Thanks Mary, Guillermo is one of the true classic gentlemen in our profession, really a wonderful guy and his wife is fantastic and if you ever get a chance to be invited over his house you'll have a true Argentinian experience and it's really amazing. He's a real ambassador for our profession and he's done an amazing job and you can see he put a lot of effort into that presentation. There's a lot of details and videos that he edited and put together which is fantastic. So I'm going to talk about the chronic AC joint injuries and this might be a little bit different but I'm going to try to just present some of the work that we've done. I'm pushing this and it's not advancing. Yeah, they had to switch over so they may have to, just let me know Phil if that works. Sorry about this. Ready? The mouse is up, so I think it should work. Let's see if I can find a spot on the screen where it will—I don't know if I have to hit the arrows down at the bottom. Okay. Very good. Thank you. It just took a minute to go through. So the title is Chronic AC Joint Injuries. What do I do to fix this? The title probably should be, should we ever fix them? Even though, with a chronic injury, even though there's a lot of work on this, as we're all well aware, the literature remains a mosaic of different opinions, ideas, and thoughts, and I'm going to try to share with you some of the things that we've been thinking about this for a long time, and I really owe Gus a lot of credit for this. When he was a fellow more than 20 years ago, and we were doing—we were done like equivalent and using strands of PDS and everything else, and he was like, that's not going to work. I'm like, you're the fellow. Just settle down. It'll work. And, of course, the patient came back at six weeks doing well, and three months it failed. He goes, we have to do a better job. Let's figure out the anatomy, and let's get this—we can get this right. We can do an anatomic reconstruction. And we've spent the last 20 years working in a variety of different ways with a lot of really great people, as you saw from Guillermo, from around the world, and try to come up with the best answer. And so the team gets larger and larger. Matt's on here, myself, and others. But, you know, over the last, you know, almost 20 years, 32 peer-reviewed papers, 25 book chapters, lots and lots of thoughts, and lots of controversy. What I'm going to share with you, a lot of people won't agree with, and we'll try to talk about the corners of that, of where that actually goes. And we've already heard about the anatomy and the physical exam and imaging, but just to talk about the things that will direct what I do, just a couple of real quick points. As Mary pointed out, the conoid is a posterior structure, very posterior, very broad, strong structure. The trapezoid is more of an anterior structure. But the clavicle really, in these cases, the problem is the scapula wants to move forward, so the clavicle goes back. So we have to pull the clavicle forward. And to do that, what we've learned is if you try to fix it right where the trapezoid is, you have a tendency to not let that come into the right position. So we typically, if we're going to fix it, try to put it more towards the posterior aspect of the clavicle, to bring the clavicle forward over the scapula. And that may have helped us out a little bit. But this is a big reconstruction, the same issue you have with PCL reconstruction. It's a very, very big insertion point. What part do you fix to make this all work? And we've talked, as Mary talked about, the CC ligaments are critical, but the reality is that there's a growing thought. The first thing we should do for an AC joint dislocation is fix the AC joint. Crazy idea. I mean, why would we do that? But that's, in fact, probably the way the paradigm should shift. Let's get the AC joint in the right spot and solid, and then we can reinforce it with the CC ligaments instead of vice versa. And Mary went over the biomechanics, so I won't go into that. But the thing is, is when you look at the AC joint and you see what's going on, we talk about horizontal and vertical, but there's a tremendous rotational component. So when these fail, typically the way they fail is the scapula rotates forward and over, so this rotates back and it comes apart in this direction. And that's after you've done a reconstruction. It's because we don't have full control of that rotational movement. We reconstruct it in a couple of planes, but three-dimensionally, we generally do not have great fixation, specifically at the AC joint. And that's where we're trying to focus on that, to really understand how to reconstruct that superior ligament and the others to try to make this work as well as possible. And so trying to figure that out, Gus has spent a lot of time, his fellows have looked at this, they've come up with a million different ways to reconstruct it. You saw Guillermo talk about putting little drill holes, sutures, anchors, others. The reality is, is that if you don't wrap the entire ligament and essentially create a capsule, so like the glenohumeral joint, this is a capsule that has thickenings that we call ligaments. It's not a straight band, like from one point to the next point. It's really hard biomechanically to solve this rotational component and to cause a constraint. You get a little bit of fixation at first, but as soon as you cycle it, it starts to loosen up. And so that remains a challenge for us, and we'll talk about what that means surgically. So it turns out that the trapezius may play a really critical role. We all know that, but