Hill Sachs Lesion: Difference between revisions

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== Clinically Relevant Anatomy<br>  ==
== Description ==
 
 


The term 'Hill-Sachs Lesion', refers to the glenohumeral joint [link to: http://www.physio-pedia.com/Glenohumeral_Joint], which is a synovial ball-and-socket diarthroidal joint. It is the articulation between the fossa glenoidalis of the scapula and the caput humeri. It’s common known that the shoulder joint has a real loose capsule and that therefore the risk for dislocation is severely high. [4][5]<br>* The bony part: the scapula with his glenoid and the humeral head from the humerus; The humerus is the “ball” of the ball-and-socket joint. This one is located in the “socket” (glenoid) which forms the shoulder joint. The scapula is a triangular shaped bone that forms the “socket” in the joint. [6] [7]<br>* The fibro cartilaginous structure surrounding the glenoid, namely the labrum; The labrum makes sure there is enough contact between the surface of the glenoid and the humeral head. There is a concavity compression mechanism which plays an important role in the stability of the shoulder. The less contact there is, the more chance there is for dislocations.[8] <br>* The capsule and ligamentous structures: Glenohumeral Ligaments (pars superior, media and inferior), which are meant for the strengthen of the capsule. Coracohumeral Ligament: is also meant for the strengthen of the capsule. [2] Transversal humeral ligament: is meant for M. Biceps Brachii [5]<br>* Muscles: Abductors: M. deltoideus and M. Supraspinatus Adductors: M. Pectoralis Major Flexors: M. Deltoid Rotator Cuff (very important for the stability of the art humeri): M. supraspinatus, M. infraspinatus, M. Teres Minor, M. Subscapularis Extensors: M. Deltoid, M. Triceps Brachii, M. Teres Major, M. Latissimus Dorsi Internal Rotators: M. Teres Major, M. latissimus dorsi, M. Subscapularis, M. Pectoralis Major External Rotators: M. Teres Minor and M. Infraspinatus. [9]<br>* Bursae: There are eight bursae in the shoulder complex. [4] This is because of the high amount of muscles on the shoulder. They make sure there is a smooth contact between the muscle and the underlying structure. The biggest one in the body is the subacromial
A Hill-Sachs lesion is an osseous defect or "dent" of the postero-supero-lateral humeral head that occurs in association with [[Anterior Shoulder Instability|anterior instability]] or [[Shoulder Dislocation|dislocation of the glenohumeral joint]].<ref name="provencher">Provencher MT, Frank RM, LeClere LE, Metzger PD, Ryu JJ, Bernhardson A, Romeo AA. [https://journals.lww.com/jaaos/Abstract/2012/04000/The_Hill_Sachs_Lesion__Diagnosis,_Classification,.11.aspx The Hill-Sachs lesion: diagnosis, classification, and management.] Journal of the American Academy of Orthopaedic Surgeons 2012;20(4):242-52.</ref><ref name=":0">Shoulder Doc. Hill-Sachs Lesion. Available from: https://www.shoulderdoc.co.uk/article/1470 (accessed 24 December 2023).</ref>  It is often associated with a [[Bankart lesion]] of the glenoid.<ref name=":2">Radiopedia [https://radiopaedia.org/articles/hill-sachs-defect?lang=gb Hills Sachs defect] Available from:https://radiopaedia.org/articles/hill-sachs-defect?lang=gb (accessed 24 December 2023)</ref> This lesion is caused by an anterior shoulder dislocation which causes a humeral head impression fracture. The posterolateral aspect of the humeral head impacts on the anterior [[Glenoid Labrum|glenoid]] in the dislocated position, causing [[Shoulder Instability|shoulder instability]].<ref name="provencher 2">Provencher MT, Frank RM, Leclere LE, Metzger PD, Ryu JJ, Bernhardson A, Romeo AA. The Hill-Sachs lesion: diagnosis, classification, and management. J Am Acad Orthop Surg. 2012 Apr;20(4):242-52. doi: 10.5435/JAAOS-20-04-242. </ref><ref name="castro">Castro WHM, Jerosch J, Grossman TV. Examination and diagnosis of musculoskeletal disorders. Georg Thieme Verlag: Germany, 2001.</ref><ref name="dodson">Dodson CC, Cordasco FA. [https://www.sciencedirect.com/science/article/pii/S0030589808000461 Anterior glenohumeral joint dislocations.] Orthopedic Clinics of North America 2008;39(4):507-18.</ref>


<br>
Watch this animated description of Hill-Sachs and [[Bankart lesion|Bankart Lesions]]  that can occur with a shoulder dislocation and contribute to further shoulder instability (2 minutes)
{{#ev:youtube|v=a6BWiufgmsc|300}}<ref> ORTHOfilms. Bankart and Hill-Sachs Lesions. Available from: https://www.youtube.com/watch?v=a6BWiufgmsc [last accessed 10.1.2023]</ref>


