Hi, I'm Dr. Courtney Holland. I appreciate the invite to speak with you today. We will go over scope or open AC and CC reconstruction. I have no relevant disclosures. AC joints comprise the three ligaments, namely the coracoclavicular ligaments, which help to restore or maintain posterior and superior movement of the clavicle, as well as the AC ligaments, which primarily responds is responsible for our horizontal stability. And then lastly, the joint capsule mechanism of injury for the AC joint is typically with direct trauma. And this can be due to a fall or blow onto the lateral chromium with the arm abducted or a neutral position, or indirectly due to a fall on an outstretched hand. In a sequential manner, the force onto the causes disruptions of the AC ligaments, the joint capsule, the CC ligaments, and lastly, the delto trapezial fascia. Classification typically used for AC injuries was classically described by Rockwood. And that is types one through seven. As you guys are well aware, type one and type two injuries have historically been treated with conservative management to include sling demobilization and PT focusing on scapular control and shoulder girdle strengthening. Type three injuries historically have been controversial. However, initial treatment is mainstay remains non-op management, and surgeries later done based on continued dysfunction to include shoulder fatigue from your patients, weight bearing and loading complaints, cosmesis and a certain subset of patients or pain. There's been no conclusive data that early surgery is better for functional outcomes. And those type four through six injuries, surgical intervention is largely favored over delayed. And that surgical intervention has been honed into AC joint reconstruction with or without repair or reconstruction of the CC ligaments. Historically, there have been over 100 described techniques, none necessarily superior to the other in terms of complication rate, loss reduction or rate of revision. And those methods have included in the past internal fixation with a hook plate or Bosworth screw, more recent open and arthroscopic approaches, the non-anatomic approaches initially described by Drs. Weaver and Dunn, and, and more recently, the more anatomic techniques championed by Dr. Romeo. So surgical goals remain the same to provide a durable construction, restore and maintain normal anatomy, maximize functional return and minimize iatrogenic complications. The open surgical history, as aforementioned, initially evolved with the non-anatomic procedures to include the CA ligament transfer champion by Weaver and Dunn. This was first published in JBGS in 1972. This was later modified with augments using either suture, wire or tendon graft to help strengthen the repair. As aforementioned, other methods to include use of formal hardware to include Bosworth clavicle screw, absorbable suture, aids in recreating some of the stability provided by the CA ligaments. And these are these were largely successful in the past in restoring the anatomy of the AC joint. However, as further research discovered, the functional anatomy of the shoulder had not been as well reconstructed as anticipated. And so there were other concerns biomechanically that utilizing the CA ligament was not durable and strong enough to recreate the same mechanical strength afforded by the CC ligaments. We also know that the free grafts were stronger than suture or the CA ligament alone. With the load to favor of those free grafts similar to the native CC ligaments, which was tested about 650 newtons, and also less clavicle translation that travel clavicle translation is what typically patients will continue to complain about when they return to more vigorous overhead or physical activities. So have been numerous anatomic techniques described. However, the positioning is basically largely been the same. And this is accomplished using a beach chair position with a commercially available arm holder. The non-surgical extremity is placed on a padded armboard, a large C-arm is used intra-op to confirm an anatomic reduction, and also placement of your hardware. A curvilinear 3.5 centimeter incision was made over the anterior shoulder for extending from the clavicle to the coracoid, full thickness skin flaps are obtained, deltoid trapezial fascia, periosteum, which allow you to expose the AC joint down to the coracoid. That deltoid trapezial fascia is split in line along the long axis of the clavicle, and then also skeletonized for later exposure. At this point, it is typically recommended to perform a trial reduction, just to assess if there's any interposed tissues to include the AC disc homolog that may have become fibrotic and scarred, depending on the time from the initial trauma. Next, bone tunnels are created, a guide pin is typically placed to 45 millimeters medial and posterior to the end of the distal clavicoid. This is what we do to reestablish the conoid tunnel. It is important to avoid posterior blowout of the clavicle, which can further complicate your surgery and cause us to have to bail to other procedures. In efforts to remedy this, it's also been described in the literature to paint the end of the empty reamer with blue surgical