Mid- to Long-Term Clinical Outcomes and Failure Rates After ALPSA Lesion Repair

Background: Anterior labroligamentous periosteal sleeve avulsion (ALPSA) lesions are associated with recurrent shoulder instability and higher rates of failure after capsulolabral repair compared with similarly treated Bankart lesions. Although these lesions can portend poor outcomes, there are limited data on the associated conditions and postoperative course in a young, active population.

Purpose: To evaluate the mid- to long-term clinical course and failure rates after ALPSA repairs and assess features associated with these outcomes.

Study design: Cohort study; Level of evidence, 3.

Methods: The authors identified all patients who underwent primary arthroscopic anterior or combined anterior and posterior labral repair between January 2010 and January 2020 at a single US military academy. Patient and injury characteristics were retrospectively reviewed while excluding patients with follow-up of <2 years. Patients were divided into 2 cohorts based on the presence of an ALPSA lesion as identified using arthroscopy, and patients with non-ALPSA lesions were matched to those with ALPSA lesions in a 5:1 ratio based on age, sex, time from injury to surgery, glenoid bone loss, and follow-up duration. The primary outcome measures were failure and revision surgery. Any recurrent shoulder instability event was considered a failure, including subjective or objective subluxation and/or dislocation, recurrence of pain consistent with instability, or functionally limiting apprehension. Survival analysis and both univariate and multivariate logistic regression analyses were performed to identify factors associated with ALPSA lesions and propensity for failure.

Results: The authors compared 225 patients with non-ALPSA labral tears against 45 patients with ALPSA lesions. ALPSA lesions were associated with multiple preoperative dislocations (odds ratio [OR], 3.0; 95% CI, 1.5-5.9; P = .00096) and increased prevalence of Hill-Sachs lesions (HSLs) (OR, 6.7; 95% CI, 2.8-16.0; P < .0001) and near-track HSLs (OR, 3.6; 95% CI, 1.7-7.6; P = .00049). At the final follow-up, there was no difference in overall failure or recurrent instability between patients with and without ALPSA lesions (20% vs 16% [P = .563] and 17.8% vs 10.2% [P = .147], respectively). On multivariate regression, ALPSA did not affect the likelihood of failure (P = .625). However, those with ALPSA lesions experienced failure earlier (1.7 vs 3.1 years; P = .020). When revision ALPSA repairs were performed, 43% failed.

Conclusion: In patients with anterior instability treated with primary arthroscopic stabilization, ALPSA lesions were associated with HSLs and multiple dislocations. Although ALPSA repair failure occurred at a similar frequency in the mid- to long term compared with Bankart repairs, ALPSA repair failure tended to occur early in the postoperative course.