High Yield Overview
HILL-SACHS LESIONS
Posterolateral humeral head impression fracture | 40-90% of anterior dislocations
88%Prevalence in recurrent instability
TrackOff-track lesions require Remplissage/Latarjet
RecurHigh recurrence if missed
CLASSIFICATION SYSTEMS
Calandra
PatternBased on depth (Mild/Mod/Severe)
TreatmentPredicts cartilage injury
Off-Track
PatternEngaging lesion
TreatmentRemplissage or Latarjet
On-Track
PatternNon-engaging lesion
TreatmentStandard Bankart
Critical Must-Knows
- Impression fracture of posterolateral humeral head from anterior glenoid rim
- Engaging vs Non-engaging lesions (dynamic evaluation)
- Glenoid Track Concept: less than 83% width rule
- Remplissage: Infraspinatus capsulotenodesis for off-track lesions
- Associated with Bankart lesions (bipolar bone loss)
Examiner's Pearls
- "Look for 'engaging' lesion on exam (Apprehension at lower abduction angles)
- "Stryker Notch View is best X-ray
- "CT with 3D reconstruction is gold standard for quantification
- "Always calculate the Glenoid Track
Clinical Imaging
Axial CT Demonstration
Click to expand
3D CT Reconstruction
Click to expand
MRI Findings
Click to expand
Reverse Hill-Sachs (Posterior Instability)
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Engaging Hill-Sachs on CT
Click to expand
Critical Exam Failures
Terminology Trap
Do not confuse 'engaging' with 'off-track'. Engaging is a clinical finding (locking). Off-track is a radiographic calculation. They are related but distinct concepts.
Missed Bipolar Loss
Failure to account for glenoid bone loss. Track = 0.83D - d. If you ignore 'd' (glenoid defect), you will misclassify an unstable lesion as stable.
Surgical Indication
Suggesting Bankart repair alone for Off-Track. This has a high recurrence rate. Off-Track lesions require Remplissage or Latarjet.
Imaging View
Forgetting the Stryker Notch view. Or failure to request AP in internal rotation. Standard AP often misses the posterolateral defect.
At a Glance
| Feature | Hill-Sachs Lesion |
|---|---|
| Pathology | Compression fracture of posterolateral humeral head |
| Mechanism | Anterior dislocation (impaction on glenoid rim) |
| Key View | Stryker Notch View (X-ray), Axioscapular (CT) |
| Critical Metric | Glenoid Track (Off-track = unstable) |
| Treatment | Remplissage (if off-track) or Latarjet (if glenoid loss) |
Mnemonic
Hill-Sachs vs Reverse
H
Hill-Sachs
Posterolateral (Anterior disloc)
R
Reverse
Anteromedial (Posterior disloc)
Memory Hook:Hills are at the Back (Posterior), Reverse is Front
Mnemonic
Remplissage Meaning
F
Fill
Fills the defect
I
Infraspinatus
Tendon used
Memory Hook:Fill-Sachs Lesion with Infraspinatus
Mnemonic
Track Calculation
8
83%
Percentage of glenoid width
3
Minus d
Subtract defect width
Memory Hook:83% is the magic number for Track
Overview and Epidemiology
Hill-Sachs lesions are compression fractures of the posterolateral humeral head resulting from impact against the anterior glenoid rim during anterior shoulder dislocation. They represent a key component of "bipolar bone loss" in shoulder instability.
Epidemiology
- Primary Dislocation: Present in 40-50% of cases.
- Recurrent Instability: Present in up to 90-100% of cases.
- Mechanism: Anterior dislocation with the arm attempting to internally rotate.
- Significance: Large or "off-track" lesions engage with the glenoid rim, causing levering out and recurrent dislocation.
Pathophysiology and Mechanisms
Pathomechanics
- Location: Posterolateral aspect of the humeral head, superior to the greater tuberosity.
- Formation: "Dent" created when the soft cancellous bone of the humeral head impacts the hard cortical bone of the anterior glenoid rim during dislocation.
