High end folks, a lot of special forces people. People in the NHL don't do well with this. People playing hockey don't do well with this. There's a lot of folks you just need to avoid doing this surgery on, because just because of the mechanism of their sport, they're gonna have a problem. I think we're waiting for computer to switch over. Geez, can you put it down here? Sorry. So yeah, everyone's, what are you doing? I'm like, where is it? So here's a, we're gonna talk a little bit about complications, and I've sort of morphed into one type of procedure, which includes CC and AC on everyone for more than the last decade. And that for me has provided the best fixation, the most reliable outcomes, even in these more trickier populations. And so we always talk about patient selection, but if you're doing every type three, we're doing more than we need to do. You can certainly take that approach. I don't think that you'll get in too much trouble with that, but you have to be careful. I sort of let these declare themselves over a certain amount of time. You don't have to wait forever and then see how they do, because my acute reconstruction or repair is the same as chronic. And here's an example, 40-year-old male, distal clavicle five years prior. Oh, no, no, this is the wrong one. That's the case presentation. This is a good case. We can do this after. So presented, this is a patient with distal clavicle insufficiency. And as Tony talked about, not to beat up Dr. Romeo and Dr. Mazzocco, but if you look at the original article that they put out, and Tony and Gus have been pioneers in this, in the original ACCR, when that term, anatomic coracoclavicular reconstruction, is Tony's and Gus's. And when you look at that original article, the article actually had you taking 10 millimeters of the distal clavicle. But now look where it's come full circle, and I take very little, if anything, and get a very good, solid reconstruction. We do think that that end of the clavicle and the strut, I liken it to a strut of your automobile or the front part of your motorcycle or whatever, you have to maintain that balance and that length. And so here's some of the complications. Here's a good injury you get to take care of. And these hurt. If you take care of these acutely, these hurt very badly. It's a great injection to do in the locker room. So if you're taking care of this acutely, it's a great injection when you're using lidocaine. Maybe a little bit of steroid, depends if you're going to operate on it, but certainly lidocaine, marcaine. And so we're going to talk a little bit about the outlines here. Phil, can I get the slides up there in the front here, too? So we're going to talk about first, loss and reduction of fixation. And this has already been alluded to. And the problem is, this happens more often than we would like. And the problem is, we can look at it all day long from an AP. And all right, everything looks good, but then it slides up. But we also have to look in the posterior plane and the horizontal plane to see where this actually comes in. So here we are, six weeks post-op. Another one, here's a classic ACCR, a la Romeo and Mazzocca style. And then you've got this button underneath. You can see the button over here. And now the button comes out. And these are all cases that have been referred to me, or they're some of my cases. And so this happens. You get some calcifications here at the end of the clavicle. You get some other injury issues. And so these anatomic AC reconstruction, and when you look at some of these original articles, this is really what was done originally and helped us really advance the science. But now I think we're so much better by preserving the end of the clavicle, going out to the AC joint, using some of these smaller anchor constructs, which we didn't have before. The anchors were too big to go in the acromion. And this is the issue, is the Weaver-Dunn, back in the day, just never does well. And so we've been fighting ourselves on this literature that exists for a long time. And this load to failure in Weaver-Dunn is terrible. And the horizontal instability in Weaver-Dunn is terrible as well. So we're getting much better with these suture button systems. But really, as Tony showed, coming out to the acromion is really where this is at. So if you look at two-year outcomes in these CC reconstructions, my partner Peter looked at this, in ACCR, seven patients had a complication, 22%. And that's real. And Peter's a very good surgeon. Graft rupture attenuation, two clavicle fractures, distal clavicle hypertrophy, eh, this may be over-coded as a complication unless it really bothers you. Adhesive capsulitis, guess what? They go on a sling for six weeks. That can happen. But patients without these complications had excellent post-op outcomes. Loss of reduction, again, 30 patients with an unstable. This is from Dr. Lim's group. Developed in 14 patients. So a loss reduction, whether it was any plane. But really, we're hyper-focused on