And we're really grateful for Tiger Lee presenting these cases. He has a significant disaster practice in Boston. So I never cease to be amazed by the severity of pathology that Tiger brings. So we'll keep going. Thanks for the panel. All right, let me see how it worked this way. Just go forward. All right, thanks so much. Let's join the day. AC joins. So we have a great panel here with me, and Alberto, Ganesh, and Colton. So thanks for joining us, guys. So we'll start with something, the first case, simple case. So this is a 26-year-old male, history of snowboard injury about three years ago. Landed directly on his left shoulder, complained of shoulder pain. On the top of the shoulder, worse with a backpack or activities. Some decrease in motion, but not terribly bad. Weakness with lifting, some deformity. He does have some trapezius spasms and physical therapy for six months or so. So you can see a deformity in the AC joint, pain and palpation, about 20 degrees less than full reflection, abduction, full cuff strength, no deltoid weakness, some problems or activities, and no resting intact. So look at the radiographs. We'll start with the first one here. Alberto, what do you think here on the radiograph? Well, so first of all, I have to say I'm biased, because I have an AC joint that actually failed. So I will try to be conservative every time, because I know how it feels. But yeah, I mean, it's interesting. And when I tell you who did it, it's actually more funny. But what I see here is like it has some ossification under the clavicle. I mean, it's a grade three for me on a plate X-ray. All right, Colin, what do you think? Grade three, grade four, grade five? Yeah, that's. Take care of a lot of athletes, a lot of football players, they land their shoulder all the time. You probably see a lot of these. Yeah, so just based on the classification, greater than 100%, you're 100% to 300% grade five, so grade three, four. Kind of depends on also are you using weighted or something like that. And if it's five, three years out, then it's still up there and it's bothering. So Ganesh, it's nine versus 23. Do you measure anywhere else when you look at these radiographs? Is it just CC distance? Is that where you start? What kind of radiographs do you like to get? You know, I really treat most of the chronic AC separations I see at least tri-conservatively. I'm sure we'll get into that. I usually just look at the CC distance primarily. I think if you're going to talk about an acute separation, the grade four is typically something we're going to consider operating on acutely, in which case, I think an axillary radiograph is helpful, but in the chronic setting, probably not as much. Grade four is posterior displaced clavicle. Usually, axillary is the only way you can actually see it. So another thing you look at, so this radiograph, there's a little ossification there. Does that concern you for the reduction at all? Do you think people who have ossification of CC in chronic setting, they don't reduce as well? Or what do you think when you see these ossifications here? Ganesh? So if I'm going to take a patient to the operating room for a chronic one with anything underneath the clavicle, you're going to do a big subclavicular dissection. And so you can remove anything that's in there. And there might even be some benefit to it just to create some more scarring when you put your ligament reconstruction in. Yes, I totally agree. Because sometimes these are a block reduction. You've got to kind of go in there and resect it if you're going to reduce it. You want to be checking them under anesthesia to make sure they can reduce. So what is the role of classification for Alberto? Any role in there? Is there a role of management for your practice? Do you care, not care? Well, it is only if it's a 3B. So again, I'm really conservative with the AC joint. And I try to convince a lot of patients to actually stay the way they are, unless they have a posterior instability or a horizontal instability. That would be pretty much to just stratify which one is going to get surgery, which one is not going to get surgery. OK. What are radiographs, Colin? Do you do them or no? Who does weighted radiographs here? Who doesn't? Weighted radiographs? Zero weighted? You? You do weighted? We do weighted. OK. Do you think that helps, just to make the deformity more? I think in the acute setting, yes. But majority of time, I'm going to try to treat most of these grade threes non-operatively, six to 12 weeks or so. So I don't know if it matters long term. In the acute setting, I'd like to know, hey, is this really raising up with the weighted