The relation of pre- and postoperative heart rate variability and baroreflex sensitivity with orthostatic intolerance in patients undergoing primary total hip or knee replacement

Background:

Glenohumeral (shoulder) dislocations are the most common large joint dislocations seen in the

emergency department (ED). They cause pain, often severe, and require timely interventions to

minimize discomfort and tissue damage. Commonly used reposition or relocation techniques often

involve traction and/or leverage. These techniques have high success rates but may be painful and

time consuming. They may also cause complications.

Recently, other techniques—the biomechanical reposition techniques (BRT)—have become more

popular since they may cause less pain, require less time and cause fewer complications. To our

knowledge, no research exists comparing the various BRTs.



Objective:

To establish which BRT or BRT combination is fastest, least painful and associated with the lowest

complication rate for adult ED patients with anterior glenohumeral dislocations (AGDs).



Methods:

Adults presenting to the participating EDs with isolated AGDs, as determined by radiographs, will be

randomised to one of three BRTs - Cunningham, modified Milch or scapular manipulation.



Main study parameters/endpoints:

 ED length-of- stay

 Patients’ self-report of pain

Secondary study parameters/endpoints: 

 Procedure times


 Need for analgesic and/or sedative medications

 Iatrogenic complications

 Rates of successful reduction



Discussion:

Non-biomechanical AGD repositioning techniques based on traction and/or leverage are inherently

painful and potentially harmful. We believe that the three BRTs used in this study are more

physiologic, more patient-friendly, less likely to cause pain, more time efficient and less likely to

produce complications. By comparing these three techniques we hope to improve the care provided

to adults with acute AGDs by reducing their ED length-of- stay and minimizing pain and procedure-

related complications. We also hope to define which of the three BRTs is quickest, most likely to be

successful and least likely to require sedative or analgesic medications to achieve reduction.



Keywords:

Anterior shoulder dislocation, glenohumeral dislocation, biomechanical reposition techniques,

Cunningham, modified Milch, scapular manipulation technique, length-of- stay, emergency

department, reduction rate

We hypothesize that a low heart rate variability and baroreflex sensitivity in the pre- or postoperative phase are associated with orthostatic intollerance when compared to subjects with normal heart rate variability.

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