this image. But we really need to be focused on that horizontal plane, which is even more important. And the final clinical scores, again, just like anything, were better if the radiographs were better at the end of the day. And the frequency of loss reduction using double-button device and inspecting radiological results. And the CC distance increased at the third month of follow-up. And then also at the last follow-up at six months. So there's a progressive stretch out of this with use and time. And these were either type 3 or type 5s. And the AC joint instability was significantly worse and had worse subjective outcomes if they had CC different distances that were greater from 3 millimeters from that first to second follow-up. So if you're starting to lose reduction early, this may be something to look at and talk with your patient about. And you may need to intervene a little bit earlier based on this. So now let's talk about some fractures. This happens. It's happened to me. I've had them referred to me. We're kidding ourselves if they don't. The good news is many of these, and you talk to Gus. You talk to Tony. And you make phone calls to your friends. Vast majority you can leave alone. And they heal. And they do OK. Sometimes you need to do a revision. You can leave that coracoid. You can leave other things. Now, some patients, and I had some special forces folks, they didn't like it if that coracoid was tilted down, or they had the coracoid that was broken off, or basically the conjoint tendon complex just wasn't working. They lost their ability to use some elbow flexion, some elbow strength through that conjoint tendon. And so those are things you may want to address. But a lot of times you can get away without doing anything to the clavicle and just letting it heal. But you also have plate options. You have suture options. You can treat these like a type 2A or a type 2B distal clavicle fracture and reconstruct it with a combination of a plate or button construct. And these, quote unquote, periprosthetic fractures, the prosthesis being this button thing here. Here's one where he had 19 months after the index surgery. Fracture morphology was quite different. But even two years after an arthroscopically assisted AC joint restriction, arthroscopic, anytime you're putting tunnels around here, you have this risk of fracture you have to be careful of. And so my tunnels have become much less and much smaller to try to help improve this and prevent these fractures. Tunnel malposition is also very important. We've learned a little bit on this from not only Tony and Gus, but also my good friend JT. And we've also published on this, too, where if your tunnels are malpositioned, whether it's directly on the clavicle or on the coracoid, there's a much higher elevation and a much higher failure rate. And that failure rate, again, guess what, is early. Six or seven weeks, here was 14 scope and 14 open from JT. And medialized tunnels, meaning those that were much more medial and were way too far on that clavicle medial, were the ones that failed much higher, three times as much in the open group versus the scope groups. That was kind of interesting. I don't know if that was a power issue, but definitely it was at least one of the findings. Distance between the tunnels was not a factor. But we do know from Tony's work that we have to be really careful on where we're putting our tunnels, not being too close. But that posterior-ish tunnel position is important to help with that stability. How about sex-based differences? The coracoid position is correlated with anatomic parameters most strongly with clavicle length. And we have to have different considerations for tunnel positioning. It's just like the Latter Jay, and we showed the demo on Wednesday. The coracoid available in a female, on average, is about 23 to 24 millimeters. So you get to the CC ligaments. In a male, it's average of 28 millimeters. You get another 5, 6, 7 millimeters. And we have to respect those differences and the sex-based differences when we're trying to optimize these reconstructions. And then lastly here, what about our other issues, recurrent instability? And we talk about this quite a bit. Here's someone that had a procedure. And you can see an arthroscopic. I think we got the blue thing a little too low. But basically what you're seeing is a big posterior. There we go. You're seeing a big posterior shift of the clavicle and superior shift. And guess why these patients don't like it. It's because the clavicle abuts the scapular spine posteriorly. It gets in the trapezius muscle and fascia. And they just have a lot of dysfunction on top of scapular dyskinesia. All arthroscopic reconstruction of chronic AC dislocations. So Pascal showed us the rate of instability was significantly higher in patients with higher grade dislocations and or previous failed surgery. So we're going to entertain it again. Guess what? Just like anything else, failed ACL, failed instability type procedure, that