What precautions should a middle-aged male patient with a near complete rotator cuff tear, mild subscapularis tendinosis, and severe acromioclavicular joint osteoarthritis take prior to surgery?

Preoperative Precautions for Rotator Cuff Surgery

This patient should focus on optimizing glycemic control if diabetic, achieving nicotine cessation if applicable, and implementing infection prevention measures, while avoiding unnecessary surgical delays for additional conservative treatments that have already failed. 1

Medical Optimization

Glycemic Control (If Diabetic)

• Delay surgery to improve glycemic control if diabetes is poorly controlled, as this significantly impacts surgical site infection risk and wound healing 1
• Target optimal hemoglobin A1c levels before proceeding, though specific thresholds vary by institutional protocols 1
• This is one of the few modifiable risk factors where delay demonstrably improves outcomes 1

Nicotine Cessation (If Applicable)

• Delay surgery for nicotine reduction or complete cessation 1
• Nicotine use increases infection risk, impairs tendon healing, and worsens fatty infiltration of rotator cuff muscles 1
• The patient should be counseled on cessation methods and provided resources, though complete abstinence may not be achievable for all patients 1

Weight Management Considerations

• Do not delay surgery solely to achieve arbitrary BMI thresholds, even with BMI ≥50 1
• However, educate the patient about increased surgical and medical complication risks associated with obesity 1
• Encourage weight loss but recognize that not all patients have resources to achieve significant weight reduction 1

Infection Prevention Strategy

Preoperative Measures

• Ensure the patient bathes or showers before surgery using appropriate antiseptic preparations 1
• Implement a multimodal infection prevention strategy including system changes, training, evaluation, and institutional safety culture 1
• Screen for and treat any active infections remote from the surgical site 1
• Optimize nutritional status, as malnutrition increases postoperative complication risk 2

Antibiotic Prophylaxis Planning

• Confirm appropriate timing and selection of prophylactic antibiotics will be administered perioperatively 1
• This is particularly important given the patient's nearly massive rotator cuff tear and need for complex repair 1

Avoid Unnecessary Delays

Do Not Delay for Additional Conservative Treatments

• Proceed directly to surgery without delay for additional physical therapy, NSAIDs, braces, or intraarticular injections 1
• The patient has already failed conservative management by definition if surgery is indicated 1
• Further delay increases pain, functional disability, and may worsen muscle fatty atrophy (already present in the infraspinatus) 1, 3
• There is no evidence that additional conservative treatment improves surgical outcomes once surgery is indicated 1

No Arbitrary Waiting Periods

• Do not mandate a 3-month "cool-down" period before proceeding to surgery 1
• Such delays worsen quality of life without improving outcomes 1

Rotator Cuff-Specific Considerations

Muscle Quality Preservation

• Minimize delay to prevent progression of infraspinatus fatty atrophy, which is already mild and will worsen with time 3
• Fatty infiltration negatively impacts surgical outcomes and is irreversible once established 3
• The nearly massive tear (2.1 x 1.9 cm) may progress to complete massive tear with further delay 3

Acromioclavicular Joint Management

• The severe AC joint osteoarthritis noted on imaging may or may not require surgical treatment 4, 5, 6
• If the AC joint is symptomatic on examination (painful palpation and cross-body adduction test), distal clavicle resection should be performed concurrently with rotator cuff repair 5, 6
• Untreated symptomatic AC joint arthritis leads to poorer functional outcomes after rotator cuff repair 6
• If asymptomatic, isolated rotator cuff repair without DCR is appropriate 4, 5

Preoperative Screening

Cardiac and Pulmonary Assessment

• Screen for preexisting cardiac and pulmonary problems, as these represent the greatest risk factors for postoperative complications 2
• Ensure communication between primary care physician, anesthesiologist, and surgeon regarding any identified issues 2

Bleeding Disorder Screening

• Screen for bleeding disorders and prior anesthetic complications 2
• Review all medications, particularly anticoagulants and antiplatelet agents that may require perioperative management 2

Common Pitfalls to Avoid

• Do not pursue imaging-driven treatment of asymptomatic AC joint arthritis without clinical correlation 1
• Do not delay surgery for rigid BMI targets imposed by institutional policies without individualized risk-benefit assessment 1
• Do not continue conservative treatments indefinitely once they have clearly failed and surgery is indicated 1
• Do not underestimate the urgency created by progressive fatty atrophy and potential tear extension in this nearly massive tear 3