Regarding CC ligament-only reconstruction, the procedure is performed nonanatomically or anatomically. Nonanatomic reconstruction is not currently used alone. Instead it is used especially in chronic AC joint pathologies, as an additional procedure. In the literature, the reconstruction procedures such as Weaver-Dunn procedure, its modification, and other surgical method variants yielded controversial results in previous studies ([20, 41–50]).

In the recent study of [53], it was stressed out that the cadaveric studies are very limited, and none of these studies assess the stability in all three planes of motion and are limited by older CC reconstruction techniques (North et al. 2018, [51–54]). A recent meta-analysis demonstrated that loop suspensory fixation in acute unstable AC joint dislocation had higher Constant-Murley scores, lower postoperative pain, but higher complication rates when compared with hook plating [55]. In the study of North et al., advantages and disadvantages of CC ligament reconstructions were summarized as follows: vertical stability equivalent to native AC joint complex, single procedure, better clinical outcomes with double TightRope technique, and significantly less horizontal stability and lack of higher evidence comparative studies, subsequently (North et al. 2018, [30, 51–54, 56]). Currently, higher level of evidence and comparative studies are necessary to put forward more concrete conclusions.

Currently, the anatomical AC and CC joint reconstruction has been increasingly and more frequently performed [57, 58]. For the anatomical reconstruction, tendon grafts (autografts, allografts), synthetic materials, and loop suspensory fixation repair have been used [38, 44, 56, 59–61]. The advantages of anatomical reconstruction are summarized as the best biomechanical results comparable to the native joint, restoration of both vertical and horizontal stability of the joint, and successful clinical results at early and mid-term (North et al. 2018, [62–65]). On the other hand, technical difficulties, lack of long-term results, and lack of determination of the best method among various techniques are the main drawbacks of the anatomical reconstruction, for now.

There is a broad spectrum of protocols for the rehabilitation after AC joint injuries. In general, following anatomic reconstruction, postoperative rehabilitation may be as follows: simple sling for 2 weeks, pendulum exercises at 2 weeks, active range of motion exercises at 6–8 weeks, and resistive exercises at 12 weeks [21]. The return to play for professional athletes is usually at fourth and sixth month in cases of acute and chronic injuries, respectively [66, 67].

Special emphasis should be given for the “gray zone” type III injuries. In all meta-analyses about the comparative analysis of surgical versus conservative management of type III acromioclavicular dislocations, it was stressed out that there has been still insufficient evidence to establish the effects of surgical versus conservative treatment on functional outcome of patients with type III AC joint dislocations and that higher level of evidence studies are required to establish whether there is a significant difference in functional outcome between surgical and nonsurgical methods [34, 68, 69]. In a recent systematic review by Longo et al. [68], it is emphasized that there is growing evidence demonstrating that persistent pain was less frequently observed in patients with type III AC joint dislocation, who were treated by surgery, comparatively. In another recent meta-analysis by Longo et al., although nonoperative treatment of Rockwood type III AC dislocations resulted in a lower incidence of ossification of coracoclavicular ligament and osteolysis of the lateral clavicle compared with operative treatment, no statistical difference was found between operative and nonoperative treatments in terms of clinical outcomes [70].

Regarding timing of the surgical treatment, early surgery yielded more satisfied reduction with better functional outcomes and lower complications rates, when compared with delayed procedure, in a systematic review [71]. In the same study, it is emphasized that higher level of evidence studies are warranted to provide stronger support for this finding.

Arthroscopy-assisted techniques have been increasingly used by the time. Although they are soft tissue friendly and minimally invasive methods with lower infection rates, surgical morbidity, learning curve, and experience of the surgeon are the main limiting factors. In the meta-analysis by Helfen et al., it was shown that currently there was insufficient evidence demonstrating significant superiority of arthroscopic/minimally invasive and open procedures to another, in terms of functional outcomes and complications rates [72].

In chronic, symptomatic cases, resistant to conservative management, and AC joint degeneration, open or arthroscopic distal clavicular resection is applicable as a salvage procedure and offers similar clinical results at long term [73, 74].