What is the recommended treatment approach for a patient with a chronic Hill-Sachs deformity?

Treatment of Chronic Hill-Sachs Deformity

For chronic Hill-Sachs deformities, the treatment approach depends critically on lesion size and engagement risk: lesions <25% of the articular surface can be managed conservatively, lesions between 25-40% require surgical intervention with techniques ranging from arthroscopic remplissage to bone grafting procedures, and lesions >40% necessitate shoulder arthroplasty. 1

Initial Assessment and Imaging

Obtain MR arthrography as the definitive imaging study to assess both the Hill-Sachs lesion and associated soft tissue injuries, particularly Bankart lesions and labroligamentous structures. 2, 3 MR arthrography demonstrates 86-100% sensitivity for detecting labral pathology and accurately quantifies bone loss comparable to CT. 2, 3

• If MRI is contraindicated, CT arthrography serves as an acceptable alternative with comparable diagnostic accuracy for osseous abnormalities. 2, 3
• Plain radiographs alone significantly underestimate bone loss and should not guide treatment decisions. 3
• The glenoid track concept should be evaluated to predict engagement risk, as this determines whether the lesion requires direct treatment. 4

Treatment Algorithm Based on Defect Size

Small Lesions (<25% of Articular Surface)

Conservative management is the treatment of choice for defects <25% with duration of dislocation <3 weeks. 5, 1

• Closed reduction followed by immobilization in 15° external rotation. 5
• This approach demonstrates excellent long-term outcomes with no redislocation at 5-year follow-up (mean Constant score 87.4, Rowe score 96.4). 5
• Clinical instability tests (jerk test, Kim test) remain negative, and patients report no activity limitations. 5

Medium Lesions (25-40% of Articular Surface)

Surgical intervention is required, with technique selection based on defect depth, bone quality, and time from injury. 1

Arthroscopic Remplissage (Preferred First-Line Surgical Option)

Perform arthroscopic remplissage with infraspinatus tenodesis into the Hill-Sachs defect for engaging lesions in this size range. 6, 7

• Use transtendinous double-pulley technique with 1-3 arthroscopic anchors placed directly into the defect. 6, 7
• This technique achieves 75-100% fill of the defect with tendon incorporation visible on MRI by 8 months. 6
• Functional outcomes are excellent with mean WOSI score of 74.3% and minimal external rotation loss (average 5.8°). 6
• The procedure can be performed entirely arthroscopically without bone grafting or open approach. 6, 7

Alternative Surgical Options

For defects where remplissage is inadequate:

• Retrograde chondral elevation for shallow defects with good bone quality. 1
• Antegrade cylindrical graft for deeper defects requiring structural support. 1
• Open approach with iliac crest bone graft for large defects requiring substantial reconstruction (achieves Constant score 92.0, Rowe score 93.3 at 5-year follow-up). 1

Large Lesions (>40% of Articular Surface)

Total shoulder arthroplasty is indicated for defects exceeding 40% of the humeral articular surface. 1

• These massive defects cannot be adequately reconstructed with soft tissue or bone grafting procedures. 1
• The humeral head destruction is too extensive to maintain joint mechanics with preservation techniques. 1

Concomitant Bankart Repair

Always address associated Bankart lesions concurrently when performing remplissage or other Hill-Sachs procedures. 6

• The combination of infraspinatus tenodesis and Bankart repair significantly reduces recurrent instability risk in high-risk patients. 6
• MR arthrography identifies these labroligamentous injuries with high sensitivity (86-100%). 2, 3

Critical Pitfalls to Avoid

• Do not rely on plain radiographs alone to quantify bone loss, as this consistently underestimates defect size and leads to inadequate treatment planning. 3
• Do not use non-contrast MRI in chronic cases without adequate joint effusion, as this provides suboptimal soft tissue assessment; MR arthrography is mandatory. 3
• Do not ignore the glenoid track concept when determining if a Hill-Sachs lesion requires direct treatment, as non-engaging lesions may not need intervention even if large. 4
• Do not perform remplissage without concurrent Bankart repair when labroligamentous injury is present, as isolated Hill-Sachs treatment has higher failure rates. 6

Postoperative Considerations

Following arthroscopic remplissage, expect MRI findings at 8+ months to show tendon incorporation with possible granulation or fibrous tissue filling the defect. 6 Some patients (4 of 9 in one series) develop tendinopathy or partial tears of the residual infraspinatus insertion, though this does not correlate with clinical outcomes. 6