ORIGINAL ARTICLE

Dimeglio Score Predicts Treatment Difficulty During

Ponseti Casting for Isolated Clubfoot
Chris Brazell, BA,* Patrick M. Carry, MS,* Alex Jones, BA,* Robin Baschal, BA,*
Nancy Miller, MD,† Kaley S. Holmes, BA,* and Gaia Georgopoulos, MD†

to the length of treatment and the possibility of recurrence fol-

Background: The Dimeglio score (DS) is widely used to assess lowing Ponseti treatment.
clubfoot severity, but its ability to predict long-term outcomes Level of Evidence: Level II—retrospective prognostic study.
following Ponseti treated isolated clubfoot (IC) is controversial.
This study tested the association between the initial DS and its Key Words: Dimeglio score, isolated clubfoot, Ponseti, recurrence
individual parameters with the number of Ponseti clubfoot casts (J Pediatr Orthop 2019;39:e402–e405)
required to achieve correction and the rate of early recurrence
following treatment.
Methods: Data were retrospectively collected from patients who
underwent treatment of IC between March 2012 and March 2015
and were followed for ≥ 2 years. DSs were collected at the initial
C ongenital talipes equinovarus (clubfoot) occurs in 1 to 2
per 1000 births and is one of the most common con-
genital skeletal defects.1 If untreated, the affected feet can
casting visit. The number of Ponseti casts required to achieve
clubfoot correction before tenotomy and recurrence of deformity
progress into severe disability with long-term sequelae.2
were collected as the primary outcome variables. Recurrence was
Treatment has shifted from a surgical approach to the more
defined as any loss of correction leading to repeat casting or
conservative Ponseti method3 which involves serial casting,
tenotomy during the bracing phase. Negative binomial and lo-
potential tenotomy, and bracing. Ponseti casting has resulted
gistic regression analyses were used to test the association be-
in excellent outcomes and has reported overall success rates
tween the 8 Dimeglio parameters and number of casts and
of nearly 100% before bracing.4,5 Although the Ponseti
incidence of recurrence, respectively.
technique provides early success, the duration of casting and
Results: A total of 53 patients (37 male and 16 female) were in-
frequency of recurrence remains variable.
cluded in the study. The median number of casts required to achieve
The Dimeglio scoring system is one of the most widely
an acceptable correction was 5 (range, 2 to 16). The incidence of
accepted scoring systems to gauge the initial severity of the
recurrence was 24.53% (13/53). An increase in derotation, varus,
deformity and track the progress of treatment for isolated
equinus, muscle condition, and total DSs at the initial cast visit were
clubfoot (IC).6 This is, in part, due to the ease of use and
associated with a significant (P < 0.05) increase in the number of
substantial intraobserver and interobserver reliability of the
casts required to achieve an acceptable correction. The derotation
Dimeglio score (DS).7 Dimeglio’s classification consists of
parameter [rate ratio: 1.30, 95% confidence interval (CI): 1.13-1.50,
multiple parameters including equinus deviation, varus devia-
P = 0.0003] was most strongly associated with number of casts.
tion, derotation, and forefoot adduction. Although the scoring
Total DSs at initial visit was the only variable significantly asso-
system has proven to be an effective tool to monitor progress,
ciated with the incidence of deformity recurrence (odds ratio: 1.36,
controversy exists with regard to the predictive nature of the
95% confidence interval: 1.01-1.84, P = 0.0482).
Dimeglio parameters for future recurrence and the number of
Conclusion: Initial DS is correlated with the number of casts
casts needed for correction.8–10 Recurrence of deformity after
required for correction in Ponseti treated IC. DS may help
successful treatment occurs in over 24% of clubfeet.11,12 For
physicians establish realistic expectations for families with regard
this reason, evaluating the prognostic capabilities of the DS
would be beneficial, as it could be used to predict future
outcomes13 and set realistic expectations for parents before
From the *Department of Orthopaedic Surgery, Musculoskeletal Research treatment initiation. Given the high rate of recurrence and
Center; and †Department of Orthopaedic Surgery, Children’s Hospital variability in casts required for IC correction, this study eval-
Colorado, Aurora, CO.
C.B., A.J., and R.B.: contributed for the study design, data collection, uated the correlation between initial DS and individual Di-
and manuscript preparation. P.M.C.: contributed for the study de- meglio parameters with the number of casts and/or recurrences
sign, statistical analysis, and manuscript preparation. N.M. and G.G.: seen in IC patients treated with Ponseti method.
contributed for the study design, project management, and manu-
script preparation. K.S.H.: contributed for the manuscript revision.
The authors declare no conflicts of interest. METHODS
Reprints: Gaia Georgopoulos, MD, Department of Orthopaedic Surgery, Following IRB approval, data were retrospectively
Children’s Hospital Colorado, 13123 East, 17th Avenue, B600, Aurora,
CO 80045. E-mail: Gaia.Georgopoulos@childrenscolorado.org. collected from patients who underwent treatment of IC
Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved. between March 2012 and March 2015 and were followed
DOI: 10.1097/BPO.0000000000001325 for a minimum of 2 years. The thrust of our study focused

