We can just run through this case. It's going to get at that exact topic. I think we're going to get to that with this case. So this will not take long. For anyone that needs to leave, please go ahead. And the mouse, I don't think, is working, unfortunately. There we go. OK. So this case, actually, Guillermo sent to me. So it's nice to have another way to incorporate him into this ICL. These are his disclosures. So this was a 32-year-old right-hand dominant male who came in complaining of right shoulder pain. He plays squash and obviously is doing overhead-type activity. He was complaining of pain and instability during sports. He had a grade 3 AC separation three years ago and was treated conservatively and has a history of contralateral glenohumeral joint instability, and he underwent a Latter-Jay. So this is his Zanke view. He has a 53% difference on the affected side compared to the contralateral side. On exam, he had a beaten score of 3 out of 9. He had apprehension, a positive anterior drawer. His relocation test was negative, and I'm not quite sure what surprise means. These were his pictures. So he had type 1 scapular dyskinesia with inframedial border winging. And so questions at this point. So are the symptoms that he's complaining of due only to the AC joint? Does the AC joint actually produce instability, or excuse me, pain and weakness? Or should we be looking at associated pathologies such as a SLAP or Bankart lesion, and then the whole question of getting an MRI? So Tony, what do you think? Well, first of all, the surprise test is when you put the arm in the apprehensive position and they're uncomfortable, or they feel like they're apprehensive, and you push back, that's the relocation test. And then you don't tell them, but you take your hand off real quickly, and then all of a sudden they feel, that's the surprise test. So in a chronic case, I will always get an MRI because of what John said. The literature suggests a minimum of around 15 to 20% of the time there's pathology. Now it doesn't necessarily always have to be fixed, but there's real pathology when these injuries occur. Many of the patients don't seem to be symptomatic of it when you take care of their AC joint. But if I'm going to do a chronic case, I'm gonna get that, because I wanna know if there's other things that I can fix while I'm there. And so this part, the part of my procedure is gonna be all arthroscopic until I get to the final reconstructive part. Matt, anything else you'd add to that? Yeah, this case is interesting in that, what part of the scapula is playing into his instability? Clearly there's an anterior instability component. He's got a prior laterge on the other side. Predisposed to it, when we look at bilateral anterior instability issues, there's a predisposition. So I'd fix the bank card and do everything together at the same time, probably arthroscopically, unless we have a significant bone loss or other issue. But then you're looking at, do you do another laterge? And that's a whole nother discussion when you've got CC ligament issues. Yeah, I think the harder question, not that this is not a hard one, but we can get away with some period of mobilization with instability, but if they have a rotator cuff tear, that one can play a role in being a bit challenging, the decision, more challenging. Although we know that the literature suggests you can still hold them pretty steady for six weeks too. But I think that seems to be a more challenging one. If it's just a labral tear, I usually fix it along with the AC joint. I've had, cover your ears, but I've had a run of over 60 to 65 AC chronic issues and they've had rotator cuff tears associated with it. But they do not like the AC joint and they were there for that alone. Although on MRI, you also found out they had a full thickness, one centimeter supraspinatus tear at the same time. Again, why we get the MRI, we do it, address it all, but these patients do very well and they're very active. So I don't, the age cutoff keeps getting pushed for me, but they've done very well with this slightly older population, but Tony's exactly right. You don't want to miss that other tear. So then Matt, last question for you before showing you some other imaging. When are you getting an MRI or MR arthrogram in patients with AC joint instability or AC separation? Mary, almost. I almost get it. Almost always. Yeah, almost always. I just, you know, it just helps me have some answers and it's really just to rule things out. And like Tony said, it's only 10, 15, 20% of the acutes. Chronics can have much more. Maybe 40 and up to 70%, as John said. Perfect. So this is just sort of reiterating some of which we've just been talking about, that there is a definitely high risk of associated pathology and so we need to take that into account and address all these different issues. So here's his imaging demonstrating a Bancart tear, Bancart lesion. And then he got a 3DCT to look for glenoid bone loss. So he does have