Welcome to the American Journal of Sports Medicine's webinar in conjunction with the American Orthopaedic Society for Sports Medicine. Thank you for joining us. I'm Christine Watt, Senior Editorial Administrator for AOSSM Publishing, and I will be the operator for the webinar today. Before we get started, I would like to take a moment to acquaint you with a few features. There are options for how you can listen to this webinar. If you have any technical difficulties hearing the audio properly, please try clicking the phone call option and calling in for the audio or switching the speakers that are being utilized. At any time, you may adjust your audio using your computer volume settings. To send a question, click in the text box and type your question. When finished, click the Send button. Questions you submit are seen by today's presenters and will be addressed at the end of the presentation. So please feel free to send those questions as you watch or at the end of the presentation. There is CME available for this online activity. Here are the learning objectives and disclosures. At the conclusion of today's program, we ask that you complete a brief evaluation by going to education.sportsmed.org and logging in. Please take a moment to complete this if you wish to collect CME for this activity. At this time, I would like to introduce our moderator, Dr. Knut Beitzel. Dr. Beitzel is a specialist in shoulder surgery who is head of shoulder surgery and orthopedic sports medicine at ATOS OrthoPark Clinic, Cologne, Germany, and a professor at the Technical University of Munich. He is a member of the AJSM Electronic Media Editorial Board and will be moderating our webinar. And with that, I'll turn the microphone over to Dr. Beitzel. Thank you very much and welcome from my side. Good evening from Europe, from Germany. I'm very happy to introduce you, our esteemed faculty. But first of all, I want to thank the American Journal of Sports Medicine to give us this podium to discuss these very relevant questions on the treatment of AC joint instabilities. And I'm happy to have this great international faculty with us tonight. We have from the University of Ghent, Alexander Fontongle. He is professor there and he has done great work, especially on scapular thoracic motion of the AC joint. We have Berthe Boe from Scandinavia. She has also done tremendous jobs and publications on this topic. I think most of us of you and us also know Pete Millett from Colorado. And we have the French option tonight with Johannes Barth. And we have Gus Mazzocca from Boston with us, who has also done a lot of publications. And we have another European view, the mixed view from Germany and Switzerland with Marcus Scheibel from Switzerland to have a great faculty and to have a nice overview. So we have a dense agenda for tonight. We'll warm up with some fireside questions for everybody. And then we try to make this webinar really case based. We kind of thought it would be better not to have presentations, but really adhere to cases. Each member of the faculty has brought some cases and we'll discuss them. And in the end, we'll have some tips and perks for you. And we'll also answer the questions which come in through the chat function. So please use this and we'll try to get the best answers. So now let's get into things and start with our first short fireside question round. So regarding the diagnostic workup, what is the best way for you to define your treatment options? So Alexander, perhaps let's start with you. First of all, thank you for the invitation. When I see patients with a C dislocation, I think it's important to differentiate between patients you see in the emergency department or patients that you see after a few days in your clinic. I think it's always a little bit of risk to immediately decide in the emergency department what to do. I think you always need to see the patients a little bit a few days after that, because then they're already a little bit more settled. For me, I think the clinical examination is very important. But I start, of course, with the anamnesis. What is the patient that I have in front of me? Is this a heavy labor worker doing a lot of activities above head? Or is this somebody who's doing a desk job that is not very active that will make an influence in my decision? Then what is his medical history, of course? These are the things that I will take into account from the anamnesis point of view. Then how is the pain right now and how I always ask if he wants to have surgery in the beginning already or if he wants to, what the patient wants on himself. And then I start with the clinical examination. For me, the most important maneuver during the clinical examination is the pro and retraction maneuver. We know that the clavicle is really working as a strut between the sternum and the scapula. If this strut function is lost, it means that the scapula will go down underneath the clavicle, because the scapula has a normal tendency to go into protraction. But this is prohibited because of the clavicle. If the strut function is lost, you can clearly see during protraction that the clavicle is pointing out upwards and that scapula is going downwards. In this case, when I see there is no strut function anymore, I think they will have some problems with overhead activities. And then for me, this is already more a type 3 or 4 that probably will have some subjective problems in the future. And when they have this type 4, I would propose surgery in the urgent situation. When there is no clear inferior translation of the scapula underneath the clavicle, I will propose, first of all, a conservative treatment. Of course, I need to see the x-ray to make sure that there are no other lesions, certainly not at the medial clavicle or any coracoid fractures. But this would be a little bit my setup if I see a patient in the clinic. I don't know, have you any comments on that or any different steps? We are just going the fireside round, so next one would be Johannes. What's your idea to find your treatment? You don't, we don't hear you. Excuse me. Thank you for the invitation. So, it's quite straightforward because I'm very prone for non-operative treatment in acute AC joint dislocation. So, for me, I just ask for standard X-rays and also to just to eliminate fractures, you know. And then I go straight forward for the clinical exam and I just want to make sure I can reduce the dislocation with an impression under the elbow, super impression under the elbow. And if I can see that I can reduce easily the dislocation, I will probably not touch the patient. Whatever the displacement is, whatever the, you know, the pain is, because I really believe those patient could do well in most of the cases. What I look for, actually, is the entrapped lateral clavicle inside the deltoid trapezius fascia or strap. In this case, the patient are not doing well. And only in this case, I will consider a surgery. This is the type four of PAT described by the classification of PAT. And this is what I look for in routine clinical exam for AC joint dislocation. And I don't rely in the Rockroot classification. It was shown by a show in the GSES, in 2014, even with CT or even with X-ray, there is a very low reliability inter-observer and intra-observer. So I don't rely in this classification. So for me, it's very difficult to use the routine Rockroot classification. So, Gav, you would be the next one. Yeah, I think I probably agree with Yohannes a little bit that I default to the non-operative to begin with. So in the history that I would take, I would really talk to them about kind of what the time course that I would expect. If it was a young athlete, I would say that we would start them on a range of motion activity immediately. And the minute they had what we call protective pain control, then they could go back to