We do have a few, I want to invite the panel up here. We do have a few minutes, about 10 minutes that we can run through. Really a couple scenarios is what I'd like to talk about first, and then we can, if we have time, we'll touch on a case or two. So we'll wait until they get it up. So the first thing, first thing I want to talk about is just kind of put some scenarios out there. And so I also, in addition to our speaker, Scott Rode is going to join us, and Julie Freymire, who's our ATPT from the Cancer Chiefs, is also going to join us, because I want to get her perspective a little bit on rehab. So touching on the AC joints, since this is something that we see that's the most common injury that we see in the shoulder in football, just some general questions, and we can kind of go down. You know, when do you inject them, what do you inject, is something I want to know. Because what Vijay mentioned is, we're pretty aggressive about injecting even grade ones, twos, and threes right away, as soon as we see them, as soon as we get them off the field kind of thing. And I'd like to get Julie's perspective. She's seen that in terms of the rehab, does she see a difference? But Mark, do you guys consider doing that? Are we crazy? What's going on? No, I, whether you consider doing it or you're crazy are two separate questions. No, I'm with you, G. This is one where we are very, very liberal about injecting these things, that the way that I think about injections, especially in this population, is what are the consequences of too many injections? And so there are certain joints, right? You don't want to deal with those consequences, the knee, the shoulder, et cetera. The AC joint, the consequences of injecting that multiple times are that, you know, potentially they get AC joint arthrosis, which if you do a distal clavicle, we know the results of that are going to be very, very good. So I think the downside is a small downside, and the upside in terms of pain relief, rehab, et cetera, is a much bigger upside. So I think you need to tell your athlete about that, but I would have a very low bar to inject frequently. What about you, Mike? Are you guys injecting right away or no? Yeah, I also think it depends upon what you inject. You know, we'll use a lot of local anesthetics for injecting these. You know, I think that with regard to the degradation to the joint, you know, if you're using steroid, you got to worry about that more than you do with a local anesthetic. So at the time of injury, we even inject it, and then frequently we'll do pregame injections, pad the area, that helps out a lot too. I think that with regard to steroids, we usually will use that depending upon how much pain they have during the week, you know, because we don't want to be injecting them before every practice. So if they have difficulty lifting their arm up, then we'll use a steroid to help with the rehabilitation. Paige? Well, you got my input on this 10 minutes ago, but the bottom line is when we inject, the AC joint is one thing, but it's also getting those CC ligaments. I find taking a needle and dragging it along the CC ligaments tends to make a big difference at the end result. And the idea behind it is to block things early to see if you can rehab them early. I think if you wait, my experience is that it doesn't really do much. So you got to get in front of it. I imagine you've heard what you need to hear. I mean, not much difference. Okay. We'll inject them, we'll use steroid the first injection. I've used lidocaine and marcaine for your pregame injection, 30 minutes before the game. As you said, it's markedly described, it's simply safe. And if you have a big problem, you're going to have some osteolysis or something you go on and you can do, you can fix it with a distal clavicle incision. One thing I would point out just, C. Acnes exists in the shoulder. And if you go ahead and do your AC joint resection, maybe you don't want to take any cultures if you've done six injections, because now it's our fault. Julie, what are your thoughts? Have you seen these both ways? Have you seen them where you've, you know, you guys have been able to inject a player right away with the injury versus, you know, hey, they didn't want the injection. What's their rehab, their return to play look like in your hands? Yes, I think with the injection, they're going to be sore either way. So we're pretty, we do the x-rays right at the game. And then we'll tend to do that if they're up for it, the cortico injection right after the game. So the next day they're sore regardless. So it's really not changing our rehab the first couple of days, because they're sore from the AC sprain in general, they're sore from the game. So they're sore from that or sore from the injection. It doesn't really matter. Your rehab is going to be pretty much the same. I think where we see the biggest difference in the rehab side of things is on day three, four. So Wednesday, Thursday, they'll make a little bit bigger jump when they have that injection versus not having the injection. Great input. What about, when do you ever consider fixing