New Research Shows Remplissage Dramatically Reduces Re-Dislocation — Even When the Hill-Sachs Lesion Appears "On-Track"
If you've dislocated your shoulder — especially if you play contact sports — your surgeon has probably talked to you about bone loss. Two things typically get damaged when the shoulder dislocates: the front rim of the socket (glenoid) and the back of the ball (a dent called a Hill-Sachs lesion). How surgeons manage these two defects together largely determines whether the repair holds long-term.
The dominant framework for making that decision is called the "glenoid track" concept. In simple terms, it asks whether the Hill-Sachs dent is positioned to catch on the front of the glenoid during normal shoulder motion. If it will catch — called "off-track" — most surgeons add a procedure called remplissage to fill in the dent and prevent it from engaging. If it won't catch — called "on-track" — the traditional approach has been to repair just the labrum (Bankart repair) and leave the Hill-Sachs lesion alone.
A multicenter study I participated in, published in the Journal of Shoulder and Elbow Surgery, challenges that conventional wisdom — particularly for contact athletes. The findings suggest that for the right high-risk patient, adding remplissage even to an on-track lesion can make a dramatic difference in outcomes.
The Problem With "On-Track" in High-Risk Patients
The glenoid track concept is a useful framework, but it has known limitations. An on-track lesion is not a single, uniform category — it exists on a spectrum. A lesion that is technically on-track but sitting very close to the edge of the track (what researchers call a "near-track" lesion) behaves very differently in practice than one that sits comfortably in the middle.
Recent studies have shown that on-track lesions with a small "distance to dislocation" (DTD) — meaning the Hill-Sachs lesion sits close to the glenoid edge — have high failure rates with labral repair alone. Add in contact sports participation, where the shoulder routinely experiences high-force collisions and extreme positions, and the risk of redislocation climbs substantially.
The question this study set out to answer was direct: in patients with on-track Hill-Sachs lesions, does adding remplissage to the Bankart repair reduce the rate of recurrent dislocation — and does it matter most for the patients who are already at highest risk?
What the Study Did
Researchers at the University of Pittsburgh, Oregon Shoulder Institute, and a center in Argentina reviewed outcomes for 183 patients aged 14 to 50 who had anterior shoulder instability with on-track Hill-Sachs lesions and less than 15% glenoid bone loss. All had a minimum two-year follow-up.
56 patients received Bankart repair with remplissage (ALR-R) and 127 received Bankart repair alone (ALR). The groups were well-matched for age, sex, contact sports participation, and preoperative shoulder function scores. As expected, the remplissage group had more significant Hill-Sachs lesions — that's why their surgeons chose to add the procedure — but both groups were classified as on-track by preoperative imaging.
A key subgroup analysis focused on "high-risk" patients, defined as contact athletes whose Hill-Sachs lesion had a distance to dislocation of less than 10mm — meaning the lesion was on-track, but very close to the edge.
The Results: A Striking Difference in Redislocation Rates
The overall findings were clear and statistically significant:
1.8% redislocation rate in the remplissage group
11.0% redislocation rate in the labral repair-only group
0 revision surgeries needed in the remplissage group
6.3% of repair-only patients required revision surgery
The difference was even more dramatic when looking specifically at contact athletes. Among contact athletes who had labral repair alone, 21% experienced a redislocation. Among contact athletes who had remplissage added, that number dropped to just 3.2%.
The high-risk subgroup — contact athletes with a DTD under 10mm — told the most compelling story. In this group, 66.7% of patients who had labral repair alone redislocated. Among those who had remplissage added, only 4.2% redislocated. That's a difference that is both statistically overwhelming and clinically enormous.
High-risk patients who received remplissage also had significantly better shoulder function scores at final follow-up than their high-risk counterparts who had labral repair alone — not just fewer dislocations, but better overall shoulder health.
