Is treatment necessary for a Hill-Sachs (Hill-Sachs lesion) deformity?

Treatment for Hill-Sachs Deformity

Treatment for a Hill-Sachs deformity is not always necessary and depends primarily on the size of the defect, with defects smaller than 25% of the articular surface typically managed conservatively, while those between 25-40% may require surgical intervention, and those larger than 40% often need prosthetic replacement. 1

Assessment and Diagnosis

• Initial evaluation should include plain radiographs to confirm the presence and characteristics of the Hill-Sachs lesion 2
• Advanced imaging is recommended for better characterization:
  • MR arthrography is the gold standard with 86-100% sensitivity 2
  • Standard MRI without contrast is highly effective 2
  • CT arthrography is comparable to MR arthrography for Hill-Sachs lesions but should be reserved for patients with contraindications to MRI 3

Treatment Algorithm Based on Defect Size

Small Defects (<25% of articular surface)

• Conservative management is appropriate 1
• Focus on rehabilitation protocol:
  • Phase 1: Pain control, gentle ROM exercises, proper positioning education
  • Phase 2: Progressive ROM exercises, light strengthening, scapular stabilization
  • Phase 3: Progressive resistance training, advanced stabilization, and activity-specific training 2

Moderate Defects (25-40% of articular surface)

• Surgical intervention may be necessary depending on:
  • Depth of the defect
  • Time interval between dislocation and treatment
  • Quality of the bone 1
• Surgical options include:
  • Retrograde chondral elevation
  • Antegrade cylindrical graft
  • Iliac bone crest graft with open approach
  • Remplissage procedure (arthroscopic capsulotenodesis of posterior capsule and infraspinatus tendon to fill the Hill-Sachs lesion) 4

Large Defects (>40% of articular surface)

• Endoprosthesis of the glenohumeral joint is typically recommended 1

Important Considerations

• The relationship between recurrent dislocations and Hill-Sachs lesions is significant - studies show correlation between number of dislocations and the extent/depth of Hill-Sachs lesions 5
• Early surgical intervention should be considered in patients with recurrent anterior dislocations to prevent progression of the Hill-Sachs lesion, which can itself become a cause of instability 5
• For engaging Hill-Sachs lesions (those that interact with the glenoid rim during normal shoulder motion), surgical intervention is more likely to be necessary 4

Follow-up Recommendations

• Initial follow-up at 1-2 weeks to assess response to treatment
• Clinical reassessment at 6 weeks
• Evaluation of rehabilitation progress at 3 months 2
• Consider surgical referral if:
  • Patient is under 30 years of age
  • Participates in high-demand or contact sports
  • Has evidence of significant Hill-Sachs lesion
  • Shows no improvement after 3 months of appropriate rehabilitation 2

Surgical Outcomes

Studies show fair to good functional outcomes following surgical intervention for moderate-sized Hill-Sachs lesions, with open approaches not necessarily disadvantageous for functional outcomes 1. The remplissage procedure has shown promising results for engaging Hill-Sachs lesions, allowing for subsequent repair of associated Bankart lesions 4.