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SPARKS ESSAY SUBMISSION 1

Expedited ‘Diffusion of Innovation’: A reflection on the Ponseti Method in the

current era of medicine

Asitha Jayawardena

4/30/12


Expedited ‘Diffusion of Innovation’: A reflection on the Ponseti Method in the

current era of medicine

Basic physical fitness has been a prerequisite for survival since the early

evolution of man. Despite technological and societal advances that currently allow

humans to succeed without basic physical function1, those who are not able to

function at levels similar to the rest of society are labeled ‘disabled.’ Developed

countries such as the United States attempt to accommodate for disability. 2 We

have laws that ensure the construction of handicap-accessible buildings, motorized

wheelchairs that enhance mobility, and other accommodations that allow the

physically disabled to function more normally within our society. 2

Unfortunately, the same cannot always be said about the developing world. 2

These regions of the globe often rely more heavily on physical labor to make a living.

Therefore, the physically disabled are unable to contribute to society as they might

have if they lived in a resource-rich county. In fact, many of the physically disabled

are relegated to a life as ‘beggars.’ 3

Advances in medicine in the past few hundred years have been profound.

The disease burden has been shifted from infectious disease to chronic disease – a

trend so successful that we have eradicated diseases such as smallpox completely. 4,5

Other examples of our success include the near eradication of polio; a disease that

previously left affected survivors in a state of profound physical disability. 6

However, our battle against physical disability is not over. In fact, the most common


congenital musculoskeletal disorder that leads to disability worldwide is a condition

that is found most often in the developing world. 7,8

That disorder is called tilapes equinovarus, but is more commonly referred

to as clubfoot. 8 At least some aspect of the disease transmission is hereditary,

although the exact pathogenesis remains unknown. 10 The disorder is found in 1-

8/1000 newborns9 and is characterized by an inward and downward positioning of

the foot that makes it impossible to walk with a physiologic gait when it is left

untreated. 10,11 Untreated clubfoot is not only very painful, but often results in social

neglect and life as a beggar. 11,13 Some cultures even believe that clubfoot is a curse

from the Gods and choose to pursue witchdoctor/voodoo medicine versus typical

Western healing. 12,13

History of Clubfoot Treatment:

Historical documentation of clubfoot occurred as early as 1000 B.C. where

the deformity was first depicted in ancient Egyptian tomb paintings. 14 In fact,

posthumous radiographic evidence suggests that the famous Egyptian pharaoh

Tutankhamen and several members of his family were burdened with untreated

clubfoot. 15 Later documentation of clubfoot occurs in 400 B.C. when the father of

Western medicine himself, Hippocrates, describes clubfoot and clubfoot treatment.

14,16,17,18 Hippocrates, whose writings and thoughts on the field of medicine have

withstood the test of time, is not commonly known for his writings on clubfoot. 18

Hippocrates, however, describes various important principles in the management of

clubfoot that 2400 years later remain important aspects of the current treatment


guidelines. 15,16,17 Hippocrates emphasized that early treatment was paramount to

success. 14 He also suggested serial manipulations using bandages that result in

overcorrection, followed by bracing was a preferred treatment. 14 Unfortunately, the

treatment Hippocrates documented was soon disregarded by his predecessors. 14

Various alternate treatments emerged throughout the Middle Ages. 14 The

details of treatment of clubfoot in the middle ages are not currently understood. 14

However, it has been documented that barber-surgeons, charlatans, and bonesetters

were the professions responsible for clubfoot treatment. 14

In 1658, the famous Spanish surgeon Arcaeus documented treatment that

included stretching and the use of two mechanical devices to maintain correction. 14

In the 1700s, a similar stretching technique was documented. 14 In 1803, the Italian

anatomist Scarpa documented a technique including forceful manipulation and the

use of a complicated device as treatment for clubfoot. 14,19 Dr. Timothy Sheldrake, a

British physician, documented the use of bandages similar to those used by

Hippocrates in his treatment of clubfoot in 1806. 14

In 1823, the French surgeon Delpech recorded the first subcutaneous

tenotomy of the Achilles tendon, albeit to unfortunately poor results. 14 However,

the German surgeon Louis Stromeyer continued to practice the subcutaneous

tenotomy in 183119 and eventually taught the practice to a young British surgeon W.

