failure and fixation issues with AC joint. So these are operative therapy treatment recommendations, acute AC joints, type five or near type two. So the operative goals, as you know, for AC joints are restore the anatomy, reduce the superiorly displaced clavicle, and provide secure fixation, allowing the AC and the CC ligaments to heal. Rich Hawkins, however, probably said it best when he said the operation waiting to fail for any kind of AC joint fixation. Numerous techniques have been described. Back in 72, as the Weaver done, rigid AC, rigid CC fixation with a screw, such as a Bosworth screw, suture, cerclage of all different kinds, and then eventually CC ligament reconstruction to more anatomically address the conoid and trapezoid ligaments through either tunnels or cerclage around. This was the Weaver done. It was basically an open Mumford release of the CA ligament from the acromion and transferring it into the distal end of the clavicle after the Mumford, and then it was augmented with a suture tape or fixation device. This had high failure rates and is pretty much abandoned as a technique. Arthroscopically, over the past decade, there have been options and different techniques published. One was a graft passed through a single large collicular tunnel down to the coracoid, which was then through which a graft, either autograft or allograft, was passed. This was secured with interference screw. However, we reported with J.T. Tokish and myself at Tripler with a 80% failure rate at average seven weeks, so this was not exactly a successful procedure. In addition, besides the loss of reduction, there was significant osteolysis of the clavicle, so this was all but abandoned. And the late effects of a large clavicular hole can result in tunnel widening, clavicle fracture, and subsequently nonunion, coracoid fracture, or early loss of fixation. So again, this was not a technique that should be in your armamentarium. Percutaneous screw fixation, such as the Bosworth screw, has been utilized successfully and still is an option. It's fluoroscopically guided. Percutaneous metal screw and washer is then passed through the clavicle down into the base of the coracoid and either a type two, near type two, or a type five AC separation can be secured, as shown here, with the steps fluoroscopically. The hole is drilled and then the coracoid is secured with this screw. This definitely can have problems. Rigid fixation can be good, but it's also bad. It probably requires hardware removal and there's a loss of coracoid fixation, or loss of fixation if you have a coracoid fracture if it's not centered on the base of the coracoid. So this still is an option, but not always a real good one. So our illustrious leader here, Gus Misaka, was one who was a big proponent of anatomical CC ligament reconstruction. It better recreates the ligament anatomy. You can use either an autoanalograft, either pass the graft around, surcloging the clavicle or through it, and then you can augment it with a suture tape fixation device above and below the coracoid and clavicle. So here's a trans-clavicular CC tunnel, which is a technique that I utilize. Two tunnels on each side of the coracoid. The graft is passed through the clavicle, underneath the coracoid, and then secured with a interference screw. There are, however, complications with this as well. You can lose fixation, like all techniques. You can get a clavicle fracture and you can get a coracoid fracture, all of which are challenges you have to be ready, prepared to face and treat intraoperatively. So one of the things that you need to have available is a hook plate. This is for a case that I had where it had an intra-clavicle fracture, and then the plate allows you to get fixation proximally and distally, and then hook this plate underneath the acromion. It does typically have to come out, so it's a second procedure required. So it's not a great technique for a single procedure. So in summary, there are multiple ways to treat AC joint injuries. There are innumerable ways to fail. You need strong but flexible fixation and have backup plans ready. Thank you.

operative therapy

AC joint injuries

ligaments healing

Percutaneous screw fixation

Anatomical CC ligament reconstruction