What is the management approach for Hill-Sachs deformity?

Management of Hill-Sachs Deformity

The management of Hill-Sachs deformity should be based on defect size, presence of instability, and engagement of the lesion, with surgical intervention recommended for lesions that are large (>25% of humeral head) or engaging, while smaller non-engaging lesions can be managed conservatively. 1

Diagnostic Approach

• Standard radiographic evaluation should include anterior-posterior views in internal and external rotation, and an axillary or scapula-Y view, with the Stryker notch view specifically recommended for evaluating Hill-Sachs lesions 2
• CT without contrast is advantageous for identifying subtle fracture characteristics and is recommended when radiographs are indeterminate for comprehensive fracture characterization 2
• MRI may be useful for evaluating associated soft tissue injuries such as Bankart lesions that commonly occur with Hill-Sachs deformities 1

Treatment Algorithm Based on Defect Size

Small Defects (<25% of humeral head)

• Conservative management with focused rehabilitation is appropriate for small, non-engaging lesions where glenohumeral joint remains stable during desired activities 1
• Physical therapy should include static stretching exercises when pain and stiffness are minimal 3
• Superficial moist heat before exercises may improve effectiveness 3

Moderate Defects (25-40% of humeral head)

• Surgical intervention is typically recommended based on stability assessment 4
• Surgical options include:
  • Retrograde chondral elevation for shallow defects 4
  • Antegrade cylindrical graft for deeper defects 4
  • Remplissage procedure (infraspinatus tenodesis into the defect) to make the lesion extra-articular 5
  • Bone grafting (iliac crest) for larger defects with good bone quality 4

Large Defects (>40% of humeral head)

• Arthroplasty (shoulder replacement) is recommended for very large defects 4
• For younger patients with large defects, bone grafting or specialized procedures may be considered to preserve the native joint 1

Special Considerations

• The presence of a "bipolar lesion" (Hill-Sachs with associated glenoid bone loss) requires careful evaluation as this significantly impacts treatment decisions 1
• Reverse Hill-Sachs lesions occur with posterior shoulder instability and require a different management approach 1
• Time interval between dislocation and treatment affects surgical options and outcomes 4
• Open surgical approaches have shown comparable functional outcomes to arthroscopic techniques in long-term follow-up 4

Post-Treatment Management

• Adequate positioning and appropriate orthotics should be used during recovery to counteract deforming forces 3
• Submaximal and aerobic exercise should be implemented, avoiding excessively strenuous activity that could worsen the condition 3
• For recurrent dislocations associated with Hill-Sachs lesions, prompt orthopedic consultation is essential 6

Common Pitfalls

• Failure to identify associated glenoid bone loss can lead to poor outcomes and recurrent instability 1
• Neglecting to assess for "engagement" of the Hill-Sachs lesion during shoulder range of motion can result in inappropriate treatment selection 1
• Prolonged immobilization beyond the necessary healing period can cause stiffness and decreased range of motion 3
• Delayed treatment of locked anterior dislocations with Hill-Sachs lesions may require more complex surgical interventions 5