hill sachs

Review Article
The Hill-Sachs Lesion: Diagnosis,
Classification, and Management
Abstract
CDR Matthew T. Provencher,
MD
Rachel M. Frank, MD
LCDR Lance E. LeClere, MD
LCDR Paul D. Metzger, MD
J. J. Ryu
LT Andrew Bernhardson, MD
Anthony A. Romeo, MD
The Hill-Sachs lesion is an osseous defect of the humeral head
that is typically associated with anterior shoulder instability. The
incidence of these lesions in the setting of glenohumeral instability
is relatively high and approaches 100% in persons with recurrent
anterior shoulder instability. Reverse Hill-Sachs lesion has been
described in patients with posterior shoulder instability. Glenoid
bone loss is typically associated with the Hill-Sachs lesion in
patients with recurrent anterior shoulder instability. The lesion is a
bipolar injury, and identification of concomitant glenoid bone loss is
essential to optimize clinical outcome. Other pathology (eg, Bankart
tear, labral or capsular injuries) must be identified, as well.
Treatment is dictated by subjective and objective findings of
shoulder instability and radiographic findings. Nonsurgical
management, including focused rehabilitation, is acceptable in
cases of small bony defects and nonengaging lesions in which the
glenohumeral joint remains stable during desired activities. Surgical
options include arthroscopic and open techniques.
T
From the Department of
Orthopaedic Surgery, Naval Medical
Center San Diego, San Diego, CA
(Dr. Provencher, Dr. LeClere,
Dr. Metzger, and Dr. Bernhardson),
the Naval Medical Center San Diego
(Ms. Ryu), and the Department of
Orthopedic Surgery, Rush University
Medical Center, Chicago, IL
(Dr. Frank and Dr. Romeo).
The views expressed in this article
are those of the authors and do not
reflect the official policy or position
of the Department of the Navy,
Department of Defense, or the
United States Government.
J Am Acad Orthop Surg 2012;20:
242-252
http://dx.doi.org/10.5435/
JAAOS-20-04-242
Copyright 2012 by the American
Academy of Orthopaedic Surgeons.
242
he Hill-Sachs lesion is a compression fracture of the posterosuperolateral humeral head that occurs in association with anterior
instability or dislocation of the glenohumeral joint. In 1940, Hill and
Sachs1 described the lesion as a socalled line of condensation on the internal rotation shoulder radiograph.
They attributed this line to the impression of the dense cortical glenoid
on the humeral head during an anterior dislocation event.
Improved understanding of the association between humeral head bony
defects and recurrent glenohumeral
instability has resulted in increased interest in identifying the optimal manner by which to classify and manage
Hill-Sachs injuries. There is an historical body of evidence supporting an association between a combined engaging Hill-Sachs lesion and anterior
glenoid bone loss in cases of recurrent
instability.2-5 Although a substantial
amount of literature exists on the
well-established relationship between
glenoid bony defects and shoulder
instability,6-8 there is a relative paucity of literature on humeral head defects.9
Epidemiology
The true incidence of Hill-Sachs lesions is unknown. However, they are
associated with approximately 40%
to 90% of all anterior shoulder instability events.10-14 The incidence
may be as high as 100% in patients
with recurrent anterior instability.13
Determining which Hill-Sachs lesions are associated with clinical
symptoms and which are incidental
remains challenging. This is espe-
Journal of the American Academy of Orthopaedic Surgeons
CDR Matthew T. Provencher, MD, et al
cially important in patients with recurrent instability because humeral
head bony deficits may contribute to
continued instability.
Reverse Hill-Sachs lesions are associated with posterior shoulder dislocation. The incidence of this type is
equally difficult to quantify, although reverse lesions occur in up to
86% of posterior shoulder dislocations.12 However, posterior shoulder
instability events are relatively uncommon, and reverse Hill-Sachs lesions are rare.