== Mechanism of Injury / Pathological Process<br> ==
== Epidemiology ==
The incidence of Hill-Sachs lesions are approximately 40%-90% of all anterior shoulder instability cases, and even as high as 100% in patients with recurrent anterior instability.<ref name="provencher" /> A study looking at this found Hill-Sachs lesions in 65% of acute dislocations and 93% in patients with recurrent instability.<ref name="christos">Yiannakopoulos CK, Mataragas E, Antonogiannakis E. [http://www.orthosurgery.gr/dimosieusis/AComparisonoftheSpectrumofIntra-articularLesionsinAcuteandChronicAnteriorShoulderInstability.pdf A comparison of the spectrum of intra-articular lesions in acute and chronic anterior shoulder instability.] Arthroscopy: The Journal of Arthroscopic & Related Surgery 2007;23(9):985-90.</ref><br>A Hill-Sachs lesion occurs in about 50% of the first-time shoulder dislocations. For people with a shoulder dislocations history (i.e. shoulder instability) humeral head compression fractures are present in most cases.<ref name="fuller" />
== Etiology ==
* [http://www.physio-pedia.com/Anterior_Shoulder_Instability Anterior shoulder instability]:
** Approximately 47% of the lesions are associated with the initial shoulder instability according to research studies<ref name="calandra">Calandra JJ, Baker CL, Uribe J. [https://www.sciencedirect.com/science/article/pii/0749806389901382 The incidence of Hill-Sachs lesions in initial anterior shoulder dislocations.] Arthroscopy: The Journal of Arthroscopic & Related Surgery 1989;5(4):254-7.</ref>
* [http://www.physio-pedia.com/Bankart_lesion Bankart lesion]<ref name="horst">Horst K, Von Harten R, Weber C, Andruszkow H, Pfeifer R, Dienstknecht T, et al. [https://www.birpublications.org/doi/pdfplus/10.1259/bjr.20130673 Assessment of coincidence and defect sizes in Bankart and Hill–Sachs lesions after anterior shoulder dislocation: a radiological study.] The British journal of radiology 2014;87(1034):20130673.</ref>
** 2.5 times more likely to for someone with either of those lesions to have the other as well<ref name="widjadja">Widjaja AB, Tran A, Bailey M, Proper S. [https://onlinelibrary.wiley.com/doi/abs/10.1111/j.1445-2197.2006.03760.x Correlation between Bankart and Hill‐Sachs lesions in anterior shoulder dislocation.] ANZ journal of surgery 2006;76(6):436-8.</ref>


The glenohumeral joint is the most commonly dislocated joint in the human body and 90% of shoulder dislocations are anterior. The reason for this is that the scapula is oriented about 30 degrees anterior and this to the coronal plane of the body. Because of this the glenohumeral joint with the humerus is orienting anterior to the glenoid.<ref name="Nepola" /><br>  
* Anterior glenoid bone loss (in cases of recurrent instability)<ref name="kim">Kim DS, Yoon YS, Yi CH. [http://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.858.1952&rep=rep1&type=pdf Prevalence comparison of accompanying lesions between primary and recurrent anterior dislocation in the shoulder.] The American journal of sports medicine 2010;38(10):2071-6.</ref>
== Classification ==
Classification systems are used to describe the amount of damage to the anterior capsule and the labrum, reflected by the depth of the lesion. Higher grade lesions are associated with increased risk of recurrent dislocation.<ref name="provencher" /><ref name=":0" /><ref name="calandra" />
*'''Grade 1:'''  Defect in the articular surface down to (but not including) the subchondral bone
*'''Grade 2:'''  Lesion includes the subchondral bone
*'''Grade 3:'''  Lesion causes large defect in the subchondral bone.


When a trauma takes place, an anterior [[Shoulder Dislocation|shoulder dislocation]] can cause a head impression fracture what we call a Hill sachs lesion. The posterolateral aspect of the humeral head impacts on the anterior glenoid in the dislocated position, what makes the glenohumeral joint unstable ([[Shoulder Instability|Shoulder_Instability]]). <ref name="Gooding">W.T. Gooding, B., M. Geoghegan, J., A. Manning, P., 'The management of acute traumatic primary anterior shoulder dislocation in young adults', Jornal compilation: British elbow and shoulder society, 2010, p. 141-146 (Level of evidence 1A)</ref><ref name="Cetik">Cetik, O., Uslu, M., K. Ozsar, B., 'The relationship between Hill sachs lesion and recurrent anterior shoulder dislocation', Acta orthopaedica Belgica, VOL. 73 (2007), p. 175-178</ref><ref name="Wilk">E. Wilk, K., C. Macrina, L., M. Reinold, M., 'Non-operative rehabilitation for traumatic and atraumatic glenohumeral instability', North american journal of  sports physical therapy, VOL. 1 (2006), februari, nr. 1, p. 16-31</ref>  
Further classification can be done by looking at the percentage of the defect of humeral head involvement in the compression fracture.<ref name="cetik">Cetik O, Uslu M, Ozsar BK. [http://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.627.9326&rep=rep1&type=pdf The relationship between Hill-Sachs lesion and recurrent anterior shoulder dislocation.] Acta orthopaedica belgica 2007;73(2):175-8.</ref> The size of the lesion correlates in most cases to the number of previous dislocations.<ref name="savoie">Fox JA, Sanchez A, Zajac TJ, Provencher MT. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5685959/ Understanding the Hill-Sachs Lesion in Its Role in Patients with Recurrent Anterior Shoulder Instability.] Curr Rev Musculoskelet Med. 2017 Dec;10(4):469-479. doi: 10.1007/s12178-017-9437-0. </ref>
* '''Minor:'''  <20%
* '''Moderate:'''  20%-45%
* '''Severe:'''  >45%


90% of shoulder dislocations are anterior, so in some cases there could be a posterior dislocation what can cause a reverse Hill sachs lesion. This lesion may be present on the anterior aspect of the humeral head. <ref name="Wilk" />


<div><br></div>
Another classification - ON track or OFF track<ref>Di Giacomo G, Itoi E, Burkhart SS. Evolving concept of bipolar bone loss and the Hill-Sachs lesion: from “engaging/non-engaging” lesion to “on-track/off-track” lesion. Arthroscopy: The Journal of Arthroscopic & Related Surgery. 2014 Jan 1;30(1):90-8.</ref>
== Clinical Presentation  ==


Shoulder dislocation don’t occur isolated. It causes damage to different tissues surrounding the glenohumeral joint like shoulder ligaments, rotator cuff tendons and the joint capsule. But the bone and cartilage of the humeral head can also be affected. This occurs when the round humeral head is forcibly impacted on the edge of the glenoid, which causes compression fractures in the humeral head. This forms a dimple structure on the articular surface of the humerus, and is called a Hill-Sachs lesion. It can be seen on MRI, CT-scan, but is difficult to see on an x-ray. [13][14][15]<br>
If the Hill-Sachs lesion engages, it is called an “off-track” Hill-Sachs lesion; if it does not engage, it is an “on-track” lesion.  


