Hi, everyone. Today, the topic for me today is AC joint reconstruction, and how can we make this reproducibly successful. My name is Misty Suri. I'm a sports guy predominantly shoulder guy down in New Orleans. And here's our topic here. So, these are my disclosures on the slide on relevant to the talk. We can check the AOS slide, of course. So, this is the classic Rockwood classification system. And, you know, it really works. It's old, but it's a goody. Really, the key thing to remember when you're seeing these patients in clinic is the difference between the type one and type two. And that's the reason why it's for return to play. So, the difference between type one and type two can be difference in terms of the time it takes to get back and the area of tenderness, of course, the type over the AC and then type two is over the CC ligaments. As you can see there with your conoid trapezoid with the conoid being more medial. So, those two are obviously non-operative as well as type three. And then once we get to the higher levels of deformity, these kind of can go into the more operative type of situations, which is what we're here to talk about. So, just anatomically, you know, trapezoid is three centimeters from the lateral edge there and the conoid is about four and a half centimeters from the lateral edge. And that's the most important, the conoid being more important for vertical stability. So, just when you're doing your reconstruction, however you want to do it, the anatomy is important to realize where you're putting your drill holes for your reconstruction. Classic paper that's referenced here with the Rockwell classification and the algorithm that we use to decide what we're going to do non-operatively versus operatively. I think as we talked about with the classification, the older Rockwell classification system, the higher numbers would lead us to a more operative situation. There are many different ways to fix the AC joints. There's over 60 described surgical procedures. So, whenever you have that many ways to fix something, maybe you can consider none of them are that great, but we'll talk about some ones that we think that work pretty well that I prefer to use. Obviously, there's the modified Weaver-Dunn, the Buzacca technique, and using autographs, analog graphs, the old Bosworth screw. There's some flip buttons that we have more recently and also the hook plate. Hook plate for me, I found that to be the most successful and reproducible and allows me to sleep at night with the least amount of difficulty. So, I have moved to that over the course of my practice over the last 14 years. We'll go over a couple of cases. This is a 52-year-old male who fell from a road bike. He's an avid cyclist. I coincidentally fixed his other clavicle, his left clavicle. I fixed about six months prior to this and he falls again and now has a problem on the right side. So, he had pain with overactivity and reaching behind obviously with a prominent AC joint. It was painful over the area with overriding just a clavicle over the acrobium with cross-body adduction and here's the x-ray. Pretty classic situation there with the superior deformity. So, how I fixed this was with a hook plate, as we can see here on this x-ray, pretty standard repair. I fixed this acutely. It was fairly straightforward and in my hands, the hook plate for me is, like I said, the procedure of choice. It just takes away the the worry, the worries of a loss of reduction. Now, the negatives are you do have to take the plate out obviously. So, that's the negative and that's, you know, no patient's really had a problem with that for me. I think with the lack of recurrence with this operation makes the whole situation a little more palatable for the patient with the lack of failures in this kind of fracture or this kind of injury. So, this is how we looked at four months, no deformity, full painless range of motion, full strength and with no tenderness. His SANE score was 90, a pre-op was 50, and he was quite happy and back to riding bikes. Another patient here, a 30-year-old softball player, a male softball player. He had a failed conservative management and he had a AC joint that was prominent, of course, here, a little less deformity, but he was painful. And so, here's a situation where he was painful and was not getting better. So, we elected to proceed with the hook plate as well on him. And again, same similar situation here, got it reduced nicely. Those two screws are actually not in the AC joint. They're close, but they're not in the AC joint, even though it looks like it. He did well as well, and he went to back to playing and 95 was his SANE score and we removed his hardware four months out. And he had no deformity and continues to do well. So, just for the chronic injuries, just technically, we want to add an allograft under the plate and tie to itself. So, that goes under the hook plate. So, then when you take the hook plate out, obviously it's easy to take out and you're not disrupting your graft. So, again, the graft of choice, typically a flatter type allograft, potentially a posterior tib, because those lay down nice and flat. I would put that underneath the plate, tie it down, and then remove that plate at the six month time. So, for the acute, I'll take those plates out at approximately four months. And then the chronics are approximately six months to remove the hardware. And no restrictions in activity, obviously, after removing the hardware. I can use a combination of soft, of buttons and soft tissue grafts, as this next case demonstrates here. This is the old, this is the, we were done, you know, classic type procedure. When I was a fellow with Dr. Hawkins, we used to use nine PDS braided together around the coracoid. And in addition to the, the lateral construct here, and that's how we did it. And so, this is the modified we were done involving the transfer of the CA ligament only was the original we were done. And then once you modify modification included the supplemental fixation. So, this was Mazzocchi's technique, which is a great technique here with the semi-T allograft, the conoid tunnels drilled first, about four and a half centimeters from the distal clavicle edge, and a little more posterior with a five millimeter reamer. And then trapezoid tunnel second, about 20 to 25 millimeters lateral to the conoid, and then more anterior with a five millimeter reamer. So, pretty, pretty well described technique and works pretty well. If you like to use it this way, there's, you can secure the conoid with a two centimeter graft exiting superiorly with a, with a peak screw or whatever screw you want. And then another screw in the trapezoid tunnel, the remaining graft suture, suture that into the periosteum and the AC, AC ligament remnants sewn together to reinforce the AC joint. Here's another case here. This is a patient here, a high school football player in 2018 was treated conservatively, had a subsequent injury. And this is what it looked like with his AC joint prominence. And so he had this prior AC separation with little HO distal clavicle area. So this is the construct here with 30 millimeters medial to the distal clavicle marks, the drill site for this, this button and seven, eight millimeters of distal clavicle was taken out with the HO present to allow, to help with the reduction and the allograft here was a semi-T allograft. And just going back to the previous reconstructions with the, with the hook plates, basically I'll take out as much AC joint as needed to get the reduction. So if there is some AC joint that is blocking your reduction, just make sure to take that out to allow yourself to get your reduction easier. And that goes for all of these reconstructions in my hands. So this was, it looked like what the patient looked like at 12 weeks with at this point, he had 110 degrees of forward elevation actively 130 degrees passively. He had external rotation with the arm at the side of 40 degrees and was stable with, with, with no complaints of pain. So to summarize, really, there's many different ways to fix each has their pros and cons as described. I've gone to the hook plate as my method of fixation to fix these injuries, the lack of failures that I've had with, with this, I've revised many of these, of these other constructs that have come in from, could have come in and put hook plates in them. And they've all done well, even in the chronic situation. So that's kind of what I've gone to. I think you could do either all, all the ways are reasonable, but I think it's important to I think you could do either all, all the ways are reasonable to fix this. But that's sort of my, my opinion over the last 14 years of evolved evolution in terms of fixation for this injury. Well, thank you very much. I appreciate it. Thanks for having me.

AC joint reconstruction

Rockwood classification system

AC joint injuries

surgical procedures

hook plate