Tendon Graft Augmentation Was Not Associated With Improved Outcomes in Acute Bidirectionally Unstable High-Grade AC Joint Injuries: A Retrospective Cohort Study

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Abstract
Background: Loss of reduction and persistent instability are among the most common complications following acromioclavicular (AC) stabilization using suture button devices. The effect of additional tendon allograft augmentation on radiographic and clinical outcomes in acute AC joint injuries with bidirectional instability has not been investigated. Purpose: To evaluate the impact of tendon graft augmentation on radiographic and clinical outcomes after acute AC joint dislocations. Study Design: Cohort study; Level of evidence, 3. Methods: This retrospective cohort study included patients with acute AC joint dislocation and bidirectional instability (Rockwood IIIb and V). All patients were treated with arthroscopically assisted double-button fixation and an AC cerclage. Patients were treated consecutively without graft augmentation between 2018 and 2021 and with augmentation between 2022 and 2024. Vertical and horizontal stability were assessed preoperatively and at the latest postoperative follow-up using bilateral Alexander and panoramic shoulder radiographs. The primary radiographic endpoints were the coracoclavicular displacement ratio (CCDR) and side-to-side difference (SSD) of the circles measurement at final follow-up. The secondary endpoint was the clinical outcome (Subjective Shoulder Value [SSV], EQ-5D-5L) at the latest follow-up (defined as 24 months when available or 12 months otherwise). Results: In total, 120 patients were included (51 graft, 69 no graft). Time to surgery was comparable (10.94 ± 10.86 vs 11.04 ± 4.95 days; P = .95). Final CCDR did not differ between groups (31.4% ± 37.7% vs 31.0% ± 34.9%; P = .95), and graft augmentation was not associated with final CCDR after adjustment for age and follow-up duration (β = −2.0; 95% CI, −16.1 to 12.2; P = .79). The SSD of the circles measurement was comparable (4.65 ± 4.68 vs 5.06 ± 4.82 mm; P = .69). No significant differences were observed in SSV (89.9 vs 92.6; P = .21) or EQ-5D-5L (0.952 vs 0.962; P = .48). Conclusion: In patients with acute, bidirectionally unstable high-grade AC joint injuries, tendon allograft augmentation added to arthroscopically assisted double-button fixation did not improve radiographic reduction maintenance or patient-reported outcomes. These findings suggest that routine tendon graft augmentation may not be necessary in acute bidirectionally unstable high-grade AC joint injuries when adequate coracoclavicular and AC stabilization is performed.

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