ink, and sort of pass that over your guide wire and you can kind of see where your circumference of the reaming will be. If there's any concern that you will violate that posterior cortex, this point, you can certainly kind of slightly enterize your guide pin few millimeters to avoid further complication. You also want to avoid excessive medial placement as we know that that puts undue strain on the graft, which can lead to early failure. That second pin to create the trapezoid tunnel was placed 15 millimeters lateral and anterior. Both of these tunnels are reamed forward under power, however, removed by hand to avoid creation of an oval or oblong tunnel. Typically would use nothing more than a five millimeter reamer and a 5.5 millimeter interference screw. The graft is prepped in a standard fashion, semi T allo or autograft or tip anterior. Allograft can be prepared in a standard fashion. You want this graft to pass easily through a 4.5 millimeter tunnel or snug five millimeter tunnel. Again, just realize this area of bone on the clavicle is quite dense and hard. And so this is not one that we can stuff a lot of tissue in there and with the hopes that the screw will kind of compensate that screw can either lacerate the graft or shed as we mentioned, blow out that tunnel posteriorly and again lead to unnecessary complications and certainly unwanted complications. With our corcord exposed, the graft is passed into the corcoid. This can be done using commercially available clamps to include like the Stensky aortic clamp or past tissue device, again, which can be easily available in the OR. The sutures are shuttled using a hugin and a number one vicryl. The soft tissue grafts are passed over the corcoid. The lateral limb is passed through the posterior medial tunnel. The medial limb is passed through the anterior lateral tunnel. At this time, you can also use a cerclage suture or tape, which also helps to reinforce the repair and help to limit the amount of creep that inevitably occurs after using soft tissue grafts. The joint is over reduced under floral. This is key. Again, this is to accommodate with that graft creep that inevitably occurs when using tissue grafts for reconstructive procedures such as this. So this is the time to kind of really confirm that to make sure before you start securing your graft. So the graft is cycled and secured initially with the screw. We established the cornoid tunnel and stabilize that first. You need that graft about two centimeter proud. This also allows us to use that excess graft to reinforce our repair along the superior aspect of the clavicle. And second, the trapezoid stabilize as well. Also leaving that long limb of graft which can be used to augment the AC joint. This can also again, confer additional stability to our construct. There are various techniques of doing this either through a bone tunnel or wrapping the graft around the lateral promium. After our graft is secured, a meticulous layer closure is performed. Again, bringing those periosteal tissues and the deltoid trapezoid fascia back over our graft and clavicle construct using non-absorbable suture. Again, these are all methods and small things to do to help minimize creep and to maintain our reduction long term. So some of the open some of the pearls for performing the open anatomic procedure include making sure that you take time to clear all the tissue from the distal clavicle and the immediate chromium. This will help to make sure that you're able to reduce and overreduce the AC joint. You want to avoid a distal clavicle resection if necessary. Keep that way for less than five millimeters. Make sure that you have graft length at minimum of 280 millimeters. This also allows for sufficient tissue to include our graft in our AC reconstruction and make sure you ream the smallest tunnel possible, keeping that to about five millimeters. You want to avoid medial placement of our cornoid to reduce the risk of early surgical failure. You want to also avoid excessive lateral tunnel placement where that bone is the weakest into the clavicle. Also, be sure to obtain full thickness flaps to restore those dynamic stabilizers of the AC joint at the time of closure. The patient is placed into a brace full time for six weeks to prevent gravity from placing undue stress across your reconstruction as it is incorporating. So arthroscopically assisted reconstruction is minimally invasive allows you to avoid disruption of the deltoid soft tissues. It provides enhanced visualization because obviously you can see inside the joint extra articular about the coracoid and undersurface of the clavicle. It gives you the ability to treat concomitant glenohumeral pathologies, which can be seen in higher grade AC injuries. It allows multiple fixation options to include the knotless low profile suture button implants that are readily available. It allows you to combine soft tissue grafts for more anatomic reconstruction of those ligaments. Please be mindful with anything arthroscopic in this. There is a steep learning curve and can be technically challenging as one step kind of sets you up for the next. So in some of the recent literature has shown that there is limited utility in the chronic