John M. Flynn, M.D.,
Renee Donohoe, P.T., William Mackenzie M.D.
Alfred I. duPont Institute
1600 Rockland Road
Wilmington, Delaware 19803
INTRODUCTION: The management of children with clubfeet has been handicapped by the lack of a widely accepted method of classification. Because the radiographic evaluation of infant feet has significant limitations, several centers have created their own classification systems that rely on physical examination alone. Of these, two classifications have been published or presented in sufficient detail to allow an independent evaluation. We have tested the classifications of Pirani, et al.1 and of Dimeglio, et al.2 to determine if , as an independent center, we can quickly and reliably classify the clubfeet that present to us for management.
METHODS: Infants with idiopathic clubfeet presenting for initial visit, cast change, or pre- operative physical exam were enrolled in the study. Children with myelodysplasia, arthrogryposis, or previous surgery were excluded. Three designated examiners participated. A staff pediatric orthopaedist and a fellow in pediatric orthopaedics examined all feet. Many feet were also assessed by a third examiner, a physical therapist. The creators of the respective classifications were contacted and asked to send their written and videotaped instructional material. All material received was reviewed by each examiner prior to the study. Each examiner assessed the foot independently, blinded to the scoring of the others. In the Pirani classification, ten different tests and findings are recorded as total score (0-10); each test or finding also contributes to a hindfoot and midfoot score (0-5 each). In the Dimeglio system, four "essential parameters" are assessed by applying a gentle corrective force and recording (1) equinus, (2) varus, (3) adductus, and (4) derotation of the calcaneo-forefoot block; each is parameter is scored 0-4. Four additional points are given for "further pejorative elements": medial crease, posterior crease, cavus, or poor musculature. A total score of 0-20 is thus generated. Once a total score is calculated, each foot can be graded I (0-5), II (5-10), III (10-15) or IV (15-20).
RESULTS: Thus far, forty-five of the feet classified by the two orthopaedists have been statistically analyzed. For the 10-point Pirani classification, 87% of the total scores were within 1 point. The mean difference between the two examiners was 0.7 ñ .57. For the 20-point Dimeglio classification, 89% were within 2 points. The mean difference between the two examiners was 1.5 ñ 1.3. Correlation coefficients were r = 0.88 (p=.0001) for the Pirani classification and r = 0.81 (p = .0001) for the Dimeglio classification. Twenty-nine of these feet were also scored by the physical therapist. In most cases, this third examiner gave a lower score in both classifications. When the scores of this third examiner are factored in, variability increased to 1.6 ñ .68 for Pirani and 3.4 ñ 2.2 for Dimeglio.
DISCUSSION: We have tested two classification systems designed to assess clubfeet by physical examination alone. In an independent, blinded evaluation, both classifications had substantial inter-observer reliability for the two physician examiners. The reliability for a third examiner was lower; this may be due to a learning curve effect that cannot yet be statistically proven due to smaller sample size. Each classification can be performed in less than 5 minutes. Given the reliability and ease of application, one of these classifications could play a valuable role in the assessment of infant clubfeet and would be an essential component of any outcome study of the clubfoot program.
1. Pirani S. et al. A method of evaluating the virgin clubfoot with substantial inter-observer reliability. Presented at POSNA, Miami, Fla. 1995.
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