Humeral Head Bone Loss in Shoulder Instability

Definition

  • Hill-Sachs lesion is an impaction fracture of the posterolateral humeral head against the anterior glenoid rim in anterior dislocation
  • Reverse Hill-Sachs (McLaughlin) lesion is an anteromedial impaction fracture after posterior dislocation
  • Glenoid and humeral defects together form bipolar bone loss. See Glenoid Bone Deficiency

Pathology

  • Glenoid track is the zone of glenoid contact on the posterior humeral head in abduction, external rotation and horizontal extension
  • Its medial margin lies about 84% of glenoid width from the cuff footprint (Yamamoto 2007)
  • A lesion extending medial to the track can engage the glenoid rim and dislocate
  • Glenoid bone loss narrows the track, so a smaller Hill-Sachs lesion can engage
  • Burkhart and De Beer found 89% recurrence after arthroscopic Bankart repair in contact athletes with engaging lesions

Investigations

  • 3D CT is the most reliable test for glenoid and humeral bone loss
  • Glenoid track width (GT) is 83% of intact glenoid diameter minus the width of glenoid bone loss
  • Hill-Sachs interval (HSI) is the lesion width plus the bone bridge to the cuff insertion
  • HSI greater than GT is off track. HSI smaller than GT is on track (Di Giacomo 2014)
  • Distance to dislocation is GT minus HSI. Near track lesions with a small margin have higher recurrence after Bankart repair alone

Management

Hill-Sachs Lesion

  • On track with glenoid loss under 13.5%. Arthroscopic Bankart repair alone
  • Off track or near track with glenoid loss under 20%. Bankart repair plus remplissage
  • Glenoid loss over 20%. Latarjet or free bone block, which widens the glenoid track
  • Lesion still off track after glenoid grafting. Add remplissage or humeral allograft
  • Remplissage is arthroscopic capsulotenodesis of infraspinatus and posterior capsule into the defect (Purchase 2008)
  • Adding remplissage lowered recurrent dislocation from 13.5% to 3.1%, with similar final external rotation

Other Humeral Procedures

  • Osteochondral allograft for large defects in young patients, or after failed remplissage
  • Disimpaction and bone grafting (humeroplasty) for acute lesions
  • Partial resurfacing implant in older, low demand patients
  • Rotational osteotomy of the proximal humerus, now rarely used
  • Hemiarthroplasty or shoulder replacement for very large defects or arthritis in older patients

Reverse Hill-Sachs Lesion

  • Under 25% of the articular surface. Reduction and immobilisation in external rotation
  • 25 to 50%. McLaughlin transfer of subscapularis, or modified McLaughlin transfer of the lesser tuberosity, into the defect. See McLaughlin and Modified McLaughlin Procedures
  • Large defect in a young patient. Osteochondral allograft
  • Over 50%, or chronic dislocation with arthritis. Arthroplasty

References

  1. Yamamoto N, Itoi E, Abe H, Minagawa H, Seki N, Shimada Y, Okada K. Contact between the glenoid and the humeral head in abduction, external rotation, and horizontal extension. A new concept of glenoid track. J Shoulder Elbow Surg. 2007, 16(5), 649-56. PubMed
  2. Burkhart SS, De Beer JF. Traumatic glenohumeral bone defects and their relationship to failure of arthroscopic Bankart repairs. Significance of the inverted-pear glenoid and the humeral engaging Hill-Sachs lesion. Arthroscopy. 2000, 16(7), 677-94. PubMed
  3. 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. 2014, 30(1), 90-8. PubMed
  4. Purchase RJ, Wolf EM, Hobgood ER, Pollock ME, Smalley CC. Hill-Sachs “remplissage”. An arthroscopic solution for the engaging Hill-Sachs lesion. Arthroscopy. 2008, 24(6), 723-6. PubMed
  5. Villarreal-Espinosa JB, Kay J, Ramappa AJ. Arthroscopic Bankart with remplissage results in lower rates of recurrent instability with similar range of motion compared to isolated arthroscopic Bankart for anterior glenohumeral instability. A systematic review and meta-analysis. Knee Surg Sports Traumatol Arthrosc. 2024, 32(2), 243-256. PubMed
  6. Calvo E, Delgado C. Management of off-track Hill-Sachs lesions in anterior glenohumeral instability. J Exp Orthop. 2023, 10(1), 30. PubMed
  7. Herman ZJ, Nazzal EM, Keeling L, Reddy RP, Como M, Hughes JD, Lin A. Bipolar bone loss and distance to dislocation. Ann Jt. 2024, 9, 7. PubMed
  8. Marcaccio SE, Kaarre J, Steuer F, Herman ZJ, Lin A. Anterior glenohumeral instability. Clinical anatomy, clinical evaluation, imaging, nonoperative and operative management, and postoperative rehabilitation. J Bone Joint Surg Am. 2025, 107(1), 81-92. PubMed
  9. Arenas-Miquelez A, Barco R, Cabo Cabo FJ, Hachem AI. Management of bone loss in anterior shoulder instability. Bone Joint J. 2024, 106-B(10), 1100-1110. PubMed
  10. Waterman BR, Leroux T, Frank RM, Romeo AA. The evaluation and management of the failed primary arthroscopic Bankart repair. J Am Acad Orthop Surg. 2020, 28(15), 607-616. PubMed
  11. Rinaldi VG, Coliva F, Favero A, Alesi D, Caravelli S, Zaffagnini S, Marcheggiani Muccioli GM. From diagnosis to decision-making. A systematic review of the management of reverse Hill-Sachs lesions after posterior shoulder dislocations. J Clin Med. 2024, 13(7), 2085. PubMed
  12. Prigmore B, Tabbaa S, Crawford DC. Osteochondral allograft transplantation in the shoulder. A systematic review of indications and outcomes. Cartilage. 2023, 15(3), 219-228. PubMed

Reviewed by Professor Phong Tran, Head of Orthopaedic Surgery, Western Health. Last updated 15 October 2026.