Web Exclusive - February 2003

Dr. Ignacio Ponseti walks briskly down the hospital hallway, stopping briefly to ask a clinic nurse, "Is the baby here yet?"

"No," she says. "Not yet."

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"I have an album at home of my babies," Ponseti tells his companion. "These are all very important babies."

The infants he's referring to are children born with clubfeet, babies whose legs terminate with a severe twist of the ankle, oftentimes turning the foot almost completely upside down. The condition is not painful for babies, who use their feet mostly for wiggling and other entertainment, but their parents are devastated. And when the babies grow into children, their feet will be clumsy at best, punctuating their walk with jerks and starts.

For a century, doctors have turned to surgery to treat clubfeet. By cutting ligaments and tendons, they are able to force the foot into a more normal position. The problem is, Ponseti says, that the surgery creates a foot that is inflexible. By the time the patient turns 20 or so, the foot is not only stiff, but also painful.

An orthopaedic surgeon himself until he was forced to leave the operating room when he reached the age of 70 (in 1984), Ponseti had much earlier concluded that surgery is not the best treatment for clubfoot.

Dr. Ponseti evaluates children with orthopaedic problems.

As a young physician, Ponseti studied patient outcomes and learned that surgical treatment for clubfoot left much to be desired. He also evaluated patients with many other orthopaedic problems.

"I came to the university in 1941 for my residency," Ponseti says. "Iowa was well known for its program in orthopaedic surgery. Arthur Steindler, a master surgeon, was here then. He was a giant in the field, and he was a good filer."

Ponseti's work included following up on patients treated years before for all sorts of orthopaedic problems. He was studying outcomes. Because Iowa's population was relatively stable at the time, Ponseti could locate patients long after they'd been treated.

"We had the X-rays, the lab tests, the histories on all these patients on file," Ponseti recalls. "I could call them in to see the outcomes of what had been done for them."

After looking at a couple dozen patients treated surgically for clubfoot, Ponseti knew there must be a better way. The young doctor began looking at stillborn fetuses with clubfoot to learn more about the abnormality. "We know that the foot grows normally for the first several weeks in the pregnancy and then something happens that we don't understand yet, and the foot twists," Ponseti explains.

He studied ligaments and tendons and collagen. "Under the microscope," he says, "I examined the ligaments and saw that they are wavy. You can stretch them gently without any damage."

Following the nudgings of his understanding, Ponseti thought about the curious way that nature responds. In infants, he thought, the young cartilage and bone cells of the deformed foot would respond to changes in the direction of low-static loading. Gentle traction to stretch the tight medial ligaments should allow some correction of the deformity. The joints would remodel somewhat if a plaster cast were applied for five to seven days.

Ponseti began applying his theory with patients in the early 1950s. He gently stretched the medial ligaments. Then he held the foot in its new position while a plaster cast was applied to the baby's foot and leg, all the way up to the upper thigh. About a week later, the cast was removed. Using his hands only, he applied more gentle ptraction to further stretch the ligaments. Another cast. The joints remodel bit by bit. After the application of five casts, the foot has responded to the change in alignment and appears normal.

It seems so easy, but the Ponseti Method is not that simple. The pressure must be exerted on the head of the talus, not the cuboid bone. The doctor doesn't touch the patient's heel. As Ponseti explains, "You invite the foot to come back in the normal position. Already, the foot knows what this position is. It was in that position for the first half of the pregnancy. The foot was normal until then."

One early patient Ponseti treated with his method was Ross Snyder, 80BS, 83BSPh, in 1956. Today, Snyder could be a poster person for Ponseti's treatment. He jogs regularly. As a pharmacist in Manchester, Iowa, he spends long days on his feet. He's run a few marathons. Ross Snyder has none of the pain or stiffness commonly exhibited by patients treated surgically for the congenital deformity of clubfeet.

In the five decades that the Ponseti Method has been used, thousands of patients worldwide have benefited. Hundreds have come to Iowa City for treatment by the master himself, but Ponseti has worked hard to train other doctors in the method, too. He published his paper on clubfoot treatment in 1963. "It was my wife who pushed me into writing the book Congenital Clubfoot," Ponseti says. First published by Oxford University Press in 1996, the book has since been reprinted.

