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Background Horizontal instability following acute acromioclavicular joint (ACJ) reconstruction still occurs with a high prevalence. Although the human acromioclavicular ligament complex (ACLC) represents the major horizontal ACJ stabilizer, experimental studies on healing characteristics are lacking. Therefore, the purpose of this histological study was to investigate the healing potential of the ACLC following acute anatomical reconstruction Methods In this prospective clinical-experimental study, 28 ACLC biopsies were performed in patients with complete ACJ dislocations (Rockwood type 4 or 5) during acute hook plate stabilization (IG: implantation group;  n  = 14) and hook plate removal (EG: explantation group;  n  = 14). Histological analyses included Giemsa staining, polarized light microscopy and immunostaining against CD68, αSMA and collagen type I and type III. Histomorphological evaluation entailed cell counts, collagen expression score, ligament tissue maturity index (LTMI) and descriptive analysis of specific ligamentous structures. Statistics consisted of nonparametric Mann–Whitney  U  tests and a level of significance of  P  &lt; .05. Results Total cell counts (cells/mm 2  1491 ± 296 vs. 635 ± 430;  P  &lt; 0.001) and collagen III expression (3.22 ± 0.22 vs. 1.78 ± 0.41;  P  &lt; 0.001) were higher in EG compared to IG. Inversely αSMA + (11 ± 9 vs. 179 ± 186;  P  &lt; 0.001) and CD68 + cell counts (56 ± 20 vs. 100 ± 57;  P  0.009) were significantly lower in the EG. The EG revealed a comparable reorientation of ligamentous structures. Consistently, ACLC samples of the EG (21.6 ± 2.4) displayed a high total but differently composed LTMI score (IG: 24.5 ± 1.2;  P  &lt; 0.001). Conclusions This experimental study proved the ligamentous healing potential of the human ACLC following acute anatomical reconstruction. Histomorphologically, the ACLC reliably showed a ligamentous state of healing at a mean of about 12 weeks after surgery. However, processes of ligamentous remodeling were still evident. These experimental findings support recent clinical data showing superior horizontal ACJ stability with additional AC stabilization in the context of acute ACJ reconstruction. Though, prospective clinical and biomechanical studies are warranted to evaluate influencing factors on ACLC healing and potential impacts of acute ACLC repair on clinical outcome. Study type Controlled Laboratory Study

Ligamentous healing potential of the acromioclavicular ligament following acute anatomical reconstruction