You Were Told You Separated Your Shoulder. You Were Also Told Surgery Has a High Failure Rate and Therefore Were Not Offered to Have it Fixed.
Both of Those Things Are True — and There Is More to the Story.
AC joint separation is one of the most common shoulder injuries in athletes and active adults — and one of the most commonly mismanaged. The injury itself is straightforward: the acromioclavicular joint, where the collarbone meets the shoulder blade, is disrupted when its supporting ligaments tear. The result is pain, a visible bump at the top of the shoulder, and varying degrees of functional loss depending on the severity.
The surgical treatment is anything but straightforward.
More than 400 different techniques have been described in the medical literature for AC joint reconstruction. That number is not a sign of progress — it is a sign that the orthopedic community has not yet reached consensus on how to solve this problem reliably. Failure rates after AC joint surgery are real and well documented. Many surgeons are reluctant to operate on this injury at all, because the anatomy demands working in close proximity to dangerous neurovascular structures, and because the risk of fracturing the coracoid process or the clavicle during fixation is not trivial.
Dr. Raffy Mirzayan has published both a classification system for AC joint injuries — cited more than 100 times in the medical literature — and his own surgical reconstruction technique. He has spent years refining an approach that addresses the most common reasons AC joint surgery fails, using a combination of FiberTape cerclage fixation and allograft tendon reconstruction that provides superior strength and stability compared to traditional methods.
If you have been told your AC separation needs surgery — or that surgery is not worth attempting — call (310) 746-5918 to get an honest assessment of where you stand and what your options are.
Understanding the Injury: The AC Joint
The acromioclavicular joint sits at the top of the shoulder where the clavicle (collarbone) meets the acromion — the bony projection at the top of the scapula (shoulder blade). This joint is stabilized by two sets of ligaments: the acromioclavicular ligaments, which control horizontal stability, and the coracoclavicular ligaments — the trapezoid and conoid — which connect the clavicle to the coracoid process of the scapula and are primarily responsible for vertical stability.
When the shoulder takes a direct blow — a fall onto the point of the shoulder, a collision in a contact sport, or an impact in a cycling or skiing accident — these ligaments can stretch, partially tear, or completely rupture. The result is separation of the joint, with the clavicle riding upward relative to the acromion and producing the characteristic bump at the top of the shoulder.
Grades of Injury
AC joint separations are classified by severity. Dr. Mirzayan contributed to the ISAKOS upper extremity committee classification system for AC joint injuries, which has been cited more than 100 times in the peer-reviewed literature and remains one of the most widely referenced classification frameworks for this condition: ISAKOS AC Joint Classification — Published Classification System
Grade I and II injuries involve partial disruption of the ligaments with the joint remaining in acceptable alignment. These injuries are typically managed nonoperatively with excellent results. Grade III injuries involve complete disruption of both the AC and coracoclavicular ligaments, with significant displacement of the clavicle. Treatment of Grade III injuries remains one of the most debated topics in shoulder surgery — some patients do well without surgery, others develop chronic pain and functional limitations that require reconstruction. Grade IV, V, and VI injuries involve severe displacement and almost always require surgical reconstruction.
Why AC Joint Surgery Is Difficult — and Why Most Surgeons Are Reluctant to Perform It
The honest answer to why AC joint surgery has such variable outcomes is that this is a genuinely hard problem. The coracoid process — the bony hook of the scapula around which the coracoclavicular ligaments attach — sits in close proximity to the brachial plexus, the subclavian vessels, and other critical structures. Passing hardware or suture around the coracoid, which is required for most fixation techniques, carries real risk of neurovascular injury in hands that are not deeply familiar with this anatomy.
Beyond the neurovascular risk, the mechanical demands on the reconstruction are extreme. The shoulder moves in every plane of motion, and the forces transmitted through the AC joint during overhead activity, lifting, and sport are substantial. Hardware can fail. Grafts can stretch or rupture. The clavicle or coracoid can fracture at the fixation site. These are not rare complications — they appear consistently across the surgical literature, which is precisely why more than 400 techniques have been proposed and none has been universally adopted.
Dr. Mirzayan approaches this problem with a technique designed specifically to address the most common failure modes: inadequate fixation strength, failure to reconstruct all of the stabilizing structures, and neglect of the superior AC joint capsule.