- Bipolar Bone Loss: The interaction between the Hill-Sachs lesion and any anterior glenoid bone loss (bony Bankart). The combined loss reduces the arc of stability.
- Engagement Mechanism: In abduction and external rotation (the "at-risk" position), the perceived width of the glenoid track narrows. If the Hill-Sachs lesion is wide enough to bridge this narrow track, the anterior glenoid rim falls into the defect. This levering action forces the humeral head out of the socket.
The Glenoid Track Concept (Itoi, DiGiacomo)
The "Glenoid Track" is the contact zone of the glenoid on the humeral head during abduction and external rotation. It essentially describes the "safe zone" on the humeral head that stays in contact with the glenoid.
Clinical Calculation Steps:
- Measure Glenoid Diameter (D): Use the inferior circle method on en-face 3D CT.
- Calculate Expected Track:
0.83 x D. - Measure Glenoid Defect (d): Linear width of anterior bone loss.
- Calculate True Track Width:
Glenoid Track = (0.83 x D) - d. - Measure Hill-Sachs Interval (HSI): Distance from the rotator cuff footprint to the OTHER side of the Hill-Sachs lesion (medial margin).
- Compare:
- If HSI less than Track: The lesion is covered by the glenoid. ON-TRACK.
- If HSI > Track: The lesion extends beyond the glenoid rim. OFF-TRACK.
Zone of Co-existence: The concept relies on the fact that the rotator cuff footprint defines the lateral margin of the contact patch. A Hill-Sachs lesion expands this "non-contact" zone medially.
Classification Systems
The Gold Standard for Surgical Decision Making
| Category | Definition | Implication |
|---|---|---|
| On-Track | Lesion width is within the glenoid track (less than 83% - glenoid defect) | Does not engage. Standard Bankart repair usually sufficient. |
| Off-Track | Lesion width extends medial to the glenoid track | Engages anterior rim in abduction/ER. Needs Remplissage or Latarjet. |
Formula: Track = (0.83 x D) - d (where D=Glenoid Diameter, d=Glenoid Bone Loss)
Clinical Assessment
History
- History of recurrent anterior dislocations.
- Feeling of the shoulder "locking" or getting stuck in abduction/external rotation.
- Mechanism typically traumatic abduction/external rotation.
Physical Examination
- Apprehension Test: Positive in abduction and external rotation.
- Relocation Test: Relief of apprehension with posterior force.
- Crepitus: May feel crepitus in the mid-range of rotation if the lesion is large.
- Engaging Sign: Reproducing symptoms (clunk/apprehension) at lower degrees of abduction may suggest an engaging lesion.
Investigations
X-Ray
- Views: AP (Internal Rotation), Axillary, Stryker Notch View.
- Stryker Notch: Hand on head, beam tilted 10° cephalad. Best view for Hill-Sachs.
- West Point: Best for glenoid bone loss.
CT Scan
- Gold Standard for quantifying bone loss.
- Protocol: 3D reconstruction with humeral head subtraction (en face view).
MRI
- Useful for soft tissue pathology (Bankart, rotator cuff tears).
- Can estimate bone loss but CT is superior.
- Axial cuts: Visualize the depth of the lesion.
Management Algorithm
Step 1: Calculate Glenoid Bone Loss
- Greater than 20-25% Glenoid Loss: Latarjet Procedure (regardless of Hill-Sachs)
- Less than 20-25% Glenoid Loss: Proceed to Step 2 (Check Track)
📊 Management Algorithm
Click to expand
Step 2: Check Glenoid Track (Hill-Sachs)
- On-Track Lesion: Arthroscopic Bankart Repair alone.
- Off-Track Lesion: Arthroscopic Bankart Repair + Remplissage.
Always address both bipolar lesions.
Surgical Technique
History of Shoulder Stabilization
1923Bankart Lesion
Bankart describes the essential lesion (labral detachment) and the technique for repair.
