Diagnosis and Treatment of Hill-Sachs Lesions

The Hill-Sachs Lesion: Diagnosis,
Classification, and Management
Abstract
The Hill-Sachs lesion is an osseous defect of the humeral head
that is typically associated with anterior shoulder instability. The
incidence of these lesions in the setting of glenohumeral instability
is relatively high and approaches 100% in persons with recurrent
anterior shoulder instability. Reverse Hill-Sachs lesion has been
described in patients with posterior shoulder instability. Glenoid
bone loss is typically associated with the Hill-Sachs lesion in
patients with recurrent anterior shoulder instability. The lesion is a
bipolar injury, and identification of concomitant glenoid bone loss is
essential to optimize clinical outcome. Other pathology (eg, Bankart
tear, labral or capsular injuries) must be identified, as well.
Treatment is dictated by subjective and objective findings of
shoulder instability and radiographic findings. Nonsurgical
management, including focused rehabilitation, is acceptable in
cases of small bony defects and nonengaging lesions in which the
glenohumeral joint remains stable during desired activities. Surgical
options include arthroscopic and open techniques.
The Hill-Sachs lesion is a com-
pression fracture of the postero-
superolateral humeral head that oc-
curs in association with anterior
instability or dislocation of the gle-
nohumeral joint. In 1940, Hill and
Sachs1
described the lesion as a so-
called line of condensation on the in-
ternal rotation shoulder radiograph.
They attributed this line to the im-
pression of the dense cortical glenoid
on the humeral head during an ante-
rior dislocation event.
Improved understanding of the asso-
ciation between humeral head bony
defects and recurrent glenohumeral
instability has resulted in increased in-
terest in identifying the optimal man-
ner by which to classify and manage
Hill-Sachs injuries. There is an histor-
ical body of evidence supporting an as-
sociation between a combined engag-
ing Hill-Sachs lesion and anterior
glenoid bone loss in cases of recurrent
instability.2-5
Although a substantial
amount of literature exists on the
well-established relationship between
glenoid bony defects and shoulder
instability,6-8
there is a relative pau-
city of literature on humeral head de-
fects.9
Epidemiology
The true incidence of Hill-Sachs le-
sions is unknown. However, they are
associated with approximately 40%
to 90% of all anterior shoulder in-
stability events.10-14
The incidence
may be as high as 100% in patients
with recurrent anterior instability.13
Determining which Hill-Sachs le-
sions are associated with clinical
symptoms and which are incidental
remains challenging. This is espe-
CDR Matthew T. Provencher,
MD
Rachel M. Frank, MD
LCDR Lance E. LeClere, MD
LCDR Paul D. Metzger, MD
J. J. Ryu
LT Andrew Bernhardson, MD
Anthony A. Romeo, MD
From the Department of
Orthopaedic Surgery, Naval Medical
Center San Diego, San Diego, CA
(Dr. Provencher, Dr. LeClere,
Dr. Metzger, and Dr. Bernhardson),
the Naval Medical Center San Diego
(Ms. Ryu), and the Department of
Orthopedic Surgery, Rush University
Medical Center, Chicago, IL
(Dr. Frank and Dr. Romeo).
The views expressed in this article
are those of the authors and do not
reflect the official policy or position
of the Department of the Navy,
Department of Defense, or the
United States Government.
J Am Acad Orthop Surg 2012;20:
242-252
http://dx.doi.org/10.5435/
JAAOS-20-04-242
Copyright 2012 by the American
Academy of Orthopaedic Surgeons.
Review Article
242 Journal of the American Academy of Orthopaedic Surgeons

cially important in patients with re-
current instability because humeral
head bony deficits may contribute to
continued instability.
Reverse Hill-Sachs lesions are asso-
ciated with posterior shoulder dislo-
cation. The incidence of this type is
equally difficult to quantify, al-
though reverse lesions occur in up to
86% of posterior shoulder disloca-
tions.12
However, posterior shoulder
instability events are relatively un-
common, and reverse Hill-Sachs le-
sions are rare.
Pathophysiology
Hill-Sachs lesions most commonly
occur during an anterior glenohu-
meral instability injury, typically
with the shoulder in abduction and
external rotation. As the humeral
head is forced anteriorly, the cap-
sulolabral structures of the shoulder
are stretched and often torn. As the
humeral head translates farther ante-
riorly, a compression fracture occurs
along the posterosuperolateral aspect
of the humeral head as it comes into
contact with the anterior glenoid
(Figure 1). The damaged anterior
soft-tissue structures are particularly
problematic in cases of recurrent
instability because the static gleno-
humeral constraints (ie, capsule,
labrum) become increasingly attenu-
ated with each episode. This attenua-
tion makes it easier for the relatively
softer cancellous bone of the hu-
meral head to sustain continued
damage as it makes repeated contact
with the harder cortical bone of the
anterior glenoid.9
The traditional Hill-Sachs lesion is
a bony defect of the posterosu-
perolateral humeral head, typically
associated with anteroinferior gleno-
humeral dislocation. An engaging
Hill-Sachs lesion, as described by
Palmer and Widén15
and Burkhart
and De Beer,2
occurs when the hu-
meral head defect engages the rim of
the glenoid while the shoulder is in a
position of athletic function (ie, 90°
abduction and 0 degrees to 135° of
external rotation) (Figure 2, A and
B). In an engaging lesion, the long
axis of the humeral head defect is
oriented parallel to the anterior gle-
noid rim and thus engages with it
when the shoulder is in abduction
and external rotation.9
When the hu-
meral defect is not in parallel with
the rim of the glenoid and thus does
not engage with it in a position of
function, the lesion is referred to as
nonengaging2
(Figure 2, C and D).
