Free CME

Join now

CASE REPORT

Hinsdale Orthopaedics

Illinois Bone & Joint Institute

(P: 115063) How would you manage this injury?

Nonoperative (physical therapy, possible injection)

95/1491

Operative

91%

1366/1491

Outside my area of expertise - best if I don't vote

30/1491

Great case, thank you for sharing. I would echo Dr. McCulloch’s sentiment that acute full-thickness rotator cuff tears should be repaired acutely. In fact, I think that policy often lags behind evidence, and that physical therapy has little role in the management of full-thickness tears with the ex...ception of “pre-hab” for patients with profound pre-operative stiffness. For acute tears, the literature demonstrates improved functional outcomes with early over delayed management. Delay in repair invariably leads to tendon retraction, muscle atrophy, and decreased mobility resulting in increased tension required to reapproximate the tendon. Furthermore, I would argue that double-row is now the standard of care for large to massive rotator cuff tears, given evidence supporting not only significantly improved structural healing but better standardized functional outcomes as compared to single-row techniques. This is no doubt related to better restoration of the tendon footprint. K

PMID: 29274903

J Shoulder Elbow Surg. 2018 Apr;27(4):606-613. Epub 2017 Dec 21.

Early versus late repair of rotator cuff tears in rats.

J Shoulder Elbow Surg. 2018 Apr

PMID: 23836477

Bone Joint Res. 2013;2(7):122-8. Epub 2013 Jul 2.

Time to surgery in acute rotator cufftear: A systematic review.

Bone Joint Res. 2013;2(7):122-8. Epub 2013 Jul 2.

I Mukovozov | S Byun | F Farrokhyar | I Wong

PMID: 20194334

J Bone Joint Surg Am. 2010 Mar;92(3):732-42.

Outcomes of single-row and double-row arthroscopic rotator cuff repair: a systematic review.

J Bone Joint Surg Am. 2010 Mar

Paul Saridakis | Grant Jones

PMID: 16517356

J Shoulder Elbow Surg. 2006 Mar-Apr;15(2):148-53.

Results of early operative treatment of rotator cuff tears with acute symptoms.

J Shoulder Elbow Surg. 2006 Mar-Apr

Hannu E Lähteenmäki | Petri Virolainen | Ari Hiltunen | Jouni Heikkilä | Olavi I Nelimarkka

PMID: 6839586

Clin Orthop Relat Res. 1983 May;(175):18-24.

Acute tears of the rotator cuff. The timing of surgical repair.

Clin Orthop Relat Res. 1983 May

R W Bassett | R H Cofield

This is a well-presented case of an acute large rotator cuff avulsion in a younger active man. This is an operative case as the results are better (and the case is technically easier) when they are repaired acutely- which is defined as within 6 weeks. Unfortunately, I occasionally have to argue with... insurance companies whose clinical practice guidelines call for a trial of 6 weeks of nonoperative treatment. Despite the significant retraction, the sagital oblique images medially show that there is no evidence of fatty atrophy to suggest any chronic or pre-existing tear, which means that this should mobilize nicely with limited to no releases or medialization needed. I perform all rotator cuff repairs arthroscpically, regardless of size, as that is my preference and I personally feel I can see everything much better that way. Double row repairs make for elegant repairs of the tendon at the articular surface and allow for a larger contact area over the entire footprint. They have been shown to have lower re-tear rates in these larger tears as well. Thanks for sharing this case!

I can understand why Thwan Sie feels that massive rotator cuff implies retraction although the author might not. Some of us define massive rotator cuff tear as greater than 5 cm or three or more tendons, however others will define a massive rotator cuff tear as a large tear with significant retrac...tion. Unfortunately, the literature is somewhat conflicted, and as such some people might feel that massive rotator cuff tears are not repairable. In my practice, I have only indicated arthroscopic repair for a limited number of massive tears that were challenging and required advancement of the footprint. That is because the patients came to me soon after injury and retraction was minimal despite the tear involving three or four tendons. The others were indicated for reverse shoulders or nonoperative intervention. I personally accept the author’s title as being appropriate and spot on. I believe the author did not mean to mislead, and I believe the definition of massive tear lacks precise agreement.

Agree with what has been said. I would fix this as soon as possible and would perform a double row, knotless repair. The retraction should not be an issue. I essentially always do an acromioplasty in these cases although there is certainly evidence on either side of this argument. I keep them in the... sling for 4-6 weeks depending on the size of the tear, tissue quality and how confident I am in the repair. In this patient I think they would be in the sling for 5 weeks or so before starting PT.

I only use the supine decubitus without problems. you should try clavicle ORIF in the supine position with out the complications of the beach Chair position.

PMID: 26216778 Magn Reson Imaging Clin N Am. 2015 Aug;23(3):495-510.

Key MR Imaging Features of Common Hand Surgery Conditions.

ABSTRACT
- The introduction of 3-T MR imaging scanners as well as dedicated wrist coils has allowed for scanning of the unique anatomic structures within the hand with unprecedented accuracy. In this article, the authors discuss common hand conditions, focusing on imaging findings and the utility of MR imaging as it pertains to hand surgery. The authors examine its role in the treatment of hand deep-space infections, scaphoid fractures, scapholunate ligament injuries, thumb ulnar collateral ligament injuries, and ulnar-sided wrist pain.