1940Hill and Sachs
Radiographic description of the posterolateral humeral head impression fracture.
1954Latarjet
Description of coracoid process transfer for bone loss.
1972Connolly
Description of open infraspinatus tenodesis for Hill-Sachs lesions.
2008Wolf
Description of arthroscopic "Remplissage" ( French for "filling").
2014Glenoid Track
Itoi and DiGiacomo popularize the biomechanical concept of the Glenoid Track.
Remplissage (Infraspinatus Capsulotenodesis)
Procedure Steps:
- Preparation: Standard posterior and anterior portals.
- Visualization: View from anterior portal. Debride the Hill-Sachs lesion to fresh bleeding bone ("decortication").
- Anchor Placement: Place 1 or 2 suture anchors into the Hill-Sachs defect through a posterior cannula (or percutaneous).
- Passage: Pass sutures through the infraspinatus tendon and posterior capsule.
- Bankart Repair: Perform standard anterior labral repair first.
- Tying: Tie the Remplissage sutures posteriorly (blindly or visualized) in the subacromial space. This pulls the infraspinatus/capsule into the defect.
Ensure good visualization.
Complications
Specific to Remplissage
- Stiffness: Excessive loss of external rotation if tied too tight (tenodesis effect). Studies show average loss of 9 degrees.
- Pain: Posterior cuff pain or infraspinatus spasm (cramping) is common in the early post-op period.
- Failures: Recurrent instability (if glenoid bone loss was underestimated and track calculation was wrong).
- Infraspinatus Strength: Minor deficit in ER strength, usually clinically insignificant.
Specific to Latarjet
- Neurological Injury:
- Musculocutaneous Nerve: Most common (approx 5%). Traction injury during retraction of conjoined tendon.
- Axillary Nerve: Risk during subscapularis split/tenotomy.
- Hardware Complications:
- Screw Breakage/Back-out: Can cause irritation.
- Proud Screws: "Kissing lesions" on the humeral head leading to rapid arthritis.
- Graft Issues: Non-union (fibrous union is stable usually), Osteolysis (resorption of graft).
- Recurrence: Lower than Bankart (less than 5%) but revision is difficult (Eden-Hybinette).
General Instability Surgery
- Infection: less than 1% for arthroscopy, slightly higher for open Latarjet.
- Chondrolysis: Historically associated with pain pumps or thermal capsulorrhaphy (radiofrequency shrinkage) - now largely abandoned.
- Stiffness: Overtightening of the anterior capsule (Accessory anteroinferior instability repair).
Postoperative Care and Rehabilitation
Rehabilitation Protocol (Bankart + Remplissage)
Standard protocol typically involves 6 weeks of sling immobilization to protect the capsulolabral repair and the tenodesis.
| Phase | Timeframe | Goals | Restrictions | Exercises |
|---|---|---|---|---|
| I. Protection | 0-2 Weeks | Protect Repair, Control Pain | Sling 24/7 (except hygiene). No active ER. | Pendulums, Wrist/Hand ROM, Scapular retraction |
| II. Passive Motion | 2-6 Weeks | Gradual PROM | No ER greater than 0° (Protect Remplissage). No Active elevation. | Passive supine elevation to tolerance. ER to neutral only. |
| III. Active Motion | 6-12 Weeks | Full AROM | Avoid combined Abduction/ER until 10-12 wks. | Active assist pulleys. Wall walks. Theraband IR/ER (start neutral). |
| IV. Strengthening | 3-6 Months | Rotator Cuff Strength | No heavy bench press or wide grip pull-downs. | Periscapular strengthening. Biceps loading. |
| V. Return to Sport | 6-9 Months | Functional Control | Contact sports only after passing clearance test. | Plyometrics. Sport-specific drills. Tackle practice (late). |
Key Precautions
- External Rotation: The tenodesis of the infraspinatus (Remplissage) is under tension in internal rotation. However, we protect against excessive external rotation to prevent pulling out the anchors. Most surgeons limit ER to neutral for 6 weeks.