Pathophysiology
Hill-Sachs lesions most commonly
occur during an anterior glenohumeral instability injury, typically
with the shoulder in abduction and
external rotation. As the humeral
head is forced anteriorly, the capsulolabral structures of the shoulder
are stretched and often torn. As the
humeral head translates farther anteriorly, a compression fracture occurs
along the posterosuperolateral aspect
of the humeral head as it comes into
contact with the anterior glenoid
(Figure 1). The damaged anterior
soft-tissue structures are particularly
problematic in cases of recurrent
instability because the static glenohumeral constraints (ie, capsule,
labrum) become increasingly attenuated with each episode. This attenuation makes it easier for the relatively
softer cancellous bone of the humeral head to sustain continued
damage as it makes repeated contact
with the harder cortical bone of the
anterior glenoid.9
The traditional Hill-Sachs lesion is
a bony defect of the posterosuperolateral humeral head, typically
associated with anteroinferior glenohumeral dislocation. An engaging
Hill-Sachs lesion, as described by
Palmer and Widén15 and Burkhart
and De Beer,2 occurs when the humeral head defect engages the rim of
the glenoid while the shoulder is in a
position of athletic function (ie, 90°
abduction and 0 degrees to 135° of
external rotation) (Figure 2, A and
B). In an engaging lesion, the long
axis of the humeral head defect is
oriented parallel to the anterior glenoid rim and thus engages with it
when the shoulder is in abduction
and external rotation.9 When the humeral defect is not in parallel with
the rim of the glenoid and thus does
not engage with it in a position of
function, the lesion is referred to as
nonengaging2 (Figure 2, C and D).
The reverse Hill-Sachs lesion is a
bony defect of the anterosuperomedial humeral head. This type most
commonly is caused by posterior
shoulder dislocation. The main differences between traditional and reverse Hill-Sachs lesions are listed in
Table 1.
Hill-Sachs lesions rarely occur in
isolation. The injury most commonly
sustained in conjunction with the
Hill-Sachs lesion is the anterior capsulolabral lesion (ie, Bankart).11
Figure 1
Three-dimensional CT scan
demonstrating the typical location
of a Hill-Sachs lesion at the
superolateral aspect of the
posterior humeral head (arrows).
The harder anteroinferior glenoid
bone compresses the soft
cancellous bone in this region as
the humeral head dislocates,
creating the characteristic osseous
lesion.
Other common coexisting injuries
are anterior glenohumeral ligamentous pathology and glenoid bone loss
(ie, bony Bankart lesion)5,16 (Figure
3). Anteroinferior glenoid bone loss
may ultimately become large enough
to create a glenoid with the appearance of an inverted pear; this presentation is associated with recurrent
anterior shoulder instability.8,17 Optimal management requires close evaluation for glenoid bone loss because
bone loss in the shoulder is frequently a bipolar phenomenon.7
It is also important to recognize
normal anatomic structures of the
posterior humeral head to avoid con-
Dr. Provencher or an immediate family member serves as a board member, owner, officer, or committee member of the American
Academy of Orthopaedic Surgeons; the American Orthopaedic Society for Sports Medicine; the Arthroscopy Association of North
America; the International Society of Arthroscopy, Knee Surgery, and Orthopaedic Sports Medicine; and the Society of Military
Orthopaedic Surgeons. Dr. Romeo or an immediate family member has received royalties from Arthrex; is a member of a speakers’
bureau or has made paid presentations on behalf of Arthrex, DJ Orthopaedics, and the Joint Restoration Foundation; serves as a
paid consultant to or is an employee of Arthrex; has received research or institutional support from Arthrex and DJ Orthopaedics; has
received nonincome support (such as equipment or services), commercially derived honoraria, or other non–research-related funding
(such as paid travel) from Arthrex and DJ Orthopaedics; and serves as a board member, owner, officer, or committee member of the
American Orthopaedic Society for Sports Medicine, American Shoulder and Elbow Surgeons, and the Arthroscopy Association of
North America. None of the following authors or any immediate family member has received anything of value from or owns stock in
a commercial company or institution related directly or indirectly to the subject of this article: Dr. Frank, Dr. LeClere, Dr. Metzger,
Ms. Ryu, and Dr. Bernhardson.
April 2012, Vol 20, No 4
243
The Hill-Sachs Lesion: Diagnosis, Classification, and Management
become the shaft. On the axial view,
this groove is located more inferior
and posterior (between 140° and
230°) than are Hill-Sachs lesions,
which typically fall more laterally
(between 170° and 260°).
