What Is Remplissage and When Does Bankart Repair Need It?

Overview

Arthroscopic Bankart repair reattaches the torn labrum to the front of the shoulder socket after a dislocation. Remplissage ("to fill") adds a step: tenodesing the infraspinatus tendon into the Hill-Sachs defect on the humeral head so it can no longer catch the socket edge and cause redislocation. Dr. Raffo adds remplissage selectively, based on bone anatomy, not routinely.

Who this is for

Bankart repair with remplissage is directed at a specific anatomic picture, not simply "anyone with a shoulder dislocation":

• Patients with recurrent anterior instability and an off-track Hill-Sachs lesion — a humeral-head defect large enough, relative to the glenoid, to engage the socket edge during normal arm positions.
• Patients with subcritical glenoid bone loss, generally in the range where a Bankart repair alone is not reliable but a bone-block procedure is more than the anatomy requires.
• Athletes and active patients who want the lowest-morbidity operation that still meaningfully reduces redislocation risk, understanding the tradeoffs discussed below.

It is not the right operation for every unstable shoulder. Patients whose glenoid bone loss is the dominant lesion — rather than the humeral side — are usually better served by a bone-block procedure such as Latarjet, discussed under "Where Surgeons Disagree" below and on the shoulder instability hub. Overhead throwing athletes, for whom even small losses of terminal external rotation may matter more than the pooled data suggest, are a group Dr. Raffo counsels individually.

How I approach it

I decide whether to add remplissage using the glenoid track concept, not a single bone-loss percentage. The glenoid track is the width of glenoid bone that the humeral head contacts through a normal arc of motion — measured at 84% ± 14% of glenoid width, or about 18.4 ± 2.5 mm (Yamamoto, JSES 2007). If a Hill-Sachs lesion extends medial to that track, it is "off-track" and will engage the glenoid edge during abduction and external rotation, which is the mechanical setup for recurrent dislocation (Di Giacomo, Arthroscopy 2014). In a clinical validation series of 57 primary arthroscopic Bankart repairs, off-track lesions failed at 75% (6 of 8) versus 8% (4 of 49) for on-track lesions — a result the underlying bone-loss percentage alone did not predict nearly as well, with a positive predictive value of only 44% for glenoid loss over 20% compared with 75% for the track classification (Shaha, JBJS Am 2016).

I also weigh glenoid bone loss on its own terms, because the number that used to be taught as "critical" has moved. The older teaching point was 20%–25% glenoid bone loss as the threshold for needing a bone-block procedure. A study of 72 patients found that outcomes deteriorated well before that: by bone-loss quartile (2.8%, 10.4%, 16.1%, 24.5%), WOSI instability scores worsened stepwise (383, 594, 840, 1188), and failure jumped from 7.3% in the lower three quartiles to 27.8% in the top quartile — with the inflection point identified at bone loss greater than 13.5% (Shaha, AJSM 2015). That figure is why I no longer treat 20% as a green light for a soft-tissue-only repair; a shoulder with 15% glenoid bone loss and an off-track humeral lesion is, in my hands, a candidate for adding remplissage rather than doing an isolated Bankart repair.

The randomized evidence for adding remplissage is unusually strong for a shoulder procedure. In a 108-patient multicentre trial, redislocation occurred in 4% of the Bankart-plus-remplissage group versus 18% of the Bankart-alone group (P=.027), and no patient in the remplissage group needed revision surgery versus six in the Bankart-alone group (P=.029) (MacDonald, JSES 2021). At medium-term follow-up of the same cohort (mean 4 years, range 3–9), the advantage held: failure was 8% versus 22%, and recurrent instability was 10% versus 30% (Woodmass, AJSM 2024).

The traditional objection to remplissage is that tenodesing the infraspinatus into the humeral head costs external rotation. The pooled data don't support that concern being clinically meaningful. A meta-analysis of 12 studies found the external-rotation loss attributable to remplissage was 1° (Ahmed, JSES 2024), and a meta-analysis of 2,100 patients found external rotation loss of 9.3° ± 12.6° with Bankart plus remplissage versus 6.8° ± 11° with Bankart alone — a difference of 5.9° that was not statistically significant (P=.13) (Gonzalez-Morgado, AJSM 2025). A separate cohort found a similar non-significant loss of 5.26° (P=.13) alongside a 95.5% return to sport at 7.0 months, with 81.0% returning to their prior level (Garcia, AJSM 2016). Return to sport overall after remplissage is 86% in meta-analysis, with an odds ratio of 2.71 favoring remplissage over Bankart alone for return to sport (Davis, AJSM 2023).

