What is the treatment plan for a patient with a Hill-Sach deformity?

Hill-Sachs Deformity Treatment Plan

For Hill-Sachs deformities, treatment depends critically on lesion size and engagement risk: defects <25% of the articular surface are managed conservatively with physical therapy, while larger engaging lesions require arthroscopic Bankart repair combined with remplissage, and massive defects (>40%) necessitate humeral head resurfacing or bone grafting. 1, 2

Initial Diagnostic Workup

Imaging Protocol

• Obtain MR arthrography as the definitive imaging study (86-100% sensitivity for labral pathology and accurate bone loss quantification), which is essential for surgical planning 3
• If MRI is contraindicated, use CT arthrography as an acceptable alternative with comparable accuracy for osseous abnormalities 3
• Standard radiographs should include AP views in internal/external rotation, axillary or scapula-Y view, and specifically the Stryker notch view for Hill-Sachs evaluation 4, 1
• Never rely on plain radiographs alone to quantify bone loss—this consistently underestimates defect size and leads to inadequate treatment planning 3

Critical Assessment Parameters

• Measure Hill-Sachs lesion size as percentage of articular surface 1, 2
• Evaluate glenoid track concept: determine if lesion is "on-track" (stable) or "off-track" (engaging), as off-track lesions where Hill-Sachs width exceeds glenoid width carry high failure risk with isolated arthroscopic repair 2
• Assess for associated injuries: glenoid bone loss, HAGL lesions, GLAD lesions, ALPSA lesions, rotator cuff tears, and axillary nerve injury 2

Treatment Algorithm

Small Lesions (<25% Articular Surface, On-Track)

Conservative management is appropriate:

• Initiate physical therapy focusing on rotator cuff and periscapular strengthening 2
• Implement static stretching exercises when pain and stiffness are minimal 1
• Apply superficial moist heat before exercises to improve effectiveness 1
• Use submaximal and aerobic exercise, avoiding excessively strenuous activity 1
• Ensure adequate positioning with appropriate orthotics to counteract deforming forces 1
• Avoid prolonged immobilization beyond necessary healing period, as this causes stiffness and decreased range of motion 1

Moderate-to-Large Engaging Lesions (25-40% Articular Surface, Off-Track)

Arthroscopic Bankart repair with remplissage is the procedure of choice:

• Perform arthroscopic capsulolabral repair with at least 4 anchors if good tissue quality exists 2
• Add arthroscopic remplissage (capsulotenodesis of posterior capsule and infraspinatus tendon into the Hill-Sachs defect) to prevent engagement 2, 5
• This combination significantly reduces recurrence rates (13% with remplissage vs 47% without in adolescents) 6
• Remplissage causes minimal external rotation loss (average 5.8°) and demonstrates 75-100% tendon fill of the defect on postoperative MRI 7
• The procedure can be performed using a transtendinous double-pulley technique with 2 anchors placed in the lesion, tying suture limbs to create a pulley repair 8

Massive Lesions (>40% Articular Surface) or Failed Prior Surgery

Humeral head resurfacing or bone grafting is required:

• Humeral head resurfacing for large Hill-Sachs deformities when defects exceed 40% 1
• Consider Hill-Sachs lesion bone grafting (autograft or allograft) in those with large engaging lesions that cannot be adequately addressed with remplissage 2

Concomitant Glenoid Bone Loss

If glenoid bone loss >20% exists:

• Perform coracoid transfer (Latarjet procedure) as the primary intervention 2
• For failed Latarjet or massive glenoid deficiency, use distal tibial allograft bone grafting 2

Special Populations

Young Athletes in Contact Sports

• Surgical intervention is strongly indicated even after first dislocation in young athletes involved in contact or high-risk sports, given extremely high recurrence rates with conservative management 2
• Male patients <20 years in contact sports are at particular risk and warrant aggressive surgical treatment 2

High Number of Recurrent Dislocations Without Bone Loss

• Consider open Bankart repair rather than arthroscopic approach in patients with multiple recurrences or those in high-risk sports 2

Common Pitfalls to Avoid

• Do not use non-contrast MRI in chronic cases without adequate joint effusion—MR arthrography is mandatory for proper soft tissue assessment 3
• Do not perform isolated Bankart repair for off-track Hill-Sachs lesions without addressing the humeral defect, as this leads to high failure rates 2
• Do not immobilize excessively during rehabilitation, as functional support with bracing is preferred over rigid immobilization 1
• Be aware that recurrent deformity occurs in approximately 29% of patients in some surgical series, emphasizing the importance of proper technique and patient selection 9