The reverse Hill-Sachs lesion is a
bony defect of the anterosuperome-
dial humeral head. This type most
commonly is caused by posterior
shoulder dislocation. The main dif-
ferences between traditional and re-
verse Hill-Sachs lesions are listed in
Table 1.
Hill-Sachs lesions rarely occur in
isolation. The injury most commonly
sustained in conjunction with the
Hill-Sachs lesion is the anterior cap-
sulolabral lesion (ie, Bankart).11
Other common coexisting injuries
are anterior glenohumeral ligamen-
tous pathology and glenoid bone loss
(ie, bony Bankart lesion)5,16
(Figure
3). Anteroinferior glenoid bone loss
may ultimately become large enough
to create a glenoid with the appear-
ance of an inverted pear; this presen-
tation is associated with recurrent
anterior shoulder instability.8,17
Opti-
mal management requires close eval-
uation for glenoid bone loss because
bone loss in the shoulder is fre-
quently a bipolar phenomenon.7
It is also important to recognize
normal anatomic structures of the
posterior humeral head to avoid con-
Three-dimensional CT scan
demonstrating the typical location
of a Hill-Sachs lesion at the
superolateral aspect of the
posterior humeral head (arrows).
The harder anteroinferior glenoid
bone compresses the soft
cancellous bone in this region as
the humeral head dislocates,
creating the characteristic osseous
lesion.
Figure 1
Dr. Provencher or an immediate family member serves as a board member, owner, officer, or committee member of the American
Academy of Orthopaedic Surgeons; the American Orthopaedic Society for Sports Medicine; the Arthroscopy Association of North
America; the International Society of Arthroscopy, Knee Surgery, and Orthopaedic Sports Medicine; and the Society of Military
Orthopaedic Surgeons. Dr. Romeo or an immediate family member has received royalties from Arthrex; is a member of a speakers’
bureau or has made paid presentations on behalf of Arthrex, DJ Orthopaedics, and the Joint Restoration Foundation; serves as a
paid consultant to or is an employee of Arthrex; has received research or institutional support from Arthrex and DJ Orthopaedics; has
received nonincome support (such as equipment or services), commercially derived honoraria, or other non–research-related funding
(such as paid travel) from Arthrex and DJ Orthopaedics; and serves as a board member, owner, officer, or committee member of the
American Orthopaedic Society for Sports Medicine, American Shoulder and Elbow Surgeons, and the Arthroscopy Association of
North America. None of the following authors or any immediate family member has received anything of value from or owns stock in
a commercial company or institution related directly or indirectly to the subject of this article: Dr. Frank, Dr. LeClere, Dr. Metzger,
Ms. Ryu, and Dr. Bernhardson.
CDR Matthew T. Provencher, MD, et al
April 2012, Vol 20, No 4 243

fusing them with Hill-Sachs lesions.
The bare spot of the humeral head,
which has no direct attachment of
the rotator cuff tendons, is located
superior and slightly medial to the
typical location of a Hill-Sachs le-
sion. As described by Richards
et al,18
the anatomic groove of the
humeral head is the normal flatten-
ing of the head as it moves caudad to
become the shaft. On the axial view,
this groove is located more inferior
and posterior (between 140° and
230°) than are Hill-Sachs lesions,
which typically fall more laterally
(between 170° and 260°).
Clinical Evaluation
History and Physical
Examination
A thorough history and physical ex-
amination are important in the clini-
cal evaluation of the patient with a
Hill-Sachs lesion associated with gle-
nohumeral instability (Table 2). Spe-
cial attention should be paid to the
mechanism of injury, which likely in-
volves an initial traumatic disloca-
tion event with the arm in abduction
and external rotation.16
In the pres-
ence of an intact glenoid, the Hill-
Sachs lesion may be clinically silent.
The patient with glenoid bone loss
and/or an engaging lesion may de-
scribe a sensation of catching as the
humeral head falls outside the gle-
noid track during movement (Figure
4). (The glenoid track is described in
detail below.) In such cases, instability
may result from trivial events such as
sleeping with the arm overhead.21
Dur-
ing the physical examination, the ap-
pearance, range of motion, strength,
and sensation of the injured shoulder
should be compared with those of the
contralateral shoulder.
Imaging
Several imaging modalities can be
used to assess humeral head osseous
deficiency. A full shoulder radio-
graphic series is typically obtained,
including AP, lateral, and axillary
views. Several other views can be
more helpful in evaluating humeral
head bone loss specifically. The mod-
ified West Point axillary view is used
in the evaluation of glenoid bone
loss, and the Stryker notch view is
specific for evaluating the Hill-Sachs
A, Illustration of an engaging Hill-Sachs lesion (dark gray area). B, With the
shoulder in a position of function or in abduction and external rotation, the
lesion is oriented parallel with the anterior glenoid and thus engages it.
C, Illustration of a nonengaging lesion (dark gray area), which is created in a
nonfunctional position. D, When the shoulder is abducted and externally
rotated, the lesion is not oriented parallel to the glenoid and thus does not
engage. (Redrawn with permission from Burkhart SS, De Beer JF: Traumatic
glenohumeral bone defects and their relationship to failure of arthroscopic
Bankart repairs: Significance of the inverted-pear glenoid and the humeral
engaging Hill-Sachs lesion. Arthroscopy 2000;16[7]:677-694.)
Figure 2
Table 1
Key Differences Between Traditional and Reverse Hill-Sachs Lesions
Traditional Reverse
Located on the posterosuperolateral
humeral head
Located on the anterosuperomedial
humeral head
Anterior or anteroinferior dislocation Posterior shoulder dislocation (rare)
Posterior cartilage damage (usually less
than in reverse lesions)
Anterior cartilage damage that is much
more extensive than the posterior carti-
lage damage seen in traditional lesions
The Hill-Sachs Lesion: Diagnosis, Classification, and Management

lesion.22
The Stryker notch view is
useful because the internal rotation
of the humeral head brings the pos-
terolateral defect into direct view.
