Delayed Onset Nodules After Hyaluronic Acid Fillers: A Case Series.

Non-surgical techniques with hyaluronic acid fillers to rejuvenate face are very popular treatment due to ease of administration and achievement of faster improvement. Although they are considered to be safe procedures, few rare adverse effects have been reported in literatures. The number of these cosmetic procedures being performed is increasing every year. Simultaneously, the rate of filler complications has also increased. This case series presents three clinical cases of delayed onset nodules after hyaluronic acid fillers after 1-5 months post-procedure. Juvederm Volift was used in all the mentioned patients. Granulomatous reactions can occur with any of the hyaluronic acid fillers. These are generally localized immunological reactions. An awareness about these rare side effects helps us in the assessment and ensurance of accurate diagnosis and treatment.

COVID-19 infection, and reinfection, and vaccine effectiveness against symptomatic infection among health care workers in the setting of omicron variant transmission in New Delhi, India.

Background: Surge of SARS CoV-2 infections ascribed to omicron variant began in December 2021 in New Delhi. We determined the infection and reinfection density in a cohort of health care workers (HCWs) along with vaccine effectiveness (VE) against symptomatic infection within omicron transmission period (considered from December 01, 2021 to February 25, 2022. Methods: This is an observational study from the All India Institute of Medical Sciences, New Delhi. Data were collected telephonically. Person-time at risk was counted from November 30, 2021 till date of infection/ reinfection, or date of interview. Comparison of clinical features and severity was done with previous pandemic periods. VE was estimated using test-negative case-control design [matched pairs (for age and sex)]. Vaccination status was compared and adjusted odds ratios (OR) were computed by conditional logistic regression. VE was estimated as (1-adjusted OR)X100-. Findings: 11474 HCWs participated in this study. The mean age was 36⋅2 (±10⋅7) years. Complete vaccination with two doses were reported by 9522 (83%) HCWs [8394 (88%) Covaxin and 1072 Covishield (11%)]. The incidence density of all infections and reinfection during the omicron transmission period was 34⋅8 [95% Confidence Interval (CI): 33⋅5-36⋅2] and 45⋅6 [95% CI: 42⋅9-48⋅5] per 10000 person days respectively. The infection was milder as compared to previous periods. VE was 52⋅5% (95% CI: 3⋅9-76⋅5, p = 0⋅036) for those who were tested within 14-60 days of receiving second dose and beyond this period (61-180 days), modest effect was observed. Interpretation: Almost one-fifth of HCWs were infected with SARS CoV-2 during omicron transmission period, with predominant mild spectrum of COVID-19 disease. Waning effects of vaccine protection were noted with increase in time intervals since vaccination. Funding: None.

SARS-CoV-2 Reinfection Rate and Estimated Effectiveness of the Inactivated Whole Virion Vaccine BBV152 Against Reinfection Among Health Care Workers in New Delhi, India.