risk of recurrence is higher. And it probably has to do to prior tunnels, prior other issues you're working around. But the other thing we've also picked up is infection. And I've picked up a number of P-acnes infections in these patients, especially from a prior open type of procedure. And that's a tricky, we can talk about in the discussion, it's a tricky management. Do you go in, do you wait, do you take tissue cultures and come back two weeks later? Or do you take cultures at the time of surgery and just address it? So that's a whole other discussion. Horizontal instability, when you look at Alberti's work in the systematic review, 23 articles, it's often missed on initial exam. I think we've beat the drum on this quite a bit today. But it's one thing that the isochost type 3b is the biggest issue. And type 3b is one I would operate on potentially acutely if they have this lots of instability. But again, we have to probably go out to the AC joint. We probably have to do a really good job reconstructing anatomically the conoid and the trapezoid ligaments. AC joint suture, quartz collage with an AC and CC reconstruction. And a commercial type of button technique really addresses this horizontal instability well. And this is where we're starting to see much improved success in the literature. And so what's my treatment approach in general? Hamstring graft, usually an allograft. And this has been shown in the literature, a very high improvement in VAS and ES, 93% return to play. So I always add collagen. I don't, whether it's acute, as Guillermo showed, I always use collagen. I did a little bit of polyester only. And those were just not what I was hoping for. The lack of fixation and the ability of those to stretch out was much higher. And I just think you need collagen at this point. And when you're looking at tenograft versus no graft, the literature, at least emerging, would support that a graft is slightly better. But it's been much better in my hands. And so how I usually treat these injuries, especially the controversial ones, a type five in the right sport, fine. Type five, Boston Bruins, NHL, guess what? You're going back to the ice as soon as I inject you and as soon as you're comfortable, but they hurt. As soon as you're on the football field in the NFL, depends because sometimes, as Tony and I were just talking, lifting and power sports to do your sport, such as football and lifting and presses and inclines, sometimes that AC joint is really important. So to be able to prepare for your sport, sometimes you just have to do it and you have to talk to your athlete about it. Although you may get slammed to the ground again on the turf, you may need that distal clavicle stabilized in order to have the ability to prepare for your sport. So just keep in mind, it's not just going out and playing. They got a lot of preparation to do. And so I usually try to have the athlete return to play within four to eight weeks. There's certainly some we would do acutely. The fives, maybe the high grade three Bs that are super horizontally unstable. If still painful, cannot return, then I operate. And I do CC and AC for both of these. I use an AC knotless type device. And then two or less holes in the clavicle is all I use. And I usually use an allograft semi T and reconstruct these. And then I use either anchors or drill tunnels. And here you can see, this is one of our articles we published on this. And you can see the difference. They're like a minimum of 15 millimeters. This has traditionally been the 10 millimeters, but we don't take any of that off. We keep that all there. If you feel their prior symptomatic AC joint, prior osteolysis that's clinically significant, then I might take one to two millimeters off the end of the clavicle, but that's it. And so I usually use either one or two grafts. You can also use an Achilles and split it in half and save the cost. But I use one tunnel in the coracoid and I pass underneath. And that tunnel is right around three millimeters, not much higher. And then we use a three millimeter with a slightly higher unicortical drill tap on the top of the clavicle. After that, pass this through. And it's nice to have these devices. You can either figure of eight loop this or come straight over. Although as Tony showed, maybe coming straight through might be a little bit better. And you fix these with tinnadesis screws. And on top of doing your commercial fixation option with these high strength sutures and button techniques and tie this down. And then at the end, we're able to pass the clavicle through. We get the clavicle down. We check it under fluoro. I still like doing that. It's a quick, easy shot. You have them rainbow set up ahead of time. And then you're able to do our delta trapezial fascia after we've already come out to the AC joint and done this out through the AC joints. And you can see we've got a tunnel, a small tunnel here. The graft actually loops around almost like a soft tissue hook plate, or it comes in through