playing. So I would say to the athlete, you can go back whenever you have what we call protective pain control, and you can return much faster without an operation than with an operation. Then I would then see them sequentially. And if they were plateauing or doing worse, then we would start thinking about surgery. So that would be kind of the first spiel just to add to what Alexander and Yohannes said. The physical exam that I do is really what we call a shrug test that Dr. Bach taught me in my fellowship where you have the patient shrug their shoulder. And if they reduce their AC joint by shrugging their shoulders, then that's a grade three. And if it doesn't reduce when they shrug their shoulders, then there's disruption of that deltoid trapezial fascia, and that's a grade five. So that's kind of how we sort that out. I agree with Yohannes that that doesn't mean if they have a grade five that we're going in an operation anyway. And then as far as x-rays, I do a bilateral Zanka view so I can look at the CC distance at the same time between the injured and the non-injured. I get an axillary view to make sure, and I can see the coracoid process. And then if I'm worried about anything else with the physical exam, in other words, they feel subluxated, they have pain with posterior jerk or some type of labral problem, then I'll get an MRI. So that's kind of how I handle the imaging. If they don't, then I really don't go looking for that right away. So Bertha, you would be the next one. Yes, thank you so much for this invitation, Knut. Those patients usually comes to the emergency department in our hospital, and then we have the ordinary x-ray AP and Sagittal view. And sometimes they ask us because these doctors are not very experienced. And then I do a little, just a little examination to rule out other injuries. But if I think this is an AC injury, I just give them information about our policy with non-operative treatment. And then we take them back for a second follow-up between seven and 10 days. And this is because it's very difficult to do the examination when they come in because they have so much pain. But I try to get an impression if the lateral clavicle is trapped in the fascia because then I already start to think about an operation. So we take them back in seven to 10 days. And if they still have a lot of pain and I suspect there's a huge dislocation, we do the Sankha view. And then I, again, inform them that I, for most of them, recommend non-operative treatment. And we do the next follow-up in six weeks to rule out those who still have a lot of pain. So Peter, how is your approach? I don't really have anything different than what's been said for the acute ones. You have to make sure it's reducible. If it's irreducible, then that to me is one that is gonna need surgery early. If there's associated injury to the SC joint, if they're an overhead athlete, you might have a different discussion, although most overhead athletes can do fairly well with the AC dislocation. The chronic ones are the ones where you're starting to talk about surgical options. So in those cases, you wanna get a sense of what their disability is and the fact that they've lost control of the scapula and they haven't been able to compensate for it. So if it's irreducible, then those would be the ones that would require acute surgical treatment in my practice. The ones that are chronically symptomatic are the ones that I would start talking about surgery. Great. And Markus, your approach, perhaps tell us something about the circle methods which you recently have published on in regards to the imaging. Yeah, I would agree with what has been said. Of course, we do AP stress fuse just for also legal reasons to, let's say, even if it's not 100% accurate to get an overview of what the injury pattern might look like. What I will do in patients who have a type five, a true type five on the true AP, I will skip any additional radiographs because we know that these patients have also posterior instability. So you don't need to do any axial fuse or any Alexander fuse, so that's not needed. In the acute and in the chronic setting, what I will also do, what we're doing right now under, let's say, academic purposes, we do an acute MRI to get a better impression on the injury pattern of the ligaments, meaning how are the ligaments torn. Are they torn into substance? Are they ruptured from the coracoid? Are they ruptured from the clavicle? And while treating this patient with an arthroscopic technique, we hope we can find out then retrospectively if a particular injury pattern is a predictive factor for the outcome, but it's more or less under academic conditions, I would say. But one thing I would like to add, what probably has not been mentioned, I will always ask the patient if he comes in in the acute setting or when one week later, two weeks later, can you live cosmetically with the condition? Because this is sometimes patients not really are aware of. If you say, we do this conservative, it will work well. And of course, many of them work well. Sometimes you forget to counsel them that it will, in most of the cases, always look different to the opposite side. And there are definitely some patients who don't want this and those who don't want this, I tend to operate earlier. The circle measurement that we, was an idea of Matthias Zumstein. He published this, yes, as you see here on a sore bone model and the idea was to, let's say, quantify the posterior translation more or less. So if you create two circles right at the edge of anterior edge of the acromion and the lateral aspect of the clavicle and you measure the distance between the two centers of the circle, we found out that in vivo, actually, Matthias did this on sore bones and we just publish it in patients preoperatively in vivo. That this correlates with Rockwood's classification and also with the degree of posterior translation that we recently did on the Alexander view. We have no data yet about the circle measurement postoperatively. And if the circle measurements, the distance basically is larger in patients who still have pain after an operation. So this is something we are looking at at the moment. Great, thank you everybody. So I have one second fireside questions and let's try to get a spontaneous short answer to keep us in time. So Berthe, if you can wish your optimal patient to have the optimal results when you do surgery, how does this patient look like? Well, this might be an athlete, a cyclist or an overhead athlete, or a heavy manual worker. And of course, like Dr. Scheibel said, you have to talk to people about the cosmetic because if you don't operate, they will never look the same if they have a large dislocation in the beginning. So Peter, how does your optimal patient look like? I think for me, the optimal patient is actually an acute injury that requires surgery that's irreducible. I think that they have excellent results and probably have a little bit better healing environment. They're active, they don't smoke and they have an isolated injury, their AC joint. Johannes, is there any patient you are doing surgery on? Yes, those who are not reducible. So this is what I already said, but for the optimal patient, one of the thing I found, and in addition what has been said is actually high BMI is against with the result. This is what we found with the SFA. This is quite funny, but I think it's related to the weight of the arm and probably this is a bad prognostic factor and we have to be aware of that. So for sure, for those patients who are more athletic, it is more, you will have a better outcome. But the optimal patient for me for sure is a non-reducible dislocation. And I think we will see a patient like that in a few moments and it's not related to the importance of the displacement. So Gareth, which would be your optimal patient? Yeah, my