Importance: A surge of COVID-19 occurred from March to June 2021, in New Delhi, India, linked to the B.1.617.2 (Delta) variant of SARS-CoV-2. COVID-19 vaccines were rolled out for health care workers (HCWs) starting in January 2021. Objective: To assess the incidence density of reinfection among a cohort of HCWs and estimate the effectiveness of the inactivated whole virion vaccine BBV152 against reinfection. Design, Setting, and Participants: This was a retrospective cohort study among HCWs working at a tertiary care center in New Delhi, India. Exposures: Vaccination with 0, 1, or 2 doses of BBV152. Main Outcomes and Measures: The HCWs were categorized as fully vaccinated (with 2 doses and ≥15 days after the second dose), partially vaccinated (with 1 dose or 2 doses with <15 days after the second dose), or unvaccinated. The incidence density of COVID-19 reinfection per 100 person-years was computed, and events from March 3, 2020, to June 18, 2021, were included for analysis. Unadjusted and adjusted hazard ratios (HRs) were estimated using a Cox proportional hazards model. Estimated vaccine effectiveness (1 - adjusted HR) was reported. Results: Among 15 244 HCWs who participated in the study, 4978 (32.7%) were diagnosed with COVID-19. The mean (SD) age was 36.6 (10.3) years, and 55.0% were male. The reinfection incidence density was 7.26 (95% CI: 6.09-8.66) per 100 person-years (124 HCWs [2.5%], total person follow-up period of 1696 person-years as time at risk). Fully vaccinated HCWs had lower risk of reinfection (HR, 0.14 [95% CI, 0.08-0.23]), symptomatic reinfection (HR, 0.13 [95% CI, 0.07-0.24]), and asymptomatic reinfection (HR, 0.16 [95% CI, 0.05-0.53]) compared with unvaccinated HCWs. Accordingly, among the 3 vaccine categories, reinfection was observed in 60 of 472 (12.7%) of unvaccinated (incidence density, 18.05 per 100 person-years; 95% CI, 14.02-23.25), 39 of 356 (11.0%) of partially vaccinated (incidence density 15.62 per 100 person-years; 95% CI, 11.42-21.38), and 17 of 1089 (1.6%) fully vaccinated (incidence density 2.18 per 100 person-years; 95% CI, 1.35-3.51) HCWs. The estimated effectiveness of BBV152 against reinfection was 86% (95% CI, 77%-92%); symptomatic reinfection, 87% (95% CI, 76%-93%); and asymptomatic reinfection, 84% (95% CI, 47%-95%) among fully vaccinated HCWs. Partial vaccination was not associated with reduced risk of reinfection. Conclusions and Relevance: These findings suggest that BBV152 was associated with protection against both symptomatic and asymptomatic reinfection in HCWs after a complete vaccination schedule, when the predominant circulating variant was B.1.617.2.

Hair Transplant Practice Guidelines.

The field of hair transplant (HT) has grown exponentially in the past decade, especially after the introduction of follicular unit excision (FUE). There is much variation in criteria for case selection, the technique, pre- and post-procedure protocols, by different surgeons. Techniques continue to evolve and evidence in the form of controlled data is not available for all techniques and protocols being used; there is also a debate as to who can do what, what should be the training for staff, role of technicians. This has led to a situation wherein medico legal issues have cropped up as to what is minimum acceptable. An attempt is made to summarize standard protocols with the available evidence. It is emphasized that the objective of these guidelines is to recommend minimum standards for practice of hair transplantation. The principles outlined in these guidelines are of a general nature only, minimal in their level and are not meant to cover all situations. It should be understood that these recommendations are by no means binding and universal, represent minimum standards only and as in all surgical techniques, variations in techniques are possible. It is also further clarified that these are based on current literature, and as science evolves, these guidelines could also change in future. Where published evidence is not available, consensus expert opinion is presented. The task force emphasizes that each patient has to be treated on his/her own merit and that these guidelines do not limit the physician from making an appropriate choice or the necessary innovation for a given patient. The task force recognizes that the treating surgeon is best suited to decide what is needed for a given patient in a given situation. Innovations in medicine need flexibility in approach and these guidelines do not limit the surgeon from undertaking innovative research.

Beard and Moustache Reconstruction.

Beard and moustache reconstruction has gained more popularity and acceptance over the last decade. The procedure is done for the correction of facial areas with hair density deficit and also for the cosmetic enhancement of pre-existing facial hair. The surgical technique includes the harvesting of grafts from the scalp by the follicular unit excision (FUE) or follicular unit transplantation (FUT) technique and then placing them in either premade slits or by stick and place method. The advancement and refinement of procedure over the years has aided in achieving the optimal aesthetic results, with minimal side effects.

Our Fight Against the Rapidly Evolving COVID-19 Pandemic: A Review of India's Actions and Proposed Way Forward.

