CC Ligament Reconstruction: Steps, Graft Options, and Recovery

Damage to the coracoclavicular (CC) ligament can lead to shoulder instability and pain, often requiring surgery when non-surgical treatments fail. Reconstruction aims to restore function and stability, particularly in severe cases. Understanding surgical options and recovery helps patients make informed decisions.

This article covers key aspects of CC ligament reconstruction, including graft choices, procedural steps, and rehabilitation.

Anatomical Structure Of The Coracoclavicular Ligament

The coracoclavicular (CC) ligament stabilizes the acromioclavicular (AC) joint by connecting the clavicle to the coracoid process of the scapula. It consists of two components: the conoid and trapezoid ligaments. The conoid ligament, positioned medially, resists vertical displacement of the clavicle. The trapezoid ligament, located laterally, counteracts horizontal and rotational forces. Together, they prevent excessive movement between the clavicle and scapula.

Histologically, the CC ligament is composed of dense type I collagen fibers, providing tensile strength for load-bearing functions. It also contains fibroblasts, which maintain and repair the extracellular matrix. Limited vascularization affects its healing capacity. Biomechanical studies show the conoid ligament is stiffer, while the trapezoid ligament is more elastic, allowing the complex to accommodate shoulder motion while maintaining stability.

The CC ligament forms an oblique suspension system that transmits forces between the upper limb and axial skeleton. During arm elevation, it undergoes tension, contributing to clavicular rotation and scapular motion. Disruptions to this ligament can alter biomechanics, leading to AC joint instability and secondary musculoskeletal complications.

Common Injury Mechanisms

Trauma to the CC ligament occurs when forces exceed its tensile capacity, leading to partial or complete rupture. A common cause is direct impact to the shoulder, frequently seen in contact sports like football, rugby, and hockey. When an athlete lands forcefully on the lateral acromion, the scapula is driven downward while the clavicle stays relatively fixed. This excessive separation strains the CC ligament, which may fail under stress.

Falls onto an outstretched hand also contribute to CC ligament injuries. Axial forces travel through the upper extremity, transmitting stress to the AC joint and CC ligament. Cadaveric studies show that falling with an extended arm can create sufficient clavicular displacement to cause ligament failure. This mechanism is common in cyclists, skiers, and older adults prone to falls.

Motor vehicle accidents can also rupture the CC ligament. High-speed collisions or falls from significant heights generate abrupt deceleration forces that displace the shoulder girdle. Studies on injury patterns in crashes have linked AC joint dislocations to seatbelt restraints, where applied force creates shearing stress on the CC ligament.

Repetitive microtrauma is another cause, particularly in overhead athletes like weightlifters, baseball pitchers, and volleyball players. Sustained tensile loading gradually weakens the ligament, leading to partial tearing and elongation. Over time, chronic stress alters structural integrity, increasing the risk of significant injury with minor trauma.

Indications For Surgical Reconstruction

Surgery is considered when conservative treatment fails to restore stability and function. The decision depends on ligament disruption severity, clavicular displacement, and patient activity level. High-grade injuries, particularly Rockwood type IV, V, and VI AC joint dislocations, often require surgery due to significant displacement that impairs shoulder mechanics. Without correction, chronic pain, weakness, and limited overhead function can result.

Athletes and laborers relying on overhead movements are especially vulnerable to long-term dysfunction if instability persists. Even minor disruptions in shoulder mechanics can lead to performance decline and secondary injuries. Studies indicate that untreated AC joint instability increases the risk of scapular dyskinesis and rotator cuff overuse injuries. Early surgical intervention may provide better outcomes.

Chronic CC ligament insufficiency is another indication, particularly when instability leads to compensatory movement patterns and joint degeneration. Over time, these adaptations cause pain and functional limitations. Surgery in such cases not only restores ligament integrity but also improves joint biomechanics, preventing further deterioration. Stress radiographs and dynamic evaluations help assess the need for surgery.

Types Of Graft Tissue

Selecting the right graft for CC ligament reconstruction is crucial. Options include autografts, allografts, and synthetic alternatives, each with distinct benefits and limitations.

Autografts

Autografts, harvested from the patient’s own tissue, offer excellent biocompatibility and lower immune rejection risk. Common donor sites include the semitendinosus or gracilis tendon from the hamstring and the palmaris longus tendon from the forearm. These tendons provide sufficient strength to replicate the CC ligament’s function while allowing biological incorporation. Studies show autografts heal well due to their preserved cellular components. However, harvesting requires an additional surgical site, which can lead to pain, weakness, or delayed recovery. Despite this, autografts remain a preferred option for younger, active patients needing a durable reconstruction.

Allografts

Allografts, sourced from cadaveric donors, eliminate donor-site morbidity. Common options include the tibialis anterior, Achilles, or peroneus longus tendons, which provide adequate strength and flexibility. These grafts undergo processing to minimize disease transmission and immune response. While allografts avoid the need for a secondary surgical site, they may integrate more slowly than autografts. Some studies suggest they have a slightly higher risk of elongation or failure over time, particularly in high-demand individuals. Despite this, allografts are widely used in revision surgeries or cases where autograft harvesting is contraindicated.

Synthetic Alternatives

Synthetic grafts, made from materials like polyethylene terephthalate (Dacron) or polytetrafluoroethylene (PTFE), provide immediate mechanical stability and eliminate concerns about donor-site morbidity. Some designs mimic native ligament properties, resisting elongation and fatigue. However, long-term outcomes have been mixed, with reports of graft failure, foreign body reactions, or material degradation. Despite these challenges, advancements in biomaterials continue to improve synthetic options, making them viable in select cases.

Basic Steps In The Procedure

CC ligament reconstruction involves precise surgical techniques to restore alignment and stability. The patient is positioned in the beach-chair or supine position for optimal access. A longitudinal incision is made over the clavicle, extending toward the coracoid. Careful dissection preserves neurovascular structures, including the supraclavicular nerves and axillary vessels. The clavicle is mobilized, and any residual ligamentous tissue is evaluated before graft placement.

The graft is prepared and secured to replicate the native CC ligament’s function. Tunnels are drilled through the clavicle and, in some techniques, the coracoid for graft passage. The graft is then looped through these tunnels and tensioned to restore clavicular position. Fixation methods may include interference screws, cortical buttons, or suture anchors. Fluoroscopy is used intraoperatively to confirm positioning. Once stability is verified, the incision is closed, and the shoulder is immobilized to protect the repair during initial healing.

Rehabilitation Considerations

Postoperative rehabilitation focuses on graft healing while gradually restoring function. The initial phase, lasting four to six weeks, emphasizes immobilization to minimize strain. Patients wear a sling and avoid overhead or weight-bearing activities. Early passive range-of-motion exercises for the elbow, wrist, and hand help prevent stiffness. Some protocols allow gentle pendulum exercises to maintain mobility.

As healing progresses, active-assisted and active range-of-motion exercises are introduced. Around six to eight weeks post-op, strengthening exercises target the rotator cuff and scapular stabilizers. Resistance training is added cautiously, ensuring clavicular stability. By three months, patients transition to functional exercises based on their activity demands. Full-contact sports or high-impact activities are generally delayed until at least six months post-surgery, once imaging and clinical assessments confirm graft integration and joint stability.