these in your collision sport athletes, football, hockey? Mark. For me, it's really symptomatic. And I would say the plus on your slide here, G is probably more important than the three. You know, the threes that we, I might be committing heresy here, but up down motion of the clavicle seems to bother nobody, right? For anybody who takes care of hockey athletes, you see the clavicle sticking up by their ear half the time. And they really just, they don't, they're in to see you about their knee or something like that. And so it's the front back. And so any of those where they're still having trapezial pain, symptoms, things like that, and that persists throughout and after the season, I would say that those are worth fixing. What do you think, Scott, John, Mike, do you? Yeah, I completely agree with what Mark said. I call them, you know, good threes and bad threes. You know, usually the ones that are the bad threes are kind of stuck to that trapezial fascia. So they'll have the issues. If you try to just do like an empty can test with them, you usually will see it stick up. But if it does that and they have no symptoms, then clearly I'm not going to fix it. Maybe a different question for Vigna and Scott. How would you fix them then? Are you fixing them differently in your collision contact sport athletes than your regular patient? Well, you know, one point I make to that, kind of related to the prior discussion there too, I think the ones you might fix are the higher grade, obviously, but if there's horizontal instability, if the acromion drives in the clavicle, you go cross body, that can push you through doing that. And that's probably more of a five, frankly. It's probably not really just a true three. And to Mark's point, so if you are, and in your question, if you're going to fix it, I think you need to consider the horizontal instability. So I think our modern contemporary techniques for C-C ligament reconstruction are pretty good. So I think you can wait, because you can do a good job late. You don't have to do anything early. If early, you can go ahead and try to put in something that's going to let the ligaments heal. In general, even if I do that, I'm putting a graft in. I mean, I'm not going to trust just the healing of the C-C ligaments. So I think our standard graft reconstruction techniques, I'll use one tunnel in the clavicle. I wouldn't put two, like Mazzocco's talked about. The contact athlete, I don't mind putting one hole, I wouldn't put two. But one limb through the clavicle, one posterior with an anchor. And then, but then bring your graft over to the A-C joint, which I think the point Mark's make, that makes the horizontal instability is critical. And I would say I've moved away from doing any holes in the clavicle, and I do a much simpler construct of a graft, just like Scott said, and wrap it around the coracoid. Then I bring both limbs posterior around the clavicle, and then bring them around the clavicle to the front. Again, just wanting to get it out of the trapezial fascia. And it'll stretch, they'll have a little bit of horizontal instability, and they'll be very, very happy. Yeah, the one thing I would, because we see a lot of this in revision work in this, is that if you're going to do it, I agree, you have to put a graft in. At any of these, just putting the anchor through the coracoid, and it just doesn't work. So please put a graft in if you're going to do that. And keeping the distal clavicle. I used to resect it because it was easier to put it down, but I think that with regard to your horizontal stability, keeping the distal clavicle's key. Julie, have you had to rehab any of these surgically treated? Not in the five years that I've been at the Chiefs, we haven't had any. I've done some in my time, and they've done well, although they were college at the time, so I don't know how they did after that. But like I said, we haven't had any with the Chiefs. You got one question I asked you guys, or the one time you might consider a three. Some of the AC joints can have an associated labral tear. Say for a reason, you think you have to fix a labral tear, you're in there doing a labrum, do you go ahead and fix the CCs while you're there, the AC joint? I mean, we had one with the Giants when I did both. I think it's probably more of a five, not a three. But that would be one consideration for you. If you're in the OR anyway, fixing the labrum, do you go ahead and fix the AC joint? On the same note, I do think that it's important to get an MRI on all these AC separations, because there is about 30% concomitant injury rate with labral pathology or rotator cuff pathology with these. That's a good point. So just shifting gears, we have a couple minutes. We'll just touch on this. We did talk a lot about instability already this morning, but I always like to kind of get the pulse of what everyone is kind of doing, just to kind of help the audience and myself. So just these three scenarios here. So you have a first time dislocator, soft tissue bankart, just go down the road. He's not getting better. How are you fixing that? Is that a scope procedure for you? Is that open? Is that a bony procedure? It's scope for me, scope. Same. Yep, good tissue quality, no bone loss. First time, scope. For the group, keep in mind, the group we're talking about here, 23-year-olds, 24-year-olds, very different than all the literature you heard earlier, 15, 16, 17-year-olds. That's a different animal. I mean, your recurrence rates there are much different. Get to the NFL level, we don't see those recurrent rates. What about if he's got a little bone fragment? 