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Humeral head bone defects in anterior shoulder instability: preoperative assessment and surgical management for Hill-Sachs lesion
Arthrosc Orthop Sports Med 2014;1:82-90
Published online July 1, 2014;  https://doi.org/10.14517/aosm13016
© 2014 Arthroscopy and Orthopedic Sports Medicine.

Nam Su Cho, Sang Phil Hwang

Shoulder & Elbow Clinic, Department of Orthopaedic Surgery, Kyung Hee University College of Medicine, Seoul, Korea
Received September 24, 2013; Revised February 11, 2014; Accepted March 17, 2014.
This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
Abstract
As engaging Hill-Sachs lesions continue to be implicated in the failure of arthroscopic Bankart repair, various procedures have been introduced to overcome them. In this regard, precise judgment of the Hill-Sachs lesion and prediction of its engagement before operation may be useful in planning additional procedures to treat a significant bone defect on the humeral head. The most difficult aspect of Hill-Sachs lesions is determining which Hill-Sachs lesions are clinically significant and need to be addressed surgically. Further, lesion size, orientation, location, and concomitant loss of glenoid bone must be evaluated in light of the patient’s symptoms. Recent literature suggests that Hill-Sachs lesions are best approached as bipolar problems in which a glenoid defect is magnified in the setting of glenoid bone loss. 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 management may be adressed solely on the glenoid side of small lesions to increase the articular arc and prevent the engagement of the lesions. However, large Hill-Sachs defects may require a combined procedure that addresses the humeral defect directly, such as arthroplasty, humeral head allograft, remplissage, and resurfacing.
Keywords : Shoulder; Anterior instability; Hill-Sachs lesion; Engagement; Surgical management
INTRODUCTION
  Hill­Sachs lesion is a compression fracture of the post er­ osu perolateral humeral head that occurs in association with anterior instability or dislocation of the glenohumeral joint (Fig. 1). In 1940, Hill and Sachs [1] described the lesion as a so­called line of condensation on the internal rotation view of the shoulder on a radiograph. They attributed this line to the dense cortical glenoid on the humeral head during an anterior dislocation event.
  Improved understanding of the association between humeral head bony defects and recurrent glenohumeral instability has revealed the need to optimize the way Hill-Sachs injuries are classified and managed. There is a historical body of evidence supporting an association between a combined engaging 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 paucity of literature on humeral head defects [9].
  Burkhart and De Beer [2] described an engaging Hill-Sachs lesion that occurs when the glenoid falls into the humeral head defect. To truly engage, the long axis of the humeral head defect must be parallel to the anterior glenoid rim with the arm in a position of abduction and external rotation. Engagement outside of this functional arc, with the arm at the side for example, is termed as a nonfunctional engagement or described as functionally nonengaging. If the humeral defect is not parallel to the glenoid rim, it may provide a sensation of subluxation when the lesion rolls over the anterior glenoid, but the rim will not fall into the defect and lever the humeral head from the glenoid socket. Anterior, inferior glenoid bone loss and engaging Hill-Sachs lesions have been implicated as factors leading to higher failure rates following soft-tissue stabilization procedures [2-4,10]. Although osseous lesions are recognized factors associated with shoulder instability, there is little information describing surgical indications and optimal techniques to restore osseous anatomy and joint stability.
CLINICAL EVALUATION
History and physical examination
  Taking a thorough history and physical examination of patients with Hill-Sachs lesions associated with glenohumeral instability are important during clinical evaluation (Table 1) [11-13]. Special attention should be paid to the mechanism of injury, which likely involves an initial traumatic dislocation event with the arm in abduction and external rotation [14]. In the presence of an intact glenoid, the Hill-Sachs lesion may be clinically silent. The patient with glenoid bone loss and/or an engaging lesion may describe a sensation of catching as the humeral head falls outside the glenoid track during movement. In such cases, instability may result from trivial events such as sleeping with the arm overhead [15]. During the physical examination, the appearance, 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 osseous deficiency of the humeral head. Typically, a full shoulder radiographic series is obtained, including anteroposterior, lateral, and axillary views. Several other views can be more helpful in evaluating humeral head bone loss specifically. The modified West Point axillary view is used in evaluating glenoid bone loss, and the Stryker notch view is specific for evaluating the Hill-Sachs lesion [16]. The Stryker notch view is useful because the internal rotation of the humeral head brings the posterolateral defect into direct view.
  Computed tomography (CT), particularly three-dimensional CT, is a superior imaging option for evaluating bone loss. Three-dimensional CT allows full appreciation of the orientation of the defect, which is extremely useful in decision making and preoperative planning [17]. Glenoid bone loss also can be precisely quantified following digital subtraction of the humeral head (Fig. 2) [18].
  Ultrasonography may be useful in detecting Hill-Sachs lesions. Cicak et al. [19] compared intraoperative findings with ultrasonography and found ultrasonography to be 100% specific and 96% sensitive for the detection of Hill-Sachs lesions, with an overall accuracy rate of 97%.
