To devise an operative approach to the management of acute posterior fracture-dislocation of the shoulder which restores or retains normal proximal humeral anatomy and allows the early restoration of a complete, stable range of motion.

Since 1996 we have treated four male patients (five shoulders) aged between 19 and 54 years at the time of first dislocation with autogenous iliac grafting of the anterior humeral head defect for acute and acuteon-chronic posterior dislocation of the shoulder. Two patients had epilepsy: one of these patients had bilateral dislocations. Two patients had motorbike RTAs. The deltopectoral approach with vertical division of the subscapularis tendon was used in all cases. The defects comprised 20– 25% of the volume of the humeral head at the equator after preparation for grafting. Grafts were fixed with compression screws. The subscapularis tendon was repaired anatomically. Active-assisted rehabilitation was started immediately, restricting external rotation to the neutral position for six weeks, thereafter allowing full rotation and elevation as comfort allowed.

The patient with bilateral dislocations died of unrelated causes 18 months after surgery. He was reported to have had no further dislocations, complete pain free functional use of both shoulders and no complications of the procedure. The remaining three patients were reviewed at a minimum of 20 months after surgery (average 35 months). All grafts had incorporated. There was no graft collapse or boundary arthrosis. The absolute Constant scores were 85.1, 90.9, and 89.2; the subjective shoulder scores were 98%, 90%, and 99%; the Oxford rating scale for pain scores were 14 out of 60, 13 out of 60, and 14 out of 60; and the Oxford rating scale for instability scores were 14 out of 60, 15 out of 60 and 15 out of 60. There were no redislocations, or complications of the procedures.

Posterior stability appears more dependant on surface arc of contact than on capsular integrity, in contrast to the anteriorly unstable shoulder. Restoration of the articular surface arc of contact by segmental autogenous grafting retains normal humeral anatomy, allows normal motion with excellent cuff function, and a return to normal daily activities. The procedure has been shown to be safe at a minimum of 20 months.