CT, particularly three-dimensional
CT, is a superior imaging option for
evaluating bone loss. Three-dimen-
sional CT allows full appreciation of
the orientation of the defect, which is
extremely useful in decision making
and preoperative planning.23
Glenoid
bone loss also can be precisely quan-
tified following digital subtraction of
the humeral head24
(Figure 1).
Ultrasonography may be useful in
detecting Hill-Sachs lesions. Cicak et
al25
compared intraoperative findings
with ultrasonography and found ul-
trasonography to be 100% specific
and 96% sensitive for the detection
of Hill-Sachs lesions, with an overall
accuracy rate of 97%.
MRI or magnetic resonance ar-
thrography may provide information
on the glenoid and/or humeral head
defects (Figure 5). Without advanced
imaging studies, it is difficult to ac-
curately quantify the size and loca-
tion of the Hill-Sachs lesion and to
adequately assess any accompanying
glenoid bone loss.
Classification
Several classification and grading
systems for Hill-Sachs lesions have
been described; controversy persists
regarding which is optimal3,4,10,18,26
(Table 3). Although the classifica-
tions and grading systems can be
useful in clinical decision making, es-
pecially with larger lesions, they have
not yet proved to be helpful in deter-
mining successful management strat-
egies.
Clinical Significance of
the Lesion
Determining the clinical significance
of a Hill-Sachs lesion can be chal-
lenging. The most important consid-
eration is establishing whether the le-
sion is responsible for the patient’s
symptoms, especially with regard to
the instability event.
The most common factors used to
A, Arthroscopic view from the anterosuperior portal demonstrating significant
bipolar bony defects, with a large Hill-Sachs lesion and concomitant
anteroinferior glenoid bone loss measuring approximately 28% of the width of
the glenoid. B, Arthroscopic view from the anterosuperior portal of the
shoulder after it was brought into the position of function. On abduction and
external rotation, the humeral defect clearly engages the anterior glenoid.
Engagement was noted at only 45° of abduction and a few degrees of
external rotation.
Figure 3
Table 2
Important History and Physical Examination Findings for Hill-Sachs
Lesions
History
Deep shoulder pain
Previous shoulder instability event
Recurrent instability with provocative positioning
Mechanical symptoms (eg, crepitus, clicking, catching)
History of shoulder reduction, especially manual reduction
Progressive ease of dislocation events: Instability with daily events, likely concomitant
glenoid defect, likely more significant bony defects
Recurrent instability events: Often unprovoked, occurring with increasing frequency,
occurring after stabilization procedure(s)
Physical examination
Assess for instability (ie, apprehension tests)
Assess for laxity (ie, translation tests)
Assess for concomitant injuries (eg, rotator cuff tear, biceps tendon pathology, superior
labrum anterior-posterior lesion)
Key findings
Apprehension at lesser degrees of abduction (mid range19,20
)
Palpable clunk with engagement: Typically done under anesthesia. May become
locked.
In advanced cases, crepitus during range of motion, extension of the lesion to the cen-
tral humerus, extensive anterior glenoid bone loss, and glenohumeral osteoarthritis
April 2012, Vol 20, No 4 245

determine the significance of a lesion
are its size and whether it is engag-
ing.2
Historically, lesions involving
<20% of the humeral head articular
surface are rarely of clinical signifi-
cance, whereas lesions >40% of that
surface are nearly always clinically
significant and are responsible for re-
current instability.3,9
Treatment
decision-making is most difficult in
the setting of midsize lesions com-
prising 20% to 40% of the humeral
head articular surface. Other factors
to consider include the location and
orientation of the lesion, the extent
of concomitant glenoid bone loss,
and the extent of engagement with
the glenoid. The location and orien-
tation of the lesion are important
factors for defects of any size.
In midsize Hill-Sachs lesions, the
injury must be recognized as a bipo-
lar problem, with glenoid bone loss
potentiating the humeral-side lesion
and increasing the risk of instability.
Yamamoto et al27
developed a novel
approach to describing Hill-Sachs le-
sions. They based their description
on the location and size of the hu-
meral head defect and on the amount
of glenoid bone loss. Using a cadaver
model, they measured the contact
area between the glenoid and hu-
meral head at various degrees of ab-
duction. With the shoulder in 60° of
abduction and maximum external
rotation to simulate anterior appre-
hension, the authors found that the
distance from the contact area to the
medial margin of the footprint was
84% of the glenoid width. The au-
thors proposed that a Hill-Sachs le-
sion outside this so-called glenoid
track was at high risk for engage-
ment and, therefore, recurrent insta-
bility. Their classification also takes
into account the amount of glenoid
bone loss.27
As an osseous glenoid le-
sion increases in size, the glenoid
track decreases accordingly, thereby
placing the construct at risk of en-
gagement. Large amounts of glenoid
bone loss increase the clinical rele-
vance of even small Hill-Sachs inju-
ries (Figure 4).
This biomechanical association
was studied clinically by Provencher
et al,28
with the goal of determining
the clinical significance of Hill-Sachs
lesions in the setting of glenoid bone
loss. The authors found that 22 of
140 patients (15.7%) had Hill-Sachs
lesions outside the glenoid track, as
determined by measuring the size of
the humeral head lesion and glenoid
bone loss on magnetic resonance ar-
thrography. These patients were felt
to be at increased risk of glenohu-
meral engagement.
The concept of the glenoid track
may be the most clinically relevant
system for classifying Hill-Sachs le-
sions, but additional work is neces-
sary to validate its routine clinical
use.
