What is the appropriate management for a 35-year-old male with a Hill‑Sachs lesion?

Management of Hill-Sachs Lesion in a 35-Year-Old Male

For a 35-year-old male with a Hill-Sachs lesion, obtain MR arthrography to comprehensively assess the lesion size, engagement status (on-track vs off-track), and associated soft tissue injuries (Bankart lesion, labral tears, rotator cuff pathology), then proceed with arthroscopic Bankart repair with remplissage for off-track lesions or isolated Bankart repair for on-track lesions. 1

Initial Diagnostic Approach

Imaging Strategy

Start with standard shoulder radiographs including AP views in internal and external rotation, plus an axillary or scapula-Y view. Add a Stryker notch view specifically to visualize the Hill-Sachs lesion 2. However, radiographs alone are insufficient for surgical planning.

MR arthrography is the gold standard for evaluating Hill-Sachs lesions and should be your next step 1. This modality:

• Assesses both osseous (Hill-Sachs) and soft tissue pathology (Bankart, labral tears, rotator cuff) simultaneously
• Evaluates glenoid and humeral head bone loss with equivalent accuracy to CT 1
• Detects cartilage-only Hill-Sachs lesions that CT misses 1
• Has 86-100% sensitivity for labral injuries 1

Critical Assessment Points

At age 35, this patient falls into the high-risk category for:

• Labroligamentous injury (more common in younger patients) 1
• Recurrent instability if inadequately treated
• Bipolar bone loss (both glenoid and humeral head defects) requiring comprehensive evaluation 3, 4

Determining Surgical Strategy

The Glenoid Track Concept

The critical decision point is whether the Hill-Sachs lesion is on-track or off-track 3:

On-track lesions:

• Do not engage the glenoid during shoulder motion
• Treated with isolated arthroscopic Bankart repair
• Soft tissue procedures alone are sufficient

Off-track lesions:

• Engage the anterior glenoid rim during shoulder motion
• High failure rate with isolated soft tissue repair
• Require additional procedures to prevent engagement 3

Treatment Algorithm

For off-track Hill-Sachs with minimal/no glenoid bone loss:

• Arthroscopic Bankart repair + remplissage (capsulotenodesis of posterior capsule and infraspinatus into the Hill-Sachs defect) 5, 3, 6
• This "fills" the humeral defect, preventing engagement
• Low complication and recurrence rates 3

For off-track Hill-Sachs with significant glenoid bone loss (>20-25%):

• Latarjet procedure or free bone block to lengthen the glenoid track 3
• Converts off-track to on-track by restoring glenoid width
• Consider Eden-Hybinette for very large defects 3

For large engaging lesions (>30% humeral head):

• May require autogenous tricorticocancellous iliac crest bone graft 7
• Reserved for massive defects not amenable to remplissage

Common Pitfalls to Avoid

1. Don't rely on radiographs alone - They miss associated soft tissue injuries and underestimate bone loss 2

2. Don't order CT instead of MR arthrography - CT cannot assess the labroligamentous complex, which is almost always injured in this age group 1

3. Don't treat Hill-Sachs in isolation - Nearly 100% of recurrent dislocations have Hill-Sachs lesions, but the Bankart lesion drives instability 4. Both must be addressed.

4. Don't ignore the bipolar nature - Glenoid and humeral bone loss interact dynamically. Assess both to determine engagement risk 3, 4

5. Don't attempt conservative management in young active patients with documented instability - At age 35 with athletic demands, surgical stabilization optimizes long-term function and prevents recurrent dislocations that worsen bone loss 5

Nuances in This Age Group

The 2018 ACR guidelines emphasize that younger patients are more likely to have labroligamentous injury and persistent instability compared to older patients, who more commonly have rotator cuff tears 1. At 35 years old, prioritize:

• Comprehensive labral assessment
• Evaluation for capsular laxity
• Assessment of activity level and return-to-sport goals

MR arthrography specifically outperforms non-contrast MRI for detecting anterior labral tears and SLAP lesions in this population 1, making it essential rather than optional.

When to Consider Alternatives

CT arthrography is comparable to MR arthrography for diagnosing Hill-Sachs and Bankart lesions 1 but should only be used if MRI is contraindicated (pacemaker, severe claustrophobia, metallic foreign body).

Ultrasound has no role in Hill-Sachs assessment - it's inferior to MRI for both labroligamentous injuries and Hill-Sachs lesions 1.