ࡱ> kmj@ zjbjbܡܡ slRRRR8LR@ (FFFFFF  ,* J+ FFFFF+ RFFRRRFFF R F RRR  , ,szRRL  @ @ R R POSTERIOR DISLOCATION OF THE SHOULDER Nikola Cicak, MD, PhD Assistant Professor Department of Orthopaedic Surgery School of Medicine, University of Zagreb Salata 7, 10000 Zagreb Croatia email nikcicak@yahoo.com Posterior dislocation of the shoulder is a rare but clinically and radiologically well defined entity. It accounts for less than 2% of all shoulder dislocations (1,2). Posterior dislocation is of diagnostic and therapeutic interest because majority of the posterior dislocations are missed by initial physician (3-6). In my experience, 21 of 24 patients with posterior dislocation were not recognized initially. Confusion exist between posterior subluxation and dislocation. Posterior dislocation is an acute entity associated with trauma and with an impression defect of humeral head that requires treatment determined with the size of the defect and duration of the dislocation. The term dislocation has been applied, but, in fact this represents subluxation because one part of the articular surface of the humeral head is in contact with the glenoid and another part of the humeral head is behind the glenoid. Recurrent posterior subluxation is a distinct and separate entity, often not associated with trauma that requires completely different treatment (nonoperative treatment or posterior reconstruction of the shoulder), (7 ). The patient complains of pain and instability with his arm in a provocative position usually including forward flexion, adduction and internal rotation. (8). Another confusion exists between posterior dislocation and fracture-dislocation. Posterior dislocations are associated with fractures of the surgical neck of the humerus and fractures of the tuberosities. These fracture-dislocation are classified by Neer as two, three or four part posterior fractures - dislocations ( 9). These fractures - dislocations require completely different approach and treatment (osteosynthesis or shoulder arthroplasty). This report describes the method for diagnosis and management of the posterior dislocation of the shoulder with an impression fracture of the articular surface of the humeral head. Chronic posterior dislocations of the shoulder have been refereed to by many terms including old, missed, locked and fixed. The term locked or fixed dislocation has been used to describe irreducible acute dislocations associated with impression defect of the humeral head (10). Chronic posterior dislocation of the shoulder is a result of a missed acute posterior dislocation which has been unrecognized for more than three weeks and is characterized by the impression fracture of the articular surface of the humeral head. HISTORY A careful history and clinical assessment of the patient is essential, otherwise the diagnosis of posterior dislocation will be missed. Posterior dislocation of the shoulder is usually caused by epileptic seizure, electric shock and trauma (fall on the outstretched arm). In the case of involuntary muscle contraction, the strong internal rotators (latissimus dorsi, pectoralis major, subscapularis and teres major) simply overpower the weak external rotators (infraspinatus and teres minor), (11). The chief complaint is a loss of range of motion of involved shoulder, especially external rotation. The loss of external rotation results in difficulty with daily activities, such as combing the hair and washing the face. When physiotherapy does not improve range of motion, these patients referred to the orthopaedic surgeon with the diagnosis of frozen shoulder, or posttraumatic stiff shoulder. PHYSICAL EXAMINATION On clinical examination the patient typically holds his arm in an internal rotation in adducted position ( Fig 1. instead of Fig. 3). External rotation from this position is impossible. This is the main clinical sign for locked posterior dislocation of the shoulder with the arm locked in internal rotation of 10-60 degrees. Both active and passive external rotation are absent. This occurs because the humeral head is fixed on the posterior glenoid rim. Rowe described a test with inability to supinate the forearm when the arm is flexed forward because of the internal-rotation deformity of the shoulder. (12). There is an increased prominence of the coracoid process anteriorly and of the humeral head posteriorly. These findings are often subtle and can be noticed in conjugation with the typical restrictions in range of motion. With a characteristical marked internal rotation of the arm, there is also restrictions of abduction and forward elevation up to 80-100 degrees. RADIOGRAPHS The standard shoulder trauma series is essential in establishing the diagnosis of a posterior dislocation. Trauma series consists of: a. an anteroposterior view in the plane of the scapula, b. an axillary view, and c. scapular lateral view (Fig 2 