Walking With Faith





Kiley Miller, Reporter
The Hawk Eye
1-800-397-1708 ext. 149
(319) 754-6824 (fax)
Created: 10:04:53 AM on 4/15/07

By KILEY MILLER

kmiller@thehawkeye.com



WAYLAND — The first step is the hardest.

Before John Mitchell could become a healer, before he could craft devices to
help children around the world break free from the shackles of a crippling
deformity, he had to act on his unwavering faith.

He had to say yes to an old man.

A legend's legacy

From the highway, MD Orthopaedics is all but invisible: a low beige and blue
building set deep in a nearly empty business park. It seems a nondescript
structure to hold such an amazing story inside. It's like a paper sack wrapped
around a Bible.

Mitchell founded this company three years ago with one worker — himself. Now
he employs 11.

But to understand the miracle he has wrought for the 4,000 babies born with a
club foot each year in the United States, one must go back further, back a
dozen years, to a visit from an elderly Spaniard and his insistent wife.

Mitchell was in another small town at the time working an odd job, one that
merged his sculptor's touch and handyman sensibilities. He made anatomical
models — plastic body parts doctors and teachers could use in the classroom.

That's just what Ignacio Ponseti needed.

Ponseti is a legend who deserves the label. He was a loyalist officer in the
Spanish Civil War half a decade before Pearl Harbor. Nearly 70 years later, a
sign at the University of Iowa hospital welcomes visitors to the Ponseti Clubfoot
Treatment Area.

The doctor traveled to Iowa City in 1941 for his residency. Soon he was
working with a master surgeon named Arthur Steindler. Part of his job was to
find patients treated years earlier for orthopedic problems and see how they
had faired. For many who had endured clubfoot surgery, the results were
clear, and they were poor. Their feet had grown rigid, weak and painful.

Clubfoot is a congenital deformity. That means it is present at birth. Officially,
the trigger is uncertain, although Ponseti zeroes in on faulty genes.

The physical problem, by contrast, is well understood. Ligaments on the inside
of the ankle and foot are too thick and tight, pulling the foot down and inward.

Stand up and lean hard on a table, palms down. In this position, your hands
represent a normal foot. The wrists, bowed backward, are the ankles, and the
fingers are the toes.

Now swing your hands inward and roll them upward so the tips of your middle
fingers nearly touch and your weight rests on the outside of your pinkies and
palms, the part of the hand used in a karate chop. This is bilateral clubfoot.

Left untreated, children learn to walk this way, their knees kinked like the sides
of an hourglass. Even those with less severe deformities move jerkily.

Surgery solves the problem with a scalpel, slicing ligaments and tendons to
free the foot.

Ponseti, through his follow-up with Steindler's patients, found the cutting
causes scarring and stiffness.

Thankfully, he didn't stop there. He also studied ligaments from babies with
club feet. They were not brittle, but cellular and ductile. They could be
stretched.

     From this knowledge
came the Ponseti Method.

The method is simple. It requires only skill, patience and plaster. Taking a
baby's foot in his gentle, age-spotted hands, Ponseti stretches the medial
ligaments slightly and holds the foot in place while an assistant applies a cast
using the same technique the doctor employed to treat the wounded in the
fight against Gen. Ferdinand Franco's fascists.

After a week, the first cast is cut away. The ligaments are stretched further,
and a second cast goes on. Another week, another cast.

The cycle typically continues for about four weeks. Then, in most cases,
comes a procedure called a tenotomy. The tough and recalcitrant Achilles
Tendon is severed. That loosens the foot for positioning before the final cast,
which stays on for three weeks to give the Achilles time to heal. When the cast
comes off, a child's foot — and life — is on the path toward normal.

"Ponseti is a gift from God," said Emily Hamelton, a rural Keokuk mother whose
twin daughters were treated with Ponseti's method. "And so is John Mitchell."

        Training multitudes

He didn't want the job.

When Ignacio Ponseti and his wife sought him out in tiny Nichols, John Mitchell
didn't see the visit as a blessing. He saw a problem.

Ponseti began putting his ideas into practice on patients in the 1950s, but
other doctors were slow to follow. The reluctance continued even after he
published an explanatory article in a medical journal in 1963, with some big-city
surgeons going so far as to say the method only worked in backwater areas
where children wore heavy boots to the fields. Ponseti also was competing with
other non-surgical methods.

Over time, results won out and physicians from around the globe began
trekking to Iowa City to learn from the master.

The Ponseti Method can be tough to teach, partly because it can be tough to
employ. The casts must exert the right pressure at the right point for the foot to
find their proper form.

