Hill Sachs Lesion: Difference between revisions

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Revision as of 12:53, 8 August 2018

Original Editors - Lien Hennebel

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  

Definition/Description[edit | edit source]


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 (frontal) plane of the body. Because of this the glenohumeral joint with the humerus is orienting anterior to the glenoid.[1]

CDR. Matthew, T. Provencher et al. Described a Hill-Sachs lesion as followed: The Hill-Sachs lesion is a compression fracture of the posterosuperolateral humeral head that occurs in association with anterior instability or dislocation of the glenohumeral joint.[2]

When a trauma takes place, an anterior 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).[3][4][5]

About 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.[5]

Several classifications and grading systems have been described for Hill-Sachs lesions, but there still is some controversy among which is most supported. Although the classifications 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.(Level of evidence 2A)[2] 

One way to grade a Hill-Sachs lesion is how J.J. Calandra et al. did it. They described the lesion arthroscopically in 3 grades (Level of evidence 2B)[6]:

  • Grade 1: there is a defect in the articular surface down to, but not including, the subchondral bone.
  • Grade 2: the lesion includes the subchondral bone
  • Grade 3: the lesion signifies means a large defect in the subchondral bone.


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.

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.)


Clinically Relevant Anatomy[edit | edit source]

The term 'Hill-Sachs Lesion', refers to the 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 commonly known that the shoulder joint has a real loose capsule and that therefore the risk for a dislocation is severely high.[5][7] 

  • 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.[8] [9]
  • The fibrocartilaginous 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.[10] 
  • 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 to strengthen the capsule.[3] Transversal humeral ligament: is meant for M. Biceps Brachii[7]
  • 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.[11] 
  • Bursae: There are eight bursae in the shoulder complex.[5] 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 bursa.



Epidemiology and Etiology[edit | edit source]

Etiology[edit | edit source]

  • Anterior shoulder instability is considered as a risk factor for Hill Sachs lesions. In their study, J.J. Calandra et al. found 47% of the lesions in their patients to be associated with the initial shoulder instability (Level of evidence 2B). They concluded that their research had the same results as the previous studies from Hovelius et al. and Simonet & Cofield et al.[6]
  • In 2006 Widjaja et al. (Level of evidence 2B) stated that there is a strong correlation between the Bankart and the Hill Sachs lesion. They found that when someone has either of those lesions he is 2.5 times more likely to have the other as well. But the correlation found in this study couldn’t be considered significant due to the small study numbers.[12]Later in 2013, Horst et al. (Level of evidence 2B) did a high-quality MRI study in order to investigate the co-occurrence between Bankart and Hill Sachs lesions. After their study, they stated that when someone has one or the other lesions, he or she is 11 times more likely to have suffered the associated injury. So having a Bankart lesion can be considered a risk factor for developing/having a Hill Sachs lesion.[13]
  • There also is a very strong association between a combined engaged Hill-Sachs lesion and anterior glenoid bone loss in case of recurrent instability according to DS. Kim et al.(Level of evidence 3B)[14]


Epidemiology[edit | edit source]

The true incidence of Hill-Sachs lesions is unknown. However, they are associated with approximately 40% to 90% of all anterior shoulder instability events. The incidence may be as high as 100% in patients with recurrent anterior instability, stated CDR. Matthew T. Provencher et al. (Level of evidence 2A)[2] K. Christos et al. investigated 127 patients with traumatic acute and chronic anterior shoulder instability prospectively. A Hill-Sachs lesion was found in 15 cases in the group with acute dislocations (65.21%) and in 97 cases in the chronic recurrent instability group (93.26%). So after their study, they stated that The incidence of shoulder lesions increases with time because the initial dislocation and secondary lesions are more common in patients with chronic instability. (Level of evidence 2B)[15]

Mechanism of Injury / Pathological Process[edit | edit source]

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.[16]

When a trauma takes place, an anterior 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). [17][18][19]

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. [19]


Characteristics/Clinical Presentation[edit | edit source]

Shoulder dislocation rarely 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.[20][21][22] 

 We can order this humeral head compression fractures according to the percentage of humeral head involvement[23]
• minor defect: less than 20% of the humeral head is involved;
• moderate defect: between 20% and 45% of the head is involved;
• severe defect: more than 45% of the head is involved.
The size of the lesion is in most cases related to the number of times a dislocation took place[24] 

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).