optimal patient is probably the opposite of Dr. Millett's, would be somebody that tried to get back to athletics and sports and failed. Their pain was getting worse and they have a lot of problems when they're going across their body. We found that that's really one of the motions that has protraction of the scapula around the clavicle. And if that person's got a lot of pain, then that would be the person that we would operate on, but only after they had failed conservative management, couldn't get back to their activity level or their sport. And I would have to say that to be a little bit of a contrarian here, it doesn't really matter how much displacement there is. I would say in a type four, they have pain that's usually out of proportion than what you would expect. Say what Bert was saying about seeing them at about seven to 10 days, if they still have tremendous pain, like splinting pain, then I'm suspicious of that grade four. So that would be the other kind of caveat, but I treat everybody conservative until they can't get back to what they wanna do and then operate. Gus, wouldn't you think, I agree with what you said about that being a great patient for surgery, but don't you think those are more difficult when they become chronic because of the fact that the healing environment's not the same? Oh, absolutely. And yeah, I mean, no question about it. And people have kind of nibbled around the acute versus the chronic and what is acute. Is it 14 days? Is it 21 days? There's a lot of prospectively collected retrospective data. I used to really canoe in my mentor, Andreas Imhoff. We used to joke that if you walk by the Technical University of Munich with any type of AC joint, you were getting an operation, but he definitely is an acute operator on that and it's had great results. I think when you operate acutely or whenever, you do risk and we don't have a very reproducible operation that always works. So although Marcus was talking about cosmetic deformity, I have not had the same results and they still have a scar. It usually quote, settles out a little bit. So they have a little bit of a different on the right versus the left. That's been my operative success rate. So that's why I try to, I get them back to sports as quick as I can and then if they fail that, then we operate later. So you're right about the healing environment, but for me, I think I get more people back to their sports much quicker without an operation. I would agree with what you're saying. I was thinking of optimal patient and optimal outcome. I think your situation is a little more difficult to treat than an acute injury that requires surgery. So I think we're on the same page. I have a question to Pete and to Gus. Maybe you're talking about the acute situation and the best environment, the best healing environment. Would you consider in the acute setting, also adding a graft to even improve the environment? Is that something you do on a regular base or is it just in the very high grade injuries that you treat acutely? Pete, you answer that first. Sure, Marcus, I put a graft in on all cases. I had some experience of just doing CC fixation and even in acute settings, I had some that didn't hold up. So I think the stresses there are pretty high. And I personally always use CC fixation and a graft in acute settings. I think in the acute setting, you could argue that you might be able to get away without doing a reconstruction of the AC ligaments as well as at the same time, but I always put a graft in as well. Does a graft mean allograft or autograft? I suppose it's allograft in your hands. We talk to the patient about it and if it's really a high level athlete, we sometimes use autograft. I think that autografts have a better healing rate in most indications. So if you're really worried about it, autograft, but in the majority of cases, we're using an allograft. Great. And Pete, what graft would that be? I use a typically a seven millimeter, seven millimeter tibialis anterior allograft is the typical size I use. Sometimes we'll use a semi-tendinosis. It just depends kind of what's available, but typically it's a seven millimeter soft tissue graft. That's much bigger than a graft that is four millimeter. So we get into the cases. Berte, you've brought us a very nice athletic case. Just tell us about it. Sure. This is a guy who you can see attended the Olympics in Pyeongchang. And the Norwegians have high expectations about medals. So he was qualifying for the final in snowboard when he fell and had this injury. So I think most of us will agree it's a record five. And of course there was a lot of discussion whether to operate or not. And he had a lot of advices from people in the Olympics and other people. And then he came home and we had this conversation and I told him about his alternatives. And I said that probably many already has told you that you had to have an operation. And that was right. He was very confused, but he thought he had to have an operation. So I told him, okay, I can do it. But then you have to do what I say for the next three months at least. And there will be no snowboarding. So he didn't like that. And then I told him about the other option. If you don't have an operation. He didn't have any pain or very little pain when I saw him after approximately 10 days. And he liked the thought of going back whenever he wanted because he was already very good in his shoulder. So he went back, no operation. And three months after it was X Games. And after that there was a lot of competitions and he's still competing and he still has his clavicle very unstable, but he has no pain and he can do whatever he wants. So this is one of the examples that even our top athletes, they don't necessarily need an operation. And for him, for sure, he will fall on that shoulder again. So I was also worried a little bit about operating him, making some weak points in his clavicle when he fall again and again. So I think this was the right solution for him. But in the beginning, he was very confused because there was several medical personnel who had told him that he needed an operation. So I would just add my case before we discuss a little bit the treatment. So I have a similar case. I have a semi-professional race driver and he was on track of winning the championship. And the last race before the final race, they kind of had their party that they won the championship and he fell off a bike and got his type five lesion. And that was the same situation. He had to race the race in his race car about three weeks later. And we talked with each other and we decided to go for a conservative treatment in his case, we made a training and then he was absolutely able to finish his last race, drive his race and has no problems and is very happy with that. And I think the last case on this topic of conservative treatment, Johannes, is this example you've sent us. Yes, this is a way to say also, there is another point that needs to be mentioned. Sometimes, what does the patient really will, you know, what does the patient really want? Because it is very interesting for this case. Can you come back, please? Can you, yeah. So he was operated in 1998 by my boss, previously, because he was operating main or acute severe acromegaly dislocation and in my city, it was the rule at that time. And, you know, the first time he really want the surgery and he had to have a lot of time to recover, to go back to the sports and to work also. This guy was, he's a physiotherapist. And the second time on the other shoulder, he come to visit me because he knew I didn't want to operate on him. So, because he already knew what I'm going to do and basically was happy to not to be operated. And finally, I asked him to show me his shoulders and finally has the same result. And basically, you know, this is exactly what we have learned from