radiographs? But most of time, we're trying to treat these folks non-operatively to begin with, unless they're type four, really type five, way up there. What about you, Ganesh? In terms of MRI, do you get one on everybody if you're going to go to surgery? Do you want to know about the cuff, the slap? And what do you think? Does that change your management? I usually don't get an MRI. There is an association of type two slap tears with AC separations that's been published. And I can't remember the exact citation a long time ago. Sometimes I will do them arthroscopic assisted. And I think it's worthwhile talking to a patient ahead of time if you're going to do an operation. If you choose to do it arthroscopic assisted, you just want to tell them there might be some other pathology. And you might want to talk to them about it or talk to a family member. Who gets an MRI if you're going to do surgery, just to see? Just to see and make sure. Yeah, I do too. I just get it because there's nothing on the MRI. I don't scope the shoulder. I just go right to the open. But I think the MRI helps me in my practice to get it because of the associated pathology. This is a Zinko view. I just put in a picture for the reference, with a 10 degrees tilt to the superior plane. You want to measure the CC distance between the two. Another thing, if you want to get really sexy, Alexander Buzminia review. This is a cross-arm adduction resisted. And you can make the deformity a lot worse if you want to get that x-rays. It's published in literature. I've never used it. But I thought it would be kind of nice just to show you a different view to look at the AC joint. Social lesion, if you look in the literature, up to 18% to 30% have associated cuff tear, slap tear. And whether it's symptomatic or not, it's hard to say. I like to get it just because I'm doing surgery on them. Then it determines whether I scope them first or not. And so difference in different practice as well. So PT versus surgery with type 5, type 3 AC separation. Do you guys, do you think it works? What do you do? And how long do you do it for? And what do you think? There's probably some role for physical therapy for the acute AC separation just to get range of motion, confidence, strength back. I'm not sure in the, and there's probably some role in the sort of subacute to chronic period where maybe you can create some influence on the patient's mechanics. But once it's really chronic, I'm not sure it's going to change. It's either an instability issue or it's not. Alberto, what do you think? Do you operate acute type 5 AC? Who's going to do surgery right away? Anybody think so? Why? Why do you guys do surgery right away, type 5 acute? Is it because you get them back quicker in sports? Or is it because? I think it depends on the patient and what they're getting back to, really. I think it's very patient-specific on if you're going right away or you're trying to get them through a season. Even if you have, if we have a big offensive lineman and he wants to play, we'll try to get him through the season. Sometimes they can settle down in six weeks, four, six weeks. Sometimes they can't. So I don't think waiting six weeks are really going to burn a bridge for me, so to speak. I typically do very conservative. I give them three to six months to see in how they do. A lot of them do fine with a type 5 separation. They really don't need surgery. And I do a reconstruction. I don't do repairs that much. So it makes no difference in the type of surgery I do, whether I do it acutely or chronically. And so indication of type 5, so acute, we talked about that. It really depends on patient-dependent. What about type 3 separation, which is about 100%, but not more than 100%? Do you guys think those considerably? Just everybody start six months PT, and then maybe surgery if they fail? I guess it depends a lot on, as Cole said, it's more like an individual statement. Because a lot of these people, if they're like amateur, sporty guys, they want to be 100%, even if they're not competitive. So it's hard to tell. But on a 3A, it wouldn't be a problem. And a 3B, I would consider surgery. OK. Do all chronic type 5 need surgery? What do you think? Yes. Definitely not. You're right. Not all chronic 5 need surgery. Are you symptomatic? Is anybody doing this for cosmesis? Yes? No? No. Just a quick question. How sure are we that, and maybe my bias will be reflected in this question, but how sure are we what symptomatic actually means versus how much of them actually care more about the cosmetic side, and they're trying to sell you on the symptomatic side? It's hard to say. But what I see is, if they