Zero Position Techniques

References Article Link
Zero Position Techniques
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(12): 2775-82. [EXPAND 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.[/EXPAND]

Journal of Bone and Joint Surgery
Saha A, Das A, Dutta S. Mechanism of Shoulder Movements and a Plea for the Recognition of “Zero Position” of Glenohumeral Joint. Curr Orth Prac. 1983; 173: 3-10. [EXPAND Abstract]

Amulya Kumar Saha, whose early work on the “zero position” of the shoulder joint is reprinted in this symposium, was born in 1913 in Pabna in undivided India (now in Bangladesh). After graduating with degrees in both science and medicine from Calcutta University, where he received his surgical training under Professor L. M. Banerjee, one of the outstanding surgeons of India in his time, he volunteered in the British Indian Army during World War II. He saw service in Burma and in the Middle East, where he became a surgical specialist and quickly rose to the rank of Major. After demobilization, he travelled to the United Kingdom for additional training and study in surgery. He received the titles of F.R.C.S (Eng.), F.R.C.S. (Edin.), and M.Ch.Orth. (L’Pool) in 1948. He became interested in the shoulder mechanism while assisting Professor S. K. Basu at the Indian Museum in 1940. He delivered his first dissertation to the Liverpool orthopedic group in 1948. Thereafter, the shoulder was one of his abiding interests.

On his return to India, Saha was first appointed to the post of Reader in Surgery in Gwalior Medical College. Subsequently, he joined the Nilratan Sircar Medical College and the University of Calcutta as Associate Professor of Surgery, where he served from 1949 to 1955. From 1955 to 1963, he served as Professor Director in the Department of Surgery at the same institution and eventually became an Honorary Consultant orthopedic surgeon, a position he held from 1964 to 1972. In 1972 he was made Emeritus Professor of Orthopaedic Surgery. During Professor Saha’s time, orthopedic surgery was just becoming recognized as a specialty in India. Through the force of circumstances, he was appointed to a post in general surgery, although he was primarily interested in orthopedics. In fact, he was largely instrumental in popularizing orthopedics in Calcutta and training a number of younger surgeons in this field. They have maintained his high standards at Nilratan Sircar Medical College Hospital in Calcutta.

Professor Saha’s major contribution to orthopedic research and clinical orthopedic practice is in relation to the shoulder joint. While at Nilratan Sircar Medical College, he conducted extensive studies on the functional anatomy of the shoulder joint from anatomic, anthropologic, morphologic, radiologic, and electromyographic, as well as mathematic, points of views. As a result of these studies, he published his work on the zero position of the glenohumeral joint in 1950. In 1957 he was invited by the Royal College of Surgeons of England to deliver a Hunterian Lecture, “Zero-position of the Glenohumeral Joint: Its Recognition and Clinical Importance.” At about this time (1954), he became interested in the study of recurrent dislocation of the shoulder joint and in rehabilitating patients with paralysis of the shoulder following poliomyelitis.

He was convinced that dynamic stability was essential during various stages of elevation of the shoulder joint with versatile ranges of movements. He postulated that there are three main factors that maintain the dynamic stability of the fully developed shoulder joint: (1) normal retrotilt of glenoid articular surface in relation to the axis of the scapula; (2) the optimum retrotorsion of the humeral head in relation to the shaft; (3) balanced power of the horizontal steerers. Based on these principles, he evolved his operations for treatment of recurrent dislocation of the shoulder joint, which he considered to be primarily due to lack of dynamic stability during abduction. In some cases of recurrent anterior dislocation of the shoulder joint, there was no history of injury, and in many cases no Bankart lesion was demonstrable. He was of the opinion that the Bankart lesion possibly was not the cause of recurrent anterior dislocation and occurred from lack of the stabilizing factors and superimposed trauma. In other words, some shoulder joints are more prone than others to undergo spontaneous dislocation, with or without minimal stress. Based on these considerations, he evolved his operations: (1) glenoid neck osteotomy to increase the retrotilt of the glenoid (modified Meyer-Burgdorff), when it was demonstrated radiologically that the glenoid retrotilt was diminished or there was actual antetilt; (2) decreasing the retrotorsion of the humeral head by rotation osteotomy of the upper shaft of the humerus, when there was excessive retrotorsion demonstrable by special radiograms; (3) augmenting the power of the horizontal steerers by transfering the tendon of the latissimus dorsi to the posterior aspect of the humeral neck. He published several monographs, one of which was translated into German in 1978.

For the post-poliomyelitis paralyzed and flail shoulder, he developed his techniques of multiple muscle transfers based on his concept of dynamic stability of the shoulder; this work was described in a supplement to Acta Orthopuedica Scundinavica in 1967. This concept and its application have been included in many books on the shoulder, including Campbell’s Operative Orthopaedics. Vol. II.

In addition to his great interest in surgery of the paralyzed shoulder, he also devoted his efforts to the rehabilitation of the paralyzed hip following poliomyelitis, using various original muscle transfer techniques to increase muscle power around the hip. He published a number of articles on this subject in Indian journals.

Professor Saha was also interested in partial and total shoulder arthroplasty and was working in this field at the time of his retirement. He designed a removable metal prosthesis based on his concept of dynamic stability of the shoulder that uses available muscles to provide motor power to the shoulder. Lately, this prosthesis has been modified by one of his colleagues to include a high-density polyethylene cover.

In addition to the subjects already mentioned, Professor Saha was interested in various other aspects of orthopedics and was first and foremost an excellent clinician and versatile surgeon. He is held in high esteem by his colleagues and students. He is a past President of the Indian Orthopaedic Association, an honor that he very much cherished. He was also the recipient of D.Sc. (Anatomy) and Coats Gold Medal of the Calcutta University for original research. Professor Saha was an active member of the Socittt Internationale de Chirurgie Orthoptdique et de Traumatologie (S.I.C.O.T.) and attended many of its meetings, presenting papers on the shoulder. He is now an Emeritus member of S.I.C.O.T.

He was invited by several universities in the United States, the United Kingdom, and Japan to deliver lectures about his work on the shoulder joint.


Milch H. Treatment of dislocation of the shoulder. Surgery 1938;3:732-740. [EXPAND Abstract]

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Cunningham Technique - EMJ
Milch H. The treatment of recent dislocations and fracture-dislocations of the shoulder. J Bone Joint Surg 1949;31-A:173-180.
Garvanos C. Modifications and improvements of the Milch technique for the reduction of anterior dislocation of the shoulder without premedication. J Trauma 1992;32:801-803.
Canales Cortés V, Garcia-Dihinx Checa L, Rodriguez Vela J. Reduction of acute anterior dislocations of the shoulder without anaesthesia in the position of maximum muscular relaxation. Int Orthop (SICOT) 1989;13:259-262.

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