Ponsetiarticle

Fifty years ago, when a baby was born with clubfoot, physicians could only recommend surgery that often left the child with a weak, stiff, and sometimes painful foot that still did not function normally. That all changed more than four decades ago, when Ignacio Ponseti, MD, UI professor emeritus of orthopaedic surgery, perfected his non-surgical method of clubfoot correction. Now 85 and officially retired, Ponseti remains dedicated to teaching his method to as many physicians as possible, ensuring that future generations of children with clubfoot will be treated promptly and non-invasively.

It might seem strange for a surgeon to promote a non-surgical treatment, but that's exactly what Ponseti has been doing since he developed the Ponseti method of clubfoot correction in the early 1950s. He has taught hundreds of UI alumni and others to use the method to treat children around the country and the world.

"I thought the treatment could be improved," Ponseti said. "I studied the anatomy of the foot, the histology, and the deformity in depth, and I was able to develop a technique to redress the joints by stretching the ligaments."

When Ponseti joined the UI faculty in 1944, the standard method of correcting clubfoot was and in some places still issurgery, which leaves the foot straight but often weak, stiff and painful in adulthood. Ponseti's dissatisfaction with the surgical treatment led him to begin in the late 1940s an extensive study of the basic nature of clubfoot, with the hope that it would lead him to a better treatment.

"If you know how to untwist the foot, that's all you need to know," he said. "Surgery has been used too much. Doctors have forgotten nature's way of treating things."

The Ponseti method works by using gentle manipulation to stretch the ligaments, joint capsules, and tendons of the foot in order to realign it, and is designed to begin shortly after birth. Once a week for six to eight weeks, the foot is manipulated and a plaster toe-to-groin cast is applied to retain the degree of correction and soften the ligaments. The displaced bones are gradually brought into the correct alignment.

After five to six plaster casts, the foot appears slightly overcorrected. The child then wears a splint consisting of shoes attached to a bar full-time for three months and at night for two to four years. After just a few weeks in splints, the foot looks normal. In most cases, patients end up with a foot that functions almost normally and, to the untrained eye, looks no different from a normal foot. Relapse rates are only 10 to 15 percent if the treatment is carefully followed.

Ponseti perfected the treatment in 1952, and since then, the method has been used with such success at the UI Hospitals and Clinics that "everybody in Iowa knows that clubfoot is an easy thing to treat," Ponseti said. "People in Iowa have never even heard of surgery for clubfoot. Parents are elated to find they can treat this so easily."

The UI's reputation for orthopaedic care has been established for decades. In 1936, as a young medical student studying at the University of Barcelona, Ponseti had already heard of Iowa. "The UI already had a big name in orthopaedic surgery," Ponseti said. "Dr. Arthur Steindler had come to the UI, and it was a very important center for specialists at the time."

While it would be several years before Ponseti would come to the UI, his career in orthopaedics began right after medical school. Born in the Balearic Islands off the east coast of Spain and raised in Barcelona, Ponseti was in medical school when the political situation in his country started to unravel. One day after Ponseti finished his final medical school exams, fighting broke out between Francisco Franco Bahamonde's forces and the Spanish Loyalist army. Franco's uprising against the Spanish government turned into the three-year Spanish Civil War.

Ponseti volunteered to serve as a medical officer with the Loyalists, serving first as a lieutenant and later as a captain in the Orthopaedic and Fracture Service. It shaped the rest of his life.

"I got a lot of experience in treating war wounds and extremity wounds, treating bone fractures, and doing extremity surgery," he said. "That's how I got into orthopaedics."

In 1939 Franco's forces, which were supported by Fascist Italy and Nazi Germany, captured Madrid and defeated the Spanish Loyalist army. Ponseti, stripped of his Spanish citizenship, sought refuge in France with thousands of other Loyalists.

With no home and no citizenship, Ponseti moved to Mexico, which was accepting certain skilled refugees such as engineers, textile workers, ironworkers, farmers, and a few physicians. He lived there for two years, practicing family medicine and studying English in his spare time. There he met Dr. Juan Farril, professor of orthopaedics at the University of Mexico, who had trained in the United States. Farril encouraged Ponseti to go to Iowa and study with Dr. Arthur Steindler, chairman of orthopaedics and a world-famous orthopaedist.

Ponseti applied for graduate studies at the UI, but his circumstances were complicated by the fact that due to the Civil War, he had never received his medical school diploma. To make matters worse, his English was not good enough at the time to explain his situation. Ponseti bridged the communication gap by speaking in French with Carl Seashore, dean of the Graduate College at the time. He was admitted to the residency program, completed it in 1944, and immediately joined the orthopaedic faculty at the UI Hospitals and Clinics.

