»» All right, no disclosures for this. So a little bit about indications. You heard about this in one of the earlier talks. I still think it's controversial, non-op versus op for the Type 3s. Hard part in the acute setting, it's hard to know if they have horizontal instability. They're hurting, they're painful. Multiple systematic reviews have been done about treatment. I think surgery can give you better cosmesis, better x-ray reduction. You have a risk of infection, you might have to take out hardware if you're doing a plate. No difference PROs over time. So people can do well either way. Certainly if you want to get back to sport, it's quicker with non-operative treatment. Two to four weeks, typically they can be back out there. It's usually a long discussion. A lot of it depends on time when they show up. Contact athletes, we certainly try to kind of nudge them towards non-surgical management. So I'm usually non-operative for the Type 3s unless there's mitigating issues. If they're still symptomatic at two or three months. My treatment hasn't changed dramatically in most cases. We still do the same thing. Exceptions are certainly out there. Very slender individuals, they don't tolerate this very well. Overhead athletes I think is certainly something you need to think carefully about. I've had a few patients that wanted to be treated because they were entering the military and they thought that would be held against them during their screening entrance activities. There have been surveys done of contact athletes, physicians. Most would try non-operative treatment first. You have to think about what bridges you burn with non-operative, with surgery. Contact athletes, certainly if you fix them, there's risks of fractures depending on how you treat them and what your technique is. And again, we talked about throwers. And just anecdotally, I have several people that have pretty ugly looking AC joints that are making a lot of money in the NFL. Had a variety of different positions that did well. And I think it's certainly a little bit more straightforward for type fours and fives. They just generally don't do as well, especially if they have pain, crepitus, non-reducible. Development of HO tends to be a poor prognostic factor for them doing well non-operatively. They can have some distal clavicle fractures or again, HO that's causing problems. The nature of the beast is we have over 150 techniques in the literature these days. That usually means that none of them are perfect. And people have analyzed and reviewed this open versus scope. My interpretation would be I don't find a significant difference one way or the other with that. Early versus delayed surgery, I know there's a paper later today that shows no difference. There is some literature to suggest that earlier surgery does reduce maybe some of the creep and loss of reduction after treatment. And biomechanical considerations continue to be looked at with a paper here today. But if you're gonna use soft tissue, two bundles seems to do a little better than one bundle. And then there's growing consideration of trying to rebuild the AC joint capsule as well as the CC ligaments. What about acute repair? This doesn't come up for me very often. I just don't see them that quickly in my practice. But acute would be defined for me within three weeks. And I do think you have an opportunity in these cases to do just a repair. For me that's sutures, tight over a button, trying to incorporate and repair the CC ligaments as best you can. And then a very aggressive soft tissue, delto-pectoral, I'm sorry, delto-trapezial fascial imbrication to support that repair that you did. And they probably recover a little bit quicker than the reconstructions. So one of those 150 or 160 techniques is something that I've been doing for the last 10 or 12 years. I still do this open. I prefer autograft. I think it makes a little bit of a difference. Again, we're trying to avoid creep. I just think giving the patient their own tissue is probably better in my level five opinion. And I try to maximize collagen. So this is a little bit of a merge with what Dr. Mazzocca has taught us over the years in trying to do a transclavicle reconstruction, but I do a double loop. So hopefully this will play. This is a SABR incision. We've identified delto-trapezial fascia here. We'll reflect that anterior deltoid down, find our corcoid, which is underneath our pickups. We're going to pass two number two loops as well as a graft around the base of the corcoid. One of those sutures. Here you can see our graft and our sutures. Then we're going to drill tunnels, as taught by Dr. Mazzocca, two and a half and four centimeters, obviously adjusting to patient size. And you want to be centered over the base of the corcoid as much as possible. We'll dock one limb of the graft, bring up one of our sutures. The second limb gets taken from P to A over the top of the clavicle between our tunnels, as we see here. And then that second loop of suture around the corcoid helps us shuttle our graft around again, and then we can dock the second limb. So I end up with twice the columns than I would otherwise do. Here's our reconstruction. These sutures get tied over a button. That second loop gets cut. We have four strands. We reduce the AC joint, tie it down over our button so we don't get bony cutout. And then I still use peak screws. This is debatable. A lot of people have gone away from screws. We're going to have some collagen left over. This can be swung over to the AC joint. I've done that a couple times. I don't think it makes a huge difference. In this case, we did a half hitch, tied it together, sutured together with some O suture, kind of in a little knot, which gives us our final construct, which looks like this on a diagram, and which looks like here. And then here's an aggressive vest over pants imbrication, because you're going to have dead space there we want to quiet down. So how to avoid failure. Level five. Take it for what it's worth. Use autograft if you can. Most of us are sports surgeons. You know how to harvest a semi-T. Clavicle tunnels, keep them as small as possible. If you're going to use them, avoid them and contact athletes, because they can fracture. If I have a contact football player, and I get pushed to surgery for one reason or another, we're just going to wrap the graft twice. I think the literature and some of the later papers would show that distal clavicle resection is really only needed when necessary. So if you can't reduce the joint, leave it there. They're more stable. When you cut the end of the clavicle, you can get further osteolysis for some reason. And if you've drilled holes, all of a sudden that osteolysis starts to creep towards your tunnels. You can cut it if you really need it, and then I don't think there's any harm in over-reducing the joint a little bit, expecting, therefore, to be a little bit of creep. Avoid tunnels and holes in the coracoid. Again, part of this is level five. I've been there, done that, disasters, anchors, drill holes. There's a lot of way to do this. When you have a coracoid fracture, it's a bit of a disaster, and there's not easy solutions. There's some other papers that have shown this. You want to be able to optimally reduce the clavicle. So take your time. There's always a bunch of scar tissue. There's always a bunch of junk there, especially in a chronic case. If there's HO, get it out, and it's not always where you think it will be. So we wrote a paper because I had a few cases where the HO, I was kind of expecting it just to go from the clavicle to the coracoid, and I get to surgery, and it's actually going posterior into the supraspinatus. Really hard to go get it. Sometimes it's going very medially, where we start to get less and less comfortable digging around underneath there. So if you have any concerns, don't be afraid to get a 3D reconstruction. How about quickly about type 1s and 2s? Certainly the most common. We're often taught that they always do well. They don't always do well, especially in our contact athletes. They can get lingering pain and crepitus. They can shred their AC joint. They just don't tolerate that very well. It stimulates this chronic synovitis inflammation. They get stuck in this early osteolysis pattern, and I've seen this in a lot of wrestlers where they land on their shoulder and they strip all the periosteum, and they eventually develop some HO on the superior aspect of their clavicle. I've even found an intra-articular disc sitting on top of the clavicle, even though they had no instability. So some of these patients, don't just blow them off. They often have things that you can help them with, and if there's any question about superior pathology sitting up on the top, HO, and so forth, doing an open distal clavicle resection is very effective. Thank you very much. Thank you.

AC joint injuries

non-operative treatment

operative treatment

reconstruction techniques

contact athletes