
http://dx.doi.org/10.1053/j.jfas.2014.10.004
 D. Cosma, D.E. Vasilescu / The Journal of Foot & Ankle Surgery 54 (2015) 582–585 583

Table 1 Table 3
Description of the Dimeglio clubfoot classification Grade in Dimeglio clubfoot classification

Four parameters assessed after applying a gentle corrective force Grade Type Score Reducibility
Equinus deviation in the sagittal plane (0 to 4 points) I Benign <5 >90 , soft-soft, reducible
Varus deviation in the frontal plane (0 to 4 points) II Moderate 5 to 10 >50 , soft-stiff, reducible, partially stiff
Derotation of the calcaneo-forefoot block (0 to 4 points) III Severe 10 to 15 <50 , stiff-soft, stiff, partially reducible
Forefoot adduction in the horizontal plane (0 to 4 points) IV Very severe 15 to 20 <10 , stiff-stiff, rigid

Pirani’s classification system (3) (Table 4) evaluates 6 well-defined contracture
clinical signs that characterize clubfoot. Every sign on the affected side is compared
with the normal corresponding foot (when the deformation is one sided).
Every child was evaluated at the initial presentation at our center, during treat-
ment, and at the end of the treatment by 2 senior staff pediatric orthopedists. The
patients were investigated independently and separately by the examiners. For every
foot, the examiners separately recorded the 2 scores using the Dimeglio and Pirani
classification systems to determine whether a correlation existed between the 2 sys-
tems, remembering that the Dimeglio score is based on reducibility and the Pirani score
considers the foot morphologic aspect and its reducibility.
The correlation coefficients, 95% confidence interval, and p value were calculated.
The degree of correlation between the Pirani and Dimeglio scores was analyzed to find
the dependency level between the 2 variables under investigation.
To uniformly evaluate the deformations of the feet, both examiners reviewed the
original description of the classification systems, and a control protocol was established
using the drawings of the investigators. Personal identification data were collected
from the patients to facilitate additional contact with them. Where possible, photo-
graphs were taken and archived for additional visual evaluations and to compare the
morphologic aspect of the foot during treatment.
Results
Dimeglio scoring system was 1.11  0.43 points (95% confidence in-
terval 1.5 points). The Pearson correlation coefficient was 0.85
(p < .0001; Fig. 1).
The mean Pirani score recorded by each of the 2 examiners was
5.1  0.23 points and 5.3  0.33 points for the 411 feet, respectively. A
difference of 1 point between the 2 examiners was noted in 123 feet
(29.92%) and 0.5 point in 290 feet (46.22%), with agreement in 98 feet
(23.84). The mean difference in the Pirani score was 0.65  0.17 points
(95% confidence interval 0.45 point). The Pearson correlation coeffi-
cient was 0.89 (p < .0001; Fig. 2).
The overall mean Dimeglio score was 10.45  0.76 points, and
the overall mean Pirani score was 5.2  0.29 points. No statistically
significant differences were present between the mean values of
the variables discussed (p > .01). The correlation coefficient was
0.82.
The mean Dimeglio classification per degrees of severity was 3,
which correlated (correlation coefficient 0.79) with a mean Pirani
score of 5.2 points.

