Live Long and Prosper

Ignacio Ponseti is an outlier. According to the latest annual survey conducted by the American Academy of Orthopaedic Surgeons, the mean age of a practicing orthopaedic surgeon in the United States is 51.4 years, ranging from 31 to 92 years. The mean age for complete retirement is 67 years, and only 1.2% of practicing orthopaedic surgeons are older than 75 years. ¹ At the age of 93 years, the renowned Dr Ponseti continues to care for some of the most youthful patients at the University of Iowa, his adopted home.^{10, 11}

Born on the outlying Spanish island of Minorca in 1914, Dr Ponseti graduated from medical school on the eve of the Spanish Civil War. ⁷ He received his medical baptism by fire as a battlefield physician for the republican forces. When a victory by the fascist side seemed imminent, Ponseti enlisted the aid of smugglers to evacuate his wounded patients via mule train across the Pyrenees to France. There, he served as both an inmate and a physician in one of the concentration camps set up to house the republican refugees. Ponseti's quest to complete his orthopaedic training took him next to Mexico and finally Iowa City, where he sought the tutelage of Arthur Steindler, then chair of the orthopaedic surgery program. What was originally envisioned as a temporary arrangement evolved into a lifelong love affair between Ponseti and Iowa.

During his career, Dr Ponseti has published scores of basic science and clinical research articles, primarily in the field of pediatric orthopaedics. His work on the treatment of clubfoot deformity constitutes his greatest orthopaedic legacy. Although a surgeon himself, Ponseti became disenchanted with surgery as the primary treatment for this condition. His detailed studies of the fetal pathoanatomy of congenital clubfoot led to a very specific system of sequential manipulation and serial casting that has come to be known as the Ponseti method of treatment.^{13, 16}

The Ponseti method came into being half a century ago as an outlier in a world that favored surgical correction of clubfoot. Dr Ponseti continued to champion his technique, which gradually gained notoriety and adherents, although not universal acceptance. In 1984, Dr Ponseti reached the age of 70 years and was required to conclude his surgical practice. This did not result in his retirement from clinical work at Iowa, where he still continues to evaluate and treat patients 3 times a week.^{10, 11}

Over the years, Ponseti's accumulated honors have ranged from the prestigious Kappa Delta Award to a quilt adorned with pictures of his diminutive patients that hangs in the University of Iowa orthopaedic clinic. Perhaps ironically, modern Internet technology has led to an expanded worldwide interest in his technique, whose allure comes from its technological simplicity as well as its impressive results. In 2006, a foundation dedicated to the propagation of his treatment methods was named in Dr Ponseti's honor. ¹³ Although the Ponseti method has developed many distinguished disciples over the years, the continued clinical presence of its charismatic originator has also been instrumental in its burgeoning acceptance.

Professional activity into the 10th decade of life is unusual, not just in orthopaedic surgery but in most fields of human endeavor. Although history is replete with celebrated people who have lived long lives, most have spent their last years in a private existence of quiet retirement. There are a number of social, psychological, and biological forces responsible for this pattern, including what appears to be a preprogrammed change in human physiology. In the current issue, Wright and Perricelli explore the tendency of older individuals to slow down—literally—in “Age-Related Decline in Performance Among Elite Senior Athletes.”

Wright and Perricelli investigated their subject in several ways. At the 2001 Senior Olympics, they compiled questionnaires from 2599 participants and analyzed the top 8 performances by pentad. In addition, they compared contemporary Masters sprinting and running records in each age group. This latter approach continues a tradition of analyzing record performances dating back at least to 1925. That year, in his presidential address to the Section of Physiology of the British Association, Prof A. V. Hill examined the records in a variety of sports from The World's Almanac and Book of Facts in an effort to explain the physiological determinants of human performance, including observed differences between men and women. ⁸

By the nature of their method of selection, the population studied by Wright and Perricelli should represent a group of outliers. Although their athletic achievements would certainly qualify them as such, they score only modestly above average when measured by the more mundane standards of the Short Form–36 (SF-36). Interestingly, their mean mental health as measured by the SF-36 exceeded the US norm by a greater margin (SD, 0.5) than did their physical health (SD, 0.2).

Examination of the performance data showed a slowly progressive decline until about age 75 years, when the rate of decline began to accelerate. The rather asymptotic performance curve of the men's 400-m run, in particular, evokes the image of an octogenarian Sisyphus struggling to push his boulder up an increasingly steep hill. In this case, our geriatric champions are battling forces such as diminishing muscle mass caused by a progressive decrease in the size of type II muscle fibers, ⁶ declining maximal oxygen uptake (VO₂ max),^{3, 5, 9, 15} and stiffening connective tissues.

Wright and Perricelli's findings replicate those of investigators in other Olympic sports. Meltzer complemented his cross-sectional study of 2 sets of Masters weight lifters with a longitudinal study of 64 Masters weight lifters over a mean of 8 years (range, 2–18 years). ¹² Both methods produced surprisingly concordant results, demonstrating a progressive diminution of lifting capacity over time that terminated in a more rapid decline after age 70 years. Tanaka and Seals conducted a cross-sectional study of the physiological functional capacity of Masters swimmers in 1997 and revisited the topic in a longitudinal study with Donato and other coauthors in 2003.^{3, 14} In both investigations, they found that swimming performance declined progressively until age 70 years, at which point the decline became exponential.

To a certain degree, it appears that deterioration in our physical capacities is programmed to occur sometime after we attain the biblically prescribed 3 score and 10. Donato et al ³ noted that a reduction “in spontaneous activity with age is a common characteristic of many animal species” but emphasized that the variability of age-related decline in performance increases markedly with advancing age. They concluded that “even within a physically elite population of healthy humans, there may be markedly varying degrees of 'successful’ aging [as] has been reported previously … in the general population of healthy adults.” In other words, outliers like Ignacio Ponseti will emerge alongside those who find it sufficiently challenging to function at a more basic level.

Declining performance in senior athletes is an unusual subject for AJSM, which normally eschews articles that deal primarily with athletic performance. Wright and Perricelli's article may help orthopaedic sports medicine specialists understand the processes at work in their older patients. Although age-related decline in our athletic patients may be inevitable, studies have also shown that continued or renewed training can mitigate its progression, even in nonagenarians.^{2, 4, 9} As sports medicine practitioners, we should accept the challenge of helping our patients maximize their physiologic potential.

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