instead of Fig. 5). Standard anteroposterior view will look normal or reveal only subtle abnormalities in posterior dislocation. The true anteroposterior view is difficult to interpret. The reason for it is that, there is only a subluxation of the shoulder. Anterior part of the humeral head is into joint and posterior part of the humeral head is outside of the joint. Several signs have been described on the AP view that suggesting the diagnosis of posterior dislocation (13,14). Radiographic signs include internal rotation of the humerus (because of fixed position of the humeral head on the posterior glenoid rim), the vacant glenoid sign (anterior glenoid fossa looks like empty), the light bulb (appearance of the humeral head) , the rim sign ( more than 6 mm between the anterior glenoid rim and humeral head), and trough line (vertical line because impaction fracture of the humeral head), (Fig 3 instead of Fig. 6). The axillary lateral view is essential for diagnosis and estimate the size of the anteromedial humeral head defect. The axillary view may be difficult to obtain because of pain and limitation of abduction. This projection can be obtained if the patients arm is passively held in position of at the least 20 degrees of abduction. If the patient does not allow enough abduction because of pain and muscle spasm to get a good axillary view, the modified axillary lateral or scapulolateral views must be obtained (15,16). The scapulolateral view is particularly helpful in determining relationship of the humeral head to the glenoid. In anterior dislocations of the shoulder, the humeral head lies anterior to the glenoid, in posterior dislocations, the humeral head lies posterior to the glenoid. A computed tomography (CT) is very useful in evaluation of the size of the humeral head defect and associated glenoid changes (17). MR imaging is not necessary because soft tissue injury is very rare in posterior dislocation of the shoulder. Sonography During the past decade sonography has become a reliable method in the diagnosis of various types of shoulder disorders, especially for rotator cuff tears. Sonography is generally not appropriate for the evaluation of shoulder instability. The capsulo -ligamentous complex is more readily investigated with CT arthrography and MR arthrography. However, ultrasound can be very useful in the evaluation of glenohumeral instability (18). Ultrasound provides a good visualization of the humeral head. It is possible to evaluate almost the entire surface of the humeral head convexity during the dynamic examination of the shoulder. Any loss of normal convexity of the humeral head in the posterolateral part represents the Hill-Sachs lesion or in the anteromedial part represents reverse Hill-Sachs lesion. (19). It assumes the appearance of depression or defect of the humeral head. Irregularities of the surface of the humeral head caused by degeneration, rotator cuff arthropathy, and postfracture deformity can be mistaken for a (reverse) Hill-Sachs lesion (20). Ultrasound can be used to determine the direction of glenohumeral instability. In a patient with anterior dislocation , glenoid fossa is empty and humeral head is located underneath coracoid in the front of the shoulder. In a patient with posterior dislocation the humeral head is more exposed posteriorly in respect to the posterior glenoid rim (Fig 4 instead of Fig. 8). In a patient with anterior instability, impression humeral head defect is located in posterolateral part of the humeral head (Hill-Sachs lesion), while in a patient with posterior instability impression humeral head defect is located in anteromedial part of the humeral head (reverse Hill-Sachs lesion). Sonography should be used as a routine method for evaluation of acute shoulder injuries, because of its simplicity, low cost and noninvasiveness. TREATMENT Before any treatment is undertaken, a careful consideration is necessary for each patient. Appropriate management of posterior dislocation depends on the size of the humeral defect, the duration of the dislocation, age and activity of the patient. I have found out useful guidance for the classification and treatment of the locked posterior dislocation of the shoulder according the size of the articular humeral impression fracture (Fig 5 instead of Fig.10). Small humeral impression defect up to 25% of the articular surface of the humeral head can be treated with closed or open reduction. If the shoulder is unstable, a transfer of upper 1/3 of the subscapularis can be performed. Medium humeral head defect from 25% to 50 % of the articular surface can be treated with lesser tuberosity transfer. Large humeral head defect of more than 50% of the articular surface can be treated with shoulder arthroplasty. The patient must be informed of the expected functional result following nonoperative or operative treatment. NONOPERATIVE