about 17% glenoid bone loss. And for the sake of just kind of trying to move through this a little bit, we'll click his Hill-Sachs. He has an on-track Hill-Sachs lesion. So the plan is to fix both, right? And so first do the Bancart repair arthroscopically. Hit the patient who's positioned in a lateral decubitus position. You can see the Hill-Sachs lesion here. There's a better view there. And so then standard sort of Bancart repair, preparing the labrum and the glenoid. You can see down there the subscap muscle belly. And then he shows his repair here. Anything else that you guys would do differently? Obviously start with this. There's of course many different implants we can use here. You just see Guillermo's technique for this. And then we've got final repair. And then he goes on, changes the position of the patient, of course, to beach chair to then do the AC joint reconstruction. And then similar to what we saw in his talk earlier, similar technique with that sort of internal fixed, internal brace type device, and then using the allograft for reconstruction. And these are his incisions post-op. Anything, so in terms of graft choice, Tony, for you, are you, like I mean it's not always or never, but like in general, are you using allograft? Are there certain situations where you're gonna use autograft? You know, I, if I'm doing an acute one and it's, and the right patient, I actually, well I learned from my European colleagues, I actually will use a pulmaris, their ipsilateral pulmaris, just like we do for the UCL. So, you know, some people don't think you need to use collagen for the UCL. If you use collagen for an acute, I believe that it will improve the overall outcome as the Society of the French Arthroscopy multicenter study showed. So I, that's the one time I'll deviate. I'll use the pulmaris graft, especially if they have a good, strong one. If it's wimpy at all, then of course, then my go-to is a allograft hamstring. In this case, it's interesting. It's probably exactly how I would have done it, including the reposition from lateral, because I'm a lateral instability person, and then gone to the beach chair to do the AC. The only thing I may have considered, and it's not, once you get your room crew used to it, you put them in the beanbag, you put them in the lateral, it's about a 10-minute repositioning time, but it is time, it's time under anesthesia. I might have considered an open Bankart plus the chronic AC fixation open. Same incision, you're right there. Great. Any questions about that case? Would you guys have considered doing those in two different settings, in that your rehab, is your rehab for your AC and your rehab for your instability the same in those conflicts? If I had that, I would have done them in two different operations. Yeah, I don't worry too much about a 32-year-old with the labral stabilization getting overly tight. Maybe I should. I would be careful about doing too aggressive a capsulography, but I might start them in a supine position, just internal and external rotation activities early, just to get some movement of the shoulder away from gravity, but I personally would do both at the same time, but I'm certainly happy to learn from your experience if that's been an issue. Just the other way, I would love to talk to you. I have a great experience, I'm gonna go on my own. If I have these, I just teach the therapist, I say we have to do this exercise of the first six weeks in the supine position because I gotta take gravity off the shoulder, so I don't mind if you do some passive elevation, if we get a little bit, but internal and external rotation, and generally speaking, I would have to go back and look at our numbers, but I don't think we've had a major problem with it. It definitely is a little bit longer. I don't think it's conflicted, but there is, I think the unweighting part of it, I think using really good passive techniques and having your star therapist, I had a NFL player with, he's active, he's still playing, and the guy is a beast, but he's now had bilateral dislocations with coracoid fractures and subsequent AC type five instability. So talk about a combination case and the, I need this done immediately as I gotta get back to training camp type thing. So does it on the other side two years later. So it's this crazy scenario where actually when in the coracoid is fractured, did a latter J with the coracoid because he did have some pretty close to a near track lesion, then also stabilized using some of the unique techniques that Mary and Tony showed, whether it's anchor or tunnels through that base remaining of the coracoid. So that's maybe a conflict as well, but they got through it very well at the same time, returned to high level of play. Great. Well, thank you everyone so much. It's 8.45. I really appreciate you staying and thanks for the excellent discussion. Thank you. Thanks Mary.

shoulder pain

AC separation

glenohumeral joint instability

Bancart tear

arthroscopic procedures