from the panel and from our audience. So first one, you actually answered, was the post-op rehab, which is really, really important, because even though it's arthroscopically assisted, they don't get stiff, and you really need to do that. Right, and there's so much force going across the AC joint with just forward elevation that you really want to scare them and just tell them, look, nothing, you know, wash underneath your arm, but nothing above 90 degrees for at least four, even six weeks, and you'll have higher success rate. And the next question was commenting on distal clavicle excision. When do you do that, and how do you make that decision, and does it change your mechanical stability? Well, again, our illustrious leader here has shown that there is great stability provided the distal clavicle. The problem is that they may have some arthritis at that AC joint, which was developed or resulted from the injury. So I tell the patients, you may get some distal clavicle pain which can be treated later very easily with an arthroscopic either injection or arthroscopic Mumford. So I want to keep that distal clavicle intact if at all possible. It's going to give you some A to P or some additional stability, so I try to keep it at all costs. Okay, one final question was, you sort of went through this in your presentation, but when you're doing the AC joint repair and you get a coracoid fracture, what's your process of fixing that at the time of surgery? It's just something you don't want to do. You can put a screw through it, try to get fixation there, but if you're relying on that coracoid for your graft, you've got to either secure that coracoid with a screw that you actually insert across or you don't get that graft fixation. I don't really have any other good ways once that occurs, so just try to avoid it. Gus, do you have any additional tricks? Yeah, one way that Romeo and Evan Letterman wrote up was drill through the supraspinous fossa and then run your graft through that drill hole. The problem is it's kind of going down on the other end of the cliff, so you want to have a suture passer that you can pass and then grab that up. And that's a very deep hole. Is the suprascapular nerve in the way? No, it's behind you. Right behind it. It's called a coracoid bypass. Yeah, good name, good name. But if you never drill the coracoid, you never fracture it, so why not just go around the coracoid routinely? Right, it's true, but if you want additional fixation besides just the graft, if you're putting in any kind of construct, you can put a very small three millimeter hole. So if you are at the base of the coracoid, you have plenty of bone there. The problem comes in when you put a larger hole or as you come more anteriorly or a smaller person, smaller coracoid, you're gonna risk fracture. If you stay close to the base, you shouldn't have any problem. Craig, one last question. Okay, yeah, we don't have to face this. So when you're doing your reconstruction, you have allograft, and do you ever extend your allograft to the AC joint, incorporate that into the repair? Yes. And how do you make that decision? Yes, I don't think there's been any evidence which has shown that that improves your overall construct strength or stability, but what it does do, it also gives you a little bit of extra support for your graft if you secure it on both sides. So now you're gonna have to secure it to the acromion. So you have to put a suture anchor and you make sure you don't wanna go through the acromion or get an acromial fracture. Now you're really gonna be in a world of hurt, but you have to fix that on both sides. So then the intact AC ligament does provide additional stability, but you've gotta be able to fixate it on both sides. I use all suture-suture anchors for the acromion. I think that helps prevent you from getting any fractures on there and leaving hardware. One quick question, you just made the comment, which I agree with wholeheartedly about not all of these need to be operated on. But how do you identify, what pearls can you give the audience about identifying which AC joint separations need to be operated on? It's a million dollar question. So we actually did a study at Tripler showing type fives in the military non-operatively did as well as those that were operated because of the high complication rate. John Dickens on his poster outside has a series of complications associated with AC joint surgery. 12%, John, if you're in here, 12% of those patients that were operated had major complications. So the question is not should you not or should you not operate? That wasn't the answer to the question, but it is fraught with high complications. But if you show that type threes certainly have never been shown to be better with operative fixation, and we've actually shown type fives to do as well. And those that are operated later did as well as those that were operated acutely. So the question is, look at all the hockey players. For those of you that are big Lightning fans, almost every hockey player out there in the NHL has at least one AC joint separation. So you look around, all of their clavicles sigh high, and they're certainly doing well. I've had like seven, so I mean between rugby and wrestling. But one thing that I've learned, one to pearl on that I've learned is that if it's like six, seven weeks out and they still have anterior posterior instability, you can move the clavicle up and down. Those are the ones I found that I eventually operate on. What's your opinion on that? Absolutely, and again, this is a long topic. I don't want to take all the time. But remember. Oh