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Writer: Melanie Laverman
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IOWA CITY, Iowa -- For 50 years, Dr. Ignacio V. Ponseti, professor emeritus of orthopaedic surgery at the University of Iowa College of Medicine, has been telling his colleagues that surgery is not the proper method for correcting clubfoot in infants.
"The foot heals stiff and weak and flat," he says. "And by the time patients reach their 20s and 30s, they are crippled by severe arthritis."
Instead, Ponseti advocates using a non-surgical method he perfected in the late 1940s. His most recent article was published in the May 1997 issue of the journal International Orthopaedics, but he first wrote about the method in 1963 when he presented a five- to 12-year follow-up study of his patients.
"When my first article was published, I thought the clubfoot treatment was solved and would be accepted by the profession," he says. "So, I went on to study other orthopaedic problems."
The treatment was not widely accepted, however. Ponseti estimates that less than 10 percent of pediatric orthopaedic surgeons in the U.S. use his procedure, and he has decided to spend his retirement trying to change that.
Clubfoot is a congenital deformity in which a foot that developed normally in the embryo becomes twisted inward after the third month of pregnancy. By studying the biomechanics of the foot, Ponseti learned to realign it by gently manipulating the joints and ligaments. Because it is not possible to stretch the ligaments enough in one treatment, he does it gradually over six to eight weeks. After stretching the foot as far as possible, he puts the entire leg in a delicately molded, padded cast. Five to seven days later, he removes the cast and stretches the ligaments a little further before applying another cast.
Because treatment begins soon after birth, the foot is pliable and gives easily. It looks normal by the time the baby is two months old. At that point, the child must wear a brace full-time for three months and then only at night for two to four years.
Ponseti says although the brace looks cumbersome, the baby adapts to it easily. Wearing the brace at night is essential to prevent the ligaments from tightening and causing a relapse.
"It takes the cooperation of the parents," Ponseti says. "Maybe that's why it has been so successful in Iowa."
Ponseti has plenty of proof that his method is successful. In 1995 Dr. Douglas M. Cooper, a private practice physician who trained at the UI, and Dr. Frederick R. Dietz, UI professor of orthopaedic surgery, published a 30-year follow-up of patients treated under Ponseti's direction. His patients were doing nearly as well as individuals of the same age who were born with normal feet.
Even in the face of that evidence, many orthopaedic surgeons insist that Ponseti's method is not feasible. They say it takes an intimate understanding of how the joints in the foot move and a skill for applying plaster casts that most orthopaedic surgeons lack.
Ponseti disagrees, saying many surgeons just don't want to invest time in learning the method.
"The fact is that interested young students easily become proficient in this method," he says. "Unfortunately, the current trend is toward surgery. Orthopaedic surgeons have lost confidence in the efficacy of manipulation and casting, and surgery may seem like an easier and faster solution."
Ponseti is perplexed by his critics' refusal to accept the method. He says part of the problem may be that many of the doctors who have trained with him are in private practice and do not publish.
Since he retired in 1984, Ponseti has been determined to publicize the procedure. In addition to the article published in May, he has written a book, published by Oxford University Press in 1996, and another journal article, published in 1992.
Ponseti continues to help other doctors correct clubfeet at the UI Hospitals and Clinics. He also travels to other hospitals in the U.S. and abroad to give instructional demonstrations on patients.
Ponseti says his love for the children won't let him give up. "I'm frustrated, but I want to fight to get our treatment accepted."
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