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J Pediatr Orthop  Volume 39, Number 5, May/June 2019 Dimeglio Score Predicts Treatment Difficulty

on the difficulty during initial treatment and early re- deformity. Multiple variable logistic regression analyses were
currence of this condition, thus, we did not report data used to test the association between DSs and the incidence of
beyond the 2-year follow-up mark, although patients recurrence. Age at first visit, laterality (bilateral vs. unilateral),
continued to be followed-up for a long term in our clinic. and sex were included as potential confounding variables in
Exclusion criteria were syndromic or neuromuscular all statistical models. Among bilateral patients, due to the high
clubfeet, patients treated at an outside facility, treatment level of correlation between affected limbs, one limb was
delay of > 6 months, and/or missing DSs. Demographics randomly selected for inclusion in the analysis. SAS software
including age, laterality, family history, sex, and DSs were (SAS 9.4; SAS Institute Inc., Cary, NC) was used to create a
collected from the initial casting visit. Primary outcomes program that automated the selection process to minimize any
were the number of casts required before Achilles tenot- bias that may occur if patients were manually selected.
omy and early recurrence. Recurrence was a subjective
finding that was defined as any relapse that resulted in RESULTS
deviations from routine follow-up including repeat casting
A total of 53 patients (37 male; 16 female) were included
after the initiation of bracing, or a need for a revision
in the study (Table 1). The median age at first casting was
tendo-Achilles lengthening followed by casting.
11 days (range: 1 to 81 d). The prevalence of bilateral clubfeet
All patients were seen in a clubfoot clinic by a
and a positive family history for IC was 47% (25/53) and 24%
Ponseti-trained team which included a physician, physical
(13/53), respectively. The median number of casts required to
therapist, cast technician, orthotist, and nurse. DSs were
achieve an acceptable correction was 5 (range: 2 to 16). The
independently assessed by the PT and surgeon. The DS
incidence of recurrences was 24.53% (13/53).
was calculated in accordance with Dimeglio et al14:
A higher total DS at initial cast visit as well as a more
4 primary variables (each worth 4 points) including
severe derotation, varus, equinus, and muscle condition
equinus deviation in the sagittal plane, varus deviation in
parameter score at the initial visit were associated with a
the coronal plane, derotation around the talus, and fore-
significant (P < 0.05) increase in the number of casts re-
foot adduction on the horizontal plane, and 4 secondary
quired to achieve an acceptable correction before tenotomy
variables (each worth 1 point) including posterior creases,
(Table 2). Of the individual parameters, the derotation
medial creases, cavus, and poor muscle condition. Scores
score at the initial cast visit was associated with the largest
were collected on a 20-point scale with more severe club-
χ2 test statistic. For every one-unit increase in derotation
feet having higher scores. Strict adherence to the Ponseti
score, there was a 30% [95% confidence interval (CI): 13%-
method was used for all patients. Tenotomy was per-
50%, P = 0.0003] increase in the number of casts required to
formed after all components of the clubfoot were cor-
achieve an acceptable correction.
rected, with the exception of the equinus. We strive to see
In an effort to determine factors or variables related to
20 degrees of forefoot abduction, 20 degrees of hindfoot
IC that may be less amenable to treatment, we also eval-
valgus, and > 50 degrees of derotation. If we have not
uated the change in total DS between the first and second
been able to obtain at least 20 degrees of dorsiflexion with
visit. To limit the number of statistical comparisons, we
casting, tenotomy is performed. The tenotomy is per-
elected to look at the change in total DS between the first
formed in the clinic with a local anesthetic and the child is
and second casting visits only. The change in total DS be-
casted for 3 weeks and then transitioned to a brace.
tween the first and second cast visit was not significantly
All initial clubfoot recurrences were treated with
associated with the number of casts required to achieve an
repeat casting and/or tenotomy. On some occasions, anterior
acceptable correction prior to tenotomy (percent change in
tibial tendon transfer was also performed. We tried to avoid
number casts per 1-unit improvement in score between the
posterior-medial release whenever possible in the idiopathic
group and were fortunate enough to not have to pursue that as
an option within this group. As an institution dedicated to TABLE 1. Patient Characteristics and Outcomes
conservative management of idiopathic clubfoot, we will recast Median (Interquartile Range)/N (%)
multiple times before resorting to a posterior-medial release.
Demographics and clinical characteristics
Bilateral 25 (47.17)
Statistical Methods Female 16 (30.19)
Descriptive statistics were used to summarize the Tenotomy 46 (86.79)
demographics and clinical characteristics of all patients Posttenotomy casts
One cast 40 (86.94)
included in the cohort. Poisson regression analyses were Two casts 6 (13.04)
used to test the association between Dimeglio parameters L Foot 27 (50.94)
and number of casts required to achieve an acceptable Positive family history 13 (24.53)
correction per foot. Total DS at initial visit as well as each Bracing 53 (100)
of the DS parameters (equinus, varus, derotation, forefoot Age at first visit 11 (7-22)
Brace duration 2.42 (1.88-3.42)
adduction, muscle condition, cavus, posterior crease, and Outcomes
medial crease) were tested in separate models. The χ2 statistic No. casts 5 (4-6)
associated with each parameter was used to identify the pa- Minor recurrence 13 (24.53)
rameter that was most strongly associated with total number Revision Cast 11 (20.75)
Repeat Tenotomy 4 (7.55)
of casts required to achieve an acceptable correction of the