<span>&nbsp;</span>We can order this humeral head compression fractures according to the percentage of humeral head involvement [11] <br>• minor defect: less than 20% of the humeral head is involved;<br>• moderate defect: between 20% and 45% of the head is involved;<br>• severe defect: more than 45% of the head is involved.<br>The size of the lesion is in most cases related to the amount of times a dislocation took place[16] <br>  
== Clinical Presentation ==
Shoulder dislocation rarely occur isolated. It causes damage to different tissues surrounding the [[Glenohumeral Joint|glenohumeral joint]], such as ligaments, [[Rotator Cuff|rotator cuff]] tendons, joint capsule as well as the [[bone]] and [[cartilage]] of the humeral head. This occurs when the round humeral head is forcibly impacted on the edge of the glenoid, which causes compression fractures in the humeral head. This forms a dimple structure on the articular surface of the humerus - a Hill-Sachs lesion.<ref name="cluett">Cluett J. Hill-Sachs Injury: Damage to the shoulder joint as result of dislocation. Orthopedics, 2013.</ref><ref name="ahmed">Radiopedia. Hill-Sachs lesion. https://radiopaedia.org/articles/hill-sachs-lesion (accessed 27/08/2018).</ref><ref name="fuller">Wiki Radiography. Hill-Sachs and Bankart lesion. Available from:http://www.wikiradiography.net/page/Hill-Sachs+and+Bankart+Lesions (accessed 25 December 2023).</ref>This is always caused by dislocation, not only subluxation.<ref name="cluett" />


Figure 1 illustrates how the percentage of the humeral head, which is involved, is calculated. Next to this percentage, a Hill-Sachs lesion is also characterized by its depth ('d' on figure 1) and its size ('s' on figure 1).
According to the page on [[Shoulder Dislocation|shoulder dislocations]], the following indicates an acute anterior glenohumeral dislocation:
* Arm held in abduction and external rotation
* Loss of normal contour of the [[deltoid]] and acromion prominent posteriorly and laterally
* Humeral head palpable anteriorly
* All movements limited and painful
* Coracoid process:  Palpable fullness and positioned towards the axilla<span style="line-height: 1.5em;"></span>
== Differential diagnosis ==
* [http://www.physio-pedia.com/Bankart_lesion Bankart lesion]: Also as a result of shoulder dislocation, and often goes together<ref name="fuller" /><ref name="ahmed" />
* Pseudo-Hill-Sachs lesion: It is normal that below the level of the coracoid, the humeral head normally flattens out, and should not be mistaken as a Hill-Sachs lesion<ref name="ahmed" />


<br>  
* Humeral avulsion fractures<ref name="savoie" />
 
* Mid capsular tears<ref name="savoie" />
[[Image:Hill sachs lesion.jpg|left|Figure 1: preoperative double contrast CT arthrography of a 20 year old patient]]<span style="line-height: 1.5em;">Figure 1: preoperative double contrast CT arthrography of a 20 year old patient. [11</span><span style="line-height: 1.5em;">]
* Floating anterior capsule<ref name="savoie" />
 
* Reverse Hill-Sachs lesion: Lesion on the anterior-superior aspect of the humeral head as the result of a posterior shoulder dislocation<ref name="fuller" /><ref name="savoie" /><ref name="ahmed" />
</span>When we diagnose a Hill-Sachs defect, we can be sure that there was a complete dislocation of the humeral head out of the socket, and that it was not just a subluxation. [13]<br>A Hill-Sachs lesion occurs in about 50 percent of the first-time shoulder dislocations. For people with a shoulders dislocations’ history (= shoulder instability) you can almost always see these humeral head compression fractures. [15] There is a link between bone loss on either the glenoid side or the humeral side and recurrent shoulder instability during activities. [16]<br>


