Halfway down the Danube

Wiggly toes

My god-daughter Catie had her casts removed yesterday! She's had them on since she was six weeks old, to help correct the development of her feet and hips. Yes, she is wiggling her toes again. Yay!

Well, anyway. To someone who grew up on tales of heroic surgeries (i.e., me), it was surprising to learn that the casting method used with Catie is not only as good as corrective surgery on a clubbed foot, but in fact is significantly superior.

The man who developed this method, Doctor Ignacio Ponseti, celebrated his 90th birthday earlier this month. He was recently profiled in the alumni magazine of the University of Iowa, where he has been affiliated for over sixty years:

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."

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

I'm going to give you Ponseti's own words on his method, its development, and its importance, because I found them fascinating (and who knows, you might too), and I think my own paraphrasing would diminish them. They're taken from a pamphlet put out by Global-HELP -- Health Education Low-cost Publications -- on the Ponseti method in use around the world, Clubfoot: Ponseti Management, with an emphasis on a recent successful program in Uganda. (Warning, it's a 1584K PDF file, with medical photography that might be distressing to some readers.) All ellipses are mine, mainly parts that would require prior knowledge of foot anatomy and development.

It is estimated that more than 100,000 babies are born worldwide each year with congenital clubfoot. Eighty percent of the cases occur in developing nations. Most are untreated or poorly treated. Neglected clubfoot causes crushing physical, social, psychological, and financial burdens on the patients, their families, and the society. Globally, neglected clubfoot is the most serious cause of physical disability among congenital musculoskeletal defects.

In developed countries, many children with clubfoot undergo extensive corrective surgery, often with disturbing failures and complications. The need for one or more revision surgeries is common. Although the foot looks better after surgery, it is stiff, weak, and often painful. After adolescence, pain increases and often becomes crippling.

Clubfoot in an otherwise normal child can be corrected in 2 months or less with our method of manipulations and plaster cast applications, with minimal or no surgery. This was proven by the results of our 35-year follow-up study and confirmed in many clinics around the world.

This method is particularly suited for developing countries where there are few orthopaedic surgeons. The technique is easy to learn by allied health professionals, such as therapists and orthopaedic assistants. A well-organized health system is needed to ensure that parents follow the instructions for use of the foot abduction brace to prevent relapses.

The treatment is economical and easy on the babies. If well implemented, it will greatly decrease the number of clubfoot cripples.

In the mid 1940s, I examined 22 patients with clubfoot that had been surgically treated in the 1920s by Arthur Steindler, a good surgeon. The feet had become rigid, weak, and painful... When operating on relapses, I noticed severe scarring in the foot and stiffness in the misshapen joints... After a few years of this experience, I was convinced that surgery was the wrong approach for treatment of clubfoot.

A study of histological sections of ligaments from virgin clubfeet, obtained in the operating room and from fetuses and stillborns, revealed that the abundant young collagen in the ligaments was wavy, was very cellular, and could be easily stretched. I conceived, therefore, that the displaced navicular, cuboid, and calcaneus could be gradually abducted under the talus without cutting any of the tarsal ligaments. I discovered that this was so based on cineradiography of clubfeet I had partially or fully reduced without surgery...

My casting technique was learned from Böhler and applied during the Spanish Civil War in 1936-1939 when treating more than 2,000 war-wound fractures with unpadded plaster casts. Precise, gentle molding of the plaster over the reduced subluxations of the tarsal bones of a clubfoot is just as basic as the molding of a plaster cast on a well-reduced fracture...

It was disappointing that my first article on congenital clubfoot, published in the The Journal of Bone & Joint Surgery in March 1963, was disregarded. It was not carefully read and, therefore, not understood. My article on congenital metatarsus adductus, published in the same journal in June 1966, was easily understood, perhaps because the deformity occurs in one plane. The approach was immediately accepted, and the illustrations were copied in most textbooks.

A few orthopaedic surgeons studied my technique and began to apply it only after the publication of our long-term follow-up article in 1995, the publication of my book a year later, and the posting of Internet support group web sites by parents of babies whose clubfoot I had treated. I have been reprimanded for not pushing the method more forcefully from the beginning...

I. Ponseti, 2003

Alas, it seems Doctor Ponseti still feels troubled over not advocating his method more strongly in the 1960s. But it's difficult to know what more he could have done, since his method sometimes meets resistance even today. I wish him an easy heart. He's done more than most.

Posted by coyu at June 18, 2004 03:35 PM