What is the gold standard surgical management for a Hill-Sachs depression fracture with a depth of approximately 1 cm and an associated bony Bankart injury, along with sprains of the deltoid (muscle) and subscapularis (muscle) muscles?

Gold Standard Surgical Management for Hill-Sachs Depression Fracture with Bony Bankart Injury

The gold standard surgical management for a 1 cm Hill-Sachs depression fracture with associated bony Bankart injury is arthroscopic Bankart repair combined with remplissage (posterior capsulodesis and infraspinatus tenodesis) to fill the Hill-Sachs lesion. 1

Pathology Assessment

When evaluating a Hill-Sachs depression fracture with bony Bankart injury:

• MR arthrography is the gold standard imaging modality for comprehensive assessment of both bony and soft tissue injuries 2, 3
• CT is valuable for detailed characterization of fracture patterns and bone loss assessment 2
• The combination of these injuries (Hill-Sachs and bony Bankart) creates a high risk for recurrent instability if not properly addressed

Surgical Management Algorithm

1. For Hill-Sachs Depression (1 cm depth) with Bony Bankart Injury:

• Primary Approach: Arthroscopic remplissage + Bankart repair
  • Remplissage involves posterior capsulodesis and infraspinatus tenodesis to fill the Hill-Sachs defect
  • Concurrent arthroscopic Bankart repair addresses the anterior glenoid bone loss
  • This combined approach has shown excellent outcomes with only 4.4% recurrence rate in long-term follow-up (2-10 years) 1

2. Additional Considerations Based on Specific Findings:

• For the deltoid and subscapularis muscle sprains: These will typically heal with appropriate post-surgical rehabilitation
• For glenohumeral joint effusion: This will resolve following definitive surgical treatment
• For previous fixation screw: Surgical planning must account for existing hardware

Evidence-Based Outcomes

Long-term follow-up of arthroscopic remplissage with Bankart repair shows:

• High success rates with 95.6% stability maintenance over 2-10 years 1
• Excellent functional outcomes with median Rowe score of 95 and Constant score of 95 1
• Effective solution for the challenging combination of glenoid bone loss and significant Hill-Sachs lesion 1

Important Surgical Considerations

• Portal placement is critical: Strategic portal placement is essential for proper mobilization and repair of both lesions 4
• Bone fragment reduction: Ensure satisfactory reduction of the glenoid fragment with the attached capsulolabral complex 4
• Capsular tension: Appropriate capsular tension must be achieved to prevent recurrent instability 4

Common Pitfalls to Avoid

1. Underestimating bone loss: Failure to address both the Hill-Sachs and Bankart lesions can lead to recurrent instability
2. Inadequate fixation: Proper anchor placement and suture management are essential for durable repair
3. Improper rehabilitation: Too aggressive early rehabilitation can compromise surgical repair
4. Isolated soft tissue repair: In cases with significant bone loss, isolated Bankart repair without addressing the Hill-Sachs lesion has higher failure rates

Alternative Techniques

While remplissage with Bankart repair is the gold standard, alternative approaches include:

• Balloon humeroplasty: A novel technique for acute Hill-Sachs lesions that has shown promising results in cadaveric models with 99.3% defect reduction 5, but has less clinical evidence than remplissage
• Open Latarjet procedure: May be considered for cases with >25% glenoid bone loss, though this appears less applicable to the described case

The arthroscopic remplissage with Bankart repair approach offers the best balance of stability restoration and functional outcomes for the described pathology, with strong evidence supporting its efficacy in long-term follow-up studies.