Interobserver variability in Pirani clubfoot severity scoring system between the orthopedic surgeons

Abstract

Background:Congenital talipes equinovarus (clubfoot) is one of the most common congenital pediatric orthopedic foot deformity, which varies in severity and clinical course. Assessment of severity of the club foot deformity is essential to assess the initial severity of deformity, to monitor the progress of treatment, to prognosticate, and to identify early relapse. Pirani's scoring system is most acceptable and popular for club foot deformity assessment because it is simple, quick, cost effective, and easy. Since the scoring system is subjective in nature it has inter- and intra-observer variability, it is widely used. Hence, the interobserver variability between orthopedic surgeons in assessing the club foot severity by Pirani scoring system.Materials and Methods:We assessed the interobserver variability between five orthopedic surgeons of comparable skills, in assessing the club foot severity by Pirani scoring system in 80 feet of 60 children (20 bilateral and 40 unilateral) with club foot deformity. All the five different orthopedic surgeons were familiar with Pirani clubfoot severity scoring and Ponseti cast manipulation, as they had already worked in CTEV clinics for at least 2 months. Each of them independently scored, each foot as per the Pirani clubfoot scoring system and recorded total score (TS), Midfoot score (MFS), Hind foot score (HFS), posterior crease (PC), emptiness of heel (EH), rigidity of equnius (RE), medial crease (MC), curvature of lateral border (CLB), and lateral head of talus (LHT). Interobserver variability was calculated using kappa statistic for each of these signs and was judged as poor (0.00–0.20), fair (0.21–0.40), moderate (0.41–0.60), substantial (0.61–0.80), or almost perfect (0.81–1.00).Results:The mean age was 137 days (range 21-335) days. The mean Pirani score was 3.86. We found the overall consistency to be substantial for overall score (total score kappa - 0.71) and also for midfoot (0.68) and hindfoot (0.66) separately. The consistency was least for the emptiness of heel (kappa - 0.39), and best for rigidity of equnius (kappa - 0.68) and rest of the parameters were moderate (kappa between 0.40 and 0.60).Conclusion:The Pirani scoring system had got substantial reliability in assessing the clubfoot deformity even when the reliability test was extended to five different orthopedic surgeons simultaneously.

The Correlation of Pirani and Dimeglio Scoring Systems for Ponseti Management at Different Levels of Deformity Severity

“…The Pirani and Dimeglio classifications are the two most widely utilized scoring systems for clubfoot, and their intra-observer and inter-observer reliability has been shown to be good by their developers at their respective institutions 18 , 19 . A recent study showed that even the reliability test was carried out by five different orthopaedic surgeons, except for emptiness of the heel (EH), the total score and component clinical signs of the Pirani scoring system had substantial reliability with ICCs and Kappa values of posterior crease (PC), EH, rigidity of equinus (RE), hind foot score (HFS), medial crease (MC), curvature of lateral border (CLB), lateral head of talus (LHT), midfoot score (MFS), and total score (TS) were 0.4022, 0.3255, 0.6546, 0.6221, 0.4294, 0.5322, 0.534, 0.6407, and 0.7004 and 0.46, 0.39, 0.68, 0.66, 0.43, 0.56, 0.53, 0.68, and 0.71, respectively 10 . With a three-point classification of severity of each clinical sign, the Pirani scoring system may have little room for error between assessors.…”

“…The intra-class correlation coefficients (ICCs; 2-way random effects model, single-measure reliability) were calculated for initial Pirani and Dimeglio scores acquired by the two reviewers. A score of 0.81 to 1 were rated as very good, 0.61 to 0.8 as good, 0.41 to 0.6 as moderate, and less than 0.4 as poor reliability 10 . The difference in standardized deformity between the Pirani score and Dimeglio scores was calculated by paired sample t-test.…”

Developing a Three-Dimensional (3D) Assessment Method for Clubfoot—A Study Protocol

“…However, several studies reported that there is no universal standard assessment method available at present to quantify the initial severity of the clubfoot or monitor the clubfoot treatment (Jain et al, 2001 ; Gigante et al, 2004 ; Dyer and Davis, 2006 ; Ramanathan et al, 2009 ; Ramanathan and Abboud, 2010 ; Yapp et al, 2012 ; Bhaskar and Patni, 2013 ). Because it is difficult to obtain the objective measurements from all these classification systems (Catterrall classification system, Pirani scoring, Dimeglio classification system, and Harrold and Walker classification system) due to subjective in nature (Wainwright et al, 2002 ; Jain et al, 2012 , 2017 ; Fan et al, 2017 ). In view of imaging assessment methods, it provides objective details of severities of the clubfoot.…”

“…Both clinical grading systems had been reported with excellent reliability and reproducibility (Flynn et al, 1999 ; Pirani et al, 2008 ; Shaheen et al, 2012 ). Also, the Pirani scoring system is gained more popularity than other scoring system for assessing the outcome of Ponseti treatment (Jain et al, 2017 ). Although these both systems considered as an effective assessment tools, some aspects of prognostic measurements, such as medial and posterior creases, cavus, and heel emptiness values are considered as imperfect (Chu et al, 2010 ; Bergerault et al, 2013 ).…”

“…Therefore, the International Clubfoot Registry Database (ICRD) suggested to record the biomechanical aspects of objective evaluation methods such as measuring the angle of foot positions of four components of clubfoot deformities (cavus, abduction, varus, and equinus) as well as Pirani score (Khan et al, 2017 ). Due to no agreed standard objective assessment methods for evaluating and monitoring the severities of the clubfoot, many studies suggested that the need of objective assessment method to quantify the severity and predict the prognosis of the treatment (Wainwright et al, 2002 ; Herd et al, 2004 ; Siapkara and Duncan, 2007 ; Ramanathan and Abboud, 2010 ; Jain et al, 2012 , 2017 ; Fan et al, 2017 ), and these studies also stated the assessment should be accurate, reliable, and valid to predict the prognosis of the clubfoot. Therefore, we propose this study by using a low-cost 3D scanner to explore the structural changes in clubfoot and quantify the severity of clubfoot.…”