Figure 2
Clinical Evaluation
History and Physical
Examination
A, Illustration of an engaging Hill-Sachs lesion (dark gray area). B, With the
shoulder in a position of function or in abduction and external rotation, the
lesion is oriented parallel with the anterior glenoid and thus engages it.
C, Illustration of a nonengaging lesion (dark gray area), which is created in a
nonfunctional position. D, When the shoulder is abducted and externally
rotated, the lesion is not oriented parallel to the glenoid and thus does not
engage. (Redrawn with permission from Burkhart SS, De Beer JF: Traumatic
glenohumeral bone defects and their relationship to failure of arthroscopic
Bankart repairs: Significance of the inverted-pear glenoid and the humeral
engaging Hill-Sachs lesion. Arthroscopy 2000;16[7]:677-694.)
Table 1
Key Differences Between Traditional and Reverse Hill-Sachs Lesions
Traditional
Located on the posterosuperolateral
humeral head
Anterior or anteroinferior dislocation
Posterior cartilage damage (usually less
than in reverse lesions)
fusing them with Hill-Sachs lesions.
The bare spot of the humeral head,
which has no direct attachment of
the rotator cuff tendons, is located
superior and slightly medial to the
244
Reverse
A thorough history and physical examination are important in the clinical evaluation of the patient with a
Hill-Sachs lesion associated with glenohumeral instability (Table 2). Special attention should be paid to the
mechanism of injury, which likely involves an initial traumatic dislocation event with the arm in abduction
and external rotation.16 In the presence of an intact glenoid, the HillSachs lesion may be clinically silent.
The patient with glenoid bone loss
and/or an engaging lesion may describe a sensation of catching as the
humeral head falls outside the glenoid track during movement (Figure
4). (The glenoid track is described in
detail below.) In such cases, instability
may result from trivial events such as
sleeping with the arm overhead.21 During the physical examination, the appearance, range of motion, strength,
and sensation of the injured shoulder
should be compared with those of the
contralateral shoulder.
Imaging
Located on the anterosuperomedial
humeral head
Posterior shoulder dislocation (rare)
Anterior cartilage damage that is much
more extensive than the posterior cartilage damage seen in traditional lesions
typical location of a Hill-Sachs lesion. As described by Richards
et al,18 the anatomic groove of the
humeral head is the normal flattening of the head as it moves caudad to
Several imaging modalities can be
used to assess humeral head osseous
deficiency. A full shoulder radiographic series is typically obtained,
including AP, lateral, and axillary
views. Several other views can be
more helpful in evaluating humeral
head bone loss specifically. The modified West Point axillary view is used
in the evaluation of glenoid bone
loss, and the Stryker notch view is
specific for evaluating the Hill-Sachs
Journal of the American Academy of Orthopaedic Surgeons
CDR Matthew T. Provencher, MD, et al
lesion.22 The Stryker notch view is
useful because the internal rotation
of the humeral head brings the posterolateral defect into direct view.
CT, particularly three-dimensional
CT, is a superior imaging option for
evaluating bone loss. Three-dimensional CT allows full appreciation of
the orientation of the defect, which is
extremely useful in decision making
and preoperative planning.23 Glenoid
bone loss also can be precisely quantified following digital subtraction of
the humeral head24 (Figure 1).
Ultrasonography may be useful in
detecting Hill-Sachs lesions. Cicak et
al25 compared intraoperative findings
with ultrasonography and found ultrasonography to be 100% specific
and 96% sensitive for the detection
of Hill-Sachs lesions, with an overall
accuracy rate of 97%.
MRI or magnetic resonance arthrography may provide information
on the glenoid and/or humeral head
defects (Figure 5). Without advanced
imaging studies, it is difficult to accurately quantify the size and location of the Hill-Sachs lesion and to
adequately assess any accompanying
glenoid bone loss.
Classification
Several classification and grading
systems for Hill-Sachs lesions have
been described; controversy persists
regarding which is optimal3,4,10,18,26
(Table 3). Although the classifications and grading systems can be
useful in clinical decision making, especially with larger lesions, they have
not yet proved to be helpful in determining successful management strategies.