== Diagnostic Procedures  ==
== Diagnostic Procedures  ==


To diagnose pathologies of the humeral head, osseus glenoid and labrum, a number of imaging techniques have been described. <br>In the acute phase, plain radiography can detect bony lesions of the humeral head related to shoulder instability. Radiographic techniques most advandageous for initial evaluation of glenohumeral instability are the Grashey view (anteroposterior view of the shoulder) with internal and external views, the scapular 'Y' view (transcapular view of the shoulder) and the Garth view (x-ray beam caudally from a standard anteroposterior view). When the mobility of the patient allows, axillary, axillary with exaggerated external rotation and West Pont views can be added. In practice, for specific cases (when clinical examination is difficult), sometimes dynamic stress tells more about the instability of the shoulder. The combination of these views is an important first step at effectively evaluating both the glenohumeral relationship as well as osseous pathology on both the humerus and the glenoid. [2][18] <br>Also ultrasound can detect and localise a compression fracture in Hill Sachs lesions. The advantage of this method is its cost effectiveness and its minimal exposure to excessive radiation (see plain radiographies or CT scan). It also provides a comfortable position for the patient. [18],[19]. <br>Firstly, with the arm in a neutral position, the convexity of the humerus in the posterior transversal plane is examined. Special attention should be payed to the layer of cartilage. Secondly, the patient has to flex the arm at a 90-degree angle, to facilitate the examination of the total posterosuperior convexity of the humerus. In Hill Sachs lesions, a triangular depression in the contour of the humerus will be apparent.[3]. <br>A study of Pancione et al. (1997) compared the advantages of using ultrasound versus CT scans for the examination of shoulder dislocations. They showed that ultrasounds demonstrated a higher sensitivity (95,6%) and specificity (92,8%) for the detection of Hill Sachs lesions. [5] Recently, Pavic et al. (2013) found a statistically significant difference between ultrasound and MRI stating that MRI is more accurate than ultrasound. (level of evidence: 3) [20] <br>MRI is useful to detect a pathology of the soft tissue and to determine the amount of humeral and glenoid bone loss. A double-blind, prospective study by Denti et al.,15 patients underwent MRI with a sensitivity of 60%, specificity of 80% and accuracy of 87´%. [21]<br>CT scans make it possible to reliably asses the location and depth of the humeral lesion. Based on the latter, surgical decision is made. Overall, sagittal- and axial-plane measurements are more accurate for evaluation of these defects than the coronal plane. [19]<br><br>
=== Physical examination ===
* [[Apprehension Test|Bony apprehension test]]:<ref name="bushnell1">Bushnell B, Creighton R, Herring M. T[https://www.sciencedirect.com/science/article/pii/S0749806308005884 he bony apprehension test for instability of the shoulder: a prospective pilot analysis.] Arthroscopy 2008:24(9):974-82.</ref>
** Positive test:  Pain/reflex muscle contraction (in case of sublaxation)<ref name="bushnell1" />
{{#ev:youtube|xzOlo5c7DpU}}
* [http://www.physio-pedia.com/Jobes_Relocation_Test Jobe relocation test]:
** Positive test:  Apprehension
** Crepitus and catching may be felt during active and passive abduction and external rotation<ref name="provencher 2" />
** Possible lesion indicated by audible/palpable clunk in active/passive abduction and external rotation or an unstable feeling during mid-range
{{#ev:youtube|watch?v=K0B1lNOVnP4}}
=== Special investigations ===
[[File:Shoulder dislocation, anteroposterior after reduction, with Bankart and Hill-Sachs lesions, with labels.jpeg|thumb|Bankart and Hill-Sachs lesions]]
[[X-Rays|X-ray]]:<ref name="provencher 2" /><ref name="omoumi">Omoumi P, Teixeira P, Lecouvet F, Chung CB. [https://onlinelibrary.wiley.com/doi/pdf/10.1002/jmri.22343 Glenohumeral joint instability.] Journal of Magnetic Resonance Imaging 2011;33(1):2-16.</ref>
* Grashey view (AP) in internal and external rotation; transcapular view (X-ray beam caudally from standard AP view); axillary views with exaggerated external rotation and West Pont views (if pain allows)
* Important first step at effectively evaluating the glenohumeral relationship as well as osseous pathology of the humerus and the glenoid
* Can detect bony lesions related to shoulder instability in the acute phase
* Difficult to see Hill-Sachs lesion
[[Ultrasound Scans|Ultrasound]]:<ref name="omoumi" /><ref name="kodali">Kodali P, Jones MH, Polster J, Miniaci A, Fening SD. [https://www.sciencedirect.com/science/article/pii/S1058274611000437 Accuracy of measurement of Hill-Sachs lesions with computed tomography.] Journal of shoulder and elbow surgery 2011;20(8):1328-34.</ref>
* Detect and localize a compression fracture
* Cost-effective, minimal exposure to excessive radiation, comfortable for patient
* Hill-Sachs lesions: Apparent triangular depression in the contour of the humerus<ref name="castro" />
[[CT Scans|CT scan]]:  Reliably assess the location and depth of the humeral lesion<ref name="pancione">Pancione L, Gatti G, Mecozzi B. [https://www.tandfonline.com/doi/pdf/10.1080/02841859709174380 Diagnosis of Hill-Sachs lesion of the shoulder: comparison between ultrasonography and arthro-CT.] Acta Radiologica 1997;38(4):523-6.</ref>


== Outcome Measures ==
[[MRI Scans|MRI]]: Detect pathology of the soft tissue; determine the amount of humeral and glenoid bone loss<ref name="pancione" /><ref name="pavic">Pavic R, Margetic P, Bensic M, Brnadic RL. [https://www.sciencedirect.com/science/article/pii/S0020138313701943 Diagnostic value of US, MR and MR arthrography in shoulder instability.] Injury 2013;44:S26-32.</ref>


add links to outcome measures here (see [[Outcome Measures|Outcome Measures Database]])
<ref name="fuller" /><ref name="cluett" /><ref name="ahmed" />
=== Outcome Measures ===


== Management / Interventions<br> ==
*[https://www.physio-pedia.com/DASH_Outcome_Measure Disabilities of the arm, shoulder and hand (DASH)]
*[[Shoulder Pain and Disability Index (SPADI)]]
*[https://www.physio-pedia.com/Numeric_Pain_Rating_Scale Numeric Pain Rating Scale (NPRS)]
== Medical management ==
The bony defect usually does not require treatment, though the linked glenohumeral instability and possible anterior labral injuries often need surgical repair.


When patients have a small or moderate defect of the humeral head, it tends to be neglected. Surgical treatment is no necessity. So, there is no need of surgical treatment, but important is handle the result, the unstability.<ref name="Cetik" /><br>  
# Minimum glenoid bone loss and without significant involvement of the humeral head (<20%), surgical management is not indicated<ref name="andrew" />. This instability can be managed conservatively in a master sling for immobilization for 2-6 weeks, before starting with rehabilitation.<ref name="cetik" /><ref name="andrew" />
# Large Defects: Management of the bony defect (as in Hill-Sachs lesion) can be treated with bone grafting or placement of soft tissue within the defect.<ref name=":2" />


The non-operative rehabilitation of the unstable shoulder consists about seven key factors: <ref name="Wilk" />  
=== Surgical management ===
The critical size of the glenoid bone loss has been clarified as 25% of the glenoid width both biomechanically and clinically. This is the determinant factor influencing the choice of the surgical technique: soft tissue procedure or bone block procedure. <ref name=":1">Yamamoto N, Shinagawa K, Hatta T, Itoi E. Peripheral-track and central-track Hill-Sachs lesions: a new concept of assessing an on-track lesion. The American Journal of Sports Medicine. 2020 Jan;48(1):33-8.</ref>


*Onset of pathology (in this case: traumatic event)
'''Arthroscopic technique'''
*Degree of instability (in this case: dislocation)
* Remplissage procedure: Defect is filled with soft tissue, usually from the infraspinatus tendon
*Frequency of dislocation (in this case acute)
*Direction of instability (in this case: anterior)
*concomitant pathologies (in this case: Hill sachs lesion)
*Neuromuscular control
*Activity level