A new strain of coronavirus named severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has overwhelmed the world with its rapid spread and high number of cases. SARS-CoV-2 causes COVID-19 disease which may present with mild, moderate, or severe illness. In severe cases, pneumonia, acute respiratory distress syndrome, sepsis, and septic shock can occur. Individuals above 60 years and people with preexisting comorbidities are at higher risk for developing serious complications. The incubation period of this new pathogen ranges from 1 to 14 days and there is no preexisting immunity to the disease. Countries across the globe have adopted various prevention and control measures to minimize negative health impacts. India has adopted various public health measures which include social distancing measures, nationwide lockdown to reduce risk of exposure, widespread IEC messaging regarding hand-washing, usage of masks, and recommending avoidance of unnecessary travel to combat the spread of disease. This manuscript reviews the global situation, contextualizes India's disease control efforts, and outlines the possible way forward by identifying specific actions under the following headings: enhancing district preparedness, enabling care for patients, and broadening community and stakeholder engagement for India.

A Case Report on Use of Cog Threads and Dermal Fillers for Facial-Lifting in Facioscapulohumeral Muscular Dystrophy.

Long-standing facial paralysis induces degenerative facial muscle changes on the involved side, thus making the individual seem older than their actual age. Furthermore, contralateral facial hypertrophy aggravates facial asymmetry (Sulamanidze MA, Fournier PF, Paikidze TG, Sulamanidze GM. Removal of facial soft tissue ptosis with special threads. Dermatol Surg 2002;28:367-71). The introduction of absorbable barbed thread has proved to be a good alternative for treating facial asymmetry. It also allows the association with other nonsurgical procedures, such as botulinum toxin use and/or dermal fillers in facial remodeling (Atiyeh BS, Dibo SA, Costagliola M, Hayek SN. Barbed sutures "lunch time" lifting: evidence-based efficacy. J Cosmet Dermatol 2010;9:132-41 and Kaminer MS, Bogart M, Choi C, Wee SA. Long-term efficacy of anchored barbed sutures in the face and neck. Dermatol Surg 2008;34:1041-7.). The aim of the treatment (threads) of the mid and lower third of the face was to promote the mechanical effect (lifting) and biological effect (neocollagenesis) with the improvement of the nasolabial folds, jaw, and jawbone contour.

Donor Harvesting: Strip Dissection.

Hair transplant is a constantly evolving science. From the time that it was conceived by Dr. Norman Orentreich to the present state, the procedure of hair transplant has undergone multiple advancements. In this article, we discuss in brief regarding the strip follicular unit transplantation. We summarize the major points regarding the procedure of strip follicular unit transplantation along with some nuggets of experience that we have gathered over time. We briefly deal with the indications, anesthesia, procedure, and complications of strip follicular unit transplantation and some special scenarios like the repeat excision of strip.

Haemodynamic-guided fluid administration for the prevention of contrast-induced acute kidney injury: the POSEIDON randomised controlled trial.

