Good morning, and it's an honor to be here. I do want to acknowledge one of our fellows, Eduardo Salazar, who I asked him, if you only had 10 minutes to talk about the AC joint and SC joint, what would be important? Because these both have extensive literature and questionable results, so this is what we came up with. I have no disclosures for this talk. While the AC joint is exponentially more common in terms of injury, we're going to talk about the SC joint first, and there are two reasons for this. One is it is uncommon, so it's very often missed. And second, if you don't diagnose this quickly, the treatment management changes rapidly, and so does the prognosis. So it's a very important topic, even though it's uncommon. If you're taking care of athletes, you want to have your radar up for this. So we all know there's a diarthrodial joint. The posterior capsule is very thick, and it aids in the AP translation, and the CC ligaments deal with the rotation and the medial lateral translation. Similarly, the issue is with nearby vasculature. One of the things, if you're dealing with high school and collegiate athletes, which I believe most of you are, it's important to realize that medial clavicular fysis ossifies at 19 and fuses at age 25. So a lot of the times, it's not a dislocation or subluxation of the SC joint, but in your young athletes, it's more often a fracture of the medial clavicle that you're dealing with. The most important thing coming off the field in football is history. One of the issues is that the pads are often in the way, and so you have to listen to the story. The thing I hear is throat symptoms. They complain that they're having, you know, complain about difficulty breathing. They just feel like there's something in their throat. There can be some deformity. They may complain of pain. It's often difficult to do a physical examination because of the pads. If you can get your hand under there, you can possibly feel for instability, possibly feel for deformity, but often I recommend taking off the pads if you have any concern regarding the SC joint and do a proper examination. The diagnosis is made by some type of radiographic evaluation. You can take plain films, but I've found that the CT scan to assess for direction of displacement is much more beneficial. I would recommend, again, if you have a concern at all, I would do this quickly as the treatment management is significantly important early on, especially for posterior dislocations. This algorithm kind of lays it out on your right, the posterior dislocation. If you can get to it early and close or reduce it, and that's usually with longitudinal traction and extension. You do this in the operating room. You hear this very rewarding clunk and off you go. You put them in a sling and off you go. If you're unable to do that, however, it turns it into a different operation. So it becomes an open reduction and some type of ligamentous reconstruction. As we go to the anterior dislocations, most often these are nonoperative, especially acutely unless it may be some type of tenting or marked displacement. And again, these are more often in your very young athletes that have medial clavicular fractures that cause this. I can't emphasize enough that timing is important. If anybody has ever dealt with these, if you can get these quickly, they tend to pop in and you feel like a rock star, off you go. However, if you can't get these in, this becomes a whole different operation. And very often we see these two or three weeks or four weeks down the road and all of a sudden it's an open operation and you have to do some type of ligamentous reconstruction. This is a paper hot off the presses. Again, this is a very unusual injury. So this was a systematic review and they called all the cases in their literature. And again, this is an issue mainly of young people, although there is in this particular they had them from 11 to 68. The return to sport timeline was all over the board. Their mean was 3.1 months, but the range was one to six months. And it was only reported in nine of these studies. If you were able to get these in, again, short-term immobilization and progressive strengthening got them back to play. Operative options, this is a talk in and of itself. However, you can reconstruct the ligamentous medial structures with either autograft or allograft tissues. There's a couple of papers. Again, these are all small studies out that suggest good result. This is one return to sport after autograft hamstring reconstruction of the SC joint. Again, small number of people, 18 shoulders with good end result throughout. This is the same type of paper in Journal of Elbow Surgery in 2015 where these were not athletes. And again, a small number, only 10. But this was the same type of surgery done with allograft, again, with a good end result. So the most important things, again, is that it is an uncommon injury and important to have your radar up if you have any concerns whatsoever. Anterior instability is more common than posterior. And anterior can mainly be managed nonoperatively. However, posterior