are scapular drooping, if the scapula is not symmetrical, and they can't lift the arm, and they have issues, those are probably symptomatic. If they're just lifting it up and going, oh, this is great, this is fine, but I have some pain there, it's probably, you know, that's a hard sell for me to do surgery on somebody just to fix that. But sometimes you get scapular drooping because you get this kinesis in the back and when you have this separation. And then those are patients that can't lift, and those are patients I think are a good indication for surgery. Is there anyone who feels there's an indication for early surgery versus late surgery? Meaning, you know, I think that when we do talk about CC ligaments reconstruction, there's a question between the biomechanics of what we do and the biology of what we do. And so does anyone do acute CC repair, or like dog bones, for bad type 5s acutely? I have not done one in a long time. That's been my practice. If someone comes in with a type 5, some people can be aggressive for it. I can make one comment that I've observed between acute and chronic. Is for me in acute, I can often repair the AC joint ligaments directly, which I think is a big deal in getting these to heal and do well. And that's easy technically. And in the chronic case, I really don't know what to do at the AC joint proper. And I feel like I should do something, and I feel like I'm reinventing that every time and kind of like flailing at it. So I mean, all other things being equal, I would prefer to do surgery acutely, because I'm going to do the same thing at the CC joint that I would do chronically. But the AC joint is much easier acutely for me. So it's actually interesting. We review a lot of these patients acutely in Germany, as I was doing my fellowship. And it's interesting, because since we opened the AC joint, you actually, most of the time, you can see that the AC ligament is between the joint. So it actually doesn't heal. But if you flip it out, and that's where the whole idea of the surclutch started, it was like flipping out the ligament and then do a surclutch plus the CC joint reconstruction. So it's without graft. So it actually worked on a bunch of patients. It didn't work on my shoulder, but it actually worked on a lot of them. Going back to the question, do you resect the AC joint when you do this, if chronic? So not acute, but chronic. Do you always resect the AC joint, never resect the AC joint? Do you guys, for a patient, if you can't reduce it, resect it? What do you guys typically do? How about you, Colton? You want to start with that? Yeah. If it is tough to reduce, or if it reduces and you have mechanical symptoms, then I'll resect it. Yeah. That's typically what I do, because I think if you resect too much AC, you can bottom mechanically compromise the shoulder. So type 5 surgery, I wrote this when I was a fellow 10 years ago and came in. I actually put in one of the highlight points is that all type 5 should do surgery. I think that's a wrong recommendation, because now I'm 10 years in practice. I know better. When you're a fellow, you don't know anything, because you don't see follow-up. You don't see patients. But that's actually a wrong recommendation. If I take that back, I think some do, some don't, depending on the patient. If you look at the outcomes for non-operative treatments, one of the better papers, not a lot of patients, but 22 patients, non-op type 5 reseparation, a quarter of them had normal functional scores, no issues at all, completely normal scores. All 77% were working at final follow-up. All the manual labor was submitted to work, 41% not a patient, none of them need surgery. So just keep that in mind when you guys think about indicating these patients with surgery. This is a guy that came in with sevens, but his primary care was telling me his shoulder needs surgery, but the primary care, and you can see he's got type 5, he's got zero issues. He's labor lifted, no pain, no other thing. I told him, listen, go back. You don't really need surgery for this at all. And if you're going to do surgery, arthroscopic versus open, so don't talk about the repair. Typically, repair is dog bun, arthroscopic. You do it, but if you do a CC reconstruction, do you guys do arthroscopic or open? What about you, Alberto? Arthroscopic. Combo, really. Combo? Combo. The only reason I like to do it arthroscopically is because I think you can decorticate the undersurface of the coracoid arthroscopically, which might help the graft heal, but that's dogma. Anybody here do arthroscopic or open? Arthroscopic? Open? Open? You pick? Does anybody pick between arthroscopic and