BACKGROUND: The administration of intravenous fluid remains the cornerstone treatment for the prevention of contrast-induced acute kidney injury. However, no well-defined protocols exist to guide fluid administration in this treatment. We aimed to establish the efficacy of a new fluid protocol to prevent contrast-induced acute kidney injury. METHODS: In this randomised, parallel-group, comparator-controlled, single-blind phase 3 trial, we assessed the efficacy of a new fluid protocol based on the left ventricular end-diastolic pressure for the prevention of contrast-induced acute kidney injury in patients undergoing cardiac catheterisation. The primary outcome was the occurrence of contrast-induced acute kidney injury, which was defined as a greater than 25% or greater than 0·5 mg/dL increase in serum creatinine concentration. Between Oct 10, 2010, and July 17, 2012, 396 patients aged 18 years or older undergoing cardiac catheterisation with an estimated glomerular filtration rate of 60 mL/min per 1·73 m(2) or less and one or more of several risk factors (diabetes mellitus, history of congestive heart failure, hypertension, or age older than 75 years) were randomly allocated in a 1:1 ratio to left ventricular end-diastolic pressure-guided volume expansion (n=196) or the control group (n=200) who received a standard fluid administration protocol. Four computer-generated concealed randomisation schedules, each with permuted block sizes of 4, were used for randomisation, and participants were allocated to the next sequential randomisation number by sealed opaque envelopes. Patients and laboratory personnel were masked to treatment assignment, but the physicians who did the procedures were not masked. Both groups received intravenous 0·9% sodium chloride at 3 mL/kg for 1 h before cardiac catheterisation. Analyses were by intention to treat. Adverse events were assessed at 30 days and 6 months and all such events were classified by staff who were masked to treatment assignment. This trial is registered with ClinicalTrials.gov, number NCT01218828. FINDINGS: Contrast-induced acute kidney injury occurred less frequently in patients in the left ventricular end-diastolic pressure-guided group (6·7% [12/178]) than in the control group (16·3% [28/172]; relative risk 0·41, 95% CI 0·22-0·79; p=0·005). Hydration treatment was terminated prematurely because of shortness of breath in three patients in each group. INTERPRETATION: Left ventricular end-diastolic pressure-guided fluid administration seems to be safe and effective in preventing contrast-induced acute kidney injury in patients undergoing cardiac catheterisation. FUNDING: Kaiser Permanente Southern California regional research committee grant.

Barriers to surgery in severe aortic stenosis patients with Class I indications for aortic valve replacement.

BACKGROUND AND AIM OF THE STUDY: Despite a dismal natural history of severe aortic stenosis (AS) in patients with symptoms, there is a high non-surgical rate. The study aim was to analyze in detail the decision-making process for aortic valve replacement (AVR) that follows the diagnosis of severe AS with Class I indications, in order to identify the barriers to surgery. METHODS: A total of 187 consecutive patients (105 men, 82 women; mean age 74 +/- 14 years) with severe AS, defined as aortic valve area (AVA) <1.0 cm2, was evaluated. Detailed reviews were performed for patient symptoms, and actions by physicians. The sources and reasons for non-surgical management were analyzed. RESULTS: The mean AVA was 0.72 +/- 0.19 cm2 and the left ventricular ejection fraction 54 +/- 21%. A Class I indication for AVR was present in 174 patients (93%), of whom 125 (72%) were referred for AVR, which was performed in 93 cases (53%). The reasons for no AVR (n = 81) were patient refusal in 29 cases (36%), comorbidities in 28 (35%), while in 19 patients (23%) the AS was considered as 'not severe', despite being categorized as severe by ACC/AHA guidelines. The predominant factors in making the non-surgical decision were the patient or family (36%), the cardiologist (33%), and the surgeon (21%). CONCLUSION: Class I indications for AVR are present in most patients with severe AS referred for echocardiography to a tertiary care center. Despite a Class I indication, the non-surgical rate remains high and attributable to patient reluctance, comorbidities and physician reluctance to offer AVR. It is speculated that patient discussions of the dismal natural history of severe AS and the major benefit of AVR, preferably conducted within a specialized valve clinic set-up, may help to improve the surgical rates.

Closed reduction and percutaneous pinning of displaced supracondylar fractures of humerus in children with delayed presentation.