Nonsurgical Management
Nonsurgical management is war-
ranted in cases of small osseous de-
fects and nonengaging lesions. Even
when surgery is warranted, these
Hill-Sachs lesions are often left alone
intraoperatively, and other clinically
relevant pathology (eg, Bankart le-
sion) is addressed instead. Patients
with larger, more clinically signifi-
cant lesions who may be poor surgi-
cal candidates (eg, elderly persons,
A, Illustration of the glenoid track, which is used in describing Hill-Sachs
lesions based on the location and size of the humeral head defect and on
the amount of glenoid bone loss. The gray area indicates the zone of contact
between the glenoid and the humeral head. The dotted line indicates the
contact area between the glenoid and the humeral head. B, The lesion lies
within the track, and the lesion cannot override the glenoid rim. C, The lesion
lies more medial than the track, thereby making it possible for the humeral
head to override the glenoid rim. (Redrawn with permission from Yamamoto
N, Itoi E, Abe H, et al: Contact between the glenoid and the humeral head in
abduction, external rotation, and horizontal extension: A new concept of
glenoid track. J Shoulder Elbow Surg 2007;16[5]:649-656.)
Figure 4

persons at high medical risk) may be
best treated nonsurgically.
A focused rehabilitation program
is essential to nonsurgical manage-
ment, under the guidance of an expe-
rienced physical therapist or athletic
trainer. The program must focus on
strengthening the deltoid, the rotator
cuff muscles, and in particular, the
scapular stabilizers. Months of reha-
bilitation may be required.
Surgical Management
The indications for surgical manage-
ment of Hill-Sachs lesions depend on
the clinical significance of the defect
and on symptoms of instability (Ta-
ble 4). A variety of arthroscopic and
open options is available.9,16,21
Most
clinically significant Hill-Sachs inju-
ries may be successfully managed by
addressing the primary instability
problem, that is, labral tear and/or
glenoid bone loss. Thus, glenoid-side
techniques are usually adequate.
However, several surgical techniques
manage the Hill-Sachs lesion directly.
Surgical management of osseous le-
sions related to anterior instability
must take into account the bipolar
nature of the injury. Several surgical
options exist for the patient with an
engaging Hill-Sachs injury. Most in-
volve glenoid bone augmentation
alone. Anterior glenoid bone loss
may be augmented with the Latarjet
procedure or iliac crest bone graft to
increase the size of the glenoid track
and prevent engagement.2,29
Proce-
dures of historical interest include
rotational humeral osteotomy and a
technique involving tightening the
anterior soft-tissue structures to limit
external rotation and shift the
glenoid track medially and superi-
orly.11,30
Rotational humeral osteot-
omy has been used for large Hill-
Sachs defects. By externally rotating
the proximal humerus surgically, hu-
meral head retroversion is reduced,
and the defect ceases to fall into the
anterior glenoid on internal rotation.
This procedure has fallen out of fa-
vor because of concerns regarding
nonunion, delayed union, over-
rotation, risk of fracture, and post-
traumatic arthritis.
Many procedures directly address the
defect, including humeral head au-
tograft or allograft, tissue filling (ie,
remplissage; see below), disimpaction,
and prosthesis replacement. Regardless
of the method chosen, the goal is to
prevent further engagement of the Hill-
Sachs lesion with the glenoid.
Capsular Shift
Glenohumeral capsular shift is per-
formed to surgically tighten the cap-
Axial (A) and coronal (B) magnetic resonance arthrograms demonstrating a
classic Hill-Sachs lesion (arrows).
Figure 5
Table 3
Classifications of Hill-Sachs Lesions
Grading System Imaging Description
Rowe et al4
Axillary radiograph Mild, 2 cm long × ≤0.3 cm deep; moderate, 2–4 cm long × 0.3–1 cm deep;
severe, 4 cm long × ≥1 cm deep
Calandra et al10
Direct visualization Grade I, confined to articular cartilage; grade II, extension into subchondral
bone; grade III, large subchondral defect
Franceschi et al26
Direct visualization Grade I, cartilaginous; grade II, bony scuffing; grade III, hatchet fracture
Flatow and Warner3
Direct visualization Clinically insignificant, <20%; variable significance, 20% to 40%; clinically
significant, >40%
Hall et al22
Notch view radiograph Percent involvement in 180° articular arc
Richards et al18
Axillary MRI Axillary degrees involved (anterior articular margin, zero degrees)
April 2012, Vol 20, No 4 247

sule in an attempt to limit external
rotation and anterior translation.
This procedure can be performed ar-
throscopically or via an open ap-
proach.31
Although this technique
can be effective in enhancing shoul-
der stability, it is not necessarily an
anatomic solution. Additionally, the
loss of external rotation may be
problematic for young patients, espe-
cially overhead-throwing athletes.
Even though capsular plication tech-
niques are among the most com-
monly performed procedures for an-
terior shoulder stabilization, they
address only the soft tissue and may
not be adequate in cases of instabil-
ity with significant Hill-Sachs le-
sions.
Glenoid Bone
Augmentation
Glenoid bone augmentation has been
well-documented as the primary pro-
cedure in addressing significant Hill-
Sachs defects associated with recur-
rent glenohumeral instability. The
most common procedures used in-
clude coracoid transfer (ie, Latarjet)
and iliac crest bone grafting.6,16,32,33
Recently, augmentation with various
allograft tissues, including femoral
head34
and distal tibia allograft,35
has
been described (Figure 6). These pro-
cedures effectively lengthen the artic-
ular arc of the glenoid. Although
they do not address the humeral
head defect directly, they prevent en-
gagement of the Hill-Sachs lesion
during normal range of motion.
