AC Joint Reconstruction

Why this approach — at MOS

We use anatomic CC ligament reconstruction as our preferred technique — recreating both the trapezoid and conoid components of the CC ligament complex — over simple suture-button fixation alone. Biomechanical data supports the anatomic two-limb reconstruction in resisting the full range of clavicle displacement directions (superior, posterior, horizontal). We use allograft for most reconstructions to avoid donor-site morbidity.

For acute Grade IV–V separations, we prefer early surgical intervention — within 3 weeks of injury — when tissue planes are cleaner and reduction is more easily maintained. Chronic reconstructions (performed months after injury) require more extensive soft-tissue work but remain effective.

Who is a candidate?

Indications

• Grade IV, V, or VI AC joint separation (all require surgery given the degree of displacement)
• Grade III separation in active young patients — athletes, manual laborers — who require full shoulder function
• Chronic AC joint separation with persistent functional limitation after conservative treatment of an acute injury
• Failed prior AC joint fixation

Contraindications

• Grade I or II AC joint injuries (conservative management)
• Grade III injuries in lower-demand patients (conservative management is appropriate)
• Active shoulder infection
• Significant osteoporosis limiting fixation quality
• Severe comorbidities precluding surgery

Conservative Treatment First

Grade I and II separations are treated non-operatively in virtually all patients. A brief period of sling use for comfort, followed by progressive physical therapy to restore range of motion and strengthen the rotator cuff and periscapular muscles, allows most patients to return to full function within 4–8 weeks. Grade III separations are treated non-operatively first in most patients — a 4–6 week trial of sling immobilization, activity modification, and physical therapy. Many Grade III patients — particularly older, less active individuals — achieve acceptable outcomes without surgery.

In young, high-demand patients with Grade III injury, particularly those who need full overhead function for their sport or work, or who develop persistent pain and weakness despite conservative treatment, surgical reconstruction provides more reliable restoration of normal shoulder biomechanics. The surgical decision for Grade III injuries in the Bethesda and Montgomery County region is made through a shared decision-making process that considers the patient's occupational and recreational demands.

The procedure

What Is AC Joint Reconstruction?

AC joint reconstruction surgically restores the position of the clavicle after a high-grade shoulder separation by reconstructing the torn coracoclavicular ligaments. It uses a tendon graft or synthetic device to hold the clavicle back in proper alignment with the acromion. Surgery is typically performed for Grade III–V separations in active patients.

The acromioclavicular (AC) joint connects the collarbone (clavicle) to the highest point of the shoulder blade (acromion). It is stabilized by two sets of ligaments: the AC ligament at the joint itself, and the coracoclavicular (CC) ligaments — the trapezoid and conoid — that connect the clavicle to the coracoid process below. A shoulder separation is a ligament injury to this complex, usually from a fall onto the tip of the shoulder or a direct blow in collision sports.

Shoulder separations are graded I–VI by the Rockwood classification. Grade I (AC ligament sprain only) and Grade II (AC ligament tear, CC ligaments intact) are treated conservatively. Grade III (complete tear of both AC and CC ligaments with mild to moderate clavicle elevation) is controversial — many patients do well without surgery, but active patients with demanding occupational or sports requirements may prefer surgical stabilization. Grades IV, V, and VI involve more severe displacement and generally require surgery.

Reconstruction recreates the CC ligaments with a tendon graft (most commonly a semitendinosus allograft) or a synthetic device, reducing the clavicle to its anatomic position and maintaining that reduction while the reconstruction heals.

What Happens During AC Joint Reconstruction?

You arrive at the ambulatory surgery center 90 minutes before surgery. An interscalene nerve block is placed and general anesthesia is administered. You are positioned in the beach chair position. A brief diagnostic arthroscopy is typically performed first to assess the glenohumeral joint for associated intra-articular injuries.

An incision is made over the AC joint and clavicle, typically 3–5 cm. The clavicle is cleaned of soft tissue and the AC joint capsule is assessed. Two small drill tunnels are made in the clavicle — one at the trapezoid footprint and one at the conoid footprint — sized to accept the graft or device. A small fixation button or cortical anchor is passed through the coracoid process (or around it) to anchor the inferior limb of the reconstruction. A semitendinosus allograft (or other appropriate graft) is passed through the clavicular tunnels and around or through the coracoid and tensioned to reduce the clavicle to its anatomic position relative to the acromion. The AC joint capsule is repaired. The wound is closed in layers and the arm placed in a sling.

Recovery timeline

Frequently Asked Questions

Meet the surgeons

Christopher S. Raffo, MD

Orthopedic Surgery · Sports Medicine

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John J. Christoforetti, MD

Orthopedic Surgery · Sports Medicine · Hip Preservation Surgery

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James S. Gardiner, MD

Orthopedic Surgery · Sports Medicine

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