Ponseti needed to give the doctors who came to him for instruction a view
down to the skeletal system. He needed a model.

When Mitchell first heard the doctor's request, spoken in an elegant Catalan
accent, he thought: "Aren't you retired?"

Ponseti turns 93 this summer. He was old even then. Knowing the model would
take months of research and design, Mitchell doubted the doctor could keep
working long enough to justify the effort.

Ponseti's wife, Helen, pleaded on her husband's behalf.

Mitchell had an unconquerable handicap, one he explained this way: "My
spiritual gift is mercy."

From ground-breaking doctors to hurting children in Africa, Mitchell wants to
aid anyone in need. Denying the Ponsetis would have been like "saying no to
grandma and grandpa." So he said yes.

Time proved him right about one thing. The model was complicated. He took
the project with him through a job change, relocating to Kalona to work for a
medical instrument company.

As for losing money off the deal, "We've shipped this thing to 65
countries," he said. Picking up one of the models from a table in the MD
Orthopaedics break room, he addded: "These have helped train multitudes of
people."

It would have been hard to mistake the basic intent of the object. Ivory-toned
and roughly the length of a new pencil, the model was made of a dozen or
more molded plastic bones. Together they shaped a club foot from the tip of
the toes to a few inches up the ankle.

Elastic string stitched the bones together and gave the model life. Holding the
model at the ankle joint with his right hand, Mitchell pushed up on the toes with
his left. The bones clicked slightly as they moved. Just like that, the clubfoot
was healed.

"Not only did this help Dr. Ponseti in his instruction method, it helped confirm
the technique worked," Mitchell said.

                Relapses

Ignacio Ponseti had his teaching tool, but his worries didn't end there.

Again, he needed John Mitchell.

As demand for the model grew, Mitchell made visits almost weekly to Ponseti's
office. Over time, he noticed children reappear whose treatment had ended
long before. Their problems had returned, even though Ponseti claimed a
success rate better than 90 percent.

The doctor's explanation was crisp: The brace didn't work.

The real challenge of the Ponseti Method begins when casting ends.
Children must wear a brace locking their feet in place 23 hours a day.
After three months, the time required begins to drop incrementally
until age 4 or 5 when, according to Ponseti, the gene that causes club
feet is no longer active.

Just five years ago, nearly all braces were made with special baby shoes
attached at opposite ends of a flat steel bar. Parents slipped their baby's feet
in the shoes and laced them up.

Too often, they didn't. The braces fell off incessantly. Worse, the stiff leather
shoes carved into tender flesh. To many parents, the device seemed cruel.

"The child does not sleep," Ponseti said, "so the family does not sleep — for
many weeks."

After describing the brace's failings to Mitchell, the doctor made a surprise
suggestion.

"He said, 'Why don't you come up with something,' " Mitchell remembered.

The appeal made no sense. "I told him I don't know (anything) about braces,"
Mitchell said.

Ponseti urged him to think on it.

The idea pulled at Mitchell like gravity. Was this what he was meant to do?

Mitchell is neither well-spoken nor well-educated, but he is well-grounded. A
devout Baptist, he lives his belief urgently and earnestly.

"You can't really talk about John without talking about his (religion)," said a
family acquaintance.

Mitchell is committed to a god of the everyday, a father figure who gives only
the best advice. So, faced with the unanswerable dilemma of the brace, he did
what his faith demands. He bowed his head.

"I felt the Lord say, 'Yeah, you could do this.' "

The Lord said more. Despite a wife and three sons to support, Mitchell felt he
should quit his job and commit to the brace.

Like her husband, Jean Mitchell believes in divine guidance. She also believes
in John. Together they took out a second mortgage on their home. The family
would live one foot fall from poverty.

Today, Jean looks back and thinks, "Wow, I can't believe I did that." But really,
she can.

"Who am I to mess with God's plans?"

       One mother's need

John Mitchell started with faith, but he didn't start with inspiration.

His first step was to buy a sewing machine that could punch through
leather. He wanted to build a better shoe.

He failed. Mitchell would stitch a new model, take it to Ponseti, and
be gently rebuffed. Pretty good, the kindly doctor would say,
meaning not much better.

Discouragement grew like shadows in the evening. Then came new
light in the form of an old Scripture — Philippians 4:13: "I can do
all things through Him who gives me strength."

Mitchell was praying when the verse struck him. He already knew it
well, but suddenly he knew it differently. He wasn't creating the brace.
He was just the potter's hands.

With that came the answer.

