Pirani Score and Dimeglio Classification for Clubfoot Assessment

Pirani socre

Pirani score for assessment of clubfoot (CTEV) consists of 6 parameters (3 each in midfoot and hindfoot) which is scored as 0, 0.5 or 1 with a maximum possible score of 6. The parameters can be remembered using the mnemonic: PER TOM

1. Posterior crease
2. Empty heel
3. Rigid equinus
4. Talar head
5. Outer (lateral) border curvature
6. Medial crease

Examination	Midfoot (MFCS)	0	0.5	1	Hindfoot (HFCS)	0	0.5	1
Look	Lateral border curvature (reference – pen held against calcaneum)	Straight	Deviates at metatarsal level	Deviates at calcaneo-cuboid joint	Posterior crease (after correction)	Several fine creases	2-3 moderate creases	Single deep crease
Feel	Talar head (palpate uncorrected and then correct)	Completely sinks under navicular	Moves partially but doesn’t completely sink	Fixed	Heel (with index finger in mild correction)	Easy to palpate calcaneum	Palpable calcaneum felt through later of flesh	Calcaneum is deep under layer of tissue and difficult to feel
Move	Medial crease (after correction)	Several fine creases	2-3 moderate creases	Single deep crease	Equinus (after correction with knee in extension)	Dorsiflexion beyond plantigrade	Upto plantigrade	Below plantigrade

Importance of Pirani Score

1. A higher Pirani Score on presentation may indicate that a higher number of casts will be required.
2. Relapse is higher with high initial HFCS.
3. The tenotomy is done when the Midfoot Contracture Score (MFCS) is less than 0.5 but the Hindfoot Contracture Score (HFCS) remains greater than 1. After the tenotomy, the HFCS improves but does not correct completely.

Dimeglio Classification

Based on degrees of reducibility of 4 deformities (Mnemonic: DAVE) –

1. Derotation of carpopedal block (1-4 points)
2. Adduction of forefoot (1-4 points)
3. Varus (1-4 points)
4. Equinus (1-4 points)

And 1 point each for presence of:

1. Posterior crease
2. Medial crease
3. Cavus
4. Hypertonia, muscle weakness or chubby foot

Interpretation:

Grade	Type	Score	Reducibility
I	Benign	0-5	Completely reducible
II	Moderate	6-10	Reducible (>50%), partially resistant
III	Severe	11-15	Resistant, partially reducible (<50%)
IV	Very Severe	>15	Resistant