TREATMENT Despite the obvious deformity of the shoulder and losses in shoulder rotation, a chronic posterior dislocation can be surprisingly well tolerated, especially in the elderly patients. Patients usually have a little pain and regain enough forward elevation to perform a lot of activities of daily living ( 21). Gerber recommends skillful neglect for old patients who have limited demands for the affected shoulder and acceptable functional range of motion and normal contralateral shoulder (22). Nonoperative treatment must be considered for the patients with uncontrolled seizure or in any patient unable to comply with a postoperative rehabilitation program. Closed reduction The time from the dislocation and the size of the humeral head are the crucial factor in determining whether or not the posterior dislocation can be reduced in a closed manner. If the humeral head defect is less than 25% of the articular surface and duration of the dislocation is less than 3 weeks a closed reduction may be attempted. When the duration of the dislocation is more than 3 weeks , closed reduction is practically impossible (4,17). Reduction of acute traumatic posterior dislocation should be carried out under general anesthesia as soon as possible. There is no agreement in literature when acute posterior dislocation has become chronic (4,7). In my experience in treatment of posterior dislocation and the review of literature, chronic posterior dislocation can be classified when shoulder has not been reduced for more than three weeks ( 12,23 ). Under general anesthesia and muscle relaxation, a gentle reduction is attempted. Reduction is performed by flexion and adduction with axial traction of the arm. Direct pressure to the humeral head from behind can facilitate reduction. If the humeral head is locked on the glenoid rim, gentle internal rotation may help stretching out posterior capsule and rotator cuff. Lateral traction allows the humeral head to unlock from the glenoid rim. Once it is unlocked, the humerus is gently externally rotated. After successful reduction, stability of the shoulder is assessed. If the shoulder is stable in internal rotation, the arm is immobilized in neutral rotation for 3 weeks. If unstable, the shoulder is immobilized with arm at the side and in external rotation of 20 degrees for 6 weeks. If closed reduction is unsuccessful, open reduction is performed under the same general anesthesia. OPERATIVE TREATMENT SMAL HUMERAL HAED DEFECT Open reduction In patients who have an irreducible dislocation and less than 25% humeral head defect, an open reduction with deltoidopectoral approach can be used. The patient is placed in a semi beach-position on the edge of the operating table with an elbow nearly at the same level as the shoulder. The arm must be freely mobile. The incision is made from the tip of the coracoid process along the deltopectoral groove, slightly laterally in case that incision should be extend distally to the insertion of the deltoid muscle. Because significant internal-rotation deformity of the arm, the biceps tendon is used as a reference point to find lesser tuberoisty and rotator interval. The biceps tendon should be found immediately underneath the upper edge of the pectoralis major insertion to the humerus. The rotator interval is opened and sometimes upper edge of the subscapularis tendon with anterior capsule are diveded for better joint visualization. Under direct visualization the shoulder is reduced. The reduction can be performed by internal rotation to unlock the humeral head defect, followed by lateral distraction, external rotation and pressure on the humeral head from behind. Once the reduction is completed, the humeral head defect and articular surfaces are examined. Posterior glenoid rim is usually damaged but rarely contribute to further instability. If the articular cartilage is good and impression fracture is small and the shoulder is stable that is all what we need to do. The rotator interval is closed. If the shoulder is unstable with the arm in internal rotation, I usually perform a transfer of the upper 1/3 of the subscapularis tendon to the humeral head defect with transosseous nonabsorbale sutures (Fig 6 instead of Fig 11 and Fig 7 instead of 12). The suture knot should be behind the bicipital groove. The shoulder following this procedure is usually stable and the arm is immobilized at the side with a slight external rotation for 3 weeks. MEDIUM HUMERAL HAED DEFECT Lesser tuberosity transfer If the impression fracture of the humeral head is between 25% to 50 % , an open reduction and lesser tuberosity transfer are recommended (24). Mc Laughlin described the transfer of the subscapularis for the humeral head defect of 20% to 40% (25), (Fig 8A instead of Fig. 13A). The subscapularis tendon is secured into the defect through drill holes in the bone. Neer has modified this