Is shoulder arthroplasty indicated for a patient with a Hill-Sachs depression fracture, bony Bankart injury, and significant soft tissue damage, including a sprain of the deltoid (deltoid muscle) and subscapularis muscle, with a moderate to large effusion in the glenohumeral joint?

Management of Hill-Sachs Depression Fracture with Bony Bankart Injury

Shoulder arthroplasty is not indicated as first-line treatment for a Hill-Sachs depression fracture with associated bony Bankart injury, deltoid and subscapularis muscle sprain, and glenohumeral joint effusion. Instead, arthroscopic or open repair techniques should be pursued as the primary treatment option 1.

Assessment of Injury Pattern

The described injury pattern represents a classic traumatic anterior shoulder instability complex:

• Hill-Sachs depression fracture (1 cm depth) with bone marrow edema
• Bony Bankart injury (truncation of anterior-inferior glenoid)
• Soft tissue damage (deltoid and subscapularis muscle sprain)
• Glenohumeral joint effusion
• Intact rotator cuff tendons

Treatment Algorithm

First-Line Treatment Options

1. Arthroscopic Bankart Repair with Hill-Sachs Remplissage

   • Preferred for Hill-Sachs lesions with moderate glenoid bone loss (<25%)
   • Involves arthroscopic capsulotenodesis of posterior capsule and infraspinatus tendon to fill the Hill-Sachs lesion 2, 3
   • Followed by repair of the anterior Bankart lesion
   • Long-term studies show excellent outcomes with only 4.4% recurrence rate 2

2. Open Bankart Repair

   • Indicated when glenoid bone loss is 10-30% with concomitant Hill-Sachs lesion
   • Provides excellent functional outcomes with acceptable recurrence rates (16.8% over 7 years) 4
   • More reliable for larger bony defects

3. Arthroscopic Osseous Bankart Repair

   • Effective for chronic recurrent instability with osseous fragments
   • Can address glenoid bone loss up to 24.8% with good to excellent results 5

When to Consider Shoulder Arthroplasty

Shoulder arthroplasty would only be considered in specific circumstances:

• Older patients with significant degenerative glenohumeral osteoarthritis
• Failed previous stabilization procedures with progressive arthritis
• Extensive humeral head damage not amenable to repair

According to the American College of Radiology guidelines, humeral head resurfacing (not full arthroplasty) may be indicated in patients with large Hill-Sachs deformity, but this is typically reserved for cases with associated osteoarthritis or osteonecrosis 1.

Important Considerations

• Age and Activity Level: Younger, active patients benefit more from repair techniques than arthroplasty
• Bone Loss Assessment: MR arthrography is the preferred imaging study for evaluating both bony and soft tissue components of this injury pattern 1
• Surgeon Experience: If arthroplasty is eventually needed, it should be performed by surgeons who do more than two shoulder arthroplasties per year to reduce complications 1
• Contraindications to Arthroplasty: Total shoulder arthroplasty is contraindicated in patients with irreparable rotator cuff tears 1

Pitfalls to Avoid

1. Underestimating Bone Loss: Failure to accurately assess glenoid bone loss can lead to recurrent instability
2. Overlooking Soft Tissue Damage: The subscapularis sprain must be addressed during surgical repair to prevent anterior instability
3. Premature Arthroplasty: Performing arthroplasty before attempting appropriate repair techniques can unnecessarily limit future options
4. Inadequate Imaging: Relying solely on plain radiographs rather than advanced imaging (MR arthrography) for surgical planning

In conclusion, the current evidence strongly supports arthroscopic or open repair techniques for the described injury pattern rather than proceeding directly to shoulder arthroplasty. Arthroplasty should be reserved for cases with significant glenohumeral osteoarthritis or as a salvage procedure after failed stabilization attempts.