OBJECTIVE: Supracondylar fractures of the humerus account for 60% of all the fractures around the pediatric elbow and even in developed countries 18% of patients undergo surgery 48 hours or longer following presentation in the hospital. Management guidelines are not clear yet for these patients who present late. The aim of this prospective study was to evaluate the clinical, radiological and functional outcome following closed reduction and percutaneous pinning of widely displaced supracondylar fractures of the humerus presenting 12 hours or more after injury. METHODS: We reviewed the functional and radiological results of closed reduction and percutaneous pinning using crossed K-wires in 40 patients with displaced extension type supracondylar fracture of the humerus (Gartland type III) with a delay of more than 12 hours in presentation. The average age of patients was 4.5 years and the mean delay in presentation was 17.55 hours. RESULTS: Closed reduction and percutaneous pinning was successful in 90% of patients. The mean follow up period was 15 months. The Baumann's angle was restored within 4 degrees of the unaffected side in all patients. Use of a small medial incision in patients with severe swelling helped us avoid ulnar nerve injury. Using Flynn's criteria, 38 patients (95%) had an excellent result. Two patients had mild myositis and both had a poor result. None of the patients developed cubitus varus. CONCLUSION: Closed reduction and crossed pinning of displaced supracondylar fractures of humerus in children is a safe and effective method even with delayed presentation.

Left ventricular pseudoaneurysm due to embolic myocardial infarction in infective endocarditis: real time three-dimensional transesophageal echocardiographic evaluation.

We report a case of a 63-year-old woman who presented with infective endocarditis and developed a pseudoaneurysm (PA) of the left ventricle presumably as a result of an embolic infarct. The diagnosis was made by typical features of PA on tranesophageal echocardiography and color Doppler studies. In addition, three-dimensional transesophageal echocardiography showed the narrow neck of the PA. Findings were confirmed at surgery and she was discharged after successful repair.

Follicular unit extraction hair transplant.

Hair transplantation has come a long way from the days of Punch Hair Transplant by Dr. Orentreich in 1950s to Follicular Unit Hair Transplant (FUT) of 1990s and the very recent Follicular Unit Extraction (FUE) technique. With the advent of FUE, the dream of 'no visible scarring' in the donor area is now looking like a possibility. In FUE, the grafts are extracted as individual follicular units in a two-step or three-step technique whereas the method of implantation remains the same as in the traditional FUT. The addition of latest automated FUE technique seeks to overcome some of the limitations in this relatively new technique and it is now possible to achieve more than a thousand grafts in one day in trained hands. This article reviews the methodology, limitations and advantages of FUE hair transplant.

Bicondylar Hoffa fracture: open reduction internal fixation using the swashbuckler approach.

Coronal plane fractures of the femoral condyle are infrequent injuries and are often missed. Unilateral bicondylar coronal plane fractures are even rarer, with only eight reported cases in scientific literature, and are often associated with other injuries. We present here a case of unilateral bicondylar Hoffa fracture that presented in our emergency department and was managed with open reduction and internal fixation by lateral parapatellar arthrotomy using the swashbuckler approach with satisfactory results.

Acetabular reconstruction using fresh frozen bone allograft.

The success of total hip arthroplasty has led to a move toward operating on a wider and younger population. All implants have a finite useful life, and bone loss is associated with all major causes of failure. The use bone allograft, either morselized or structural has the aim of reconstituting the bone stock. We retrospectively reviewed the clinical and radiological results of 72 acetabular reconstructions both primary and revision, done at our institute between May 1999 and October 2004 with a minimum follow-up of one year. The Harris Hip Score (HHS) was calculated and follow-up radiographs were evaluated for graft incorporation; evidence of loosening and migration. Preoperatively 28 acetabular defects were type III (AAOS), 18 were type II, 16 were type I and 10 were type IV. 60 reconstructions were done using cementless acetabular prostheses, and the remaining twelve had cemented implants. Patients were followed up for an average of 30.69 months (range 12 - 64 months). The mean preoperative HHS was 36.13 points which improved to a mean of 81.6 points (range 61 to 91) at final follow-up. None of the patients required reoperation. Dislocation was the commonest complication (8 hips). Short and medium term results were encouraging with the use of this technique.

Femoral revision using long hydroxyapatite-coated interlocking stem.

