A method of “docking” the allograft to the acromion has been found to be effective as a sturdy construct. Two 2.4 mm drill holes are made from the lateral acromial edge to the superior acromial edge at the joint (Fig. 9.2a). The acromial edge is lightly debrided to provide an attachment site and to stimulate healing, and a #2 PDS suture is passed as a loop suture passer (Fig. 9.2b) to be employed later.

The CC interval can then be visualized through a deltoid splitting incision. Careful dissection around the coracoid frees up the scar and creates a tunnel for graft passage. Passage of the instrument from the medial to lateral side and shuttling the graft from the lateral to medial side minimizes the risks to the underlying neurovascular structures.

The CC reconstruction construct consists of a semitendinosus allograft (6.0 mm × at least 260 mm) and 5 #2 PDS sutures to be used as an internal splint. Each of the graft ends is prepared with a baseball type stitch running about 25 mm on each end. This construct is passed around the undersurface of the coracoid and is passed through anatomically positioned 4.5 mm clavicular drill holes. The conoid drill hole is placed from the posterior superior edge of the clavicle, aimed at the conoid tubercle, a readily palpable landmark on the undersurface which is present directly superior to the medial edge of the coracoid. The trapezoid drill hole is placed about 1 cm anterior and 1.5–2.0 cm lateral to the conoid hole, depending on patient size, and is aimed at the trapezoid ridge on the undersurface at about a 30° angle to the vertical from the lateral coracoid edge (Fig. 9.3). Both limbs of the graft construct are then passed, and the joint is manually reduced by bringing the acromion to the clavicle. The sutures are tied down over the clavicle to provide initial stability for the CC reconstruction. The graft limbs are tensioned and then sutured together over the clavicle with multiple nonabsorbable sutures. Stability of the CC reconstruction can be checked by demonstration of elimination of inferior/superior laxity.

The AC ligament reconstruction includes superior, anterior, and posterior components. The graft tails can be used to reconstruct the superior AC ligaments, and the native tissues can be used to repair the anterior and posterior ligaments. Two biocompatible anchors (PushLock, Arthrex, Naples, FL) double loaded with #1 nonabsorbable suture are placed into the anterosuperior and posterosuperior clavicle, and the sutures are passed through the mobilized native AC ligament tissues, but not tied. The allograft tails are brought to the acromial edge; the correct length to ensure graft tension and attachment to the acromion is determined, and a passing suture of #1 nonabsorbable suture is placed (Fig. 9.4). These sutures are then passed through the previously placed acromial drill holes and tied over the lateral acromion, attaching the graft tails to reconstruct the superior AC ligament. The anterior and posterior native tissues are then tied down, completing the repair (Fig. 9.5). The stability of the entire construct is then assessed to demonstrate elimination of both inferior/superior and anterior/posterior laxity. The deltoid split is closed, the wound is closed in layers, and a sling and swathe is applied.