Figure 1: preoperative double contrast CT arthrography of a 20 year old patient

Figure 1: preoperative double contrast CT arthrography of a 20-year-old patient.[23]
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.[20] A Hill-Sachs lesion occurs in about 50 percent of the first-time shoulder dislocations. For people with a shoulder dislocations history (= shoulder instability) you can almost always see these humeral head compression fractures.[22]  There is a link between bone loss on either the glenoid side or the humeral side and recurrent shoulder instability during activities.[24] 


Differential Diagnosis[edit | edit source]

It is important to note that below the level of the coracoid the humeral head normally flattens out posterolaterally (also known as Pseudo-Hill-Sachs lesion), and this should not be misinterpreted as a Hill-Sachs lesion.[21]
Both a Hill-Sachs lesion (fig 1) as a Bankart lesion (fig 2)  of the glenoid can be the result of a shoulder dislocation. They often occur together. It is important to inspect the anterior glenoid rim and labrum carefully, to see if there is a potential Bankart Lesion. [21][22]
Fig 1: Hill Sachs lesion Fig 2: Bankart lesion 
Savoie (2014) describes 3 other injuries that occur commonly with Hill-Sachs lesion:[24]
• Humeral avulsion (HAGL) and mid capsular tears
• Floating anterior capsule

Anterior glenohumeral ligamentous pathology and glenoid bone loss.[24] 
Anterior shoulder dislocation is more common, but sometimes a posterior shoulder dislocation takes place. If that’s the case and there is some damage to the cartilage and bone, we can speak of a Reverse Hill-Sachs lesion. This lesion can be seen on the anterior-superior aspect of the humeral head.[21][22][24] 

  

Diagnostic Procedures[edit | edit source]

To diagnose pathologies of the humeral head, osseus glenoid and labrum, a number of imaging techniques have been described.
In the acute phase, plain radiography can detect bony lesions of the humeral head related to shoulder instability. Radiographic techniques most advantageous 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.[3][25] 
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 radiographs or CT scan). It also provides a comfortable position for the patient.[25][26]  
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.[4] 
A study by 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.[27] 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)[28] 
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´%.[27] 
CT scans make it possible to reliably asses the location and depth of the humeral lesion. Based on the latter, a surgical decision is made. Overall, sagittal- and axial-plane measurements are more accurate for evaluation of these defects than the coronal plane.[26] 

Outcome Measures[edit | edit source]

An outcome measure is a tool the physical therapist can use to follow up the progress of the patient.

  • The bony apprehension test [29]

Examination[edit | edit source]

A major (passive) test to physically examine a clinically important Hill-Sachs injury is the bony Apprehension test. The therapist brings the arm in a 45 degrees abduction and a 45 degrees external rotation. Pressure is applied with the hand on the caput of the humerus to anterior. The test is positive if pain is felt or if the muscle contracts by reflex in the case of a (sub)luxation.[1] The apprehension test is often combined with jobes relocation test.
In addition to a positive apprehension test, crepitus (palpable and audible) and catching may be felt during active and passive abduction and external rotation.[3] Also, an audible or palpable clunk in these positions or an unstable feeling during mid-ranges of these motions indicates a possible lesion.

Medical management[edit | edit source]

In the setting of humeral bone loss (Hill-Sachs) injury, treatment can be directed at the restoration of the glenohumeral articular arc with either glenoid-based solutions, humeral-based strategies, or a combination. These strategies include open as well as arthroscopic procedures, depending on the extent of the pathology.[3]
Most of the Hill-Sachs injuries are treated with glenoid-based bone augmentation techniques. Treating the glenoid defects is often the solution to the glenohumeral instability.

Of these techniques, the (open) Latarjet procedure remains the most frequently applied procedure. This procedure includes a variety of methods. The technique whereby the bone from the processus coracoideus is used as an augment to the anteroinferior glenoid bone loss is the most common. By reforming the concavity and width of the glenoid, a Hill-Sachs lesion does not influence the anterior glenoid rim of unstable shoulders. This method is successful in preventing the overtime instability, proving at least two prospective cohort studies by Hovelius et al. (2004) and Schroder et al. (2006) (evidence based level: 1B). However, shoulder arthrosis and loss of function were negative consequences. [3][30][31]

The majority of Hill-Sachs defects can successfully be solved with glenoid-based strategies, however, some of the Hill-Sachs injuries, especially when the glenoid is not touched, require a direct treatment of the injury. Generally taken, the Hill-Sachs deformity can be managed by two techniques: arthrosocopic and open techniques.[3]

