European Journal of Cardiovascular Medicine

Congenital Idiopathic Talipes Equinovarus (CTEV), also known as clubfoot, is a complicated deformity characterized by abnormal anatomy in the foot, including ankle equinus, hindfoot varus, midfoot cavus, and forefoot adductus [1]. The prevalence of congenital clubfoot in Europe is 1.2 cases per 1000 live births [2]. However, this abnormality continues to cause significant handicap in nations with low resources. For instance, in Malawi, the occurrence of CTEV is twice as high as in Western Europe [2].

The widespread adoption of the Ponseti approach, supported by reported successful outcomes in both the short and long terms [2-4], has resulted in a unanimous consensus that this non-operative protocol is the preferred initial treatment for clubfoot. Regardless of the approach employed, the treatment strategy for CTEV should strive to attain a foot that is pain-free, with a normal weight-bearing position and flexible, while also meeting aesthetic and functional standards. The objectives are anticipated to be accomplished within the shortest possible timeframe, while ensuring minimal disruption to the socio-economic well-being of both the parent and kid [1].

The management of club foot entails a systematic evaluation of the deformed foot prior to and throughout the treatment procedure [5].The scoring system established by Pirani, which has shown excellent interobserver reliability and reproducibility [2,6,7], is straightforward and can be easily used in many clinical situations.

Due to the requirement of many castings with weekly changes, the traditional protocol of the Ponseti procedure might be inconvenient for patient groups living far away from referral medical centers, who may face difficulties in reaching these clinics on a weekly basis. In this study, we expand upon the idea of expediting the Ponseti procedure [8–11].

We utilize the Ponseti approach with an accelerated treatment schedule, consisting of the application of five castings over the period of one week. Reducing the duration of treatment alleviates the hardship faced by patients and their families who have to travel vast distances or remain near medical centers for extended periods of time for treatment, as is the case with the traditional Ponseti technique.

This prospective observational study was conducted at a tertiary care institute in Central India. The study included infants with idiopathic clubfoot deformity who were between the ages of birth and 12 months. Informed written consent was obtained from their parents.

The study excluded children who were 12 months or older, had already undergone clubfoot surgery, or had atypical or secondary clubfoot. A total of 60 patients were included based on the specified inclusion and exclusion criteria.

A comprehensive overall and specific examination was conducted, and a meticulous history was gathered. The malformation was assessed using Pirani's scoring system. Weekly manipulation and successive correction casts were administered in accordance with Ponseti's approach.

The order of correcting the deformities was first addressing the cavus deformity, followed by the adduction and varus deformities. The equinus deformity, which is typically addressed with percutaneous heel cord tenotomy, was successfully rectified following the midfoot deformity repairs guided by Pirani's score. During the process of placing the cast, a pacifier was utilized to soothe the kid. Weekly follow-ups were conducted to monitor cases, and serial corrective casting was administered for a duration of six to eight weeks, if needed.

Replacing plaster casts more frequently yields superior outcomes. Prior to putting the cast during each visit, the improvement in deformity was recorded using Pirani's scoring method. Percutaneous tendoachilles tenotomy was performed under general anesthesia when needed, guided by Pirani's score. Following the procedure, a final cast was put for a duration of three weeks. The application of Denis Browne splints lasted for a duration of three months.

Children who had begun putting weight on their lower limbs were provided with altered CTEV shoes. They were instructed to wear night-time braces for a period of three to four years. The combination of parental education and consistent reassurance had a crucial role in ensuring the effectiveness of long-term brace treatment, therefore minimizing the occurrence of relapses.

Pirani scoring system

In 1995, Pirani proposed a method for evaluating the severity of clubfoot. The assessment consists of six distinct observations during a physical examination: three at the midfoot level and three at the hindfoot level. Each observation is assigned a score of 0 for no abnormality, 0.5 for moderate abnormality, and 1.0 for severe abnormalities. Each foot was assigned a score ranging from zero to six, with a higher number indicating a more severe deformity and a very atypical foot. The midfoot score includes three components to assess the level of involvement: a curved lateral border, a medial crease, and coverage of the talar head. The hindfoot score consists of three components: the posterior crease, rigid equinus, and empty heel (Table 1).

The Pirani scoring system is a method used in the assessment of clubfoot severity, particularly in infants. It involves evaluating specific parameters related to the midfoot and hindfoot. For the midfoot, criteria such as the presence of a curved lateral border, deep medial crease, and uncovering of the talar head are considered, with corresponding scores for mild, moderate, and severe cases. Similarly, hindfoot assessment includes criteria like an empty heel, posterior crease, and rigidequinus, each with varying scores based on severity. This scoring system provides clinicians with a standardized approach to assess the severity of clubfoot deformities, aiding in treatment planning and monitoring of patient progress.

Table 2 provides demographic variables of cases related to clubfoot deformities. Among the cases analyzed, 75% were male and 25% were female. In terms of the side of involvement, bilateral cases constituted the majority at 55%, while 20% were left-sided and 25% were right-sided. Regarding the age at presentation, 50% of cases were seen between 0-2 months, 30% between >2-6 months, and 20% after 6 months. Birth order data indicates that 70% of cases were firstborn, while 30% were second or above. Additionally, only 5% of cases resulted from consanguineous marriages, with the vast majority, 95%, originating from non-consanguineous marriages.