I've seen over the years cases where patients come in and you can see they did the reconstruction, but you look and there's a fairly significant soft tissue defect. They never really brought the deltoid trapezial fascia up and over the top and really reinforced that. And we've known for years at the least it provides about a 15% of biomechanical strength. But actually the muscle itself may in fact, if we put it in exactly the right spot, help to dynamically control that rotational component. And so to really make sure you get that down in the right spot is critical, we think, to get long-term results for these chronic reconstructions. So horizontal stability, Mary went over this very clearly, especially when it's out up through the deltoid trapezial fascia. And we can see that, and we know that's the CC ligaments. And then we have these patients here. And what we're trying to do is, you heard Guillermo say, they want to fix these within the first 10 days. Well, if most of these people do well without surgery, then if we're operating within the first 10 days, we're going to do a lot of surgery on people that don't need it. So we're looking for clues, who are the people that are not going to get better? Scapular dyskinesia and others. And again, I want to go over this because I want to tell you who I would do these operations even in the chronic case, or try to do this acutely. And I don't do very many acute reconstructions of the AC joint. But here's a guy that can barely move his arm. He has scapular dyskinesia. This is another guy, within a very short period of time, shrugs his shoulders without a problem. He's got the same deformity on radiographs, but he can raise his shoulder all the way up. He's got the same degrees. And he's doing fine. You're not going to get him functionally better by doing a reconstruction. And if you did acute reconstruction, you'd probably get a better cosmetic result. As you heard, about 70% of patients with the scar. So that's probably not a good use of our health care dollars for many of these people. The Rockwood classification is incomplete for determining who should we operate on. I think we're pretty good about the fours and sixes because they can be really difficult on the patient, really bind up the shoulder. But the difference between the three and the five, you've heard the joke, you know, the five is the people that have good insurance is a five, and the people that don't have good insurance is a three. You treat them non-operatively. But that's not the way we're supposed to do things. And so we try to do this with weighted views. That hasn't really helped us out. And Mary gave you the clue. If we can advance. I don't know why it just froze up for a second. Phil. Did it freeze? Did it freeze? So, and I'm just going to show you real quickly, again, the Basmania view. So this is probably the one view, if you don't do this on your AC joint, patients that are injured, even if they're painful, you really should do this. These weighted views don't really give us enough information, but the Basmania view or crossing here, as Dr. Arce said, the ISACOST group agreed internationally. This is probably the best way to know or predict that this patient's not going to do well non-operatively. So when that comes all the way underneath, that's that rotational component I'm talking about. These patients have a really hard time getting their function back to the level that you would like, and may be a good way to actually consider who you should do this. So we've talked about the Rockwood classification, but let's go over some of the research that helps guide us in the three questions, then I'll finish with the surgical management. So non-operative versus non-operative. Mary talked about that in detail and how you decide. For me, acute AC joint reconstruction is a rare procedure. Matt and I were just talking. If it's a hockey player, they're not even going to show up at your office. They're going to keep playing. They're not going to get that fixed. If it's a skier and they're worried about the deformity, or if it's someone who has to do a lot of power, pressing activities, then acute AC joint reconstruction, especially for a type 5, may be helpful, as opposed to waiting and trying to do it chronically, where it takes a little bit more effort to get a good result. But the literature suggests that we're all over the place, and many of these people do just fine with non-operative management. And that's what the Isacost people came up with, is that basically this is the one where you can kind of bank on it. So if you have a Rockwood 3, or you're not sure if it's a 3 or 5, they have no persistent pain. You just go on and treat them non-surgical, and that's after one to two weeks. They're getting better. They're feeling good. They can raise up their arm. But if they have persistent pain with scapula dyskinesis, or that's cross-body view, those are the patients that are not going to do well. And early intervention may be quite valuable for them, although the literature would suggest you only get a slight bump in your overall results. So but there's something to think about in terms of that. So the evidence is there, but like, so how do you decide what surgical procedure? I mean, reduction of conoid and trapezoid, there's 13 different anatomic types of ways of doing it, non-anatomic 53, fixation using various forms of stiff hardware. It's all over the place in terms of variation. These numbers keep growing every year as people try to say, well, I tried that, it didn't work, so I'm going to do something different next time. And so