Jun 032017

Today is the birthday (1914) of Ignacio Ponseti, a Spanish orthopedist responsible for developing the Ponseti Method used to correct clubfoot. In his honor today has been designated as World Clubfoot Day to raise awareness of the problem of clubfoot and its treatment. I know it does not seem like a world-shattering anniversary, but there are two significant issues for me. First, is the fact that around 100,000 children are born with congenital clubfoot each year, and without treatment would be subject to a life of hardship.  With treatment they can live normal lives, and some have even gone on to be world famous athletes. Second, Ponseti sits in my ever-growing Hall of Fame for unsung heroes. He saw a problem and worked diligently on finding a solution which is now the standard of treatment, and it is nearly 100% effective without the need for surgical intervention (which was the standard before Ponseti, and was not nearly as effective). Hundreds of thousands of lives have been immeasurably improved because of this man, and his name is unknown outside of orthopedics.

Ponseti was born in Menorca (English: Minorca), one of the Balearic Islands. He was the son of a watchmaker and helped repair watches as a young boy. 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 orthopedics. Without ambulances, Ponseti used the help of local smugglers to take the injured into France. He soon escaped to France himself and went to Mexico, where for two years he practiced family medicine. A physician there helped Ponseti to get to Iowa in 1941 to study orthopedics under Aerthur Steindler. Ponseti completed a residency at Iowa in 1944 and became a member of the orthopedic 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 successful and patients ended up with limited movement as a result. He set out to develop a treatment that made the most of babies’ flexible ligaments. 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. Well into his 90s 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 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.

Clubfoot affects well over 100,000 newborns annually. 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 the need for more surgery. 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% 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.

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 (PIA) 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. Groups that work with Ponseti International include CURE International and A Leg to Stand On (India)and Pehla Qadam (Pakistan).

The actor/musician Dudley Moore, who was a major player in the British satire boom of the 1960s before starring in Hollywood films, was born in 1935 with two clubfeet before the Ponseti Method had been developed. His right foot was able to be corrected with surgery but his left foot did not respond to treatment, and ultimately his left leg withered below the knee. Nonetheless he became proficient on organ and piano, and, in fact, won an organ scholarship to Magdalen College, Oxford.

Other famous people born with clubfoot who were treated with the Ponseti Method include actor Damon Wayans, Superbowl MVP quarterback Troy Aikman, Olympic footballer Mia Hamm, and Olympic gold medal figure skater Kristi Yamaguchi.

The most iconic dish from Menorca, Ponseti’s birthplace, is flaó de Menorca (plural: flaons), a yeast pastry stuffed with young Maó cheese, for which the island is famous, plus other ingredients. Good Minorca flaons are very puffy in the middle, and there are both salty and sweet versions. They were once typical as an Easter treat only, but now are generally available at bakeries year round. Here is a case where you need to get on a plane, though.

They are not usually made at home, and you won’t find soft Maó cheese at your local supermarket (unless you happen to live in the south of Spain). Instead, here’s flaó d’Eivissa, from neighboring Ibizza. It is more like a conventional pie with a filling of sheep or goat cheese, eggs and sugar, slightly aromatized with peppermint leaves and aniseed. The cheese must be a young, soft white cheese like queso de Burgos. These flaons are usually eaten along with a glass of sweet wine or the local liqueur, frígola, a thyme-based digestive.

Flaó d’Eivissa



zest of ½ lemon
30 g sugar
250 g baking flour
2 eggs, beaten
¼ tsp salt
1 tbsp anise liqueur
30 g lard
1 tsp dried baker’s yeast


4 eggs
250 g sugar
500 g soft white cheese (can be a mix of cow’s, goat’s, or sheep’s cheese), grated
2 tbsp crushed peppermint leaves


To make the dough, cream together the lard and sugar using a mixer. Add the eggs, liqueur, salt, and yeast. Beat until well mixed.

Beat in the flour, a little at a time, until you have formed a pliable dough.  Knead for a few minutes and then let rest, covered for 15 minutes.

Grease a 22 cm (9”) pie dish. Roll out the dough and line the pie dish with it.

Preheat the oven to 180°C/350°F.

For the filling, beat the eggs with the sugar, add the cheese and finally the peppermint. Do not use a beater for the peppermint, but fold the leaves in gently by hand with a spatula to avoid coloring the filling.

Pour the filling into the prepared pie crust, and bake for 50 minutes.

Let cool on a wire rack, and then refrigerate. Serve in slices, chilled.