Outcomes of Arthroscopic Anterior Labroligamentous Periosteal Sleeve Avulsion Lesions: A Minimum 2-Year Follow-up

Abstract

Background: Anterior labroligamentous periosteal sleeve avulsion (ALPSA) lesions can occur in recurrent anterior shoulder instability, which may lead to the labrum scarring medially to the glenoid. ALPSA lesions have also been associated with greater preoperative dislocations, larger Hill-Sachs lesions, and greater degrees of glenoid bone loss. Therefore, patients with these lesions have historically had a higher failure rate after repair, with nearly double the recurrent instability rate compared with those undergoing standard arthroscopic Bankart repair. Purpose: To compare minimum 2-year outcomes of arthroscopic mobilization and anatomic repair of ALPSA lesions with those after standard arthroscopic Bankart repair. Study Design: Cohort study; Level of evidence, 3. Methods: Consecutive patients who underwent arthroscopic repair of ALPSA lesions were matched in a 1-to-3 fashion to patients who underwent standard Bankart repair by age, sex, number of previous ipsilateral shoulder instability surgical procedures, and number of anchors used. Patient-reported outcome (PRO) scores were compared preoperatively and postoperatively (American Shoulder and Elbow Surgeons [ASES]; 12-Item Short Form Health Survey [SF-12] Physical Component Summary [PCS]; Single Assessment Numeric Evaluation [SANE]; shortened version of Disabilities of the Arm, Shoulder and Hand; and satisfaction). Recurrent instability, on- versus off-track Hill-Sachs lesion, and reoperation rates were analyzed. Results: A total of 100 shoulders (25 ALPSA and 75 Bankart) with an overall mean age of 25.7 years were evaluated. Patients in the ALPSA group demonstrated significant improvements in the ASES (preoperative, 74.8; postoperative, 89.7; P = .041) and SF-12 PCS (preoperative, 46.9; postoperative, 53.4; P = .021) scores but not the SANE score (preoperative, 65.2; postoperative, 75.3; P = .311). Patients in the Bankart group had significant improvements in all outcome scores at final follow-up: ASES (preoperative, 67.1; postoperative, 90.3), SANE (preoperative, 58.0; postoperative, 85.7), and SF-12 PCS (preoperative, 45.3; postoperative, 52.9) (all P < .001). There were no significant differences in PRO scores between the groups preoperatively or postoperatively ( P > .05). The median satisfaction for the ALPSA group was 10 of 10 and for the Bankart group it was 9 of 10 ( P = .094). There was a significantly higher rate of recurrent dislocation in the ALPSA group (8/25 [32.0%]) compared with the Bankart group (10/75 [13.3%]) ( P = .040). Additionally, 5 patients (20.0%) in the ALPSA group underwent revision surgery at a mean of 5.6 years, and 8 patients (10.7%) in the Bankart group underwent revision surgery at a mean of 4.4 years ( P = .311). Conclusion: Despite improvements in the recognition of and surgical techniques for ALPSA lesions, they still lead to significantly higher postoperative dislocation rates; however, no differences in PRO scores were found. These findings highlight the importance of early surgical interventions in anterior shoulder instability with the hope of lessening recurrent instability and the risk of developing an ALPSA lesion, as well as careful assessment of the quality of soft tissues and other risk factors for recurrence when considering what type of shoulder stabilization procedure to perform.

Surgical Outcomes and Associated Injuries of Anterior Labroligamentous Periosteal Sleeve Avulsion (ALPSA) Lesions: A Systematic Review

“…1 However, two of the studies included in this review found higher rates of recurrence in ALPSA patient groups as compared to isolated Bankart groups. 4,7 rence rates, physicians likely continue to perform arthroscopic ALPSA repairs due to the high frequency of preoperative dislocations in patients with ALPSA lesions, which was cited as over 12 dislocations per patient in one study. 6 It should be noted however that the studies included in this review span nearly 30 years, during which time arthroscopic techniques have improved and different approaches to ALPSA repair have been developed.…”

“…8 METHODOLOGICAL ASSESSMENT AND RISK OF BIAS Two blind reviewers (CR, CN) evaluated included studies for methodological quality and risk of bias according to the JBI Clinical Appraisal tools for cohort studies, case series, and case reports, respectively. Two cohort studies 4,6 had a mean score of 10.5 out of 11. Three case series 3,7,10 scored a mean of 9.3 out of 10 and one case report 11 scored an 8 out of 8.…”

“…Four studies 4,6,7,10 reported shoulder outcomes scores which can be seen in Table 1. Two studies 4,10 of 90 patients had a mean American Shoulder and Elbow Surgeons Shoulder (ASES) score of 68.1 preoperatively and 89.89 postoperatively, while two additional studies 6,7 of 79 patients reported a postoperative Rowe score of 85.5. Range-of-motion (ROM) data was available in 3 studies 3,6,11 and outlined in Table 1.…”

“…3 ALPSA lesions can occur in similar injury mechanisms to that of Bankart lesions, 3 although ALPSA lesions may be more likely to occur as a result of repetitive dislocations rather than a single traumatic event. [4][5][6][7] ALPSA lesions have repeatedly been identified as a risk factor for recurrent shoulder instability following arthroscopic Bankart repairs. 1,2 Higher arthroscopic failure rates are also associated with ALPSA lesions compared to isolated Bankart lesions.…”

“…1,2 Higher arthroscopic failure rates are also associated with ALPSA lesions compared to isolated Bankart lesions. 4,7 To our knowledge, no systematic review has synthesized surgical outcomes or associated injuries following ALPSA lesion repairs. Therefore, the purpose of this review was to evaluate postoperative outcomes of ALPSA lesions, including recurrence rates, outcome scores, range-of-motion, re- turn-to-activity, and surgical complications.…”