Humeral Head Bone
Augmentation
Procedures that directly address Hill-
Sachs lesions are traditionally indi-
cated in the setting of significant
Hill-Sachs injuries without concomi-
tant glenoid bone loss. In the rare in-
stance of a large Hill-Sachs lesion
without concomitant glenoid bone
loss, restoration of the anatomy has
been advocated, in addition to a va-
riety of soft-tissue procedures. Bone
augmentation of the humeral defect
has been described to manage large
defects with or without glenoid bone
injury.
The intent with these procedures is
to fill the defect and restore native
anatomy by effectively increasing the
articular arc of the humerus as it ro-
tates on the glenoid, thereby prevent-
ing engagement and instability. Bone
plugs are typically size-matched to
the defect. These plugs may be au-
tograft (typically from the iliac
crest), fresh or frozen allograft, or
synthetic (ie, metal, polyethylene)
material. Fresh humeral head os-
teoarticular allografts have been
used with success, either with entire
humeral head replacement or with
grafts size-matched to the defect
(Figure 7).
Clinical studies describing out-
comes following humeral head bone
augmentation procedures are limited
to small cohorts and case reports.
Diklic et al36
reported on the out-
comes of 13 patients treated with
fresh-frozen femoral head allograft
for humeral head defects measuring
approximately 25% to 50% (mean
age, 42 years). At an average of 54
months postoperatively, 12 patients
had stable shoulders, and 1 patient
had evidence of osteonecrosis. The
mean Constant score for the cohort
was 86.8. In a slightly larger cohort
Table 4
Indications for Surgical Management of Hill-Sachs Lesions
Absolute
Displaced humeral head fracture with humeral head fracture-dislocation and associ-
ated Hill-Sachs injury
Lesion >30% to 40% of the humeral head with chronic dislocation or recurrent anterior
instability. These cases typically require glenoid augmentation and/or management of
the humeral head (eg, remplissage, allograft).
Reverse lesion with >20% to 40% of humeral head articular surface involvement and
symptoms of posterior instability, catching, or pain
Relative
Lesion >20% to 35% of the humeral head with glenoid engagement on examination
Lesion >20% of the articular surface and signs of humeral head engagement on
examination
Lesion >10% to 25% of the humeral head that does not remain well-centered in the
glenoid fossa after arthroscopic instability repair
Reverse lesion with humeral head cartilage involvement on 10% to 30% of the
humeral head, with symptoms of posterior instability, catching, or pain
Intraoperative photograph
demonstrating the use of iliac crest
autograft harvested from the
contralateral hip (white arrows) to
reconstruct a 25% anterior glenoid
bone deficiency. The capsule was
sutured to washers under the
screw heads (black arrows) on the
anterior aspect of the iliac crest,
thus making an intra-articular graft
of the iliac crest material. This
patient also had a 30% Hill-Sachs
lesion that easily engaged prior to
the iliac crest bone graft. Once
grafted, the lesion was unable to
engage the glenoid.
Figure 6

study, Miniaci and Gish37
described
18 patients with recurrent traumatic
instability and Hill-Sachs defects
>25% who underwent augmentation
with size-matched, fresh-frozen hu-
meral head allografts. At an average
follow-up of 50 months postopera-
tively, 16 patients were able to return
to work. However, several complica-
tions were noted, including partial
radiographic graft collapse (two pa-
tients), early radiographic osteoar-
thritis (three patients), mild sublux-
ation (one patient), and hardware
complications (two patients). The
mean Constant score was 78.5.
Tissue Filling
(Remplissage)
The Connolly procedure has been
successfully used to fill humeral head
defects by converting them into
extra-articular lesions.38
Originally
described in 1972, this open proce-
dure involves transfer of the infraspi-
Intraoperative photographs illustrating the use of fresh proximal humerus allograft to replace a large symptomatic Hill-
Sachs lesion. The humeral head is exposed through a deltopectoral approach (A), and the large Hill-Sachs lesion is
visualized (B) (arrows). C, The donor humeral head allograft is marked in preparation for harvest of a size-matched
graft with an oscillating saw (arrows). D, The size-matched allograft. E, The graft is secured to the native humeral head
with buried screws.
Figure 7
April 2012, Vol 20, No 4 249

natus tendon with a portion of the
greater tuberosity into the humeral
head defect.
Recently, surgeons have begun to
manage Hill-Sachs lesions ar-
throscopically using available gleno-
humeral capsulotendinous tissue.
The term remplissage, French for fill-
ing, is a surgical technique in which
a bony intra-articular defect is con-
verted to an extra-articular defect
with soft-tissue coverage, with the
goal of preventing engagement.29,39-42
Originally described by Wolf et al,42
the technique involves arthroscopic
posterior capsulodesis and infraspi-
natus tenodesis, with fixation of the
tissue to the surface of the Hill-Sachs
defect. In 2009, the technique was
modified by Koo et al,41
who de-
scribed a double-pulley suture tech-
nique in which two anchors were
used to insert the infraspinatus ten-
don into the entire Hill-Sachs defect.
This modification created a broader
footprint of fixation, and tying the
sutures over rather than through the
infraspinatus tendon allowed for a
more anatomic and tissue-preserving
approach.
Remplissage is performed in pa-
tients with moderate to large Hill-
Sachs defects associated with glenoid
defects of <20% to 25%. Patients
with larger glenoid defects may re-
quire conversion to an open Latarjet
procedure. Potential disadvantages
associated with remplissage are de-
creased postoperative range of mo-
tion and sequelae of a nonanatomic
repair construct. In 2008, Deutsch
and Kroll40
described a case of signif-
icant postoperative loss of external
rotation following remplissage. Mo-
tion was improved following ar-
throscopic release of the infraspina-
tus tenodesis; the authors proposed
that the infraspinatus tendon and
posterior capsular tissue created a
mechanical block to motion. In their
series, Purchase et al29
noted unpub-
lished findings indicating good re-
sults with remplissage, with no nota-
ble loss of external rotation. Most
patients did not experience recurrent
instability.