"I thought, Why don't you use your molding ability?" he said. "That was my
expertise."

The sewing machine silent, Mitchell finally got to work.

What he came up with is a sort of Roman sandal for the preemie set, with
supple split grain leather that buckles over the foot and up the ankle. The real
advance, however, is on the inside: A molded urethane insole with a cupped
heel that rises over the Achilles tendon. The plastic is not stiff, but rubbery.

Mitchell finished his first brace and took it straight to Iowa City. He was excited,
but Ponseti and his fellow doctors were not.

"This was a completely different thing," he said. "They were like, it will never
work. It's way too flimsy."

Mitchell's ankle and foot orthosis, or AFO, could have ended there. But there
was a mother in the office that day. Her child's feet had been torn and bloodied
by the old brace and she needed help.

"You can try in on my baby," she said.

With that, the doctors' perspectives changed. Here was a parent offering
permission for a trial. Mitchell took measurements of the baby's itty-bitty feet.
This brace would have to be perfect.

It was. The baby stopped crying at night. More importantly, weekly
examinations showed the feet were holding their shape.

"Because it is much easier to accept, parents are more able to use it," Ponseti
said. "There is not a single night the baby does not sleep."

After six months of testing, the doctors knew the brace worked. By then,
Mitchell had made several more braces for Ponseti's patients. He wasn't
making more money, though. Most children he helped were uninsured, and he
was not eligible for reimbursement through state programs. Eighteen months
after he left his job, Jean went to work at a bank. Their tax returns would show
they made it through one year on $17,000.

But, oh, was it ever worth it. The brace was a leap ahead, and not just
because of the sandal. Mitchell eliminated the heavy nut joining the shoes to
the bar on the old braces. That lowered the profile, so children in the Ponseti
AFO (Mitchell named it after the doctor) could stand and walk, rocking side to
side like toy soldiers come to life.

In January 2004, two years after the project began, the paperwork
came through. MD Orthopaedics was born.

"Praise God," Mitchell said. "I mean, think about it, I don't have any schooling
or anything."

The sales force

Gold-medal-winning figure skater Kristi Yamaguchi was born with club feet. So
were world-class soccer player Mia Hamm, Hall of Fame quarterback Troy
Aikman and reining National League batting champion Freddy Sanchez.

So were Maddie and Ali Hamelton.

On a recent spring afternoon, the toddling twins with the soft eyes and "yes-
we're-cute" attitudes ran through the back yard of their family home in tiny
Mooar, a Keokuk satellite.

Alternately joyful as bird song and angry as wet hens, they tumbled and
toppled, climbing to the top of a slide and chirping to get their mother's
attention before swooping down into the waiting hands of a babysitter.

Seeing her daughters now, it's troubling to imagine the hurt Emily Hamelton felt
six months into her pregnancy when a sonogram revealed club feet on both
girls. Hamelton allowed herself to grieve for a time, then she got busy
researching treatments. All the clues pointed to Ponseti and his colleagues
fewer than 100 miles north.

"You don't want your child to have any kind of birth defect, but I
learned this is one of the easiest to correct," Hamelton said.

The casts worked perfectly and Maddie and Ali graduated into the Ponseti
AFO, which costs $350 new. Hamelton compares the device to the retainers
people wear after having braces on their teeth. Doctors told her success was
"all about the parent," and she has learned they were right.

Maddie and Ali wear their braces 12 hours a day. Amazingly — and annoyingly
for parents with tighter-wound toddlers — that's about how long they sleep at
night. When bedtime comes, Hamelton said, they "just know to put on their
brace."

She and husband, Chris, can do the job in a split instant. Newer models of the
brace make the job even easier, with clips on the soles of the shoes that free
them to be taken off the bar and buckled on the girls' feet first.

"This is all we've got," Hamelton said. "They'll wear this brace until they're 5 at
most. Then the chance of relapse will be 5 percent. My kids will be normal."

Mothers like Hamelton are Mitchell's sales team. They hit Internet chat rooms
to talk up anything related to Ponseti and his method, including the brace
bearing the doctor's name.

One of the most dedicated is Shawnee Reese, an eastern Oklahoma
mother who had her three boys in Iowa City last month. *sidenote: Shawnee
now lives near Gainesville, Florida.

Reese has perspective. Each of her sons has club feet. The two youngest
are being treated by Ponseti. The oldest was not — at least not at first.

Nine-year-old Brian (Adams) Reese has been through six months of casting,
multiple surgeries, braces that ripped his feet apart and nearly two years of
physical therapy. Yet, in his mother's words, "his feet are a mess."

