Arthroscopic Fiber Tape-Augmented Coracoclavicular Ligament Reconstruction Using Semitendinosus Tendon for Chronic Acromioclavicular Joint Separation

Abstract

This article describes an improved arthroscopic, drill-free technique for chronic acromioclavicular joint separations, avoiding the risks of coracoid or clavicular fracture associated with bone tunnels. The technique eliminates bone drilling by passing No. 5 sutures and FiberTape (Arthrex) around the coracoid base and clavicle. A semitendinosus tendon graft is guided doubly around this path using the sutures. This creates a FiberTape-tendon complex that replicates native coracoclavicular ligament function, offering vertical stability and biological integration for long-term healing. This approach offers a safe, effective solution for chronic acromioclavicular joint instability.

Acromioclavicular joint separation represents a prevalent injury in sports medicine, predominantly affecting young male individuals. It accounts for approximately 9% of all shoulder injuries,¹ with the incidence exceeding 40% among athletes engaged in high-impact sports including rugby, boxing, and ice hockey. The stability of the acromioclavicular joint relies on the coordinated function of ligamentous structures and muscular contributions. The coracoclavicular ligament, serving as the primary vertical stabilizer, is critically important for maintaining acromioclavicular joint stability.

According to the Rockwood classification, acromioclavicular joint injuries are categorized into 6 types. Types I and II primarily involve partial ligamentous injury and are typically managed conservatively, whereas types III, IV, V and VI often require surgical intervention to restore stability.¹ Contemporary surgical strategies focus primarily on coracoclavicular ligament reconstruction or coracoclavicular interval fixation techniques. Although over 150 surgical techniques for symptomatic acromioclavicular joint separations have been described, no consensus exists on the optimal approach. Arthroscopy provides superior visualization of pericoracoid structures while avoiding extensive dissection of the deltoid fascia, thereby significantly reducing the risk of injury to adjacent neurovascular structures.² These distinct technical advantages establish it as an ideal surgical approach.

Traditional surgical techniques often require bone tunnel drilling in the coracoid process or clavicle, which carries long-term risks of coracoid fracture and osteolysis. The use of fixation implants—including screws, hook plates, and suture anchors—also carries significant risks, such as implant failure or migration, clavicular erosion or fracture, and recurrent separation. Chronic injuries (separation duration >6 weeks) present significantly greater therapeutic challenges owing to scar adhesions, ligament atrophy, and osseous remodeling at the injury site.³ Studies have shown that chronic injuries exhibit near-complete impairment of the coracoclavicular ligament's self-healing capacity. Mere reduction and fixation rarely achieve ligament regeneration, whereas drilling techniques carry elevated complication and recurrence risks in these cases.⁴ To address these limitations, this article describes an arthroscopic autologous tendon suture technique for separation reduction, thus eliminating the need for coracoid or clavicular drilling.

Surgical Technique

Preoperative Evaluation and Patient Preparation

Physical examination, radiography, and magnetic resonance imaging are performed preoperatively to assess rotator cuff pathology. The patient is positioned in the beach-chair position, shoulder anatomic landmarks are marked, and sterile preparation with draping is performed.

Surgical Procedure

A 3-cm longitudinal incision is made medial to the left tibial tuberosity to expose the semitendinosus tendon. The tendon is harvested using a tendon extractor and set aside for later use.

The posterior portal is established for intra-articular imaging and exploration. Under arthroscopic visualization through this portal, the anterior portal is created using a spinal needle (Smith & Nephew. Andover, MA). Subsequently, anterior and posterior clavicular portals are established. The anterior clavicular portal is positioned 1 cm anterior to the acromioclavicular joint, whereas the posterior clavicular portal lies at the posterior aspect of the junction between the middle and distal quarters of the clavicle. Figure 1 illustrates their surface locations.

Fig 1.