  • Arthroscopic techniques: include the ‘Remplissage procedure’, a method whereby the defect is filled with soft tissue, usually from the infraspinatus tendon. A second arthroplasty method is the percutaneous humeroplasty, a technique that fills the lesion by using a bone tamp brought into a drilled osseus window 180 degrees from the lesion. The advantage of this procedure is that no rotational osteotomy of the humeral head is needed and the humeral head can be restored without transpositioning the soft tissue. Limitations of this technique are moderate-sized defects and the lack of management of osteochondral defects. Other procedures where arthroscopy intervenes are techniques that use various small bone plugs.[3] 
  • Open humeral bony techniques include autologous bone plugs, size-matched osteoarticular allografts and rotational humeral osteotomy. The latter, a procedure that includes an osteotomy of the surgical neck and rotates the humeral head for 25 degrees, is not the best chosen method nowadays, given the related risks and the success rates of more recent procedures. The osseus humeral allograft bone plug technique uses a size-matched humeral bone plug of a donor. It is an open procedure because it is performed through a delto-pectoral approach or a deltoid-splitting approach. Advantages of this procedure are its minimal exposure and the fact that the head of the humerus remains in the capsule. A downside of this resurfacing technique is its limitation to small and moderate lesions and the risk of using cadaveric tissue.[3]


Physical therapy management[edit | edit source]

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.[23][32] 

But most of the time a Hill-Sachs lesion can be neglected, certainly, if there is a minimum of glenoid bone loss and without significant involvement of the humeral head. There is no need for surgical treatment, but important is handling the instability.[23] The non-operative rehabilitation of the unstable shoulder consists about seven key factors:[33] 

  • The onset of pathology (in this case: traumatic event)
  • The degree of instability (in this case: dislocation)
  • The frequency of dislocation (in this case acute)
  • TheDirection 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.[33]

According to a study from A. L. Chen (Level of evidence 3A), you can treat a Hill Sachs lesion nonoperatively. Therapy aims to prevent reoccurrence of dislocations. So the therapy is based on strengthening the deltoid muscle and the rotator cuff muscles and periscapular muscles.[34]

In patients with small defects (< 20% Hill Sachs lesion), nonoperative treatment is recommended. These patients will be immobilized with a sling (2-6 weeks). After this, immobilization, a physical therapist must mobilize the joint. Patients will start with pendulum exercises, followed by passive, active-assisted and active range of motion exercises. Abduction and external rotation is restricted during the initial phase of the rehabilitation, because the ligaments need time to heal, like this we want to prevent other dislocations as well. The patient will do exercises to strengthen the deltoid muscle, the periscapular muscles (pectoralis major) and the rotator cuff muscles. Recent related evidence of A.L Chen et al proofs that the long-term success rate of nonoperative treatment is very high. (Level of evidence 3A)[34]

Based on this information the authors will be able to design a treatment program and start physiotherapy.

Key Evidence[edit | edit source]

CRD Matthew, T. Provencher et al. The Hill-Sachs lesion: Diagnosis, classification and management. Journal of the American Academy of orthopaedic surgeons. 2012; 20:242-252 (Level of evidence 2A)[2]

Resources[edit | edit source]

- PubMed
- Web of Science
- Pedro
- Google scholar

Clinical bottom line[edit | edit source]

A Hill Sachs lesion is an injury that mostly is secondary to a shoulder dislocation. The humeral head ‘collides’ with the anterior part of the cavitas glenoidale, this often causes a lesion, bone loss, defect and deformity of the humeral head. There are different grades (3) in the severity of the lesion, these grades are described in the definition. The incidence of Hill Sachs lesion in patients with anterior shoulder instability approaches 100%. A Hill Sachs lesion is a deformity or a type of fracture that change the shape of the humeral head. This may cause a change in the range of motion. Other symptoms are instability feeling, pain. (Level of evidence 2A)[2]  (Level of evidence 2B)[6]

The most common dislocation in the glenohumeral joint is an anterior dislocation. Secondary to this injury there may occur a Hill Sachs lesion. When the patient got a fracture in the humeral head caused by a posterior dislocation, then it is called a reverse Hill Sachs lesion.  Level of evidence 2A)[2]

Conservative treatment is only recommended in cases of small bony defects (Less than 20% Hill sachs lesion), in other cases (larger and more significant lesions), surgical treatment is needed. Elderly people or people with high medical risk may be best treated nonsurgically. The conservative treatment should be based on strengthening the deltoid, the rotator cuff muscles and scapular stabilizers.(Level of evidence 2A)[2] (Level of evidence 3A)[34]