this meta-analysis from Chang that was written in 2018. If you compare the conservative treatment and the operative treatment, whatever type, actually, you will have no clinical difference in functional outcomes, which is the case of this case and the two previous cases. But the advantage of non-operative treatment and you really show that very well, it's a more rapid return to sports and rapid return to work also. But for sure, sometimes you have a poor cosmetic result, but not always, like you can see here, because it's really symmetric. The only difference is actually the scar on the operated side. Thank you. You can take the other case, maybe. Now, I just wanted to step in there. And Gus, you have published on how to do the conservative treatment. You've mentioned it shortly. What would be the treatment by itself when you go conservative? It's just wait and see, or what is your key points for the conservative treatment? I think the key points are to really work on stabilization of the scapula. If they can control their scapula, and a lot of times they'll be in a really protracted position and we'll teach them how to retract their scapula, engage their rhomboids and trapezius. And that's kind of what we concentrate on as they work on increasing their range of motion. So as they increase their range of motion, we're working on opening up the scapula, having them retracted so they're not protracted. And then if they can do that, then we're good to go. But that's kind of what we work on. So we work on engaging those muscles of the scapula to have that reduced. And then we work on making sure they get full motion. And once their pain's controlled, they're back. I'm good. Yeah. Can I ask a question to Bertha and to Peter? Also that showed in this case, or in your case, these are all athletes that don't do any activities above head. If you would have a baseball player or a basketball player with the same kind of lesion, would you treat them differently in the acute situation? Or would you also try to treat them conservatively? If that would be their dominant arm, for example, to throw or something like that. I would give them the same information, but I will have a much lower threshold to offer operation to a thrower or a basketball player. But the case with the snowboarders and with ice hockey players and athletes that you know are gonna fall on the shoulder again, I think they have the higher risk for surgical treatment. Because you make a weak point in their clavicle when you drill through it. And I think that they will be faster back to what they do. And also then, you know, they will fall on it again. So the complications after surgery might be more severe in those kind of athletes. So Berthe, Alexander put a little bit forward because I wanted to touch on the different sports. And here you have the cyclist you've brought us. Basically, he has also a high risk to fall again. Tell us about this cyclist. Yes, and the history of this cyclist was that he came in with this. And I could of course see that he had had a fracture before. So I did the same information as I always do. And I told him that his option also was to have non-surgical treatment for this dislocation. However, he was so tired after this fracture because he had to wait six weeks until he was able to do any kind of cycling because he had so much pain. So he said, no, this time I want an operation. And after giving him all this information, I offered him an operation and he had this arthroscopic acute operation with dog bone put in place. And he was already after two weeks on his bike and he was very happy and had no complaints afterwards. So this was an acute operation and I don't use a graft when I can do the operation within the first two weeks. So at least the tunnel in his clavicle is only like three millimeters thick. So can I ask a question? Yes, sure. Bert, how much time do you immobilize the patient just after a surgery like this? And what kind of advice do you give the patient? Is he allowed to go back to sports at two weeks post-op? No, but he did. I recommend them to use a small amount of time I recommend them to use a sling for three to four weeks, but even if they use the sling, I allow them to carefully start movements with a limit of 60 degrees of flexion and abduction and 20 degrees of rotation just to start careful movements. But I did not advise him to go back to cycling in two weeks, but he did. That's how the cyclists do it. Yep. Does anybody has a good idea for these hyperactive patients? Because I agree the ones difficult to treat are the mid ages, 50 year old active males, like the cyclist who really start early motions, start early swimming and all that. And I feel that with the acute treatments, I get some problems afterwards because they kind of worry it out. Perhaps, Markus, you're going a little bit more of adding a graft even in the acute settings. Do you think that this helps if the patients go back earlier? Yeah, I think it's a good idea. Yeah, I think over the years we became stronger with just synthetic stabilization techniques using a dog bone or a low profile and adding a synthetic surcharge around the AC joint. But I would also say adding a graft in addition would even improve the primary fixation. Unfortunately, I have to say we are doing this now since almost a year. It's not that you have 100% success even in the acute setting. So yes, we do it in the high grade ones. And in those patients where they are very active, those you mentioned, but it does not seem to me that we are having a huge success at the moment. Markus, let me ask you, and actually the whole panel, when you do the acute reconstruction, how many of those patients do you actually have to go back and do a revision on? It's almost none. I mean, let's say the main complication after this operation is loss of reduction that is usually asymptomatic. Which I think is very interesting, right? Is that true for everybody? When you have one of these acute stabilizations and they lose radiographic reduction, they have the bump back again, have you ever had to go back and do a revision? Well, I think sometimes these patients, there's two points. One point is after three months, you have to tell your patient that there is a slack of about three to five millimeters and they have lost reduction, which does not bring them back happy to you. And the second thing is, I think these ones who start motion very early, they have some problems. It takes a long time for them to be happy, especially with overhead and supportive motions. And sometimes that even takes longer than three or four months. And I think it's because there's micromotion on the synthetic grafts and they are stronger than the bone and you have bone edema and reaction. Is that something you see as well? I agree that not all of the patients would need revision if they have a loss of reduction, but I do not agree that. Okay. We lost you, Johannes. Gus, I have a case I'm gonna show in a few minutes of that. It was fixed acutely with a loss of reduction and I'll show you what we did. But I agree that most of the patients who do lose reduction usually do pretty well. The biggest problems I've had is either hardware irritation in thin people because of the buttons or the graft or the knot stack or loss of reduction. Those are the two most common things we see. And usually when they lose the reduction, they don't go up to a five, they kind of stretch out a bit, but they're not going, there may be 50% of the joints lost or maybe 100%, but it's not as unstable as like a great five would be. I would agree. And I mean, if you look at studies with a large patient population, usually using synthetic stabilization, either hook plates or whatever buttons, we have a success rate of around 60%. So that means to me that 60% are healing in a more or less anatomic position. But we