- Active Elevation: Avoided for 6 weeks to protect the Bankart repair from the shear forces of the humeral head translating.
Outcomes and Prognosis
- Bankart Alone (On-Track): 85-90% success.
- Bankart Alone (Off-Track): High recurrence rate (greater than 20-30%).
- Bankart + Remplissage (Off-Track): Success rates approach Latarjet (90-95%) with lower morbidity.
- Latarjet: Gold standard for collision athletes and significant bone loss (greater than 95% stability).
Evidence Base
Evidence Base
Level IV
📚 Itoi, DiGiacomo et al.
(2014)
Key Findings:
- Introduced the concept of On-Track vs Off-Track.
- Off-track lesions extend medial to the glenoid track and engage.
- Defined the 83% rule for glenoid track width.
Clinical Implication: This study revolutionized the management of bipolar bone loss by providing a quantifiable method (The Glenoid Track) to predict engagement, moving beyond 'size' to 'interaction' as the key surgical indicator for Remplissage.
Source: J Bone Joint Surg Am 2014
Level III
📚 Wolf et al.
(2014)
Key Findings:
- Compared Bankart alone vs Bankart + Remplissage.
- Significant reduction in recurrence with Remplissage for engaging lesions.
- No significant difference in ROM.
Clinical Implication: Remplissage is safe and effective for off-track lesions with sub-critical glenoid bone loss, significantly reducing recurrence rates without clinically relevant stiffness.
Source: J Shoulder Elbow Surg 2014
Level I
📚 Yang et al. - Remplissage vs Latarjet
(2018)
Key Findings:
- Meta-analysis showing comparable stability rates.
- Latarjet had higher complication rate (nerve, bone block issues).
- Remplissage preferred if glenoid bone stock is adequate.
Clinical Implication: Reserve Latarjet for cases with significant glenoid bone loss (greater than 20%). For off-track lesions with intact glenoids, Remplissage offers equal stability with fewer complications.
Source: Am J Sports Med 2018
Level III
📚 Camus et al.
(2018)
Key Findings:
- Long term follow up of Remplissage.
- Average loss of ER is 9 degrees.
- High return to sport rate.
Clinical Implication: Long-term data supports Remplissage as a durable solution. Stiffness concerns are largely unfounded if rehabilitation is appropriate and the tenodesis is not overtightened.
Source: Am J Sports Med 2018
Level III
📚 Arciero et al.
(2015)
Key Findings:
- Biomechanical study of bipolar bone loss.
- Combined defects reduce stability exponentially.
- Addressing only one side (e.g. Bankart only) leads to failure.
Clinical Implication: Surgeons must assess both humeral and glenoid sides (Bipolar concept). Addressing the 'Track' is as important as fixing the Bankart lesion to prevent failure.
Source: Am J Sports Med 2015
Hill-Sachs Lesion Viva
Practice these scenarios to excel in your viva examination
VIVA SCENARIOStandard
The Engaging Lesion
EXAMINER
"During an arthroscopy for 'recurrent instability', you see a large posterolateral defect. How do you assess if it's 'engaging'?"
EXCEPTIONAL ANSWER
I would perform a dynamic assessment intraoperatively. While visualizing from the posterior portal, I would take the arm through a physiological range of motion, specifically abduction and external rotation. I observe the interaction between the anterior glenoid rim and the humeral defect. If the anterior glenoid rim drops into the humeral defect and acts as a fulcrum to lever the head out of the socket, it is an 'engaging' lesion (Off-Track). This confirms that a simple soft-tissue repair will fail, and a Remplissage or Latarjet is required.
KEY POINTS TO SCORE
Dynamic intraoperative assessment
Abduction and External Rotation (ABER) position
Defect levers over anterior glenoid rim
Corresponds to 'Off-Track' concept
COMMON TRAPS
✗Assessing only with arm at side
✗Ignoring the anterior glenoid bone loss component
✗Proceeding with isolated Bankart repair for engaging lesions
LIKELY FOLLOW-UPS
"How does this clinical finding correlate with preoperative imaging?"
