Type 4 Acromioclavicular Joint Separation Reconstruction With Suspensory Fixation, Allograft, and Suture Augmentation

This is a case of surgical treatment of a type 4 acromioclavicular (AC) joint separation via an arthroscopically assisted approach and reconstruction with combined suspensory fixation, allograft ligament reconstruction, and suture augmentation. AC joint injuries are relatively common, representing approximately 9% of shoulder injuries and approximately 50% of sport-related shoulder injuries. Most AC joint injuries do well when treated conservatively. However, the literature supports surgical treatment for high-grade injuries, failed conservative treatment, and open injuries or those with threatened soft tissues, with good clinical outcomes.

Given the patient's age (14 years), activity level as a multisport high school athlete, limited shoulder function, and type 4 AC joint separation, surgical intervention for AC joint reduction and reconstruction was recommended.

The patient is positioned in the beach-chair position. Standard shoulder arthroscopy is performed to evaluate for intra-articular pathology. The rotator interval is opened, and the undersurface of the coracoid is identified and cleared. An incision is created along the distal clavicle in line with the AC joint. The distal clavicle is found tethered in the trapezius muscle and is freed, reduced to its AC joint position, and secured with a K-wire. The AC reconstruction guide is positioned 3 cm medial to the AC joint and hooked under the coracoid base. Using arthroscopic guidance and fluoroscopy for anatomic positioning, a tunnel is drilled. The suspensory fixation device is passed through this tunnel and secured under the coracoid. The ends of the semitendinosus allograft with suture augmentation are passed medially and laterally around the coracoid base through the anterior arthroscopic portal, respectively, and retrieved through the superior incision. The medial limb is shuttled through a 3-mm drill hole in the clavicle, 15 mm medial to the suspensory fixation device, with adequate spacing to decrease fracture risk. The superior button of the suspensory device is tightened, the allograft ends are tied and sutured together, and the suture augment is tied securely to complete the AC joint reconstruction construct.

The patient was able to resume his activities of daily living without pain, with a full range of motion, and returning strength at 5 months postoperatively. He began a sports-specific return-to-golf program for the upcoming season.

Arthroscopic-assisted reconstruction of type 4 AC joint separations with combined suspensory fixation, allograft ligament reconstruction, and suture augmentation is an effective surgical method to return patients to painless functional use of the extremity.

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