Surface anatomic locations of the anterior portal (black arrow), posterior portal (white arrow), anterior clavicular portal (blue arrow), and posterior clavicular portal (red arrow) on the right shoulder with the patient in the beach-chair position.

An arthroscopic shaver (Smith & Nephew) and radiofrequency device (Smith & Nephew) are introduced through the anterior portal into the acromioclavicular joint region to clean and open the joint capsule, progressively exposing the inner edge of the coracoid process (Fig 2, Video 1). When the surgeon is operating on the inner edge of the coracoid, the instruments must stay close to the inner edge and move down along the bone surface carefully to avoid injury to the brachial plexus, axillary artery, and axillary vein.

Fig 2.

Arthroscopic view from the posterior portal in the right shoulder with the patient in the beach-chair position, showing the radiofrequency device (blue arrow) introduced via the anterior portal for soft-tissue debridement within the joint capsule.

A lasso (Smith & Nephew) loaded with coiled No. 0 polydioxanone sulfate (PDS) suture is introduced through the posterior clavicular portal (Fig 3, Video 1). A thread grasper (Smith & Nephew) is inserted through the anterior portal and grasps and pulls out the PDS loop from beneath the coracoid process. A doubled No. 5 suture is tied to this PDS loop in an extracorporeal manner; pulling out the PDS loop delivers one No. 5 suture end through the anterior portal and the other through the posterior clavicular portal (Fig 4). A FiberTape (Arthrex. Naples, FL) is introduced by the same method. A thread grasper (Smith & Nephew) is inserted through the anterior clavicular portal. It grasps the protruding ends of the No. 5 suture and the FiberTape from the anterior portal and pulls them out through the anterior clavicular portal (Fig 5, Video 1). The remaining ends of the No. 5 suture and the FiberTape at the posterior clavicular portal are then delivered superior to the clavicle and pulled out through the anterior clavicular portal. At this point, the No. 5 suture and the FiberTape have completed a full circumferential loop around the base of the coracoid process and the clavicle (Fig 6, Video 1). With an assistant applying external pressure to confirm proper reduction of the acromioclavicular joint, the tape is tensioned and secured with a knot (Fig 7). The extracorporeal suture tails of the No. 5 suture are measured (Fig 8, Video 1). An isometric suture is used as a reference standard to calculate the length required for a full circumferential loop around the coracoid process and clavicle. On the basis of this measurement, the graft is designed to be 22 cm in length. A 2-cm segment at each end is woven with Orthocord suture (Johnson & Johnson).

Fig 3.

Arthroscopic view from the posterior portal in the right shoulder with the patient in the beach-chair position, showing a lasso (black arrow) loaded with polydioxanone sulfate suture (white arrow) introduced through the posterior clavicular portal. The red arrow indicates the coracoid base.

Fig 4.

Shuttling of a No. 5 suture. A doubled No. 5 suture (black arrow) is passed around the base of the coracoid process, guided by a polydioxanone sulfate suture loop, with its two ends exiting through the posterior clavicular portal (blue arrow) and anterior portal (red arrow).

Fig 5.

Arthroscopic view from the posterior portal in the right shoulder with the patient in the beach-chair position, showing a thread grasper (red arrow) introduced through the anterior clavicular portal grasping and transferring the No. 5 suture (white arrow) and FiberTape (blue arrow) from the anterior portal to the anterior clavicular portal.

Fig 6.

Arthroscopic view from the posterior portal in the right shoulder with the patient in the beach-chair position, demonstrating a FiberTape (black arrow) and No. 5 suture (blue arrows) encircling the coracoid process and clavicle.

Fig 7.

Suture shuttling. The No. 5 suture (blue arrow) and FiberTape are completely encircling the coracoid process and clavicle, with both ends exteriorized through the anterior clavicular portal (black arrow). The acromioclavicular joint is reduced under external compression applied by an assistant and subsequently secured with knot fixation of the FiberTape (red arrow).

Fig 8.