J. Little, who perfected the technique to much success. 14,17,20 The method arrived in

the US in 1834 and 1835 due to the work of Drs. Rogers and Dixon. 14 In 1838, one of

the most celebrated orthopaedists in Europe, Dr. M. Jules Guerin first demonstrated

the use of plaster of paris in the treatment of clubfoot. 14 In the 1860s, advanced


surgical techniques allowed for the use of complex surgeries to attempt to correct

the anatomical deformities associated with clubfoot. 14 In 1939, John Hopkins

surgeon Dr. Joseph Kite published his non-surgical method to treat clubfoot. His

method soon became the standard of care within the orthopaedic community. 16

However, as it is understood today, the principles of Kite’s method were not

sound, leading to alterations in its practice and surgical additions resulting in most

cases being treated by extensive surgery. 16 Clubfoot centers around the world

began publishing and presenting on alterations to the surgical technique to achieve

‘better’ results. 16 Unique surgical procedures for clubfoot were published by a

number of different physicians including: Dr. Dilwyn Evans, Dr. Vincent Turco, Dr.

Leonard Goldner, Dr. Douglas McKay, Dr. George Simons, Dr. George Lloyd-Roberts,

Dr. Anthony Catterall, Dr. G Imhauser, Dr. Henri Bensahel, Dr. Sherman Coleman, Dr.

Alain Dimeglio, Dr. John Roberts, Dr. Arthur Steindler and Dr. Norris Carroll. 16 The

novelty of surgery and the tendency of orthopaedic surgeons to favor surgery

allowed surgical treatment of clubfoot to be the preferred method of treatment until

the past 15 years. 14 However, in parallel to the surge in publications about surgical

treatments in clubfoot, Dr. Ignacio Ponseti at the University of Iowa was perfecting a

non-surgical method of his own.

Dr. Ponseti began work on what would soon become the Ponseti method in

the 1940s after Dr. Arthur Steindler of the University of Iowa asked Dr. Ponseti to

review the technique Steindler had created16. Dr. Ponseti concluded the technique

was unsatisfactory and left children with stiff ankles and a compromised gait. 16

Ponseti understood what others had failed to understand – that ‘calcaneal internal


rotation (adduction) and plantar flexion are the key deformity.’ 16 He developed a

specific non-surgical manipulation technique that required up to 5 weeks in plaster

of paris casts followed by the use of a foot-abduction brace during the child’s sleep

for 4 years. 10 The 5-6 casts are a progressive treatment that corrects all deformities

of clubfoot simultaneously. 10 The foot abduction brace is an essential component for

preventing painful and debilitating clubfoot relapse. 9 To complete the correction, a

percutaneous tenotomy is performed to lengthen the Achilles tendon. 10 This

procedure can be completed in an outpatient setting with local anesthesia. 10

Despite publishing his specific method of serial casting and percutaneous

tenotomy to treat clubfoot in the 1960s, Dr. Ponseti’s method did not gain

popularity amongst the orthopaedic community until recently. 14,16,21 However,

despite its late dissemination, today the Ponseti method is considered the standard

of care for clubfoot treatment throughout the world. Studies have shown the

method to be over 95% effective when administered correctly. 8,9,10,14,16 The low

cost, highly efficient Ponseti method is especially important in developing countries,

where the majority of clubfoot occurs, because of their lack of capital to pursue

highly complex surgical treatments. 7,9,11,13

Diffusion of Innovation:


Everett Rogers first described the ‘Diffusion of Innovation’ theory in 1962. 22

Rogers was a rural sociologist at Iowa State University who grew up on his father’s

rural farm. 23 He developed the ‘Diffusion of Innovation’ theory after watching his

father fail to adopt the best-practice farming techniques of his time. 23 His model

outlines the adoption of any innovation until it is accepted as commonplace amongst

a society. 23

Initially, only the innovator uses an innovation. 23 The innovation is

eventually spread to early adopters, who are characterized by their willingness to

try new things. This group makes up 13.5% of society. 23 Next, the early majority will

accept the innovation. The early majority represents 34% of society and adopts the

innovation only after having observed others’ success. 23 The late majority tends to

be more conservative in their approach and adopts only after observing the early

majorities continued success. They make up 34% of society. Finally, the laggards are

those who refuse to adopt until they have no other option. This often occurs when

the previous product (i.e. VCRs) is no longer being sold because the industry

standard has shifted (ie. DVD/Blu-ray). Laggards represent 16% of society. 23

Rogers suggests that various factors influence an innovation’s diffusion

throughout these groups23. The factors, which describe the innovation, include:

relative advantage, compatibility, complexity, trialability, and observability. 23 An

individual carefully weighs these factors when deciding to utilize a particular

innovation. 23 Other factors that influence an innovation’s diffusion include the

social context of the innovation and the communication channels used for

dissemination. 23


The Clinical context of Diffusion theory:

The decision-making process an individual undergoes when accepting an

innovation in a clinical setting is described by RW Sanson-Fisher. 24 First, knowledge

must be attained by researchers regarding the clinical change. 24 In the context of

the Ponseti method, this was initially completed by Dr. Ignacio Ponseti and his

colleagues at the University of Iowa. The individual physician then must be

persuaded by the advantages of the innovation over their current practice. 24 The

clinician then independently engages in activities that help them choose to reject or

accept the new practice. 24 These activities may include attending conferences,

conversing with ‘expert’ colleagues in the field, and reading medical journals. 24 The

innovation must then be incorporated into the daily activities of the physician. 24

Once this innovation is incorporated, the clinician then seeks reinforcement from

their peers and results justifying their acceptance of the innovation. 24

The hierarchal nature of the field of medicine may hinder effective diffusion.

24 Despite being a field of constant innovation, the tendencies of our mentors are

inevitably passed on to our students. Despite an effective trend towards enhancing

evidence-based medicine, a gap exists between evidence-based practice and current

care. This gap has previously been characterized as the Knowledge Gap. 25

Relative Advantage:

Innovation in the field of medicine is passed through rigorous scrutiny

regarding its relative advantage over previous techniques. Easy-to-access online

medical databases with up-to-date medical literature such as Pubmed,


Uptodate.com, and others allow physicians to access recent evidence-based

medicine techniques. 26,27 Strict peer-reviewed publication guidelines establish a

necessary statistically significant difference to be demonstrated in treatment

results.

Exactly 244 studies populate a Pubmed search for ‘Ponseti method.’ 26 Most

all of these studies agree that the Ponseti method is the gold standard treatment for

clubfoot, with an over 95% treatment success. 9 The previous surgical treatment for

clubfoot has been documented with over a 50% relapse rate. The relative advantage

of the Ponseti method is made remarkably clear in the field of medicine by access to

peer-reviewed journal articles.

Physicians, however, might be hindered in their perspective of the

innovation if they observe physicians claiming to be practicing the true Ponseti

method, but are practicing a method with inadequate technique. Observing the

limited success of these substandard manipulations might negatively influence one’s

perception on the Ponseti method.

Compatibility:

The Ponseti method, especially when first proposed, provided a clear

contrast to the previous treatment standard of surgery. Surgery has been especially

popular with orthopaedic surgeons, the specialist of choice for clubfoot patients, for

multiple reasons. 16 Surgeons, who have spent decades training about the art and

complexity of surgery, exhibit a certain bias towards surgical methods of treatment

versus non-surgical methods. Additionally, surgeons are trained in a culture that


favors short immediate fixes. The Ponseti method is a patient method that requires

at least 5-7 weeks of casting and up to 4-5 years in a foot abduction brace.

Most groundbreaking innovations in the current era of medicine involve

technological advances such as nuclear imaging, use of stem cells, etc. The Ponseti

method of a simple casting and bracing technique was not compatible with the

medical innovation orthopaedic surgeons have grown accustomed to. In fact, the

Ponseti method may reminds surgeons of the very first treatments of clubfoot

described by Hippocrates himself over 2400 years ago. 14,16,18 The ‘compatibility’ of

non-surgical treatment in the circles of orthopaedic surgeons may play a role in

hindering clubfoot’s dissemination throughout the orthopaedic social sphere.

Complexity:

Although the Ponseti method is a complex maneuver that requires

experienced hands to achieve the most successful manipulation, it is not a technique

that many in the orthopaedic world would consider remarkably difficult. In fact,

many have described the method as one that non-orthopaedic specialists can

perform. This flexibility in administration makes the method especially useful in the

developing world. 28 However, the perceived simplicity of the method might hinder

surgical perceptions on effectiveness.

Trialability:

Another remarkable feature in the Ponseti Method’s diffusion is its

trialability. Practitioners can learn the basic method themselves in a weekend long

workshop administered by the Ponseti International Association from the

University of Iowa. Additionally, the method is one that can be taught from


practitioner to practitioner. The ease of use when it comes to trying the method is

favorable to its dissemination.

Observability:

Clubfoot and the Ponseti method are assisted in their diffusion by some

remarkably observable results. 10 Clubfoot is an easily distinguishable deformity

that is characterized by a midfoot cavus, forefoot adductus, hindfoot varus, and

hindfoot equinus. 10 The widespread extent of clubfoot throughout the world as well

as its characteristic appearance have led to many different names for the deformity

within each culture. Parents and physicians can easily observe the characteristic

clubfoot deformity return to a physiologically normal looking foot within weeks. 29

The easily observable correction with each applied cast helps practitioners observe

the utility of the method.