  Magnetic resonance imaging or magnetic resonance arthrography may provide information on the glenoid and/or humeral head defects (Fig. 3). Without advanced imaging studies, it is difficult to accurately quantify the size and location 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 optimal (Table 2) [3,4,11,16,20-22]. Although the classification and grading systems can be useful in clinical decision making, especially with larger lesions, they have not yet proved to be helpful in determining successful management strategies.
CLINICAL SIGNIFICANCE OF THE HILL-SACHS LESION
  Determining the clinical significance of a Hill-Sachs lesion can be challenging. The most important consideration is establishing whether the lesion is responsible for the patient’s symptoms, especially with regard to the instability event.
  The most common factors used to determine the significance of a lesion are its size and whether it is engaging [2]. Historically, if lesions involve < 20% of the humeral head articular surface, it is rarely of clinical significance, whereas if lesions involve > 40% of the surface, it is nearly always clinically significant and are responsible for recurrent instability [3,9]. Treatment decision-making is most difficult in the setting of midsize lesions comprising 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 orientation of the lesions are important factors for defects of any size.
  Midsize Hill-Sachs lesions must be recognized as a bipolar problem, where glenoid bone loss also potentiates the humeral-side lesion and increases the risk of instability. Yamamoto et al. [23] developed a novel approach to describe Hill-Sachs lesions. They based their description on the location and size of the humeral head defect and on the amount of glenoid bone loss. Using a cadaver model, they measured the contact area between the glenoid and humeral head at various degrees of abduction. With the shoulder in 60°C of abduction and maximum external rotation to simulate anterior apprehension, the authors found that the distance from the contact area to the medial margin of the footprint was 84% of the glenoid width. The authors proposed that a Hill-Sachs lesion outside this so-called glenoid track was at high risk of engagement and, therefore, recurrent instability. Their classification also takes into account the amount of glenoid bone loss [23]. As an osseous glenoid lesion increases in size, the glenoid track decreases accordingly, thereby placing the construct at risk of engagement. Large amounts of glenoid bone loss increase the clinical relevance of even small Hill-Sachs injuries.
  This biomechanical association was studied clinically by Provencher et al. [24] 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 arthrography. These patients were felt to be at increased risk of glenohumeral engagement.
  The concept of the glenoid track may be the most clinically relevant system for classifying Hill-Sachs lesions, but additional work is necessary to validate its routine clinical use.
NONSURGICAL MANAGEMENT
  Nonsurgical management is warranted in cases of small osseous defects and non-engaging lesions. Even when surgery is warranted, these Hill-Sachs lesions are often left alone intraoperatively, and other clinically relevant pathology (e.g., Bankart lesion) is addressed instead. Patients with larger, more clinically significant lesions who may be poor surgical candidates (e.g., elderly persons) are best treated nonsurgically.
  A focused rehabilitation program is essential to nonsurgical management, under the guidance of an experienced physical therapist or athletic trainer. The program must focus on strengthening the deltoid, the rotator cuff muscles, and in particular, the scapular stabilizers. Several months of rehabilitation may be required.
SURGICAL MANAGEMENT
  The indications for surgical management of Hill-Sachs lesions depend on the clinical significance of the defect and on symptoms of instability (Table 3) [11]. A variety of arthroscopic and open options are available [9,14,15]. Most clinically significant Hill-Sachs injuries may be successfully managed by addressing the primary problem of instability, that is, labral tear and/or glenoid bone loss. However, several surgical techniques manage the Hill-Sachs lesion directly.
  Treatment options to reconstruct symptomatic Hill-Sachs lesions can be broadly categorized into 4 groups. The defects may be disimpacted, filled with soft tissue or allograft bone, rotated away, or partially or completely replaced.
  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 involve 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 to prevent engagement [2,25]. Procedures of historical interest include rotational humeral osteotomy and a technique involving tightening the anterior soft-tissue structures to limit external rotation and to shift the glenoid track medially and superiorly [26,27]. Rotational humeral osteotomy has been used for large Hill-Sachs defects. By externally rotating the proximal humerus surgically, humeral head retroversion is reduced, and the defect ceases to fall into the anterior glenoid on internal rotation. This procedure has fallen out of favor 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 autograft or allograft, tissue filling (i.e., remplissage), 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
  tighten the capsule in an attempt to limit external rotation and anterior translation. This procedure can be performed arthroscopically or via an open approach [28]. Although this technique can be effective in enhancing shoulder stability, it is not necessarily an anatomic solution. Additionally, the loss of external rotation may be problematic for young patients, especially overhead-throwing athletes. Even though capsular plication techniques are among the most commonly performed procedures for anterior shoulder stabilization, they address only the soft tissue and may not be adequate in cases of instability with significant Hill-Sachs lesions.