there's really no way to compare all these studies. So we try to go back to the anatomy itself. And what we're trying to do now is think more about that posterior rotation, and how to capture the AC joint, and then also address the CC ligament. So when we're in the operating room, we're really looking for the amount of rotation around the end of the clavicle that we can try to resolve with a surgical stabilization procedure. And so again, the cutting studies have shown us in terms of these ligaments and their strength, and this is a lot of the work that Gus has done in his lab with his fellows, that it's the strength of this overall is that you really have to have the whole joint intact, but the posterior and superior part of it, of course, is the most important. And if you can get fixation of your CC ligaments, even if you have a fairly good reduction, here's a guy who has a, when he leans his arm forward and he rotates, he's still rotating around his AC joint. It's not that he has arthritis of his AC joint. Most people want to say, well, that's because you didn't take the clavicle out. It's generally not the problem. The problem is they have instability and rotation at their AC joint, and that's the biggest issue. And so we've tried to think about this more, about what we can do dynamically. And so I think that spending a little more time on the deltoid trapezial fascia is important. So what we do is we make incision, and then we just don't, you always hear people say, then just go straight down to bone. We don't do that. We make incision, and then we clean it off, and we elevate the subdermal layer, and then we go down to the fascia layer. And then we specifically cut through the fascia with the intent that we're going to close that when we're done. So we really try to preserve as much of the AC joint ligaments. Even if they're injured, even if the clavicles come through that area, we want to peel that off so that we have a very strong and robust native tissue to use. And we will reinforce that often with our graft from our CC ligament, and we'll show you that. So we like to see if we can get these people back. We look to try to return people back from an acute injury within about six weeks. If they're improving steadily and doing well, of course, it could take longer. We're not big on using cortisone, but in certain situations where someone has to perform at a certain level in a short period of time, it may be valuable. Some people are using PRP to do that instead. But in general, by six weeks, you should have an idea, but now you're in the chronic phase. There's no longer just an acute reconstruction, and a synthetic device is going to work. And so we've spent a lot of time trying to figure that out, and Guillermo sort of talked about that a little bit in terms of where to put these grafts. A lot of times we were putting the graft and we thought it would be better if we crisscrossed them. That actually turns out to not really do the best job. It's just a loop seems to work better than anything. So we tried a loop around the coracoid and a loop around the clavicle, but it doesn't really bring the clavicle up as far as we would like it to into its normal anatomy. And so that makes it harder to control that rotational deformity. Ben Kibler, this is just a schematic about some of the things that he was doing. So once he does his CC ligament reconstruction and brings it through, then he fixes it over the top of the acromion. And this is actually what we do most at this time. We try to repair the AC joint capsules best we can. We may even use some of these soft anchors or small anchors to fix the capsule down nice and secure. But usually we're still adding a graft around the coracoid and I'll show you through the clavicle, which is a point of controversy we'll talk about. And then once that's well fixed, we'll fix it over to the acromion. Posterior superior corner to try to help support, get this to heal and minimize the rotational deformity that we have. And these are some videos from, Gus made a nice video for this. And again, this is just the idea of raising good skin flaps so you can see. So this is big open surgery. A lot of people would like to do a lot of the passing of the ligament. And if you use Dr. Guillermo's technique with the dog bone, you can do the passing of the ligament, the coracoid surgery, all of that can be done arthroscopically. And then you can bring it up through a small incision and use a smaller incision. Or you can do the whole thing open through a larger incision and your access to the coracoid is once you peel off the deltoid correctly and bring it all the way off the clavicle, you're straight down on top of the coracoid. You just have to have a couple of tools to safely pass that around the coracoid. And you can do it arthroscopically assisted, even though it's open, you can, if you've scoped it in the initial part, you can put the scope in and look and see it so you can see below the coracoid to help you out with that. But the key here is, again, we wanna really try to reconstruct and not just blow through the AC joint tissues as if they don't count at all, because we think they do and they help us with our deltoid trapezial repair. So we really try to peel this off very carefully. We think this is an important part to control the rotational stability when we're doing these reconstructions. Now, what about where to put the holes and things like that? Controversial, people have talked about it, you put holes in the clavicle fracture, and we know that that's true, but the reality is is that we've done a lot of cases