Dr. Mirzayan's Technique: FiberTape Cerclage with Allograft Tendon Reconstruction
Dr. Mirzayan's approach to AC joint reconstruction combines two elements that together provide a level of strength and stability that neither achieves alone.
FiberTape Cerclage Fixation
The foundation of the reconstruction is Arthrex FiberTape cerclage — a high-strength synthetic tape construct that loops around the coracoid and over the clavicle, recreating the function of the coracoclavicular ligaments and holding the reduction while the biological reconstruction heals. FiberTape provides superior fixation strength compared to traditional suture-based constructs and resists the cyclic loading that causes many repairs to stretch and fail over time.
Dr. Mirzayan described his surgical technique for AC joint reconstruction in a peer-reviewed publication in the Journal of Shoulder and Elbow Surgery: Reconstruction of the Acromioclavicular Joint — Surgical Technique
Additional technical details on the FiberTape cerclage approach are available through Arthrex here: AC FiberTape Cerclage — Arthrex
Allograft (Donor) Tendon Reconstruction
FiberTape alone holds the reduction — but it does not rebuild the torn biological structures. Dr. Mirzayan augments the fixation with a donor tendon allograft, which is used to reconstruct the coracoclavicular ligaments and — critically — the superior capsule of the AC joint.
The superior AC joint capsule is one of the most important and most neglected stabilizing structures of this joint. Most AC joint reconstructions focus exclusively on the coracoclavicular ligaments and ignore the capsule entirely. The result is a reconstruction that may hold vertical reduction but lacks the rotational and horizontal stability that the capsule provides. By bringing the limbs of the allograft tendon up to reconstruct the superior capsule in addition to the coracoclavicular ligaments, Dr. Mirzayan creates a more complete and biomechanically sound reconstruction — one that addresses the full three-dimensional stability requirements of the joint.
What to Expect: Diagnosis, Surgery, and Recovery
Diagnosis
Diagnosis of AC joint separation is made through a combination of physical examination and imaging. Standing X-rays of both shoulders — taken with and without weights — allow precise measurement of the degree of displacement and comparison to the uninjured side. MRI can provide additional information about associated soft tissue injuries. Dr. Mirzayan will review your imaging personally and give you his honest assessment of the grade of your injury and whether surgical reconstruction is appropriate.
Surgery
AC joint reconstruction is performed as an outpatient procedure under general anesthesia with a nerve block for postoperative pain control. The procedure involves reducing the displaced clavicle back to its anatomic position, passing the FiberTape cerclage construct around the coracoid and over the clavicle, and securing the allograft tendon to reconstruct the coracoclavicular ligaments and superior capsule. Patients go home the same day.
Recovery Timeline
The arm is placed in a sling for approximately 6 weeks to protect the reconstruction during the early healing phase. Physical therapy begins with gentle range-of-motion exercises and progresses to strengthening as healing allows. Return to full activity and sport typically occurs at 4 to 6 months, depending on the demands of the activity and the individual's healing progress. Dr. Mirzayan will give you a personalized return-to-activity timeline based on your specific injury and goals.
Coming from Las Vegas, Phoenix, or Out of State?
AC joint reconstruction is a procedure where surgical experience and technique selection matter enormously. If you have been told that surgery for your AC separation carries a high failure risk — or that no good surgical option exists — a second opinion from a surgeon who has published both a classification system and a reconstruction technique for this specific injury is worth pursuing before making any final decisions.
Dr. Mirzayan regularly treats patients from Las Vegas, Henderson, Phoenix, Scottsdale, and across the country. If you carry a commercial insurance plan — Blue Cross Blue Shield PPO, Aetna, Cigna, United Healthcare, or a self-funded employer plan — you likely have out-of-network benefits that cover a substantial portion of the cost of surgery. His office will verify your coverage before you commit to anything.
Virtual consultations are available. You can submit your imaging in advance, meet Dr. Mirzayan on video, and get an honest assessment of your injury and your options before committing to travel or time off work.
Call (310) 746-5918 or contact us online to schedule your consultation.
Frequently Asked Questions
What is an AC joint separation?
An AC joint separation occurs when the ligaments connecting the clavicle to the scapula are stretched or torn, causing the collarbone to displace upward relative to the shoulder blade. It is one of the most common shoulder injuries in contact sport athletes, cyclists, skiers, and active adults. The severity ranges from a mild sprain to a complete disruption of all stabilizing structures.
