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Reduction of Acute Anterior Dislocations: A Prospective Randomized Study Comparing a New Technique with the Hippocratic and Kocher Methods
Fares E. Sayegh, MD1; Eustathios I. Kenanidis, MD2; Kyriakos A. Papavasiliou, MD3; Michael E. Potoupnis, MD4; John M. Kirkos, MD5; George A. Kapetanos, MD6
1 “Papageorgiou” General Hospital, Ring-Road, Nea Efkarpia, 546 03 Thessaloniki, Greece
2 7 Anoikseos Street, 570 10 Thessaloniki, Greece. E-mail address: kena76@otenet.gr
3 3 Natalias Mela Street, 546 46 Thessaloniki, Greece
4 65 Olinthou Street, 543 51 Thessaloniki, Greece
5 138 Al. Papanastasiou Street, 542 49 Thessaloniki, Greece
6 8 25th Martiou Street, 552 36 Panorama, Thessaloniki, Greece
View Disclosures and Other Information
Disclosure: The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.
Investigation performed at Third Orthopaedic Department, Aristotle University of Thessaloniki Medical School, "Papageorgiou" General Hospital, Thessaloniki, Greece

The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2009 Dec 01;91(12):2775-2782. doi: 10.2106/JBJS.H.01434
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Abstract

Background: There are several methods to reduce anterior shoulder dislocations, but few studies have compared the efficacy, safety, and reliability of the different techniques. As a result, deciding which technique to use is seldom based on objective criteria. The aim of the present study was to introduce a new method to reduce an anterior shoulder dislocation, which we have termed "FARES" (Fast, Reliable, and Safe), and to compare it with the Hippocratic and Kocher methods in terms of efficacy, safety, and the intensity of pain felt by the patient during reduction.

Methods: Between September 2006 and June 2008, a total of 173 patients with an acute anterior shoulder dislocation (with or without a fracture of the greater tuberosity) were enrolled in the study. One hundred and fifty-four patients, who met all inclusion criteria, were randomly assigned to one of the three study groups (FARES, Hippocratic, and Kocher) and underwent reduction of the dislocation by first or second-year orthopaedic surgery residents. A visual analog scale was used to determine the intensity of the pain felt by the patient during reduction.

Results: Demographically, the groups were comparable in terms of age, male:female ratio, the mechanism of dislocation, and the mean time between the injury and the first attempt at reduction. Reduction was achieved with the FARES method in 88.7% of the patients, with the Hippocratic method in 72.5%, and with the Kocher method in 68%. This difference was significant, in favor of the FARES method (p = 0.033). The mean duration of the reduction maneuver was significantly shorter for the FARES method (2.36 ± 1.24 minutes for the FARES method, 5.55 ± 1.58 minutes for the Hippocratic method, and 4.32 ± 2.12 minutes for the Kocher method; p < 0.001), and the mean visual analog pain score was significantly lower for the FARES method (1.57 ± 1.43 for the FARES method, 4.88 ± 2.17 for the Hippocratic method, and 5.44 ± 1.92 for the Kocher method; p < 0.001). No complications were noted in any group.

Conclusions: The FARES method is a significantly more effective, faster, and less painful method of reduction of an anterior shoulder dislocation in comparison with the Hippocratic and Kocher methods. It is easily performed by only one physician, it is applicable to anterior shoulder dislocations as well as simple fracture-dislocations, and its use is associated with no more morbidity than that associated with the other two methods.

Level of Evidence: Therapeutic Level I. See Instructions to Authors for a complete description of levels of evidence.

