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Abstract

Background:

In recent years, on-track lesions have been subclassified as peripheral- and central-track lesions based on the Hill-Sachs lesion occupancy within the glenoid track. Studies have stated that arthroscopic Bankart repair can be performed in noncontact athletes with on-track lesions, regardless of whether they are classified as peripheral or central track. However, this assumption currently remains theoretical and requires confirmation or refutation through clinical follow-up studies.

Purpose/Hypothesis:

The purpose of this study is to evaluate the effect of peripheral- and central-track lesions on long-term clinical outcomes in a homogeneous cohort of noncontact athletes undergoing arthroscopic Bankart repair. It was hypothesized that arthroscopic Bankart repair provides satisfactory long-term outcomes for both central-track and peripheral-track lesions in noncontact athletes.

Study Design:

Retrospective cohort study; Level of evidence, 3.

Methods:

Patients who underwent arthroscopic Bankart repair for shoulder instability from 2013 to 2017 were retrospectively evaluated. Patients with a glenoid defect <25%, on-track lesions, and participation in noncontact sports were included in the study. Patients were classified as having peripheral-track lesions (lesion in the medial one-fourth of the glenoid track) and central-track lesions (lesion in the lateral three-fourths of the glenoid track). The 2 groups were compared in terms of demographic characteristics, redislocation rates, return to sports, and patient-reported outcome measures, including the American Shoulder and Elbow Surgeons, Western Ontario Shoulder Instability Index, and visual analog scale scoring systems.

Results:

The study included 101 patients: 62 with central-track lesions (mean ± SD; age, 26.6 ± 8.7 years; follow-up, 9.1 ± 1.2 years) and 39 with peripheral-track lesions (mean ± SD; age, 25.9 ± 6.9 years; follow-up, 8.8 ± 1.2 years). At the final follow-up, no significant differences were observed between the 2 groups for Western Ontario Shoulder Instability Index (P = .162), American Shoulder and Elbow Surgeons (P = .524), or visual analog scale (P = .754) scoring systems. Additionally, redislocation rates and return-to-sport proportions were similar between both groups, with rates of 13% and 15% for redislocation (P = .471) and 82% and 80% for return to sports (P = .461), respectively.

Conclusion:

In patients with shoulder instability who participate in noncontact sports and have on-track lesions, arthroscopic Bankart repair provides satisfactory long-term clinical outcomes regardless of whether the lesion is classified as peripheral track or central track.

Keywords

shoulder instability noncontact athletes peripheral track central track

Over the past decade, the glenoid track concept has significantly advanced our understanding of bipolar bone lesions in patients with anterior shoulder instability and their impact on surgical outcomes following arthroscopic Bankart repair.^{1,4,5,8,9,12,26,29} However, recent studies have indicated that certain on-track Hill-Sachs lesions—those close to the medial margin of the glenoid track—may be associated with poorer functional outcomes when treated with arthroscopic Bankart repair alone.^{7,10,11,16,17,31} Consequently, questions have begun to arise regarding the adequacy of binary categorization.

In 2020, Yamamoto et al³¹ suggested that if a subcritical zone is present in cases of glenoid bone loss, a similar approach could be applied to the glenoid track concept. Thus, they emphasized that evaluating on-track lesions as a single category may be insufficient and proposed a subclassification of on-track lesions based on the Hill-Sachs lesion occupancy ratio. They divided on-track lesions into 2 subgroups: peripheral-track lesions, located within the most medial one-fourth of the glenoid track, and central-track lesions, occupying the remaining lateral three-fourths. Their findings suggest that peripheral-track lesions, particularly in contact athletes, may exhibit clinical outcomes similar to those of off-track lesions. Furthermore, the same research group proposed that arthroscopic Bankart repair is an optimal treatment for noncontact athletes with on-track lesions, regardless of the Hill-Sachs lesion occupancy ratio.^28,31 Given the incidence of Bankart lesions among athletes and the importance of careful management, this recommendation could provide valuable guidance for the surgical decision-making process.^19-21,25 However, this assumption currently remains theoretical and requires confirmation or refutation through clinical follow-up studies. Demonstrating the long-term success of arthroscopic Bankart repair in noncontact athletes may enable safer, evidence-based surgical decision-making, reducing reliance on theoretical assumptions.