"What is the recurrence rate if you simply repair the Bankart lesion here?"
VIVA SCENARIOChallenging
Track Calculation
EXAMINER
"Describe how you calculate the Glenoid Track on a CT scan."
EXCEPTIONAL ANSWER
I use the method described by Itoi and DiGiacomo on an en-face 3D glenoid reconstruction. First, I measure the diameter of the inferior glenoid circle (D). The theoretical track width is 83% of this diameter (0.83 x D). Next, I measure any anterior bone loss (d). The true available track is therefore (0.83 x D) minus d. I then compare this value to the Hill-Sachs Interval (HSI) measured on the humeral head. If the HSI is greater than the calculated Track, the lesion is Off-Track and requires addressing.
KEY POINTS TO SCORE
En-face 3D glenoid view
Track width is 83% of glenoid diameter
Subtract anterior bone loss from the 83%
Compare to Hill-Sachs Interval (HSI)
COMMON TRAPS
✗Measuring diameter on standard sagittal views
✗Forgetting to subtract the bone loss (d)
✗Confusing 'Off-Track' (bad) with 'On-Track' (good)
LIKELY FOLLOW-UPS
"What does 'Off-Track' actually mean biomechanically?"
"How does the track width change in a Latarjet procedure?"
VIVA SCENARIOStandard
Remplissage Indications
EXAMINER
"When would you choose a Remplissage over a Latarjet?"
EXCEPTIONAL ANSWER
My decision algorithm is based on the interaction of glenoid bone loss and the track. I choose Remplissage for 'Off-Track' lesions where the glenoid bone loss is sub-critical (less than 20-25%). In these cases, converting the intra-articular defect to extra-articular (check-rein effect) is sufficient. However, if the glenoid bone loss is CRITICAL (greater than 25%), a Remplissage is insufficient because the arc is too small. These cases require a Latarjet to physically rebuild the glenoid arc and provide the triple-blocking effect.
KEY POINTS TO SCORE
Sub-critical glenoid bone loss (less than 20-25%)
Off-Track lesion
Check-rein effect of infraspinatus
Converts intra-articular defect to extra-articular
COMMON TRAPS
✗Performing Remplissage for critical glenoid bone loss (greater than 25%)
✗Concerns about stiffness in overhead athletes
✗Failing to address the Bankart lesion simultaneously
LIKELY FOLLOW-UPS
"Does Remplissage affect external rotation range of motion?"
"What is the healing rate of the tenodesis?"
VIVA SCENARIOStandard
Imaging Protocol
EXAMINER
"What specific X-ray views do you order for suspected Hill-Sachs?"
EXCEPTIONAL ANSWER
I request a complete Trauma Series, including a True AP (Grashey), Scapular Y, and Axillary view. Crucially, I specifically request a Stryker Notch view. This is an AP view with the hand on the head and the beam tilted 10 degrees cephalad. It profiles the posterolateral humeral head and is the most sensitive plain film view for detecting Hill-Sachs lesions, which might be missed on a standard internal rotation view.
KEY POINTS TO SCORE
Trauma Series (AP, Lat, Axillary)
Stryker Notch View is specific
Hand on head, 10 degrees cephalad tilt
Profiles posterolateral humeral head
COMMON TRAPS
✗Relying on standard AP (often misses defect)
✗Accepting poor quality axillary views
✗Not ordering a CT for quantifiction
LIKELY FOLLOW-UPS
"What is the West Point view used for?"
"How do you measure the Hill-Sachs Interval on MRI vs CT?"
VIVA SCENARIOStandard
Engaging Definition
EXAMINER
"Define an 'engaging' lesion clinically."