Advantages of remplissage include
the arthroscopic approach, the abil-
ity to perform concomitant proce-
dures, and fast recovery time. Addi-
tionally, this approach has none of
the risks and morbidity associated
with bone grafting procedures.
Disimpaction
Disimpaction of a humeral head defect
(ie, humeroplasty) involves elevating
the impaction fracture and supporting
it with bone graft, thereby allowing for
approximate restoration of humeral
head geometry without internal fixa-
tion.43,44
The procedure can be per-
formed using bone tamps inserted
retrograde through a distal cortical
window.43
Alternatively, disimpac-
tion can be performed percutane-
ously using an 8-mm cannulated
reamer drilled to within 1 cm of the
posterior surface, followed by back-
filling of the defect with cancellous
bone chips.44
This technique is rela-
tively new, and little biomechanical
and clinical research has been pub-
lished on the topic. Disimpaction
may be most suited to acute lesions
<3 weeks old and with <40% in-
volvement of the articular surface.19
Resurfacing and Prosthesis
Replacement
Complete and partial resurfacing of the
humeral head articular surface has
been described. Limited resurfacing of
the defect with a metal implant is done
in an attempt to restore the humeral
head articular arc.20,45
Although par-
tial resurfacing is promising in the-
ory, only limited case reports with
short-term follow-up are available in
the literature. Outcomes have been
reported to be positive at 1 to 2
years postimplantation.20,45
With this
technique there is no risk of disease
transmission or resorption, as can
occur with allograft. However, dis-
advantages include loss of fixation,
incomplete geometric restoration,
and eventual glenoid wear.
Complete humeral head resurfacing
(ie, humeral head hemiarthroplasty) is
an option for Hill-Sachs lesions that
cause recurrent instability, in particu-
lar lesions that involve >40% of the ar-
ticular surface.46
However, indications
are not clearly defined. Older (>65
years), low-demand patients may ben-
efit from hemiarthroplasty or total
shoulder arthroplasty (TSA) in the
presence of concomitant glenoid degen-
eration. However, outcomes of hemi-
arthroplasty and TSA are much less
predictable, with high failure rates in
young, active patients. In these pa-
tients, hemiarthroplasty should be con-
sidered a salvage procedure in cases of
severe defects causing recurrent insta-
bility. Pritchett and Clark46
described
humeral hemiarthroplasty and TSA in
seven patients with chronic dislocations
and significant Hill-Sachs lesions. Av-
erage patient age was 55 years (range,
36 to 67 years). Five patients had good
results, and there were no occurrences
of repeat dislocation. These procedures
should be reserved for older or less ac-
tive patients with defects involving
>40% of the articular surface and/or
significant articular cartilage degener-
ation.
Surgical Management of
Reverse Hill-Sachs
Lesions
Management of reverse Hill-Sachs le-
sions is based on the same philoso-
phy as management of traditional
Hill-Sachs lesions. The primary
cause of the instability is addressed
with a procedure that prevents en-
gagement of the lesion through direct
or indirect means. One fundamental
difference between a traditional and
a reverse Hill-Sachs lesion is that, in

reverse injury, the anterior humeral
head cartilage is more extensively in-
jured and involved. As such, soft-
tissue filling of the defect has been
advocated. However, concerns per-
sist regarding loss of articulation of
the humeral head resulting from the
generally large and extensive carti-
lage injury.
The well-described McLaughlin
procedure involves an open transfer
of the subscapularis tendon and
lesser tuberosity to fill the humeral
head defect.47
The tuberosity transfer
involves creation of an osteotomy of
the lesser tuberosity while maintain-
ing attachment of the subscapularis
tendon and anterior capsule, fol-
lowed by elevation and transfer to
the site of the defect bed. This
procedure can result in restriction
of internal rotation postoperatively.
Krackhardt et al48
described an ar-
throscopic modification of the
McLaughlin procedure and reported
successful outcomes and no major
complications in 12 patients. Fresh
osteoarticular allograft is a viable
option for reverse Hill-Sachs lesions
because of the increased extent of
cartilage involvement compared with
a traditional Hill-Sachs injury. Pros-
thetic reconstruction may also be
considered for patients with ex-
tremely large reverse Hill-Sachs le-
sions (ie, >40%).
Summary
Osseous lesions of the humeral head
create challenging clinical scenarios.
The most difficult aspect of these
cases involves determining which
Hill-Sachs lesions are clinically sig-
nificant and need to be addressed
surgically. Lesion size, orientation,
location, and concomitant glenoid
bone loss must be evaluated in light
of the patient’s symptoms. Recent lit-
erature suggests that Hill-Sachs le-
sions are best approached as bipolar
problems in which a glenoid defect is
magnified in the setting of glenoid
bone loss. The concept of the glenoid
track advanced the understanding of
engagement and recurrent instability
by defining the humeral head defi-
ciency in relation to glenoid width
and bone loss.
A meticulous approach to the diag-
nostic workup is essential and must
include a complete history and thor-
ough physical examination. Imaging
and arthroscopic findings can aid in
the decision-making process. Small
lesions may be addressed solely on
the glenoid side to increase the artic-
ular arc and prevent engagement.
However, large Hill-Sachs defects
may require combined procedures
that directly address the humeral de-
fect, including arthroplasty, humeral
head allograft, remplissage, and re-
surfacing.
References
Evidence-based Medicine: Levels of
evidence are described in the table of
contents. In this article, references 10
and 13 are level II studies. References
5 and 17 are level III studies.