Figure 3
A, Arthroscopic view from the anterosuperior portal demonstrating significant
bipolar bony defects, with a large Hill-Sachs lesion and concomitant
anteroinferior glenoid bone loss measuring approximately 28% of the width of
the glenoid. B, Arthroscopic view from the anterosuperior portal of the
shoulder after it was brought into the position of function. On abduction and
external rotation, the humeral defect clearly engages the anterior glenoid.
Engagement was noted at only 45° of abduction and a few degrees of
external rotation.
Table 2
Important History and Physical Examination Findings for Hill-Sachs
Lesions
History
Deep shoulder pain
Previous shoulder instability event
Recurrent instability with provocative positioning
Mechanical symptoms (eg, crepitus, clicking, catching)
History of shoulder reduction, especially manual reduction
Progressive ease of dislocation events: Instability with daily events, likely concomitant
glenoid defect, likely more significant bony defects
Recurrent instability events: Often unprovoked, occurring with increasing frequency,
occurring after stabilization procedure(s)
Physical examination
Assess for instability (ie, apprehension tests)
Assess for laxity (ie, translation tests)
Assess for concomitant injuries (eg, rotator cuff tear, biceps tendon pathology, superior
labrum anterior-posterior lesion)
Key findings
Apprehension at lesser degrees of abduction (mid range19,20)
Palpable clunk with engagement: Typically done under anesthesia. May become
locked.
In advanced cases, crepitus during range of motion, extension of the lesion to the central humerus, extensive anterior glenoid bone loss, and glenohumeral osteoarthritis
Clinical Significance of
the Lesion
Determining the clinical significance
of a Hill-Sachs lesion can be chalApril 2012, Vol 20, No 4
lenging. The most important consideration is establishing whether the lesion is responsible for the patient’s
symptoms, especially with regard to
the instability event.
The most common factors used to
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The Hill-Sachs Lesion: Diagnosis, Classification, and Management
Figure 4
A, Illustration of the glenoid track, which is used in describing Hill-Sachs
lesions based on the location and size of the humeral head defect and on
the amount of glenoid bone loss. The gray area indicates the zone of contact
between the glenoid and the humeral head. The dotted line indicates the
contact area between the glenoid and the humeral head. B, The lesion lies
within the track, and the lesion cannot override the glenoid rim. C, The lesion
lies more medial than the track, thereby making it possible for the humeral
head to override the glenoid rim. (Redrawn with permission from Yamamoto
N, Itoi E, Abe H, et al: Contact between the glenoid and the humeral head in
abduction, external rotation, and horizontal extension: A new concept of
glenoid track. J Shoulder Elbow Surg 2007;16[5]:649-656.)
determine the significance of a lesion
are its size and whether it is engaging.2 Historically, lesions involving
<20% of the humeral head articular
surface are rarely of clinical significance, whereas lesions >40% of that
surface are nearly always clinically
significant and are responsible for recurrent
instability.3,9
Treatment
decision-making is most difficult in
the setting of midsize lesions comprising 20% to 40% of the humeral
head articular surface. Other factors
to consider include the location and
orientation of the lesion, the extent
of concomitant glenoid bone loss,
and the extent of engagement with
the glenoid. The location and orientation of the lesion are important
246
factors for defects of any size.
In midsize Hill-Sachs lesions, the
injury must be recognized as a bipolar problem, with glenoid bone loss
potentiating the humeral-side lesion
and increasing the risk of instability.
Yamamoto et al27 developed a novel
approach to describing Hill-Sachs lesions. They based their description
on the location and size of the humeral head defect and on the amount
of glenoid bone loss. Using a cadaver
model, they measured the contact
area between the glenoid and humeral head at various degrees of abduction. With the shoulder in 60° of
abduction and maximum external
rotation to simulate anterior apprehension, the authors found that the
distance from the contact area to the
medial margin of the footprint was
84% of the glenoid width. The authors proposed that a Hill-Sachs lesion outside this so-called glenoid
track was at high risk for engagement and, therefore, recurrent instability. Their classification also takes
into account the amount of glenoid
bone loss.27 As an osseous glenoid lesion increases in size, the glenoid
track decreases accordingly, thereby
placing the construct at risk of engagement. Large amounts of glenoid
bone loss increase the clinical relevance of even small Hill-Sachs injuries (Figure 4).