10%, 15%. I don't even know how close you can measure these, but let's say it's in that range. I still have a low bar to do a scope, and then if I don't love the fragment or anything like that, like Dr. Bradley said earlier today, I'm still old enough to believe in the open Bankart, so I think that works very well in this group. If it's a first-time dislocator that has a bony Bankart that's 10% and I can reduce it, then I think I would do the arthroscopic. You can reduce that fairly well. If it's somebody that's a recurrent dislocator, they started dislocating three years ago, this has occurred a while ago, it's healed down, and you can't reproducibly get that back up, then I would go with a coracoid transfer. Well, I'm going to be the dissenter, I believe. I would do everything possible to fix the bone. More often than not, these are fixable, and it's rare that I have to do, and I do a fair number of Bankarts, that I have to do any type of bony work other than fixing the bone. If you do have to do bony work, the other thing you need to consider is, and I'm not a big believer in this, but I do use it occasionally as a remplissage. Yeah, if it's truly just 10%, to the issue of later-givers, can you fix it, look at the quality of your bone. You can see if it's ischemic. If it's old and ischemic bone, then I'm not going to fix it, but otherwise, I'm on the side of trying to fix it. Like John, I think you can fix that. I don't think you need to do a later-give for 10%. You tell me it's 15 or 20, it's probably different, but 10%, cute, I'd try to fix that. I think you can. And you might add a remplissage. I'm starting to do that more and more, adding the remplissage. And Julie, just let you have the last word on this, not so much on terms of fixing it, but on the rehab side, do you see a significant difference when you're rehabbing your arthroscopic Bankarts versus your open Latter-day type procedures? No, I would say for the most part, regardless of the procedure, our guys do really well. I think they don't really have any problems with football activity. The biggest place we have to make any modifications or they have any issues is the weight room, but they get back to football fine. We really don't have any complications. And bracing, what do you guys like to use there? Depends on the position of the player and what they'll let us put them in. Your skilled players typically won't let you put them in the ones that attach to the pads that are gonna restrict more motion. Those will be more your linemen, sometimes a linebacker. Otherwise, it'll be like a Sully, which is the neoprene with the straps on it for your skilled positions. Excellent. I'd like to thank the panel. We're gonna stay right on time here. I'm gonna invite Dr. Kender. Oh, wait, sorry. The great Dr. Bruce. No, I had two quick questions. One is the AC joint is the one we inject the most. That's probably our most frequent injection. Quick sense from the panel. I know Dr. Rodeo mentioned the steroid injection at the beginning and then either lidocaine or marcaine to follow pregame. Is that consistent amongst the group? Is anyone injecting them with steroid multiple times? And then the second one is that early activation that Julie mentioned. If you can get them moving in that first three or four days, they seem to be able to play versus the ones that stay weak. Any thoughts, Julie or panel, in terms of getting them in the pool or what other unique modalities there are to get that early activation? Because that seems to be, if you can get them moving by Wednesday, they play. If not, they seem to be having trouble. Yeah, my biggest thing, I always say this and people make fun of me, but motion is lotion. The more you move, the better you're gonna feel. So our guys are gonna come in and they are not gonna wanna move, but we make them move. So I'm a big proponent of the pool. They always feel better after they get out of the pool. They have more motion. The orthostatic pressure from the pool, they just feel better after being in the pool. So we'll use that a lot and we'll use dumbbells in there. We have webbed hands that we can do some strengthening stuff in there as well. And then the other thing we do to get early motion is we'll put like a bio-wave unit, which is a E-stem that targets for pain. And we'll put that right over the AC joint and get them moving with that E-stem unit on as well. So we are getting them moving as much as possible in the first day. Excellent. Thank you guys. And Julie. Object to early. Thank you.

shoulder injuries

football players

injection of AC joints

rehab methods

individualized care