EXCEPTIONAL ANSWER
A lesion is clinically engaging if the patient experiences apprehension or mechanical locking when the arm is brought into functional positions of abduction and external rotation. This corresponds to the defect levering over the anterior glenoid rim. It is distinct from the radiographic 'Off-Track' definition, although they correlate strongly. Clinically, this manifests as 'locking' in the overhead athlete or apprehension in mid-range abduction.
KEY POINTS TO SCORE
Clinical locking or apprehension
Functional ABER position
Distinct from 'Off-Track' (radiographic term)
Correlates with higher failure rate
COMMON TRAPS
✗Confusing engaging (clinical) with off-track (radiographic)
✗Thinking all Hill-Sachs lesions engage
✗Failing to reproduce the position of engagement
LIKELY FOLLOW-UPS
"Can an On-Track lesion be clinically engaging?"
"What is the primary stabilizer that is failing in an engaging lesion?"
MCQ Practice Points
Bankart Lesion Association
Q: What is the most common pathology associated with a clinically significant Hill-Sachs lesion? A: Anterior labroligamentous complex injury (Bankart lesion), which creates "bipolar bone loss".
Remplissage Mechanism
Q: How does the Remplissage procedure prevent engagement? A: It converts the intra-articular defect to an extra-articular one (rendering it non-engaging) and provides a "check-rein" effect via the infraspinatus tenodesis.
Critical Bone Loss
Q: What is the cutoff for 'Critical' glenoid bone loss requiring a Latarjet? A: Most consensus definitions state greater than 20-25% glenoid width loss, or greater than 13.5% in high-demand contact athletes (Subcritical).
Track Calculation
Q: What is the formula for calculating the Glenoid Track? A: Track = (0.83 x Glenoid Diameter) - Glenoid Defect Width (d).
Imaging Gold Standard
Q: Which imaging modality is essential for quantifying bipolar bone loss? A: 3D CT reconstruction with humeral head and glenoid subtraction.
Australian Context
Based on current clinical practice in Australia, the management of Hill-Sachs lesions follows international guidelines. The Remplissage procedure has gained significant popularity among Australian shoulder surgeons for off-track lesions with subcritical bone loss, often performed in conjunction with arthroscopic Bankart repair. The Latarjet procedure remains the workhorse for critical bone loss and revision instability cases, particularly in collision athletes (e.g., Rugby, AFL). Pre-operative planning almost universally involves CT 3D reconstruction in the Australian setting for quantification.
Hill-Sachs Lesions Essentials
High-Yield Exam Summary
Key Concepts
- •**Hill-Sachs Interval (HSI):** Distance from cuff insertion to medial defect edge
- •**Glenoid Track:** Contact zone of the glenoid on the humerus (83% of width)
- •**Off-Track:** HSI > Glenoid Track (Engaging)
- •**On-Track:** HSI less than Glenoid Track (Non-engaging)
- •**Bipolar Loss:** Combined glenoid and humeral defects exponentially increase risk
Imaging
- •**Stryker Notch View:** Best X-ray for defect profile
- •**Internal Rotation AP:** Alternate view if Stryker not available
- •**3D CT:** Mandatory for surgical planning/quantification
- •**MRI:** Assesses soft tissue envelope (labrum, cuff)
- •**Axillary View:** Demonstrates relationship of head to glenoid
Management Rules
- •**On-Track:** Standard arthroscopic stabilization (Bankart)
- •**Off-Track + Subcritical Glenoid Loss (less than 20%):** Bankart + Remplissage
- •**Off-Track + Critical Glenoid Loss (greater than 20%):** Latarjet
- •**Revision Instability:** Lower threshold for Latarjet
- •**Engaging Lesion:** Clinical sign of Off-Track status
Surgical Details
- •**Remplissage:** Infraspinatus tenodesis into defect
- •**Anchor Position:** Posterior/Superior aspect of defect
- •**Latarjet:** Coracoid transfer (Triple blocking mechanism)
- •**Sling:** 6 weeks neutral rotation (protect tenodesis)
- •**Return to Sport:** 6-9 months (Contact)