Why did it take so long for Ponseti to apply what he learned during the 18 months or so he studied the anatomy and biology and histology of clubfoot in the 1940s? Eight years after he completed the bulk of his research, he treated Ross Snyder. Seven years after that, he published his first paper on the Ponseti Method. And 33 years after that, he wrote the book.

"I showed Dr. Steindler that the results of surgery are not good," Ponseti says."He was an excellent surgeon, but no surgeon can prevent the formation of scar tissue, and, when that develops, the foot becomes stiff." Arthur Steindler retired from the University of Iowa in 1949. Still, Ponseti adds, "No institution even now wants to publish their results on clubfoot surgery. The outcomes are not good. The patients' feet often become very painful after about age 20."

Around the world, the frequency with which the clubfoot deformity exhibits itself depends very much on race. In Caucasians, about one in 1,000 babies is born with clubfoot. In people of African descent, frequency rises to about one in four or five hundred births. Among the Maori, clubfoot is seen in one in 200 births.

The statistics for doctors adopting the Ponseti Method vary, too. Thousands of physicians worldwide continue to perform surgery for their patients.

"This isn't easy surgery," Ponseti says. "Clubfoot surgery is very difficult. Sometimes a very accomplished surgeon can get away with it, but a doctor who does not see the condition regularly can easily become lost."

"When parents are faced with this disaster of seeing a baby born with clubfeet, they get to be very depressed," Ignacio Ponseti says. "When they go to the doctor and are told that their baby must have surgery, they are sad. But when they can see that this deformity is nothing, that is a very easy thing to correct and the child is normal, they have hope."

Ponseti praises the Internet for providing information to people, and he applauds the parents who are willing to share their experiences with others. "We have more than 240 parents who offer to advise other parents about their options," he says.

With information about the Ponseti Method online and with parents willing to share their own experiences with clubfeet, the word is getting out.

Clubfoot on the Virtual Hospital Website

Parent Information Leader
martinegbert@earthlink.net

photo by Doug Benton, Fisheye Photography

Ponseti estimates that in the United States now, about 70 percent of clubfoot cases are treated surgically, while about 30 percent are treated with the Ponseti Method. Acceptance varies geographically. "In France, about half of clubfoot cases are treated surgically and the other half with manipulation," he says, "but the French technique is to wiggle the foot to limber it up. The cells get confused and the joints don't remodel." Only in northern France and the city of Lyons do physicians practice the Ponseti Method.

Doctors who acknowledge the superior results of the Ponseti Method are eager to spread the word about its benefits. Some of them write to Ponseti to alleviate the guilt they feel for not adopting his method sooner.

"You have changed my thinking regarding the clubfoot," one orthopaedic surgeon wrote recently. "I have read many of your articles about clubfoot before and was unwilling to accept them as truth or I simply did not understand the method. I was so wrong. I have to live with the fact that I operated on many children who did not need surgery and may eventually have adversely affected their lives. I have no doubt after watching you and Drs. [Stuart] Weinstein and [Frederick] Dietz these past two days that my training and therefore experience has been incorrect."

Parents, too, are convinced. No infant whose treatment for clubfoot has begun at the UI has needed ligament release surgery for the condition later. On the other hand, parents whose children have suffered from unsuccessful treatment elsewhere have come to Iowa for corrective surgery or treatment with the Ponseti Method.

"The technique works very well until the child reaches the age of 22 months," Ponseti explains. "There is enough flexibility." The youngest patient he's treated has been about ten days old. "We like to allow time for the baby to bond with the mother and to become accustomed to something of a routine," Ponseti explains.

It is evident that he loves his tiny patients. He remembers Oscar, grandson of legendary Iowa football coach Forest Evashevski; Isabella, a dark-haired child who was dancing gracefully on a gymnastics balance beam by the time she turned three; and hundreds of others whose families continue to send cards and letters.

"Even as babies, they have their personalities," Ponseti says. "Each one is different; each one is special."

And now their parents can expect their little ones to walk and run and jump joyfully on new feet, feet restored to their proper position thanks to Ponseti's healing touch.

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