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    Eustathios I. Kenanidis, MD
    Posted on August 23, 2010
    Dr. Sayegh and colleagues respond to Mr. Hassan and Mr. Tavakkolizadeh
    3rd Orthopaedic Dept., Aristotle University of Thessaloniki Medical School, Thessaloniki, Greece

    We thank Mr. Hassan for his interest in our recent article and we would like to make the following comments in response:

    1. This is an accurate and correct comment. We also use adequate sedation and analgesia in our everyday practice before attempting to reduce a dislocated shoulder. However, it is clearly stated in the Introduction section of our article (p 2776, left column, 3rd paragraph, lines 6-7) that the aim of this “...study was to introduce a new method of reduction of an acute anterior dislocation of shoulder...and to provide an objective comparison of this new method with the Hippocratic and Kocher methods in terms of efficacy, safety, and the intensity of pain felt by the patient during reduction.” Mr. Hassan would certainly agree that the administration of any analgesics or sedation and the subsequent potentially different response of each patient to this administration, would compromise our objectivity when trying to evaluate the pain felt by the patient during reduction. As far as the “lack of senior supervision” is concerned, the law in our country prohibits any medical practice performed by residents without adequate supervision by a consultant. Furthermore, all reductions were performed by the same team of first or second-year resident orthopaedic surgeons who had attended a brief instructional course prior to involvement in the study; hence success rates between the three methods could be compared. It is possible that, if consultant surgeons had performed the reductions, the success rates might have been higher for all three methods. Nevertheless, by performing this study we also wanted to prove that the FARES method could easily and adequately be performed by relatively inexperienced physicians.

    2. The application of gentle longitudinal traction obliterates the need to apply counter-traction as well. Traction without counter-traction has been used in other reduction techniques as well, such as the Milch (1) and the Spaso technique (2). We can assure Mr. Hassan that, after having reduced hundreds of dislocations with this method, there is not a single case of a patient who was “pulled off the bed” during the reduction maneuver.

    3. Following the instructions of the scientific research board at our institution and in order to minimize the patients’ discomfort and to be more accurate when evaluating the success rates of each method, only two attempts of reduction were allowed. As far as the “guidance from a more senior surgeon” is concerned, we feel that this point has already been addressed in paragraph 1.

    References

    1. Milch H. The treatment of recent dislocations and fracture-dislocations of the shoulder. J Bone Joint Surg Am. 1949;31:173-80.

    2. Miljesic S, Kelly AM. Reduction of anterior dislocation of the shoulder: the Spaso technique. Emerg Med. 1998;10:173-5.

    Amr Adel Abd Elaal Hassan
    Posted on August 02, 2010
    Shoulder Reduction Under No Analgesia?
    King's College Hospital, London, United Kingdom

    To the Editor:

    We read with interest the article, "Reduction of Acute Anterior Dislocations: A Prospective Randomized Study Comparing a New Technique with the Hippocratic and Kocher Methods", by Sayegh et al. (2009;91:2775-82). Whilst we congratulate the authors on the concept of their new technique, we have several queries:

    1). “No sedation or analgesics were used” for any of the patients and we are not sure of the reasons for this. In our experience of using the Kocher and the Hippocratic methods under adequate sedation and analgesia, it is very uncommon to fail in a closed reduction of an anterior dislocation. It seems that the techniques used had a lower than expected success rate and we feel that this is largely due to failure of administration of adequate analgesia and sedation and lack of senior supervision.

    2). The technique description suggests that during the reduction maneuver no counter traction was employed. There is also an emphasis on “continuous and brief short-range vertical oscillating movements” as a means of muscle relaxation. We feel with this technique, adequate counter traction is likely to be both helpful as well as safe to prevent the patient being pulled off the bed in particular in absence of any assistants.

    3). “Each physician was allowed to apply the same method of reduction twice; after that, the reduction was characterized as unsuccessful and the patient underwent further treatment under general anesthesia”. We are unclear as to the reasons for the two attempts only and not seeking advice and guidance from a more senior surgeon before taking the patient to theaters where a consultant then performed the procedure under general anesthesia?

    The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity.