In the non-operative rehabilitation program of the traumatic dislocation of the shoulder, it's important to consider all these seven factors and thus also with the concomitant 'Hill sachs lesion': [[Rehabilitation program of the shoulder|rehabilitation program of the shoulder]]
* Second arthroplasty method:  Percutaneous humeroplasty
** Lesion is filled by using a bone tamp brought into a drilled osseous window 180° from the lesion
** Advantage: Rotational osteotomy of the humeral head is not needed and the humeral head can be restored without transpositioning the soft tissue
** Limitations: Limited to moderate-sized defects; lack of management of osteochondral defects
* Other procedures:  Techniques that use various small bone plugs
<ref name="provencher 2" />
[[File:Latarjet-Procedure, Bankart repair.jpeg|thumb|Latarjet-Procedure]]
'''Open technique'''
* Laterjet procedure:  Most frequently done<ref name="provencher 2" /><ref name="schroder">Schroder DT, Provencher MT, Mologne TS, Muldoon MP, Cox JS. [https://www.researchgate.net/profile/Matthew_Provencher/publication/7371754_The_modified_bristow_procedure_for_anterior_shoulder_instability_26-Year_outcomes_in_Naval_Academy_Midshipmen/links/0912f509b2b2743dea000000.pdf The modified Bristow procedure for anterior shoulder instability: 26-year outcomes in Naval Academy midshipmen.] The American journal of sports medicine 2006;34(5):778-86.</ref><ref name="hovellus">Hovelius L, Sandström B, Sundgren K, Saebö M. [https://www.sciencedirect.com/science/article/pii/S1058274604000916 One hundred eighteen Bristow-Latarjet repairs for recurrent anterior dislocation of the shoulder prospectively followed for fifteen years: study I—clinical results.] Journal of shoulder and elbow surgery 2004;13(5):509-16.</ref>
** Most commonly, bone from the coracoid process is used as an augment to the antero-inferior glenoid bone loss. By reforming the concavity and width of the glenoid, a Hill-Sachs lesion does not influence the anterior glenoid rim of unstable shoulders.
** Successful in preventing instability over time
** Negative consequences associated with the Laterjet are shoulder arthrosis and loss of function


<br>  
* Autologous bone plugs
* Size-matched osteo-articular allografts
* Rotational humeral osteotomy: 
** Osteotomy of the surgical neck to rotate the humeral head for 25°
** Currently not method of choice, given the related risks and the success rates of more recent procedures.
* The osseus humeral allograft bone plug technique: 
** A size-matched humeral bone plug of a donor is used
** Approach: Delto-pectoral or deltoid-splitting
** Advantages: Minimal exposure; humeral head remains in the capsule.
** Disadvantage: Limited to small and moderate lesions; risks of using cadaveric tissue<ref name="provencher 2" />
== Physiotherapy management    ==
'''Aim''':  Prevent reoccurrence of dislocations


Some studies say that: 'there is no relationship between the number of dislocations and Hill sachs lesion'. But several studies have shown that when the number of dislocations increases, the incidence and size of Hill sachs lesion also increases. It can be a cause of instability and in this case surgical treatment is considered. Frequently, authors consider that surgical treatment of recurrent shoulder dislocation is indicated when someone had more than five shoulder dislocations. <ref name="Cetik" /><ref name="Cutts" />  
The non-operative rehabilitation of the unstable shoulder consists about seven key factors. It is important to consider this in the [http://www.physio-pedia.com/Rehabilitation_program_of_the_shoulder rehabilitation program of the shoulder] after a Hill-Sachs lesion.<ref name="wilk">Wilk KE, Macrina LC, Reinold MM. Non-operative rehabilitation for traumatic and atraumatic glenohumeral instability. North American journal of sports physical therapy 2006;1(1):16.</ref>
* The onset of pathology
* The degree of instability
* The frequency of dislocation
* The direction of instability
* Concomitant pathologies
* Neuromuscular control
* Activity level
[[File:Stiff Brace for after Shoulder Surgery.jpeg|thumb|Stiff sling]]
Physiotherapy interventions include:
* 2-6 weeks of immobilization in a mastersling:
** Scapula stabilization exercises
** Hand, wrist and elbow exercises
** Teach patient on functional adaptions (e.g. personal hygiene, dressing and undressing)
** No driving while still in sling
* When use of sling is discontinued (on recommendation of orthopaedic surgeon):
** Pendulum exercises
** Passive, active-assisted and active range of motion exercises (progressions)
** Abduction and external rotation is restricted during the initial phase of the rehabilitation
*** Ligaments healing needs to take place to prevent dislocation
** Strengthening of the deltoid, rotator cuff and periscapular (e.g. pectoralis major) muscles
<ref name="andrew">Chen AL, Bosco III JA. [http://go.galegroup.com/ps/anonymous?id=GALE%7CA166094301&sid=googleScholar&v=2.1&it=r&linkaccess=abs&issn=19369719&p=AONE&sw=w Glenohumeral bone loss and anterior instability.] Bulletin of the NYU hospital for joint diseases 2006 Dec 22;64(3-4):130.</ref>


== Differential Diagnosis<br>  ==
Post-surgical rehabilitation should be guided by the orthopaedic surgeon, and depends on the procedure that was done.


add text here relating to the differential diagnosis of this condition<br>
== Clinical bottom line  ==


== Key Evidence  ==
A Hill-Sachs lesion is an injury that occurs secondary to an anterior [http://www.physio-pedia.com/Shoulder_Dislocation shoulder dislocation]. The humeral head ‘collides’ with the anterior part of the glenoid, causing a lesion, bone loss, defect and deformity of the humeral head. This may cause a change loss of range of motion, feelings of instability and pain. A grading system is used based on the amount of bone loss or severity of the humeral head deformity. The incidence of Hill-Sachs lesion in patients with anterior shoulder instability can be as high as 100%.<ref name="provencher" /><span style="line-height: 1.5em;"><ref name="calandra" /></span> A<span style="line-height: 1.5em;">nother pathology secondary to an [http://www.physio-pedia.com/Anterior_Shoulder_Instability anterior shoulder dislocation] is a [http://www.physio-pedia.com/Bankart_lesion Bankart lesion]. This is an injury of the anterior glenoid labrum of the shoulder and often often accompanied by a Hill-Sachs lesion.<ref name="widjadja" /></span>


add text here relating to key evidence with regards to any of the above headings<br>  
<span style="line-height: 1.5em;">Conservative treatment is only recommended in cases of small bony defects (<20% Hill-Sachs lesion), in other cases (larger and more significant lesions), surgical treatment is needed. The conservative treatment should be based on strengthening the deltoid, the rotator cuff muscles and scapular stabilizers.<ref name="provencher" /><ref name="andrew" /></span>  
 