Do all AC joint separations need surgery?
No. Grade I and II injuries — where the ligaments are partially intact and the joint remains in acceptable alignment — are almost always managed successfully without surgery. Grade III injuries, where all ligaments are completely torn, represent a gray zone where some patients do well without surgery and others develop chronic pain and dysfunction that eventually requires reconstruction. Grade IV, V, and VI injuries with severe displacement typically require surgical reconstruction. Dr. Mirzayan will evaluate your specific injury and give you an honest assessment of whether surgery is appropriate.
Why does AC joint surgery have such a high failure rate?
Because it is genuinely difficult surgery, performed near dangerous neurovascular structures, under extreme mechanical demands. More than 400 techniques have been described in the literature — which tells you that no single approach has proven reliably superior. The most common failure modes are inadequate fixation strength, hardware failure, fracture of the coracoid or clavicle, and failure to reconstruct all of the stabilizing structures — particularly the superior AC joint capsule. Dr. Mirzayan's technique is specifically designed to address each of these failure modes.
What is the superior AC joint capsule and why does it matter?
The superior capsule of the AC joint is a soft tissue structure that provides rotational and horizontal stability to the joint — distinct from the vertical stability provided by the coracoclavicular ligaments. Most AC joint reconstructions ignore it entirely. When the capsule is not reconstructed, the joint may hold its vertical reduction but remain rotationally unstable, leading to persistent symptoms and eventual failure of the reconstruction. Dr. Mirzayan incorporates superior capsule reconstruction into every AC joint procedure using the allograft tendon.
What is FiberTape cerclage and why do you use it?
FiberTape is a high-strength synthetic tape manufactured by Arthrex that is looped around the coracoid and over the clavicle to recreate the function of the coracoclavicular ligaments. It provides superior fixation strength compared to traditional suture-based constructs and is more resistant to the cyclic loading that causes many repairs to stretch and fail over time. Dr. Mirzayan uses it as the fixation foundation of his reconstruction, combined with allograft tendon to provide the biological component of the repair.
Why do you use a donor tendon instead of the patient's own tissue?
Using a donor tendon — allograft — avoids the need to harvest tissue from another part of the patient's body, eliminating donor site pain and additional surgical morbidity. Allograft tendons are strong, reliable biological scaffolds that incorporate over time and provide durable reconstruction of the torn ligaments and capsule. There is no meaningful difference in outcomes between allograft and autograft for this procedure, and the avoidance of a second surgical site is a meaningful advantage for the patient.
Do you offer virtual consultations for out-of-state patients?
Yes. Dr. Mirzayan offers virtual consultations for patients traveling from out of state. You can submit your X-rays and MRI in advance, meet Dr. Mirzayan on video, and get a clear assessment of your injury and your surgical options before committing to travel. Call (310) 746-5918 to schedule.
Does being out-of-network mean I will pay full price out of pocket?
Not necessarily. Many patients with commercial insurance — especially PPO plans and self-funded employer plans — have strong out-of-network benefits. Dr. Mirzayan's office will verify your coverage before your consultation so you have a clear picture of what to expect before making any decisions.
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About Dr. Raffy Mirzayan
Dr. Raffy Mirzayan, MD is a double-board certified orthopedic sports medicine surgeon with 25 years of experience treating shoulder injuries in athletes and active adults at every level of competition. He contributed to the ISAKOS upper extremity committee classification system for AC joint injuries — cited more than 100 times in the peer-reviewed literature — and has published his own surgical reconstruction technique in the Journal of Shoulder and Elbow Surgery. With 88 peer-reviewed publications, 4 edited textbooks, and more than 200 invited lectures globally, Dr. Mirzayan brings a depth of academic and clinical expertise to AC joint reconstruction that is rare in any practice. He practices at DOCS Health in Los Angeles, serves as a Clinical Professor of Orthopaedic Surgery at USC, and welcomes patients from across the United States, including Las Vegas, Phoenix, and Scottsdale, for virtual consultations and in-person care.
DOCS Health | 8436 W 3rd St #800, Los Angeles, CA 90048 | (310) 746-5918 | raffymirzayan.com