method by osteotomizing the lesser tuberosity with the attached subscapularis (26), (Fig 8B instead of Fig. 13 B). The advantages of lesser tuberosity transfer are better bone filling of the humeral head and more secure reinsertion of the subscapularis (23). The deltoidopectoral interval is developed and the biceps tendon identified as a landmark to the lesser tuberosity. The rotator interval and lower edge of the subscapularis tendon are identified. The circumflex vessels are ligated. Under direct visualization of the joint through the rotator interval, osteotomy of the lesser tuberosity is performed starting from the bicipital sulcus to the humeral head defect. The lesser tuberosity with the attached subscapularis is elevated to expose the humeral head and the glenoid. Reduction can be very difficult in cases with locked chronic dislocation with large humeral head defect. Appropriate soft tissue releases are very important to fascilite the reduction. Reduction is achieved by placement of an elevator into the humeral head defect and levering the humeral head into the glenoid. When the humeral head is lateralised enough to the level of the glenoid, a gentle external rotation should be performed. The lesser tuberosity with attached subscapularis tendon is fixed into the defect with two cancellous lag screws (Fig 9 instead of Fig. 14). If the shoulder is stable, the arm is immobilized in neutral rotation for 4 weeks. Other procedures for medium humeral head defect Another option for the treatment of the humeral head defect between 25 to 50% are rotational osteotomy of the humerus and auto or allograft reconstruction of the humeral head. Rotational osteotomy of the humerus After an open reduction, transverse osteotomy of the surgical neck of the humerus is performed. The humeral shaft is rotated internally and the osteotomy is fixed with an angled blade plate (Fig 10 instead of Fig.15). The increased internal rotation insures that the humeral head defect remains anterior to the glenoid throughout the entire range of motion (27). The advantages of a rotational osteotomy is a stable osteosynthesis and immediate postoperative rehabilitation. The disadvantage of this procedure is a limitation of external rotation (28). Indication for this procedure may be considered in a young patient in whom the only other option is shoulder arthroplasty. Allograft reconstruction of the humeral head defect The humeral head defect is filled with a femoral head allograft. The allograft is contoured to fit the segmental defect and to restore the sphericity of the humeral head. The graft is fixed with cancellous screws. This procedure yielded similar results to the subscapularis transfer without altering normal anatomy of the proximal humerus (29). This procedure should be used in patient with good bone quality of the residual head and without osteoathritis. Autograft reconstruction of the humeral head defect Osteochondral autograft of the humeral head can be used in a patient with medium or large anteromedial articular impression defect in case of bilateral acute posterior dislocation (30). After removing the humeral head from the contralateral shoulder following hemiarthroplasty, the articular segment of the humeral head is fashioned into a well-fitting osteochondral autograft and fixed into the impression defect of the humeral head with Herbert screws. LARGE HUMERAL HAED DEFECT Arthroplasty Shoulder hemiarthroplasty is used in patients with an impression fracture involving more than 50% of the articular surface or when the humeral head is very soft and not viable (31,32). Total shoulder arthroplasty is used in cases with a significant erosion of the glenoid (33- 35). It is important to decide before surgery to do the lesser tuberosity transfer or arthroplasty. If you decide to do the arthroplasty it is important not to do osteotomy of the lesser tuberosity. If you do the osteotomy you must do reconstruction of the tuberosity with potential problems, including, malunion or nonunion of the lesser tuberosity (22). Reduction can be very difficult in case with a large humeral head defect and duration of the dislocation more than 6 months. Again it is important to release soft tissue around shoulder and slowly reduce shoulder using elevator or opposite side of the retractor, as lever with lateral distraction and external rotation. I usually try to put the opposite side of the retractor behind posterior glenoid rim and humeral head. Also, I am using the opposite side of the hard chisel as a lever between posterior glenoid rim and humeral head defect. It is necessary to try several times both techniques. When the humeral head is closed to the posterior rim, the arm is externally rotated and the shoulder is reduced. I have never used the posterior approach for reduction of the shoulder in chronic posterior dislocation of the shoulder. The retroversion