open, depending on the indication of the patient, or just everybody gets an arthroscopic scope, you can't do it, and then you open? Just depends. So I do a mixture. And I'll show you a video of what I do for arthroscopic, and you guys can tell me if you do anything differently, where you can make it better. Graft choice, auto or allograft? Just go down the line really quick. Allograft. Allo. Allo. I use allo. Brassilis, semi-T? Brassilis. Semi-T. Semi-T, and I always pre-tension my grafts. I do semi-T. Size of tunnel, what do you draw? I normally do, so if I do only on the clavicle, I do a horizontal tunnel, so I can feed it a 475 swivel lock. So that'll be... Do you do interference screws, or you just wrap it over the top of the clavicle? I try not to do holes in the clavicle, big holes, but the ones I have, it's an anatomic reconstruction with screws. How about you, Ganesh? Tunnels? 5mm, small screws. Yeah, I do about 5.5 or 5.5 screws, usually line to line, fit with semi-T. And you augment? Tape? Yes or no? No. I do. Tape. I do every time. So I'm just going to go through, there's a lot of different techniques you can do. One thing we talked about, AC joint, you know, Rob, do you guys reconstruct AC joint if you have extra ligament in these cross-sections? You reconstruct, you wrap the ligament around the AC to do the horizontals? You do? I do. Yeah, I do AC reconstruction. If it's acute, then I'll do a repair, because I think that's important, like you. How do you do it? You drill a tunnel in the acromion, and then you wrap it around? So if it's acute to repair, I'll do, I'll suture anchor in the acromion, wrap it through, and then repair the ligaments over the top. If it's a reconstruction, then I'll take the leftover graft from the clavicle and then tie it over laterally to the anterior posterior ligaments. Anybody different? It's the same. Okay. So a lot of different options out there, Bosworth screw, dynamic muscle transfers, CC reconstruction. So this is a technique that I do for arthroscopically. Medial portals for the dissecting of the clavicle, Vs for visualization, accessory portal. I use some IT. I used to wrap with suture. I don't do that anymore. I just put a tape in, super easy. And then you find the rotator involvement, you go in there, you dissect out the coracoid on the surface, and then you can do a 70-degree scope, kind of help you get back there, or you can do an accessory portal, you can look right at the coracoid. Anything different for you guys when you start this case? You do the same thing? Okay. So now I move to the, our scope to the front, and I'm looking at the back, in the top. Using the end portal, which you can do a spinal needle, I use a curved RF device now, I don't use a straight. The curved one can get you over the coracoid really easy. Release the pec minor, go over there, and you can shuttle sutures around the coracoid pretty easy with a 90-degree passer. So once you shuttle the suture across, you just dock it, both of them, out of the accessory portal, in portal A. And then you go to the top of the clavicle, to basically resect the clavicle, to do the tunnels. And here's the 90-degree passer coming in, just going underneath. So passing here, and then when you do the clavicle, how do you guys, you de-corricate the bottom, how do you guys do that? You just put an ortho-keratin, you just kind of de-corro, just smooth out everything on their surface, how do you know how far you're going? On the bottom? Yeah, on the clavicle. Since I'm going to make an incision on the top, I'm always going to, I think to do it arthroscopic-assisted, you can kind of leave a little bit more of sort of the undersurface of the pec on the clavicle, but I'm always going to make an open incision to see the clavicle and at least make a small window to pass the grafts from the clavicle inferior. I do three small needles on top just to get my position so I'm not off. So I put the tunnel where I think it's going to be, and then I can dissect out with a portal just in line with the clavicle, and to dissect it out. And then once you see it, you get a 70-degree scope looking up, then you can see exactly where you're drilling. And then you can drill the tunnel, but like you said, Ganesh, you have to make a small incision on top. You can't cheat that. You just, you have to be able to see it. And then once you drill the pen in, typically I put a, just a little curette underneath so that it doesn't plunge underneath, depending who's drilling, whether it's your resident or assistant or you doing it. You want to get all the scar tissue underneath, so you put a RF device in there and just get it out so that it's