This biomechanical association
was studied clinically by Provencher
et al,28 with the goal of determining
the clinical significance of Hill-Sachs
lesions in the setting of glenoid bone
loss. The authors found that 22 of
140 patients (15.7%) had Hill-Sachs
lesions outside the glenoid track, as
determined by measuring the size of
the humeral head lesion and glenoid
bone loss on magnetic resonance arthrography. These patients were felt
to be at increased risk of glenohumeral engagement.
The concept of the glenoid track
may be the most clinically relevant
system for classifying Hill-Sachs lesions, but additional work is necessary to validate its routine clinical
use.
Nonsurgical Management
Nonsurgical management is warranted in cases of small osseous defects and nonengaging lesions. Even
when surgery is warranted, these
Hill-Sachs lesions are often left alone
intraoperatively, and other clinically
relevant pathology (eg, Bankart lesion) is addressed instead. Patients
with larger, more clinically significant lesions who may be poor surgical candidates (eg, elderly persons,
Journal of the American Academy of Orthopaedic Surgeons
CDR Matthew T. Provencher, MD, et al
persons at high medical risk) may be
best treated nonsurgically.
A focused rehabilitation program
is essential to nonsurgical management, under the guidance of an experienced physical therapist or athletic
trainer. The program must focus on
strengthening the deltoid, the rotator
cuff muscles, and in particular, the
scapular stabilizers. Months of rehabilitation may be required.
Surgical Management
The indications for surgical management of Hill-Sachs lesions depend on
the clinical significance of the defect
and on symptoms of instability (Table 4). A variety of arthroscopic and
open options is available.9,16,21 Most
clinically significant Hill-Sachs injuries may be successfully managed by
addressing the primary instability
problem, that is, labral tear and/or
glenoid bone loss. Thus, glenoid-side
techniques are usually adequate.
However, several surgical techniques
manage the Hill-Sachs lesion directly.
Surgical management of osseous lesions related to anterior instability
must take into account the bipolar
nature of the injury. Several surgical
options exist for the patient with an
engaging Hill-Sachs injury. Most involve glenoid bone augmentation
alone. Anterior glenoid bone loss
may be augmented with the Latarjet
procedure or iliac crest bone graft to
increase the size of the glenoid track
and prevent engagement.2,29 Procedures of historical interest include
rotational humeral osteotomy and a
technique involving tightening the
anterior soft-tissue structures to limit
external rotation and shift the
glenoid track medially and superiorly.11,30 Rotational humeral osteotomy has been used for large HillSachs defects. By externally rotating
the proximal humerus surgically, humeral head retroversion is reduced,
and the defect ceases to fall into the
anterior glenoid on internal rotation.
This procedure has fallen out of fa-
vor because of concerns regarding
nonunion, delayed union, overrotation, risk of fracture, and posttraumatic arthritis.
Many procedures directly address the
defect, including humeral head autograft or allograft, tissue filling (ie,
remplissage; see below), disimpaction,
and prosthesis replacement. Regardless
of the method chosen, the goal is to
prevent further engagement of the HillSachs lesion with the glenoid.
Capsular Shift
Glenohumeral capsular shift is performed to surgically tighten the cap-
Figure 5
Axial (A) and coronal (B) magnetic resonance arthrograms demonstrating a
classic Hill-Sachs lesion (arrows).