== Resources <br> ==
 
add appropriate resources here
 
== Case Studies  ==
 
add links to case studies here (case studies should be added on new pages using the [[Template:Case Study|case study template]])<br>  


== References  ==
== References  ==


References will automatically be added here, see [[Adding References|adding references tutorial]].
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[[Category:Vrije_Universiteit_Brussel_Project]]
[[Category:Vrije_Universiteit_Brussel_Project]]
[[Category:Primary Contact]]
[[Category:Sports Medicine]]
[[Category:Sports Injuries]]
[[Category:Conditions]]
[[Category:Shoulder - Conditions]]

Latest revision as of 16:37, 25 December 2023

Original Editors - Lien Hennebel as part of the Vrije Universiteit Brussel's Evidence-based Practice project

Top Contributors - Jelle Van Hemelryck, Lien Hennebel, Leana Louw, Pauline Bouten, Simisola Ajeyalemi, Uchechukwu Chukwuemeka, Admin, Kim Jackson, Lucinda hampton, Shreya Pavaskar, Rachael Lowe, Fasuba Ayobami, Wanda van Niekerk, Nupur Smit Shah, 127.0.0.1 and Claire Knott

Description[edit | edit source]

A Hill-Sachs lesion is an osseous defect or "dent" of the postero-supero-lateral humeral head that occurs in association with anterior instability or dislocation of the glenohumeral joint.[1][2] It is often associated with a Bankart lesion of the glenoid.[3] This lesion is caused by an anterior shoulder dislocation which causes a humeral head impression fracture. The posterolateral aspect of the humeral head impacts on the anterior glenoid in the dislocated position, causing shoulder instability.[4][5][6]

Watch this animated description of Hill-Sachs and Bankart Lesions that can occur with a shoulder dislocation and contribute to further shoulder instability (2 minutes)

[7]

Epidemiology[edit | edit source]

The incidence of Hill-Sachs lesions are approximately 40%-90% of all anterior shoulder instability cases, and even as high as 100% in patients with recurrent anterior instability.[1] A study looking at this found Hill-Sachs lesions in 65% of acute dislocations and 93% in patients with recurrent instability.[8]
A Hill-Sachs lesion occurs in about 50% of the first-time shoulder dislocations. For people with a shoulder dislocations history (i.e. shoulder instability) humeral head compression fractures are present in most cases.[9]

Etiology[edit | edit source]

  • Anterior glenoid bone loss (in cases of recurrent instability)[13]

Classification[edit | edit source]

Classification systems are used to describe the amount of damage to the anterior capsule and the labrum, reflected by the depth of the lesion. Higher grade lesions are associated with increased risk of recurrent dislocation.[1][2][10]

  • Grade 1: Defect in the articular surface down to (but not including) the subchondral bone
  • Grade 2: Lesion includes the subchondral bone
  • Grade 3: Lesion causes large defect in the subchondral bone.

Further classification can be done by looking at the percentage of the defect of humeral head involvement in the compression fracture.[14] The size of the lesion correlates in most cases to the number of previous dislocations.[15]

  • Minor: <20%
  • Moderate: 20%-45%
  • Severe: >45%


Another classification - ON track or OFF track[16]

If the Hill-Sachs lesion engages, it is called an “off-track” Hill-Sachs lesion; if it does not engage, it is an “on-track” lesion.

Clinical Presentation[edit | edit source]

Shoulder dislocation rarely occur isolated. It causes damage to different tissues surrounding the glenohumeral joint, such as ligaments, rotator cuff tendons, joint capsule as well as the bone and cartilage of the humeral head. This occurs when the round humeral head is forcibly impacted on the edge of the glenoid, which causes compression fractures in the humeral head. This forms a dimple structure on the articular surface of the humerus - a Hill-Sachs lesion.[17][18][9]This is always caused by dislocation, not only subluxation.[17]

According to the page on shoulder dislocations, the following indicates an acute anterior glenohumeral dislocation:

  • Arm held in abduction and external rotation
  • Loss of normal contour of the deltoid and acromion prominent posteriorly and laterally
  • Humeral head palpable anteriorly
  • All movements limited and painful
  • Coracoid process: Palpable fullness and positioned towards the axilla

Differential diagnosis[edit | edit source]

  • Bankart lesion: Also as a result of shoulder dislocation, and often goes together[9][18]
  • Pseudo-Hill-Sachs lesion: It is normal that below the level of the coracoid, the humeral head normally flattens out, and should not be mistaken as a Hill-Sachs lesion[18]
  • Humeral avulsion fractures[15]
  • Mid capsular tears[15]
  • Floating anterior capsule[15]
  • Reverse Hill-Sachs lesion: Lesion on the anterior-superior aspect of the humeral head as the result of a posterior shoulder dislocation[9][15][18]

Diagnostic Procedures[edit | edit source]

Physical examination[edit | edit source]

  • Jobe relocation test:
    • Positive test: Apprehension
    • Crepitus and catching may be felt during active and passive abduction and external rotation[4]
    • Possible lesion indicated by audible/palpable clunk in active/passive abduction and external rotation or an unstable feeling during mid-range

Special investigations[edit | edit source]

Bankart and Hill-Sachs lesions

X-ray:[4][20]

  • Grashey view (AP) in internal and external rotation; transcapular view (X-ray beam caudally from standard AP view); axillary views with exaggerated external rotation and West Pont views (if pain allows)
  • Important first step at effectively evaluating the glenohumeral relationship as well as osseous pathology of the humerus and the glenoid
  • Can detect bony lesions related to shoulder instability in the acute phase
  • Difficult to see Hill-Sachs lesion

Ultrasound:[20][21]

  • Detect and localize a compression fracture
  • Cost-effective, minimal exposure to excessive radiation, comfortable for patient
  • Hill-Sachs lesions: Apparent triangular depression in the contour of the humerus[5]

CT scan: Reliably assess the location and depth of the humeral lesion[22]

MRI: Detect pathology of the soft tissue; determine the amount of humeral and glenoid bone loss[22][23]

[9][17][18]

Outcome Measures[edit | edit source]

Medical management[edit | edit source]

The bony defect usually does not require treatment, though the linked glenohumeral instability and possible anterior labral injuries often need surgical repair.