Even the untrained eye can see it; Brian's feet are blocky and crooked. His
toes turn in. He seems more comfortable on the balls of his feet than walking
normally.

Plus, "he's so clumsy," his grandmother said.

Brian's feet don't bother him now, but "when he is about 15 or 20, they
will become stiff and painful," Ponseti said.

Compare that to his two little brothers. Three-year-old Everett and 1-
year-old Garrison have feet that are indistinguishable from those of
regular children. Their grandmother tells them they "have pretty feet
now."

Shawnee Reese has a Web site to promote the Ponseti Method (www.six-feet.
com). At the University of Iowa, she met two mothers who said they were there
on her guidance.

These days, that guidance includes Mitchell's brace. Her younger boys
have been through several pairs of sandals. Remembering the damage
previous braces did to Brian's feet, she has a true appreciation for the soft
spoken guy in Wayland who spared her other children pain.

"They really do go hand-in-hand," she said. "Without Ponseti, there
would be no reason for the Mitchell Brace. But without the Mitchell
Brace, the chance for a relapse would go way up."

        Reaching the world

This Easter morning, John Mitchell has so many reasons to be thankful. Every
working day, his employees receive moldings of tiny feet. Every working day,
braces go into the mail to help babies from Uganda to Russia to eastern
Oklahoma.

On a recent flight, Mitchell was explaining his business to a man sitting next to
him. As he talked, Jean thumbed through the airline's in-flight magazine.

"Here it is," she exclaimed. The magazine had an article about Ponseti — and
a picture of a child in their brace.

MD Orthopaedics has seven products, from the braces and replacement
shoes to the one that started it all — Ponseti's model. Mitchell will soon hold
three patents.

He also will soon hold a new child. Five years ago, John and Jean
wondered how they would provide for their three sons. This spring,
they will travel to Guatemala to meet their adopted daughter.

Mitchell has an even greater journey in mind.

The Ponseti Method is a "win/win" for underdeveloped regions, he said, curing
club feet without surgery in Africa and elsewhere where surgeons and
antibiotics are in short supply. Yet his brace is too expensive to help all of the
world's poorest people, and the demand is staggering. He recently asked a
doctor from India how many braces were needed there. About 50,000, the
doctor replied.

Mitchell is in talks with a Mount Pleasant company to develop cheaper
production methods. Still the challenge can seem impossible.

Then he opens his Bible. The other day, he came upon a passage in Hebrews:
"Therefore, strengthen your feeble arms and weak knees. Make level paths
for your feet, so that the lame may not be disabled, but rather healed."

So the lame may be healed. The words awe Mitchell, and humble him.

"This happened because I was obedient," he said. "By one person being
obedient, we're changing the world.

- End.
Return to Clubfoot in The News

Return to Walking In Faith Top of Page

Return to Six-Feet.com Home Page
.
Garrison Reese (baby) standing in
exam room with Dr. Ponseti as Hawk
Eye reporter Kiley Miller and his
photographer interview us for this story
(above).  Dr. Ponseti examines Brian's
feet, same day (below)
Garrison, age 2 months, happily
wearing his foot abduction brace (FAB)
designed and built by John MItchell
and his outstanding employees at MD
Orthopaedics.
Proper implimentation of the Ponseti
Method, followed by strict use of the
prescribed bracing system, can help
avoid the need for surgery in almost
every case of clubfoot.   The photo
above, and those below show Brian's
feet on the day the post-op casts were
coming off of him.
If this one small photograph doesn't tell
the whole story, nothing does.  It's
been seven years and I can't look at
this with out crying.

If Brian's own tears can't convince you
to use the (real bona fide) Ponseti
Method, you're hopeless.
In this photo, Brian is holding Everett
who is still attempting to wear the
Markell FAB.   While the Markell style
has been used successfully by
thousands of children over the past
several decades, it did not work for us.
By comparison to the Mitchell's design,
it is heavy and cumbersome, as well as
stiff; it caused blisters and pressure
sores on Everett's newborn feet.

When we called Dr. Ponseti with our
failures, he said, "Call this man. He has
made a brace that fits like a glove."

Indeed!  John Mitchell sent us a
prototype to test out.

The rest is  history.
Everett, held by Daddy, hangs from his
Mitchell FAB.  This photo is posted by
the designer's work bench at the MD
Orthopaedics facility in Iowa.
Left to Right:  Baby Garrison, Shawnee, Brian
and Everett standing outside John's shop
March 23, 2007.

(That's Emily coming out the door! Hi Emily!)