D. Casielles, Spanish pioneer in the ‘Ponseti Method’ for knock-kneed foot

September 23, 2015

Founding member of the Spanish Society of Paediatric Orthopaedics (SEOP) and the study group of the Ponseti Procedure in Spain and in the rest of Europe, D. Casielles learned the mentioned method from the emeritus D. Ponseti at the Iowa University Hospital.

Why did you decide to study medicine?

I didn´t have a better option. I used to live in a familiar medical environment, so I thought it was the most convenient. It was a very rational decision, to be honest. It didn’t exist a clear vocation.

And about the choice of this speciality?

I chose it after a period studying medicine. Although it was meditated, you always surprise yourself. I enjoyed a lot doing sport, so I leaned toward sportive medicine. I was very interested in spinal pathology, but one day life turns around and I began to work with children orthopaedics. All started because I moved to the Materno Infantil Hospital in Malaga, which was an authentic deal for me. Reaching the knowledge and the experience that I have today has cost me much money, time and getting over the difficulties that Medicine puts in your path, but I feel very proud of myself.

How much time have you been practising?

Since I was a bit more than twenty until now that I have sixty five; I have been practising the whole life.

What has been your biggest achievement in this professional career?

I moved to the US in 1992 because of the poor condition of the specialty in Malaga at that moment, there was incompetence in a technical level. This specialty needs a huge amount of equipment. The equipment we use is very complex on a par with simple. In those days, the equipment was much neglected. At my arrival at the US, I had a professor called Ponseti who led me; he was a worldwide authority. He invented a technique, the ‘Ponseti Technique’ to apply on knock-kneed foot, that was completely different from the techniques used back then in Spain.

For the knock-kneed foot I don’t make a surgery, I only make certain incisions and then put plaster and, later, a device, it all takes its time. I am the first one that began to work with this kind of method in Spain. I have a mate in Barcelona who started three or four years later and she uses too.

Public or private health system?

I have just left the public one and now I only work in the private system, but along my career I have juggled both.

What do you think about the current position of the private medicine in Andalucía and, specifically, in Malaga?

There are plenty of supplies, regarding clinics there is everything, worse and better. In relation to professionals, there is fantastic people like cardiovascular doctors. But the point I can complain about is that the excellent professionals are not being paid at the level they should be. Some private companies pay for a pair of hours of surgery only one hundred and a few euros for the operation. Obviously, we don’t only live off of that, in my case, I have private patients thanks to my prestige, and there are patients which come from other cities searching for a second opinion and who arrive to my consultation directly. For example, a patient from Gibraltar called to the University Hospital of Iowa, and they referred him to us, they told him that he oughtn’t to go there, that he had us here near him.

How would you define your specialty?

The specialty is Orthopaedic Surgery in the children’s branch, Paediatric Orthopaedics. In Orthopaedic Surgery and Traumatology we fix people chassis, we put in order bones and joints that aren’t properly. Children’s part has its particularities, the child is not a miniature adult, like most of people cold think. We often treat many neurological patients. Knock-kneed foot is present in one out of one thousand births, provided that it’s already possible to get ahead complicated pregnancies. And there are illness and circumstances that can create neurological issues.   

Which are the pioneering techniques currently offered by the market and which of them do you have in your medical team?

The protocols that were performed at the University Hospital of Iowa and which I imported to Malaga. Treatments for the congenital luxation of the hip and for other neurological cases. We are a very prestigious service thanks to the contacts I brought with me from the US, we can say that Malaga is in the global first line. It’s very important for the medicine what which Americans call the super-specialty, the specialty of the specialty.

What are the most common cases?

Knock-kneed foot and congenital luxation of the hip, fractures and certain diseases which are less known, viral infectious illness. Foot and hip pathologies. Some of my patients, whom I treated new-born, now are twenty-five. Most of the cases remain solved, although there are some in which the case reverts, but they have solution, there is treatment.

Which cases have been the most difficult?

The most difficult to diagnose are the neurological ones and a disease called arthrogryposis, which is not so common, but it exists. To evaluate a child and then design a treatment is complicated. To treat a knock-kneed foot requires of six years of treatment. A hip luxation also needs some years. All of them have a long monitoring and controls. There are very laborious surgeries or methods like making different cuts from the pelvis to the foot, tightened muscles are cut to achieve the right positioning of the limb, it’s made with a scalpel leaf, it is more about the professional’s hand.

What are the difficulties between an adult and a child in this specialty?

Almost the 80% of the children doesn’t have anything. With children it’s more complex getting to know what they have, it is more like a police inquiry, you don’t reach a clear diagnosis until several previous examinations, after talking with family and immediate family, since the child cannot say if it hurts him here or that is happening something. The diagnosis is more difficult.

What is your opinion about health tourism?

I spent some time operating injured patients from the coast with very good results. Solving problems to foreign patients provides a lot, it culturally enriches. Treating people who have different ways of thinking provides culture. I have helped patients who come searching for you from other places and it’s one of the things that most satisfies me, that people look for you and that you can fix their problems. Even if they don’t show gratitude, because they don’t even know what you did to them, but it doesn’t matter what people think, satisfaction is yours, not others. Traumatology might be a vast specialty, but to do something as best as possible it’s necessary to specialize, you can’t treat everything, if so, the specialization decreases. In the US, they do the ‘super-specialty’, and by the half of the internship you already know what you are going to choose. The more specialized, the more advances the professional labour. I advance knowing what I’m looking for, repeating and repeating the shot. I have an only learning curve, but if you have fourteen, you are never going to reach the top of the curve.

Do you recommend the experience of going abroad to the beginners?

Doubtlessly, it is rewarding. I was taught freely, as Ponseti did on his day, so I consider I must teach free the same to other persons and, if I can, help people, but I don’t feel more or less proud, it’s only that I believe that, as an human being, it is what we have to do, it is our work. When I went to Madagascar I had to haggle the price of the theatres as if it was a market, in that way I was able to operate a higher number of patients. Whereas in India, Vicente Ferrer had it all very organized, it is excellent what he has put together there. I enjoy a lot in my job, I’m in love with what I do and I am a passionate, I know I wasn’t wrong when choosing. Life has brought me to this way, believing that you can choose in life is not truth, life directs you.