References 2, 4, 11, 12, 14, 15, 18, 24,
26, 27, 30-34, 39, 40, 45, and 46 are
level IV studies. References 7-9, 16,
20-23, 29, 35, 38, 41, 42, 44, 47, and
48 are level V expert opinion.
References printed in bold type are
those published within the past 5
years.
1. Hill HA, Sachs MD: The grooved defect
of the humeral head: A frequently
unrecognized complication of
dislocations of the shoulder joint.
Radiology 1940;35:690-700.
2. Burkhart SS, De Beer JF: Traumatic
glenohumeral bone defects and their
relationship to failure of arthroscopic
Bankart repairs: Significance of the
inverted-pear glenoid and the humeral
engaging Hill-Sachs lesion. Arthroscopy
2000;16(7):677-694.
3. Flatow EL, Warner JI: Instability of the
shoulder: Complex problems and failed
repairs. Part I: Relevant biomechanics,
multidirectional instability, and severe
glenoid loss. Instr Course Lect 1998;47:
97-112.
4. Rowe CR, Zarins B, Ciullo JV:
Recurrent anterior dislocation of the
shoulder after surgical repair: Apparent
causes of failure and treatment. J Bone
Joint Surg Am 1984;66(2):159-168.
5. Kim DS, Yoon YS, Yi CH: Prevalence
comparison of accompanying lesions
between primary and recurrent anterior
dislocation in the shoulder. Am J Sports
Med 2010;38(10):2071-2076.
6. Ghodadra N, Gupta A, Romeo AA, et al:
Normalization of glenohumeral articular
contact pressures after Latarjet or iliac
crest bone-grafting. J Bone Joint Surg
Am 2010;92(6):1478-1489.
7. Provencher MT, Bhatia S, Ghodadra NS,
et al: Recurrent shoulder instability:
Current concepts for evaluation and
management of glenoid bone loss. J Bone
Joint Surg Am 2010;92(suppl 2):133-
151.
8. Piasecki DP, Verma NN, Romeo AA,
Levine WN, Bach BR Jr, Provencher
MT: Glenoid bone deficiency in
recurrent anterior shoulder instability:
Diagnosis and management. J Am Acad
Orthop Surg 2009;17(8):482-493.
9. Armitage MS, Faber KJ, Drosdowech
DS, Litchfield RB, Athwal GS: Humeral
head bone defects: Remplissage,
allograft, and arthroplasty. Orthop Clin
North Am 2010;41(3):417-425.
10. Calandra JJ, Baker CL, Uribe J: The
incidence of Hill-Sachs lesions in initial
anterior shoulder dislocations.
Arthroscopy 1989;5(4):254-257.
11. Rowe CR, Patel D, Southmayd WW:
The Bankart procedure: A long-term
end-result study. J Bone Joint Surg Am
1978;60(1):1-16.
12. Saupe N, White LM, Bleakney R, et al:
Acute traumatic posterior shoulder
dislocation: MR findings. Radiology
2008;248(1):185-193.
13. Taylor DC, Arciero RA: Pathologic
changes associated with shoulder
dislocations: Arthroscopic and physical
examination findings in first-time,
traumatic anterior dislocations. Am J
Sports Med 1997;25(3):306-311.
14. Yiannakopoulos CK, Mataragas E,
Antonogiannakis E: A comparison of the
spectrum of intra-articular lesions in
acute and chronic anterior shoulder
instability. Arthroscopy 2007;23(9):985-
990.
15. Palmer I, Widén A: The bone block
method for recurrent dislocation of the
shoulder joint. J Bone Joint Surg Br
1948;30(1):53-58.
April 2012, Vol 20, No 4 251

16. Lynch JR, Clinton JM, Dewing CB,
Warme WJ, Matsen FA III: Treatment of
osseous defects associated with anterior
shoulder instability. J Shoulder Elbow
Surg 2009;18(2):317-328.
17. Mologne TS, Provencher MT, Menzel
KA, Vachon TA, Dewing CB:
Arthroscopic stabilization in patients
with an inverted pear glenoid: Results in
patients with bone loss of the anterior
glenoid. Am J Sports Med 2007;35(8):
1276-1283.
18. Richards RD, Sartoris DJ, Pathria MN,
Resnick D: Hill-Sachs lesion and normal
humeral groove: MR imaging features
allowing their differentiation. Radiology
1994;190(3):665-668.
19. Chen AL, Hunt SA, Zuckerman JD:
Humeral head impression fractures and
head-splitting fractures, in Zuckerman
JD, Koval KJ, eds: Shoulder Fractures:
The Practical Guide to Management.
New York, NY, Thieme Medical
Publishers, 2005, pp 120-145.
20. Scalise J, Miniaci A, Iannotti J:
Resurfacing arthroplasty of the humerus:
Indications, surgical technique, and
clinical results. Techniques in Shoulder
& Elbow Surgery 2007;8:152-160.
21. Bollier MJ, Arciero R: Management of
glenoid and humeral bone loss. Sports
Med Arthrosc 2010;18(3):140-148.
22. Hall RH, Isaac F, Booth CR:
Dislocations of the shoulder with special
reference to accompanying small
fractures. J Bone Joint Surg Am 1959;
41(3):489-494.
23. Miniaci A, Gish M: Management of
anterior glenohumeral instability
associated with large Hill-Sachs defects.
Techniques in Shoulder & Elbow
Surgery 2004;5(3):170-175.
24. Griffith JF, Yung PS, Antonio GE, Tsang
PH, Ahuja AT, Chan KM: CT compared
with arthroscopy in quantifying glenoid
bone loss. AJR Am J Roentgenol 2007;
189(6):1490-1493.