clean because otherwise the graft would never pass. So once you do that, you can pass the suture with a 90-degree passer, come down, you grab the suture out from the sensory portal, and then you just shuttle the graft. Do you guys crisscross graft doing this or straight up and down? Why not? So the reason for me to crisscross is actually that, so it goes under the clav, the coracoid, and then it crisscross, and then I put one strand from behind to the front and one to the front to the back. So it's not up and down, it's like through the clavicle. You crisscross? Or it goes straight up and down? I crisscross. What about you, Ganesh? I've done both and can't tell a difference. I don't think a difference. I used to crisscross, now it just goes straight up and down. It's much easier. Anybody crisscross or graft in a tunnel, you could create the coranoid or just go up and down. Up and down. It's easier? Yeah. All right, so here's a suture coming in. I think, so you just basically now, you just get the sutures out of the two tunnels and then you're able to pass the graft across. It's pretty easy. You just shuttle it, clean it up, make sure you drill a 5-5 or 6, and then I use the interference screws for mine and with the tape backup fixation. So here's the graft coming in. So in the open technique, what do you guys do open? Do you open? Open? Do you guys do open or not really? Kind of a combo. So this is what I do when I do open. If you can't reduce it, you can't do arthroscopy, you put the scope in for some reason, then you want a big incision. I do a saber incision, just straight up and down. And then I take the anterior deltoid, flap it down, and just make a little flap on the clavicle. And then once you do that, you tie, you suture, you tag it with a couple of number 2 ethabonds. And then you split down the fibers. These are deltoid pectoral, deltoid region. So you can actually see the top of the coracoid. You put your finger on, you can feel the top of the coracoid. And then when you do that, you put a sharp homin on the medial side. You dissect that out so you can see it. Sharp homin on the lateral side, you dissect that out so you can see it. And then you have to use a coracoid pass through, and it makes your life much easier. I don't want to say the company, but there's a coracoid pass through that goes in. It's a really nice curve that you can go underneath. And now you can get the graph, you can get a suture pass through in there, you can graph around the coracoid. It makes your life much, much easier to do. So here's the sharp homin on the medial side, and then the lateral side, and then you just dissect out the clavicle, drill the tunnels, shuttle the graph across. I would just say one of the most important thing in the tensioning is you put the medial screw in first, and then you tension the lateral side. It's much easier to do that. You can get more reduction. If you do the lateral side first, you don't get as much reduction on the CC reconstruction. So that's what I do. Anybody do anything different? Or medial screw first, then the lateral. All right, for the sake of time, can you just fast forward this to Dan? I don't know if they can. So just 90-degree pass through, and then I repair the deltoid back. And typically, I tie the graph on top to itself, and then I tie the deltoid in that flap to the graft after reconstruction, and then close it as a layer. I never had any issues doing this with the deltoid. So here's a graph coming in, and then the tunnels come around. So the two tunnels drill, and then you just use a 90-degree pass through to pass the graft. This is the one I did the previous arthroscopic post-op as well. Just for the sake of time, I'm going to second case. So post-op PT, what do you guys do? Same thing? Six weeks on a sling, no external rotation. Okay. Second case, gets a little harder. 35-year-old guy, AC reconstruction. Five years ago, allograft, persistent pain, deformity, can't lift the shoulder. Decreased range of motion, no cuff problems. This is radiograph. Colton, what do you think? Yeah. Way up there, a lot of calcification on that inferior part of the clavicle. So that's going to be a problem. So I would CT scan this one to kind of see what that bone looks like. Alberto, what do you think? Is that what your shoulder looked like after your surgery? Hopefully not. I haven't got an x-ray yet, but yeah, that's horrible. So it was way up, right? So you see a huge osteophyte. It was really hard to reduce. You have to take that out to reduce it. And he's symptomatic. Any more imaging for you guys? X-ray, CT? Yeah, CT scanning, yeah. What about this? Constant infection. How do you