began about 12 years ago. I was part of the iSACOS shoulder committee with very very smart guys as Klaus Bach, Eiji Itoi, Gazma Soka, Andreas Simov, Emilio Calvo and Ben Kibler. And luckily I joined this team at the iSACOS shoulder committee and we have a consensus meeting we met in Copenhagen to try to reach a consensus with a global view about acromioclavicular disorders and we published this book and papers with iSACOS. At that time, about 12 years ago, we began to perform all arthroscopically assist AC joint reconstructions in chronic and in acute setting and we report 32 patients, about half of them with graft only in a figure eight position between the coracoid and the clavicle, nine with supersutures, only six patients with an internal brace, but the failure rate at that time was very high with more than 20 percent loss of reduction. Therefore, my goal today will be to try to answer two or three questions about AC joint dislocation and one of them is if the acute setting is a golden opportunity to improve the results, what can we do better with the surgical technique? All of us use the Rogut classification system and we know that the grade three is controversial, but we need to take into account that this bi-directional instability and the instability has a superior and also posterior component. We published at the Arthroscopic Journal with Nat Beitzel this statement trying to identify two different types of grade three AC joint dislocation. Grade 3a, this is stable, no scapular dyskinesia and a negative Alexander Vazvania cross-arm x-ray and 3b is unstable, therapy resistant with the scapular dysfunction and at the cross-arm x-ray we can see a posterior overriding of the clavicle. But many times in the acute setting it's difficult to wait for a rehabilitation trial and you need to decide for surgical and non-surgical treatment based on contact on collision sports versus overhead or throwing sports, time and the season, type of work, the cosmesis and the deformity and not to wait to really evaluate the scapular dyskinesia after an acute injury. The preparative evaluation, we take the regular x-ray with both joints at the same cassette and we measure the cc distance between both sizes and we also use the 3d CT scan to evaluate the dislocation and mainly the posterior component of the dislocation. In many cases the decision is easy, for example my six sons, they play rugby in Argentina and perhaps all of them are not suitable for AC joint reconstruction playing collision sports but I am sure that the the new bride will be and she will be very happy to avoid the cosmetic deformity. We know that all the overhead or throwing athletes deserve a fixation after grade three to five AC joint dislocations and there is plenty of literature and systematic review demonstrated that the surgical treatment leads to less pain and deformity than the conservative group. This is another paper, a systematic review that describes that the surgical treatment leads to better outcomes than the conservative one and describes the surgical complications of the surgical procedures but many of them don't exist anymore such as hematoma, stiffness, high rate of infection, pin migration or scar or keloid. The only complication that we still have is loss of reduction and deformity. To operate this patient we need to know the surgical anatomy, we need to realize that these ligaments are core-like, are like a rope, like the ACL, you can see the trapezoid on the right on the base of the coracoid, here is the coracoid t-view, you have the coracoid base and the trapezoid, then in this left shoulder with the scope at the lateral view you can see all the coracoid process and the trapezoid arising from the coracoid forearm to the clavicle on the top, there you can see the coracoid elbow on the right where we put the internal brace, this is the conoid, this is the clavicle and the conoid, here is the anatomical point where we try to put the internal brace and if we follow the conoid we discover the transverse ligament over the suprascapular nerve which is about eight millimeters from the target. Why did they fail in the past? They fail due to timing and technique. Sawa Wu about 30 years ago described that the inflammatory phase was only 48 to 72 hours and the proliferative phase of the healing of the soft tissue was only seven days. Recently, a mayor reported last year their biopsies of the acromocavicular ligaments and the disease ligaments and from the day one to seven cellular activation and early inflammatory changes and we have up to 14 days for proliferation and fibroblast-like cells but 15 to 21 days is too late. Therefore, we redefine the acute and say that acute is less than one week and we change the surgical technique with new devices with the thinner drill bits and larger bottoms and implants to avoid pull-out. The first generation was very wide tunnels and very small implants. Therefore, to avoid biological and mechanical failures, we use internal brace and an allograft semitendinous or tibialis anterior allograft in every patient with an acute AC