Kevin,
As I stated previously, it is possible to apply an external torque to the tibia, but this of course is going to be secondary to the torque being applied to the foot for example. Can you be sure that your correction is occuring in the right place?
I understand your stance in regard to treatment without the evidence, however, my concern here is that the possibility for complications outweighs the perceived improvements.
If you are using the DB bar to alter sleep position, and therefore enabling normal derotation to occur I can think of other ways that are less intrusive, e.g. place a pillow between the child's legs, not withstanding the fact that these days most infants are placed on their backs to reduce the incidence of SIDS.
Really enjoying the debate
Cheers
Tony 

________________________________

From: A group for the academic discussion of current issues in podiatry on behalf of Kevin Kirby
Sent: Sun 21/11/2004 20:55
To: [log in to unmask]
Subject: Re: Serial Casting for Internal Tibial Position


Tony and Colleagues:
 
Tony wrote:
 
<<I can accept that if you apply an external torque to the lower limb, once the hip has reached it's end ROM and the knee has been externally rotated as far as it's soft tissue structure and bony architecture will allow it, you will eventually apply an external torque to the proximal end of the tibia, but where does your 'correction' take place?
Stanley, you feel that the external rotation occurs at the knee, could you further explain this?
My concern is that in applying an external torque in the lower limb, where in a young child the acetabulum in relation to the head and neck of femur is in an externally rotated position, which subsequently reduces form 60 degrees to approx 10 degrees ext. rotated, what effect this external torque will have on the natural ontogenic development?  The knees being in a flexed position will allow further external rotation at the knee, but surely the force will be applied along the path of least resistance i.e. the hip!
I find it very diffficult to comprehend the use of a "splint" in which there is no evidence to support it's use, and I do not doubt that lower limb external rotation occurs, but I find it unlikely to have occured within the tibia. For example a gait plate can alter an intoeing gait pattern by altering the line of progression, but it does not solve the underlying pathology.>>
 
First of all, proper use of night splints (Denis Browne, Fillauer, Uni-bar, Ganley, etc)  dictates that these devices **should not be applied** at the end of the external range of motion of the hip, since, indeed, this will likely result in some of the pathologies that you describe above.  The idea is to hold the foot and lower extremity **in a less internally rotated position than the normal relaxed hip position but not at or beyond its external range of motion limit**.   Ron Valmassy was very clear on this procedure when he taught it to us at CCPM.  Ron's chapter on proper use of night splints goes into great detail as to the procedure that he recommends in regard to amount of correction that one should initially place into the night splint and how one should progress with the correction as time progresses (Valmassy RL:  "Lower Extremity Treatment Modalities for the Pediatric Patient" in Valmassy RL (ed): Clinical Biomechanics of the Lower Extremities. Mosby, St. Louis, 1996, pp. 425-452).
 
Second, one does not need to be at the external range of motion limit of the foot and lower external extremity in order to achieve an external rotation moment on the tibia with a night splint.  As long as the night splint is resisting an internal rotation moment of the foot and lower extremity, then, the tibia will have an external rotation moment being placed on it by the night splint. Those of you who saw my lecture on abductory twist at the PFOLA meeting in Boston may remember the video I showed demonstrating the elastic strain energy in the hip joint soft tissue elements that caused rapid external rotation of the whole lower extremity when released from an internally rotated position.  Understanding these forces and moments allows one to better understand the mechanical effect of night splints when treating internal torsional problems in the pediatric patient.  Biomechanical modeling of the mechanical effects of the night splints will clearly show that it places an external rotation moment on the tibia, if properly used.
 
Third, I don't have any problem comprehending the use of night splint in a growing child.  Do orthodontists expect to achieve correction of bony structures of the jaw that surrounding the roots of the teeth by applying forces to the teeth over long periods of time in children?  Doesn't the scientific literature support the fact that bones remodel (especially the bones of young children) depending on how stresses and where stresses are placed on them?  Is this too much of a "leap of faith" to then hypothesize that a properly applied night splint might indeed change the tibial/malleolar torsion over time when it is worn for half of the hours of a day, months in a row?  
 
I am wondering what is the podiatric clinician to do when a concerned parent brings their child in for help with significant torsional problems of the lower extremity?  Do you just tell the parent that there is nothing you can do for their child since there is no evidence for its use, and then tell them that you will have to wait to see if they grow out of it and then perform surgery on them or live with the deformity it if they don't grow out of it? Or do you tell the parent that you will try this therapy that has been used for generations by many respected pediatric authorities with some success and that if this treatment doesn't work then we will know that we have at least tried our best to treat their child's condition without surgery?
 
And, please, don't get me started on discontinuing treatments that don't have sufficient evidence to support their use since this would effectively eliminate about 75% of the treatments that podiatrists use on a daily basis to help literally millions of patients with painful deformities and pathologies of the foot and/or lower extremities.  
 
Cheers,
 
Kevin
 
****************************************************************************
Kevin A. Kirby, DPM
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine at Samuel Merritt College
 
Private Practice:
107 Scripps Drive, Suite 200
Sacramento, CA  95825  USA
 
Voice:  (916) 925-8111     Fax:  (916) 925-8136
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