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Journal Club

April 2010

Reduction of Acute Anterior Dislocations: A Prospective Randomised Study Comparing a New Technique with the Hippocratic and Kocher Methods

• Authors:Fares E. Sayegh, Eustathios I. Kenanidis, Kyriakos A. Papavasiliou, Michael E. Potoupnis, John M. Kirkos, George A. Kapetanos
  
• Institution: Third Orthopaedic Department, Aristotle University of Thessaloniki Medical School,‘‘Papageorgiou’’ General Hospital, Thessaloniki, Greece
  
• Journal: J Bone Joint Surg Am. 2009;91:2775-82

Introduction

• Aim of reducing anterior dislocations
• Effective, quick, safe, easy, relatively painless.
• Minimal literature comparing different techniques
• Study Aim
  
  • To introduce a new technique
  • And compare objectively with the hippocratic and kocher technique

Methodology

• Prospective randomised study
• Exclusion criteria
  • Three or four part prox humerus #
    
  • Greater than 24hours dislocated
  • Intoxication
  • Analgesics or muscle relaxants.
• 3 orthopaedic residents
  • Max of 2 attempts = failure = GA in theatre
  • No sedation or analgesia given
• End Points
• Successful reduction
• Time to reduction
• Pain score (Visual analog scale)
  • 0 = no pain
    
  • 10 = intolerable pain
• Reduction Methods
  • FARES (Fast, Reliable &Safe)
    • Gentle traction arm in neutral
      
    • Continuous vertical oscillations
      
    • Arm abducted
      
    • 90 degrees arm externally rotated.
      
    • Reduction achieved around 120 degree
      
  • Hippocratic
    • Downward traction applied
      
    • Counter traction with a sheet wrapped around the axilla
      
    • Slight rotational movements
      
  • Kocher
    • Elbow flexed at 90 degrees adducted against side.
      
    • Arm externally rotated
      
    • Then flexed
      
    • Then internally rotate the arm

Results

• Successful Reductions (p=.033)
  
  • FARES - 88.7%
    
  • Hippocratic - 72.5%
    
  • Kocher - 68%
    
• Unsuccessful went to theatre
  
  • FARES – 11.3%
    
  • Hippocratic – 27.5%
    
  • Kocher 32%
    
• All 1st attempt
  • FARES = 15, Hippocratic = 9, Kocher = 8, Milch = 4
    
• Reduction Time (min) (p<0.001)
  
  • FARES – 2.36 +/- 1.24
    
  • Hippocratic – 5.55 +/- 1.58
    
  • Kocher – 4.32 +/- 2.12
    
• Results
  
  • VAS pain score out of 10 (p<0.001)
    
    • FARES – 1.57 +/- 1.43
      
    • Hippocratic – 4.88 +/- 2.17
      
    • Kocher – 5.44 +/- 1.92

Discussion

• Increased efficacy
  
• Decreased time to reduction
• Less pain

Pros of Study

• Randomisation
  
• Inexperienced users
  
• Homogenous groups
• Standardised protocol

Cons of Study

• Inexperienced practitioners
• If experienced using other technique improved efficacy?
• No sedation
  
• Other results applicable to these techniques only.
  
• Single blinded (impossible to double blind)

Consultant Discussion

• It's interesting that this technique has been used also for many years in Australia. At least 30 years.
• It is often used to reduce shoulders on sporting fields eg. AFL, rugby