Ignacio Ponseti 

 

Ignacio Ponseti (3 June 1914 – 18 October 2009) was a physician, specializing in orthopedics. A native of Spain, he fled the Spanish Civil War and became a faculty member and practicing physician at the University of Iowa.
He developed in the 1950s the Ponseti Method (also known as the Ponseti Technique), a non-surgical technique that uses a series of casts, followed by a brace, to correct congenital clubfoot. The condition causes a baby's feet to turn inward and downward; if not corrected, a child is unable to walk or move properly.

Biography

Known for the method for the clubfoot treatment that bears his name, Ignacio Ponseti was Professor Emeritus in the Department of Orthopaedic Surgery at University of Iowa Hospitals and Clinics.
Born 3 June 1914 in Menorca, part of the Balearic Islands, Spain, Ponseti was the son of a watchmaker and helped repair watches. The skill was said to eventually contribute to his abilities as an orthopedist.^[1]
Ponseti studied medicine at Barcelona University. Not long after he graduated, fighting broke out between the Nationalists and the Republicans - the start of the Spanish Civil War. Ponseti served as a medical officer with the Loyalists as a lieutenant, then captain, in the Orthopaedic and Fracture Service. His duties included setting fractures, which put him on a career in orthopaedics. Without ambulances, Ponseti used the help of local smugglers to take the injured into France.^[1] He soon escaped to France himself and went to Mexico, where for two years he practiced family medicine. A physician there helped Ponseti get to Iowa in 1941 to study orthopaedics under Arthur Steindler, M.D. Ponseti completed a residency at Iowa in 1944 and became a member of the orthopaedic faculty at University of Iowa Hospitals and Clinics.
Early in his career at Iowa, Ponseti saw that the outcomes of clubfoot surgical treatments were not very good—patients had limited movement. He set out to develop a treatment that made the most of babies' flexible ligaments.^[2] The method was met with some opposition but over the past 50 years it has been adopted by many doctors and other health care providers worldwide, including in Britain ^[3] and Turkey ^[4]
Well into his nineties, Ponseti continued to see patients and trained visiting doctors from around the world. He also developed new prosthetic devices with John Mitchell of MD Orthotics [1] and produced training and information DVD's on the method.
Ponseti's other research focused on congenital and developmental bone and joint disorders, skeletal growth disorders in children, and the biochemistry of cartilage. He gained insight in the early 1950s on the effect of amino nitriles on collagen cross linking, defined the curvature patterns of idiopathic scoliosis, and demonstrated 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.

The Ponseti Method

Clubfoot affects well over 100,000 newborns annually.^[5] Early in his career at the University of Iowa, Ponseti realized that surgical approaches did not fully correct clubfoot and/or created problems later in life, such as severe arthritis or even requiring more surgery.^[2] In working to develop a new approach, he determined it could be nonsurgical. The Ponseti method uses gentle, manual manipulation of the foot, followed by application of toe-to-groin plaster casts. The casts are changed weekly after a clinician manipulates softened foot ligaments to gradually achieve near-normal muscle and bone alignment.
In addition to the improved physical outcomes, compared to surgery, the Ponseti method is less expensive and can be taught to nonphysician health care providers, which is useful in areas with few or no doctors. Nearly 80 percent of children born with clubfoot live in impoverished nations. The Ponseti method is used, for example, in Uganda, where efforts continue to improve the availability of the treatment.^[6]
Information about the use of Ponseti method can be found at these sites: World Health Organisation, American Academy of Orthopedic Surgeons, Pediatric Orthopaedic Society of North America, STEPS Charity UK and STEPS Charity South Africa.
At the 2007 International Clubfoot Symposium attended by 200 doctors from 44 countries, papers were presented regarding an estimated 10,000 children successfully treated with the technique around the world in the past few years.
The Ponseti International Association for the Advancement of Clubfoot Treatment was founded in 2006 to improve the treatment of children born with clubfoot through education, research and improved access to care. PIA has a related Web site devoted to the interests and needs of parents.^[7] Groups that work with Ponseti International include Cure International and A Leg to Stand On (India).


The Ponseti method is a manipulative technique that corrects congenital clubfoot without invasive surgery. It was developed by Dr. Ignacio V. Ponseti of the University of Iowa, USA in the 1950s, and was repopularized in 2000 by Dr. John Herzenberg in the USA and Europe and in Africa by NHS surgeon Steve Mannion. It is a standard^[1] for the treatment of club foot.

Description

Ponseti treatment was introduced in UK in the late 1990s and widely popularized around the country by NHS physiotherapist Steve Wildon. The manipulative treatment of clubfoot deformity is based on the inherent properties of the connective tissue, cartilage, and bone, which respond to the proper mechanical stimuli created by the gradual reduction of the deformity. The ligaments, joint capsules, and tendons are stretched under gentle manipulations. A plaster cast is applied after each manipulation to retain the degree of correction and soften the ligaments. The displaced bones are thus gradually brought into the correct alignment with their joint surfaces progressively remodeled yet maintaining congruency. After two months of manipulation and casting the foot appears slightly over-corrected. After a few weeks in splints however, the foot looks normal.
Proper foot manipulations require a thorough understanding of the anatomy and kinematics of the normal foot and of the deviations of the tarsal bones in the clubfoot. Poorly conducted manipulations will further complicate the clubfoot deformity. The non-operative treatment will succeed better if it is started a few days or weeks after birth and if the podiatrist understands the nature of the deformity and possesses manipulative skill and expertise in plaster-cast applications.^[2]