of the humeral component should be decreased from 35 degrees approximately to 20 degrees (4), (Fig 11 instead of Fig. 16). Excessive anteversion is not necessary. Plication of the posterior capsule also is not necessary. If there is a concern regarding stability of the humeral component, the arm is immobilized in external rotation of 10-20 degrees. CONCLUSION The treatment of the chronic posterior dislocation of the shoulder remains difficult. The most important is to recognize initially posterior dislocation of the shoulder from the patient history, physical examination and radiological examination. A history of epileptic seizure and electro shock, must alert the surgeon to the posterior dislocation. The key physical sign is fixed internal rotation of the arm . The axillary lateral view is essential for diagnosis and estimate the size of the anteromedial humeral head defect. One of the reasons for missed posterior dislocation is that axillary lateral x-ray is never taken. Skillful neglect should be considered in patient with limited disability and low functional expectations. Closed reduction should be attempted if the humeral head defect is less than 25% of the articular surface and the duration of the dislocation is less than 3 weeks. Open reduction should be performed in a patient with irreducible dislocation and less than 25% humeral head defect. If the shoulder is unstable after open reduction the transfer of the upper 1/3 of the subscapularis tendon to the humeral head defect with transosseous nonabsorbale suture should be performed. The transfer of the lesser tuberosity remains the operation of choice in patients with humeral head defect between 25 and 50% of the articular surface. Shoulder hemiarthroplasty should be performed in patients with an impression fracture involving more than 50% of the articular surface or when the humeral head is very soft and not viable. Total shoulder arthroplasty should be performed in cases with a significant erosion of the glenoid. Open reduction with transfer of the lesser tuberosity or shoulder arthroplasty is very demanding procedure and should be performed only by experienced shoulder surgeon. REFERENCES 1. Cave EF, Burke JF, Boyd RJ. Trauma management. Chicago: Year Book Medical Publishers, 1974; 437. 2. Beker R, Weyand F. Die seltene doppelseitige hintere Schulterluxation. Unfallchir 1990;93:66-8. 3. Dubousset J. Luxation Poterieures de lepaule. Rev Clin Orthop 1967;53:65-85. 4. Hawkins RJ, Neer CS, Pianta RM, Mendoza FX. Locked posterior dislocation of the shoulder. J Bone Joint Surg (Am) 1987;69-A:9-18. 5. Heller KD, Forst J, Forst R. Differentialaltherapie der traumatisch induzierten persistierenden hinteren Schulterluxation. Unfallchirurg 1995;98:6-12. 6. Michos IB, Michaelides DP. Reduction of missed posterior dislocation of the shoulder. Acta Orthop Scand 1993;64:599-600. 7. Petersen SA. Posterior shoulder instability. Orthop Clin North Am 2000;31:263-74. 8. Hawkins RJ, Morin WD, Noble JS. Posterior instability. In: Pettrone FA, ed. Athletic injuries of the shoulder. New York, etc: McGraw-Hill, Inc, 1995:103-15. 9. Neer CS. Displaced proximal humerus fractures. Part I: Classification and evaluation. J Bone Joint Surg (Am) 1970;52A:1077-89. 10. Standeffer WC, Pagnani MJ, Anderson AF. Fixed and chronic shoulder dislocation. In: Warren RF, Craig EV, Altchek DW, ed. The unstable shoulder. Philadelphia, New York: Lippincott - Raven, 1999:263-70. 11. Matsen FA, Thomas SC, Rockwood CA, Wirth MA. Glenohumeral instability. In: Rockwood CA, Matsen FA, eds. The shoulder. Vol.2. Philadelphia, etc:W.B. Sauders Company, 1998:611-754. 12. Rowe C, Zarins B. Chronic unreduced dislocation of the shoulder. J Bone Joint Surg Am 1982;64A:494-505. 13. Arndt J, Sears A. Posterior dislocation of the shoulder. Am J Roentgenol 1965;94:639-45. 14. Cisternino S, Rodgers L, Stuffeban B, et al. The trough line: A radiographic sign of posterior shoulder dislocation. Am J Roentgenol 1978;130:951-4. 15. Bloom MH, Obata WG. Diagnosis of posterior dislocation of the shoulder with use of Velpeau axillary and angle-up roentgenographic views. J Bone Joint Surg Am 1967;49A:943-9. 16. Wallace WA, Hellier M. Improving radiographs of the injured shoulder. Radiography 1983;49:229-33. 17. Aparicio G, Calvo E, Bonilla L, Espejo L, Box R. Neglected traumatic posterior dislocation of the shoulder: controversies on indication for treatment and new CT scan findings. J Orthop Sci 2000;5:37-42. 18. Cicak N, Matasovic T. The place of diagnostic sonography in evaluation of the shoulder. Period Biolog 1993;95:209-12. 19. Cicak N, Bilic R, Delimar D. Hill-Sachs lesion in recurrent shoulder dislocation: sonographic detection. J Ultrasound Med 1998 ;17:557560. 20. Farin, PU, Kaukanen E, Jaroman H, Harju A, Vaatainen U. Hill-Sachs lesion: Sonographic detection. Skeletal Radiol 1996;25:559-62. 