have, let's say asymptomatic, mainly asymptomatic failures in 30 to 40%, depending on which studies you read. And I think the future needs to be to figure out which of those do heal very, very well. What are the predictive factors that we can maybe collect preoperatively and counsel the patient better? And also maybe find out negative factors where we know, okay, we don't operate at all, or we add additional graft, maybe in a different technique. I think that's the challenge at the moment and we are not there yet. So I want to keep the momentum and give, so Bertha, these are two examples you've brought us for horizontal and vertical instability. Can you tell us something about it? Yeah, this video was actually just to show that there's different instabilities. So the video to the left is showing vertical instability. It was a Rockwood three or five. And I don't know if you can play them again, but I'm holding my finger on the posterior corner of the acromion. So the bone coming up is the lateral clavicle. So you can see it's clearly overriding the acromion. My finger is on the posterior corner right there. And he had no complaint. So he just came to show me this. And the other one is a nice example of a horizontal instability. This is a ice hockey player. He doesn't care about cosmetics, but he had a lot of pain. So the guy to the right needed an operation and the guy to the left, he had no complaints. So of course no operation for him. And I also want to ask the rest of the panelists, if you have such a case as to the right where the instability is obviously more of a horizontal clavicle, what would be your strategy for operation then? Would you still do the CC ligament reconstruction or would you in some cases do only the AC joint capsule reconstruction? I could jump in there with my next case, which fits exactly into this. That's a 22 year old patient. He had a snowboard accident eight months ago with a type four instability, like a more horizontal instability. And he had clicking pain, exactly what you showed in the video, clicking pain when playing tennis. And we did a hybrid stabilization with a dog bone and a graft and also address the AC joint. And there's, besides your question, I want to just kick in the scores we had from this patient, the patient reported outcomes. We went into this surgery with an ASES score of 92 and we got him after surgery to a ASES score of 97, which made him happy in playing tennis. But that's something we have to keep in mind when we see our studies that we don't pick these problems of these patients as you've told us. So for me in the chronic situations, I would address the AC capsule as well, try to have a graft in there as well. Perhaps Peter, how is your idea to this? You touched on this before. I think it makes sense when there's horizontal instability. Personally, if I have purely someone with horizontal instability, they have pain at the spine of the scapula from the clavicle hitting. I've addressed both. I have not just done an AC reconstruction, conceivably that could work. I think usually addressing both and trying to pull the clavicle anteriorly at the CC ligaments is helpful and then fixing them at the AC joint as well. I think if you just fix the CC ligaments in some chronic situations, I've seen it where the clavicle will just pivot around the CC ligaments and will continue to have horizontal instability. So I think these approaches that you've shown here make a lot of sense. Yeah, and Berta, we published a biomechanical study where we thought that that may be the best way where we just concentrated on the AC capsule and we were still not able to get it back to normal. So we believe you have to do both just to reconstruct everything. And also we did both in this case, but I was just, I remember we discussed this, whether this could be a case where you could do only the AC joint, but we did both. Yeah, biomechanically, we didn't find it to be as successful as I thought it was gonna be. Can I ask you something? How did it look during surgery, the CC ligaments? Were they just intact or were they torn or was there some scar formation there? Well, I don't look at it in this case because I open up on top of the clavicle and I do the rest of the work arthroscopically, but what I found, and perhaps that's also an interesting thing to discuss, if you look in the MRI in these chronic cases, you see a continuous CC ligament, which is elongated a little bit like the PCL. So in the chronic case, the MRI tells you there is a ligament, but your weight-bearing x-ray or your bilateral Sankha tells you that there is an increased distance in the CC. So is anybody thinking about the same way that the MRI might not be good in the chronic setting compared to like Marcos, like you said, in the acute setting where you're studying it? We don't usually do an MRI in the chronic setting. Oh, that's good. Unless, I mean, unless we have, let's say, a symptomatic shoulder where we believe that some of the symptoms originate from the glenoma joint, but that would be the only indication. Go ahead, sorry. Marcos, maybe a question, because I thought it was an interesting study to see where did the ligament turns. From my surgical view, I always had the impression that it's some kind of interceptions, but do you think it can be on one or both sides, or there will be a difference between the ligaments where it's torn? Yeah, I agree. I cannot give you the exact data, but the majority is intrasubstance, and then there's a minority that either ruptures from the clavicle or the coracoid. I cannot give you the exact number at the moment, but the same is true for the acromioclavicular ligaments. They also can tear off either from the acromion or from the clavicle, and there can also be intrasubstance tears. And we have no idea at the moment which tearing pattern heals better than the other. So that might be another, let's say, parameter that we need to take into account for the future. From the cadaver world, we did a study where we tried to look at that. And what we found is they would, it depends on what you call intrasubstance. So they fray, but they came off of the clavicle, the CCs came off of the clavicle more than the coracoid process. So, and it's a frayed, you know what I mean? So it's not like right in the middle, it's more on the clavicle side than on the coracoid side. And on the AC joint, usually there's a greater attachment on the acromial side than on the clavicle side. So we found that it was coming off of the clavicle, and that's really where we get into, we'll talk about this later, but that's where we really think the problem is, is with rotation. We call it rotation, but it's really the scapula rotating forward in protraction around the clavicle strut. So we'll have to go on. So Peter, you've brought us this case. Perhaps you tell us about this case. Sure, this is an interesting case, a 25 year old woman. It's her dominant shoulder that was affected. She was a recreational rock climber, so she did a lot of overhead sports. And she was unfortunately a pedestrian who was struck by a car, had polytrauma with a type five AC separation, an associated coracoid fracture, and she had some lower extremity trauma that required nails in her tibia and her femur. So she presented to me a number of months out from her injury with a non-union of her coracoid and a symptomatic instability of her distal clavicle. And she had an associated, you know, labral tears. She doesn't recall if she dislocated her shoulder or not, but there's a report that the EMTs reported that her shoulder clunked in place when they found her. So, and she had a scapular body fracture. So, you know, maybe we could just go back a slide before you move on. You know, maybe I just open it to the panel. When you have a case like this, maybe Marcus or, Marcus, what goes through your mind a little bit