25. Cicak N, Bilić R, Delimar D: Hill-Sachs
lesion in recurrent shoulder dislocation:
Sonographic detection. J Ultrasound
Med 1998;17(9):557-560.
26. Franceschi F, Longo UG, Ruzzini L,
Rizzello G, Maffulli N, Denaro V:
Arthroscopic salvage of failed
arthroscopic Bankart repair: A
prospective study with a minimum
follow-up of 4 years. Am J Sports Med
2008;36(7):1330-1336.
27. Yamamoto N, Itoi E, Abe H, et al:
Contact between the glenoid and the
humeral head in abduction, external
rotation, and horizontal extension: A
new concept of glenoid track. J Shoulder
Elbow Surg 2007;16(5):649-656.
28. Provencher MT, Metzger PD, Peace WJ,
Barlow B, Leonardelli D, Solomon DJ:
Poster P294: Clinical grading of Hill-
Sachs injuries: Association with glenoid
bone loss and humeral engagment. 77th
Annual Meeting Proceedings. Rosemont,
IL, American Academy of Orthopaedic
Surgeons, 2010, pp 617-618.
29. Purchase RJ, Wolf EM, Hobgood ER,
Pollock ME, Smalley CC: Hill-Sachs
“remplissage”: An arthroscopic solution
for the engaging Hill-Sachs lesion.
Arthroscopy 2008;24(6):723-726.
30. Weber BG, Simpson LA, Hardegger F:
Rotational humeral osteotomy for
recurrent anterior dislocation of the
shoulder associated with a large Hill-
Sachs lesion. J Bone Joint Surg Am 1984;
66(9):1443-1450.
31. Pagnani MJ: Open capsular repair
without bone block for recurrent
anterior shoulder instability in patients
with and without bony defects of the
glenoid and/or humeral head. Am J
Sports Med 2008;36(9):1805-1812.
32. Boileau P, Bicknell RT, El Fegoun AB,
Chuinard C: Arthroscopic Bristow
procedure for anterior instability in
shoulders with a stretched or deficient
capsule: The “belt-and-suspenders”
operative technique and preliminary
results. Arthroscopy 2007;23(6):593-
601.
33. Burkhart SS, De Beer JF, Barth JR,
Cresswell T, Roberts C, Richards DP:
Results of modified Latarjet
reconstruction in patients with
anteroinferior instability and significant
bone loss. Arthroscopy 2007;23(10):
1033-1041.
34. Weng PW, Shen HC, Lee HH, Wu SS,
Lee CH: Open reconstruction of large
bony glenoid erosion with allogeneic
bone graft for recurrent anterior
shoulder dislocation. Am J Sports Med
2009;37(9):1792-1797.
35. Provencher MT, Ghodadra N, LeClere
L, Solomon DJ, Romeo AA: Anatomic
osteochondral glenoid reconstruction for
recurrent glenohumeral instability with
glenoid deficiency using a distal tibia
allograft. Arthroscopy 2009;25(4):446-
452.
36. Diklic ID, Ganic ZD, Blagojevic ZD,
Nho SJ, Romeo AA: Treatment of locked
chronic posterior dislocation of the
shoulder by reconstruction of the defect
in the humeral head with an allograft.
J Bone Joint Surg Br 2010;92(1):71-76.
37. Miniaci A, Gish MW: Management of
anterior glenohumeral instability
associated with large Hill–Sachs defects.
Techniques in Shoulder & Elbow
Surgery 2004;5(3):170-175.
38. Connolly JF: Humeral head defects
associated with shoulder dislocation:
Their diagnostic and surgical
significance. Instr Course Lect 1972;21:
42-54.
39. Abdelhady AM: Neglected anterior
shoulder dislocation: Open remplissage
of the Hill-Sachs lesion with the
infraspinatus tendon. Acta Orthop Belg
2010;76(2):162-165.
40. Deutsch AA, Kroll DG: Decreased range
of motion following arthroscopic
remplissage. Orthopedics 2008;31(5):
492.
41. Koo SS, Burkhart SS, Ochoa E:
Arthroscopic double-pulley remplissage
technique for engaging Hill-Sachs lesions
in anterior shoulder instability repairs.
Arthroscopy 2009;25(11):1343-1348.
42. Wolf EM, Pollock ME, Smalley CC: Hill-
Sachs “remplissage”: An arthroscopic
solution for the engaging Hill-Sachs
lesion. Arthroscopy 2007;23(6):e1-e2.
43. Kazel MD, Sekiya JK, Greene JA, Bruker
CT: Percutaneous correction
(humeroplasty) of humeral head defects
(Hill-Sachs) associated with anterior
shoulder instability: A cadaveric study.
Arthroscopy 2005;21(12):1473-1478.
44. Re P, Gallo RA, Richmond JC:
Transhumeral head plasty for large Hill-
Sachs lesions. Arthroscopy 2006;22(7):
798, e1-e4.
45. Moros C, Ahmad CS: Partial humeral
head resurfacing and Latarjet coracoid
transfer for treatment of recurrent
anterior glenohumeral instability.
Orthopedics 2009;32(8).
46. Pritchett JW, Clark JM: Prosthetic
replacement for chronic unreduced
dislocations of the shoulder. Clin Orthop
Relat Res 1987;(216):89-93.
47. McLaughlin HL: Posterior dislocation of
the shoulder. J Bone Joint Surg Am
1952;24(3):584-590.
48. Krackhardt T, Schewe B, Albrecht D,
Weise K: Arthroscopic fixation of the
subscapularis tendon in the reverse Hill-
Sachs lesion for traumatic unidirectional
posterior dislocation of the shoulder.
Arthroscopy 2006;22(2):227, e1-e227,
e6.

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