Glenoid bone augmentation
  Glenoid bone augmentation has been well-documented as the primary procedure in addressing significant Hill-Sachs defects associated with recurrent glenohumeral instability. The most common procedures used include coracoid transfer (i.e., Latarjet procedure) and iliac crest bone grafting [6,14,29,30]. Recently, augmentation with various allograft tissues, including femoral head [31] and distal tibia allograft [32], has been described. These procedures effectively lengthen the articular arc of the glenoid. Although they do not address the humeral head defect directly, they prevent engagement of the Hill-Sachs lesion during normal range of motion.

Humeral head bone augmentation
  Procedures that directly address Hill-Sachs lesions are traditionally indicated in the setting of significant Hill-Sachs injuries without concomitant glenoid bone loss. In the rare instance of a large Hill-Sachs lesion without concomitant glenoid bone loss, restoration of the anatomy has been advocated, in addition to a variety 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 rotates on the glenoid, thereby preventing engagement and instability. Bone plugs are typically size-matched to the defect. These plugs may be an autograft (typically from the iliac crest), a fresh or frozen allograft, or a synthetic (i.e., metal, polyethylene material. Fresh humeral head osteoarticular allografts have been used with success, either with entire humeral head replacement or with grafts size-matched to the defect.
  Clinical studies describing outcomes following humeral head bone augmentation procedures are limited to small cohorts and case reports. Diklic et al. [33] reported on the outcomes of 13 patients treated with fresh-frozen femoral head allografts 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 points. In a slightly larger cohort study, Miniaci and Gish [17] described 18 patients with recurrent traumatic instability and Hill-Sachs defects > 25% who underwent augmentation with size-matched, fresh-frozen humeral head allografts. At an average follow-up of 50 months postoperatively, 16 patients were able to return to work. However, several complications were noted, including partial radiographic graft collapse (two patients), early radiographic osteoarthritis (three patients), mild subluxation (one patient), and hardware complications (two patients). The mean Constant score was 78.5 points.