    Eustathios I. Kenanidis, MD
    Posted on May 25, 2010
    Dr. Sayegh and colleagues respond to Dr. Sharma and colleagues
    Aristotle University of Thessaloniki Medical School, Thessaloniki, Greece

    To the Editor:

    We thank Dr. Sharma for his interest in our recent article (1) and we would like to make the following comments in response:

    The so-called “close resemblance” by Dr. Sharma of the FARES method of reduction with the Milch technique (2) and the forward elevation method which was introduced by Janecki et al. (3), have already been addressed both in our published paper (p. 2781, Discussion section, first paragraph) and in our response to Dr. Kerr’s Letter to the Editor (http://www.ejbjs.org/cgi/eletters/91/12/2775). We fail to understand the difference between the term “gentle longitudinal traction”, which was used in our published paper (p. 2778, Reduction Techniques section, first paragraph, line 9), and the term “gentle pull” which is preferred by Dr. Sharma. The application of longitudinal traction without counter-traction is not a novelty of the FARES technique (4). In fact it has been used in other reduction techniques as well, such as the Milch (2) and the Spaso technique (5). We agree with Dr. Sharma’s comment that there is currently no scientific basis that oscillatory motion is causing muscle relaxation. Nevertheless, we believe that this oscillatory motion does help achieving muscle relaxation and furthermore it allows the patient to realize from the moment this method is initiated that it is painless. The external rotation is “given” past 90° of abduction. It could certainly be applied from the beginning. However, it is our belief that this arch of 90° of gradual abduction without external rotation, allows the patient to feel at ease and further facilitates reduction. We agree with Dr. Sharma that “it is not only the method of reduction important, but also the way it is carried out”. We do claim and prove that the FARES method is fast, reliable and safe. We do not claim that the FARES method is the only fast, reliable and safe method existing. However, the results of the comparison between the FARES and the Hippocratic and Kocher methods were in favor of our method. Whether the Kocher method is the gold standard or not, remains to be further validated. Our study was a randomized one. We encourage Dr. Sharma to carefully read the section where this information is clearly stated (p. 2776, Materials and Methods section, third paragraph, lines 1-3). It is true that ligamentous laxity is an important parameter which may affect the ease of reduction. However, proper randomization of our patients obliterated the need to evaluate this parameter. As far as the question by Dr. Sharma regarding the methods of anesthesia which were used, it is clearly stated in the text that all reductions were performed without sedation, anesthesia, or pain control (p. 2776, Materials and Methods section, third paragraph, lines 18-19). The Milch technique is only described in order to differentiate it from the FARES technique (p. 2781, Discussion section, first paragraph). We did not use the Milch method of reduction in any of our patients. As far as the “small number of the patients” and the “low power” of the study are concerned, we encourage Dr. Sharma to study the Statistical Analysis section of our paper (p. 2777) where it is clearly explained that the number of patients that needed to be enrolled in order to reach statistically significant results was accurately pre-calculated. Regarding the number of re-dislocations, it is clearly stated in the Introduction section of our paper (p.2776, third paragraph) that “the aim of our study was to introduce a new method of reduction of an acute anterior dislocation of shoulder and to provide an objective comparison of this new method with the Hippocratic and Kocher methods in terms of efficacy, safety, and the intensity of pain felt by the patient during reduction”. Studying the number of re-dislocations would certainly be interesting. However, it was not an aim of our study. Finally, we do agree with Dr. Sharma that the FARES method has to achieve universal validation before it can be put into routine practice. However, the results so far are promising.

    References

    1. Sayegh FE, Kenanidis EI, Papavasiliou KA, Potoupnis ME, Kirkos JM, Kapetanos GA. Reduction of acute anterior dislocations: a prospective randomized study comparing a new technique with the Hippocratic and Kocher methods. J Bone Joint Surg Am. 2009;91:2775-82.

    2. Milch H. The treatment of recent dislocations and fracture-dislocations of the shoulder. J Bone Joint Surg Am. 1949;31:173-80.

    3. Janecki CJ, Shahcheragh GH. The forward elevation maneuver for reduction of anterior dislocations of the shoulder. Clin Orthop Relat Res. 1982;164:177-80.

    4. Ufberg JW, Vilke GM, Chan TC, Harrigan RA. Anterior shoulder dislocations: beyond traction-countertraction. J Emerg Med. 2004;27:301-6.

    5. Miljesic S, Kelly AM. Reduction of anterior dislocation of the shoulder: the Spaso technique. Emerg Med. 1998;10:173-5.

