Reply to comment on Agarwal et al.: Does initial Pirani score and age influence number of Ponseti casts in children?

We read the reply by the authors of the article by Agarwal et al. [1]. We congratulate them for a quick reply for an important issue raised in the article. We also agree that the resistant and recurrent clubfoot are a special category of clubfoot patients which require an individualized approach. It has been repeatedly proven that parental education status affects the compliance and hence the prognosis of clubfoot [2], and the authors are in agreement with us.

We still stick to our opinion that assessment of severity of clubfoot and conservative management of clubfoot in older children is quite different. Assessment of severity by Pirani score is difficult since there are no empty heel signs, distinct medial and posterior creases in walking children [3]. We still feel that it is necessary to modify the Ponseti technique of conservative management in neglected clubfoot, including the duration of manipulation, interval between cast change, maximum abduction limit, indication for tenotomy, and post correction brace protocol. Though this issue has been raised by many articles [3, 4, 5], the topic remains controversial. We appreciate the present authors effort in addressing an important issue in the management of clubfoot.