  1. Minimum glenoid bone loss and without significant involvement of the humeral head (<20%), surgical management is not indicated[24]. This instability can be managed conservatively in a master sling for immobilization for 2-6 weeks, before starting with rehabilitation.[14][24]
  2. Large Defects: Management of the bony defect (as in Hill-Sachs lesion) can be treated with bone grafting or placement of soft tissue within the defect.[3]

Surgical management[edit | edit source]

The critical size of the glenoid bone loss has been clarified as 25% of the glenoid width both biomechanically and clinically. This is the determinant factor influencing the choice of the surgical technique: soft tissue procedure or bone block procedure. [25]

Arthroscopic technique

  • Remplissage procedure: Defect is filled with soft tissue, usually from the infraspinatus tendon
  • Second arthroplasty method: Percutaneous humeroplasty
    • Lesion is filled by using a bone tamp brought into a drilled osseous window 180° from the lesion
    • Advantage: Rotational osteotomy of the humeral head is not needed and the humeral head can be restored without transpositioning the soft tissue
    • Limitations: Limited to moderate-sized defects; lack of management of osteochondral defects
  • Other procedures: Techniques that use various small bone plugs

[4]

Latarjet-Procedure

Open technique

  • Laterjet procedure: Most frequently done[4][26][27]
    • Most commonly, bone from the coracoid process is used as an augment to the antero-inferior glenoid bone loss. By reforming the concavity and width of the glenoid, a Hill-Sachs lesion does not influence the anterior glenoid rim of unstable shoulders.
    • Successful in preventing instability over time
    • Negative consequences associated with the Laterjet are shoulder arthrosis and loss of function
  • Autologous bone plugs
  • Size-matched osteo-articular allografts
  • Rotational humeral osteotomy:
    • Osteotomy of the surgical neck to rotate the humeral head for 25°
    • Currently not method of choice, given the related risks and the success rates of more recent procedures.
  • The osseus humeral allograft bone plug technique:
    • A size-matched humeral bone plug of a donor is used
    • Approach: Delto-pectoral or deltoid-splitting
    • Advantages: Minimal exposure; humeral head remains in the capsule.
    • Disadvantage: Limited to small and moderate lesions; risks of using cadaveric tissue[4]

Physiotherapy management[edit | edit source]

Aim: Prevent reoccurrence of dislocations

The non-operative rehabilitation of the unstable shoulder consists about seven key factors. It is important to consider this in the rehabilitation program of the shoulder after a Hill-Sachs lesion.[28]

  • The onset of pathology
  • The degree of instability
  • The frequency of dislocation
  • The direction of instability
  • Concomitant pathologies
  • Neuromuscular control
  • Activity level
Stiff sling

Physiotherapy interventions include:

  • 2-6 weeks of immobilization in a mastersling:
    • Scapula stabilization exercises
    • Hand, wrist and elbow exercises
    • Teach patient on functional adaptions (e.g. personal hygiene, dressing and undressing)
    • No driving while still in sling
  • When use of sling is discontinued (on recommendation of orthopaedic surgeon):
    • Pendulum exercises
    • Passive, active-assisted and active range of motion exercises (progressions)
    • Abduction and external rotation is restricted during the initial phase of the rehabilitation
      • Ligaments healing needs to take place to prevent dislocation
    • Strengthening of the deltoid, rotator cuff and periscapular (e.g. pectoralis major) muscles

[24]

Post-surgical rehabilitation should be guided by the orthopaedic surgeon, and depends on the procedure that was done.

Clinical bottom line[edit | edit source]

A Hill-Sachs lesion is an injury that occurs secondary to an anterior shoulder dislocation. The humeral head ‘collides’ with the anterior part of the glenoid, causing a lesion, bone loss, defect and deformity of the humeral head. This may cause a change loss of range of motion, feelings of instability and pain. A grading system is used based on the amount of bone loss or severity of the humeral head deformity. The incidence of Hill-Sachs lesion in patients with anterior shoulder instability can be as high as 100%.[1][10] Another pathology secondary to an anterior shoulder dislocation is a Bankart lesion. This is an injury of the anterior glenoid labrum of the shoulder and often often accompanied by a Hill-Sachs lesion.[12]

Conservative treatment is only recommended in cases of small bony defects (<20% Hill-Sachs lesion), in other cases (larger and more significant lesions), surgical treatment is needed. The conservative treatment should be based on strengthening the deltoid, the rotator cuff muscles and scapular stabilizers.[1][24]

References[edit | edit source]