work it up? You have saturated proteins normal. Do you care? Do you work it up? Do you biopsy? Do you do an interop and then see what happens? What do you guys typically do in the setting and revision? I would probably take interoperative cultures, keep them on doxycycline for two weeks. And then you do the reconstruction with a new graft and wash everything out? Unless your suspicion is, I mean, then you have to use your spider sense. If your suspicion is super high, you could do an arthroscopic biopsy. OK, I'll finish up. OK. Yeah, I do interop cultures. And I do the reconstruction and wash it out. If there's high suspicion of pus coming out, then obviously you want to wash it out and don't put any graft in there. But I had low suspicion for this guy. So revision, more PT, obviously failed PT, referred to junior. I was a junior partner years ago when I did this, so I couldn't refer to my junior partner. And how do you fix this? So this guy, this is why I was left when I got here. What do you think? More graft, or how do you guys approach this? Well, for sure, for me, it would get an AC sort of clash as well. So I have to be clever in that. The thing is, you get not enough bone to work with. So I would strongly recommend to not operate on this guy the most that I can, and then, yeah. Too late. I took him to it already. Yeah, it's too late, man. I'm sorry. It's too late. Yeah, it's too late. Wait for the miracle. Was he missing a bunch of lateral bone from a prior distal clavicle? What? Did they do a distal clavicle? They did. So he sucked a lot, actually. So he's like, so he couldn't do anything there. I'd probably do a no tunnel technique with a cerclage. Yeah, I think he already had tunnels in there, didn't he? He already had tunnel in there. So I went in with the original tunnel. He resected a lot. And I basically did the revision, took the graft out. That's the original graft. And the retractors, you drill original. They took a lot of clavicle. I couldn't do anything about it. And then I wrapped the graft from front to back. I just put four ligament strand grafts. There's still a little bit more reconstruction. Took out the HO. So you use an osteophyte. Make sure you take out HO. It wasn't going to reduce without the HO taking it out. And once you do that, it got reduced. Put everything back together. It's post-op. He did pretty well. And just to take a time, I'm going to show one minute of this case, just because it took me 30 minutes to put this together. So I just got to show it real quick. Potpourri SC joint reconstruction. Does anybody do SC joint reconstruction? SG. So this lady came in. This is her exam. I'm just going to go through them. So she has a three-year skull fault by sternoclavicular proximal clavicle fracture nonunion deformity pain. And it's right there. And she's bothered by it a lot. So here's the x-ray. You can see it's deformed. It's actually shortened. And she saw six orthopedic surgeons out of the seven surgeons that she saw in Boston region. You can see the nonunion there and then the deformity. So for that, for the surgery, just so people who does SC reconstruction in the room, you could do the osteotomy, dissect it out, which is what I did. Do clamp it, and then put two leg screws. Try to get it back out to length as best as you can. When you do the osteo, cut this thing, you use an ACL saw blade. But you don't want to go through it. You want to complete it with an osteotome so that you don't violate that posterior capsule and go into the artery if you can. And then you complete the osteo. And then put two leg screw across, a little plate on top. And then the maneuver is right there. So one thing I found, I learned from SC reconstruction is that when you get the SC reconstruction, the maneuver, you don't drill up and down. You want to drill oblique tunnels. You dissect it out. You look at it. You put a retractor underneath. And then you drill these tunnels in this oblique fashion. This is another patient that I did. So that you're able to see the pin coming out. So you're not up and down. That's a much safer way to do an SC reconstruction than trying to do it straight up and down, where you can't see the tip of your pin. So once you do that, you can do the graph. You wrap around. The other lady I did, it's just a single tunnel because she had deformity there for the reconstruction. And here's the post-op. And you can see she's got much more stability here. And this is a post-op. All right, man. Thanks. I appreciate it. Water. Thank you.

orthopedic surgery

shoulder injuries

AC joint complications

surgical reconstruction

individualized patient care

SC joint reconstruction