Table 3 outlines treatment and complication-related variables for clubfoot cases. The majority of cases (87.10%) underwent treatment involving both casting and heel cord tenotomy, while a smaller proportion (12.90%) received casting only. In terms of the number of casts required for full correction, 51.62% of cases necessitated 5-6 casts, while 48.38% required 7-8 casts. Complications were relatively rare, with only 3.23% experiencing superficial blister formation, while the overwhelming majority (96.77%) had no complications following treatment.

Table 4 illustrates the relationship between Pirani scores at initial presentation and after final cast removal for clubfoot cases. Before treatment, Pirani scores ranged from 2.00 to 6.00, with a mean score of 5.016 ± 0.96. After treatment, Pirani scores significantly decreased to a range of 0.00 to 1.00, with a mean score of 0.103 ± 0.241. The p-value associated with this change was less than 0.001, indicating a significant reduction in Pirani scores following treatment.

Clubfoot is a challenging musculoskeletal malformation of the foot that necessitates meticulous and constant efforts from both the surgeon and parents to repair it. Approximately 85-90% of patients who undergo scheduled serial cast repair have reported satisfactory functional outcomes. All 40 instances in our study were categorized using the Pirani scoring system, which facilitated the evaluation of the extent of the deformity. While there are other categorization systems such as Carroll or Dimeglio, the Pirani scoring system sheds some light on the prognosis of CTEV (Congenital Talipes Equinovarus) and aids in its management. 

Out of the 40 patients, 20 children (50%) appeared within the first two months of life, seven instances (30%) were presented between the third to sixth months, and the other eight patients (20%) were presented between This may indicate a flawed system for referring individuals and a lack of knowledge among parents and guardians.  The current study demonstrates a higher prevalence of males. Out of a total of 40 newborns, 30 were male, resulting in a male-to-female ratio of 3:1.This is similar to the series of studies conducted by Yamamoto [12] and Chesney et al. [13] which also found a larger proportion of instances in men. This can be attributed to the prevailing preconceptions, biases, and societal norms that exhibit a preference for the masculine gender in our region. In this study, bilateral involvement was observed in 55% of cases.

A total of 25% of instances were located on the left side, while 20% were located on the right side. In the study undertaken by Guruprasath et al. [14], bilateral involvement was identified in 57.89% of patients, while 26.3% were on the right side and  In this investigation, 28 instances (70%) were of firstborn children, which aligns with findings from previous studies conducted by Pulak et al. [15] and Yamamoto [12].

This indicates that congenital clubfoot was more prevalent in firstborn children. All 20 cases in the present study had no associated conditions. On the other hand, Guruprasath et al. (2013) found that 10.52% of patients had related disorders, including cleft lip (5.26%), developmental dysplasia of the hip 4 In this study, 52% of the foot cases required five to six casts for correction, whereas 48% of the foot cases required seven to eight casts. The average number of casts needed for full correction was Our observation revealed that infants in the later half of the infancy period and those with a higher initial Pirani score required a greater number of casts.

The average number of casts required in the study conducted by Laave et al. [16] was seven. A more frequent replacement of plaster casts at shorter intervals and a reduced number of casts per foot have been found to yield superior outcomes. As a result, this approach has been embraced by several orthopedic specialists. In our study, the highest first Pirani score observed was 12, the lowest score recorded was 5, and the mean initial Pirani score was 4.8.These findings are consistent with the results reported by Syed et al. [17] and Pulak et al. [15].

Heel cord tenotomy is performed for equinus deformity only after correcting forefoot adduction and heel varus. Out of the patients included in our study, 87% required tenotomy. Similarly, in the study conducted by Pirani et al., 90%In Dobbsetal.'s series, 91% of patients required tenotomy, while [18] underwent tenotomy. During our investigation, we saw that individuals with a Pirani score of 5 or above at presentation typically needed to have tenotomy. In the current study, two patient (3.13%) out of 61 feet developed a superficial blister, which was successfully treated by applying appropriate soft padding, continuing with casting, and allowing the skin to heal. In Lehman's study [19], 10.2% of cases reported complications. Guruprasathetal.[14] found a complication rate of 13.15%, which included superficial ulcers and crowding of toes.

These were controlled by soft cushioning and provided sufficient space for the toes, particularly the dorsum, to move freely. In the current investigation, the final average Pirani score was 0.055, with the p-value (p<0.001) being extremely significant. This indicates that the Ponseti techniqueIn a research conducted by Thacker et al. [20], the final Pirani score was 0.00 at the last follow-up, demonstrating effective repair of the clubfoot deformity using the Ponseti approach.

Based on our analysis, we can determine that the Ponseti technique greatly eliminates the necessity for invasive surgical operations. Additionally, it is very safe, effective, and cost-efficient.The Ponseti approach of cast correction is essential due to its high effectiveness and low cost. It effectively avoids surgical problems and results in a painless, plantigrade foot that is cosmetically acceptable and has improved functional outcomes for patients. Providing consistent support and encouragement to parents to embrace long-term brace treatment is crucial for sustaining correction and minimizing relapses. Our investigation has found that the Ponseti method of serial cast repair is highly effective for correcting idiopathic CTEV deformity.

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