and fractures of the clavicle are extremely rare. So we think we have some ideas on how that can be minimized. Now, what about distal clavicle? We hear all the time people say, well, once I take the distal clavicle out, how do I, and I say, stop right there. Why'd you take the distal clavicle out? Well, because it's arthritic. And if it's not arthritic now, it's gonna get arthritic. And we've done about 100 cases, and I think we've gone back once or twice to take out the distal clavicle. As you all know from many, many x-rays, there's a lot of people get arthritis of their AC joint, they don't have any pain. And the distal clavicle orientation and relationship to the acromion is a very powerful stabilizer of that joint, particularly in rotation. So we do not take out the distal clavicle. People say, well, sometimes I can't reduce it. You can't reduce it because it's a soft tissue problem. It can be reduced, you just have to do a little bit more release to get it over there. But we do not take out the distal clavicle. We've shown with as little as five millimeters of resection, it really changes the biomechanics substantially. And so we think this is important. And you know how easy it would be if, let's say they did get arthritis three or four years from now, it's an outpatient procedure, less than an hour, arthroscopic distal clavicle resection. So, and I can tell you that if you're trying to make a business off that, you'll go out of business because they don't come back with AC joint arthritis pain. And even just a small amount will change that dramatically. It really, really is very important in terms of the posterior and rotational stability to maintain that distal clavicle. So we think that's important to get these to work well. And again, once we dissect around the coracoid, you can use a variety of different tools to wrap around that area. We'll talk about, so that's just one of the tools that wraps around there. And then here's the thing, again, that's more controversial. It's like, what about the holes in the clavicle? J.T. Tokish and others have talked about how if you put this a little too far medial, they fracture more. But basically what we do is we want to have two centimeters between the center of those two pins. And we want to make sure we're far enough away from the lateral clavicle. So we measure about two centimeters from the lateral clavicle in our male patients, or about that, maybe slightly more. And then go two centimeters from there. So it turns out to be about 2.5 centimeters and 4.5 centimeters where we put our grafts. And what we try to do is put them more posterior. This one here, we're putting even more posterior. So the trapezoid ligament, we're going at the center of the clavicle, but we've learned that that doesn't get the clavicle up as far as we'd like it to. And we've started to move that back. The five millimeter holes makes people very nervous. You can do this with a smaller graft. We use a Semi-T, the five millimeter holes. You can use a gracilis, or in Europe, they even use the ipsilateral palmaris, just like we do for UCLs. And you can make a smaller hole, like a 3.0 hole, if you're nervous about that, or in some of your patients, smaller bone patients, that you have to deal with with that. And again, those are just the principles. Just don't make the latter one too lateral. And as you can see from here, in terms of the bone density and strength of the clavicle, you don't want to get too far out there. So we try to stay at least two centimeters or more from that edge, as you can see from the bone density studies. And it turns out to be about right here is the sweet spot to get it in the anatomic position. And again, we're trying to keep this a little bit more posterior than we have in the past, which helps bring the clavicle forward or keep the scapula back, however you want to look at that. Remember, the scapula is a bone that has 17 muscles that either originate it or attach to it, and its only connection to the axial skeletal is through the AC joint. And so it's really a very mobile structure, and you want to get that clavicle so it's sitting right over the top of it, and you want to make sure you prevent that posterior rotational component. And then we tap these, we use peak screws, they're very strong, and then we take radiographs to make sure that things are reduced properly or even slightly over-reduced. And the graft we've been using is primarily the SEMIT. Gracilis will also work. And we pass that through pretty steadily, and you can imagine how that goes. We try not to put a hole through the coracoid with this graft, and we'll talk about in just a minute about putting a hole with the dog bone procedure. What's a modification of this that many people do is that they'll pass their graft around the coracoid, around the clavicle, but then they'll use the synthetic device to fix the CC ligaments and use this as their secondary device. And that does work for horizontal stability a little bit. It works very well for vertical, so it keeps us together. But it has a very high rate of separation, 30 to 50% from where you put it. And so you should over-reduce them, and hopefully they'll settle into the right spot. But it doesn't have as a consistent anatomic reconstruction as when we do these ligaments. Can this work in high-level collision athletes? Yes, we've done it in those. We've been warned that if they're gonna fracture, it's gonna be a problem. But I have a few patients that have been through the NFL. I have some that have gone through baseball and had this reconstruction and have done okay. And it's