joint dislocation. We pass the graft in order to improve the posterior stability of the joint. Therefore, we pass the graft posterior to the clavicle, medial to the coracoid and then anterior to the clavicle, lateral to the coracoid. In very high grade AC joint dislocation like grade 5, we reduce the joint under x-ray control and pin it in order to have a better reduction and almost over reduction of the joint. The right shoulder in picture position, this patient has a grade 5 AC joint dislocation with a huge superior displacement and also posterior instability. First, we address the distal end of the clavicle and then through the scope after preparing the graft, we find the tip of the coracoid in this right shoulder and then we dissect the coracoid and go to the lower part of the coracoid elbow as you saw in the previous video at the cadaver dissections. And then we use a clamp, a bended clamp to release part of the pectoralis minor in order to pass the graft after a fixation of the dislocation with the internal brace. The technique is easy today with the new implants and the new instruments. We pass a drill bit, it's a 2.4 or 3 millimeters drill bit, cannulated drill bit, and inside the drill bit we deliver a nitinol wire, we retrieve the nitinol wire through the anterior lateral portal and then we are ready to introduce the button from distal to proximal. It's very important that with this technique the button doesn't pass through the tunnels, so the button is quite big, about 10 millimeters and the tunnel is 3 millimeters, so the possibility of pulling out is very rare. So this is a very strong fixation that we get with this button. After doing so with the cannula dilator we use a switching stick and then a cannula dilator. The switching stick goes posterior to the clavicle to medial to the coracoid and with the cannula dilator and a fiber stick we deliver a suture through the cannula dilator in order to then take the legs and the loop and then this will lead us to pass the graft first posterior to the clavicle to the medial side of the coracoid and then from the lateral part of the coracoid anterior to the clavicle. There you can see that almost all the time the internal braces on the coracoid elbow and the graft is a little bit anterior at the coracoid around the coracoid. This is the view of the inferior part of the coracoid with the internal brace and the graft in the right position. After doing so we tie the fiber tape of the internal brace and then we tie the knot with the with the graft and put some sutures to final fixation. Only in patients that have grade 5 acute shoulder dislocations or non-compliant patients we really think that it's necessary to do a surclash at the acromioclavicular intrinsic ligaments. We do a fiber tape surclash some surgeons use anchors but we prefer to use tunnels. We do an horizontal tunnel and anterior posterior horizontal tunnel at the lateral end of the clavicle and a vertical tunnel at the acromion in order to increase the posterior stability of the intrinsic ligament in a figure eight configuration of double sutures or tape in the acute setting. To follow up we ask for bilateral shoulder x-rays and to compare the cc distance and we also take the basmania alexander views. We use the acromioclavicular joint instability score published by Shavell with the pain 20 points daily living activity limitation 10 points, cosmesis 10 points, function 25 points and this score gives a lot of importance and weight to the radiological assessment with vertical plus horizontal stability. With this technique in an acute setting less than 10 days after the injury we have 26 patients with the mean follow-up of 25 months all of them with internal brace and a graft 20 allo and six autograft and in 26 patients only three failures that we define the failures as a loss of reduction of the cc distance more than eight millimeters or 50 percent of the clavicle width. The acromioclavicular joint instability index was average 87. This is an ACL this is not a research paper it's an ACL where all of us come to to know what what we have to do and how and I would like to give you the message that early acute AC joint dislocation is a golden opportunity to fix them and to for achieving better results with the current techniques the old described complication are no longer seen the scapular rehabilitation trial we use it only in cases where the surgical indication is weak but in patients where the patient deserve a cronoglavicular joint reconstruction we have a belt and suspender approach with internal brace and allograft even in the acute acute setting to avoid biological and biomechanical failures. I would like to thank you for your attention. I would like to thank Mary for inviting me and I will I will send my best regards to Mary to Tony and to Matt good friend of mine I'm looking forward to see you soon one of my friends in any place of the world so stay safe and have a great day and have a great day in Nashville today thank you very much

AC joint dislocations

surgical anatomy

internal brace

allograft

x-rays