when you see a, you know, coracoid fracture with an AC? It can either be someone who's had a prior Latergé or a trauma case like this. It's something that I've seen not often, but not infrequently. I completely agree from your observation in terms of prevalence. It's rare, but it can occur. We usually don't call it a type five AC separation because if you measure the CC distance, it's usually on both sides the same. Since the ligaments, the CC ligaments do not tear, but the coracoid fractures. So you have an AC separation, of course, because the AC ligaments are torn, but the CC ligaments are usually intact. And I, what I usually do, that's what, this is one of my rare indications for a hook plate, plus minus putting a screw in the coracoid. But in this particular case, she's out already four months of this injury, right? The chronic, it's a- She's about four months out from her injury, yeah. Yeah. Great. So- I've seen this, I've seen this after Latergé, prior Latergés where people have had an AC dislocation. And I've seen it after drill holes have been placed in the coracoid for prior AC fixation devices. Some of the earlier devices that were used were large and they would make the coracoid weak and you could get a fracture. And also with some cerclage techniques, I've seen it where it's cut through the coracoid. Maybe if you could go to the next slide, Newt, we could. So we, we use an allograft around the coracoid. There was enough coracoid to actually put it around the coracoid, but it wasn't great. I was concerned that it might not have optimal fixation. We repaired her labrum and her capsule as well at the same time. The fracture was not deemed to be repairable. So we excised it and just did a conjoint tendon tenodesis to the stump. And then we used a hook plate as well to neutralize forces on the graft. And we put the graft in first and the hook plate is under the, is on the top of the graft so that we can take the hook plate out later if we need to. And the graft then hopefully will be incorporated by that, by that time. So in the, I had a case, a similar case in the acute setting. And I did a fixation of the coracoid with a screw, like because the ligament between the coracoid and the clavicle is still intact. And if you reposition the coracoid and fix it, you have like a bony healing. Has anybody of you seen the same thing? Interestingly, in this case, the ligaments were not attached to that fragment. So I don't know if she fractured it off when she dislocated her shoulder. So interestingly, you know, what Marcus said was true that usually the ligaments are attached, but in this case it wasn't. And I think that's why we were able to actually put a graft around the base of the coracoid because the CC ligaments are right at the base. This was a little bit out farther, farther into the body and tip. But I would agree in the acute settings. In my experience, when you reduce the clavicle using a hook plate, you get auto-reduction of the coracoid fracture. So it's rarely the situation that you need to put an additional screw inside. Of course you can do a screw without a hook plate, but I would say the hook plate in this particular condition is a little bit more stable. So I would start with a hook plate and it's easier. I mean, it's a much easier operation than putting a screw into the sometimes very tiny coracoids. So I would do a hook plate and then do X-ray and see if the screw is still needed. Thank you. Peter, when did you take out the hook plate? It's still in. She's about four and a half months out now and it's not really bothering her very much. These X-rays are four month X-rays. It doesn't look like there's any erosion on the acromion. So I'm gonna probably leave it in for another two months. And at about six months, I think the graft will hopefully be well enough incorporated that we can take it out. Perfect. So you did a labor repair also? There are some holes in the glenoid? Yes, we did repair her labrum as well. Yeah. So we have to continue. Alexander, you've brought us this 35 year old case. Oh, patient. You have to turn on the well, your mic. He's a 35 year old dominant male, heavy labor, no medical history, had a fall on a bike two days before and he was treated somewhere else. And this was the first post-op X-ray. Maybe just to ask to the panel, I think this case will show us some surgical tips to make sure that you get a good result. Maybe Johannes, can you comment on the first X-ray? What would you think or what would you do when you see this first X-ray? Well, yes, you can be concerned about the placement of the tunnel in the coracoid, but for sure, there is a secondary loss of reduction due to this misplacement, but probably I won't touch the patient and I won't do anything. Even if this patient would be operating somewhere else, I would just say, it's gonna be fine and we'll try to rehab as long as possible and see how he's going, but I would not touch this. Would somebody else do something else right now in this situation? At three weeks? Three weeks, yes. Yes, I wouldn't revise a patient at three weeks post-op, even with a hardware disassembly like this. I wouldn't do anything. How is the patient? Well, we continue with the case, maybe. So they did a revision, maybe indeed the first, yes? The only thing I would do is consider a better view of the coracoid to make sure the coracoid didn't fracture. You can see on the first view, if you can go back on the slide, it's possible that they put multiple drill holes through the coracoid and I've seen iatrogenic coracoid fractures. So although it looks like it probably just pulled out, you wanna make sure there's not a fracture there too. I think here it's important, if you drill into the coracoids to drill, of course, into the center, because certainly when you're trying to do it autoscopically, it can be a little bit dangerous to go a little bit too much to the middle side and then there is a risk of rupturing. So, but they did, okay, go to the next slide. So they did a revision after four weeks. And so you can see the X-ray immediately post-operatively and the X-ray 40 days after the surgery. They used an holograph here. Maybe just a question for the audience also, can you go back? If you see to the X-ray, so normally in my practice, when I do a suspension technique, I use something like 3.5 centimeters from the lateral clavicle to go into the clavicle. When I use a graft, then I try to go two and a half centimeters for the trapezoid and four and a half for the conoid. Here in this case, they used the 3.5 centimeter drill hole that they used for the suspension technique. Also for the same hole for the grafts. Would you use the same hole or would you have done another hole or can we have a comment on that? Marcus, maybe, would you have done, would you have used the same hole again or would you use another hole? It depends a little bit. I always do in revisions a pre-op CT to determine how centered the previous drill holes are. And if they are at least on the clavicle, very nicely centered, you can use them. You can put the K-wire through and over drill it if you need a larger diameter for your graft. So yes, sometimes I'm using the pre-tunnels. Sometimes I don't, if they are, you know, too close to anterior posterior edge of the clavicle. Alexander, we have to go on. Yeah, sorry. So this is, now he came to my clinic four days ago. And you can see still the vertical and horizontal instability. And he, so now we're three months after the last surgery. And of course he came to me with the question because it was bothering him, can you do something about it? So maybe also a question to the panel, how would you treat this patient? Would you try to use a different hole? This patient, would you try to use another graft? And would you use, would you revise it or not? Injection. He gets an injection at this point. In