Review Question - QID 214082

The patient in the vignette is a young patient with a massive rotator cuff tear (RCT) involving the superior cuff and subscapularis without evidence of muscle atrophy and little to no joint arthritis. The next best step in management is to proceed with a rotator cuff repair (RCR)

Massive rotator cuff tears in a young patient are challenging clinical problems. These injuries have higher failure rates and can be often not amendable to repair given the degree of retraction or atrophy if they present in a delayed fashion. The general consensus is to proceed with an attempt at repair in patients without evidence of significant muscle atrophy before proceeding with salvage options such as superior capsular reconstruction (SCR) or tendon transfers. Furthermore, studies have shown that patients with acute tears have superior clinical outcomes when surgeries are performed within 6 months of the injury.

Duncan et al. performed a retrospective review on patients with acute RCTs to determine the effect of time to repair on the outcome after an acute RCT. The authors reviewed 20 patients who underwent RCR within 6 months of injury and compared them to 20 age/sex-matched patients who had undergone delayed RCR (6-18 months after injury). The authors noted that the early repair group had an improvement in Oxford scores that was nearly double that of the delayed repair group (20.3 for early vs 10.4 for delayed, P = .0014). The authors conclude that early repair (within 6 months) of rotator cuff tears leads to improved outcomes.

Greenspoon et al. reviewed treatment options and clinical outcomes of massive RCTs. The authors describe an algorithm that first separates massive RCTs between acute and chronic/degenerative. Authors recommend giving patients with chronic/degenerative tears a non-operative trial to see if any improvement is obtained but push for early surgery of all acute massive RCTs (within 6 months). The authors state that several salvage options exist for irreparable massive RCTs which include patch augmentation, superior capsular reconstruction, latissimus dorsi transfer (for irreparable posterior/superior tears) pectoralis major transfer (for irreparable anterior/superior tears) and reverse total shoulder for older low demand patients with significant muscle atrophy.

Figure A is the AP of the right shoulder showing no fractures or evidence of glenohumeral arthritis. Figures B and C are T2-weighted coronal MRI images that reveal a massive superior RCT with tendon retraction. Figure D is the T1-weighted coronal MRI images showing the absence of significant supraspinatus and infraspinatus muscle atrophy. Figure E is the T2-weighted axial MRI studies showing a large subscapularis tendon tear.

Incorrect Answers:
Answer 1: Given the size and involvement of both the superior rotator cuff and subscapularis, the patient should be offered rotator cuff repair and not debridement to restore function.
Answer 2 and 3: The patient has very little muscle atrophy on sagittal MRI and is only 5 months out from injury and should be offered RCR prior to a salvage procedure such as SCR or tendon transfer.
Answer 4: Operative management should not be delayed any further given that this is a massive RCT, that there are proven benefits of early RCR, and the fact that the patient already has full passive ROM.