What is the best treatment approach for an elderly female patient with an Anterior Labroligamentous Periosteal Sleeve Avulsion (ALPSA) shoulder lesion, considering her age and potential comorbidities?

Treatment of ALPSA Shoulder Lesion in Elderly Females

For an elderly female with an ALPSA lesion, arthroscopic mobilization and anatomic repair is the recommended surgical approach if she remains symptomatic after conservative management, though she faces a significantly higher risk of recurrent dislocation (32%) compared to standard Bankart repairs, and age alone should not preclude surgical intervention in patients over 80 years who are otherwise healthy. 1, 2

Initial Assessment and Diagnostic Confirmation

Critical History Elements

• Document the exact mechanism of injury, including how any fall or trauma occurred, height of fall, and landing position 3
• Determine if the patient has recurrent instability (shoulder "giving way"), persistent pain, or both, as these drive treatment decisions 4
• Assess for prior shoulder dislocations, as ALPSA lesions are associated with recurrent anterior shoulder instability and greater numbers of preoperative dislocations 1
• In elderly patients, maintain high suspicion for concurrent rotator cuff tears, which occur in 64.3% of patients over 35 years with traumatic shoulder instability 4

Physical Examination Priorities

• Evaluate for signs of rotator cuff pathology: focal weakness during abduction with external or internal rotation, positive empty can test, and external rotation weakness 3
• Assess for instability with apprehension and relocation tests 4
• Document baseline range of motion and strength, as these guide postoperative expectations 1

Imaging Requirements

• Magnetic resonance angiography in the adduction internal rotation (ADIR) position is the most sensitive and specific imaging modality for identifying ALPSA lesions 5
• Assess for concurrent pathology: Hill-Sachs lesions (present in 100% of cases), glenoid bone loss, and rotator cuff tears 4, 1
• Determine if Hill-Sachs lesion is on-track versus off-track, as this affects surgical planning 1

Treatment Algorithm

Conservative Management (Initial Approach)

• All patients should initially undergo a period of nonoperative rehabilitation unless there is acute locked dislocation 4
• Physical therapy focusing on rotator cuff and scapular stabilizer strengthening once pain-free motion is achieved 3
• NSAIDs for acute pain management 3
• Consider corticosteroid injections for more severe pain 3

Indications for Surgical Intervention

Proceed to surgery if the patient has:

• Recurrent instability episodes despite rehabilitation 4
• Persistent pain limiting function after 3-6 months of conservative treatment 4
• Combined pain and instability 4

Surgical Technique: Arthroscopic Repair

The standard approach is arthroscopic mobilization of the medially displaced labrum followed by anatomic repair to the glenoid rim. 1, 5

Key Technical Steps

• Use the anterosuperior portal for accurate identification of the ALPSA lesion 5
• Distinguish the true labrum from dense reactive fibrous tissue, which is critical in chronic ALPSA lesions 5
• Mobilize the labrum laterally from its medial malposition on the glenoid neck 6, 5
• Reattach the labrum to the correct anatomic glenoid footprint using suture anchors 1, 5
• Use the anteroinferior portal for optimal surgical repair 5
• Address concurrent rotator cuff tears if present (found in 64.3% of elderly patients) 4

Special Considerations for Elderly Patients

Age Is Not a Contraindication

• Primary shoulder surgery in patients over 80 years demonstrates 98.9% survivorship free from revision at 2 years and 98.3% at 5 years 2
• 90-day mortality is only 0.4% in patients over 80 undergoing shoulder arthroplasty 2
• Medical complications occur in only 3% of patients over 80 2

Comorbidity Assessment

• Carefully evaluate for peripheral vascular disease, which correlates with higher complication rates 2
• Screen for cardiac disease, as this may influence anesthesia risk 2
• Assess bone quality, as osteoporosis may affect anchor fixation 4

Alternative Surgical Options for Chronic ALPSA with Bone Loss

• If significant glenoid bone loss is present (>20-25%), consider bone block procedures (Latarjet) or soft tissue augmentation rather than isolated labral repair 5
• These augmentation procedures are necessary when the labrum quality is poor or when there is substantial bone deficiency 5

Expected Outcomes and Counseling Points

Realistic Outcome Expectations

• Patient-reported outcome scores (ASES, SANE, SF-12 PCS) improve significantly after ALPSA repair and are comparable to standard Bankart repairs at final follow-up 1
• Median satisfaction is 10/10 for ALPSA repairs 1
• However, recurrent dislocation rate is significantly higher: 32% for ALPSA versus 13.3% for standard Bankart repairs 1
• Revision surgery rate is 20% for ALPSA lesions at mean 5.6 years postoperatively 1

Critical Pitfalls to Avoid

• Do not delay surgical intervention in younger patients with recurrent instability, as chronic ALPSA lesions develop worse scarring and have poorer outcomes 1, 5
• Do not assume absence of rotator cuff tear in elderly patients with shoulder instability—maintain high index of suspicion as 64.3% have concurrent tears 4
• Do not mistake dense reactive fibrous tissue for the true labrum during arthroscopy, as this leads to inadequate repair 5
• Do not perform isolated labral repair when significant glenoid bone loss (>20-25%) is present, as this leads to failure 5
• Do not use age alone as a contraindication to surgery in otherwise healthy elderly patients, as outcomes are excellent even in patients over 80 years 2

When to Consider Non-Surgical Management Definitive

• Elderly patients with minimal functional demands who achieve acceptable pain control and stability with conservative measures 4
• Patients with severe medical comorbidities where surgical risk outweighs benefit 2
• Patients who decline surgery after informed discussion of risks and benefits 1