my hands, it doesn't look like the end result was any better than the first result when it ripped out. If he's really bothered by this, I think he needs a revision reconstruction with a graft, CC fixation, and fixation of the AC joint to stabilize it. Peter, let's just... My plan. Perfect. Peter, let's continue with your revision case. Okay. This is the case I was referring to earlier. It's a 50 year old left-hand dominant gentleman. He had a mountain bike accident with a grade five AC separation. He was treated non-operatively initially, and then underwent a CC fixation using cortical buttons and tape at an outside institution. Two months later, and I personally would have put a graft in at time zero, but this was just pure CC fixation. Two months later, he presented with loss of deformity and stability pain. And one year later after living with it, he presented me for question about whether this could be fixed again. He's failed non-operative treatment. And he has a prior tunnel, he has hardware in place, and he has loss of the reduction. Could we have the next slide? So he underwent arthroscopically and fluoroscopically assisted procedure. I always like to use C-arm and have fluoro interop. I did a CC ligament reconstruction with a tibialis tendon allograft. And when I set a seven millimeter graft earlier, that's the double diameter of the graft, not the single diameter. He underwent CC ligament reconstruction with a tape as well, and CC fixation with cortical buttons and two tapes. And then I did an AC ligament or joint reconstruction as well with suture tape and then to close the capsule over the top. So I pretty much did everything I could possibly do without putting a hook plate on to try and secure and stabilize it. Can we go to the next slide? So here's the intra picture. I use a 70 degree scope from the back and visualize the undersurface of the coracoid, take out the cortical button, went on the top, made an incision, took out the button on the top. His tunnel appeared to be in good position on preoperative imaging and intraoperatively. So we elected to reuse that for additional CC fixation. If you can go to the next slide. Here's shuttling of the suture for the new CC fixation with buttons. And then go to the next slide, please. And then what we do is we pass a graft. You can see the tibialis graft coming around. I used to use a switching stick and then put cannula dilators over that to create soft tissue tunnels. And then I can pass a fiber wire or fiber stick down that and then pull the graft. So the graft goes from posterior on the clavicle underneath the coracoid and then anterior on the clavicle. And you can see the cortical button in place there. Go to the next slide, please. There's also a suture as well. And I use this tensioning device so I can control the reduction. So I tension, I have a cerclage suture around the whole construct. Use this tensioning device to reduce it. And then I can tie my sutures on the top to fixate the cortical button on the top. And then we'll secure the graft. And then in this case, we also left that tape in place. Next slide, please. So here you can see the graft in place. At this point, you can see the suture cerclages here that are gonna be used as a use for the tensioning device. Next slide. And then here you see the final construct with the tibialis graft over the top. I like to go with the graft over the clavicle as opposed to through drill holes in the clavicle. I've found that those drill holes can weaken the clavicle and can result in fracture. So I tend not to put them through the clavicle anymore. And you can see the figure of eight AC reconstruction. This patient had trouble getting the reduction. So we did have to resect a little bit of the distal clavicle as well, but we were still able to use a figure of eight AC reconstruction as well. Next slide. And here's kind of the final X-ray image of that reconstruction. Perfect, thank you. You just touched on it and we didn't talk about it. Is resection of the lateral clavicle, does this play a role for you or for anybody of you in treatment of these AC joint instabilities? Or how's your opinion on that? I'll start. My preference is to leave the distal clavicle. I've talked with Gus quite a bit about this and I know that it definitely makes the joint more stable. And if you have to do a reconstruction of the AC ligaments, it's probably better to have more bone. But there are certain cases where the joint is very arthritic or in revision settings or in complex situations where you can't get it reduced, where you do have to perform a distal clavicle excision. And I think you can do that and still do a reconstruction if you have to. But my preference is to preserve it. I mean, I find it personally, I agree with you in these situations, but sometimes we have these patients who had a Mumford procedure with like two centimeter resection and I find them very hard to treat in the chronic situation. Has anybody of you experienced with adding bone and using bone in these situations as an add-on or something like that to get more length on the clavicle? I had one case where we did a 3D print of the bone to make sure that we have, again, enough extra bone. But I think from theoretical point of view, it makes sense to make, again, more bone, but the result was not perfect. So currently this is only one bad case for me. I've also have one case where we used a patella tendon allograft and used a bone plug and sutured it with fiber tape to the distal clavicle and then sutured the tendon part to the acromion. But it's just one case. He's doing fine. He lost a little bit of the reduction, but he's more stable than he was. So, so far, one year down the line, he's happy. Great. So now we are coming to our last part, the pearls. And again, we are trying to do a fireside with try to get a short answer. Alex, like what's the hardest lesson? What's the no touch thing in AC joint instability? The no touch thing, I would say the hardest lesson is that don't be too aggressive. Like we, all the speakers already showed that we can have really good results with the conservative treatment. And it seems that the long-term results of treatment in chronic cases are also very good. So don't be too aggressive when you see a patient with an AC joint instability on your clavicle. AC joint instability on your clinic. Bertha, what's your hardest lesson? Well, I think we always have to remember that there are strong forces around this joint. So you have to make solid fixation if you do operations because I've seen the rotions both on the clavicle side and on the coracoid side. So if you do operation, you have to make it solid, both the CC ligament and the AC capsule for most chronical cases. Peter, what's your hardest lesson? Well, I had two very good mentors who told me a lesson which I didn't take to heart. Rich Hawkins and Russ Warren. And they said, if you want to have complications in your practice, then operate on the AC joint. But I've operated on a lot of AC joints and I finally have learned that if you want to have complications, operate on the AC joint. It's a very difficult joint to treat. And I think the comments that the panelists made today were very spot on that many of these patients do well with non-operative treatment. And if you're going to operate on them, you need to have very strong fixation and you need to be very meticulous about your surgical technique because they're small bones and you don't have a lot of room for error in where you place your fixation devices. And there's a lot of forces, as we just heard, that are working against you in the fixation. Johannes, what's your lesson? Well, my lesson is I used to operate a lot of them at the beginning of my career. And I honestly, with looking at the result with the number of complication and the functional outcome, I was really, really