setting. So acute, certainly something that can be worthwhile with those first three to four weeks. However, when dealing with more of a chronic injury, I would stay stick to open to allow you to further appreciate the anatomy to address any scar tissue that inevitably occurs. So there's numerous variations described. However, again, the setup is quite similar to a beach chair with a routine commercial arm holder. A large C-arm is used intra-op to confirm our anatomic reduction. I also encourage you guys to have the C-arm in place prior to sterile draping to make sure that there's not getting in the way of your position, your instruments, the anesthesia provider also that you're able to obtain adequate films. Some beach chair holders may have other types of metal protrusions that may not be easy to see through if it's not a carbon fiber, some of the newer ones. So and at this time, if you cannot reduce it, now's the time that you know that you have to convert to a mini open so that you can have that those instruments available in the OR just to expedite your case. So we began with a diagnostic arthroscopy, including a standard posterior portal. This is done by a 30 degree scope, be sure to have a 70 degree available and then routine anterior portals are established in an outside in fashion. Those include the anterior inferior and anterolateral portal. Be sure to place your anterior lateral portal, touch more inferior lateral than the core core than what you're typically used to performing. This will allow more exposure to the medial and inferior aspects of the core cord with use of your blader and arthroscopic shaver when needing to read that space for a visualization. The 30 degree scope is placed in your standard portal. The shaver and RF wand are used to open the RF interval at this time, you can change to a 70 degree scope, place your camera through your anterior lateral portal and allows you to use your instruments to your anterior inferior portal. This allows you to expose the clavicle, release your pec. And lastly, an incision is made over the distal clavicle again directly overlying the AC joint quite similar with an open procedure. A commercially available aiming guide may be placed through this anterior inferior portal and our skin incision. Be sure to place your drill sleeves centered on the clavicle and on the center of the coracoid again to avoid blowout. The cannulated drill is placed to the clavicle and the coracoid under visualization. The C-arm can be used to confirm placement of our positioner before you drill. Passing suture is placed through the drill and retrieved in the subcoracoid recess. Your suspensory implant can be secured on the clavicle and the coracoid. A secondary graft can be placed at this time through an open incision to recreate those CA ligaments. This does help to improve primary stability. The CC and AC interval is reduced under fluoro. Our button is deployed and our graft is secured at this time. The shoulder can be taken throughout a range of motion to ensure that there are no impingement, that there's no additional creep in our construct which can be addressed at this time, as opposed to later in the post-op visit when you get an x-ray and realize that there was a little bit more slack or laxity than what you anticipated. So some of the pearls for these is again, arthroscopic AC-CC reconstruction is best done for acute cases. If it is a chronic case, consider using an open technique for that. Proper portal placement is key to aid in visualization and exposure, particularly placing that AI portal more inferior and lateral to the coracoid. Make sure a 70-degree scope is available, which can also give you a little bit more of a panoramic view. Have your CR in place prior to initiation of the case. Again, make sure that the clavicle can be easily reduced and that this is not something that you're trying to readjust in the midst of having your scope equipment in place while the shoulder is draped sterile. And lastly, any procedures such as this can be technically demanding. So plan ahead, take your time, and when in doubt, no harm in bailing to an open procedure. So surgical complications for AC-CC ligament reconstructions range anywhere between 9% to 80% in the literature. Those do include clavicle fractures, implant graft and suture irritation due to soft tissue coverage, loss of reduction, more commonly seen with non-anatomic reconstruction techniques, single tunnel reconstruction, medial placement of our coronary tunnel, use of a hook plate. And then lastly, residual shoulder pain that can be developed with AC joint arthrosis that can be easily addressed with distal clavicle wafer excision later if need be. So in summary, there are numerous surgical techniques described but non-clinically superior. But the trend has been towards anatomic techniques when a reconstruction is indicated. Despite complication concerns, surgical treatment of high-grade AC injuries yields good to excellent functional outcomes, but decrease overall clinical failure rates and a high return to sports. Thank you very much for your time.

AC joint reconstruction

coracoclavicular ligaments

Rockwood classification system

surgical techniques

complications