the acromion, but the graft comes out here, loops around almost like a soft tissue hook plate. So I have a small four millimeter or four and a half millimeter tunnel in the acromion. And then we loop that back and tie it into small anchors here on the acromion. As well as the clavicle. And so that's a really nice way to get around this in this kind of soft tissue hook plate construct that we've written up quite a bit and had really good results with. So in summary, these complications happen more often. Fractures, especially through coracoid if you're doing a larger one. And then if you're doing more than two tunnels in the clavicle, I think you have to be really careful. Consider anatomic parameters, watch that medial positioning on the clavicle. And then history of dislocations or other problems. Please be careful with those patients and consult them appropriately. Thank you. Does anybody have any questions before we kind of go into a case? I guess one quick question for you, Matt. For the AC joint, are you always, I mean for the horizontal instability sort of component, you're doing the CC reconstruction, but then are you always stabilizing the AC joint or is it only when there's actual, like you evaluate and there's horizontal instability? Yeah, any time I say always, I get in trouble, but it's almost always. I almost always come out to the acromion. Like I said, I've really morphed into one technique with this in the last 10 years because it's been so stable for my patients. Great, Tony, I think, oh sorry, Matt, go ahead. Dr. Conway, yeah. We were waiting for you to ask. I actually have a lot of stuff I'm trying not to ask. Too many things. We have to get him a mic. Just talk loud, John, if you can. So a lot of guys are trying to do this arthroscopically now but I see this is really an open technique for you guys in the long term, is that correct? Yeah, for me, I need an incision on the top. If I'm just doing the, if you were just planning on doing the button, you can do that all arthroscopically or if you're doing the. I want to state, well, you want to get tissue in there. Yes, I think that the delta trapezial fascial is a critical part of the procedure and I don't know how to do that arthroscopically. I probably should ask Buddy Seboah because he's probably figured out how to do that. No, he's still doing it open. Okay. I'm gonna say, Peggy, the question I was gonna ask is the downside of taking down the rotator interval in order, and all the soft tissues around the corcoid in the process of trying to get to that because you still have to make the incision on the top. The other thing is that, since we know that we see scapula dyskinesis and malposition that occurs with this operation, why are we not more aggressive in managing some of these somewhat horizontally unstable ACs in our throwers? What is y'all's interpretation of our current process? When you say management, you mean surgically managing? Okay, yeah. I mean, I know we're trying to all be conservative, but our explanation is we don't want to operate on pictures we don't have to, but at the same time, if they have horizontal instability, if they're really Bs, three Bs, do you think our current indication for a thrower where the three Bs should be immediate surgery? Personally, I think that if you don't, you've changed their performance permanently. In other words, if you do the surgery, you may or may not get them back to the same level of performance, but if you don't do the surgery, I think that if you really look carefully at the statistics, you'll see that their performance has changed, and they're not quite the same if they have true horizontal instability. So I do share that with them, and most of them still go by what is considered the standard, which is not to have that operated on, but I tell them ahead of time that because of that movement, it's gonna be hard for you to control your scapula. You have to do, like you say, all the rehab, and I think their performance levels will go down if they have that true three B. I agree with that absolutely, Matt. What do you think about that? Completely agree. My baseball players are ones I will do earlier, no question, especially if it's their throwing, or their gloved infielder skill. They need to have that shoulder absolutely optimized, as you know, and there's just been no way. The problem is they work so hard to try to compensate for the mechanical differences they have, and they can't get there. They lose 10, 15%, and at that level, they just can't get it back. And so just in quick follow-up to that, in what time frame are you trying to get to those patients? So that's what I talked about. I had the talk on chronic, and my comment was, should we be operating on anyone? But this is, as John was implying, if you have one of these high-level overhead athletes, and they're demonstrating scapular dyskinesia, there's something really wrong. They're such talented people, and have done so much to maintain their scapula in the right position