21. Loebenberg MI, Cuomo F. The treatment of chronic anterior and posterior dislocation of the glenohumeral joint and associated articular surface defects. Orthop Clin North Am. 2000;31:23-34. 22. Gerber C. Chronic, locked anterior and posterior dislocation. In: Warner JJP, Iannotti JP, Gerber C, ed. Complex and revision problems in shoulder surgery. Philadelphia, New York: Lippincott - Raven, 1997:99-113. 23. Randelli M, Gambrioli PL. Chronic posterior dislocations of the shoulder. In: Duparc J, eds. Surgical techniques in orthopaedics and traumatology, Paris:Elsevier, 2001:55-190-B-10. 24. Finkelstein JA, Waddell JP, ODriscoll SW, Vincent G. Acute posterior fracture dislocation of the shoulder treated with the Nee modification of the McLaughlin procedure. J Orthop Trauma 1995;3:190-3. 25. McLaughlin HL. Posterior dislocation of the shoulder. J Bone Joint Surg (Am) 1952;34-A:584-90. 26. Hughes M, Neer CS II. Glenohumeral joint replacement and postoperative rehabilitation. Phys Ther 1975;55:850-8. 27. Vukov V. Posterior dislocation of the shoulder with a large anteromedial defect of the head of the humerus. Int Orthop 1985;9:37-40. 28. Keppler P, Holtz U, Thielemann FW. Locked posterior dislocation of the shoulder: Treatment using rotational osteotomy of the humerus. J Orthop Trauma 1994;8:286-92. 29. Gerber C, Lambert SM. Allograft reconstruction of segmental defects of the humeral head for the treatment of chronic locked posterior dislocation of the shoulder. J Bone Joint Surg (Am) 1996;78-A:376-82. 30. Connor PM, Baatright JR, DAlessandro DF. Posterior fracture/dislocation of the shoulder. Treatment with acute osteochondral grafting. J Shoulder Elbow Surg 1997;6:480-5. 31. Page AE, Meinhard BP, Schulz E, Toledano B. Bilateral posterior fracture-dislocation of the shoulder: management by bilateral shoulder hemiarthroplasties. J Ortho Trauma 1995:6:526-9. 32. Hawkins RJ. Unrecognized dislocations of the shoulder. Inst Course Lecture 1986;258-63. 33. Cheng SL, Mackay MB, Richards RR. Treatment of locked posterior fracture-dislocation of the shoulder by total shoulder arthtroplasty. J Shoulder Elbow Surg 1997;6:11-7. 34. Checchia SL, Santos PD, Miyazaki AN. Surgical treatment of acute and chronic posterior fracture dislocation of the shoulder. J Shoulder Elbow Surg 1998;7:53-65. 35. Pritchett JW, Clark JM. Prosthetic replacement for chronic unreduced dislocations of the shoulder. Clin Orthop 1987;216:89-93. FIGURES Figure 1. The patient with a chronic posterior dislocation of the shoulder has limited external rotation and cannot rotate the arm to neutral. Figure 2. Trauma series of posterior dislocation of the shoulder. An true anteroposterior view (A), axillary view (B) and scapulolateral view (C) Figure 3. Radiographic signs of the posterior dislocation on the anteroposterior view. The vacant sign (A), the light bulb (B), and the trough line (C). Figure 4. Ultrasound of the shoulder with posterior dislocation. The humeral head (H) is exposed more posteriorly in respect to the posterior glenoid rim (G). Infraspinatus (I). Figure 5. Diagram and CT scan of locked posterior dislocation of the shoulder with impression fracture of the humeral head. Determination and classification of the size of the humeral head defect. A. Small humeral impression defect up to 25% of the articular surface of the humeral head. B. Medium humeral impression defect from 25% to 50% of the articular surface of the humeral head. C. Large humeral impression defect more than 50% of the articular surface of the humeral head. Figure 6. Diagram of the transfer of the upper 1/3 of the subscapularis tendon into humeral head defect. Figure 7. An axillary lateral view preoperatively (A) and postoperatively (B). CT scan of the same patient on figure 5A. Figure 8. Diagram of transfer of the subscapularis tendon (A) and transfer of the lesser tuberosity (B). Figure 9. A computed tomography (CT) scan of the patient with a chronic locked bilateral dislocation of the shoulder (A). The same patient after the lesser tuberosity transfer. Axillary view (B) of the right shoulder and axillary view (C) of the left shoulder Full elevation postoperatively (D). Figure 10. Intraoperative view demonstrating a large anteromedial humeral head defect (A). After the transfer of the lesser tuberosity the shoulder was unstable and rotational osteotomy was performed. Anteroposterior view (B) postoperatively. Postoperative elevation of the right shoulder (C). Note the paralysis of the left arm. The transfer of the lesser tuberosity and rotational osteotomy of the humerus were performed instead of hemiarthroplasty because of the age of patient and paralysis of the contralateral arm. Figure 11. Hemiarthroplasty was performed in a patient with large humeral head defect (CT scan of the same patient on figure 5 C). Anteroposterior view (A) and axillary view (B). 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