What is the management approach for Hill-Sachs deformity?

Management of Hill-Sachs Deformity

The management of Hill-Sachs deformity should be based on the size of the defect, with humeral head resurfacing indicated for large Hill-Sachs deformities, while defects smaller than 25% of the articular surface can be treated conservatively. 1, 2

Diagnostic Evaluation

• Standard radiographic evaluation should include anterior-posterior views in internal and external rotation, axillary or scapula-Y view, with the Stryker notch view specifically recommended for evaluating Hill-Sachs lesions 3
• CT without contrast is recommended when radiographs are indeterminate, as it provides comprehensive fracture characterization and helps identify subtle features of the defect 3
• It's essential to identify concomitant pathology, especially glenoid bone loss, as Hill-Sachs is often a bipolar injury requiring comprehensive assessment 2

Treatment Algorithm Based on Defect Size

• Defects smaller than 25% of the humeral head articular surface:

  • Conservative management with focused rehabilitation 2, 4
  • Physical therapy focusing on static stretching exercises when pain and stiffness are minimal 3

• Defects between 25% and 40% of the articular surface:

  • Surgical intervention based on bone quality and defect characteristics 4
  • Options include:
    • Retrograde chondral elevation 4
    • Antegrade cylindrical graft 4
    • Iliac bone crest graft with open approach 4
    • Remplissage procedure (infraspinatus tenodesis into the defect) 5

• Defects larger than 40% of the articular surface:

  • Glenohumeral joint arthroplasty 4
  • Humeral head resurfacing for large Hill-Sachs deformity 1

Rehabilitation and Post-Treatment Management

• Physical therapy should include static stretching exercises when pain and stiffness are minimal 3
• Superficial moist heat before exercises may improve effectiveness 3
• 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 3
• Avoid prolonged immobilization beyond the necessary healing period to prevent stiffness and decreased range of motion 3

Special Considerations

• For recurrent anterior shoulder instability with Hill-Sachs lesions, additional stabilization procedures may be necessary to address associated pathology (e.g., Bankart repair) 2
• In cases with concurrent glenoid defects, procedures like the Latarjet may be required 5
• For neglected anterior shoulder dislocations with Hill-Sachs lesions, open procedures are typically required 5
• Reverse Hill-Sachs lesions can occur with posterior shoulder instability and require specific management approaches 2, 4

Clinical Pearls and Pitfalls

• The incidence of Hill-Sachs lesions approaches 100% in patients with recurrent anterior shoulder instability 2
• Failure to identify and address concomitant glenoid bone loss can lead to poor outcomes 2
• Prompt reduction and immobilization of acute anterior shoulder dislocations can help minimize complications 6
• Open surgical approaches for Hill-Sachs lesions do not necessarily lead to inferior functional outcomes compared to arthroscopic techniques 4