over their careers, and balance the muscles, and if they can't do that, and then you have an X-ray that shows that it goes underneath the clavicle, I tell them they should have it fixed. So that's the one that I look for the most, and whether it's a five or a three, those are the ones that I would suggest that they should have that fixed, to have the best chance to getting back to the same level of performance. And like within four weeks, is that sort of an ideal goal? Honestly, within two weeks. Within two weeks. John, back to your arthroscopic question. I mean, the open approach to this, I mean, you can get as cosmetic as you want. I mean, it's probably four or five centimeters. It's not that big. You can access a lot right there. That AC distance is eight, nine millimeters, and if you have the right tools, the right instruments, the right passers, this is an easy, open case, and very reproducible, and the fascia's huge. You just can't do that arthroscopically, and believe me, I do think there's basically a benefit from early arthroscopic. Guillermo's shown that. Many others have shown that. Marcus Scheibel's work, but I just, in my hands, it's just been much more reproducible with this quote-unquote mini-open approach. First off, great idea. Second, I absolutely agree with that. I do all of them open. I tried the arthroscopic approach earlier, and I abandoned it, and the last question that someone asked my friend is why a single suture connection instead of a twin tail or some other type? Because you can replicate that anterior lateral, posterior medial, conoid, trapezoid construct, and then grab your graft, and perhaps have a little bit better AP rotational control than you get with a single, and I thought it was a paper that says you can restore it. So I think, John, that one slide I showed you where there's so many different variations, I think that's one of the variations that's been presented so that either the twin tail or the two synthetic grafts with that, and then wrapping the graft all the way around without putting a third hole through the clavicle has been a technique that's been presented. I haven't done it that way, but that follows the principles that we're talking about, so I would believe that that may have a good potential of equaling putting the attendant through the clavicle. So I think that follows the same principles. I just don't have the experience to tell you that that works the same, but it may work just as well, just as you're thinking about. Just to add to that, too, that definitely is an option. I've learned that technique from Buddy, too, at Tulane. So using two, three, wrapping three strands of PDS together and having two sets of that three PDS and using that to sort of replicate the conoid and trapezoid and still using an allograft definitely works well, and it's good to just have in your armamentarium. John, the only issue, though, with that anatomically is it almost doesn't make sense because the ligament on the coracoid is anterior to posterior, and so you're gonna have, you have to have this front-back ligament complex to reconstruct it appropriately. It's a big oval that goes for about 10, 12 millimeters front to back. It's only three, four, five millimeters medial-lateral. So that's what we need to be addressing if you're doing this bridal technique a la slap bicep strangulation we used to do. That's a good question. What are you trying to do? Do you find a spot between the conoid and trapezoid on the base of the coracoid and then try to find a similar spot between the two on the bicep? Sure, I think so. I'm just wondering, this doesn't really Correct. Correct anything. It's a one-point fixation on the coracoid, which we're not, we need to address that better, but we're super nervous about putting too much drill hole in there. Yeah, thanks. Thanks, it's a great ICL, guys. Peter takes care of the Winnipeg NHL team. Most of our hockey players, as you guys already alluded to, we're just sending back non-operative. We thought Canada was gonna do it this year. Yeah, it came close. Peter, honestly, you don't send them back because they won't even come into your office. They're like, you're not touching my shoulder. Well, what we found, though, is we did an MRI study on all of them, and some of them that you think are grade one or maybe a low grade two or actually grade three, like when you MRI them, there's a lot more soft tissue damage because we had a few re-injuries where we thought they're grade one, send them back in like three, four weeks, and they re-injure, and now we MRI all of them if they're returning to high-level contact sports, and it's surprising what pathology you'll find, including the trapezius, as you outlined. So you're saying, like, for the ones or twos, just go ahead and get an MRI, make sure the ligaments- It's not so much whether you're deciding on surgery versus no surgery, it's deciding on return to play. You wait longer. Yeah, a little bit longer, so I don't know if that's your experience. No, that's