Table 3
Classifications of Hill-Sachs Lesions
Grading System
Imaging
Rowe et al4
Axillary radiograph
Calandra et al10
Direct visualization
Franceschi et al26
Flatow and Warner3
Direct visualization
Direct visualization
Hall et al22
Richards et al18
Notch view radiograph
Axillary MRI
April 2012, Vol 20, No 4
Description
Mild, 2 cm long × ≤0.3 cm deep; moderate, 2–4 cm long × 0.3–1 cm deep;
severe, 4 cm long × ≥1 cm deep
Grade I, confined to articular cartilage; grade II, extension into subchondral
bone; grade III, large subchondral defect
Grade I, cartilaginous; grade II, bony scuffing; grade III, hatchet fracture
Clinically insignificant, <20%; variable significance, 20% to 40%; clinically
significant, >40%
Percent involvement in 180° articular arc
Axillary degrees involved (anterior articular margin, zero degrees)
247
The Hill-Sachs Lesion: Diagnosis, Classification, and Management
Figure 6
Table 4
Indications for Surgical Management of Hill-Sachs Lesions
Absolute
Displaced humeral head fracture with humeral head fracture-dislocation and associated Hill-Sachs injury
Lesion >30% to 40% of the humeral head with chronic dislocation or recurrent anterior
instability. These cases typically require glenoid augmentation and/or management of
the humeral head (eg, remplissage, allograft).
Reverse lesion with >20% to 40% of humeral head articular surface involvement and
symptoms of posterior instability, catching, or pain
Relative
Lesion >20% to 35% of the humeral head with glenoid engagement on examination
Lesion >20% of the articular surface and signs of humeral head engagement on
examination
Lesion >10% to 25% of the humeral head that does not remain well-centered in the
glenoid fossa after arthroscopic instability repair
Reverse lesion with humeral head cartilage involvement on 10% to 30% of the
humeral head, with symptoms of posterior instability, catching, or pain
sule in an attempt to limit external
rotation and anterior translation.
This procedure can be performed arthroscopically or via an open approach.31 Although this technique
can be effective in enhancing shoulder stability, it is not necessarily an
anatomic solution. Additionally, the
loss of external rotation may be
problematic for young patients, especially overhead-throwing athletes.
Even though capsular plication techniques are among the most commonly performed procedures for anterior shoulder stabilization, they
address only the soft tissue and may
not be adequate in cases of instability with significant Hill-Sachs lesions.
Glenoid Bone
Augmentation
Glenoid bone augmentation has been
well-documented as the primary procedure in addressing significant HillSachs defects associated with recurrent glenohumeral instability. The
most common procedures used include coracoid transfer (ie, Latarjet)
and iliac crest bone grafting.6,16,32,33
Recently, augmentation with various
allograft tissues, including femoral
248
head34 and distal tibia allograft,35 has
been described (Figure 6). These procedures effectively lengthen the articular arc of the glenoid. Although
they do not address the humeral
head defect directly, they prevent engagement of the Hill-Sachs lesion
during normal range of motion.
Humeral Head Bone
Augmentation
Procedures that directly address HillSachs lesions are traditionally indicated in the setting of significant
Hill-Sachs injuries without concomitant glenoid bone loss. In the rare instance of a large Hill-Sachs lesion
without concomitant glenoid bone
loss, restoration of the anatomy has
been advocated, in addition to a variety of soft-tissue procedures. Bone
augmentation of the humeral defect
has been described to manage large
defects with or without glenoid bone
injury.
The intent with these procedures is
to fill the defect and restore native
anatomy by effectively increasing the
articular arc of the humerus as it rotates on the glenoid, thereby preventing engagement and instability. Bone
plugs are typically size-matched to
Intraoperative photograph
demonstrating the use of iliac crest
autograft harvested from the
contralateral hip (white arrows) to
reconstruct a 25% anterior glenoid
bone deficiency. The capsule was
sutured to washers under the
screw heads (black arrows) on the
anterior aspect of the iliac crest,
thus making an intra-articular graft
of the iliac crest material. This
patient also had a 30% Hill-Sachs
lesion that easily engaged prior to
the iliac crest bone graft. Once
grafted, the lesion was unable to
engage the glenoid.
the defect. These plugs may be autograft (typically from the iliac
crest), fresh or frozen allograft, or
synthetic (ie, metal, polyethylene)
material. Fresh humeral head osteoarticular allografts have been
used with success, either with entire
humeral head replacement or with
grafts size-matched to the defect
(Figure 7).
Clinical studies describing outcomes following humeral head bone
augmentation procedures are limited
to small cohorts and case reports.