Making Sense of These Numbers
The multivariate analysis — which accounts for multiple variables simultaneously — found that after adjusting for Hill-Sachs size and contact sports participation, the remplissage group had a 99% lower risk of recurrent instability than the repair-only group. Contact sports participation and Hill-Sachs interval size were the two strongest independent predictors of failure.
Why does remplissage help even when the lesion is technically on-track? The answer likely lies in what happens during high-force situations that push the shoulder to its limits. A contact athlete hitting a tackle, a collision sport player falling on an outstretched arm — these forces can transiently push an on-track lesion to the edge of the glenoid track, especially when the lesion is already near the boundary. Remplissage fills in the Hill-Sachs dent with tendon and capsule, eliminating it as a point of engagement regardless of the shoulder's position.
It also matters that 93% of all redislocations in this study occurred in contact athletes. Non-contact athletes had a redislocation rate of just 1.1% with labral repair alone — suggesting that for lower-demand patients, the standard approach remains appropriate. The risk is concentrated in the contact sports population, and that's exactly where remplissage provides its greatest benefit.
What About External Rotation?
A common concern with remplissage is that filling the Hill-Sachs lesion with posterior soft tissue creates some stiffness and limits external rotation. This is a real trade-off and should be part of any surgical discussion.
In this study, postoperative external rotation was similar between the two groups (62.3 degrees vs 60.6 degrees), with no statistically significant difference. The return-to-sport rate also trended higher in the remplissage group (91.1% vs 79.5%), though this did not reach statistical significance.
For most athletes — even contact athletes — a modest potential reduction in external rotation is a reasonable trade for dramatically lower redislocation risk. For overhead throwing athletes in particular, this trade-off deserves a more individualized discussion.
What This Means for Patients and the Evolution of Instability Surgery
This study adds important nuance to how surgeons should use the glenoid track concept. The on-track/off-track binary is a useful starting point, but it is not the whole story. For patients who are:
- Participating in contact sports (football, rugby, hockey, wrestling, martial arts, basketball, etc.)
- Have a Hill-Sachs lesion that sits close to the edge of the glenoid track (DTD < 10mm)
- Young and planning to return to high-demand activity
...the evidence now strongly supports adding remplissage even if the Hill-Sachs lesion technically qualifies as on-track. The failure rate with labral repair alone in this specific group is unacceptably high. Remplissage brings it down to levels comparable to or better than what's reported after more invasive open procedures like the Latarjet.
This doesn't mean every patient with an on-track lesion needs remplissage. Non-contact athletes, recreational patients, and those with lesions comfortably in the center of the glenoid track have excellent outcomes with standard Bankart repair. The art is in identifying who is truly at high risk — and the data from this study gives surgeons a much clearer picture of where that line is.
The Bottom Line
The glenoid track concept has been one of the most important advances in shoulder instability surgery over the past two decades. But like any framework, it is a guide — not an absolute rule. This study makes clear that for contact athletes with near-track Hill-Sachs lesions, the standard on-track algorithm leaves too many patients at risk of redislocation.
Adding remplissage in this high-risk group cuts the failure rate from 66.7% to 4.2%. That is one of the most dramatic risk reductions in shoulder instability surgery literature. For contact athletes who want to return to their sport and stay there, the message is straightforward: a more complete surgical treatment upfront leads to far better outcomes than revision surgery later.
If you've had a shoulder dislocation — especially if you play contact sports — the details of your imaging matter enormously in planning the right surgery. A careful evaluation of glenoid bone loss, Hill-Sachs size, and distance to dislocation should guide that conversation.
Patrick J. Denard, MD is a fellowship-trained orthopedic surgeon specializing in shoulder surgery at the Oregon Shoulder Institute in Medford, Oregon. He is a co-author of "Remplissage Reduces Recurrent Instability in High-Risk Patients With On-Track Hill-Sachs Lesions," published in the Journal of Shoulder and Elbow Surgery (2023).
If you have questions about shoulder instability or would like to discuss your surgical options, request an appointment at Oregon Shoulder Institute.
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