Therefore, the present study aimed to evaluate the effect of peripheral- and central-track lesions on long-term clinical outcomes in a homogeneous cohort of noncontact athletes undergoing arthroscopic Bankart repair. We hypothesized that arthroscopic Bankart repair provides satisfactory long-term outcomes for both central-track and peripheral-track lesions in noncontact athletes.

Methods

Study Design and Patient Selection

The study protocol was approved by the institutional review board (Protocol: 2025-800) prior to initiation of the study. This retrospective review was conducted to identify consecutive patients who underwent shoulder arthroscopy for traumatic anterior shoulder instability between February 2013 and April 2017. The inclusion criteria for patients were those who had undergone arthroscopic repair of labral tears using suture anchors, had a follow-up period of at least 8 years, participated in noncontact sports, and had accessible data sets, including clinical history, computed tomography (CT) images, patient-reported outcome measures (PROMs), and intraoperative video recordings. Patients with the following criteria were excluded from the study: (1) glenoid bone defect >25%; (2) presence of an off-track Hill-Sachs lesion or absence of a detectable Hill-Sachs lesion; (3) combined labral tears; (4) anterior labrum periosteal sleeve avulsion lesions; (4) concomitant long head of the biceps tendon pathologies, rotator cuff tears, or glenohumeral arthritis, (5) history of revision surgery; (6) participation in contact sports or absence of sporting activity; (7) hyperlaxity (Beighton score ≥4); (8) lost to follow-up; (9) declined to participate in the final follow-up evaluation; and (10) missing data. An overview of the selection process is presented in Figure 1.

Figure 1.

Flowchart illustrating the patient selection process.

Surgical Technique

All surgical procedures were performed with the patient in the semi-decubitus position. Surgeries were conducted under general anesthesia and/or an interscalene block. The procedure began by inserting the arthroscope through the posterior portal to evaluate the structural integrity of the anterior and superior labrum. At this stage, intra-articular evaluation of the rotator cuff and biceps was performed. Additionally, the acromioclavicular joint and rotator cuff structures were examined from the subacromial space. Subsequently, the arthroscope was repositioned through the anterosuperior portal for examination of the inferior and posterior regions of the labrum. Following arthroscopic identification of the tear location, debridement was performed within the lesion area, and the labrum was repositioned as close as possible to its native anatomic position. The labral tear was repaired using double-loaded suture anchors (2.9 mm GRYPHON; DePuy Mitek). The initial anchor was inserted at the 5:30 to 6:00 position, followed by placement of 2 additional anchors at 8- to 10-mm intervals. In cases where the labral tear extended further, additional anchors were placed at similar intervals, based on the extent of detachment. Repair was completed once the labrum was properly stabilized along the glenoid rim.

Following surgery, the affected arm was immobilized in internal rotation with a sling for 6 weeks. Passive shoulder movements, along with active range of motion exercises for the elbow, wrist, and hand, were initiated on the third postoperative day. Active shoulder motion commenced 4 weeks postsurgery while maintaining relative immobilization. All patients participated in a supervised rehabilitation program for 8 weeks. From the third postoperative month onward, strengthening exercises and a gradual return to daily activities were introduced.