Diklic et al36 reported on the outcomes of 13 patients treated with
fresh-frozen femoral head allograft
for humeral head defects measuring
approximately 25% to 50% (mean
age, 42 years). At an average of 54
months postoperatively, 12 patients
had stable shoulders, and 1 patient
had evidence of osteonecrosis. The
mean Constant score for the cohort
was 86.8. In a slightly larger cohort
Journal of the American Academy of Orthopaedic Surgeons
CDR Matthew T. Provencher, MD, et al
Figure 7
Intraoperative photographs illustrating the use of fresh proximal humerus allograft to replace a large symptomatic HillSachs lesion. The humeral head is exposed through a deltopectoral approach (A), and the large Hill-Sachs lesion is
visualized (B) (arrows). C, The donor humeral head allograft is marked in preparation for harvest of a size-matched
graft with an oscillating saw (arrows). D, The size-matched allograft. E, The graft is secured to the native humeral head
with buried screws.
study, Miniaci and Gish37 described
18 patients with recurrent traumatic
instability and Hill-Sachs defects
>25% who underwent augmentation
with size-matched, fresh-frozen humeral head allografts. At an average
follow-up of 50 months postoperatively, 16 patients were able to return
April 2012, Vol 20, No 4
to work. However, several complications were noted, including partial
radiographic graft collapse (two patients), early radiographic osteoarthritis (three patients), mild subluxation (one patient), and hardware
complications (two patients). The
mean Constant score was 78.5.
Tissue Filling
(Remplissage)
The Connolly procedure has been
successfully used to fill humeral head
defects by converting them into
extra-articular lesions.38 Originally
described in 1972, this open procedure involves transfer of the infraspi-
249
The Hill-Sachs Lesion: Diagnosis, Classification, and Management
natus tendon with a portion of the
greater tuberosity into the humeral
head defect.
Recently, surgeons have begun to
manage Hill-Sachs lesions arthroscopically using available glenohumeral capsulotendinous tissue.
The term remplissage, French for filling, is a surgical technique in which
a bony intra-articular defect is converted to an extra-articular defect
with soft-tissue coverage, with the
goal of preventing engagement.29,39-42
Originally described by Wolf et al,42
the technique involves arthroscopic
posterior capsulodesis and infraspinatus tenodesis, with fixation of the
tissue to the surface of the Hill-Sachs
defect. In 2009, the technique was
modified by Koo et al,41 who described a double-pulley suture technique in which two anchors were
used to insert the infraspinatus tendon into the entire Hill-Sachs defect.
This modification created a broader
footprint of fixation, and tying the
sutures over rather than through the
infraspinatus tendon allowed for a
more anatomic and tissue-preserving
approach.
Remplissage is performed in patients with moderate to large HillSachs defects associated with glenoid
defects of <20% to 25%. Patients
with larger glenoid defects may require conversion to an open Latarjet
procedure. Potential disadvantages
associated with remplissage are decreased postoperative range of motion and sequelae of a nonanatomic
repair construct. In 2008, Deutsch
and Kroll40 described a case of significant postoperative loss of external
rotation following remplissage. Motion was improved following arthroscopic release of the infraspinatus tenodesis; the authors proposed
that the infraspinatus tendon and
posterior capsular tissue created a
mechanical block to motion. In their
series, Purchase et al29 noted unpublished findings indicating good re-
250
sults with remplissage, with no notable loss of external rotation. Most
patients did not experience recurrent
instability.
Advantages of remplissage include
the arthroscopic approach, the ability to perform concomitant procedures, and fast recovery time. Additionally, this approach has none of
the risks and morbidity associated
with bone grafting procedures.
Disimpaction
Disimpaction of a humeral head defect
(ie, humeroplasty) involves elevating
the impaction fracture and supporting
it with bone graft, thereby allowing for
approximate restoration of humeral
head geometry without internal fixation.43,44 The procedure can be performed using bone tamps inserted
retrograde through a distal cortical
window.43 Alternatively, disimpaction can be performed percutaneously using an 8-mm cannulated
reamer drilled to within 1 cm of the
posterior surface, followed by backfilling of the defect with cancellous
bone chips.44 This technique is relatively new, and little biomechanical
and clinical research has been published on the topic. Disimpaction
may be most suited to acute lesions
<3 weeks old and with <40% involvement of the articular surface.19
Resurfacing and Prosthesis
Replacement
Complete and partial resurfacing of the
humeral head articular surface has
been described. Limited resurfacing of
the defect with a metal implant is done
in an attempt to restore the humeral
head articular arc.20,45 Although partial resurfacing is promising in theory, only limited case reports with
short-term follow-up are available in
the literature. Outcomes have been
reported to be positive at 1 to 2
years postimplantation.20,45 With this
technique there is no risk of disease
transmission or resorption, as can
occur with allograft. However, disadvantages include loss of fixation,
incomplete geometric restoration,
and eventual glenoid wear.
