What is the approach to repairing a Hill-Sachs (Hill-Sachs lesion) lesion?

Approach to Hill-Sachs Lesion Repair

The optimal approach to repairing a Hill-Sachs lesion depends on the size of the defect, with arthroscopic remplissage being the preferred treatment for engaging Hill-Sachs lesions when combined with Bankart repair for anterior shoulder instability. 1, 2

Diagnostic Assessment

• Imaging:
  • Plain radiographs are first-line imaging for all shoulder pain 3, 4
  • Specific views for Hill-Sachs detection:
    • Stryker notch view (patient supine, arm externally rotated and abducted, x-ray beam angled 10° cephalad) combined with AP internal rotation view 3
    • MR arthrography is the gold standard for evaluating associated labral tears (rated 9/9) 4
    • Standard MRI without contrast is highly effective (rated 7/9) 4
    • CT arthrography if MRI is contraindicated 4

Treatment Algorithm Based on Defect Size

Small Defects (<25% of Humeral Head Articular Surface)

• Conservative management is appropriate 5
• Physical therapy focusing on:
  • Rotator cuff strengthening
  • Scapular stabilization
  • Range of motion exercises
  • Activity modification 4

Medium-Sized Defects (25-40% of Humeral Head)

• Surgical intervention recommended, options include:

  1. Arthroscopic Remplissage: Preferred technique for engaging Hill-Sachs lesions 1, 2

     • Involves capsulotenodesis of posterior capsule and infraspinatus tendon to fill the Hill-Sachs lesion
     • Typically combined with Bankart repair for anterior instability
     • Procedure "exteriorizes" the humeral head defect 6

  2. Retrograde Chondral Elevation: For acute lesions with salvageable cartilage 5

  3. Antegrade Cylindrical Graft: For deeper defects 5

  4. Iliac Bone Crest Graft: Open approach with good functional outcomes (Constant score 92.00, Rowe 93.33 at 5-year follow-up) 5

  5. Balloon Humeroplasty: Arthroscopically assisted disimpaction with bone cement to support and maintain reduction 6

Large Defects (>40% of Humeral Head)

• Glenohumeral joint arthroplasty recommended 5

Key Considerations for Surgical Decision-Making

1. Glenoid Track Evaluation:

   • Off-track lesions (Hill-Sachs width > glenoid width) have higher risk of failure with isolated arthroscopic treatment 2
   • These require addressing both the Hill-Sachs and any glenoid bone loss

2. Associated Injuries:

   • Bankart lesions (anterior labral tears) should be repaired concurrently 1, 2
   • Evaluate for HAGL, GLAD, ALPSA, rotator cuff injuries, and axillary nerve damage 2

3. Timing Considerations:

   • Treatment algorithm should consider time interval between dislocation and surgical treatment 5
   • Acute lesions may be amenable to elevation techniques
   • Chronic lesions often require grafting or remplissage

Surgical Technique for Arthroscopic Remplissage

1. Position patient in lateral decubitus position
2. Establish posterior portal at lateral aspect of humeral head convexity centered over lesion
3. Establish anterior-inferior and anterior-superior portals
4. Place camera in anterior-superior portal
5. Freshen Hill-Sachs lesion with a bur through posterior portal
6. Insert cannula in posterior portal through deltoid (not through infraspinatus/capsule)
7. Place anchor in inferior aspect of humeral lesion
8. Pass penetrating grasper through tendon and posterior capsule 1cm inferior to initial portal
9. Place second anchor superiorly with similar suture passage
10. Tie inferior suture first with extra-articular knots, pulling infraspinatus and capsule into lesion
11. Complete Bankart repair 1

Post-Surgical Rehabilitation

• Follow-up schedule:
  • Initial evaluation with radiographs at 1-2 weeks
  • Clinical assessment at 6 weeks
  • Assessment for recurrent instability at 3 months
  • Long-term follow-up at 6-12 months 4
• Supervised physical therapy shows better outcomes than unsupervised home exercise 4

Pitfalls and Caveats

• Failure to recognize an engaging Hill-Sachs lesion may lead to recurrent instability despite Bankart repair
• Remplissage can result in some loss of external rotation, which may be significant for overhead athletes
• Inadequate freshening of the Hill-Sachs lesion may lead to poor healing of the capsulotenodesis
• Aggressive range-of-motion exercises early in rehabilitation may compromise repair 4