Another pathology secondary to an anterior shoulder dislocation is a bankart lesion. This is not located at the humeral head like a Hill Sachs lesion, but this is an injury of the anterior glenoid labrum of the shoulder. When people got a Hill Sachs lesion, it is often accompanied by a Bankart lesion. (Level of evidence 2B)[12]

A study by Arciero et al. proves that combined humeral and glenoid bone defects have a negative effect on the glenohumeral stability. (Level of evidence 5)[35]


Recent related research (from pubmed)[edit | edit source]

1. Wolf et al.; Hill-Sachs remplissage, an arthroscopic solution for the engaging Hill-Sachs lesion: 2- to 10-year follow-up and incidence of recurrence, Journal of Shoulder and Elbow Surgery 2014; 23(6):814-20. (Level of evidence 4)[36]

2. Zhu et al.; Arthroscopic Bankart repair combined with remplissage technique for the treatment of anterior shoulder instability with engaging Hill-Sachs lesion: a report of 49 cases with a minimum 2-year follow-up.; 2011; 39(8):1640-7. (Level of evidence 4)[37]


References[edit | edit source]

  1. ↑ 1.0 1.1 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. Level of evidence: 3
  2. ↑ 2.0 2.1 2.2 2.3 2.4 2.5 2.6 CRD Matthew, T. Provencher et al. The Hill-Sachs lesion: Diagnosis, classification and management. Journal of the American Academy of orthopaedic surgeons. 2012; 20:242-252 (Level of evidence 2A )
  3. ↑ 3.0 3.1 3.2 3.3 3.4 3.5 3.6 3.7 3.8 Provencher, M, Rose, M., Peace, W., Management of the unstable shoulder: arth and open repair. H 18: Hill-Sachs Injuries of the Shoulder: When are these important and how should I manage them? (2011). pp. 235-252. (Level of evidence: 2)
  4. ↑ 4.0 4.1 Castro, Jerosch & Grossman. (2001), Examination and diagnosis of musculoskeletal disorders. . Georg Thieme Verlag, Germany.
  5. ↑ 5.0 5.1 5.2 5.3 Dodson, C.C. and Cordasco, F.A. (2008). Anterior glenohumeral joint dislocations. Orthtopedic Clinics of North America; 2008: 39(4), 507-518. (Level of evidence : 2c)
  6. ↑ 6.0 6.1 6.2 Calandra et al. The Incidence of Hill-Sachs Lesions in Initial Anterior Shoulder Dislocations. The Journal of Arthroscopic and Related Surgery 1989; 5(4): 254-257( Level of evidence: 2B)
  7. ↑ 7.0 7.1 Gray’s anatomy, Anatomy of the human body, 1918, 11th edition, 6c. Humeral articulation or shoulder joint .
  8. ↑ Gray’s anatomy, Anatomy of the human body, 1918, 11th edition, 6a. 2. The scapula.
  9. ↑ Gray’s anatomy, Anatomy of the human body, 1918, 11th edition, 6a. 3 . The humerus.
  10. ↑ Dutton, M. (2008). Orthopaedic: Examination, evaluation, and intervention (2nd ed.). New York: The McGraw-Hill Companies, Inc. level of evidence : 2B
  11. ↑ Gray’s anatomy, Anatomy of the human body, 1918, 11th edition, 7c., The muscles and fasciae of the shoulder.
  12. ↑ 12.0 12.1 B. Widjadja et al. Correlation between Bankart and Hill-Sachs lesions in anterior shoulder dislocation. ANZ journal of surgery. 2006; 76: 436-438 (Level of evidence: 2B)
  13. ↑ K. Horst et al. Assessment of coincidence and defect sizes in Bankart and Hill–Sachs lesions after anterior shoulder dislocation: a radiological study.Britisch journal of radiology. 2014; 87: 20130673 (Level of evidence: 2B)
  14. ↑ DS. Kim et al. Prevalence comparison of accompanying lesions between primary and recurrent anterior dislocation in the shoulder. The American journal of sports medicine 2010; 38(10) ; 2071-2076. (Level of evidence: 3B)
  15. ↑ K. Christos et al. A comparison of the spectrum of intra-articular lesions in acute and chronic anterior shoulder instability. The Journal of Arthroscopic and Related Surgery. 2007; 23(9); 985-990 (Level of evidence: 2B)
  16. ↑ Cite error: Invalid <ref> tag; no text was provided for refs named Nepola