  1. ↑ 1.0 1.1 1.2 1.3 1.4 Provencher MT, Frank RM, LeClere LE, Metzger PD, Ryu JJ, Bernhardson A, Romeo AA. The Hill-Sachs lesion: diagnosis, classification, and management. Journal of the American Academy of Orthopaedic Surgeons 2012;20(4):242-52.
  2. ↑ 2.0 2.1 Shoulder Doc. Hill-Sachs Lesion. Available from: https://www.shoulderdoc.co.uk/article/1470 (accessed 24 December 2023).
  3. ↑ 3.0 3.1 Radiopedia Hills Sachs defect Available from:https://radiopaedia.org/articles/hill-sachs-defect?lang=gb (accessed 24 December 2023)
  4. ↑ 4.0 4.1 4.2 4.3 4.4 4.5 Provencher MT, Frank RM, Leclere LE, Metzger PD, Ryu JJ, Bernhardson A, Romeo AA. The Hill-Sachs lesion: diagnosis, classification, and management. J Am Acad Orthop Surg. 2012 Apr;20(4):242-52. doi: 10.5435/JAAOS-20-04-242.
  5. ↑ 5.0 5.1 Castro WHM, Jerosch J, Grossman TV. Examination and diagnosis of musculoskeletal disorders. Georg Thieme Verlag: Germany, 2001.
  6. ↑ Dodson CC, Cordasco FA. Anterior glenohumeral joint dislocations. Orthopedic Clinics of North America 2008;39(4):507-18.
  7. ↑ ORTHOfilms. Bankart and Hill-Sachs Lesions. Available from: https://www.youtube.com/watch?v=a6BWiufgmsc [last accessed 10.1.2023]
  8. ↑ Yiannakopoulos CK, Mataragas E, Antonogiannakis E. A comparison of the spectrum of intra-articular lesions in acute and chronic anterior shoulder instability. Arthroscopy: The Journal of Arthroscopic & Related Surgery 2007;23(9):985-90.
  9. ↑ 9.0 9.1 9.2 9.3 9.4 Wiki Radiography. Hill-Sachs and Bankart lesion. Available from:http://www.wikiradiography.net/page/Hill-Sachs+and+Bankart+Lesions (accessed 25 December 2023).
  10. ↑ 10.0 10.1 10.2 Calandra JJ, Baker CL, Uribe J. The incidence of Hill-Sachs lesions in initial anterior shoulder dislocations. Arthroscopy: The Journal of Arthroscopic & Related Surgery 1989;5(4):254-7.
  11. ↑ Horst K, Von Harten R, Weber C, Andruszkow H, Pfeifer R, Dienstknecht T, et al. Assessment of coincidence and defect sizes in Bankart and Hill–Sachs lesions after anterior shoulder dislocation: a radiological study. The British journal of radiology 2014;87(1034):20130673.
  12. ↑ 12.0 12.1 Widjaja AB, Tran A, Bailey M, Proper S. Correlation between Bankart and Hill‐Sachs lesions in anterior shoulder dislocation. ANZ journal of surgery 2006;76(6):436-8.
  13. ↑ Kim DS, Yoon YS, Yi CH. Prevalence comparison of accompanying lesions between primary and recurrent anterior dislocation in the shoulder. The American journal of sports medicine 2010;38(10):2071-6.
  14. ↑ 14.0 14.1 Cetik O, Uslu M, Ozsar BK. The relationship between Hill-Sachs lesion and recurrent anterior shoulder dislocation. Acta orthopaedica belgica 2007;73(2):175-8.
  15. ↑ 15.0 15.1 15.2 15.3 15.4 Fox JA, Sanchez A, Zajac TJ, Provencher MT. Understanding the Hill-Sachs Lesion in Its Role in Patients with Recurrent Anterior Shoulder Instability. Curr Rev Musculoskelet Med. 2017 Dec;10(4):469-479. doi: 10.1007/s12178-017-9437-0.
  16. ↑ Di Giacomo G, Itoi E, Burkhart SS. Evolving concept of bipolar bone loss and the Hill-Sachs lesion: from “engaging/non-engaging” lesion to “on-track/off-track” lesion. Arthroscopy: The Journal of Arthroscopic & Related Surgery. 2014 Jan 1;30(1):90-8.
  17. ↑ 17.0 17.1 17.2 Cluett J. Hill-Sachs Injury: Damage to the shoulder joint as result of dislocation. Orthopedics, 2013.
  18. ↑ 18.0 18.1 18.2 18.3 18.4 Radiopedia. Hill-Sachs lesion. https://radiopaedia.org/articles/hill-sachs-lesion (accessed 27/08/2018).
  19. ↑ 19.0 19.1 Bushnell B, Creighton R, Herring M. The bony apprehension test for instability of the shoulder: a prospective pilot analysis. Arthroscopy 2008:24(9):974-82.
  20. ↑ 20.0 20.1 Omoumi P, Teixeira P, Lecouvet F, Chung CB. Glenohumeral joint instability. Journal of Magnetic Resonance Imaging 2011;33(1):2-16.
  21. ↑ Kodali P, Jones MH, Polster J, Miniaci A, Fening SD. Accuracy of measurement of Hill-Sachs lesions with computed tomography. Journal of shoulder and elbow surgery 2011;20(8):1328-34.
  22. ↑ 22.0 22.1 Pancione L, Gatti G, Mecozzi B. Diagnosis of Hill-Sachs lesion of the shoulder: comparison between ultrasonography and arthro-CT. Acta Radiologica 1997;38(4):523-6.
  23. ↑ Pavic R, Margetic P, Bensic M, Brnadic RL. Diagnostic value of US, MR and MR arthrography in shoulder instability. Injury 2013;44:S26-32.
  24. ↑ 24.0 24.1 24.2 24.3 Chen AL, Bosco III JA. Glenohumeral bone loss and anterior instability. Bulletin of the NYU hospital for joint diseases 2006 Dec 22;64(3-4):130.
  25. ↑ Yamamoto N, Shinagawa K, Hatta T, Itoi E. Peripheral-track and central-track Hill-Sachs lesions: a new concept of assessing an on-track lesion. The American Journal of Sports Medicine. 2020 Jan;48(1):33-8.
  26. ↑ Schroder DT, Provencher MT, Mologne TS, Muldoon MP, Cox JS. The modified Bristow procedure for anterior shoulder instability: 26-year outcomes in Naval Academy midshipmen. The American journal of sports medicine 2006;34(5):778-86.
  27. ↑ Hovelius L, Sandström B, Sundgren K, Saebö M. One hundred eighteen Bristow-Latarjet repairs for recurrent anterior dislocation of the shoulder prospectively followed for fifteen years: study I—clinical results. Journal of shoulder and elbow surgery 2004;13(5):509-16.
  28. ↑ Wilk KE, Macrina LC, Reinold MM. Non-operative rehabilitation for traumatic and atraumatic glenohumeral instability. North American journal of sports physical therapy 2006;1(1):16.


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