Data Collection

A retrospective analysis of patient charts was conducted to collect relevant data. The following variables were recorded for each patient: age, sex, date of operation, dominant/affected extremity, preoperative number of dislocations, duration from the first episode of dislocation to the time of surgery, and preoperative PROMs. Preoperative CT scans (0.625-mm slice thickness; Lightspeed VCT, GE Healthcare) were analyzed to assess the on-track/off-track lesions, peripheral-track/central-track lesions, and size of the glenoid defect. Using an en face image of the glenoid, a reference fitted circle was drawn aligned with the inferior glenoid border. Glenoid defect size was measured as the percentage ratio of the defect width relative to the diameter of this reference fitted circle.¹⁸ The assessment of on-track/off-track lesions was performed following the methodology described by Di Giacomo et al.⁶ The classification of peripheral-track and central-track lesions was conducted using a method based on Hill-Sachs occupancy (HSO), as described by Yamamoto et al.³¹ HSO was initially determined using the following formula: Hill-Sachs interval (the distance between the medial margin of the rotator cuff footprint and the medial margin of a Hill-Sachs lesion) / glenoid track width (83% of fitted circle – defect width) × 100 (%).^2,6,31 Lesions with an HSO >75% were categorized as “peripheral-track lesions,” whereas those with an HSO <75% were categorized as “central-track lesions” (Figure 2). Based on this calculation, patients were classified into peripheral- and central-track groups, and a comparative analysis was performed between them. Additionally, the relationship between HSO and PROMs was analyzed by modeling HSO as a continuous variable. To ensure consistent evaluation of radiologic parameters, intraobserver and interobserver reliability assessments were conducted. For intraobserver reliability, a radiologist (S.N.T.) reevaluated the CT scans at a minimum of 2 weeks following the first assessment. To assess interobserver reliability, another radiologist (E.B.G.O.), who was blinded to the evaluations of the first radiologist, reviewed CT scans in an arbitrary sequence.

Figure 2.

Four zones were defined within the glenoid track, depending on the percentage of Hill-Sachs occupancy (HSO). Lesions with HSO <75% (zones 1-3) were defined as central-track lesions, while those with an HSO >75% (zone 4) were defined as peripheral-track lesions.

Functional Outcome Evaluation

A final follow-up evaluation was scheduled for all eligible participants. Data collection and physical examinations were conducted by an orthopaedic surgeon (F.A.) who remained blinded to the objectives and methodology of the present research. Clinical assessment began with an evaluation of the occurrence of recurrent dislocations after the surgical procedure. Patients were asked whether they had experienced a dislocation following surgery. If a patient reported a redislocation, their national health database records were examined to confirm their history. Cases in which redislocation could not be confirmed were considered “missing data” and excluded from the study (n = 3). Functional outcomes of the shoulders were evaluated using the American Shoulder and Elbow Surgeons (ASES), Western Ontario Shoulder Instability Index (WOSI), and visual analog scale (VAS) scoring systems.

Statistical Analysis

Data analysis was performed using SPSS (version 29.0; SPSS) and R through RStudio (2025.05.0+496). The Shapiro-Wilk test was applied to assess the normality of the data distributions. Continuous variables were analyzed using the Mann-Whitney U test for nonnormally distributed data and the independent t test for normally distributed data. Pearson chi-square or Fisher exact test was applied for categorical comparisons, as appropriate to the data. The pre- and postoperative scores were analyzed using the Wilcoxon signed-rank test. To evaluate nonlinear associations between PROMs and HSO, restricted cubic spline regression models were fitted using the rms package in R. Predicted probabilities across the range of each variable were plotted with 95% confidence intervals. Interobserver and intraobserver reliabilities were assessed using the κ statistic for peripheral-track/central-track classification (κ > 0.8, indicating excellent agreement) and the intraclass correlation coefficient for glenoid defect size (intraclass correlation coefficient >0.75 considered good).^14,15 An a priori power analysis based on data (WOSI score) from previous studies determined that a total of 74 participants (37 per group) would be required to achieve a statistical power of 95%.

Results

After applying inclusion and exclusion criteria, 101 patients were available for analysis, of whom 62 had central-track lesions (mean ± SD age, 26.6 ± 8.7 years; 81% male; mean ± SD follow-up, 9.1 ± 1.2 years) and 39 had peripheral-track lesions (mean ± SD age, 25.9 ± 6.9 years; 90% male; mean ± SD follow-up, 8.8 ± 1.2 years) (Table 1). No statistically significant differences were observed between the central- and peripheral-track groups regarding the mean number of preoperative dislocations (4.3 ± 3.7 vs 4.8 ± 4.5) or the mean duration from initial dislocation to surgery (10.9 ± 13.8 months vs 9.8 ± 14.3 months) (Table 1). The mean glenoid bone loss percentages were also similar between the groups (5.1% ± 5.3% [90% <13.5%] vs 5.7% ± 6.0% [87% <13.5%]) (Table 1). Patients with peripheral-track lesions demonstrated a significantly higher mean HSO (84.8% ± 7.7%) than those with central-track lesions (38.5% ± 16.2%) (Table 1). Analysis of sports participation revealed the following distribution: in the central track group, 17 patients participated in volleyball, 13 in tennis, 9 in swimming, 11 in athletics, 8 in cycling, 3 in skiing, and 1 in archery; in the peripheral track group, 10 patients participated in volleyball, 8 in tennis, 7 in swimming, 7 in athletics, 5 in cycling, and 2 in table tennis. In the central-track group, 66% (n = 41) of patients engaged in sports at a recreational level, while 34% (n = 21) participated competitively. In the peripheral-track group, 59% (n = 23) were involved at a recreational level and 41% (n = 16) at a competitive level (P = .527).