done, again, for chronic reasons, the reason why we've done that. And usually for revision. So a lot of times, they'll be sent, and they've already had a reconstruction. And it's failed. And now they're still not doing well. So what are you gonna do on the second time around? And we do this. And so then we'll tighten that cerclage first. We'd like to use some synthetic to really reduce that internally. And then we fix our graft. And then we're gonna repair that over the top and bring that into our final repair. And fix over to the posterior superior aspect of the AC joint and into the acromion. And then we'll repair our delta trapezial fascia, as you see here, with good, strong flaps. Very secure repair right over the top. And add that to our reconstruction. And pulling that all together to really make that a very, very solid repair in this situation. Post-operatively, we do immobilize for about six weeks. We like to have them in a brace that really supports their arm. And patients usually feel pretty comfortable within a couple of weeks. So it's important to tell them ahead of time that this is an important part of the reconstruction. Gravity is not your friend. And let's get to six weeks and get this done and over with. And you won't have to worry about this anymore. After about 12 weeks, we'll be more aggressive in strengthening. I'll start some rotator cuff below shoulder level strengthening as early as six weeks, if they're doing well. And then we go more aggressive after about three months. And then we try to get them back at six months. Our highest level competitors, just like almost anything else we do, it's nine to 12 months before they feel like they're back to the performance level that they used to experience. This is Gus's series. So 99 cases up to February of 21. And you can see that the results are pretty remarkable. Those that required revision, 4%. One did fracture and went on to a non-union needed treatment. The others have done very, very well. And we just haven't seen the concerns that a lot of other people have been worried about. And so when should we do this? Well, that still becomes a bit of a challenge because when we look at the failed non-op versus successful non-op, it's about the same. So for us, why not treat them non-operatively and see how they do? And then if they fail, you can get them back to the level they would have been, not necessarily all the way back 100%, but at least back to the level if they had been successful with non-operative treatment. And so we think that this is a really good way of doing things, but there's a couple of controversies. Matt's gonna talk about the complications. We do recognize the bone tunnels get slightly wider, but if you go back in on this, the bone tunnels don't look wider. They sort of get an osteopenia to it. They don't actually widen out that much. And so we think this is just a reaction from the bone. And Matt's gonna talk about complications, and certainly there's a few things there. And really, if we put the grafts in the right spot and we've stabilized the AC joint, we've been very happy avoiding the complications. Couple of things. One, this is just a unique thing we wrote up because some people go on and fracture the coracoid. You can actually go down again through an open approach, lift up the supraspinatus, make sure you know where the suprascapular nerve is, and drill from back to front with a protected front area. You put a retractor there. And instead of going around the coracoid, you go through the scapula, through the base of the coracoid. So this is a good salvage procedure if the coracoid does happen to fracture. It fractures when the hole or fixation is put too far out onto the neck of the coracoid. We've done a lot of work to try to figure out how to prevent this problem. We think the AC joint capsule is really important. We think you want to keep that lateral tunnel at least two centimeters from the lateral cortex. We reamed five millimeters, but people are going down to three or 3.5 millimeters, and that may help reduce that risk too. We brace them and try to do this anatomically. We tap the bone. We increase the stability because of what we're doing with regards to the AC joint and the trapezius and deltoid. And if we have a bailout, if there's something wrong with the coracoid. So a couple of just finer points on this, and that is that if you are taking care of a professional athlete in the NFL or Major League Baseball or the NBA, and you say that you're going to put a hole in the coracoid, you'll probably lose that patient. Because the word out on the street is that even a small hole to put a dog bone in will cause a fracture of the coracoid. And so having lost a few of those patients, what's been remarkable is the high rate of failure radiographically when you wrap around the coracoid and don't get the same fixation. So the patients, however, still get back to playing their sport. And so even though radiographically they're not so good. But I think that if you have the right patient, a CC ligament reconstruction with a dog bone and a graft is a good way to do it, but you're going to have a higher failure rate than doing this larger operation, which I know a lot of you would feel probably a little angst over doing it. But our results over many years has suggested this is a great way to go. So maybe you'll consider it for your revision cases when the first one didn't go so well for you. Thank you.

chronic AC joint injuries

surgical management

anatomic reconstruction

rotational instability

distal clavicle preservation

grafts and holes controversy