From the Guidelines
The treatment for a patient with a chronic Hill-Sachs deformity of the humeral head and a possible chronic osseous Bankart lesion typically requires surgical intervention due to the high risk of recurrent shoulder instability. The recommended approach is a combined procedure addressing both defects, such as a Latarjet procedure (coracoid bone transfer) or an iliac crest bone graft for the glenoid defect, along with a remplissage procedure for the Hill-Sachs lesion. The remplissage technique involves filling the humeral head defect by attaching the infraspinatus tendon and posterior capsule into the defect, effectively converting it into an extra-articular lesion. Preoperative imaging is essential to accurately assess the size and location of both defects, as lesions involving more than 20-25% of the glenoid or engaging Hill-Sachs defects have poorer outcomes with soft tissue repairs alone 1. Some studies suggest that MRI has been shown to be equivalent to CT for assessing both glenoid and humeral head bone loss 1. However, CT arthrography has the advantage of characterizing both bony lesions and significant soft-tissue injuries, and has been shown to be comparable with MR arthrography in diagnosing Bankart, Hill-Sachs, superior labral anterior-to-posterior (SLAP), and full-thickness rotator cuff tears 1. Postoperatively, patients typically require immobilization for 3-6 weeks followed by a structured rehabilitation program focusing initially on passive range of motion exercises, progressing to active motion at 6 weeks, and strengthening exercises at 12 weeks. Return to full activities, including sports, usually occurs at 6 months postoperatively. This combined approach addresses the bipolar nature of these lesions, with the glenoid reconstruction restoring the anterior buttress and the remplissage preventing engagement of the Hill-Sachs defect during external rotation, significantly reducing recurrence rates compared to isolated soft tissue repairs. Key considerations in the treatment plan include:
- Accurate preoperative assessment of the defects using imaging studies such as CT or MRI
- A combined surgical approach addressing both the glenoid and humeral head defects
- A structured postoperative rehabilitation program to ensure optimal recovery and return to function.
From the Research
Definition and Causes
- A chronic Hill-Sachs deformity of the humeral head refers to an osseous defect of the humeral head, typically associated with anterior shoulder instability 2, 3.
- This deformity is usually caused by anterior shoulder dislocation with impaction of the posterosuperior humeral head onto the anterior glenoid rim 3.
- A possible chronic osseous Bankart lesion refers to a bony defect of the glenoid rim, which can occur in conjunction with a Hill-Sachs lesion 4.
Treatment Options
- Treatment for a patient with a chronic Hill-Sachs deformity of the humeral head and a possible chronic osseous Bankart lesion depends on the severity of the lesions and the patient's symptoms 2, 5.
- Nonsurgical management, including focused rehabilitation, may be acceptable in cases of small bony defects and nonengaging lesions in which the glenohumeral joint remains stable during desired activities 2.
- Surgical options include arthroscopic and open techniques, such as soft tissue transfer, rotational osteotomy, bone grafting, or osteochondral transplantation 2, 3, 6.
- Recent studies have demonstrated successful results stemming from purely arthroscopic procedures in treating Hill-Sachs lesions 6.
Diagnosis and Evaluation
- Diagnosis and evaluation of Hill-Sachs lesions and Bankart lesions can be performed through an accurate history, physical examination, and interpretation of imaging studies, such as MRI or 3D-CT 3, 4, 6.
- The glenoid track concept has been clinically validated as a method to predict engagement, and 3D-CT has become the "gold standard" for Hill-Sachs imaging 6.