"I thought it would be a temporary stay in the United States, that I would go back to Spain and teach there," Ponseti said. "But I remained here. Spain was dominated by a Fascist regime for 40 years, and I didn't want to be in a place where a dictatorship dominated."

Although his life didn't go quite as he planned it, Ponseti is happy with the way things turned out and feels fortunate to have been able to settle in Iowa, where the people have "a high level of niceness and kindness." He added, "With my wife, Helena, who taught at Grinnell College for many years, we have had a very happy life together.

"I consider myself a very lucky man to come live and work in Iowa and at the University," he said. "It's a population of nice people who follow the advice of the doctor and work with you. They are extremely reliable. It makes for a pleasant environment for a doctor."

Ponseti's 55-year career has not been limited to clubfoot correction. Over the years, he has contributed 140 basic science and clinical articles, mainly focusing on his primary research interests in congenital and developmental bone and joint disorders, skeletal growth disorders in children, and the biochemistry of cartilage. He performed pioneering work in the early 1950s on the effect of amino nitriles on collagen cross linking, defined the curvature patterns of idiopathic scoliosis, and was the first to demonstrate that curves progressed after skeletal maturity. He also conducted many studies evaluating the long-range results of treatments for congenital dislocation of the hip, clubfoot, and scoliosis. These contributions have brought Ponseti many honors, including the Kappa Delta Award for Outstanding Orthopaedic Research Work in 1955, the Hektoen Gold Medal from the American Medical Association in 1960, and hundreds of visiting professorships at institutions around the world.

It's his work at the UI, however, that has given Ponseti the most pleasure throughout the years. He considers caring for patients, teaching, and performing research to be the highlights of his career.

"Caring for children is the most gratifying, because our results are so good," he said. "I like children and feel comfortable with them, and the children feel comfortable with me. I've developed close and loving relationships with many people in Iowa, particularly the children I've treated. It's pleased me very much to do scientific work on the background of most of the disorders we saw in the clinic, and it's also been most rewarding to teach and work together with the residents," he said. "You develop very close relationships, warm friendships that last forever."

Ponseti's work will last forever too, in the form of future generations of children who will be able to walk normally. Although he officially retired in 1984, Ponseti is still actively involved in clubfoot correction, directing the UI Health Care Clubfoot Clinic two days a week, teaching one or two classes a year on clubfoot plaster casting, participating in conferences, and seeing "a few patients on occasion."

Ponseti seeks to pass along his knowledge to an upcoming generation, ensuring that more children will have access to this safer, gentler way of correcting clubfoot. To help orthopaedists understand the method, Ponseti wrote Congenital Clubfoot: Fundamentals of Treatment in 1996, and also has traveled around the world, describing and teaching his method to physicians in Europe, Japan, New Zealand, and elsewhere. He recently returned from trips to France, Spain, England, Boston, Vancouver, and Los Angeles.

"I first explained how this should be treated in 1963, when I published my first paper on the method," Ponseti said. "But nobody paid attention. My goal now is to expand the use of this method throughout the United States and the world, so children will not be crippled by excessive surgery on clubfeet."

The Ponseti method of clubfoot correction has already helped thousands of children lead normal, pain-free lives. Now, a project aims to extend the knowledge and use of the Ponseti method to Uganda, a country with unusually large numbers of children born with clubfoot.

The Uganda Clubfoot Project is a four-year project proposed by a group of physicians from Canada, the United Kingdom, and Uganda, and led by Dr. Shafique Pirani, associate professor of orthopaedics at the University of British Columbia. It began its first phase in November 1999.

The project aims to raise awareness of clubfoot, initiate early intervention with the Ponseti method, upgrade the skills of local surgeons to enable them to treat cases unsuitable for the Ponseti method, and train local practitioners to teach the method. Organizers also plan to collect data on the children treated to measure the effectiveness of the project.

More than 10,000 children in Uganda live with clubfoot, and each year 1,000 more are born with the disorder. Many have never been treated for the disorder, and in fact, many village families are unaware that treatment is even possible. Very few rural health care workers are trained to recognize clubfoot, and even when it is recognized, there is often no local source of treatment.

The Ponseti method is especially suitable for use in Uganda because it doesn't require fancy equipment or surgical facilities, is implemented shortly after birth, and has the best long-term results. It is also easier to learn than surgery, and can be taught to medical and paramedical professionals working both in urban and rural settings.

Organizers hope that eventually, the project will allow all children in Uganda with clubfoot to be identified at birth and to have access to corrective treatment in all of Uganda's 39 districts.