needs a reduction. And the sooner you do it, the better. It's nice to have your friendly thoracic surgeon available with a saw, although fortunately, although we always talk about that, there's not a whole lot in the literature that suggests that that's a major complication risk. But obviously, it's catastrophic if it does occur. There's really no high level of data available, again, because of its uncommonness. But any type of autograft or allograft reconstruction appears to have good outcome. I'm going to switch to the AC joint. We're all aware of the anatomy of the AC joint and the mechanism of injury. People always ask about landing on the shoulder and why does that cause it. The real mechanism is that the acromion gets pushed away from the distal clavicle. It's not you land on it and compress the joint. It pushes it away from the distal clavicle, causing the AC joint to rupture. And if the force is good enough, the CC ligaments. Rockwood classification still remains the gold standard with type 1, 2, and 3 almost always treated nonoperatively, at least acutely. 3B is the elephant in the room. And then 4 and 5, where there's clavicle tenting through the trapezius or deltopectral fascia require surgery. Type 6 is for academic purposes only. Anybody who has one of those needs to publish it. The latest study really comes from 2013 as our colleagues in Chicago, Mark Bowen, Gordy Neuber and Associates, followed AC joint injuries for 12 years. And several important things came out of this paper. One is that approximately 30% of all shoulder injuries in the NFL are AC joint injuries. I know Jim Braley left, but he also published a paper much earlier, I believe it was in 2005, that demonstrated he did it in collegiate athletes and it was 40% of all shoulder injuries were AC joint injuries. The things we also learned from this paper is that over 80% of these injuries are game related as opposed to practice. More often it happens on grass fields and more often happens during passing plays. The distribution is as you would expect, it's much more common, grade 1 and 2s and 3s. Of note, during this entire 12 year in the NFL, there was no 4s or 5s. The quarterback has the highest incidence of AC joint injury, but the most AC joint injuries happen in defensive back, wide receivers and special teams players for obvious reasons. The amount of time lost to AC joint injuries, the AC joint dislocation, that is your 3B. Fortunately that's a very small number, at least in this study, and usually not an issue in athletes as we do everything we can to not operate on the AC joint due to complications and concerns down the road. As we go from grade 1 to 3, the loss of time increases. Again, the quarterback is the one that loses the most time and it's the tight ends and running backs after that. Again, fortunately this is rarely needed to be treated surgically. The suggestion is approximately 2% of AC joints require surgery and most of these are something done after a season or a career in which we do some type of AC joint resection for degenerative changes or osteolytic changes as opposed to any type of ligamentous reconstruction. Power management at our institution is on the sideline as we return to play, full strength and range of motion. We are not afraid to inject the AC joints, especially grade 1s, very early with corticosteroid to decrease the inflammatory response and try to get them to early rehabilitation symptom management during that week to return to play earlier on. Medical options, there really are no studies comparing outcomes for different surgical treatments for AC joint injuries in NFL athletes. There's a multitude out there in the literature for most other people. Fortunately most database numbers that we get demonstrate low-grade AC joint injuries which we can treat nonoperatively. No talk would be complete without busted hardware of an AC joint. But the reality of it is most of these are now fixed with some type of ligamentous reconstruction and minimally invasive techniques and fixation devices. The concern remains, however, a high rate of loss of reduction in the athlete and there's also concern regarding posterior instability with some of these reconstructive procedures. This is a paper that talks about the complications of AC joint reconstructions and it had 34% of the 116 were contact athletes. As you can see there was a fair number of complications, loss of reduction and clinical failure and this is the main concern in contact athletes and why we have a high propensity to dissuade them from fixation until at least their career is over. The interesting part of this paper I found was that clinical failures had no effect on the return to work people for the population. However it had a huge effect in return to sports. So in conclusion most injuries are low-grade fortunately. There's no gold standard surgical treatment for fixation and we do need more studies comparing the high level of athletes with AC joint injuries. Thank you for your time. �

AC joint injuries

SC joint injuries

diagnosis

treatment options

Rockwood classification