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Brazell et al J Pediatr Orthop  Volume 39, Number 5, May/June 2019

controversial.16 In the current study, the total DS obtained at

TABLE 2. Association Between Dimeglio Scores and Number
of Casts the initial cast visit was associated with the number of casts
required for correction and the incidence of deformity re-
Rate Lower Upper
currence following bracing. Derotation, a continuous parame-
Parameters Ratio χ2 Statistic 95% CI 95% CI P
ter of the DS, was the most significant parameter related to the
Continuous parameters number of casts needed to obtain deformity correction.
Derotation 1.30 13.34 1.13 1.50 0.0003
Varus 1.43 11.87 1.17 1.75 0.0006
The Dimeglio scoring system for IC was first described in
Equinus 1.33 10.79 1.12 1.57 0.0010 1995 with the intent to characterize IC accurately, assess
Forefoot 1.17 3.32 0.99 1.39 0.0684 treatment progress, and standardize terminology for the ex-
Binary parameters change of information between the treating clinicians.14 Despite
Muscle 2.04 4.39 1.05 3.96 0.0361 having excellent interobserver and intraobserver reliability, to
condition
Posterior 1.17 0.63 0.80 1.72 0.4256 date,13 the literature has conflicting reports with regard to its
crease ability to predict treatment strategies or recurrence. Originally,
Cavus 0.89 0.56 0.64 1.22 0.4548 Ponseti believed that relapses were difficult to recognize in early
Medial crease 1.07 0.22 0.80 1.44 0.6353 stages,17 and Bensahel is later quoted stating that the “pre-
Total score 1.08 11.65 1.04 1.14 0.0006
diction of the future of a clubfoot after treatment is not pos-
All estimates are adjusted for sex, age at first visit, and laterality. Strength of sible.”18 Two studies specifically addressed the number of
association represented by the χ2 test statistic. Ponseti casts required for IC correction, but found low corre-
CI indicates confidence interval.
lations with the initial DS.9,19 Lampasi et al,20 in 2018, con-
cluded that the initial DS is strongly correlated with the number
first and second cast visits: 33%, 95% CI: −28% to 64%, of casts required for correction. In relation to IC recurrence
P = 0.2271). In this model, age at first cast visit (rate ratio per rates, multiple studies show no correlation with the initial
1-day increase in age: 1.01, 95% CI: <1.00-1.01, P = 0.0560) DS.10,16,21 Alternatively, positive correlations between the
and sex (rate ratio male vs. female: 1.07, 95% CI: 0.82-1.39, initial DS and the need for future surgery22 and optimal
P = 0.6151) were not significantly related to the number of outcomes8 have been reported.
casts. Individuals with bilateral clubfoot required sig- The lack of consistency in conclusions of the related
nificantly more casts than subjects with unilateral clubfoot studies may be attributable to differing key methodological
(rate ratio: 1.31, 95% CI: 1.02-1.67, P = 0.0336). approaches which highlight the limitations of retrospective
Total DS at the initial visit was the only variable analyses and statistical modeling, particularly in relation to
significantly associated with the incidence of deformity re- bilateral extremity deformity. Clubfoot can often affect
currence (Table 3). An increase in the total DS at initial visit both limbs. The analysis of bilateral data requires special
was associated with increased odds of deformity recurrence statistical considerations to account for the within-subject
[odds ratio (OR) per 1-unit increase in total DS:1.36, 95% CI: correlation. Several studies included in our review did not
1.01-1.84, P = 0.0482]. Age (OR per 1-day increase in age: account for this within-subject correlation.9,10,16,19,21 In our
1.00, 95% CI: 0.97-1.04, P = 0.8429), sex (OR female vs. male: analysis, the correlation between feet was extremely high and
2.52, 95% CI: 0.62-10.26, P = 0.1961), and laterality (OR thus we elected to randomly drop 1 limb from the analysis.
unilateral vs. bilateral: 1.53, 95% CI: 0.38-6.17, P = 0.5498) Selected studies utilized alternative statistical models that
were not significantly related to odds of deformity recurrence. appropriately consider the within-subject correlation. In ad-
dition, the definition of the number of casts varies across
studies as some chose to include posttenotomy casts while
DISCUSSION others did not. Consistent with Goldstein et al,22 we did
The DS is a widely accepted scoring system to monitor not count posttenotomy casts due to concerns that not all
Ponseti treated IC.15 Although the scoring system is an effective patients undergo a tenotomy (~15% of patients will not
tool for characterizing clubfoot severity, its prognostic value is need a tenotomy23). Inclusion of posttenotomy casts dis-
proportionately focuses on a single aspect of the deformity,
equinus. For example, multiple reports suggest no associa-
TABLE 3. Association Between Dimeglio Scores and Deformity
Recurrence During Bracing tion between DSs and number casts when including post-
tenotomy casts.10,16,19,21 Finally, many of the papers did not
Score* Odds Ratio Lower 95% CI Upper 95% CI P
provide a detailed description of casting method and/or used
Total Score 1.36 1.01 1.84 0.0482 a variation of Ponseti’s original method. Strict adherence to
Equinus 2.92 0.96 8.89 0.0589 Ponseti method is critical and is associated with lower risk of
Varus 2.97 0.85 10.35 0.0872
Derotation 2.01 0.87 4.63 0.1035
subsequent unplanned surgical intervention.24
Medial crease 2.25 0.38 13.16 0.3698 Among the individual parameters of the Dimeglio
Forefoot 1.35 0.54 3.35 0.5242 scoring system we tested, derotation was the most significant
*Muscle condition, posterior crease, and cavus scores were not estimable due to
parameter associated with the number of casts needed for
lack of variability in the incidence of deformity recurrence across the parameter deformity correction (highest χ2 test statistic). Derotation is
score range. the best determination of reduction of the talus and must
All estimates are adjusted for sex, age at first visit, and laterality.
CI indicates confidence interval. reach at least 20 to 30 degrees before correction of the equinus
deformity can be initiated.