Remplissage
  The Connolly procedure has been successfully used to fill humeral head defects by converting them into extra-articular lesions [34]. Originally described in 1972, this open procedure involves transfer of the infraspinatus tendon with a portion of the greater tuberosity into the humeral head defect.
  Recently, surgeons have begun to manage Hill-Sachs lesions arthroscopically using available glenohumeral capsulotendinous tissue. The term remplissage, French for filling, is a surgical technique in which a bony intra-articular defect is converted to an extra-articular defect with soft-tissue coverage, with the goal of preventing engagement [25,35-38]. Originally described by Wolf et al. [38], the technique involves arthroscopic posterior capsulodesis and infraspinatus tenodesis, with fixation of the tissue to the surface of the Hill-Sachs defect. In 2009, the technique was modified by Koo et al. [37], who described a double-pulley suture technique in which two anchors were used to insert the infraspinatus tendon 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 patients with moderate to large Hill-Sachs defects associated with glenoid defects of < 20% to 25%. Patients with larger glenoid defects may require conversion to an open Latarjet procedure. Potential disadvantages associated with remplissage are decreased postoperative range of motion and sequelae of a nonanatomic repair construct. In 2008, Deutsch and Kroll [36] described a case of significant postoperative loss of external rotation following remplissage. Motion was improved following arthroscopic release of the infraspinatus tenodesis; the authors proposed that the infraspinatus tendon and posterior capsular tissue created a mechanical block to motion. In their series, Purchase et al. [25] noted unpublished findings indicating good results with remplissage, with no notable loss of external rotation. Most patients did not experience recurrent instability. Advantages of remplissage include the arthroscopic approach, the ability to perform concomitant procedures, and fast recovery time. Additionally, this approach has none of the risks and morbidity associated with bone grafting procedures.
  Recently, several clinical outcome studies [39-44] have been published in the peer-reviewed literature (Table 4). In 2012, Boileau et al. [39] reported that arthroscopic Hill-Sachs remplissage, performed in combination with a Bankart repair, is a potential solution for patients with a large engaging humeral head bone defect but no substantial glenoid bone loss. In their clinical study, the posterior capsulotenodesis heals predictably in the humeral defect. The slight restriction in external rotation (approximately 10o) does not significantly affect return to sports, including those involving overhead activities. They concluded that the procedure, which may also be useful for revision of previously failed glenohumeral instability surgery, is not indicated for patients with glenoid bone deficiency.

Disimpaction
  Disimpaction of a humeral head defect (i.e., humeroplasty) involves elevating the impaction fracture and supporting it with bone graft, thereby allowing for approximate restoration of humeral head geometry without internal fixation [45,46]. The procedure can be performed using bone tamps inserted retrograde through a distal cortical window [45]. Alternatively, disimpaction can be performed percutaneously using an 8-mm cannulated reamer drilled to within 1 cm of the posterior surface, followed by backfilling of the defect with cancellous bone chips [46]. This technique is relatively new, and little biomechanical and clinical research has been published on the topic. Disimpaction may be most suited to acute lesions < 3 weeks old and with < 40% involvement of the articular surface [12].

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 [13,47]. Although partial resurfacing is promising in theory, only limited case reports with short-term follow-ups are available in the literature. Outcomes have been reported to be positive at 1 to 2 years postimplantation [13,47]. With this technique, there is no risk of disease transmission or resorption, as can occur with allografting. However, disadvantages include loss of fixation, incomplete geometric restoration, and eventual glenoid wear.
  Complete humeral head resurfacing (i.e., humeral head hemiarthroplasty) is an option for Hill-Sachs lesions that cause recurrent instability, in particular lesions that involve > 40% of the articular surface [48]. However, indications are not clearly defined. Older (> 65 years), low-demand patients may benefit from hemiarthroplasty or total shoulder arthroplasty (TSA) in the presence of concomitant glenoid degeneration. However, outcomes of hemiarthroplasty and TSA are much less predictable, with high failure rates in young, active patients. In these patients, hemiarthroplasty should be considered a salvage procedure in cases of severe defects causing recurrent instability. Pritchett and Clark [48] described humeral hemiarthroplasty and TSA in seven patients with chronic dislocations and significant Hill-Sachs lesions. Average 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 active patients with defects involving > 40% of the articular surface and/or significant articular cartilage degeneration.
CONCLUSION
  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 significant 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 literature suggests that Hill-Sachs lesions 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 deficiency in relation to glenoid width and bone loss.
  A meticulous approach to the diagnostic workup is essential and must include a complete history and a thorough 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 articular arc and to prevent engagement. However, large Hill-Sachs defects may require combined procedures that directly address the humeral defect, including arthroplasty, humeral head allograft, remplissage, and resurfacing.
CONFLICT OF INTEREST
  No potential conflict of interest relevant to this article was reported.
Figures
Fig. 1. Arthroscopic view of the large-sized Hill-Sachs lesion.
Fig. 2. Three-dimensional computed tomography 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.
Fig. 3. Axial (A) and coronal (B) magnetic resonance imaging demonstrating a classic Hill-Sachs lesion (arrows).
Tables
Table. 1. Important history and physical examination findings for Hill-Sachs lesions [11]
Table. 2. Classifications of Hill-Sachs lesions [11]
Table. 3. Indications for surgical management of Hill-Sachs lesions [11]
Table. 4. Functional results after arthroscopic remplissage with Bankart repair
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