Coracoclavicular ligament reconstruction (CCLR) is an orthopedic procedure designed to restore stability to the shoulder girdle following a severe injury to the acromioclavicular (AC) joint. This surgery is typically reserved for patients with significant and persistent displacement of the clavicle, often those with high activity levels. The goal is to re-establish the normal alignment between the clavicle and the scapula by recreating the damaged internal support structures. This intervention prevents chronic pain and dysfunction when the body’s own healing processes are insufficient to stabilize the joint.
Understanding the Injury That Requires Reconstruction
The stability of the AC joint relies on two groups of ligaments: the AC ligaments, which surround the joint, and the coracoclavicular (CC) ligaments, which lie below it. The CC ligaments consist of two distinct bundles, the trapezoid and the conoid, anchoring the clavicle to the coracoid process of the scapula. The trapezoid ligament is positioned horizontally and laterally, while the conoid ligament is vertically oriented and medial. Together, they provide the primary restraint against vertical separation of the clavicle.
An injury requiring reconstruction is typically the result of high-impact trauma, such as a direct blow or a fall. This mechanism drives the scapula downward while the clavicle remains in place, causing a sequential failure of the supporting structures. Failure begins with the AC ligaments and progresses to the CC ligaments. When both are completely torn, the clavicle loses its anchor and displaces significantly, often visible as a prominent bump on the shoulder.
Surgeons use the Rockwood classification system to categorize the severity of these injuries. Reconstruction is necessary for higher-grade separations. Type III injuries involve rupture of both AC and CC ligaments and are sometimes treated operatively. Reconstruction is consistently recommended for Type IV, V, and VI injuries, which involve severe displacement and represent a complete failure of the ligamentous complex.
Determining the Need for Surgery
The decision to proceed with CCLR is based on confirming the severity of ligament damage and assessing joint instability. The initial evaluation includes a physical examination checking for tenderness, swelling, and the extent of clavicle movement, known as a “step-off” deformity. The patient’s functional demands are also weighed heavily, as those performing frequent overhead work require greater joint stability.
Imaging studies are essential for diagnosis and surgical planning. Standard X-rays confirm the clavicle’s superior displacement, and stress X-rays can accentuate the displacement, confirming CC ligament failure. Advanced imaging like MRI or CT scans may be utilized to evaluate surrounding soft tissue structures and confirm the precise tear pattern. A CC distance that is doubled compared to the uninjured side is a strong indicator favoring surgical reconstruction.
How Coracoclavicular Ligament Reconstruction is Performed
The objective of the surgical procedure is to reduce the displaced clavicle to its proper anatomical position and anchor it securely to the coracoid process. The procedure is typically performed under general anesthesia, often involving a small incision, though some techniques are performed arthroscopically. The surgeon identifies the coracoid process and the underside of the clavicle, preparing the area for fixation.
Restoring stability is achieved using biological reconstruction or synthetic fixation. Biological reconstruction utilizes a tendon graft, either an autograft harvested from the patient or an allograft from a donor, to replace the ligaments. The graft is looped around the coracoid process and passed through two bone tunnels drilled into the clavicle, mimicking the native attachments. The graft is then secured using interference screws or specialized buttons, providing a biological scaffold that incorporates into the bone.
Synthetic fixation uses high-strength, non-absorbable materials, such as suture tapes or specialized button devices, for immediate stabilization. A common technique uses a cortical button placed beneath the coracoid process, connected via strong sutures that pass through drill holes in the clavicle. The sutures are tensioned and secured over the clavicle, pulling the bone into the reduced position. While this method offers immediate mechanical strength, it is often augmented with a tendon graft to provide a more durable, long-term solution.
The Recovery Timeline and Rehabilitation Process
Recovery following CCLR is a multi-phase process that focuses on protecting the repair while gradually restoring mobility and strength. The initial phase, lasting four to six weeks, focuses on immobilization, requiring the patient to wear a sling constantly. During this time, the patient performs gentle, pain-free exercises for the elbow, wrist, and hand to prevent stiffness.
The intermediate phase focuses on regaining passive and then active range of motion (ROM). A physical therapist guides controlled passive ROM exercises, often limiting elevation and abduction to 90 degrees initially to avoid undue stress. As healing progresses, typically six to twelve weeks post-surgery, active motion is introduced, and gentle strengthening exercises for the rotator cuff and scapular stabilizers begin.
The final phase, starting around three to four months, centers on advanced strengthening, endurance, and functional training. The goal is to achieve full, pain-free ROM and restore strength for a return to pre-injury activities. Return to light sports occurs between four and six months, but a full return to collision sports or heavy overhead labor is generally not permitted until six to twelve months after the operation.