Table 1

Patients Characteristics ^a

Variable	Central Track (n = 62)	Peripheral Track (n = 39)	P Value
Age at surgery, y	26.6 ± 8.7	25.9 ± 6.9	.997
Sex, male/female	50 (81)/12 (19)	35 (90)/4 (10)	.174
Extremity involved, dominant/nondominant	43 (69)/19 (31)	29 (74)/10 (26)	.379
Preoperative number of dislocations	4.3 ± 3.7	4.8 ± 4.5	.321
Time from first dislocation to surgery, mo	10.9 ± 13.8	9.8 ± 14.3	.891
Follow-up time, y	9.1 ± 1.2	8.8 ± 1.2	.092
Glenoid bone loss, %	5.1 ± 5.3	5.7 ± 6.0	.860
Hill-Sachs occupancy, %	38.5 ± 16.2	84.8 ± 7.7	<.001

Values are presented as mean ± SD or number (%). Significant at P≤ .05.

During the follow-up period, redislocations occurred in 8 patients (12.9%) in the central-track group and 6 patients (15.4%) in the peripheral-track group (P = .471). The central-track group demonstrated significant improvements in ASES, VAS, WOSI_Total, WOSI_Physical, WOSI_{Sports/Recreational/Work}, WOSI_Lifestyle, and WOSI_Emotions scores at the final follow-up compared to the preoperative values (Table 2). Similarly, in the final follow-up examination of the peripheral-track group, there were significant improvements in ASES, VAS, WOSI_Total, WOSI_Physical, WOSI_{Sports/Recreational/Work}, WOSI_Lifestyle, and WOSI_Emotions scores compared to the preoperative period (Table 2). Comparative analysis of the final PROMs revealed that there were no statistically significant differences between both groups (Table 2). The return-to-sport rate was 82% (n = 51) in the central-track group and 80% (n = 31) in the peripheral-track group.

Table 2

Clinical Outcome Assessments at Final Follow-up ^a

	Central Track (n = 62)			Peripheral Track (n = 39)
Variable	Preoperative	Postoperative	P Value ^b	Preoperative	Postoperative	P Value ^b	P Value ^c
ASES	41 ± 12	85 ± 10	<.001	41 ± 9	82 ± 15	<.001	.524
VAS	5.0 ± 1.8	1.5 ± 2.2	<.001	5.0 ± 1.8	1.6 ± 2.5	<.001	.754
WOSI (Total)	1329 ± 252	266 ± 102	<.001	1299 ± 231	257 ± 111	<.001	.162
Physical	624 ± 152	83 ± 31	<.001	649 ± 127	88 ± 41	<.001	.922
Sports/recreational/work	260 ± 56	74 ± 24	<.001	224 ± 54	69 ± 26	<.001	.115
Lifestyle	236 ± 59	50 ± 41	<.001	242 ± 43	45 ± 42	<.001	.440
Emotions	187 ± 48	66 ± 37	<.001	185 ± 53	62 ± 35	<.001	.429

Values are presented as mean ± SD. Significant at P≤ .05. ASES, American Shoulder and Elbow Surgeons; VAS, visual analog scale; WOSI, Western Ontario Shoulder Instability.

Represents the comparison of preoperative and postoperative outcomes within each group.

Indicates the comparison of postoperative outcomes between the 2 groups.