  17. ↑ 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)
  18. ↑ 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
  19. ↑ 19.0 19.1 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
  20. ↑ 20.0 20.1 Cluett J., Hill-Sachs Injury: Damage to the shoulder joint as result of dislocation, Orthopedics, 2013. (Level of evidence: 5)
  21. ↑ 21.0 21.1 21.2 21.3 Dr. Ahmed Abd Rabou and Dr. Frank Daillard et al. Hill-Sachs lesion, radiopedia.org (Level of evidence: 5)
  22. ↑ 22.0 22.1 22.2 22.3 Fuller, M. Hill-Sachs and Bankart lesion, wikiradiography.com. (Level of evidence: 5)
  23. ↑ 23.0 23.1 23.2 23.3 Cetik, O., Uslu, M. & Ozsar, B.(2007).The relationship between Hill sachs lesion and recurrent anterior shoulder dislocation. Acta orthopaedica Belgica, 73: 175-178. (Level of evidence: 2B)
  24. ↑ 24.0 24.1 24.2 24.3 24.4 Savoie F. O’Brien M., Management of Hill-Sachs Lesion, International Conress for Joint Reconstruction, 2014. (Level of evidence: 5)
  25. ↑ 25.0 25.1 Omoumi, P. et al. Glenohumeral joint instability. Journal of Magnetic Resonance Imaging. 2010: 33(1): 2-16. (Level of evidence: 1B)
  26. ↑ 26.0 26.1 Kodali et al. Accuracy of measurement of Hill-Sachs lesions with computed tomography. Journal of shoulder and elbow surgery. 2012: 20 (8): 1328-1334. (Level of evidence: 3)
  27. ↑ 27.0 27.1 Pancione, L., Gatti, G. Diagnosis of Hill-Sachs lesion of the shoulder. Comparison between ultrasonography and arthro-CT. 1997: 38 (4): 523-526. (Level of evidence : 3)
  28. ↑ Pavic et al. Diagnostic value of US, MR and MR arthrography in shoulder instability. Injury-international journal of the care of the injured. 2013: 44: (supplement): 26-32. (Level of evidence: 2A)
  29. ↑ Bushnell BD et al.; The bony apprehension test for instability of the shoulder: a prospective pilot analysis.; Arthroscopy. 2008; 24(9): 974-82 (level of evidence 2C)
  30. ↑ Hovellus et. Al. Hundred eighteen Bristow-Latarjet repairs for recurrent anterior dislocation of the shoulder prospectively followed for fifteen years: study 1 clinical results. J Shoulder Elbow Surg. 2004:13(5):509-516. (Level of evidence: 1B)
  31. ↑ Schroder et al. The modified Bristow procedure for anterior shoulder instability: 26-year outcomes in Naval Academy Midshipmen. American Journal Sports Medicine. 2006; 34(5):78-86. (Level of evidence: 1B)
  32. ↑ Cutts, S., Prempeh, M. & Drew, S. Anterior shoulder dislocation, Ann R coll Surg Engl. 2009: 91 (Level of evidence: 2A)
  33. ↑ 33.0 33.1 Wilk, K., Macrina, L., Reinold, M. Non-operative rehabilitation for traumatic and atraumatic glenohumeral instability. North american journal of sports physical therapy. 2006; 1 (1): 16-31. (Level of evidence: 1B)
  34. ↑ 34.0 34.1 34.2 Andrew L. Chen et al. Glenohumeral Bone Loss and Anterior Instability, Bulletin of the NYU hospital for joint diseases, 2006 (Level of evidence 3A)
  35. ↑ Arciero RA et al., The Effect of a Combined Glenoid and Hill-Sachs Defect on Glenohumeral Stability: A Biomechanical Cadaveric Study Using 3-Dimensional Modeling of 142 Patients. The American journal of sports medicine, July 2014. (Level of evidence 5)
  36. ↑ Wolf et al.; Hill-Sachs remplissage, an arthroscopic solution for the engaging Hill-Sachs lesion: 2- to 10-year follow-up and incidence of recurrence, Journal of Shoulder and Elbow Surgery 2014; 23(6):814-20 (Level of evidence 4)
  37. ↑ Zhu et al.; Arthroscopic Bankart repair combined with remplissage technique for the treatment of anterior shoulder instability with engaging Hill-Sachs lesion: a report of 49 cases with a minimum 2-year follow-up.; 2011; 39(8):1640-7 (Level of evidence 4)




Sites
http://www.eorif.com/hill-sachs-lesion
http://orthodoc.aaos.org/
http://orthopedics.about.com/
www.wikiradiography.com

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