Arthroscopic Acromioclavicular Joint Reconstruction Using Knotless Coracoclavicular Fixation and Soft- Tissue Anatomic Coracoclavicular Ligament Reconstruction

Acromioclavicular (AC) joint injuries are one of the most common shoulder injuries, with an estimated incidence of 1.8/1,000 per year, and approximately 50% are sustained by athletes participating in contact sports. Although the treatment of Rockwood grade III AC joint injuries is controversial, a recently described subclassification may have helped solve the treatment algorithm with evidence supporting nonoperative treatment of Rockwood grades I, II, and IIIA (horizontally stable) whereas Rockwood grades IIIB (horizontally unstable), IV, V, and VI should be treated with surgical reconstruction.

Historically, open procedures have been the dominant surgical treatment strategy, although more recently, arthroscopically assisted techniques have become more popular because of the minimally invasive operation, the enhanced visualization, and the ability to diagnose and treat concomitant glenohumeral pathologies, which are common in higher-grade injuries. Complications of AC joint reconstruction techniques include coracoid or clavicle fractures, loss of reduction, and residual shoulder pain sometimes resulting from knot or hardware irritation at the superior clavicle fixation site, where there is minimal soft- tissue coverage.

For AC joint reconstruction techniques using suture-button systems and/or soft-tissue grafts, the risk of coracoid and clavicle fractures is associated with the number and size of drill holes and bone tunnels. Single-point fixation devices were sometimes inadequate and loss of reduction occurred, so techniques using 2 self-reinforcing suture-button systems to re- create each of the coracoclavicular (CC) ligaments were developed. These required multiple drill holes and bone tunnels, which sometimes resulted in clavicle or coracoid fractures. These double tightrope constructs evolved into single suture-button systems with thicker tape-like suture and larger buttons to better dissipate the forces.9 Additional soft-tissue grafts to reconstruct the CC ligaments are advocated by most investigators for chronic cases,3,10 whereas others advocate soft-tissue graft reconstruction of the CC ligaments in all cases of surgical AC joint reconstruction, with the goal of achieving improved primary stability.

Techniques that obviate drill holes in which the soft- tissue graft is looped around the coracoid and clavicle were developed to decrease the risk of clavicle or coracoid fracture. Despite the advantage of single bone tunnels with a lower fracture risk, these newer techniques had the disadvantage of having a thicker knot stack on top of the clavicle. In a systematic review assessing the rates of complications of AC joint procedures, Woodmass identified hardware irritation as the most common source of postoperative pain, with 4 studies using a suture-button fixation technique reporting the rate of this complication as 25% or greater.

An arthroscopically assisted anatomic CC ligament reconstruction technique that combines the potential advantages of a low-profile CC fixation device without knots and an anatomic reconstruction of the CC ligaments with a graft is presented in this report. The technique can be combined with an additional looped tendon graft stabilization for the treatment of both acute and chronic AC joint dislocations requiring surgical reconstruction.

Full Article: Arthroscopic Acromioclavicular Joint Reconstruction Using Knotless Coracoclavicular Fixation and Soft- Tissue Anatomic Coracoclavicular Ligament Reconstruction