yeah, you're taking all the time. Yeah. You owe some minutes or beers to everybody else. One of the problems that I've treated is patients that have residual sagittal plane instability. So someone that's had a more aggressive Mumford, and they now are unstable both anterior to posterior. That's a big problem that also can be addressed with a CC ligament reconstruction. Because remember, your conoid and trapezoid, remember they're lamp structures, lateral, anterior, medial, posterior, teach my residents that. So your obliquity of those ligaments really help you out in that sagittal plane. So if you do have that instability, the CC ligament reconstruction, if put in anatomically, can really help you. And scapuloscenesis, Merrick. If they have scapuloscenesis, they're less compensated. But don't forget, Ben Kibler tells us you make a five, a three by arm position. Question in the back. Well, there's a question. I just want to mention, Kelly Kilcoyne from all three. That study, the poster, I just want to mention that we found independent of drilling the coracoid, you could have coracoid fractures. Someone earlier mentioned don't drill the coracoid. We found even if you just pass the graft, you can also have a coracoid fracture. Excellent poster, by the way. Glenn Ross. Craig, what are your thoughts on overreduction in the operating room of the coracoid clavicular distance? Great question. I think it's really hard to do. So I think if you really pull that down, I think it's hard to actually get that clavicle all the way down to the coracoid because of soft tissue. Remember, if you're doing it acutely, you're trying to get those CC ligaments to heal. So if you bring it down, I don't think it's very easy, Glenn, to actually overreduce it, but I think it's a possibility. I just haven't seen it. It's almost always loss of some reduction. Bill. Yeah, the question about how to decide who to operate on. Carl Bassamania taught us many years ago, if you get an AP of the shoulder with the arm AD ducted, there's a certain group of people whose acromion will slide medial lateral. It's not a superior inferior problem. And this is total anecdote, but that group seems to be more symptomatic than the people that just have the true superior inferior. Excellent point. Yeah, Carl talked about the adduction view you can get. And Craig has to deal with people who jump out of airplanes and wear 150 pound rucksacks. So those people, I remember, we tend to prepare more. How about just down the panel, who treats AC injuries acutely? Jan, start us off. Well, just to side, Dr. Levine's comment about that x-ray, I think that's called the Alexander view. And you just position the patient and you can screen them like that. Generally, what we wind up doing is treating them non-operatively, waiting for that four, six week interval. And if they're still pretty symptomatic or if they really have significant, both superior inferior as well as AP laxity, then we'll do the repair reconstruction. And it's sort of a combination of allograft going around the coracoid, drill holes, and also transferring the CC ligament as well as extending it out to the AC joint. So it's sort of a modification of the, I think the guys in German and Munich. Good, good, good. John. Yes, a couple of year, I think if you get it acutely, and all I do is sutures and bring the torn ligaments together, they heal. And I'm happy to share that with you. So if the skin is threatened with a true bad type five, that to me is the only one. The rest of them, I put an allograft in everybody. So you get to try it out for free as far as I'm concerned. So you delay until they fail and then do them when you have to. Yeah, unless the skin is a problem. Sure. Have you seen that recently? No. Yeah, exactly. Okay, next. Frank. I agree with Mark. There's the occasional thin person where you can just palpate the clavicle in the subcutaneous tissue and it's buttonhole through the trapezius. It's very rare, but when that happens, you know that they're not going to do well because I've tried it and they don't do well. But that's where you do the acute on. Correct. Nobody else. Swimsuit models and narcissists. Perfect. So orthopedic surgeons. That's quite a patient population. Dr. Kelly. No, I do them. Tony's already talked enough. Yeah. So the only time I'll do it is with the panel that said, but number one, literature's clear, delay versus acute repair, no difference. So I have a hard time operating on acute ones. So no, you don't. Is that the answer? No, and don't forget Mike O'Brien left. Those of you who haven't tried Buddy Savoie's elastoplast tape, try it. You can get a grade three and grade two. Try it. Okay, one more question for the panel, from the audience. For decision-making of arthroscopic versus open subscapularis repair. Jan. I would say 90% of those are arthroscopic. If it's a massive subscap tear, then we would do a deltopectral open and do the biceps tunities at the same time. John. My last open was 2008. So I would tell you to do whatever you do best. I do all my subscaps arthroscopically. I've done a couple open that were eight years out. Chronic, scarred in. Scope. Yeah. I think once you get comfortable with the scope. The bigger the tear, the more you need the scope. Once you get comfortable with the scope repair, you'll never go back to doing them open unless you absolutely have to, like, in a great contract. All right, great job. Thank you all for your attention. Session over. Great job. Next session. John, great.

shoulder surgeries

post-operative rehabilitation

distal clavicle excision

coracoid fractures

arthroscopic subscapularis repair