INTRODUCTION: Cementless femoral revision has become increasingly popular because the cementless implants provide the potential for long-term biologic implant fixation. The IOTA interlocking femoral stem is a hydroxyapatite-coated stem with the option of interlocking the stem distally. The aim of the current study was to evaluate the short-term results of IOTA interlocking stem. MATERIALS AND METHODS: We retrospectively reviewed the results of 18 total hip arthroplasties in 17 patients performed between July 2002 and 2004 using the IOTA interlocking stem. In-patient records were retrieved and in addition to demographic data the indication for revision, the preoperative and postoperative Harris Hip scores, need for allografts were noted. The bone deficiency was classified based on the AAOS classification. Intraoperative complications and problems if any were retrieved from the authors' operative notes. Radiographs at the final follow up were evaluated by the criteria described by Engh et al. (Clin Orthop 257:107-128, 1990) RESULTS: Average age at the time of revision was 57 years. Preoperatively five femora showed type I deficiency, type II deficiency was seen in three, type III in nine and type IV deficiency in one femur. In five hips the calcar replacing prosthesis was implanted to manage the proximal calcar defect, in one hip allograft was used to reconstruct the calcar. One patient sustained intraoperative fracture of the shaft of the femur while implanting the trial prosthesis and one patient had a perforation of the posterior cortex of femur while trying to remove the cement. The mean follow up period was 33.5 months (range 27-45 months). The mean preoperative Harris Hip score was 36 (range 23-50), which improved to 77 (range 68-92) at the time of final follow up. None of the stems required revision and at minimum 27 months follow up, bony ingrowth was noted in 83.33% of the stems. CONCLUSION: IOTA interlocking stem has shown promising short-term results for femoral revisions. The advantages are initial axial and rotational stability and consistent bony in growth owing to hydroxyapatite coating. Intraoperative fracture is a potential drawback because of the straight nature of the stem. The calcar replacing option of the stem is especially useful in patients with deficient calcar as a substitute for the allograft.

Endoscopic versus open carpal tunnel release: A short-term comparative study.

OBJECTIVE: To compare the results of endoscopic carpal tunnel release (CTR) with open CTR in patients with idiopathic Carpal tunnel syndrome (CTS). MATERIALS AND METHODS: Seventy-one patients with CTS were enrolled in a prospective randomized study from May 2003 to December 2005. All patients had clinical signs or symptoms and electro-diagnostic findings consistent with carpal tunnel syndrome and had not responded to nonoperative management. Sixty-one cases were available for follow-up. Endoscopic CTR was performed in 30 CTS patients and open CTR was performed in 31 wrists (30 patients). Various parameters were evaluated, including each patient's symptom amelioration, complications, operation time, time needed to resume normal lifestyle and the frequency of revision surgery. All the patients were followed up for six months. RESULTS: During the initial months after surgery, the patients treated with the endoscopic method were better symptomatically and functionally. Local wound problems in terms of scarring or scar tenderness were significantly more pronounced in patients undergoing open CTR compared to patients undergoing endoscopic CTR. Average delay to return to normal activity was appreciably less in group undergoing endoscopic CTR. No significant difference was observed between the endoscopic CTR group and open CTR group in regard to symptom amelioration, electromyographic testing and complications at the end of six months. CONCLUSION: Short-term results were better with the endoscopic method as there was no scar tenderness. Results at six months were comparable in both groups.

An experimental model for the study of lymphedema and its response to therapeutic lymphangiogenesis.