Furthermore, restricted cubic spline regression models assessing the relationship between HSO and ASES, VAS, and WOSI_Total scores demonstrated a nonlinear association between HSO and these PROMs (Figure 3). These findings indicate that there is no significant association between HSO and clinical outcomes, thereby supporting the validity of the binary classification into peripheral and central groups. Intraobserver and interobserver reliability were good or excellent, with values of 0.916 and 0.873 for peripheral-track/central-track grouping and 0.936 and 0.890 for glenoid defect size measurements, respectively.

Figure 3.

Spline-modeled predicted probabilities of Hill-Sachs occupancy (HSO) in relation to Western Ontario Shoulder Instability Index (WOSI), American Shoulder and Elbow Surgeons (ASES) score, and visual analog scale (VAS).

Discussion

The present study demonstrated that arthroscopic Bankart repair provides satisfactory long-term clinical outcomes in patients participating in noncontact sports who present with shoulder instability characterized by an on-track lesion. An additional notable finding was that no significant differences were observed in redislocation rates, functional outcomes, or return-to-sports rates between patients with peripheral-track and central-track lesions.

Yamamoto et al³¹ introduced the concepts of “peripheral track” and “central track,” changing the perspective of shoulder surgeons in evaluating on-track lesions. Using this subclassification, they conducted a study involving 50 patients with on-track lesions (10 classified as peripheral-track lesions and 40 as central-track lesions) with a mean follow-up duration of 28 months. They found that patients in the peripheral-track group had lower WOSI scores than those in the central-track group. However, the current study did not reveal any significant differences in PROMs between the peripheral- and central-track lesion groups, including the WOSI, ASES, and VAS scores. This discrepancy may be attributed to the larger patient population in the present study, as well as the homogeneous nature of the study cohort. In the present study, both groups consisted solely of individuals participating in noncontact sports, whereas in the study by Yamamoto et al,³¹ the peripheral-track group included 10 patients, of whom 6 participated in contact sports and 4 in noncontact sports. Remarkably, it was observed that 3 of the 5 patients with significantly lower WOSI scores in their study were involved in contact-based activities. As is known, the clinical outcomes of arthroscopic Bankart repair tend to be less favorable for patients who participate in contact disciplines than for those who participate in noncontact disciplines.^22,23,30 Thus, the lower functional outcomes observed in the peripheral-track group of the aforementioned study may have been influenced by the inclusion of contact sport athletes.³¹ With a similar interpretation but from a different perspective, the absence of a significant difference between the peripheral- and central-track groups in the present study may be attributed to the elimination of heterogeneity related to sports participation level and the inclusion of a cohort consisting solely of patients participating in noncontact sports.

In another component of the current study, regression analysis revealed no linear relationship between HSO and PROMs, including ASES, WOSI, or VAS scores. This finding leads us to an ongoing debate in the literature regarding the evaluation of the relationship between bipolar bone lesion measurements and clinical outcomes. One criticism of the glenoid track concept is that collapsing a continuous variable into a categorical variable may limit its effectiveness for use in treatment decision-making.^3,16 In addressing this criticism, Yamamoto et al²⁸ and Itoi et al¹⁰ suggested conducting an assessment of the relationship between the track concept and clinical outcomes in relation to the biomechanical principles of mid-range and end-range instability. From this perspective, they underscored that glenoid bone loss is primarily linked to mid-range instability, whereas Hill-Sachs lesions are more associated with end-range instability. Accordingly, they stated that a binary classification approach is more appropriate than using continuous variables in the evaluation of bipolar lesions, and they demonstrated a nonsignificant correlation between continuous parameters, including WOSI scores and HSO.^28,31 Similarly, Verweij et al²⁷ observed no significant association between recurrence and the short distance from the medial edge of the Hill-Sachs lesion to the medial edge of the glenoid track—a continuous variable—in patients with on-track lesions, and they suggested that this finding may be attributed to the effect of mid-range instability. In the present study, the finding of a nonsignificant difference in the binary comparison between the peripheral- and central-track groups made it difficult to interpret whether the null association between HSO and PROMs in the continuous analysis was due to this finding or to notions of mid-range/end-range instability.^28,31 Therefore, more detailed studies are needed to investigate the relationship between continuous and binary data analyses within the track concept.