Communication Channels:

In addition to characterizing the factors of an innovation, one must also

understand the communication channels in which the innovation is presented. In

fact, communication channels are one of the most important elements in an

innovation’s dissemination speed. 23,24 Communication channels can include both

micro-level communication and macro-level communication. Micro-level

communication includes face-to-face interactions between like-minded people.

Macro-level communication includes mass media campaigns including television,

radio, and billboards.


Medically, innovations are often initially published in medical journals. 24 The

higher rank and viewership of the medical journal results in expedited diffusion.

Additionally, face-to-face communication occurs at medical conferences. 16,24

Specialty-specific medical conferences offer physicians to not only speak with the

innovator themselves, but also with their medical peers who are similarly weighing

whether or not to utilize a particular innovation within their own practice. 24

The Ponseti method underwent a unique dissemination within the field of

medicine. Despite documenting his success in the medical literature the method was

not widely disseminated until an additional communication channel was

introduced. In the 1990’s, the use of the Internet amongst parents of children with

clubfoot jumpstarted the demand for the Ponseti Method at the University of Iowa.

21 Five large support groups with a total of 30000 messages were the primary

communication channel for parents wishing to share either their treatment success

with the method or their frustration with surgical treatment. 21 After the University

of Iowa Hospitals and Clinics posted a virtual hospital webpage on the Internet

about their Ponseti care, they received a drastic increase in patients from previous

years. 21 Morcuende, Egbert, and Ponseti reported 790,084 hits to the virtual

hospital web pages. 21 The University received requests for information from all 50

states and 72 different countries. 21 The Internet and clubfoot support groups were a

major communication channel to spread the Ponseti method amongst physicians.

Physicians were soon introduced to a new communication channel – parents

requesting information about the Ponseti method. 21 After this surge of popularity in


the 1990s, Dr. Ponseti and the University of Iowa began educating physicians who

wished to become familiar with the Ponseti method.

Strategic Implementation of Diffusion Theory Eradicate Neglected Clubfoot:

Traditionally, physician education on the Ponseti method has been

administered through weekend long hands-on workshops in which Ponseti experts

travel to areas of the world bereft in Ponseti care and teach local practitioners how

to utilize the method. While this method was initially successful, careful analysis of

Everett Rogers’ Diffusion of Innovation Theory suggests an alternate education

method.

Rogers describes heterophily and homophily as important aspects in

communication channels when it comes to dissemination. 23 Heterophily is

described by Rogers as, ‘the degree to which pairs of individuals who interact are

similar in certain attributes, such as beliefs, education, social status, and the like.’ 23.

Homophiles are very effective communicators because of their similarities in

behavior, attitude, and knowledge. 23 However, complete homophily is detrimental

to initiating change because the two participants are so alike, no information can be

exchanged. 23 Unfortunately, the previous method to spread the Ponseti method

resulted in heterophiles, the opposite of homophiles, spreading information about

the innovation. The differences in language, interests, healthcare systems,

socioeconomic status, etc. resulted in inadequate diffusion. The ideal situation

would be two near-complete homophiles, alike in every way except for knowledge

of the innovation, to interact in order to spread the method.


The new strategy in the diffusion of the Ponseti method utilizes this theory-

based concept. The Ponseti International Association with support from a Ronald

McDonald House grant and funds raised by the American Medical Student

Association Iowa chapter are utilizing a ‘fellowship’ system that brings individual

physicians from areas of the world in Ponseti need to the University of Iowa to

master the Ponseti method from the Department of Orthopaedics, Dr. Ponseti’s

former department. These physicians will then return to their country as

homophiles, however, with a thorough knowledge of how to both use the Ponseti

method as well as teach it to their peers.

To best enhance diffusion, Rogers suggests targeting ‘change agents.’ 23

Change agents, or opinion leaders, are very influential (positive and negative) in the

diffusion of an innovation. 23 Change agents are typically more innovative,

charismatic, have many social contacts, have a high socioeconomic status, and have

much social experience and exposure. 23 By targeting these change agents as

fellowship participants, we can use our knowledge of Rogers’ Diffusion of

Innovation Theory to expedite the spread of Dr. Ponseti’s best-practice method to

treat clubfoot.

The fellowship model may be the most cost-effective way to ensure physician

understanding of the Ponseti method throughout the world. Worldwide physician

education on the Ponseti method is certainly the best way to eradicate neglected

clubfoot and the resulting physical disability. Strategic implementation of the

‘Diffusion of Innovation theory’ will be instrumental in achieving this goal.


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