What are the recommended next steps for treating an Anterior Labroligamentous Periosteal Sleeve Avulsion (ALPSA) lesion with associated mild superior labral fraying and minimal subacromial subdeltoid bursitis after failed conservative therapy?

Surgical Intervention is Recommended for ALPSA Lesion After Failed Conservative Therapy

For patients with an Anterior Labroligamentous Periosteal Sleeve Avulsion (ALPSA) lesion who have failed conservative therapy, arthroscopic repair is the recommended next step to prevent recurrent instability and improve functional outcomes.

Understanding ALPSA Lesions

ALPSA lesions represent a specific type of anterior shoulder instability where:

• The labrum and attached ligaments are displaced medially and rotated inferiorly on the scapular neck
• Unlike Bankart lesions, the anterior scapular periosteum remains intact
• These lesions are associated with higher rates of recurrent instability if not properly addressed

Evidence-Based Management Algorithm

Failed Conservative Management

Conservative management typically includes:

• Physical therapy focusing on rotator cuff and periscapular strengthening
• Activity modification
• Anti-inflammatory medications
• Possible corticosteroid injections (limited to 1-2 to avoid tendon weakening) 1

Surgical Management

When conservative measures fail, surgical intervention becomes necessary:

1. Arthroscopic Repair:

   • Convert the ALPSA lesion to a Bankart-type lesion
   • Mobilize the labrum and reattach it to its anatomical position
   • Repair associated pathologies (superior labral fraying, subacromial bursitis)

2. Surgical Technique:

   • Arthroscopic approach is preferred over open surgery for combined intra-articular and extra-articular pathologies 2
   • Labral mobilization followed by anatomic repair with suture anchors 3

Outcomes and Expectations

Research demonstrates that arthroscopic repair of ALPSA lesions results in:

• Significant improvements in American Shoulder and Elbow Surgeons (ASES) scores
• Improved SF-12 Physical Component Summary scores 3
• High patient satisfaction (median 10/10) 3

However, patients should be counseled that:

• Despite modern surgical techniques, ALPSA lesions have higher recurrent dislocation rates (32%) compared to standard Bankart lesions (13.3%) 3
• Early surgical intervention is preferred to prevent development of chronic changes

Associated Pathologies

When addressing the ALPSA lesion, concomitant treatment of associated pathologies is recommended:

• Superior labral fraying should be debrided or repaired depending on extent
• Subacromial subdeltoid bursitis should be addressed with subacromial decompression if significant 4

Postoperative Rehabilitation

Following arthroscopic repair:

1. Initial phase (0-6 weeks): Immobilization in a sling with limited range of motion
2. Intermediate phase (6-12 weeks): Progressive range of motion and gentle strengthening
3. Advanced phase (3-6 months): Sport-specific or occupation-specific rehabilitation

Pitfalls and Caveats

• Failure to recognize and properly mobilize the medially displaced labrum can lead to inadequate repair
• Addressing only the ALPSA lesion without treating associated pathologies may result in persistent symptoms
• Patients should be counseled about the higher risk of recurrent instability compared to standard Bankart repairs
• Early surgical intervention is preferred as chronic ALPSA lesions may develop scarring, making mobilization more difficult 5

By following this evidence-based approach, patients with ALPSA lesions who have failed conservative management can expect improved shoulder stability and function, though they should be counseled about the higher risk of recurrent instability compared to other labral pathologies.