Complete humeral head resurfacing
(ie, humeral head hemiarthroplasty) is
an option for Hill-Sachs lesions that
cause recurrent instability, in particular lesions that involve >40% of the articular surface.46 However, indications
are not clearly defined. Older (>65
years), low-demand patients may benefit from hemiarthroplasty or total
shoulder arthroplasty (TSA) in the
presence of concomitant glenoid degeneration. However, outcomes of hemiarthroplasty and TSA are much less
predictable, with high failure rates in
young, active patients. In these patients, hemiarthroplasty should be considered a salvage procedure in cases of
severe defects causing recurrent instability. Pritchett and Clark46 described
humeral hemiarthroplasty and TSA in
seven patients with chronic dislocations
and significant Hill-Sachs lesions. Average patient age was 55 years (range,
36 to 67 years). Five patients had good
results, and there were no occurrences
of repeat dislocation. These procedures
should be reserved for older or less active patients with defects involving
>40% of the articular surface and/or
significant articular cartilage degeneration.
Surgical Management of
Reverse Hill-Sachs
Lesions
Management of reverse Hill-Sachs lesions is based on the same philosophy as management of traditional
Hill-Sachs lesions. The primary
cause of the instability is addressed
with a procedure that prevents engagement of the lesion through direct
or indirect means. One fundamental
difference between a traditional and
a reverse Hill-Sachs lesion is that, in
Journal of the American Academy of Orthopaedic Surgeons
CDR Matthew T. Provencher, MD, et al
reverse injury, the anterior humeral
head cartilage is more extensively injured and involved. As such, softtissue filling of the defect has been
advocated. However, concerns persist regarding loss of articulation of
the humeral head resulting from the
generally large and extensive cartilage injury.
The well-described McLaughlin
procedure involves an open transfer
of the subscapularis tendon and
lesser tuberosity to fill the humeral
head defect.47 The tuberosity transfer
involves creation of an osteotomy of
the lesser tuberosity while maintaining attachment of the subscapularis
tendon and anterior capsule, followed by elevation and transfer to
the site of the defect bed. This
procedure can result in restriction
of internal rotation postoperatively.
Krackhardt et al48 described an arthroscopic modification of the
McLaughlin procedure and reported
successful outcomes and no major
complications in 12 patients. Fresh
osteoarticular allograft is a viable
option for reverse Hill-Sachs lesions
because of the increased extent of
cartilage involvement compared with
a traditional Hill-Sachs injury. Prosthetic reconstruction may also be
considered for patients with extremely large reverse Hill-Sachs lesions (ie, >40%).
Summary
Osseous lesions of the humeral head
create challenging clinical scenarios.
The most difficult aspect of these
cases involves determining which
Hill-Sachs lesions are clinically significant and need to be addressed
surgically. Lesion size, orientation,
location, and concomitant glenoid
bone loss must be evaluated in light
of the patient’s symptoms. Recent literature suggests that Hill-Sachs lesions are best approached as bipolar
April 2012, Vol 20, No 4
problems in which a glenoid defect is
magnified in the setting of glenoid
bone loss. The concept of the glenoid
track advanced the understanding of
engagement and recurrent instability
by defining the humeral head deficiency in relation to glenoid width
and bone loss.
A meticulous approach to the diagnostic workup is essential and must
include a complete history and thorough physical examination. Imaging
and arthroscopic findings can aid in
the decision-making process. Small
lesions may be addressed solely on
the glenoid side to increase the articular arc and prevent engagement.
However, large Hill-Sachs defects
may require combined procedures
that directly address the humeral defect, including arthroplasty, humeral
head allograft, remplissage, and resurfacing.
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