External surgical view of the right shoulder with the patient in the beach chair position, showing No. 5 suture encircling the coracoid process and clavicle, exiting through the anterior clavicular portal (white arrow).

Subsequently, the pre-placed No. 5 sutures are used to introduce two additional doubled No. 5 sutures. This ensures that both newly introduced sutures circle around the clavicle and coracoid process, with their ends delivered out through the anterior clavicular portal. These two No. 5 sutures guide the tendon graft for double-loop fixation around the coracoid and clavicle: First, the Orthocord suture at one end of the graft is tied to one end of the first No. 5 suture. The first No. 5 suture is pulled to complete the first circumferential loop. Subsequently, the same Orthocord suture is tied to the second No. 5 suture and is pulled through to achieve the second loop (Fig 9, Video 1). Finally, the surgeon tensions both Orthocord sutures from the graft and secures them with knots, thereby completing the double-loop fixation (Fig 10).

Fig 9.

Arthroscopic view from the posterior portal in the right shoulder with the patient in the beach-chair position, showing a double-looped tendon graft (blue arrow) encircling the coracoid process and clavicle.

Fig 10.

Double-loop fixation. The tendon graft is passed in 2 loops around the coracoid process and clavicle. Fixation is achieved by knotting the ORTHOCORD sutures at both ends (red arrow). The FiberTape is not depicted in this illustration.

Discussion

Arthroscopic surgery typically requires coracoid and clavicular tunnel drilling with implant fixation such as screws, hook plates, suture anchors, and buttons. However, drilling-related complications—including coracoid or clavicular fractures, infections, and reduction loss—remain clinically significant. Moreover, the incidence of postoperative complications in cases of chronic injuries is far higher than that in cases of acute acromioclavicular joint injuries.⁵ In a study analyzing 279 patients who underwent acromioclavicular joint surgery, Chen et al.⁶ found that 276 patients underwent intraoperative drilling of the clavicle or coracoid process. Another study indicated that the incidence of coracoid fractures with both mono-tunnel and double-tunnel techniques is 5.3%.⁵ Thus, drilling operations on the coracoid and clavicle require high caution.⁷

This article presents an arthroscopic technique for chronic acromioclavicular joint separation: FiberTape-augmented semitendinosus tendon reconstruction of the coracoclavicular ligament. By eliminating bone tunnel drilling and using autologous tendon fixation, this approach provides a solution for chronic injuries. The FiberTape-augmented tendon wrapping delivers vertical stability mimicking native ligament function, ensuring excellent postoperative stability while avoiding coracoid or clavicular drilling, significantly reducing the risks of tunnel-related fractures, osteolysis, and implant complications.

Studies indicate that in cases of chronic acromioclavicular injuries, isolated tendon graft reconstruction carries a risk of long-term recurrent separation. This may be associated with progressive elongation of the tendon graft over time.⁵ To address this, our technique innovatively uses FiberTape augmentation: First, the FiberTape provides immediate rigid fixation to ensure reduction stability. Second, the tendon graft facilitates biological integration for long-term stabilization. The double-loop configuration synergistically forms a FiberTape-tendon complex, which exhibits significantly superior shear resistance compared with single-suture techniques. The risk of this procedure lies in exposing the medial margin of the coracoid process during the operation. Conventional surgery usually avoids this region because of its adjacency to the axillary artery, axillary vein, and brachial plexus, where manipulation carries risks of injury to the blood vessels and nerves. Consequently, this procedure requires higher operative skills from surgeons to ensure safety. Table 1 summarizes the advantages and disadvantages of this surgical technique, and Table 2 presents pearls and pitfalls. We expect this technique to promote recovery and reduce postoperative complication risks, thereby enhancing patients' quality of life.

Table 1.