The operation

Bankart repair with remplissage is performed arthroscopically through small shoulder portals, typically as a single combined procedure:

1. The torn anterior labrum is identified and mobilized off the glenoid neck.
2. Suture anchors are placed along the anterior glenoid rim, and the labrum and capsule are repaired back to bone, restoring the labral "bumper" that normally deepens the socket.
3. The Hill-Sachs defect on the back of the humeral head is identified and assessed against the glenoid track.
4. If the lesion is off-track, one or two additional suture anchors are placed into the floor of the Hill-Sachs defect, and the infraspinatus tendon and posterior capsule are tenodesed into the defect, filling it so it cannot engage the glenoid edge during abduction and external rotation.
5. Portals are closed and the arm is placed in a sling.

Risks and honest tradeoffs

• Recurrent dislocation still occurs even with remplissage added — 4% at short-term follow-up in the randomized trial, rising to 8% failure and 10% recurrent instability by a mean of 4 years (MacDonald, JSES 2021; Woodmass, AJSM 2024).
• Loss of external rotation is the most-discussed tradeoff and, across pooled data, has not reached statistical significance — 1° in one meta-analysis and 5.9° (P=.13) in another (Ahmed, JSES 2024; Gonzalez-Morgado, AJSM 2025) — but individual patients, especially throwers, can still notice a difference that a population average does not capture.
• Return to sport is not universal. Meta-analysis puts overall return to sport at 86% (Davis, AJSM 2023), and a systematic review of 738 shoulders found return-to-sport rates as low as 46% in overhead/throwing athletes versus 80%–100% in contact athletes (Gouveia, Arthroscopy 2023).
• The glenoid track concept is not perfect. In a review of failed Bankart repairs, 15% of failures occurred in shoulders classified as on-track — the framework improves decision-making, it does not guarantee it (failure analysis).
• General arthroscopic shoulder-surgery risks apply, including stiffness and, rarely, infection or nerve injury.

Recovery and rehabilitation

Recovery from Bankart repair with remplissage follows the same broad arc as isolated Bankart repair, with attention to protecting both the anterior repair and the posterior tenodesis.

• 0–4 weeks: Sling immobilization; passive range of motion only, as directed.
• 4–8 weeks: Progressive active-assisted and active motion.
• 8–12 weeks: Strengthening begins, with attention to regaining external rotation.
• 4–6 months: Sport-specific training and return-to-throwing or return-to-contact progression, if applicable.
• 6–9 months: Return to full contact sport or unrestricted overhead activity, timed individually; meta-analysis puts mean return to sport around 7 months (Garcia, AJSM 2016).

1. 0–4 weeks

   Sling immobilization; passive range of motion only, as directed.

2. 4–8 weeks

   Progressive active-assisted and active motion.

3. 8–12 weeks

   Strengthening begins, with attention to regaining external rotation.

4. 4–6 months

   Sport-specific training and return-to-throwing or return-to-contact progression, if applicable.

5. 6–9 months

   Return to full contact sport or unrestricted overhead activity, timed individually; meta-analysis puts mean return to sport around 7 months (Garcia, AJSM 2016).

Alternatives I considered

For patients where remplissage is a reasonable option, I also discuss:

• Isolated Bankart repair without remplissage, appropriate when the Hill-Sachs lesion is on-track and glenoid bone loss is low. It carries a higher recurrence rate in off-track shoulders specifically, which is why I don't use it as a default once a lesion is shown to be off-track.
• Latarjet or another bone-block procedure, which I favor over remplissage when glenoid bone loss itself — not the humeral-side lesion — is the primary problem, or when a patient has already failed a prior soft-tissue stabilization. Latarjet carries a lower recurrence rate but a materially higher complication rate, discussed above and in more detail on the shoulder instability hub.