disappointed with this joint. So for me now, less is more. And I really tried not to operate in acute setting. And obviously, 90% of those patients will do good. Those doing good at three months, then I would consider for a chronic stabilization with a graft augmentation. But honestly, in acute setting, I stopped to operate those patients because I don't think it's necessary. Only for those who have an irreducible and an entrapped distal clavicle in the deltoid trapezius fascia, then I do operation. So again, displacement is not the main criteria for gravity. These are my two pearls. It was already the pearls. We'll skip you later with the next question. Gus, what's your hardest lesson? For me, the hardest lesson is when patients have, like you just were talking about earlier, when they've had too aggressive distal clavicle excision. That's really a hard problem. We've tried a lot of different techniques and have been unsuccessful with all of them. So I think right now that would be probably the time that I would try the hook plate. I think that may go. I just don't have a lot of experience long-term after the hook plate comes out on how well they do. So the hardest lesson for me is when people come with too much distal clavicle taken and pain there. Marcos. I agree with Gus. Perfect. That's rare. That's rare. Nobody. Okay. I mean, now it's hard. Johannes, you already told us your most important pearls. We want to have the positive ending. Marcos, give us your pearls to have a positive ending in this. Well, I mean, if we talk about surgical pearls, I would really recommend to use intraoperative fluoroscopy to place your tunnels in addition to the scope. This has helped us tremendously in the last years. I would say in the last 15 years, not to have had a single complication that was really serious. I'm talking about neurovascular injuries. I would say that primary tunnel malpositioning is also very rare if you use a combined approach of arthroscopy and intraoperative fluoroscopy. And I would also recommend, I mean, this is a really an operation, one of these operation that you can teach step by step to the residents. It's very standardized, and there is not a lot that you need to modify intraoperatively. So I think a stepwise approach to this operation with mini incisions, and I think this is really something we compare, we can compare with the involvement of cuff repairs. I mean, when we were doing cuff repairs open and we had a re-tear, it was a double disaster. The shoulder was open and now there is a re-tear. At least now with the AC joint, we can make minimal invasive incisions, even placing the grafts minimal invasively. And even if this operation fails, you did not cause a lot of, let's say, collateral damage. Bertha, what are your pearls? My first pearl will be for those who come in with an acute case, that you take your time to inform them about the alternatives and especially about the cosmetics, because they find it very strange that you're not gonna operate on such a thing that they can see is looking very different than it did before. So you need to take time to inform them in both way, and you need to get them understand that non-surgical treatment is not nothing. It's also treatment with the help of a physiotherapist and that the surgical treatment is not a quick fix necessarily. Things might happen. And when you tell them about complications, you have to make them realize that it might happen to you and not to everybody else. To give a small surgical tip, I always tell my residents to place the guide that are going from the coracoid to the clavicle a little bit more posterior than they think, because you pull the clavicle anterior with the suspensory device. And my experience is that if you tell them to put it a little bit more posterior, it will be central, because putting it to anterior will make a weakness in the clavicle and they might pull the suspensory device through the cortical. And also to make them feel that they're drilling through four corticals. So you know that you have passed in the center of both the clavicle and the coracoid. Peter, tell us your pearls. I think some of the pearls were talked about. I use fluoro. I want to have good visualization. They're small bones, so you want to make sure that your tunnels are in the appropriate places. Those are kind of the main pearls. The other ones is try the tensioner to help with a provisional reduction. You can just pass a suture tape around everything when you're passing your graft and it gives you a really controlled reduction. Also, sometimes you have to do a distal clavicle excision or remove scar tissue to get it reduced first. So if it doesn't reduce passively very easily, then taking the time to clear out all that before you drill is really important, because you want to have it in a semi-reduced position or fully reduced position when you drill. It makes it a lot easier. So those are just some simple pearls. Alex, we want to hear your pearls. Well, a little bit the same like Bert. I think first of all, reinsurance to the patients that in an acute setting, there is no urgency to do something. And I think on the other hand, if we have an irreducible lesion, I think it's also very important in surgery to address the deltoid trapezoid fascia. So I'm still doing it open because then I put an anchor into the clavicle and try to fix again the AC ligaments together with the deltoid trapezoid fascia who covered the horizontal instability. Gus, your pearls. Yeah, first from a selfish, I'd like to shout out to my daughter, Jillian, who's a pre-med major senior who's watching this. Knut knew her when she was a baby. So that's a big thrill for me. I would say my surgical pearl that we're really working on now is when we would open up the deltoid trapezoid fascia to get access to the CC, we used to tie that over the top. And what we found that may help with that rotatory instability that I talk about is we take an old PDS and run it on the deltoid, which is almost a muscular attachment to the clavicle. And we'll run a PDS, old PDS on the trap if you take it. And then what we do is put mini anchors in the clavicle and do horizontal mattresses. So instead of tying the deltoid trapezoid fascia over the top, we tie it now into those AC ligaments. And we feel biomechanically so far, it's working out that that also helps mitigate some of that rotatory with the acromion coming over the clavicle. So that's probably the one thing that Alexander mentioned a little bit, but that I can offer. So perfect. So thank you, everybody. Basically, I think we have touched base on all the questions we have seen in the chat, and we're a little bit ahead of time. So I want to thank you, our great faculty, for this very interesting discussion and all your cases you brought with us. I want to thank the office of the AGSM, Donna Tilton and Christine Ward, who really helped us prepare this whole thing. And with these thanking words, I want to say goodbye to all the audience. Thank you, the audience, for being with us for this one and a half hour, and all faculty. And the last words will be with Christine, who tells us a little bit about your CME, et cetera. Yes, a big thanks to our panelists and presenters for their work on tonight's webinar. And thank you, attendees, for your participation. If you're interested in CME or would like to view the recording of this webinar, please go to education.sportsmed.org, log in, click My Resources, and then click the course title. You can then complete the evaluation for CME or view the recording, which will be available by Friday. This information will be emailed to you in 24 hours, so please don't worry about remembering it all. We thank you again for your participation, and have a great rest of your night. Thank you.

AC joint instabilities

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