Advantages and Disadvantages of Technique

Advantages

Avoid drilling into coracoid process and clavicle, thereby minimizing risk of complications such as clavicular or coracoid fractures

Achieves high-strength acromioclavicular joint stabilization: FiberTape augmentation provides robust fixation while tendon grafts enable biological integration for long-term stability

Disadvantages

Technique indicated exclusively for chronic acromioclavicular joint separations

Procedure requires manipulation at medial border of coracoid process, therefore demanding advanced surgical skills from operator

Risks

Manipulation medial to coracoid process carries potential risks of injury to brachial plexus, axillary artery, and axillary vein

Table 2.

Pearls and Pitfalls

	Pearls	Pitfalls
Portal placement	Accurate localization of surgical portals facilitates subsequent procedural steps while minimizing potential injury risks.	Incorrect portal placement complicates instrument maneuvering, increasing risk of neurovascular injury.
Coracoid exposure	The surgeon should use a combination of an arthroscopic shaver and radiofrequency through the anterior portal to systematically debride the soft tissue. He or she should always keep the instrument in view and move down along the bone surface carefully when working on the medial coracoid border.	Aggressive debridement away from the bone on the medial side can easily injure the brachial plexus and axillary vessels. Inadequate exposure may lead to improper suture passage.
Suture shuttling	A coiled PDS suture lasso is used to shuttle the No. 5 suture and FiberTape, thereby preventing entanglement during passage.	Pulling a tangled suture may lead to breakage or fraying during shuttling, necessitating a restart of the process and prolonging surgery time.
Graft preparation and measurement	Accurate measurement of the required tendon graft length is essential to avoid over-tensioning or laxity after fixation. The measurement should be performed after the joint is reduced and fixed using FiberTape.	Inaccurate measurement of the graft length can result in a graft that is too tight (risking fracture or loss of reduction) or too loose (leading to persistent instability).
	Both ends of the tendon graft are woven with Orthocord suture to facilitate graft shuttling and fixation.
Reduction and fixation	It is critical that an assistant maintain firm, sustained downward pressure on the clavicle during tensioning and knot tying of the FiberTape and graft to ensure an anatomic reduction.	Incomplete reduction may lead to poor clinical outcomes and postoperative complications, which can potentially result in recurrence.
General technique	This drill-free technique is ideal for chronic cases with osteopenic bone or prior failed surgery in which tunnel drilling carries a high risk of fracture.	This technique is technically demanding and requires a significant learning curve.

PDS, polydioxanone sulfate.

Disclosures

All authors (Z.L., W.Y., T.P., Y.H., Z.H., P.L.) declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Supplementary Data

Video 1

Key surgical steps of chronic acromioclavicular joint (ACJ) separation reconstruction in a patient with prior failed EndoButton fixation (Smith & Nephew). The procedure includes (1) portal establishment (posterior, anterior, anterior clavicular, and posterior clavicular portals); (2) joint preparation (radiofrequency ablation [Smith & Nephew] via anterior portal to debride ACJ capsule and expose medial coracoid border), with caution to maintain the instruments close to the bone surface to avoid brachial plexus or axillary vasculature injury; (3) implant removal (extraction of existing EndoButton from prior surgery); (4) FiberTape and suture passage (polydioxanone sulfate [PDS] suture lasso [Smith & Nephew] introduced via posterior clavicular portal and retrieved beneath coracoid by thread grasper [Smith & Nephew], with doubled No. 5 suture and FiberTape sequentially passed around coracoid base using PDS shuttle technique); (5) reduction and FiberTape fixation; (6) graft preparation (semitendinosus tendon preparation); and (7) double-loop tendon fixation (two additional doubled No. 5 sutures passed around coracoid-clavicle; graft guided by sutures: first loop, Orthocord tied to No. 5 suture and pulled circumferentially; second loop, same Orthocord tied to second No. 5 suture, completing dual fixation; and final tensioning and knot security of Orthocord sutures.) Key technical highlights include FiberTape augmentation for primary stability, isometric suture measurement for precise graft length, and double-loop semitendinosus tendon fixation, enhancing biomechanical strength.