Clubfoot (talipes equinovarus) affects almost 150,000 children annually. Almost 80% of these children live in developing nations. Dr Ponseti's technique is painless, fast, cost-effective and successful in almost 100% of all congenital clubfoot cases. The Ponseti method is endorsed and supported by World Health Organization^[3][4]National Institutes of Health^[5], American Academy of Orthopedic Surgeons^[6], Pediatric Orthopedic Society of North America^[7], European Pediatric Orthopedic Society^[8], CURE^[9], STEPS Charity UK^[10], STEPS Charity South Africa^[11], A Leg to Stand On (India)^[12] and others.
At the 2007 International Clubfoot Symposium attended by 200 doctors from 44 countries, papers were presented for an estimated 10,000 children successfully treated with the technique around the world in the past few years.
The Ponseti International Association for the Advancement of Clubfoot Treatment was founded in 2006 at the University of Iowa. The Ponseti International Association aims to improve the treatment of children born with clubfoot through education, research and improved access to care.
Steps are as follows:
1. The calcaneal internal rotation (adduction) and plantar flexion is the key deformity. The foot is adducted and planter-flexed at the subtalar joint, and the goal is to abduct the foot and dorsiflex it. In order to achieve correction of the clubfoot, the calcaneum should be allowed to rotate freely under the talus, which also is free to rotate in the ankle mortise. The correction takes place through the normal arc of the subtalar joint. This is achieved by placing the index finger of the operator on the medial malleolus to stabilize the leg and levering on the thumb placed on the lateral aspect head of the talus while abducting the forefoot in supination. Forcible attempts at correcting the heel varus by abducting the forefoot while applying counter pressure at the calcaneocuboid joint prevents the calcaneum from abducting and therefore everting.
2. Foot cavus increases when the forefoot is pronated. If cavus is present, the first step in the manipulation process is to supinate the forefoot by gently lifting the dropped first metatarsal to correct the cavus. Once the cavus is corrected, the forefoot can be abducted as outlined in step 1.
3. Pronation of the foot also causes the calcaneum to jam under the talus. The calcaneum cannot rotate and stays in varus. The cavus increases as outlined in step 2. This results in a bean-shaped foot. At the end of step 1, the foot is maximally abducted but never pronated.
4. The manipulation is carried out in the cast room, with the baby having been fed just prior to the treatment or even during the treatment. After the foot is manipulated, a long leg cast is applied to hold the correction. Initially, the short leg component is applied. The cast should be snug with minimal but adequate padding. The authors paint or spray the limb with tincture of benzoin to allow adherence of the padding to the limb. The authors prefer to apply additional padding strips along the medial and lateral borders to facilitate safe removal of the cast with a cast saw. The cast must incorporate the toes right up to the tips but not squeeze the toes or obliterate the transverse arch. The cast is molded to contour around the heel while abducting the forefoot against counter pressure on the lateral aspect of the head of the talus. The knee is flexed to 90° for the long leg component of the cast. The parents can soak these casts for 30–45 minutes prior to removal with a plaster knife. The authors' preferred method is to use the oscillating plaster saw for cast removal. The cast is bivalved and removed. The cast then is reconstituted by coapting the 2 halves. This allows for monitoring of the progress of the forefoot abduction and, in the later stages, the amount of dorsiflexion or equinus correction.
5. Forcible correction of the equinus (and cavus) by dorsiflexion against a tight Achilles tendon results in a spurious correction through a break in the midfoot, resulting in a rockerbottom foot. The cavus should be separately treated as outlined in step 2, and the equinus should be corrected without causing a midfoot break. It generally takes up to 4–7 casts to achieve maximum foot abduction. The casts are changed weekly. The foot abduction (correction) can be considered adequate when the thigh-foot axis is 60°After maximal foot abduction is obtained, most cases require a percutaneous Achilles tenotomy. This is performed in the cast room under aseptic conditions. The local area is anesthetized with a combination of a topical lignocaine preparation (eg, EMLA cream) and minimal local infiltration of lidocaine. The tenotomy is performed through a stab incision with a round tip (#6400) Beaver blade. The wound is closed with a single absorbable suture or with adhesive strips.The final cast is applied with the foot in maximum dorsiflexion, and the foot is held in the cast for 2–3 weeks.
6. Following the manipulation and casting phase, the feet are fitted with open-toed straight-laced shoes attached to a Dennis Brown bar. The affected foot is abducted (externally rotated) to 70° with the unaffected foot set at 45° of abduction. The shoes also have a heel counter bumper to prevent the heel from slipping out of the shoe. The shoes are worn for 23 hours a day for 3 months and are worn at night and during naps for up to 3 years.
7. In 10–30% of cases, a tibialis anterior tendon transfer to the lateral cuneiform is performed when the child is approximately 3 years of age. This gives lasting correction of the forefoot, preventing metatarsus adductus and foot inversion. This procedure is indicated in a child aged 2–2.5 years with dynamic supination of the foot. Prior to surgery, cast the foot in a long leg cast for a few weeks to regain the correction.