    Mrinal Sharma
    Posted on May 09, 2010
    Comments on the Article, "Reduction of Acute Anterior Dislocations..."
    University College of Medical Sciences, Delhi, India

    To the Editor:

    We read with interest the article by Sayegh et al. (1) on a new technique for reducing anterior shoulder dislocations. We also congratulate the authors for publishing a Level 1 study on the topic. However we have certain queries that we would like to be addressed by the authors.

    The method described has close resemblance to the Milch technique (2) and the forward elevation method given by Janecki et al. (3). We fail to understand how longitudinal traction can be applied without counter-traction to reduce the dislocation in a person who is not sedated since the majority would not relax their muscles, making the reduction difficult. Probably the word used should have been "gentle pull". Secondly, is there any scientific basis for oscillatory motion (that too at 2-3 cycles/second) causing muscle relaxation? Thirdly, how does it matter if external rotation is given initially along with the abduction or later in the over head position?

    The authors claim this method to be fast, reliable and safe. We have been using the Kocher method in our institution without sedation and have achieved prompt reduction without any complications. We believe that not only the method but also the way it is carried out is important. It still remains the gold standard (4). The authors missed out on ligamentous laxity in all their patients which is a major compounding factor that affects the results of the study. How were the patients allocated the methods of reduction under anesthesia (were they randomized)? Where did the need to include the Milch method arise? The power of the study is low. It lacks large numbers and long follow-up. How many of them re-dislocated? The method has to achieve universal validation before it can be put into routine practice.

    The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity.

    References

    1. Sayegh FE, Kenanidis EI, Papavasiliou KA, Potoupnis ME, Kirkos JM, Kapetanos GA. Reduction of acute anterior dislocations: a prospective randomized study comparing a new technique with the Hippocratic and Kocher methods. J Bone Joint Surg Am. 2009;91:2775-82.

    2. Milch H. The treatment of recent dislocations and fracture-dislocations of the shoulder. J Bone Joint Surg Am. 1949;31:173-80.

    3. Janecki CJ, Shahcheragh GH. The forward elevation maneuver for reduction of anterior dislocations of the shoulder. Clin Orthop Relat Res. 1982;164:177-80.

    4. Uglow MG. Kocher's painless reduction of anterior dislocation of the shoulder: a prospective randomised trial. Injury. 1998;29:135-7.

    Eustathios I. Kenanidis, MD
    Posted on January 25, 2010
    Dr. Sayegh and colleagues respond to Dr. Garnavos
    3rd Orthopaedic Department -Aristotle University of Thessaloniki, Thessaloniki, Greece

    We thank Dr. Garnavos for his interest in our recent article (1) and we would like to make the following comments in response: We would like to congratulate Dr. Garnavos on his publication (2) and we share his enthusiasm for the significant recognition it subsequently received. It is true that we probably should have cited his article as well, and we apologize for not having done so. However, we cannot accept his accusations that we deliberately chose not to cite it. Although he briefly mentions it in his letter, Dr. Garnavos seems to miss the point that this (1) was a prospective randomized trial comparing three methods of reduction. We did not write a review article concerning the reduction techniques of anterior shoulder dislocation, we did not write a technical note on a new method of reduction, and we certainly made every effort to cite all relevant literature. Complaining for not citing his article is one thing.

    Claiming that the FARES method of reduction (1) is similar to Dr. Garnavos’ method (2) is a completely different issue. We do not claim any patency for our method but we do believe it is original, and we strongly encourage Dr. Garnavos to also read our response to Dr. Kerr’s Letter to the Editor concerning that issue. Furthermore, we strongly disagree with Dr. Garnavos’ statement “…that the only difference between the two techniques is the pendulum movement during reduction”. The FARES technique is not a modification of Dr. Garnavos’ technique. It is true that the FARES method and Dr. Garnavos’ modification of the Milch’s technique to reduce anterior shoulder dislocations share certain similarities. This is not at all unexpected, since abduction and external rotation maneuvers of the arm are frequently implied in most reduction techniques. This is probably the reason why our article’s Figures 3 and 4 are similar to Dr. Garnavos’ Figures 2 and 3 respectively. However, we cannot find any similarities between the remaining Figures (1 and 4) of Dr. Garnavos’ article and our article’s Figures 2 and 5. After carefully reading Dr. Garnavos article (2) we detected the following important differences between the two methods:

    1. In Dr. Garnavos’ modification of the Milch’s technique (2) the elbow of the patient is initially flexed. In the FARES technique (1) the elbow is extended during the whole procedure.