A total of 382 children (562 feet) were reviewed for inclusion in
the study group. Of the 382 patients, 232 (60.73%) were male and 150
(39.27%) were female, with a male/female ratio of 1.54. Of the 382
children, 180 children (47.12%) presented with a bilateral deformity
and 202 (52.88%) with unilateral clubfoot. The mean age at the first
evaluation was 4.03 months (range 1 week to 13 years). Of the 382
patients, 280 (73.29%) had not been previously treated, and 102
(26.71%) had received previous conservative treatment that had been
ineffective. These 102 previously treated patients were excluded from
the final analysis. Thus, the final patient group included 280 children
(411 feet).
The Pirani score for the entire group ranged from 1 to 6 (of 6) and
the Dimeglio score from 3 to 19 (of 20). The mean Dimeglio score
recorded by each of the 2 examiners was 10.3  0.69 and 10.6  0.81
points for the 411 feet, respectively. The greatest difference between
the 2 examiners in the Dimeglio classification was 3 points (observed
in 63 feet [15.32%]). In 84 feet (20.43%), the difference was 2 points, in
103 feet (25.06%), 1 point, and in 161 feet (39.17%), the score was
identical between the 2 examiners. The mean difference in the
Table 2
Points given in Dimeglio clubfoot classification for reducibility and aggravating
elements
Discussion
A great need exists for a reliable clinical classification of club-
foot clear enough to compare the results from one institution or
treatment method to another. Without a universal method to assess
the initial severity of the deformity, the results cannot be judged
accurately.
Idiopathic congenital clubfoot has been classified using many
different methods, mainly clinical examination (5–7). Until the re-
ported success of the Pirani and Dimeglio classifications, it was not
possible to quantify the components of the deformity on a mathe-
matical scale. The Pirani and Dimeglio clubfoot classifications were
both studied by their developers at their respective institutions and
showed good interobserver reliability.
The aim of our study was to assess the reliability and reproduc-
ibility of the 2 classification systems at an independent center.
The statistical analysis of our series highlighted the good correla-
tion coefficient between the examinations of the 2 examiners: 0.85
coefficient for the Dimeglio classification and 0.89 for the Pirani
classification. The correlation coefficient was relatively constant for all
the examinations, demonstrating that the learning curve is relatively
short.

Variable Points Table 4

Reducibility Pirani clubfoot classification
45 to 90 4
20 to 45 3 Variable Score
0 to 20 2 Hindfoot score 0 to 3
20 to 0 1 Posterior crease 0, 0.5, 1
> 20 0 Empty heel 0, 0.5, 1
Aggravating elements Rigid equinus 0, 0.5, 1
Posterior crease 1 Midfoot score 0 to 3
Medial crease 1 Curvature of the lateral border 0, 0.5, 1
Cavus 1 Medial crease 0, 0.5, 1
Fibrous musculature 1 Talar head reducibility 0, 0.5, 1
Total score possible 0 to 20 Total score 0 to 6
584 D. Cosma, D.E. Vasilescu / The Journal of Foot & Ankle Surgery 54 (2015) 582–585

Fig. 1. Correlation between the Dimeglio score of the 2 examiners.

Flynn et al (2), in 1998, reported from their smaller series, a
similar correlation coefficient for the Pirani classification (correlation
coefficient 0.90) and Dimeglio classification (correlation coeffi-
cient 0.83). In their study, the evaluations were performed by a staff
pediatric orthopedist and a fellow in pediatric orthopedics. In our
series, the classifications were performed by 2 senior pediatric
orthopedists.
In both studies, the correlation coefficients were smaller for the
Dimeglio classification, which has a greater number of variables to be
evaluated. We believe that the greater number of variables leads to a
greater possibility for increased variance among examiners. The Pirani
classification includes only 6 parameters, although some elements are
difficult to note, such as emptiness of the heel and talar head
coverage.
Although the 2 systems of classification, Dimeglio and Pirani,
include differences in the principles noted (reducibility for Dimeglio
and morphologic aspect for Pirani), the high correlation coefficient
indicates that a high severity of a deformity using the Dimeglio
classification will be correlated by the score from the Pirani classifi-
cation and vice versa.
An ideal classification system should be practical and repro-
ducible (8,9). It should consider the 3-dimensional characteristics of
the clubfoot deformation and also be simple enough to be imple-
mented in clinical practice. The same ideal system of classification
must be universal, such that it can be applied before, during, and
after treatment for all children, irrespective of their age. Finally,
treatment must be conducted in relation to the classification,
making reference to the various components of the deformation,
and the prognosis should be able to be estimated at any stage of the
treatment (10,11).
Our study limitations were related to the heterogeneity of the age
of the patients included. The lowest age in the study group was 1
week and the oldest patient was aged 13 years. Although none of the
patients had been previously treated, the large age span could have
influenced the results of the clubfoot classifications owing to changes
related to growth.
In conclusion, implementation of the classification systems
defined by Dimeglio and Pirani at an independent center has shown
that both systems are proper for the purpose and easy to apply
practically, once the initial learning stage is complete. The good

Fig. 2. Correlation between the Pirani score of the 2 examiners.

 D. Cosma, D.E. Vasilescu / The Journal of Foot & Ankle Surgery 54 (2015) 582–585
correlation coefficient between 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.
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