‘A Turn in the Road’: How Ignacio Vives Ponseti, MD, Changed the Landscape of Orthopaedics after Retirement

“Retirement isn’t the end of the road but just a turn in the road”—this sentiment encapsulates the journey of Ignacio Vives Ponseti, MD, reflecting how his career took an unexpected but profoundly impactful turn after his official retirement. Dr. Ponseti’s remarkable life story and contributions to orthopaedics provide invaluable lessons and inspiration for professionals in every field.

A distinguished career
Dr. Ponseti was born in Spain in 1914. He developed an early interest in science and problem solving and later studied medicine at the University of Barcelona. During the Spanish Civil War, he served as a medic, treating wounded soldiers. When the war ended, he went into exile in France and ultimately moved to Mexico. Eventually, he found his way to the United States, where he completed his residency at the University of Iowa in 1944 and ultimately joined their faculty. He stayed at Iowa for his entire professional career, teaching and studying bone pathology. He developed an interest in the natural history of congenital and developmental skeletal disorders, and he pioneered studies that laid the foundation for early understanding of extracellular matrix biology. He was also one of the first to describe the pathology, histology, biochemistry, and ultrastructure of many pediatric orthopaedic disorders.

This extensive body of work led to him becoming one of the founders and president of the Orthopaedic Research Society. He received many awards from multiple organizations, including AAOS and the American Medical Association, as well as an honorary degree from his alma mater, the University of Barcelona, among others. Certainly a very successful career, and who would have thought that he would be even more successful after retirement? At the time, regulations at the University of Iowa required faculty to retire at the age of 70, so Dr. Ponseti retired in 1984. However, his “retirement” was short-lived, and a new turn in the road led him to return a few years later to experience the most important phase of his long and impactful professional career.

Reimagining clubfoot treatment
Dr. Ponseti’s interest in the treatment of patients with clubfoot started prior to his retirement, when he evaluated young adult patients treated surgically as infants. Even after surgery, the patients had very stiff, painful feet that dramatically limited their daily activities. He was inspired to understand clubfoot more deeply and, in turn, developed a groundbreaking treatment to correct the deformity without extensive surgery. His method involved precise manipulation followed by application of well-molded casts, which were changed weekly. In 1948, he treated his first patient, and in 1963 he published a paper describing the basic principles of the method and its early results. The paper was followed by a long-term follow-up study, published in 1980 (when the patients reached maturity), which demonstrated that the technique successfully reduced pain and improved function, without limitations on daily or recreational activities.

As German philosopher Arthur Schopenhauer once said, “All truth passes through three stages: First, it is ridiculed. Second, it is violently opposed. Third, it is accepted as being self-evident.” As with many other innovations in medicine—especially those that go against current standard practice—the orthopaedic community across the globe did not initially understand this new method. Dr. Ponseti presented his method and its results at several national and international meetings, but the orthopaedic community showed little interest. Surgeons continued performing surgery for clubfoot for decades. It was said, “If a clubfoot can be corrected with casting, it was not a true clubfoot.” Discouraged by this lack of understanding and interest, Dr. Ponseti dedicated the remainder of his career to studying other disorders and considered the treatment of clubfoot “solved.”

Reevaluation of the Ponseti method
In the late 1980s and early 1990s–after Dr. Ponseti’s retirement—many orthopaedic professionals began to recognize the devastating outcomes of surgery for clubfoot, leading to renewed interest in more conservative options. Given this interest, Dr. Ponseti was invited to write current concept papers describing his method. In 1995, Frederick R. Dietz, MD, a colleague in the department at University of Iowa, conducted a 34-year follow-up study of the patients originally treated by Dr. Ponseti in the 1950s. Dr. Dietz’s study found that the majority of them had similar functional and pain outcomes as a control population. Motivated by this confirmation that his treatment had lasting results, Dr. Ponseti—who was aged 82 years at the time—published the book Congenital Clubfoot: Fundamentals of Treatment in 1996. Encouraged by the long-term follow-up studies and his book, some pediatric orthopaedic surgeons began to visit Dr. Ponseti to learn directly from “the source.” Once those surgeons began treating their own patients with the “new” method, they recognized they could replicate the excellent results achieved in Iowa. Studies showing these results were presented at national and international meetings, further stimulating interest over time.

Impact and legacy
The rise of the internet during those years empowered parents of children with clubfoot to explore treatment options independently, which significantly contributed to the method’s growing popularity. Dr. Ponseti posted his method on the newly created University of Iowa Hospital website, and patients began seeking treatment from him. Some patients’ families began advocating for their physicians to learn the method. Online support groups for families with children with clubfoot were critical for the global expansion of the method. It is very possible that without their advocacy, the spread of the Ponseti Method would have been much slower and probably would not have reached every corner of the world.

In 2007, the first International Clubfoot Symposium was held in Iowa City, marking a turning point in global awareness of the Ponseti method. This event brought together 240 professionals from 50 countries to share groundbreaking research and validate the method’s efficacy, establishing it as a transformative approach in pediatric orthopaedics. Studies from hospitals worldwide reported success rates of more than 95 percent. At the meeting, Dr. Ponseti felt “vindicated” that the method he had developed decades earlier had become the global standard of care for clubfoot treatment. Most importantly, because 80 percent of clubfoot cases occur in developing countries, the method’s efficacy and low costs made it a public health intervention that could help eliminate clubfoot disability worldwide.

Realizing this impact and to honor Dr. Ponseti, the Iowa State Board of Regents allowed the University of Iowa to establish the Ponseti International Association, dedicated to continuing his legacy to “improve the treatment of children born with clubfoot through education, research, and improved access to care.” Dr. Ponseti passed away 2 years later in 2009 at the age of 95, while working in his office. For all his work, he is recognized as one of the most brilliant minds in the history of orthopaedics, and he is best known for the method of clubfoot treatment he helped popularize after his formal retirement.

Jose A. Morcuende, MD, PhD, FAAOS, is the Marvin and Rose Lee Chair and Professor in the Department of Orthopedic Surgery and Rehabilitation at the University of Iowa in Iowa City.