Yamamoto et al^28,31 also proposed a practical treatment strategy for shoulder surgeons in both their initial study, which introduced the peripheral-central track concept, and their recently published review. This treatment algorithm recommends arthroscopic Bankart repair for central-track lesions, regardless of the level of sports participation. For peripheral-track lesions, arthroscopic Bankart repair is similarly advised in noncontact athletes; however, in contact athletes, the addition of remplissage or the consideration of a Latarjet procedure is suggested. Similarly, in a study of 56 patients with on-track lesions and a minimum 2-year follow-up, Lin et al¹⁷ reported significantly worse clinical outcomes in contact athletes who underwent labral repair alone when the Hill-Sachs lesion was located more peripherally. Furthermore, they demonstrated that combining the remplissage procedure with labral repair improved clinical outcomes in these cases. On the other hand, they found that arthroscopic Bankart repair provided satisfactory clinical outcomes in noncontact athletes, regardless of lesion location. The findings of the present study suggest that arthroscopic Bankart repair is a reliable treatment strategy for noncontact athletes with on-track lesions in the long term, regardless of peripheral- or central-track subclassification, and support the clinical applicability of the treatment strategy proposed in the literature.^28,31 The long-term follow-up data revealed that both groups achieved comparable outcomes, with shoulder stability maintained in approximately 85% of patients, a return-to-sport rate of nearly 80%, and statistically significant improvements in functional scores, including WOSI, ASES, and VAS. In brief, considering all these findings and recommendations, it can be stated that in patients with on-track lesions who participate in noncontact sports, soft tissue repair provides satisfactory clinical outcomes in the long term. An important point to emphasize is that although this study included patients with <25% glenoid bone loss, the mean defect size in both groups was approximately 5%. Therefore, it is not possible to draw definitive conclusions regarding the adequacy of arthroscopic repair alone in noncontact athletes with glenoid bone loss exceeding the commonly cited subcritical threshold of 13.5%. Further comparative studies are needed to evaluate the outcomes of primary repair, remplissage, and Latarjet procedures in patients with glenoid bone loss >13.5% and to determine whether remplissage may provide better results even in on-track lesions with <13.5% bone loss.^13,17,24

This study has several limitations. First, the retrospective nature of the study, along with the high percentage of male participants, may introduce potential bias. Second, the present study did not assess parameters such as distance to dislocation, peripheral-track length, and vertical placement of the Hill-Sachs lesion; therefore, the impact of these variables on clinical outcomes and their relationship with peripheral- and central-track subgroups could not be analyzed. Third, although the study reported return-to-sport rates, it did not include information about the timing of patients’ return to sports. Additionally, although there was no difference in sports participation levels between the 2 groups, a separate analysis based on specific sport type or level was not performed. Lastly, since none of the noncontact sports participants in our study underwent remplissage or Latarjet procedures, a comparative evaluation involving these surgical techniques could not be provided.

Conclusion

In patients with shoulder instability who participate in noncontact sports and have on-track lesions, arthroscopic Bankart repair provides satisfactory outcomes, regardless of whether the lesion is classified as peripheral track or central track. Evidence of long-term success following arthroscopic repair in noncontact athletes could support surgeons in making more informed, evidence-based decisions in this patient population.

Footnotes

Final revision submitted September 28, 2025; accepted October 29, 2025.

The authors have declared that there are no conflicts of interest in the authorship and publication of this contribution. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto.

Ethical approval for this study was obtained from the Gazi University Ethical Committee (Decision E-77082166-604.01-1233325, research code: 2025-800).

ORCID iDs

Muhammed Furkan Tosun

Ethem Burak Oklaz

Ahmet Emin Okutan

Furkan Aral

Toygun Kagan Eren

Seda Nur Tosun

Ulunay Kanatli

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Hatta

Itoi

Peripheral-track and central-track Hill-Sachs lesions: a new concept of assessing an on-track lesion. Am J Sports Med. 2020;48(1):33-38.

Arthroscopic Bankart Repair Provides Satisfactory Outcomes for Both Central-Track and Peripheral-Track Lesions in Noncontact Athletes With a Minimum 8-Year Follow-up

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Study Design and Patient Selection

Surgical Technique

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Functional Outcome Evaluation

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