great. Yeah, the other thing is- I've got an MRI on almost everyone, and it's pretty easy to get through insurance. I mean, that's not to read, but I don't wanna fight. I don't wanna spend a lot of time, but we've learned a lot through that, and it's interesting what you found on the twos. It's just much more damage on the MRI than meets the eye. Right, it's kinda scary sometimes. Yeah. The other thing is, do you think, when we're evaluating the results of surgery, we're a little bit too hard on ourselves in terms of a little bit of vertical translation, whereas we get rid of the horizontal instability? Correct. Because I think, like, I tell my patients, you know, I'm not gonna get rid of that bump. Probably it's gonna stretch out a little bit, but you're gonna be happy in terms of horizontal translation and they're quite functional and quite happy, as long as they have that reasonable expectation. So do you think we're a little bit too hard on ourselves in evaluating a surgeon? I think absolutely that, in terms of the clinical outcome, it's the horizontal and rotational stability. So if we get that good enough so they don't have an abutment or impingement between the clavicle and their scapula, most of them do pretty well. And it's when you don't get that figured out, we have problems. Yeah, and I think just adding to that, too, just setting expectations ahead of time. So helping them understand, like, yeah, you're likely still going to have some deformity, but it's not going to impact you clinically. And symptomatically, they'll feel a ton better. Please. When you pass the ligament laterally under the euphonium, do you have to take a little clavicle out to pass it comfortably, or what's your technique for that? Yeah, so kind of the soft tissue hook plate concept, or, you know, you can come front back. There's a lot of ways to do this. I've done kind of a hybrid of both, but that soft tissue kind of hook plate concept has worked very well. If that clavicle's super hypertrophied, I'll smooth it down on the top a little bit. But again, now you're having to, you know, repair the capsule more, repair the delt trap more. You know, you have to do horizontal imbrication, pants over a vest type of suturing to bring it down. But I'll take down a very little. I get very nervous every time I'm thinking about taking some clavicle down. I don't like to do it. And that's what I was going to say. I mean, Gus, when his fellows did the, presented it to literature, I just, I said, okay, I'm just going to leave the clavicle no matter what. So I will, and so my graft doesn't necessarily go over the clavicle underneath the acromion. It comes just off the back corner. And then underneath the acromion, or with some of the devices like Ben Kibler showed, with some of the devices we have now, you can use like the all suture, because you can go way past it and pull it and cinch it up, and you can use an all suture anchor to sew that down or reinforce that if you want. I am not a super big fan of putting holes in the acromion either. If, you know, we've already put some holes in the clavicle, so I try to fix it securely to the soft tissues in the bone without, with anything more than just putting in at the most a small anchor in there. Yeah, usually they're those high tensile strength sutures. And, you know, some people in Europe, they've done, they use fiber tape. And some people have even talked about going from front to back on the clavicle neocromion and doing a figure of eight, almost tension band over the top. And that's been another technique. And again, each time you're putting a little bit more of a hole in these areas. So you just have to be a little careful about that. But that's, I don't, I think it's more about the principles than it is about we don't have the specific technique yet, how to really reconstruct that AC joint. There's ways that we can really minimize that rotational, but it does gradually stretch out when you cyclically load it. So we don't have the perfect answer yet. But I do think thinking about that and doing something to reinforce that put together with the rest of your reconstruction makes it a much smaller three-dimensional fixation of that joint. And you have a much better chance of success. Great. So it is, it's 834, but we can run through one quick case if you guys want to. John has a quick question. So, as he was mentioning, MRI, GCP pathology, and the study documented 25, 40, more recently, 70% of the right of joint recovery pathology, not necessarily acute pathology. How do you manage acute, documented pathology on MRI and on the human joint? Are you willing to do it at the same time or are you doing it after you? This case will address that. Is that your case? Yeah. So we can just run through this case. It's going to get at that exact time. I think we're going to get to that

distal clavicle insufficiency

anatomic coracoclavicular reconstruction

patient selection

horizontal instability

suture button systems

acute pathology