BACKGROUND: Evaluation of the efficacy of molecular treatment strategies for lymphatic vascular insufficiency requires a suitable preclinical animal model. Ideally, the model should closely replicate the untreated human disease in its pathogenesis and pathological expression. OBJECTIVE: We have undertaken a study of the time course of the development and resolution of acquired, experimental lymphedema and of its responses to vascular endothelial growth factor (VEGF)-C lymphangiogenesis in the mouse tail model. STUDY DESIGN: We provoked post-surgical lymphedema in the mouse tail model and assessed the effects of exogenously administered human recombinant VEGF-C. Quantitative assessment of immune traffic function was performed through sequential in vivo bioluminescent imaging. RESULTS: In untreated lymphedema, tail edema was sustained until day 21. Exogenous administration of human recombinant VEGF-C produced a significant decrease in volume. Untreated lymphedema in the mouse tail model was characterized by the presence of dilated cutaneous lymphatics, marked acute inflammatory changes, and hypercellularity; VEGF-C produced a substantial reversion to the normal pattern, with notable regression in the size and number of cutaneous lymphatic vessels that express lymphatic vessel endothelial hyaluronan receptor-1 (LYVE-1). In vivo imaging confirmed the presence of an impairment of immune traffic in lymphedema that was ameliorated after VEGF-C administration. CONCLUSION: The post-surgical murine tail model of lymphedema closely simulates attributes of human lymphedema and provides the requisite sensitivity to detect therapeutically induced functional and structural alterations. It can, therefore, be used as an investigative platform to assess mechanisms of disease and its responses to candidate therapies, such as therapeutic lymphangiogenesis.

Dome osteotomy for posttraumatic cubitus varus: a surgical technique to avoid lateral condylar prominence.

The indication for surgery in most children with posttraumatic cubitus varus is the presence of an unsightly deformity. The function of the limb is generally not impaired. Lateral closing-wedge supracondylar osteotomy, although a widely used corrective procedure, tends to produce lateral condylar prominence, thus jeopardizing the cosmetic outcome. The authors used the dome supracondylar osteotomy, as described by Tien et al, as the corrective procedure for cubitus varus in 12 consecutive children. The average follow-up was 2.3 (range 1-4) years. The objective evaluation was done by one of the authors by measuring the pre- and postoperative lateral condylar prominence index, carrying angle, and the range of movement at the elbow. The patients and parents were also asked to self-assess the cosmetic outcome. There were seven excellent and five good results. None of the children showed a prominent lateral humeral condyle. Hypertrophic scar formation and ulnar neurapraxia were seen in one patient each. These results were comparable to the published results of lateral closing-wedge osteotomy in terms of correction of carrying angle and preservation of elbow motion and were superior to those of the lateral closing-wedge osteotomy in terms of the prominence of lateral humeral condyle, acceptability of the scar, and cosmesis. The authors offer independent verification of the observation that the technique of dome osteotomy as described by Tien et al for the correction of the posttraumatic cubitus varus is a simple, safe, and technically sound procedure that prevents the lateral condyle from becoming prominent and yields an excellent cosmetic outcome.

The external rotation method for reduction of acute anterior dislocations and fracture-dislocations of the shoulder.

BACKGROUND: Several methods of reducing an acute anterior dislocation of the shoulder have been described. The aim of this study was to assess the effectiveness of the external rotation method in the reduction of acute anterior shoulder dislocations with and without fractures of the greater tuberosity and to evaluate the causes of failure. METHODS: Senior and junior orthopaedic residents attending in the Emergency Department were instructed in the external rotation method for the reduction of a shoulder dislocation in a classroom setting. Forty patients with an acute anterior dislocation of the shoulder, with or without an associated fracture of the greater tuberosity, who were treated with this method were evaluated prospectively. Data sheets completed by the orthopaedic residents when this method was used were evaluated with regard to the type of dislocation, the effectiveness of the procedure in achieving reduction, the need for premedication, the ease of performing the reduction, and complications, if any. RESULTS: Of the forty patients, thirty-six had a successful reduction. No premedication was required in twenty-nine patients who had a successful reduction, and the average time required for reduction in twenty patients was less than two minutes. Only four patients reported severe pain during the process of reduction. The method was not successful in four patients, two of whom had a displaced fracture of the greater tuberosity. CONCLUSIONS: The external rotation method for the reduction of an acute anterior dislocation of the shoulder is a safe and reliable method that can be performed relatively painlessly for both subcoracoid and subglenoid dislocations provided that a displaced fracture of the greater tuberosity is not present.