    2. In Dr. Garnavos’ technique (2) the surgeon initially “…places his or her free hand on the patient’s affected arm”. In the FARES technique, the physician holds the patient’s hand with both of his/her hands.

    3. In Dr. Garnavos’ technique (2) “…the traction must be increased gradually after the abduction has been achieved”. In the FARES technique, gentle traction starts at the beginning of the reduction maneuver and before abducting the arm.

    4. In Dr. Garnavos’ technique (2) “…pressure on the head of the humerus, when necessary, should be applied with all the fingers…’. In the FARES technique, pressure on the humeral head is never applied.

    5. In Dr. Garnavos’ technique (2) “…the surgeon pushes the humeral head back into the glenoid…”. In the FARES technique, this is not done.

    Last but not least, we believe that the “…so called pendulum movement during reduction” that Dr. Garnavos refers to is an important feature of the FARES reduction technique that helps achieving muscle relaxation rendering this new method less painful and more efficient.

    References

    1. Sayegh FE, Kenanidis EI, Papavasiliou KA, Potoupnis ME, Kirkos JM, Kapetanos GA. Reduction of acute anterior dislocations: a prospective randomized study comparing a new technique with the Hippocratic and Kocher methods. J Bone Joint Surg Am. 2009;91:2775-82.

    2. Garnavos C. Technical note: modifications and improvements of the Milch technique for the reduction of anterior dislocation of the shoulder without premedication. J Trauma. 1992;32:801-3.

    Christos Garnavos
    Posted on January 11, 2010
    Modifications and Improvements of Milch Technique
    NULL

    To the Editor:

    With great interest I have read the recent article by Sayegh et al. (1). I would like to congratulate the authors on completing a prospective randomized comparative study between different reduction techniques of anterior shoulder dislocations. They have provided Level 1 evidence on a debatable issue. However, on parallel, the authors claim that they introduce a new reduction technique, and use an abbreviation (FARES), which is also the first name of the first author. Your journal has already received a letter addressed to the Editor and to the authors by Dr. Douglas Kerrr, MD, expressing his reservations about the originality of the introduced FARES technique.

    Dr. Sayegh and co-authors chose to include in their references three studies (2-4) where the modifications and improvements of Milch’s original technique are discussed and referenced. These studies refer to the “Technical Note: Modifications and Improvements of Milch’s technique” as described in 1992 (5). In the manuscript of 1992, there are 4 sketches from which a complete replication in the form of photographs are the 3 figures of the article of Sayegh et al.

    The only difference between the FARES method and the 1992 Milch’s modified technique is the so-called “pendulum” movement during reduction. I leave it on your discretion if this pendulum movement during the reduction maneuver could be considered an important addition to justify the title of a “New Technique” that Sayegh et al. claim.

    Furthermore, the authors of the recently published randomized trial chose did not refer to the technical note from 1992. That article has received significant recognition, having been cited 20 times in scientific articles (Scopus) and 6 times in international textbooks dealing with trauma (including the Wheeless' Textbook of Orthopaedics on the internet).

    I would have expected that experienced reviewers of the well respected American edition of the Journal of Bone and Joint Surgery would have prevented Sayegh et al. from claiming the patency of a reduction technique which, to the greatest extent, is already published in a well respected English language journal as a modification of the original method of Milch.

    I would highly appreciate the Editors comments and justifications as well as the Authors reply. In anticipation...

    The author did not receive any outside funding or grants in support of his research for or preparation of this work. Neither he nor a member of his immediate family received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the author, or a member of his immediate family, is affiliated or associated.

    References

    1. Sayegh FE, Kenanidis EI, Papavasiliou KA, Potoupnis ME, Kirkos JM, Kapetanos GA. Reduction of acute anterior dislocations: a prospective randomized study comparing a new technique with the Hippocratic and Kocher methods. J Bone Joint Surg Am. 2009;91:2775-82.

