Acromioclavicular Joint Reconstruction: Modern Techniques for a Complex Problem

The acromioclavicular joint transmits forces between the upper extremity and the axial skeleton during every overhead and loaded activity. Its disruption in high-grade injuries — Rockwood Type IV, V, and VI, and the subgroup of Type III injuries in high-demand individuals — produces functional consequences that go beyond the cosmetic deformity most patients first notice. Weakness in overhead activities, difficulty with cross-body loading, and the mechanical instability that prevents confident return to contact sport or heavy manual work are the functional drivers of surgical reconstruction in appropriately selected patients.

The evolution away from hook plate fixation

The hook plate — a device that hooks under the acromion to maintain AC joint reduction while ligament healing occurs — was for many years the dominant surgical technique for acute AC joint reconstruction. Its limitations have become progressively clearer with outcome data: acromial erosion, hook migration, subacromial impingement, and the mandatory second operation for plate removal create a complication and morbidity profile that anatomical reconstruction techniques avoid. Most high-volume upper limb centres have moved away from hook plate fixation toward reconstructive approaches that restore the coracoclavicular ligament anatomy rather than simply maintaining reduction mechanically.

Anatomical reconstruction: the evidence and the technique

Anatomical coracoclavicular ligament reconstruction — recreating the conoid and trapezoid ligaments through native tissue grafts, synthetic ligament augmentation, or a combination — produces biomechanical stability that more closely approximates the native ligament complex than hook plate or simple fixation techniques. The addition of synthetic ligament augmentation — particularly in acute repairs where the native tissues are insufficient for immediate load-bearing — provides additional stability during the biological healing phase while maintaining the anatomical reconstruction that supports long-term function.

The evidence base for anatomical reconstruction techniques, while growing, is less mature than that for hook plate fixation simply because the techniques are newer. Comparative studies and registry data consistently support equivalent or superior medium-term outcomes with lower reoperation rates for anatomical approaches compared to hook plate fixation. The absence of a mandatory second operation — with its associated anaesthetic risk, recovery period, and resource consumption — is a significant advantage that the evidence base supports adopting.