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J Pediatr Orthop  Volume 39, Number 5, May/June 2019
The aim of the current study was to establish a
predictive element of length of casting and risk of re-
currence for our new clubfoot families. Parental education
and expectations at the initiation and progression of
Ponseti treatment for IC are important,25 as these factors
have been related to compliance with treatment and the
potential of subsequent recurrence of the deformity.16
Noncompliance within the extended bracing period fol-
lowing casting has been shown to be a significant factor of
IC relapse.26 Although we agree that brace noncompliance
is a common reason for relapse or recurrence of deformity,
it is also clear that there are some clubfeet that recur in the
face of excellent brace compliance. In contrast, there are
clubfeet that maintain excellent correction despite lack of
brace wear. This study may point to another factor pre-
dictive of recurrence.
The strength of our work is the consistency of the
Ponseti treatment protocol that has been initiated at our
facility with a trained team of physicians and therapists.
Our providers maintained all clinic notes with doc-
umentation of brace compliance, however, the study is
limited by the lack of sensors in the braces that are able to
determine the accuracy of these reports. This study is in-
herently limited to the characteristics of a patient pop-
ulation in the midwest metropolitan area, and thus, our
results may only be generalizable to a population of a
similar region. In addition, due to the purpose of our
analysis, variables that were not available to the clinician
at baseline, such as compliance or other factors that occur
after casting, were not considered. There are likely other
variables that cause recurrence that were not measured in
this study. Another limitation to our work is that the de-
termination of deformity recurrence, while based partially
on the DS, is also influenced by the surgeon’s discretion.
Lastly, the current study is focused on the short-term
outcomes, or results, of a life-time condition. Future
studies need to consider the relationship of the DS and
long-term functional outcomes and the cumulative effects
of treatment burden on both individuals and families.
CONCLUSIONS
The Dimeglio scoring system is an objective means
to gauge the severity of IC deformities with significant
prognostic utility in our treatment setting. The initial DS is
correlated with the number of casts required for correction
in Ponseti treated IC, and the rate of deformity recurrence
following casting. The derotation parameter was most
strongly associated with the number of casts required to
achieve an acceptable reduction of IC. Correlating ob-
jective scores with treatment and long-term outcomes can
help clinicians plan for future procedures and develop
realistic expectations for families.
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