    2. Eachempati KK, Dua A, Malhotra R, Bhan S, Bera JR. The external rotation method for reduction of acute anterior dislocations and fracture-dislocations of the shoulder. J Bone Joint Surg Am. 2004;86:2431-4.

    3. Ufberg J W, Vilke GM, Chan TC, Harrigan RA. Anterior shoulder dislocations: beyond traction-countertraction. J Emerg Med. 2004;27:301-6.

    4. Ugras AA, Mahirogullari M, Kural C, Erturk AH, Cakmak S. Reduction of anterior shoulder dislocations by Spaso technique: clinical results. J Emerg Med, 2008;34:383-7.

    5. Garnavos C. Technical note: modifications and improvements of the Milch technique for the reduction of anterior dislocation of the shoulder without premedication. J Trauma. 1992;32:801-3.

    Eustathios I. Kenanidis, MD
    Posted on December 21, 2009
    Dr. Sayegh and colleagues respond to Dr. Kerr
    3rd Orthopaedic Department -Aristotle University of Thessaloniki, Thessaloniki, Greece

    We thank Dr. Kerr for his interest in our recent article (1) and we would like to make the following comments in response: It is true that the method of reduction which is described in the article published by Janecki and Shahcheragh (2) uses a slightly different technique to position the arm in the same final position as the FARES method prior to reduction. However, there are some other differences between the two methods as well. The application of continuous vertical oscillation on the arm with the FARES method (as a means to achieve muscle relaxation) is one. The need to internally rotate the arm with gentle pressure applied to the humeral head by the surgeon’s thumb in cases of incomplete reduction with the forward elevation method is another (2). Last but not least is the use of medication in a substantial number of patients, before attempting reduction with the forward elevation method. Nevertheless, as far as the last difference is concerned, it is our feeling that the forward elevation method as well could certainly be applied without the use of medication. Regardless of any differences between the two methods and the fact that the original Milch method (3) is cited and discussed in our article, we recognize that the forward elevation method, as presented by Janecki and Shahcheragh, should probably have been cited as well. We apologize for this.

    References

    1. Sayegh FE, Kenanidis EI, Papavasiliou KA, Potoupnis ME, Kirkos JM, Kapetanos GA. Reduction of acute anterior dislocations: a prospective randomized study comparing a new technique with the Hippocratic and Kocher methods. J Bone Joint Surg Am. 2009;91:2775-82.

    2. Janecki CJ, Shahcheragh GH. The forward elevation maneuver for reduction of anterior dislocations of the shoulder. Clin Orthop Relat Res. 1982;164:177-80.

    3. Milch H. The treatment of recent dislocations and fracture-dislocations of the shoulder. J Bone Joint Surg Am. 1949;31:173-80.

    Douglas Kerr, MD
    Posted on December 03, 2009
    Forward Elevation Maneuver
    Upstate Medical University, Syracuse, New York

    To the Editor:

    After reviewing the article by Sayegh et al. (1), I was reminded of another similar reduction method published by Janecki and Shahcheragh (2). It uses a slightly different method to position the arm in the same position as the FARES method prior to reduction. This has been my preferred reduction method. It was not cited by the authors.

    The author did not receive any outside funding or grants in support of his research for or preparation of this work. The author, or a member of his immediate family, received, in any one year, payments or other benefits in excess of $10,000 or a commitment or agreement to provide such benefits from a commercial entity (Stryker Orthopedics). No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the author, or a member of his immediate family, is affiliated or associated.

    References

    1. Sayegh FE, Kenanidis EI, Papavasiliou KA, Potoupnis ME, Kirkos JM, Kapetanos GA. Reduction of acute anterior dislocations: a prospective randomized study comparing a new technique with the hippocratic and kocher methods. J Bone Joint Surg Am. 2009;91:2775-82.

    2. Janecki CJ, Shahcheragh GH. The forward elevation maneuver for reduction of anterior dislocations of the shoulder. Clin Orthop Relat Res. 1982;164:177-80.

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